Use of a Paclitaxel Drug-Eluting Stent for the Treatment of Hemodialysis Access Outflow Stenosis

PURPOSE

To evaluate the outcomes and durability of drug-eluting stents (DESs) for the treatment of hemodialysis access outflow stenosis.

MATERIAL AND METHODS

A single-center retrospective analysis was conducted of all patients with hemodialysis vascular access outflow stenosis treated with a paclitaxel-coated DES (Eluvia; Boston Scientific, Marlborough, Massachusetts) between January 2020 and July 2022. A total of 34 DESs were implanted to treat outflow stenosis in 32 patients. Primary target lesion patency after stent deployment was the main outcome. Comparison between the time interval free from target lesion reintervention (TLR) after previous plain balloon angioplasty (PBA) and that after stent deployment for the same target lesion was considered a secondary outcome.

RESULTS

The primary patency at 6, 12, and 18 months was 63.1%, 47.6%, and 41.7%, respectively. The secondary patency rate was 100% at 18 months. The median time interval free from TLR increased from 4.1 to 11.9 months (P < .001). No adverse events were observed during the median follow-up period of 387 days.

CONCLUSIONS

The patency rates after use of DES for hemodialysis access outflow stenosis were comparable with results for drug-coated balloons and stent grafts, addressing recoil and minimizing the risk of jailing by a covered stent.

Unveiling the Potential Distribution of the Highly Threatened Madeira Pipistrelle (Pipistrellus maderensis): Do Different Evolutionary Significant Units Exist?

The isolation of islands has played a significant role in shaping the unique evolutionary histories of many species of flora and fauna, including bats. One notable example is the Madeira pipistrelle (Pipistrellus maderensis), which inhabits the Macaronesian archipelagos of the Azores, Madeira, and the Canary Islands. Despite the high biogeographic and conservation importance of this species, there is limited information on its ecology and evolutionary history across different archipelagos. In our study, we employed species distribution models (SDMs) to identify suitable habitats for the Madeira pipistrelle and determine the environmental factors influencing its distribution. Additionally, we conducted molecular comparisons using mitochondrial DNA data from various Macaronesian islands. Molecular analyses provided compelling evidence for the presence of distinct Evolutionary Significant Units on the different archipelagos. We identified distinct haplotypes in the populations of Madeira and the Canary Islands, with a genetic distance ranging from a minimum of 2.4% to a maximum of 3.3% between samples from different archipelagos. In support of this, SDMs highlighted relevant dissimilarities between the environmental requirements of the populations of the three archipelagos, particularly the climatic niche. Our research demonstrates that deeper investigations that combine ecological, morphological, and genetic areas are necessary to implement tailored conservation strategies.

Outflow Rescue of Elbow-Blockade Forearm Arteriovenous Fistulas: Outcomes of Open Surgical Techniques

BACKGROUND

Venous scarring at the elbow is a common problem that can cause early and late forearm arteriovenous fistula (AVF) dysfunction in hemodialysis patients. However, any effort to prolong the long-term patency of distal vascular accesses could benefit the patient's survival, maximizing the use of restricted venous patrimony. This study aims to report a single-center experience in the recovery of distal autologous AVF with venous outflow obstruction at the elbow using different surgical techniques.

METHODS

Retrospective observational study of all patients treated at a single vascular access center from January 2011 to March 2022, with dysfunctional forearm AVFs presenting with outflow stenosis or occlusions at the elbow treated by open surgery, using 3 different surgical techniques. Demographics and clinically relevant data were collected. Evaluated endpoints included primary, assisted primary, and secondary patency rates at 1 and 2 years.

RESULTS

Twenty-three patients with elbow-blocked outflow forearm AVFs have been treated with a mean age of 64 ± 15 years. The majority (96%) had a radiocephalic fistula. The median time from vascular access creation to intervention was 34.5 months (12-216 months). A total of 24 procedures have been performed using 3 different surgical techniques for bypassing the obstructed venous outflow at the elbow. Technical success was achieved in 96% of the surgically treated patients. Primary and secondary patency rates at 1 year were 67.4% and 89.4%, respectively, and 52.9% and 82.0% at 2 years, with a median follow-up of 19 months (6-92 months).

CONCLUSIONS

AVFs outflow stenosis or occlusions at the elbow not amenable to endovascular therapy could lead to vascular access abandonment. Our study demonstrates multiple surgical solutions to avoid this adverse outcome. Elbow venous outflow surgical reconstruction seems effective for distal vascular access preservation. Close surveillance is essential for timely endovascular treatment of newly developed stenosis at the venous drainage.

Asymptomatic Hypogastric Arteriovenous Fistula Detected 40 Years After Shotgun Injury

84-year-old male, with a history of firearm incident with accidental gunshot shooting, and multiple projectile injuries, 40 years prior. No advanced medical treatment was required at the time. A CT was recently performed for unrelated reasons, and the scout view shows multiple projectiles, a total of 50, scattered in the thoracoabdominopelvic region as well as the lower limbs. CT angiography exposed CT's scout view of the multiple projectiles scattered. an arteriovenous fistula in posterior branches of the hypogastric artery with moderate dilations of the superior gluteal vein. The patient was completely asymptomatic and had no findings suggestive of AVF-related cardiac failure. Physical examination was unremarkable. Conservative treatment without further imagiological follow-up was decided, if patient continued asymptomatic.

