Clinical Outcomes of Arteriovenous Graft in End-Stage Renal Disease Patients with an Unsuitable Cephalic Vein for Hemodialysis Access

Background@#As the population of patients with end-stage renal disease has grown older, the proportion of patients with poorly preserved vasculature has concomitantly increased. Thus, arteriovenous grafts (AVG) have been used more frequently to access blood vessels for hemodialysis. Despite this increasing demand, studies of AVG are limited. In this study, we examined the surgical outcomes of upper-limb AVG creation. @*Methods@#Among the arteriovenous fistula formation procedures performed between January 2014 and March 2019 at Dankook University Hospital, 42 cases involved AVG creation. We compared patients in whom the axillary vein was used (group A; brachioaxillary AVG [B-Ax AVG]; n=20) with those in whom upper limb veins were used (group B; brachiobasilic AVG or brachioantecubital AVG; n=22). @*Results@#The 1-year primary patency rate was higher in group A than in group B (57.9% vs. 41.7%; p=0.262). The incidence of postoperative complications was not significantly different between groups. @*Conclusion@#AVG using the axillary vein showed no major differences in safety or functionality compared to AVG using other veins. Therefore, accounting for age, underlying disease, and expected patient lifespan, B-Ax AVG can be considered an acceptable surgical method.

Localized Pretibial Varicose Vein Caused by an Intraosseous Venous Anomaly

A 36-year-old man presented to the hospital with protruding blood vessels in his left lower leg accompanied by cramping. An ultrasonographic examination of the leg revealed focal reflux without truncal vein reflux. During phlebectomy, the varix was found to be connected to the intraosseous vein through a tibial opening. Postoperative computed tomography and magnetic resonance imaging showed an osteolytic lesion in the tibial shaft and an intraosseous vascular anomaly. The patient was discharged without complications and scheduled for periodic follow-ups. This young man’s varicose vein seemed to be from a tibial intraosseous vascular anomaly, which is extremely rare.

Delayed massive hemothorax requiring surgery after blunt thoracic trauma over a 5-year period: complicating rib fracture with sharp edge associated with diaphragm injury

Delayed massive hemothorax requiring surgery is relatively uncommon and can potentially be life-threatening. Here, we aimed to describe the nature and cause of delayed massive hemothorax requiring immediate surgery. Over 5 years, 1,278 consecutive patients were admitted after blunt trauma. Delayed hemothorax is defined as presenting with a follow-up chest radiograph and computed tomography showing blunting or effusion. A massive hemothorax is defined as blood drainage >1,500 mL after closed thoracostomy and continuous bleeding at 200 mL/hr for at least four hours. Five patients were identified all requiring emergency surgery. Delayed massive hemothorax presented 63.6±21.3 hours after blunt chest trauma. All patients had superficial diaphragmatic lacerations caused by the sharp edge of a broken rib. The mean preoperative chest tube drainage was 3,126±463 mL. We emphasize the high-risk of massive hemothorax in patients who have a broken rib with sharp edges.

Clinical Results of Arteriovenous Fistulas Constructed Using Autologous Vessels in End-Stage Renal Disease Patients on Hemodialysis

BACKGROUND: For hemodialysis patients with end-stage renal disease (ESRD), it is important to construct an efficient vascular access with a superior patency rate. This study investigated the factors influencing the efficiency of arteriovenous fistulas (AVFs) constructed using an autologous vessel and evaluated the necessity of ultrasonography as a preoperative tool for AVF construction. METHODS: A retrospective analysis was performed of 250 patients in whom an AVF was constructed using an autologous vessel due to ESRD at our institution from January 2009 to April 2016. RESULTS: The 1-, 3-, and 5-year patency rates for all subjects were 87.6%, 85.6%, and 84.4%, respectively. The patients who underwent a preoperative evaluation of their vessels via ultrasonography had better patency rates than those who did not. Superior patency rates were found in patients under 65 years of age or with an anastomotic vein diameter of 3 mm or more. The 1-year patency rate and the diameter of the anastomotic vein showed a positive relationship. CONCLUSION: Ultrasonography is strongly recommended for AVF construction, and efforts should be made to increase the patency rate in patients over 65. Superior clinical results can be expected when an AVF is made using an autologous vessel with an anastomotic vein diameter of at least 3 mm.

