The role of vacuum-assisted mechanical thrombectomy in the management of acutely thrombosed arteriovenous fistulas and grafts

PURPOSE

The purpose of this study is to evaluate the safety and efficacy of the mechanical thrombectomy with the Indigo System in the treatment of thrombosed arteriovenous fistulas and grafts.

METHODS

A retrospective search of endovascular procedures performed from November 2018 to June 2020 was conducted. Inclusion criteria were: acute arteriovenous fistula or graft thrombosis that underwent endovascular mechanical thrombectomy with Indigo System. The following information was collected from each case: sex, age, fistula modality, fistula location, treatment modality, and outcomes. Endpoints evaluated were: technical and clinical success rates; primary, assisted primary, and secondary patency rates; complication rates.

RESULTS

Twenty-six mechanical thrombectomy procedures for declotting of arteriovenous fistula thrombosis, using the Indigo System, were performed in 22 patients. Technical and clinical success was achieved in 23/26 cases (88%). Mean follow-up was 9 months (range 11-539 days). The 6-month primary, primary assisted, and secondary patency rates were 71%, 86%, 93% and the 12-month primary, primary assisted, and secondary patency rates were 71%, 72%, 80%, respectively. No technical or device-related complications were observed during thrombectomy, however two venous ruptures occurred on the angioplasty of the underlying stenosis.

CONCLUSION

In conclusion, vacuum-assisted thrombectomy of acutely thrombosed arteriovenous fistulas and grafts with Indigo System is safe and effective, providing good short term patency rates.

Effects of lyotropic series salts on the functional properties of bambara groundnut (Voandzeia subterranean) protein isolate

Lyotropic series salts have profound effects on the stability and the biochemical equilibrium of proteins colloids. The influence of kosmotropic and chaotropic salts on some functional properties of a protein isolate prepared from Voandzeia subterranean was investigated. Experimental results showed that the foaming, emulsifying and gelation properties were better in dispersions prepared with chaotropic salts (NaI, NaClO4 and NaSCN) than those prepared with kosmotropic salts (Na2SO4, NaCl and NaBr). However, kosmotropic salts improved water holding capacity more than the chaotropic salts. Increase in the water holding capacity followed the lyotropic or Hofmeister trend: NaSCN<NaClO4<NaI,<NaBr<NaCl<Na2SO4 while the reverse was observed in foaming, emulsifying and gelation properties. This study provides relevant information in understanding the bio-physical behaviour of the seed protein colloids in chaotropic or kosmotropic solutions.

Isolated iliac artery aneurysm in association with congenital pelvic kidney treated with iliac branch device: case report

Background

Association of abdominal aortic aneurysm with congenital pelvic kidney is rare and association with isolated iliac artery aneurysm is not yet described in the literature.

Case presentation

We present a case of successful repair of an isolated common iliac artery aneurysm associated with a congenital pelvic kidney treated by an endovascular technique. A 75-year-old man was referred for the treatment of an asymptomatic left common iliac artery aneurysm. A computed tomography angiography revealed an isolated left common iliac artery aneurysm and a left pelvic kidney. The maximum diameter of the aneurysm was 32 mm. The congenital pelvic kidney was supplied by three small superior polar arteries that emerged from the proximal non-aneurysmal portion of the common iliac artery and the main artery that arose from the left internal iliac artery. The aneurysm exclusion was accomplished by using an iliac branch device (Gore Excluder Iliac Branch, Flagstaff, AZ). The 1 and 6 months computed tomography angiography after the procedure demonstrated complete exclusion of the aneurysm and preservation of all renal arteries.

Conclusion

Treating patients with an association of iliac artery aneurysms and pelvic kidneys can be a challenge due the variable arterial anatomy. The use of iliac branch device is a safe and effective alternative in selected cases.

Inferior Vena Cava Filter in Cancer Patients: On Whom Should We Be Placing Them?

BACKGROUND

Standard treatment for venous thromboembolism is anticoagulation; vena cava filter placement is an alternative in special situations. We aimed to evaluate the outcomes in patients with cancer undergoing filter placement in a cancer center during a 10-year period and assess which preoperatory variables were associated with poorer survival.

METHODS

Retrospective unicenter analysis during a 10-year period was carried out in patients with cancer who had undergone placement of vena cava filter. Early deaths were those that occurred less than 30 days after the filter placement or that occurred during the same hospital stay of the placement.