Resisted Inspiration: A New Technique to Aid in the Detection of CSF-Venous Fistulas

We describe a technique termed "resisted inspiration" that could be used during myelography to decrease superior vena cava venous pressure and increase lumbar CSF pressure, potentially aiding in the detection of CSF-venous fistulas.

Angiosarcoma of a Femoropopliteal Bypass Thrombosed Vein Graft

BACKGROUND

Angiosarcoma is a rare subtype of malignant vascular tumours which has been only anecdotally described in patients submitted to lower limb revascularization.

CASE PRESENTATION

This paper reports a patient previously submitted to a femoropopliteal bypass using autologous great saphenous vein (GSV). Nine years after the initial surgery, a primary angiosarcoma of the thrombosed vein graft was diagnosed, requiring en bloc surgical resection. Rampant metastatic spread was documented despite primary tumour surgical resection with a dismal outcome within months.

CONCLUSIONS

Malignant transformation of autologous vein for lower limb revascularization is extremely rare and anecdotally described in the literature. It is a poorly studied complication with an aggressive behaviour. This report further reinforces the need for early recognition of this pathology.

MAMMALS IN PORTUGAL: A data set of terrestrial, volant, and marine mammal occurrences in Portugal

Mammals are threatened worldwide, with ca. 26% of all species being included in the IUCN threatened categories. This overall pattern is primarily associated to habitat loss or degradation, and human persecution for terrestrial mammals, and pollution, open net fishing, climate change and prey depletion for marine mammals. Mammals play a key role in maintaining ecosystems functionality and resilience, and therefore information on their distribution is crucial to delineate and support conservation actions. MAMMALS IN PORTUGAL is a publicly available data set compiling unpublished geo-referenced occurrence records of 92 terrestrial, volant, and marine mammals in mainland Portugal and archipelagos of Azores and Madeira that includes 107,852 data entries between 1873 and 2021 (72% of the data occurring in 2000 and 2021). The methods used to collect the data were: live observations/captures (42%), sign surveys (38%), camera trapping (16%), bioacoustics surveys (4%) and radio-tracking and inquiries that represent less than 1% of the records. The data set includes 13 types of records: 1) burrows | soil mounds | tunnel, 2) capture, 3) colony, 4) dead animal | hair | skulls | jaws, 5) genetic confirmation, 6) inquiries, 7) observation of live animal, 8), observation in shelters, 9) photo trapping | video, 10), predators diet | pellets | pine cones/nuts, 11) scat | track | ditch, 12) telemetry and 13) vocalization | echolocation. The spatial uncertainty of most records ranges between 0 and 100 m (76%). Rodentia (n = 34,754) has the highest number of records followed by Chiroptera (n = 18,858), Carnivora (n = 18,594), Lagomorpha (n = 17,679), Cetartiodactyla (n = 11,568) and Eulipotyphla (n = 6400). The data set includes records of species classified by the IUCN as threatened (e.g., Oryctolagus cuniculus (n = 12,407), Monachus monachus (n = 1512), and Lynx pardinus (n = 197)]. We believe that this data set may stimulate the publication of other European countries data sets which would certainly contribute to ecology and conservation-related research, and therefore assisting on the development of more accurate and tailored conservation management strategies for each species. There are no copyright restrictions; please cite this data paper when the data are used in publications.

Ruptured arteriovenous fistula pseudoaneurysm treatment by balloon-assisted direct percutaneous thrombin injection

We present the case of a male patient on hemodialysis with a ruptured pseudoaneurysm in a brachiocephalic arteriovenous fistula (AVF) and with edema and pain in the right arm attended to in the emergency department. An ultrasonographic scan identified a ruptured pseudoaneurysm with hemorrhagic infiltration of the arm muscular tissues. We performed a percutaneous ultrasound-guided thrombin injection with an angioplasty balloon inflated in the lumen of the AVF achieving the pseudoaneurysm thrombosis. After 6 months of follow-up, the patient's arteriovenous access remains functional. Percutaneous ultrasound-guided thrombin injection assisted by an angioplasty balloon may be a good alternative to surgical intervention in the treatment of symptomatic growing pseudoaneurysms of the arteriovenous fistula with the benefit of preserving the vascular access.

SURGICAL TREATMENT OF A SPONTANEOUS RUPTURE OF A MYCOTIC ANEURYSM

Saccular mycotic aorto-iliac aneurysms are rare but, when ruptured, they are an important life-threatening condition. We present the case of a 52 years-old male transferred from another hospital and admitted to the emergency room with a ruptured iliac artery aneurysm. He complained of persistent fever and abdominal discomfort that swiftly established as hemorrhagic shock. Image study with computed tomographic angiography revealed a ruptured left common iliac artery saccular aneurysm. The patient was instantaneously and successfully submitted to endoaneurismorraphy of the hypogastric artery, common and external iliac artery ligation and construction of an extra anatomic bypass, right to left femorofemoral bypass. Blood culture revealed a Streptococcus anginosus and the patient received appropriate targeted antibiotics. Post-operative period was uneventful and the patient discharged ten days after admission. He has now eleven months of follow up with no intercurrences. Even though surgical approach carries a relative risk of perioperative morbidity, it is a feasible and durable solution for extreme situations like the one here described.