Surgical Outcomes of Forearm Loop Arteriovenous Fistula Formation Using Tapered versus Non-Tapered Polytetrafluoroethylene Grafts

BACKGROUND: Tapered grafts, which have a smaller diameter on the arterial side, have been increasingly used for arteriovenous fistula (AVF) formation. We compared the outcomes of 4–6-mm tapered and 6-mm straight forearm loop arteriovenous grafts. METHODS: A total of 103 patients receiving forearm loop arteriovenous grafts between March 2005 and March 2015 were retrospectively analyzed and separated into 2 groups (group A, 4- to 6-mm tapered grafts, n=78; group B, 6-mm straight grafts, n=25). In each group, complications and patency rates after surgery were assessed. RESULTS: Clinical characteristics and laboratory results, except for cerebrovascular disease history (group A, 7.7%; group B, 28.0%; p=0.014), were similar between the groups. No significant differences were found for individual complications. Kaplan-Meier survival analysis revealed no significant differences in 1-year, 3-year, and 5-year patency rates between groups (61.8%, 44.9%, and 38.5% vs. 62.7%, 41.1%, and 35.3%, respectively). CONCLUSION: We found no significant differences in complication and patency rates between the tapered and straight graft groups. If there are no differences in complication and patency between the two graft types, tapered grafts may be a valuable option for AVF formation in light of their other advantages.

A Case of Recurrent Aortic Rupture Associated with Klebsiella pneumoniae Pericarditis Treated by Two Separate Aortic Operations

A 49-year-old female presented with severe dyspnea. She was diagnosed with cardiac tamponade combined with ascending aortic pseudoaneurysm and rupture, which was caused by Klebsiella pneumoniae infection. This extremely rare condition was managed by an emergency pericardiostomy and two separate aortic operations. Antibiotics active for the K. pneumoniae isolate were used throughout. The patient was well for nine months after discharge and continues to be followed up for signs of possible reinfection.

Tangential Resection of a Popliteal Vein Aneurysm in a Patient Complaining of Localized Popliteal Pain

A 48-year old man presented with left popliteal pain. A 2.2×1.6 cm sized saccular aneurysm at the level of the left popliteal fossa was diagnosed by ultrasonography. Tangential aneurysmectomy and popliteal vein repair was performed uneventfully. The patient fared well for a year without symptoms. Popliteal vein aneurysms are rare and typically found in patients with fatal thromboembolic features without warning symptoms. Fortunately, our patient had localized pain which was helpful in its early diagnosis and treatment.

Extracorporeal Membrane Oxygenation for the Support of a Potential Organ Donor with a Fatal Brain Injury before Brain Death Determination / 대한구급학회지

The shortage of available organ donors is a significant problem and various efforts have been made to avoid the loss of organ donors. Among these, extracorporeal membrane oxygenation (ECMO) has been introduced to help support and manage potential donors. Many traumatic brain injury patients have healthy organs that might be eligible for donation for transplantation. However, the condition of a donor with a fatal brain injury may rapidly deteriorate prior to brain death determination; this frequently results in the loss of eligible donors. Here, we report the use of venoarterial ECMO to support a potential donor with a fatal brain injury before brain death determination, and thereby preserve donor organs. The patient successfully donated his liver and kidneys after brain death determination.

Extracorporeal Membrane Oxygenation for the Support of a Potential Organ Donor with a Fatal Brain Injury before Brain Death Determination / 대한중환자의학회지

The shortage of available organ donors is a significant problem and various efforts have been made to avoid the loss of organ donors. Among these, extracorporeal membrane oxygenation (ECMO) has been introduced to help support and manage potential donors. Many traumatic brain injury patients have healthy organs that might be eligible for donation for transplantation. However, the condition of a donor with a fatal brain injury may rapidly deteriorate prior to brain death determination; this frequently results in the loss of eligible donors. Here, we report the use of venoarterial ECMO to support a potential donor with a fatal brain injury before brain death determination, and thereby preserve donor organs. The patient successfully donated his liver and kidneys after brain death determination.