RESULTS

About 250 patients were analyzed. About 51.6% were females; 77.2% had proximal lower limb deep vein thrombosis; 34.8% had contraindications to anticoagulation; 32.8% presented bleeding after the onset of anticoagulation; and 18.4% had the filter implanted because they were going to undergo surgery and could not be anticoagulated immediately after. About 51.2% of the filters were removable. However, only 2 had the filter removed. About 59.2% had metastatic disease at the time of filter placement. About 31.2% fulfilled criteria for early death. Of those, 34 patients were put in palliative care after filter insertion (median, 13.5 days). Body mass index >18 kg/m², the absence of metastatic disease, and filter placement during the same anesthesia of another surgery (especially if elective and curative) were associated with a higher chance of survival.

CONCLUSIONS

Multidisciplinary evaluation (and possibly consideration for palliation) should take place before the decision to insert a vena cava filter in severe oncologic cases depending on overall status. Patients with a greater chance of survival at a 3 or 5 years interval seem to be those whose filters were placed in the perioperative context of other surgeries (specially elective and curative), who were not undernourished, and whose disease was not metastatic at that time. For patients who survived, an active investigation protocol for filter removal should be implemented.

An alternative approach to treatment of inferior vena cava filter perforation

Abstract We report a case of inferior vena cava filter perforation immediately after filter implantation, recognized intraoperatively in a patient undergoing laparotomy for resection of locally advanced ovarian cancer. We describe an alternative approach with strut resection, less invasive than filter removal, enabling the device to be maintained and bleeding to be controlled.

Totally Implantable Ports Connected to Valved Catheters for Chemotherapy: Experience from 350 Groshong Devices

Purpose

There are few studies regarding the use of totally implantable valved ports for chemotherapy. The objective of this study was to analyze the results obtained from consecutive implantation of 350 devices.

Methods

Adult patients submitted to port insertion in veins of the superior vena cava system over a 17-month period (July 2006 to December 2007) were considered. The device used was composed of a titanium and silicone rubber port (Dome Port™; Bard Inc, Salt Lake City, UT) connected to an 8.0 Fr silastic Groshong™ catheter tube. Follow-up was conducted on outpatient data and during clinical readmissions, until the device was removed or the patient died.

Results

Three hundred and fifty devices, total of 74,691 days in situ, were inserted, with a median follow-up of 176 days. There were 11 early complications (3.1%) and 49 late complications (14%), 21 of these (6%) were considered major ones. Early complications comprised four instances of phlebitis of the external jugular, three of pocket infection, two of technical failure and two of ecchymosis. Late complications comprised 33 instances of withdrawal difficulty, 12 of port-related bacteremia, two of deep venous thrombosis, one of occlusion and one of catheter fracture. Out of the 350 catheters implanted, 258 (73.5%) were still being used, 73 (21%) remained in use until the patient died, five (1.5%) were removed at the end of the treatment and 14 (4%) were removed because of complications.

Conclusions

There was a low rate of major complications associated with this valved system justifying its use.

Retained Catheter: A Rare Complication Associated with Totally Implantable Venous Ports

Totally implantable venous ports are the main access for chemotherapy. The complications associated with these devices occur most frequently over the course of their use. We report two cases of a complication that had only been described in patients with partially implantable catheters for hemodialysis: retention of a catheter fragment within a vessel during port removal. Both patients underwent adjuvant chemotherapy through the port and even after indication of catheter removal because at the end of treatment, they remained with the devices for long periods of time (7 and 8 yrs, respectively). Due to adherence of the catheters along their intravascular portions, complete removal was impossible. The catheters were sectioned and ligated close to the site where it entered the access vein. After 1 yr of follow-up, both patients were asymptomatic and imaging examinations showed the retained catheters. We believe that an implantable port should be removed after appropriate oncological follow-up.

Comparison between Saline Solution Containing Heparin versus Saline Solution in the Lock of Totally Implantable Catheters

BACKGROUND

There are only 3 studies comparing the efficacy of 2 different types of lock used in totally implantable catheters regarding occlusion or reflux dysfunction. The present study contains the largest published casuistry (862 patients) and is the only one that analyzes 3 parameters: occlusion, reflux dysfunction, and flow dysfunction.

METHODS

This was a retrospective study of patients operated at a large oncology center and followed up in the outpatient clinic between 2007 and 2015. The patients were divided into 2 groups according to the type of lock: the Hep group (heparine), whose lock was composed of saline solution 0.9% with heparin (100 IU/mL) and the SS group (saline solution), whose lock was composed of saline solution 0.9%.