Emergency Repair of a Ruptured Para-Renal Abdominal Aortic Aneurysm in a Patient with a Functional Renal Graft: A Case Report and Review of the Literature

INDRODUCTION

Rupture of and abdominal aortic aneurysm (AAA) in a kidney transplant patient is a rare and rarely reported event. Emergent treatment can be challenging and should achieve effective aortic repair while minimizing ischemic damage to the renal graft during aortic cross-clamping. Several renal protective measures have been proposed such as permanent or temporary shunts, renal cold perfusion and general hypothermia.

CASE REPORT

We report the effective treatment of a para-renal AAA in a patient with a functional renal allograft. A temporary extra-corporeal axillofemoral shunt was constructed to maintain graft's perfusion during open surgical repair. EVAR was not an option due to a short aortic neck. The postoperative period was complicated by colon ischemia and aortic graft infection. At 3 years follow-up the patient was well and graft's function was unchanged.

CONCLUSION

This case is a reminder that renal graft protection must be accounted for when AAA rupture occurs in kidney transplant patients. We reviewed the literature to find previously reported cases and how they were managed.

Salvage of a Near-Total Penile Amputation following Urinary Fistulization and Carbapenemase-Producing Klebsiella pneumoniae Infection with a Composite ALT Flap and Vascularized Fascia Lata

Reconstruction of complex penile defects is always challenging, as some defects are not possible to reconstruct with skin or mucosa grafts, and even local flaps may be precluded in complex wounds. We present a case of a 63-year-old otherwise healthy man, who underwent transurethral resection of the prostate for benign prostatic hyperplasia. After the procedure, he developed panurethral necrosis with consequent stricture. Three urethroplasties for reconstruction of the bulbar and distal urethra using buccal mucosa grafts, a preputial flap, and penile skin were performed by urology team in different institutions, but serious urinary fistulization and carbapenemase-producing Klebsiella pneumoniae (KPC) infection translated in a chronic wound, urethra necrosis, and near-total penile amputation. A composite anterolateral thigh flap and vascularized fascia lata were used with success together with a perineal urethroplasty in different stages, improving the ischemic wound condition. The extended segment of fascia lata was used for Buck's fascia replacement and circumferential reinforcement to cover the erectile bodies of the penis. The postoperative period was uneventful and after 12 months, there were no signs of recurrence or wound dehiscence. He was able and easily adapted to void in a seated position through the perineal urethrostomy that was made. To the best of our knowledge, this procedure has not been reported previously as a salvage procedure in a fistulizated and KPC infected penis, but it may be considered to avoid penile amputation in chronic infected and intractable wounds.

Jejunojejunal Intussusception After Roux-en-Y Gastric Bypass and Abdominoplasty: A Rare Association or a Mere Coincidence?

Small bowel intussusception is a rare complication after Roux-en-Y gastric bypass, with few cases reported, and none in the immediate post-operative period of an abdominoplasty. We report the case of a 42-year-old woman, with an history of a laparoscopic Rouxen-Y gastric bypass, who developed small bowel occlusion secondary to a retrograde jejunojejunal intussusception in the second post-operative day of an abdominoplasty. This is the first report of a small bowel intussusception after Roux-en-Y gastric bypass in the post-operative period of an abdominoplasty. Doubts remain about the possible causal effect abdominoplasty might have in small bowel intussusception after Roux-en-Y gastric bypass.

Arterial percutaneous angioplasty in hemodialysis access: Endovascular treatment of hand ischemia

BACKGROUND

Hemodialysis access-induced distal ischemia consists of symptomatic extremity malperfusion after vascular access creation. It is usually caused by discordant vascular resistance, with arteriovenous shunting of a high blood volume from arterial into venous system and subsequent hand hypoperfusion. Less often, hemodialysis access-induced distal ischemia is caused by arterial stenosis. In these cases, access frequently has normal/low flow, radial pulse is usually absent and not recoverable with vascular access digital compression, diabetes is often present, and percutaneous transluminal angioplasty can be critical for access and limb salvage.

METHODS

Retrospective study conducted between June 2011 and February 2018 of patients with vascular access submitted to arterial percutaneous transluminal angioplasty for limb-threatening ischemia.

RESULTS

Twenty-nine patients were referred for arterial angiography after hemodialysis access-induced distal ischemia diagnosis and physical examination or ultrasound findings suggestive of arterial disease. In 11 patients, percutaneous transluminal angioplasty was not technically feasible. Among 18 treated patients, 83.3% had diabetes and 60% had skin ulcerations. Target arteries were radial (11), brachial (7), axillar (2), ulnar (2), and subclavian (1). Clinical success, defined as arteriovenous maintenance and wound healing/pain resolution, was observed in 12 patients (66.7%). Concomitant procedures included adjuvant banding (n = 2) and finger amputation (n = 1), and one reintervention was performed. No intra- or postoperative complications were reported.