Iatrogenic Bronchial Injury: A Rare Complication of Tube Thoracostomy with a Small Bore Catheter

A 69-year-old male was admitted for dyspnea and chest pain. The patient had undergone coronary artery bypass graft surgery and tube thoracostomy three years ago. The chest radiograph showed pleural effusion, which was drained using a percutaneous catheter with CT guidance. However, residual pneumothorax was observed four days later. Despite insertion of the 12 Fr trocar-type tube, pneumothorax did not improve and air leaks were observed. Chest CT showed that the tube was placed in the left main bronchus. After removal of the tube, the patient recovered uneventfully from pulmonary hemorrhage and bronchial perforation without complications.

Delayed Diagnosis of Pulmonary Artery Injury, Due to Blunt Trauma, which Mimicked Traumatic Lung Pseudocyst

A 67-year-old female presented to the emergency department with complaints of dyspnea and chest wall pain after a fall from a cultivator. Initial chest CT showed multiple left rib fractures, a loculated hematoma without active bleeding, and hemothorax. On the third day of admission, the chest X-ray showed an abrupt aggravation of haziness and the chest CT showed that the size of the hematoma had increased with active bleeding from the pulmonary artery. In cases of loculated hematomas adjacent to the hilum on CT scan, the diagnosis of pulmonary artery injury should be considered.

Surgical Treatment for Occlusion of Graft Arteriovenous Fistula in Patients Undergoing Hemodialysis

BACKGROUND: Maintenance of adequate vascular access for hemodialysis is important in patients with end-stage renal disease. Once arteriovenous fistula (AVF) occlusion occurs, the patient should be treated with rescue therapy. This study was performed to evaluate the results of a rescue therapy for AVF occlusion. METHODS: From January 2008 to December 2012, 47 patients who underwent surgical rescue therapy for AVF occlusion after graft AVF formation, were enrolled in this study. The patients were divided into two groups, namely the graft repair group (group A, n=19) and the thrombectomy group (group B, n=28). Postoperative results of both groups were analyzed retrospectively. RESULTS: There were no statistically significant differences in the clinical characteristics between the two groups. In terms of the duration of AVF patency after the first rescue therapy, group A showed a longer AVF patency duration than group B (24.5+/-21.9 months versus 17.7+/-13.6 months), but there was no statistically significant difference (p=0.310). In terms of the annual frequency of AVF occlusion after the rescue therapy of group A was lower than that of group B (0.59 versus 0.71), but there was no statistically significant difference (p=0.540). The AVF patency rates at 1, 2, 3, and 5 years after the first rescue therapy in group A were 52.6%, 31.5%, 21.0%, and 15.7%, respectively, and those in group B, they were 32.1%, 25.0%, 17.8%, and 7.14%, respectively. There was no statistically significant difference (p=0.402). CONCLUSION: Graft repair revealed comparable results. Although there was no statistically significant difference, the patent duration and annual frequency of AVF occlusion of group A were better than those of group B. Therefore, graft repair is considered as a safe and useful procedure for maintaining graft AVF.

A Case of Advanced Malignant Pleural Mesothelioma Treatment with Chemotherapy and Photodynamic Therapy / 결핵및호흡기질환

Malignant pleural mesothelioma (MPM) is an aggressive, treatment-resistant, and generally fatal disease. A 68-year-old male who was diagnosed with MPM at another hospital came to our hospital with dyspnea. We advised him to take combination chemotherapy but he refused to take the treatment. That was because he had already received chemotherapy with supportive care at another hospital but his condition worsened. Thus, we recommended photodynamic therapy (PDT) to deal with the dyspnea and MPM. After PDT, the dyspnea improved and the patient then decided to take the combination chemotherapy. Our patient received chemotherapy using pemetrexed/cisplatin. Afterwards, he received a single PDT treatment and then later took chemotherapy using gemcitabine/cisplatin. The patient showed a survival time of 27 months, which is longer than median survival time in advanced MPM patients. Further research and clinical trials are needed to demonstrate any synergistic effect between the combination chemotherapy and PDT.

Whole Spontaneous Spinal Epidural Hematoma

A 26-year-old male who had no underlying disease, including coagulopathy, underwent thoracotomy and bleeding control due to hemothorax. On the fifth postoperative day, paralysis of both lower limbs occurred. Urgent spine magnetic resonance imaging showed a massive anterior spinal epidural hematoma from C2 to L1 level with different signal intensities, which was suspected to be staged hemorrhage. Hematoma evacuation with decompressive laminectomy was performed. The patient's neurologic deterioration was recovered immediately, and he was discharged without neurological deficits. A drug history of naftazone, which could induce a drug-induced platelet dysfunction, was revealed retrospectively. To our knowledge, this is the first report of whole spontaneous spinal epidural hematoma in a young patient, with a history of hemorrhoid medication.