RESULTS

The Hep group was composed of 270 patients (31%) and the SS group of 592 patients (69%). Regarding occlusion, there were 8 cases in the Hep group (2.96%) and 8 in the SS group (1.35%; P = 0.11); in relation to reflux dysfunction, there were 8 cases in the Hep group (2.96%) and 8 in the SS group (1.35%; P = 0.11); in relation to flow dysfunction, there was 1 case in the Hep group (0.37%) and 4 cases in the SS group (0.68%; P = 1).

CONCLUSIONS

There was no statistically significant difference between the groups regarding occlusion, reflux dysfunction, and flow dysfunction.

Brachial insertion of fully implantable venous catheters for chemotherapy: complications and quality of life assessment in 35 patients

Objective

To prospectively evaluate the perioperative safety, early complications and satisfaction of patients who underwent the implantation of central catheters peripherally inserted via basilic vein.

Methods

Thirty-five consecutive patients with active oncologic disease requiring chemotherapy were prospectively followed up after undergoing peripheral implantation of indwelling venous catheters, between November 2013 and June 2014. The procedures were performed in the operating room by the same team of three vascular surgeons. The primary endpoints assessed were early postoperative complications, occurring within 30 days after implantation. The evaluation of patient satisfaction was based on a specific questionnaire used in previous studies.

Results

In all cases, ultrasound-guided puncture of the basilic vein was feasible and the procedure successfully completed. Early complications included one case of basilic vein thrombophlebitis and one case of pocket infection that did not require device removal. Out of 35 patients interviewed, 33 (94.3%) would recommend the device to other patients.

Conclusion

Implanting brachial ports is a feasible option, with low intraoperative risk and similar rates of early postoperative complications when compared to the existing data of the conventional technique. The patients studied were satisfied with the device and would recommend the procedure to others.

Oral Rivaroxaban for the Treatment of Symptomatic Venous Thromboembolism in 400 Patients With Active Cancer: A Single-Center Experience

PURPOSE

To study the safety and efficacy of rivaroxaban-a direct oral anticoagulant-use in patients with active cancer and venous thromboembolism (VTE).

PATIENTS AND METHODS

Retrospective cohort study of 400 patients with active cancer and associated VTE, defined as deep venous thrombosis and/or pulmonary embolism. This single-center study was carried out from January 2012 to June 2015. The aim of this study was to determine the efficacy and safety, using the incidence of recurrent symptomatic VTE and major bleeding, respectively, throughout the treatment with rivaroxaban.

RESULTS

Of the 400 patients enrolled, 223 (55.8%) were female. A total of 362 (90.5%) patients had solid tumors and 244 (61%) had metastatic disease. A total of 302 (75.5%) received initial parenteral therapy with enoxaparin (median: 3, mean: 5.6, standard deviation [SD]: 6.4 days) followed by rivaroxaban. Ninety-eight patients (24.5%) were treated with on label rivaroxaban treatment. Recurrence rates were 3.25% with major bleeding occurring in 5.5% during the anticoagulant therapy (median: 118, mean: 163.9, SD: 159.9 days).

CONCLUSION

Rivaroxaban can be an attractive alternative for the treatment of cancer-associated thrombosis.

Vascular Reconstruction in Limbs with Malignant Tumors

Patients with tumors in limbs who undergo surgical treatment may present involvement of major vessels. Major arteries must be reconstructed for limb salvage. Major veins may be reconstructed to avoid the onset of venous hypertension. The objective of this study is to analyze the results from surgical treatment of malignant tumors associated with vascular reconstruction in limbs. A prospective follow-up was made of 20 patients with malignant tumors involving major vessels in limbs who underwent vascular reconstruction. Arterial and venous reconstructions were performed in 11 patients, arterial reconstruction in 7, and venous reconstruction in 2. The vascular substitutes utilized were: greater saphenous vein (21), expanded polytetrafluoroethylene (ePTFE) prosthesis (5), and Dacron prosthesis (5). Vascular complications occurred in 9 patients: 1 rupture of the arterial graft, 4 occlusions of the venous graft, and worsening of previous edema in 4 patients. Nonvascular complications occurred in 6 patients: infection (2), neurologic deficit (2), partial necrosis of the flap (1), and enteric fistula (1). Four patients presented local recurrence, and 1 of them underwent transfemoral amputation. Seven patients presented pulmonary metastases, of whom 4 died. Arterial revascularization in association with the resection of limb neoplasm is a safe procedure with a low rate of complications. Venous revascularization should be performed using an autologous substitute.

Carbon dioxide as a substitute for iodine contrast in arteriography during embolectomy

Acute limb ischemia can be potentially harmful to the limb and life threatening. Renal failure is a possible outcome associated with release of products of ischemic limb reperfusion. Some authors reported the benefit of performing angiography after embolectomy, even though iodine contrast is also nephrotoxic. We report a case of embolectomy on a patient with renal insufficiency in whom carbon dioxide was used as a substitute for iodine contrast.