CONCLUSION

Hemodialysis access-induced distal ischemia is a serious complication of hemodialysis vascular access, with multifactorial etiology. Correct and timely diagnosis is crucial for maintaining access and limb salvage. Percutaneous transluminal angioplasty is a minimally invasive procedure that may be effective and long-lasting in carefully selected patients with ischemic complaints.

Giant chondrosarcoma of the chest wall: a rare surgical challenge

The chest wall chondrosarcoma (CWC) is a rare slowly growing primary tumor of the chest wall with an incidence of <0.5 per million person-years. We present the case of a giant CWC that caused a mass effect on the mediastinum, heart, and lung. Large tumors with thoracic structures compression may be life threatening, and its resection and subsequent chest wall reconstruction represent a significant multidisciplinary surgical challenge. In this case, despite the large tumor dimensions, the preoperative planning—sparing key reconstructive options without compromising the tumor resection—allowed a complete en bloc tumor excision of a grade III chondrosarcoma with negative histologic margins. Successful reconstruction of the large full-thickness chest wall defect, with a latissimus dorsi muscle flap and methyl methacrylate incorporated into a polypropylene mesh in a sandwich fashion, was accomplished. Patient recovery was uneventful with good functional and aesthetic outcomes, and no evidence of recurrence at 1.5 years follow-up. This case report illustrates the main clinical, radiological, and histologic features of a CWC while discussing the surgical goals and highlighting the principles for chest wall reconstruction following extensive resection of a large and rare entity.

Fournier's gangrene: a review of reconstructive options

Introduction

Fournier’s gangrene is a rapidly progressive necrotizing fasciitis of the genital and perineal tissues with a high mortality rate. Early diagnosis and treatment with fluid resuscitation, surgical debridement and wide-spectrum antibiotics are essential in the management of Fournier’s gangrene. After primary treatment, reconstructive surgery is often necessary for coverage of soft-tissue defects. This review article aims to provide an overview of the main reconstructive procedures used in Fournier’s gangrene.

Material and methods

A literature search was performed on the subject of reconstructive surgery in Fournier’s gangrene.

Results

Techniques of reconstructive surgery for soft-tissue defects following Fournier’s gangrene include skin grafts, local advancement flaps, scrotal flaps, multiple fasciocutaneous and myocutaneous flaps, and testicular transposition. The surgical goal is to achieve the best functional and cosmetic result possible with minimal morbidity. Advantages and disadvantages of each technique and potential indications are discussed.

Conclusions

Characteristics of the defect, patient preference and surgeon experience should guide the choice of reconstructive procedure. Further comparative studies are needed to optimize results.

Impaired decision-making and time perception in individuals with stroke: Behavioral and neural correlates

Several studies have demonstrated that stroke subjects present impairment of functions related to decision-making and timing, involving the information processing in the neural circuits of the cerebellum in association with the prefrontal cortex. This review is aimed to identify the gaps, and demonstrate a better understanding of decision-making and timing functions in the patients with stroke. Electronic literature database was searched and the findings of relevant studies were used to explore the mechanisms of decision-making and timing in patients with stroke, as well as the circuit connections in timing mediated by prefrontal cortex and cerebellum. A literature review was conducted with 65 studies that synthesized findings on decision-making and time perception in individuals with stroke. Types of neurobiological modalities in this study included: Relationships among decision-making, time perception, related cognitive aspects (such as discrimination tasks, verbal estimation, bisection tasks, time production and motor reproduction), and motor control. We demonstrate that the timing processes are important for the performance in cognitive tasks and that the cerebellum and prefrontal cortex are involved in decision-making and time perception. In the context, the decision-making is impaired in stroke patients has a great impact on executive functions, and this seems to be important in determining neurobiological aspects relevant to the time interval interpretation.

Dupuytren's disease: where do we stand?

Dupuytren’s disease is a fibroproliferative disease that involves collagen deposition, leading to hand contractures that ultimately affect hand mobility and grip strength.

It is a benign disorder but can cause high morbidity by limiting daily activities.

Many factors have been proposed for its aetiology: namely genetics, smoking, alcohol intake and diabetes. However, there is still controversy as to the main aetiological cause of the disease.

Treatment is not yet uniform around the world and still varies with the surgeon’s experience and preference.

In this review, the authors review the pathogenesis and treatment options for Dupuytren’s disease in an attempt to summarize the current state of the art.

Cite this article: EFORT Open Rev 2019;4:63-69. DOI: 10.1302/2058-5241.4.180021.

Abstract P5-15-04: Oncotype DX cost effectivity to a Brazilian public hospital

Introduction: The Oncotype DX was associated to 14% of adjuvant chemotherapy administration to Hormonal Receptor positive (HR+) and HER2 negative, T1N0 or T2N0 breast cancer patients at Tailor X trial recently published (RS&gt;25)

Objective: To describe the adjuvant chemotherapy administration to a Brazilian public hospital for HR+ HER2 negative, T1N0 or T2N0 breast cancer patients. And the estimate the cost effectivity of Oncotype DX in our low income scenary.

