Clinical analysis of 4 acute ischemic stroke children treated with endovascular thrombectomy / 中华儿科杂志

Objective: To assess the feasibility of endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) in children. Methods: Clinical data and follow-up information of 4 AIS children who received EVT in the Department of Intervention & Hemangioma at the Children's Hospital of the Capital Institute of Pediatrics from December 2020 to June 2021 were collected retrospectively. The vascular recanalization after EVT was assessed by the modified thrombolysis in cerebral infarction (mTICI) score. Efficacy outcomes were assessed with initial and postprocedural Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score, and the modified Rankin scale (mRS) score at 3 and 6 months after treatment. Safety assessments included perioperative complications and intracranial hemorrhage post-treatment. Results: A total of 5 EVT treatment were performed on 4 children with AIS, of whom 3 were male. The age of onset was 4.6, 13.8, 7.8, 8.0, 8.9 years, respectively. The time from symptom onset to initiation of EVT was 19.0, 25.0, 22.0, 4.0, 16.5 hours, respectively and all patients achieved successful recanalization of the vessel after EVT (mTICI≥2b). The PedNIHSS score was 39, 14, 25, 39, 24 before treatment and decreased to 8, 1, 12, 39, 5 at discharge. All the procedures were performed with no perioperative complications. Only 1 patient with congenital heart disease had a recurrent AIS with malignant brain oedema and brain hernia. Although the occluded vessels were successfully recanalized,the symptoms were not improved and this patient died after treatment abandonment. The other 3 patients achieved good recovery at 6 months postoperatively. The mRS score of 3 patients was 3, 1, 2 at 3 months after EVT and decreased to 2, 1, 1 at 6 months. Conclusion: EVT treatment may be feasible and safe for pediatric AIS due to large vessel occlusion even when the treatment was initiated 6 hours post stroke, but children with heart disease may have a dismal prognosis.

Emerging utility of endovascular thrombectomy in the Philippines: A single-center clinical experience

Background and Objective@#Stroke has remained one of the primary causes of significant morbidity and mortality. Among the therapeutic options for acute stroke management, endovascular thrombectomy is intended to remove the thrombi within the intracerebral vasculature and restore adequate perfusion to the surrounding penumbra. It is recommended up to 24 hours from onset of neurologic symptom. In the Philippines, only a few tertiary healthcare institutions are able to offer and perform endovascular thrombectomies. The aim was to describe the profile and discharge outcomes of endovascular thrombectomy for acute ischemic stroke at a tertiary hospital in our country. @*Methods@#We conducted a retrospective records review among 924 patients admitted for acute ischemic stroke from October 2018 to August 2021 who underwent mechanical thrombectomy. Clinical and functional outcomes were measured using the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Score (mRS). @*Results@#Among 31 patients included in the study, 29 subjects (93.5%) had moderate to severe disability (mRS 3–5), and 25 (80.6%) had moderate stroke (NIHSS 6–21) on admission. The identified site of the cerebrovascular thrombi was within the M1 segment of the middle cerebral artery (41.9%, n=13). The stent retriever approach was performed in 19 participants (61.2%). Upon discharge, only 7 (22.6%) had favorable functional outcomes (MRS 0–2), and 9 (29.0%) resulted in mortality. Successful reperfusion was achieved in 92.3% of the patients.@*Conclusion@#Overall, endovascular thrombectomy is a possible treatment option for large vessel acute ischemic stroke in developing countries.

Clinical Comparison of the Efficacy of Systemic Thrombolysis,Catheter-Directed Thrombolysis,and AngioJet Percutaneous Mechanical Thrombectomy in Acute Lower Extremity Deep Venous Thrombosis / 中国医学科学院学报