Combined use of GORE TAG® and Gore Exculder® endografts for treatment of abdominal aortic aneurysm with severe angulation

The advances in endovascular surgery for treatment of aortic aneurysms have allowed a greater number of patients, who were previously considered unsuitable for the approach, to benefit from this therapeutic modality. Despite the current availability of highly comfortable endografts, cases with unfavorable anatomy remain a challenge for surgeons. We report a case with difficult anatomy that was successfully managed using an unconventional endovascular technique.

Ethanol sclerotherapy of head and neck venous malformations

OBJECTIVE

This retrospective study evaluated the results of sclerotherapy with low doses of ethanol for treatment of head and neck venous malformations.

METHODS

We treated 51 patients, 37 females. Median age was 23 years. Patients were treated with percutaneous intralesional injection of alcohol every two weeks and followed up prospectively for a median period of 18 months. Most lesions affected the face and cosmetic disfigurement was the most frequent complaint.

RESULTS

We performed a median of 7 sessions of sclerotherapy. Complete resolution or improvement was observed in 48 patients presented. Five cases of small skin ulceration, two cases of hyperpigmentation and two of paresthesia were documented; all of them were treated conservatively.

CONCLUSION

Percutaneous sclerotherapy with low doses of ethanol is a safe and effective treatment modality for venous malformations affecting the head and neck.

Fracture and migration into the coronary sinus of a totally implantable catheter introduced via the right internal jugular vein

There has been an increase in the use of totally implantable devices. Catheter fractures are rare but known complications. This case report presents a rare migration site of the catheter fragment into the coronary sinus. The totally implantable catheter was introduced into the right internal jugular vein to deliver chemotherapy. Although it was an unusual site, the catheter fragment was removed without complications using loop-snare technique.

Effect of Heat Treatment on Dilute Solution Properties of Sugar Beet Pectin

Beet Pectin (SBP) polysaccharide. Aqueous solution properties of these samples have been studied using Ubbelohde capillary viscometer in the dilute regime. Intrinsic viscosity [?] was estimated for different SBP solution samples prepared from heat-treated SBP powdered samples with different heating time. Results suggest that heat treatment has a significant effect on solution behavior of SBP samples. Intrinsic viscosities decreased with increasing heating time indicating that heat-treated SBP molecules are compact than the untreated one and the compactness increases with increasing heating time at 80°C. The intrinsic viscosities of these samples were plotted as a function of the corresponding molecular weight of the samples and can be expressed by a power law. The power law exponent was estimated as 1.4 indicating that pectin molecules takes the conformation of stiff polymer chains in dilute solution. Dhaka Univ. J. Sci. 61(1): 117-123, 2013 (January) DOI: http://dx.doi.org/10.3329/dujs.v61i1.15107

Concomitant aortic and vena caval reconstruction associated with germ-cell tumor resection with creation of a new venous bifurcation

Aortic and vena caval reconstruction associated with tumor resection is very rare. We describe a 22-year-old man with a retroperitoneal metastasis from a germ-cell tumor previously treated with chemotherapy who presented with a huge mass involving the infrarenal aorta and the inferior vena cava. He underwent retroperitoneal lymph node dissection with concomitant aortic and caval reconstruction that included customization of a new caval bifurcation. His postoperative recovery was uneventful, and he remained well 36 months after the operation. Complementary follow-up imaging examinations demonstrated that the aortic and venous interposition grafts were patent and that there was no local or distant disease recurrence.

Isolated limb perfusion with hyperthermia and chemotherapy: predictive factors for regional toxicity

OBJECTIVE

Isolated limb perfusion combined with melphalan is an accepted treatment for obtaining locoregional control in advanced melanoma of the extremities and other malignant neoplasias restricted to the limb. This study aims to examine the factors associated with toxicity caused by the regional method. We considered the technical aspects of severe complications associated with the procedure in an attempt to diminish the patient morbidity that occurs during the learning curve.

METHODS

We conducted a retrospective analysis of the records of patients who underwent perfusion at the AC Camargo Hospital in São Paulo, Brazil between January 2000 and January 2009. The Wieberdink scale was applied to classify local toxicity and its relation to clinical and laboratory variables.