Materials and Methods:This retrospective cross-sectional study was conducted at the Oncology Division of the Women's Hospital - CAISM of the State University of Campinas (UNICAMP), Brazil. All patient data were found from the hospital records from 2007 to 2009. It was included T1N0 and T2N0 HR+/HER2 negative breast cancer patients. Patients submitted to neoadjuvant treatment were excluded.

We calculate the final cost of different types of chemotherapy used and the potential impact to oncotype DX introduction in this scenary.

Results: It was found 109 patients records. 66% (72/109) had received adjuvant chemotherapy. 35% (38/109) had AC (X6), 29% (32/109) had CMF (X6) and 2% (2/109) had AC-T (X4). The total cost for chemotherapy scheme were; AC (X6) US$ 346,9; CMF (X6), US$300,6; ACT (X4), US$395,9. The total cost of chemotherapy was US$ 23.596,83 to 72 patients. If we consider 14% (15/109) of adjuvant chemotherapy associate to a Oncotype DX use (Tailor X RS&gt;25), It would reduce adjuvant chemotherapy administration to 15 patients. The chemotherapy cost would be US$ 4588,27. In our scenary, It could save US$ 19.008,56. Nevertheless, the Oncotype Dx cost to Brasil is US$ 3.200,00 for each test. To 109 patients the total cost would be (109 X US$ 3.200,00) US$ 348.800,00. Therefore, the total cost for Oncotype DX program plus adjuvant chemotherapy for our patients would be US$ 348.800,00 + US$ 4.588,27= US$ 353.388,27. While in the real situation we had spent US$ 23.596,83. The total estimate cost would be 15 times more.

Conclusion: At the moment, because of the assay high cost and the low cost of the adjuvant chemotherapy to HR+, HER2 negative T1N0 and T2N0, It would be difficult to consider Oncotype DX cost-effective to Brazilian public heath system. Even considering many advantages to spare chemotherapy to this population.

Citation Format: Cabello C, de Andrade RN, Cabello TF, Teixeira S, da Costa LS, Ramalho S. Oncotype DX cost effectivity to a Brazilian public hospital [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-15-04.

Application of experimental design methodology to optimize antibiotics removal by walnut shell based activated carbon

Three-level Box-Behnken experimental design with three factors (pH, temperature and antibiotic initial concentration) combined with response surface methodology (RSM) was applied to study the removal of Metronidazole and Sulfamethoxazole by walnut shell based activated carbon. This methodology enabled to identify the effects of the different factors studied and their interactions in the response of each antibiotic. The relationship between the independent variable (sorption capacity) and the dependent variables (pH, temperature and antibiotic concentration) was adequately modelled by second-order polynomial equation. The pH factor exerted a significant but distinct influence on the removal efficiency of both antibiotics. The removal of Metronidazole is favoured by increasing pH values, with the maximum value obtained for pH 8 - upper limit of the study domain; while Sulfamethoxazole displays a maximum value around 5.5, with a decrease in the extent of adsorption as the pH increases. The best conditions, predicted by the model, for the removal of the antibiotic Sulfamethoxazole (106.9 mg/g) are obtained at a temperature of 30 °C, initial concentration of 40 mg/L and a pH value of 5.5. For the antibiotic Metronidazole, the highest removal value (127 mg/g) is expected to occur at the maximum levels attributed to each of the factors (pH = 8, C_in = 40 mg/L, T = 30 °C). The results of isotherm experiments (at 20 °C and pH 6) displayed a good agreement with the models predictions. The maximum sorption capacity, estimated by the Langmuir model, was 107.4 mg/g for Metronidazole and 93.5 mg/g for Sulfamethoxazole.

Radiocephalic Fistula Recovery Using the Brachial Vein and Forearm Basilic Vein: A Case Series and Literature Review

Vascular access dysfunction is a serious problem in dialysis units. Some patients have complex dysfunctions that are difficult to resolve. In this article, we report the case a of two patients with radiocephalic arteriovenous fistulae (RC-AVF) who had stenosis/occlusion of the forearm median vein and where we used the basilic vein of the forearm as a solution. We reviewed the use of this surgical solution in RC-AVF. Two male patients on hemodialysis exhibited stenosis/occlusion of the forearm median vein. The forearm basilic vein was isolated and rotated toward the forearm median vein in order to solve RC-AVF problems. One patient had fistula thrombosis 5 months after the procedure, while for the other patient, the fistula continues to work without problems. Literature describes only a few cases using the forearm basilic vein or the brachial vein for fistula recovery. This procedure increased the patency of fistulas. This approach has been proven to be a good solution for solving outflow problems using the superficial or deep veins, increasing fistula patency and avoiding the need to place a central venous catheter and all the related complications.