Objective To compare the clinical effects of three treatment methods including systemic thrombolysis(ST),catheter-directed thrombolysis(CDT),and AngioJet percutaneous mechanical thrombectomy(PMT)in acute lower extremity deep venous thrombosis(LEDVT). Methods The data of 82 patients diagnosed with LEDVT in the Department of Vascular and Gland Surgery of the First Affiliated Hospital of Hebei North University from January 2017 to December 2020 were collected.The patients were assigned into a ST group(n=50),a CDT group(n=16),and a PMT group(n=16)according to different treatment methods.The efficacy and safety were compared among the three groups. Results Compared with that before treatment,the circumferential diameter difference of both lower limbs on days 1,2,and 3 of treatment in the ST,CDT,and PMT groups reduced(all P<0.001).The PMT group showed smaller circumferential diameter difference of lower limbs on days 1,2,and 3 of treatment than the ST group(all P<0.001)and smaller circumferential diameter difference of the lower patellar margin on day 1 of treatment than the CDT group(P<0.001).The PMT group showed higher diminution rate for swelling of the affected limb at the upper and lower edges of the patella than the ST group(P<0.001)and higher diminution rate for swelling at the upper edge of the patella than the CDT group(P=0.026).The incidence of complications after treatment showed no significant differences among the three groups(all P>0.05).The median of hospital stay in the PMT group was shorter than that in the ST and CDT groups(P=0.002,P=0.001).The PMT group had higher thrombus clearance rate than the ST group(P=0.002)and no significant difference in the thrombus clearance rate from the CDT group(P=0.361).The vascular recanalization rates in the PMT(all P<0.001)and CDT(P<0.001,P=0.002,P=0.009)groups 3,6,and 12 months after treatment were higher than those in ST group,and there were no significant differences between PMT and CDT groups(P=0.341,P=0.210,P=0.341). Conclusions ST,CDT,and PMT demonstrated significant efficacy in the treatment of LEDVT,and PMT was superior to ST and CDT in terms of circumferential diameter difference of the lower limbs,diminution rate for swelling of the affected limb,thrombus clearance rate,length of hospital stay,and long-term vascular recanalization.There was no obvious difference in safety among the three therapies.

Clinicopathologic features and prognosis of young renal tumors with tumor thrombus / 北京大学学报(医学版)

OBJECTIVE@#To retrospectively analyze clinical data of patients under 40 years old who underwent surgical treatment for renal tumors with tumor thrombus from January 2016 to December 2022 at Peking University Third Hospital, and to evaluate the surgical effect and investigate the relationship between clinicopathological characteristics and prognosis.@*METHODS@#The clinical data of 17 young patients with renal tumor thrombus were retrospectively analyzed, and the clinicopathological features and prognosis were summarized. The patients were grouped according to the presence or absence of symptoms, 2017 American Joint Committee on Cancer (AJCC) clinical stage, and postoperative combined adjuvant therapy. Kaplan-Meier method was used to plot the survival curve, and Log-rank test was used to compare the differences in postoperative survival time and progression-free survival time between the different groups. The relationship between clinicopathological features and prognosis was analyzed.@*RESULTS@#All the 17 patients received venous tumor thrombectomy, including 16 patients (94.1%) who underwent radical nephrectomy and 1 patient (5.9%) who underwent partial nephrectomy. Twelve patients (70.6%) had symptoms and 5 (29.4%) had no symptoms before operation. A total of 17 renal tumors were observed, with 2 patients (11.8%) identified as benign and 15 patients (88.2%) classified as malignant. Among the malignant tumors, 1 patient (6.7%) was diagnosed as clear cell carcinoma, while the remaining 14 patients (93.3%) were categorized as non-clear cell carcinoma. In terms of tumor stage, 8 patients (53.3%) were classified as stage Ⅲ according to the AJCC classification, while 7 patients (46.7%) were categorized as stage Ⅳ. Additionally, 6 patients (40%) received multiple adjuvant therapy, while 9 patients (60%) did not undergo such treatment. The follow-up period ranged from 2 to 78 months, with a median follow-up of 41 months. During this time, 3 patients (20%) died. The median survival time after surgery was 39.0 (2.3, 77.8) months, and the progression-free survival time was 16.4 (2.3, 77.8) months. There was no significant difference in postoperative survival time and progression-free survival time among young patients with renal tumor with tumor thrombus, based on the presence of symptoms before surgery (P=0.307, P=0.302), clinical stage of AJCC (P=0.340, P=0.492), and postoperative adjuvant therapy (P=0.459, P=0.253) group.@*CONCLUSION@#The pathological types of young patients with renal tumor with tumor thrombus are more complex and varied due to symptoms, and the proportion of non-clear cell carcinoma in malignant tumor with tumor thrombus is higher. Symptomatic and non-clear cell carcinoma may be potentially associated with poor prognosis. Surgical operation combined with adjuvant therapy is a relatively safe and effective treatment for young patients with renal tumor and tumor thrombus.