RESULTS

Fifty-eight perfusions were performed in 55 patients. Most patients (86.2%) presented a toxicity level between I and III. Grade V toxicity was seen in five cases (8.6%), four of which occurred in the first 2 years. Creatine phosphokinase, an important predictive factor for toxicity, had an average value of 231.8 for toxicity grades I-III and 1286.2 for toxicity grades IV-V (p = 0.001). There was a relationship between the melphalan dose and toxicity, which was 77 mg (25 to 130 mg) for toxicity grades I-II and 93.5 mg (45 to 120 mg) for toxicity grades IV-V (p = 0.0204).

CONCLUSION

It is possible to prevent the toxicity associated with melphalan by adjusting the dose according to the patient's body weight (especially for women and obese patients) and the creatine phosphokinase values in the postoperative period.

Covered stent treatment for an aneurysm of a saphenous vein graft to the common carotid artery

Aneurysmal degeneration of a saphenous vein graft is a rare complication and, so far, only three cases involving a carotid artery have been described. We report the case of a patient with a cervical neoplasm presenting carotid invasion, who underwent en bloc tumor resection and carotid reconstruction with a saphenous vein graft. Six years later, during follow-up, an aneurysm of the carotid graft was detected. Endovascular intervention was performed using a covered stent. Three years after this intervention, the patient was found to be asymptomatic, and computed tomography showed that the covered stent was patent, without complications.

Outpatient percutaneous treatment of deep venous malformations using pure ethanol at low doses under local anesthesia

INTRODUCTION

Venous malformations are the most frequent vascular malformation. Deep venous malformations are located in subcutaneous tissue or in the muscles. Percutaneous sclerotherapy is the treatment of choice, and the use of ethanol at low doses has not yet been described.

OBJECTIVE

To analyze the results of treating Deep venous malformations patients with low doses of ethanol.

METHODS

Thirty-nine patients treated between July 1995 and June 2007 were followed up prospectively over a median period of 18 months. Twenty-nine were female (74.4%) and 10 were male (25.6%), with ages ranging from 11 to 59 years (median of 24 years). All of the lesions affected limbs, and the main symptom reported was pain (97.4%). Each patient underwent fortnightly alcohol application sessions under local anesthesia on an outpatient basis. The lesions were classified into three groups according to size using nuclear magnetic resonance imaging: small, up to 3 cm (4 patients); medium, between 3 and 15 cm (27 patients); and large, greater than 15 cm (8 patients).

RESULTS

The symptoms completely disappeared in 14 patients (35.9%) and improved in 24 (61.5%). The lesion size reduced to zero in 6 patients (15.4%) and decreased in 32 (82%). The median number of sessions was 7. There were no complications in 32 patients (82%), while 3 presented local paresthesia (7.7%), 2 superficial trombophlebites (5.1%), 1 skin ulcer (2.6%), and 1 case of hyperpigmentation (2.6%).

CONCLUSION

Outpatient treatment for Deep venous malformations patients using ethanol at low doses was effective, with a low complication rate.

Venous reconstructions in lower limbs associated with resection of malignancies

BACKGROUND

Patients with tumors in the limbs who undergo surgical treatment may have involvement of major vessels. Major arteries are always reconstructed for limb salvage. Major veins may be reconstructed to avoid the onset of venous hypertension signs and symptoms. The objective of this study was to analyze the results from surgical treatment of a sample of patients who underwent lower limb venous reconstructions associated with the resection of malignant tumors.

METHODS

Follow-up was performed of 17 patients with malignant tumors involving major vessels in the lower limbs. The median length of follow-up was 22 months. Venous reconstruction concomitant to arterial reconstruction was performed in 15 patients, and an isolated venous reconstruction was performed in 2 patients. The venous substitutes used were the contralateral long saphenous vein (n = 12), expanded polytetrafluoroethylene prosthesis (n = 3), and Dacron prosthesis (n = 2).

RESULTS

Vascular complications occurred in seven patients: three occlusions of the venous graft, edema in seven patients, and one rupture of the arterial graft. The primary 2- and 5-year patency rates of venous reconstructions were 79.3% and 79.3%, respectively. Nonvascular complications occurred in six patients: neurological deficit (n = 3), partial necrosis of the flap (n = 2), wound infection (n = 1), hematoma (n = 1), and enteric fistula (n = 1). Eight patients were still alive and disease free, although one of them underwent above-knee amputation as a result of local disease recurrence. One patient experienced regional disease recurrence and is undergoing chemotherapy. Eight patients died due to pulmonary metastases. The 2- and 5-year overall survival rates were 58.6% and 42.4%, respectively. The 2- and 5-year thrombosis-free survival rates were 51.9% and 35.2%, respectively.

CONCLUSIONS

Lower limb venous reconstructions associated with tumor resection in this study gave good functional results, although the prognosis for these patients had been unfavorable. The saphenous vein is a suitable substitute.