The Role of Doppler Ultrassonography in Significant and Borderline Stenosis Definition

Background: The definition of significant stenosis (SS) remains controversial. Methods: We retrospectively reviewed 1,040 consultations. SS was defined in the presence of clinical and echo-Doppler (DDU) criteria: Qa <500 mL/min or Qa decrease >25%; RI >0.7 in the feeding artery or absolute minimal luminal stenosis diameter <2.0 mm. Stenosis without any additional criteria were considered borderline stenosis (BS). Results: Two hundred twenty-one arteriovenous fistulas (AVFs) were included: 58.8% had SS, 18.6% had BS, and 22.6% had no dysfunctional access (ND). SS had a significantly higher thrombotic events than BS and ND (13.1 vs. 4.4%, p = 0.018). The annual thrombosis rate was 0.007, 0.037, and 0.004 in the ND, SS, and BS, respectively. AVF cumulative survival at 5 years was significantly lower in SS (89.5%) compared to BS (100%) and ND (97.4%; p = 0.03). BS had an HR for AVF failure of 1.1, p = 0.955, while the SS presented an HR of 5.9, p = 0.09. Conclusion: AVF clinical monitoring with additional DDU criteria appear to be appropriate for therapeutic referral.

Radio-cephalic arteriovenous fistula recovered with drainage through the brachial vein

Dysfunction of arteriovenous access for hemodialysis is a challenge for the vascular surgeon. Some patients have complex vascular access with problems that are difficult to solve. Careful analysis of the vascular network with ultrasound and dissection of the veins during surgery can help to identify the best option for each access. We introduce and discuss the case of creation of a radio-cephalic fistula with outflow into the brachial vein in 64-year-old hemodialysis male patient. This technique enables extending fistula patency, arterializing the brachial vein, and improves cost efficiency.

Congenital Ocular Motor Apraxia

Purpose

Congenital ocular motor apraxia is a rare disease characterized by defective or absent voluntary and optically induced horizontal saccadic movements. Jerky head movements or thrusts on attempted lateral gaze are a compensatory sign. Most affected children have delayed motor and speech development. Cases associated with systemic diseases, neurologic maldevelopment, metabolic deficits, and chromosomal abnormalities have been described.

Methods

Case report and review of the scientific literature.

Results

The authors describe the ophthalmologic, pediatric, and neurologic evaluations and follow-up of a child with impaired horizontal saccades, jerky head movements, and delayed motor and speech development.

Conclusions

Congenital ocular motor apraxia is an uncommon disorder of ocular motility. Even so, ophthalmologists should be aware of the developmental delay and the other associated conditions, in order to grant the patients the multidisciplinary assistance they often require.

Giant Ruptured Common Iliac Artery Infected Aneurysm

INTRODUCTION

Saccular mycotic aorto-iliac aneurysms are extremely rare and when presented with ruptured, they are an important life- threatening condition.

METHODS

We present a 52 years old male transferred from another Hospital and admitted to the emergency room with a ruptured iliac artery aneurysm.

RESULTS

He complained of persistent fever and abdominal discomfort that swiftly established as hemorrhagic shock. Imagiological study with angioCT revealed a ruptured left common iliac artery saccular aneurysm with 90mm. The patient was instantaneously and successfully submitted to endoaneurismorraphy, common and external iliac artery ligation and construction of an extra anatomic bypass, right to left femoro-femoral bypass. Blood culture revealed a Streptococcus anginosus and the patient received appropriate targeted antibiotics. Post-operative period was uneventful and the patient discharged ten days after admission. He has now eleven months of follow up with no intercurrences.

CONCLUSION

Long term antibiotics along with aggressive surgical debridement of the infected tissue and vascular revascularization with an extra anatomic bypass remain the most definitive solution while endovascular aneurysm repair may generally constitute a bridge life-saving procedure in mycotic infected aneurysms. Even though surgical approach carries a relative risk of perioperative morbidity it is a feasible and durable solution for extreme situations like the one here described.

Aneurysmal Degeneration of the Brachial Artery after Vascular Access Creation: Surgical Treatment Results

True peripheral artery aneurysms proximal to a longstanding arteriovenous fistula is a well-recognized complication. Late aneurysmal degeneration is rare. This study analyzed the characteristics, therapeutic options, and outcomes of true donor brachial artery aneurysms (DBAA) after arteriovenous fistula (AVF) for hemodialysis. We retrospectively collected the data of patients with DBAA after AVF creation, surgically repaired between January 2001 and September 2015. We excluded patients with pseudoaneurysms, anastomotic aneurysms, and infected aneurysms. We recorded patient's demographics, type of access, aneurysm characteristics, symptoms, treatment, and follow-up. Ten patients were treated for aneurysmal degeneration of the brachial artery. Average aneurysm diameter was 37.5 mm. All cases had, at least, one previous distal AVF, ligated or thrombosed, at the time of diagnosis. The first access was created in mean 137 months before the diagnosis of DBAA. Nine patients had previous medical history of renal transplant and were under immunosuppressive therapy. All patients were symptomatic at the time of diagnosis. In all cases, the treatment was aneurysmectomy followed by interposition bypass. One patient developed a postoperative hematoma with the need of surgical drainage. At 50 months of follow-up, one patient was submitted to percutaneous angioplasty due to an anastomotic stenosis. No other complications occurred during the entire follow-up period (mean: 69 months). The pathogenesis underlying DBAA remains unclear. Increased blood flow after AVF creation, immunosuppressive therapy, and ligation/thrombosis of the AVF may contribute to aneurysm formation. Surgical treatment by aneurysmectomy and bypass, with autogenous conducts, is a safe and effective option.