Risk factors for massive hemorrhage after radical nephrectomy and removal of venous tumor thrombus / 北京大学学报(医学版)

OBJECTIVE@#To investigate and analyze the risk factors of massive hemorrhage in patients with renal cell carcinoma and venous tumor thrombus undergoing radical nephrectomy and removal of venous tumor thrombus.@*METHODS@#From January 2014 to June 2020, 241 patients with renal cancer and tumor thrombus in a single center of urology at Peking University Third Hospital were retrospectively analyzed. All patients underwent radical nephrectomy and removal of venous tumor thrombus. The relevant preoperative indicators, intraoperative conditions, and postoperative data were statistically analyzed by using statistical software of SPSS 18.0. The main end point of the study was intraoperative bleeding volume greater than 2 000 mL. Logistic regression analysis was used to determine the relevant influencing factors. First, single factor Logistic regression was used for preliminary screening of influencing factors, and variables with single factor Logistic regression analysis P < 0.05 were included in multivariate Logistic regression. In all statistical analyses, P < 0.05 is considered statistically significant.@*RESULTS@#Among the 241 patients included, there were 60 cases of massive hemorrhage, 48 males and 12 females, with a median age of 62 years. The number of non-massive hemorrhage was 181. There were 136 males and 45 females, with a median age of 59 years. Univariate analysis showed that the clinical symptoms (both systemic and local symptoms, OR 2.794, 95%CI 1.087-7.181, P=0.033), surgical approach (open surgery, OR 9.365, 95%CI 4.447-19.72, P < 0.001), Mayo grade (Mayo 3-4, OR 5.257, 95%CI 2.806-10.886, P < 0.001), American Society of Anesthesiologists (ASA) score (ASA level 3, OR 2.842, 95%CI 1.338-6.036, P=0.007), preoperative hemoglobin (OR 0.978, 95%CI 0.965-0.991, P=0.001), preoperative platelet count (OR 0.996, 95%CI 0.992-1.000, P=0.037), maximum tumor thrombus width (OR 1.061, 95%CI 1.033-1.091, P < 0.001), Complicated with bland thrombus (OR 4.493, 95%CI 2.264-8.915, P < 0.001), adrenalectomy (OR 3.101, 95%CI 1.614-5.958, P=0.001), segmental resection of the inferior vena cava (OR 2.857, 95%CI 1.395-5.852, P=0.004). There was a statistically significant difference in these aspects(P < 0.05). Multivariate Logistic regression analysis showed that there was a statistically significant difference in surgical approach (open surgery, OR 6.730, 95%CI 2.947-15.368;P < 0.001), Mayo grade (Mayo 3-4, OR 2.294, 95%CI 1.064-4.948, P=0.034), Complicated with bland thrombus (OR 3.236, 95%CI 1.492-7.020, P=0.003).@*CONCLUSION@#Combining the results of univariate and multivariate Logistic regression analysis, the surgical approach, Mayo grade, and tumor thrombus combined with conventional thrombus were associated risk factors for massive hemorrhage during surgery for renal cell carcinoma with tumor thrombus. Patients who undergo open surgery, high Mayo grade, and tumor thrombus combined with conventional thrombus are at a relatively higher risk of massive hemorrhage.

Tratamento microcirúrgico do Acidente Vascular Cerebral isquêmico na fase aguda e validação de face e conteúdo de tabela de acompanhamento funcional / Microsurgical treatment of ischemic stroke in the acute phase and validation of the face and content of a functional monitoring table