Arterial reconstructions associated with the resection of malignant tumors

OBJECTIVE

When trunk arteries are affected by malignant neoplasia, and surgical treatment involving tumor and arterial resection is used, the vascular reconstruction must be performed immediately to avoid ischemia in the brain and large tissue masses. The objective of this study was to analyze the results obtained with the treatment of patients with malignant neoplasia who underwent tumor and vascular resection associated with arterial reconstruction. The primary patency of reconstructions, the occurrence arterial complications, and patient survival were assessed.

METHODS

Thirty-six patients with cervical, abdominal, or lower limb neoplasias were followed up. These patients underwent elective operations at Hospital do Câncer A.C. Camargo, São Paulo, between September 1997 and September 2004. They were divided into 3 groups according to tumor location: Cervical (14), lower limbs (13), and Abdomen (9). Thirty-eight arterial reconstructions were performed in these 36 patients.

RESULTS

There were 5 arterial complications: 2 early- and 3 late-stage. The early complications consisted of 1 symptomatic carotid occlusion with sequelae and 1 femoral graft rupture without sequelae. The late-stage complications consisted of 1 symptomatic carotid occlusion, 1 occlusion of an axillary-carotid graft, and 1 occlusion of a branch of the aortobifemoral graft, all without sequelae. There was no difference between the primary arterial patency rates. All the deaths (22) resulted from progression of neoplasic disease.

CONCLUSIONS

Arterial reconstructions associated with resection of malignant neoplasia in cervical, abdominal, or lower limbs can be carried out with low rates of morbidity and mortality. There was no difference in the primary arterial patency rates among the groups studied.

Vena cava filters in cancer patients: experience with 50 patients

OBJECTIVE

To study the immediate and late results obtained from the implantation of vena cava filters in cancer patients with deep vein thrombosis concomitant with neoplasia.

METHODS

This was a retrospective evaluation of 50 patients with an association of cancer and deep venous thrombosis who underwent interruption of the inferior vena cava and the insertion of permanent vena cava filters. The indications for the procedure, filter implantation technique, early and late complications related to the operation, and the clinical evolution were evaluated.

RESULTS

The most frequent indication for filter implantation was the contraindication for full anticoagulant treatment (80%). The femoral vein was the preferred access route (86% of the patients). There were no complications related to the surgical procedure. During the follow-up, the following complications were observed: 1 episode of nonfatal pulmonary thromboembolism, 2 cases of occlusion of the inferior vena cava, and 1 case of thrombus retained in the device. Twenty patients (40%) died due to progression of the neoplasm.

CONCLUSIONS

Interruption of the inferior cava vein using an endoluminal filter is a procedure with a low rate of complications. It is a safe and efficient measure for preventing pulmonary embolism in cancer patients who have deep vein thrombosis of the lower limbs.

A new test to avoid arterial complications during pancreaticoduodenectomy

Celiac trunk or superior mesenteric artery stenosis are usually innocuous conditions. In such patients, arterial blood supply to the stomach, spleen, liver and bowel is sustained through extraordinarily well-developed pathways through the pancreas. If division of these collateral vessels is necessary during a surgical procedure such as pancreaticoduodenectomy, life-threatening celiac organ or bowel ischemia may occur. The authors describe a new test, using pancreatic inflow occlusion, to reliably identify celiac trunk or superior mesentery artery stenosis. The authors describe two cases of celiac axis occlusion and one case of superior mesenteric artery stenosis. In all three presented cases the gastroduodenal artery clamping test was negative and ischemia was only noticed after pancreatic section, suggesting that in severe occlusions this test may fail in diagnosing the vascular abnormality. All patients were successfully treated by revascularization with no operative mortality. If the diagnosis is unsuspected and in cases where appropriate angiographic studies have not been obtained before pancreatic resection, a test occlusion of the gastroduodenal artery should always precede its ligation. However, this test may not be effective in all cases and in instances where high suspicion of celiac axis or mesenteric stenosis is present, other maneuvers, such as pancreatic inflow test, could be helpful for the diagnosis of these rare and morbid situations.

Surgical treatment of paragangliomas of the carotid bifurcation: Results of 36 patients

BACKGROUND

Paragangliomas of the carotid bifurcation are rare and usually benign neoplasms arising from the carotid body chemoreceptors. The aim of this retrospective study was to report long-term results of carotid bifurcation paragangliomas treated in a single institution over a period of 20 years. The following variables are described: age, sex, localization, diagnostic workup, operative procedure, complications, proportion and characteristics of malignant tumors, and cure rates.