Radio-cephalic fistula recovered with drainage to forearm basilic vein

Dysfunction problems with vascular access are a concern to patients and dialysis units. The vascular surgeon should analyse such dysfunction and perform a careful assessment of the vascular network in order to find new fistula layouts. We introduce and discuss the case of creation of a radio-cephalic fistula with outflow into the forearm basilic vein through rotation of the forearm basilic vein toward the cephalic vein in the forearm of an 88-year-old hemodialysis male patient. This technique enables extending fistula patency and improves cost efficiency.

The Keystone Perforator Island Flap and its Use in Complex Defects of the Trunk: a Case Report

Complex defects of the trunk present a reconstructive challenge and conservative treatment is frequently unsuccessful. Perforator flaps have become a common option for this problem. The keystone perforator island flap (KPIF) is a fasciocutaneous advancement flap, based on randomly located perforators vessels, whose dissection and exposure is not required. Designed in a curvilinear trapezoidal shape, it allows primary closure of large defects, while avoiding secondary defects and minimizing the need for more complex pedicled flaps or microsurgical reconstructive techniques. The clinical case of a 52-year-old male with stable coronary artery disease and severe aortic stenosis, with severe left ventricular dysfunction, who underwent coronary artery bypass graft surgery and aortic valve replacement is presented. During the post-operative period, he developed anterior mediastinitis and presented a large median sternotomy wound dehiscence, refractory to medical treatment and surgical debridement. The patient underwent reconstruction of the defect with a bilateral KPIF and application of VAC therapy, with favorable outcome. The KPIF is an useful and reliable reconstruction technique for complex defects, that has shown shorter operative times, lower risk of total flap necrosis, reduced donor-site morbidity and favorable aesthetic results, making it a good option in patients with multiple comorbidities.

Food and pathogen adaptations in the Angolan Namib desert: Tracing the spread of lactase persistence and human African trypanosomiasis resistance into southwestern Africa

OBJECTIVES

We investigated the frequency distribution and haplotype diversity of human African trypanosomiasis (HAT) resistance and lactase persistence (LP) variants in populations from the Angolan Namib to trace the spread of these genetic adaptations into southwestern Africa.

MATERIALS AND METHODS

We resequenced two fragments of the LCT enhancer and the APOL1 gene and genotyped flanking short tandem repeat loci in six groups with different subsistence traditions living in the Angolan Namib, and in a comparative dataset including other populations from Africa and Europe. LP in the Angolan Namib is represented by the -14010*C allele, which is associated with a predominant haplotype that is shared with other southern and eastern African populations. While LP was found to be more frequent in foragers than in pastoralists, the frequencies of the two APOL1 variants associated with HAT-resistance (G1 and G2) did not differ between the two groups. The G1 allele is mostly associated with a single widespread haplotype. The G2 allele is linked to several haplotypes that are molecularly related to haplotypes found in other African Bantu-speaking populations. The putatively archaic G3 variant displayed more intra-allelic diversity in Africa than in Europe.

DISCUSSION

The LP adaptation was carried to southern Africa by non-Bantu speaking pastoralists from eastern Africa, but an obvious link between its presence in southern Angola and groups speaking languages of the Khoe-Kwadi family, as previously found in other areas, could not be confirmed. The presence of APOL1 variants G1 and G2 is linked to the Bantu expansions. Our results suggest that the G3 variant was retained in modern humans by incomplete lineage sorting.

Abstract P4-01-04: Immunohistochemical and histological features of mammographic dense and non-dense tissue in breast cancer patients

Objective: We investigated immunohistochemical and histological composition of dense and non-dense breast tissue in 18 women undergoing mastectomy as the initial treatment for breast cancer. Materials and Methods: In each mammogram, we localized the dense and the non-dense areas. We used a localization technique based on a linear approximation method with interpolation of mammogram images and breast pictures. The selected areas were retrieved during mastectomy and analyzed. Results: Estrogen and progesterone receptors, Ki-67 and CD-34, were equally expressed in both tissues, as well as the percentage composition of fat. The percentage compositions of brownish spots among dense and non-dense tissues were significantly different (p = 0.0226). The number of terminal ductal lobular units was higher for dense than for non-dense breast tissues (p = 0.0019). In the non-dense breast tissue, there were no proliferative lesions with atypia, while we found flat epithelial atypia in 3 of the dense areas evaluated. Proliferative lesions without atypia and non-proliferative lesions were found in both tissues, but they were more frequent in dense than in non-dense breast tissues (23.5% vs 11.8%, p = 0.0455, and 17.6% vs 2.9%, p = 0.0253, respectively). Fibrosis was more frequently extensive or moderate in dense tissue, while it was predominantly mild in non-dense tissue (p = 0.03). Conclusion: There was no difference in the expression of the estrogen and progesterone receptors, Ki-67 and CD-34, in the dense and non-dense tissue areas in breast-cancer women. In addition, both stroma fibrosis and epithelial proliferation were responsible for higher mammographic density.