Introdução: A trombectomia microcirúrgica (TM) é usada há muitos anos em casos de Acidente Vascular Cerebral (AVC) e não há descrição detalhada da técnica sistematizada. Com a difusão de procedimentos de trombectomia endovascular é também esperado aumento de falha nesses procedimentos e a TM como procedimento de resgate tende a ser progressivamente mais demandada. Considerando a potencial demanda é crítico o desenvolvimento de planejamento cirúrgico sistematizado que permita a efetividade e celeridade do precedimento e, para isso, descrevemos a técnica microcirúrgica 2-1-2. Além disso, não existem estudos que demonstram o prognóstico funcional do indivíduo baseado no tipo de oclusão vascular encontrado durante a cirurgia, levando em consideração trombo convencional e placa de aterosclerose, e escala funcional para ser realizada com o indivíduo após o procedimento e avaliando de forma fiel a funcionalidade no dia a dia. Método: Foram avaliados oito indivíduos admitidos em pronto-atendimento com quadro de AVC isquêmico extenso e não foi possível realizar ou teve falha na trombectomia por via endovascular. Eles foram encaminhados a TM 2-1-2 após a imagem mostrar colaterais cerebrais ao vaso acometido na angiotomografia de crânio e Alberta stroke program early CT score (ASPECTS) maiores que 6 pontos. O procedimento consistiu em duas punções com agulha hipodérmica, 4 mm, na artéria alvo, arteriotomia transversa com microtesoura de 1mm, retirada do trombo utilizando manobras de ordenha e 2 micro pontos simples. Os indivíduos foram acompanhados por 60 dias com exames físicos e de imagem. Os materiais oclusivos foram coletados e enviados ao setor de anatomia patológica para análise histopatológica. E, para avaliação funcional real, um novo instrumento chamado FOLLOW Scale foi desenvolvido para avaliar diversos aspectos funcionais de indivíduos pós AVC, permitindo que tanto os próprios pacientes quanto seus familiares e cuidadores monitorem a evolução funcional. Foi feita aplicação da escala para sua validação de face e conteúdo através da opinião de 51 indivíduos pós AVC, familiares/cuidadores e profissionais de diferentes áreas. Resultados: Todos os indivíduos tratados com a técnica TM 2-1-2 tiveram a remoção completa do trombo por meio de técnica precisa com controle dos movimentos manuais e do tempo cirúrgico. A angiotomografia de crânio evidenciou restabelecimento integral da circulação cerebrovascular com melhora clínica em 60 dias de seguimento sem complicações ou reinternações hospitalares. O trombo convencional, é de fácil remoção e não obstrui o vaso após o procedimento. Em relação a aparência externa, quando possui aspecto branco o resultado tendeu a ser pior quando comparado com o vaso que possui aparência externa arroxeada. E, a FOLLOW Scale é útil para mensurar a funcionalidade do indivíduo pós três meses do AVC, apresentando fácil entendimento por leigos e não leigos sem diferença estatisticamente significativa. Conclusões: A técnica TM 2-1-2 pode ser realizada de forma rápida e eficaz de forma sistematizada, oferecendo terapêutica terciária ou de resgate para o tratamento do AVC agudo. Foi observado que o trombo convencional possui fácil remoção, podendo levar a melhor prognóstico funcional. A escala FOLLOW é instrumento proposto para acompanhamento funcional longitudinal desses indivíduos e conta com a vantagem de poder ser aplicada por profissionais sem formação específica e ter sido submetida a validação piloto no presente estudo. Treinamento microcirúrgico específico é crítico para realizar esse tratamento e estudos maiores são necessários para confirmar os achados do presente estudo.

Introduction: Microsurgical thrombectomy (MT) has been used for many years in cases of stroke. There is no detailed description of the systematic technique. With the spread of endovascular thrombectomy procedures, an increase in failure in these procedures is also expected and MT as a rescue procedure tends to be progressively more demanded. Considering the potential demand, it is critical to develop a systematized surgical planning that allows the effectiveness and speed of the procedure, and, to this end, we describe the 2-1-2 microsurgical technique. Furthermore, there are no studies that demonstrate the individual's functional prognosis based on the type of vascular occlusion found during surgery, taking into account conventional thrombus and atherosclerosis plaque, and a functional scale to be carried out with the individual after the procedure and faithfully evaluating functionality on a daily basis. Method: Eight individuals admitted to emergency care with extensive ischemic stroke and not possible to perform or the failure of endovascular thrombectomy were evaluated. They were referred to TM 2-1-2 after the image showed cerebral collaterals to the affected vessel on cranial CT angiography and Alberta stroke program early CT score (ASPECTS) greater than 6 points. The procedure consisted of two punctures with a 4 mm hypodermic needle in the target artery, transverse 1mm arteriotomy with micro scissors, removal of the thrombus using milking maneuvers and 2 simple points. The individuals were followed for 60 days with physical and imaging exams. The occlusive materials were collected and sent to the pathological anatomy department for histopathological analysis. A new instrument called the FOLLOW Scale was developed to evaluate various functional aspects of post-stroke individuals, allowing both the patients themselves and their families and caregivers to monitor functional evolution. The scale was applied for face and content validation through the opinion of 51 post-stroke individuals, family members/caregivers and professionals from different areas. Results: All individuals treated with the TM 2-1-2 technique had complete thrombus removal using a precise technique with control of manual movements and surgical time. Skull tomography angiography showed full re-establishment of cerebrovascular circulation with clinical improvement in 60 days of follow-up without complications or hospital readmissions. The conventional thrombus is easy to remove and does not obstruct the vessel after the procedure. Regarding the external appearance, when it has a white appearance, the result tended to be worse when compared to the vessel that has a purplish external appearance. The FOLLOW Scale has face and content validity for measuring an individual's functionality three months after the stroke and is easy to understand by laypeople and non-laypeople with no statistically significant difference. Conclusions: The TM 2-1-2 technique can be performed quickly and effectively in a systematic way, offering tertiary or rescue therapy for the treatment of acute stroke. It was observed that conventional thrombus is easy to remove, which can lead to a better functional prognosis. The FOLLOW scale is an instrument proposed for longitudinal functional monitoring of these individuals and has the advantage of being able to be applied by professionals without specific training and had the initial validation in the present study. Specific microsurgical training is critical to perform this treatment and larger studies are needed to confirm the findings of the present study.