METHODS

Thirty-six patients,10 men and 26 women, were treated. Twenty-three patients had tumors on the right side, 10 patients had tumors on the left side, and three patients had bilateral tumors. All patients were symptomatic. The most common complaint was a neck mass that had been present for 1 to 144 months. All patients had diagnostic procedures done before treatment. The most widely used was ultrasonography (26 patients). Angiography was performed in 14 patients.

RESULTS

All patients underwent complete tumor resection. In three cases, resection of the internal carotid was necessary. In all patients who underwent internal carotid resection, immediate reconstruction was performed. No patients had postoperative strokes. Five patients had postoperative nerve palsies. During the follow-up period of 4 months to 12 years, no patients had local recurrence develop. Four patients had distant metastasis.

CONCLUSION

The complete removal of paragangliomas of the carotid bifurcation is effective with acceptable morbidity. All recurrences of the malignant tumors were distant metastasis.

Totally implantable femoral vein catheters in cancer patients

INTRODUCTION

Totally implantable devices are increasingly being utilized for chemotherapy treatment of oncological patients. When it is impossible to implant the reservoir on the anterior wall of the thorax, or when there is an obstruction of the superior vena cava system, alternative access routes must be sought. Of these, the femoral vein is the most utilized. Few studies have been performed to analyse the results obtained from the implantation and utilization of such catheters in the femoral vein. The goal of this work was to prospectively study the results obtained from the implantation of 20 TIC in femoral veins in a large-sized cancer hospital with its own dedicated vascular clinical team.

MATERIAL AND METHODS

Twenty femoral TIC were inserted in 20 patients out of a group of 560 cancer patients submitted to TIC implantation for chemotherapy. Evaluations were made of the early and late-stage complications and patient evolution until removal of the device, death or the end of the treatment.

RESULTS

The prospective analysis showed a mean duration of 215 days for the catheters. There were 16 patients with no complications. There were no early complications. Among the late complications, three were infections, representing 0.69/1000 days of catheter use, and one was a deep vein thrombosis (0.23/1000 days of catheter use). One catheter was removed due to primary bacteremia and one due to subcutaneous pocket infection. Fourteen patients died while the catheter was functioning and four patients are still making use of the catheter.

CONCLUSION

The low rate of complications implying catheter loss in this study confirms the safety and convenience of the use of femoral TIC in patients who cannot be submitted to implantation in the superior vena cava system.

Gelation of Xyloglucan by Addition of Epigallocatechin Gallate as Studied by Rheology and Differential Scanning Calorimetry

Interaction of tamarind seed xyloglucan (TSX) and epigallocatechin gallate (EGCG) was investigated. TSX alone showed the rheological behaviors of dilute and semidilute solution types in the temperature range from 10 to 50 degrees C and the concentration range from 1 to 10%. Addition of a small amount of EGCG changed the rheological properties of TSX solutions to induce a thermoreversible gelation. The sol-gel transition was detected as a crossover of the storage and loss shear moduli at a certain temperature in thermal scanning rheological measurements and an endo- and exo- thermic peaks in curves obtained by differential scanning calorimetry on heating and cooling. High storage modulus of the gels at all experimental frequencies also indicated the formation of a network structure. Increase in the gel strength and the enthalpy of the transition with increasing EGCG concentration at fixed TSX concentration suggested that EGCG was directly involved in the network formation through association with TSX. The TSX gel was obtained by addition of appropriate amount of EGCG. Addition of an excessive amount of EGCG induced precipitation.

Totally implantable venous catheters for chemotherapy: experience in 500 patients

CONTEXT

Totally implantable devices are increasingly being utilized for chemotherapy treatment of oncological patients, although few studies have been done in our environment to analyze the results obtained from the implantation and utilization of such catheters.

OBJECTIVE

To study the results obtained from the implantation of totally implantable catheters in patients submitted to chemotherapy.

TYPE OF STUDY

Prospective.

SETTING

Hospital do Cancer A.C. Camargo, Sao Paulo, Brazil.

METHODS

519 totally implantable catheters were placed in 500 patients submitted to chemotherapy, with preference for the use of the right external jugular vein. Evaluations were made of the early and late-stage complications and patient evolution until removal of the device, death or the end of the treatment.