Citation Format: dos Santos CC, Marshall P, Torresan R, Tinóis E, Duarte G, Teixeira S. Immunohistochemical and histological features of mammographic dense and non-dense tissue in breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-01-04.

[Acute mesenteric ischemia: the importance of early diagnosis and aggressive revascularization]

AIM

Despite the advances in diagnostic and therapeutic approaches, acute mesenteric ischemia (AMI) remains associated with a dismal prognosis. The goal of this study was to review and report our department's experience in the surgical treatment of AMI and to identify predictive factors of postoperative morbidity and mortality.

MATERIALS AND METHODS

We performed a retrospective analysis of the patients that underwent surgical revascularization after embolic or thrombotic AMI, between January 2008 and December 2015. Patient's comorbidities/cardiovascular risk factors, chosen diagnostic and therapeutic strategies, and postoperative complications were studied.

RESULTS

Fifteen patients (66.7% female) were treated, with a mean age of 68.6±16.3 years (41-88). The most common cause of AMI was embolism (n=9; 60%). The most prevalent cardiovascular risk factor was hypertension (86.7%). All patients complained of abdominal pain, and in 66.7% of cases leukocytosis and elevated lactate dehydrogenase levels were observed. All patients were studied with abdomino-pelvic CT angiography. The mean ischemic time was 27.9±29.5 hours (3-96 hours). Midline laparotomy was performed in 14 patients [thromboendarterectomy of the superior mesenteric artery (SMA) (n=1; 6.7%); embolectomy of the SMA (n=8; 53.3%); mesenteric bypass (n=3; 20%); retrograde PTA and stenting of the SMA (n=2; 13.3%)]. One patient (6.7%) underwent thromboaspiration and catheter fibrinolysis. Four patients required enterectomy (26.7%). Second-look surgery was performed in 9 patients (60%). The 30-day mortality rate was 33%.

CONCLUSIONS

A serum lactate level above 2 mmol/L on admission may be associated with an unfavorable prognosis. Early diagnosis, referral, and rapid revascularization are critical for therapeutic success in AMI.

Dynamic footprint of sequestration in the molecular fluctuations of osteopontin

The sequestration of calcium phosphate by unfolded proteins is fundamental to the stabilization of biofluids supersaturated with respect to hydroxyapatite, such as milk, blood or urine. The unfolded state of osteopontin (OPN) is thought to be a prerequisite for this activity, which leads to the formation of core-shell calcium phosphate nanoclusters. We report on the structures and dynamics of a native OPN peptide from bovine milk, studied by neutron spectroscopy and small-angle X-ray and neutron scattering. The effects of sequestration are quantified on the nanosecond- ångström resolution by elastic incoherent neutron scattering. The molecular fluctuations of the free phosphopeptide are in agreement with a highly flexible protein. An increased resilience to diffusive motions of OPN is corroborated by molecular fluctuations similar to those observed for globular proteins, yet retaining conformational flexibilities. The results bring insight into the modulation of the activity of OPN and phosphopeptides with a role in the control of biomineralization. The quantification of such effects provides an important handle for the future design of new peptides based on the dynamics-activity relationship.

[Renal artery embolism: thromboaspiration and catheter directed thrombolysis - A successful case]

Renal artery embolism is a rare event and is associated with high risk of hypertension and functional renal loss. We report the clinical case of a renal artery embolism, which was treated using a combination of thromboaspiration and catheter directed thrombolysis, as well a short literature review on this subject. A 60-year-old male with previous medical history of atrial septal defect surgical repair and cardiac pacemaker was presented in the Emergency Department with complains of abdominal pain and vomiting. Patient had suspended oral anticoagulation to undergo a dental surgical procedure. The Angio-CT scan revealed a left renal artery occlusion, suggestive of embolism, with infarction of the ipsilateral kidney. We underwent, 36 hours after the beginning of complains, a left renal artery recanalization with recovery of renal perfusion, using percutaneous thromboaspiration and catheter directed thrombolysis. Renal scintigraphy, at the end of first month, showed left kidney differential function of 38.9%. In the follow-up period (32 months), serum creatinine levels stabilized at 1 mg/dL (1.59 at the admission). Percutaneous interventions, including thromboaspiration and catheter directed thrombolysis, can be used effectively to treat renal artery embolism. Clinical suspicion, lenght of evolution and previous development of a collateral circulation network are key factors to achieve a therapeutic success.

[Subclavian Steal Syndrome and Cerebral Hypoperfusion during Hemodialysis: A case report]

Subclavian steal syndrome is caused by retrograde vertebral artery flow "stealing" vertebrobasilar perfusion. We report the clinical case of a 53 year-old dialysis dependent woman with several cardiovascular risk factors, who had episodes of vertebrobasilar insufficiency and resting pain of the left upper extremity, during hemodialysis sessions, through a left arm brachiobasilic arteriovenous fistula. Noninvasive studies demonstrated a preoclusive stenosis at the origin of left subclavian artery, together with a stenosis on the left internal carotid artery superior to 70% and reversion of flow in the left vertebral artery. The patient underwent endarterectomy and Dacron patch angioplasty of the left internal carotid artery and carotid-subclavian ePTFE bypass, with total resolution of the previously described clinical presentation.