Complete Vascular Ring Caused by Kommerell's Diverticulum and Right Aortic Arch with Mirror Image Branching

Vascular ring, caused by Kommerell's diverticulum and ligamentum arteriosum, in a patient with right aortic arch and mirror image branching is extremely rare. A 10-month-old boy with coughing and stridor was diagnosed as having tracheo-esophageal stenosis, which is caused by a vascular ring with Kommerell's diverticulum, ligamentum arteriosum, right aortic arch, and mirror image branching. Kommerell's diverticulum was successfully resected via a left thoracotomy. The patient has been free from tracheo-esophageal stenosis for a year after the surgery.

Surgical Treatment of Native Valve Aspergillus Endocarditis and Fungemic Vascular Complications

Systemic infection with Aspergillus is an opportunistic disease that affects mainly immunocompromised hosts, and is associated with a high mortality rate. It typically occurs in patients with several predisposing factors, but Aspergillus endocarditis of native valves is rare and experience in diagnosis and treatment is limited. We report a case of native valve endocarditis caused by Aspergillus. A 35-yr-old male patient who underwent pericardiocentesis four months previously for pericardial effusion of unknown etiology presented with right leg pain and absence of the right femoral artery pulse. Cardiac echocardiography revealed severe mitral insufficiency with large mobile vegetations, and computed tomographic angiography showed embolic occlusion of both common iliac arteries. We performed mitral valve replacement and thromoembolectomy, and Aspergillus was identified as the vegetation. We started intravenous amphotericin B and oral itraconazole, but systemic complications developed including superior mesenteric artery aneurysm and gastrointestinal bleeding. After aggressive management, the patient was discharged 78 days post surgery on oral itraconazole. He was well at 12 months post discharge but died in a traffic accident 13 months after discharge.

Surgical Treatment of Patients with Abdominal Aortic Aneurysm / 대한흉부외과학회지

BACKGROUND: Open surgical repair of abdominal aortic aneurysms was initiated by Dubost in 1952. Despite the rapid expansion of percutaneous endovascular repair, open surgical repair is still recognized for curative intent. We retrospectively analyzed surgical outcome, complications, and mortality-related factors for patients with abdominal aortic aneurysms over a 6 year period. MATERIAL AND METHOD: We analyzed 18 patients who underwent surgery for abdominal aortic aneurysms between March 2002 and March 2008. The indications for surgery were rupture, a maximal aortic diameter >60 mm, medically intractable hypertension, or pain. RESULT: The mean age was 66.6+/-9.3 years (range, 49~81 years). Twelve patients (66.7%) were males and 6 patients were females. Extension of the aneurysm superior to the renal artery existed in 6 patients (33.3%), and extension to the iliac artery existed in 13 patients (72.2%). Five patients (27.8%) had ruptured aortic aneurysms. The mean maximal diameter of the aorta was 72.2+/-12.9 mm (range, 58~109 mm). Surgery was performed by a midline laparotomy, and 6 patients underwent emergency surgery. The mean total ischemic time from aorta clamping to revascularization was 82+/-42 minutes (range, 35~180 minutes). The mortality rate was 16.7%; the mortality rate for patients with ruptured aneurysms was 60%, and the mortality rate for patients with unruptured aneurysms was 0%. The postoperative complications included one each of renal failure, femoral artery and vein occlusion, and wound infection. The patients who were discharged had a long-term survival of 34+/-26 months (range, 4~90 months). Rupture and emergency surgery had a statistically significant mortality-related factor (p<0.05). CONCLUSION: Emergency surgery for ruptured aortic aneurysms continues to have a high mortality, but unruptured cases are repaired with relative safety. Successfully operated patients had long-term survival. Even though endovascular aortic repair is the trend for abdominal aortic aneurysms, aggressive application should be determined with care. Experience and systemic support of each center is important in the treatment plan

Percutaneous Cardiopulmonary Support (PCPS) for Patients with Cardiopulmonary Bypass Weaning Failure during Open Heart Surgery / 대한흉부외과학회지