RESULTS

The prospective analysis showed an average duration of 353 days for the catheters. There were 427 (82.2%) catheters with no complications. Among the early complications observed, there were 15 pathway hematomas, 8 cases of thrombophlebitis of the distal stump of the external jugular vein and one case of pocket infection. Among the late-stage complications observed, there were 43 infectious complications (0.23/1000 days of catheter use), 11 obstructions (0.06/1000 days of catheter use) and 14 cases of deep vein thrombosis (0.07/1000 days of catheter use). Removal of 101 catheters was performed: 35 due to complications and 66 upon terminating the treatment. A total of 240 patients died while the catheter was functioning and 178 patients are still making use of the catheter.

CONCLUSION

The low rate of complications obtained in this study confirms the safety and convenience of the use of totally implantable accesses in patients undergoing prolonged chemotherapy regimes.

Aneurysm of superior mesenteric vein: case report with 5-year follow-up and review of the literature

Venous aneurysms are less common than arterial aneurysms in clinical practice, and the occurrence of isolated cases is a topic for publication. Aneurysms of the superior mesenteric vein are rare, and their origin is unknown. Many aneurysms are asymptomatic, and the diagnosis is established from radiologic findings. Others are diagnosed after complications such as gastrointestinal bleeding or thrombosis with associated abdominal pain. Because of the rarity of this disease and consequent absence of standard treatment, therapy must be adapted to fit each case. We present a case report of an aneurysm of the superior mesenteric vein. The diagnosis of this anomaly was made after investigation of abdominal pain. Computed tomography (CT) scans demonstrated the mass. Clinical treatment was administered, and no aneurysm growth was observed after 5 years of follow-up.

Endovascular techniques for placement of long-term chemotherapy catheters

PURPOSE

To analyze the results from using endovascular techniques to place long-term chemotherapy catheters when advancing the catheter using the external jugular vein is difficult due to obstructions or kinking.

METHODS

Between July 1997 and August 2000, 320 long-term chemotherapy catheters were placed, and in 220 cases the external jugular vein was used as the primary venous approach. In 18 of these patients, correct positioning was not achieved and several endovascular techniques were then utilized to overcome these obstacles, including manipulation of a J-wire with a moveable core, venography, and the exchange wire technique.

RESULTS

In 94.5% of the patients with difficulties in obtaining the correct positioning, we were able to advance the long-term catheter to the desired position with the assistance of endovascular techniques.

CONCLUSIONS

Venography and endovascular guidance techniques are useful for the placement of long-term catheters in the external jugular vein.

Vascular Reconstruction in Limbs Associated with Resection of Tumors

Patients with tumors in limbs who undergo surgical treatment may present involvement of major vessels. The artery must be reconstructed for limb salvage and the vein may be reconstructed to avoid the onset of venous hypertension. The objective of this study was to analyze the results from surgical treatment of tumors associated with vascular reconstruction in limbs. A prospective follow-up was made of 17 patients with tumors involving major vessels in limbs who underwent vascular reconstruction. Arterial and venous reconstructions were performed in nine patients, arterial reconstruction was performed in six, and venous reconstruction in two patients. The vascular substitutes used were greater saphenous vein (19), expanded polytetrafluoroethylene prosthesis (5), and Dacron prosthesis (2). Vascular complications occurred in seven patients: one arterial graft rupture, three venous graft occlusions, and lymphedema in five patients. The following nonvascular complications occurred in 10 patients: pulmonary metastasis (7), local recurrence (2), neurological deficit (2), infection (2), partial necrosis of the flap (1), and enteric fistula (1). Six patients with pulmonary metastasis died. One patient underwent transfemoral amputation. Major vessel reconstruction in limbs associated with resection of neoplasms is a safe procedure. Venous revascularization should be performed using an autologous substitute.

Microstructure of aggregated and nonaggregated kappa-carrageenan helices visualized by atomic force microscopy

Gelation of kappa-carrageenan is believed to involve two steps: helix formation on cooling and a further specific cation (salt) induced side-by-side aggregation of helices. Samples that should contain aggregated and also nonaggregated "helices" of kappa-carrageenan were prepared in aqueous solutions, spread onto freshly cleaved mica surfaces, and visualized under butanol using atomic force microscopy. In the presence of an excessive amount of a gel-promoting salt, KCl, kappa-carrageenan appeared to form rigid rodlike structures considered as large aggregates of double helices. Even when the side-by-side interhelical aggregation was suppressed by diluting random coiled solutions prior to cooling, by adding an aggregation-impeding salt, NaI, or by transforming kappa-carrageenan into the tetramethylammonium (TMA) salt, branched rodlike structures were still evident, suggesting that the side-by-side aggregation of helices is not a prerequisite for kappa-carrageenan to form a network structure, at least locally. Even in the absence of factors that promote side-by-side aggregation, kappa-carrageenan helices appeared to be capable of associating and forming gel networks.