BACKGROUND: Recently, percutaneous cardiopulmonary support (PCPS) has been widely used to rescue patients in cardiogenic shock or cardiac arrest. However, patients with cardiopulmonary bypass (CPB) weaning failure during open heart surgery still have very poor outcomes after PCPS. We investigated clinical results and prognostic factors for patients who underwent PCPS during open heart surgery. MATERIAL AND METHOD: From January 2005 to December 2008, 10 patients with CPB weaning failure during open heart surgery underwent PCPS using the CAPIOX emergency bypass system (EBS(R), Terumo Inc, Tokyo, Japan). We retrospectively reviewed the medical records of those 10 patients. RESULT: The average age of the patients was 60.2+/-16.5 years (range, 19~77 years). The mean supporting time was 48.7+/-64.7 hours (range, 4~210 hours). Of the 10 patients, 6 (60%) were successfully weaned from the PCPS While 5 (50%) were able to be discharged from the hospital. Complications were noted in 5 patients (50%). In univariate analysis, long aortic cross clamp time during surgery, mediastinal bleeding during PCPS and high level of Troponin-I before PCPS were significant risk factors. All of the discharged patients are still surviving 34+/-8.6 months (range, 23~48 months) post-operatively. CONCLUSION: The use of PCPS for CPB weaning failure during open heart surgery can improve the prognosis. More experience and additional clinical studies are necessary to improve survival and decrease complications.

Treatment of Malperfusion Caused by Acute Aortic Dissection / 대한흉부외과학회지

Malperfusion of a major organ with aortic dissection has various clinical features according to the involved aortic branch. The morbidity and mortality rate can increase without suspicion especially during the intraoperative and postoperative period. Surgical outcomes and prognosis are influenced by early detection and active treatment, and expeditious diagnostic and therapeutic measures are mandatory for successful treatment. The authors report four successful cases of acute aortic dissection with malperfusion of various organs, such as the brain, kidney, and the lower extremities.

Initial Experience of the Emergency Bypass System (EBS(R)) for the Patients with Cardiogenic Shock due to an Acute Myocardial Infarction / 대한흉부외과학회지

BACKGROUND: Percutaneous cardiopulmonary support (PCPS) has the potential to rescue patients in cardiogenic shock who might otherwise die. PCPS has been a therapeutic option in a variety of the clinical settings such as for patients with myocardial infarction, high-risk coronary intervention and postcardiotomy cardiogenic shock, and the PCPS device is easy to install. We report our early experience with PCPS as a life saving procedure in cardiogenic shock patients due to acute myocardial infarction. MATERIAL AND METHOD: From January 2005 to December 2006, eight patients in cardiogenic shock with acute myocardial infarction underwent PCPS using the CAPIOX emergency bypass system (EBS(R), Terumo, Tokyo, Japan). Uptake cannulae were inserted deep into the femoral vein up to the right atrium and return cannulae were inserted into the femoral artery with Seldinger techniques using 20 and 16-French cannulae, respectively. Simultaneously, autopriming was performed at the EBS(R) circuit. The EBS? flow rate was maintained between 2.5~3.0 L/min/m2 and anticoagulation was performed using intravenous heparin with an ACT level above 200 seconds. RESULT: The mean age of patients was 61.1+/-14.2 years (range, 39 to 77 years). Three patients were under control of the EBS? before percutaneous coronary intervention (PCI), three patients were under control of the EBS? during PCI, one patient was under control of the EBS after PCI, and one patient was under control of the EBS(R) after coronary bypass surgery. The mean support time was 47.5+/-27.9 hours (range, 8 to 76 hours). Five patients (62.5%) could be weaned from the EBS(R) after 53.6+/-27.2 hours (range, 12 to 68 hours) of support. All of the patients who could successfully be weaned from support were discharged from the hospital. There were three complications: one case of gastrointestinal bleeding and two cases of acute renal failure. Two of the three mortality cases were under cardiac arrest before EBS(R) support, and one patient had an intractable ventricular arrhythmia during the support. All of the discharged patients are still surviving at 16.8+/-3.1 months (range, 12 to 20 months) of follow-up. CONCLUSION: The use of EBS(R) for cardiogenic shock caused by an acute myocardial infarction could rescue patients who might otherwise have died. Successfully recovered patients after EBS(R) treatment have survived without severe complications. More experience and additional clinical investigations are necessary to elucidate the proper installation timing and management protocol of the EBS? in the future.