Manejo avanzado del infarto cerebral en un hospital público chileno: trombectomía mecánica en el Hospital Barros Luco Trudeau / Mechanical thrombectomy in a Chilean public hospital. Experience in 149 patients

BACKGROUND: Mechanical thrombectomy is the accepted treatment for acute ischemic stroke in Large Vessel Occlusion. The Barros Luco Trudeau hospital developed endovenous thrombolysis in 2010, and since 2012, implemented endovascular management, becoming the neurovascular center in the southern area of the metropolitan region. AIM: To describe endovascular management of acute ischemic stroke in a Chilean public hospital. Material and Methods: Analysis of patients with acute ischemic stroke that were treated with mechanical throm-bectomy from 2012 to 2019 in the Barros Luco Hospital. RESULTS: In the study period, a mechanical thrombectomy was carried out in 149 patients aged 61 ± 15 years (46% females). The average National institute of Health Stroke Scale (NIHSS) at presentation was 19 ± 4-5. Anterior or posterior circulation involvement was present in 89.9 and 10.1 % of patients. Twenty-five percent of patients were referred from other public centers. The mean lapse between onset of symptoms and thrombectomy was 266 ± 178 in. Ninety days after the procedure, 58% of patients had minimal or absent disability (Modified Ranson score of 0-2), and 19,2% died. CONCLUSIONS: Mechanical thrombectomy, according to this experience, has favorable clinical outcomes in patients with high NIHSS scores at entry.

Nefrectomía radical con trombectomía de vena cava: 20 años de cirugías por tumor renal / Vena cava thrombectomy in kidney cancer. Report of 32 nephrectomies

BACKGROUND: Vena cava (VC) involvement in kidney tumors occurs in 4 to 10% of cases, and is associated with a higher mortality. Nephrectomy with thrombectomy of the VC, performed by a multidisciplinary team, improves survival. Aim: To report a series of consecutive nephrectomies with caval thrombectomy performed in an academic center. PATIENTS AND METHODS: We report 32 patients with cT3b and 3c renal tumors, who underwent radical nephrectomy with VC thrombectomy between 2001 and 2021. A descriptive analysis of clinical, surgical and pathological variables was performed. Overall survival (OS) and cancer-specific survival (CSS) was calculated using Kaplan-Meier curves. Results: The mean tumor size was 9.7 cm. According to Mayo classification 3/32 (9%) patients had a type I thrombus, 10/32 (31%) had a type II thrombus, 8/32 (25%) had a type III thrombus, and 5/32 (16%) had a type IV thrombus. The mean bleeding was 2000 cc. There was one intraoperative death. Nineteen percent of patients had complications >= 3 according to Clavien-Dindo classification. Reoperations occurred in 9%. Pre and postoperative creatinine levels were 1.17 and 1.91 mg/dl respectively (p < 0.01). Pre and postoperative Hematocrit levels were 47.9 and 31% respectively (p = 0.02). Sixty six percent of tumors were clear cell renal cancer, 9% were papillary and 3% were chromophobic. Mean OS was 10 months. Two-year SCE was 40%. CONCLUSIONS: Our results are similar to those reported elsewhere. Despite being an unusual pathology, the surgical technique has been improving, thanks to the multidisciplinary work of urologists and surgeons.

Reperfusion Strategies in Acute Myocardial Infarction: State of the Art

Abstract ST elevation myocardial infarction (STEMI) is a highly prevalent condition worldwide. Reperfusion therapy is strongly associated with the prognosis of STEMI and must be performed with a high standard of quality and without delay. A systematic review of different reperfusion strategies for STEMI was conducted, including randomized controlled trials that included major cardiovascular events (MACE), and systematic reviews in the last 5 years through the PRISMA ( Preferred Reporting Items for Systematic Reviews and Meta-Analysis) methodology. The research was done in the PubMed and Cochrane Central Register of Controlled Trials databases, in addition to a few manual searches. After the exclusion criteria were applied, 90 articles were selected for this review. Despite the reestablishment of IRA patency in PCI for STEMI, microvascular lesions occur in a significant proportion of these patients, which can compromise ventricular function and clinical course. Several therapeutic strategies - intracoronary administration of nicorandil, nitrates, melatonin, antioxidant drugs (quercetin, glutathione), anti-inflammatory substances (tocilizumab [an inhibitor of interleukin 6], inclacumab, P-selectin inhibitor), immunosuppressants (cyclosporine), erythropoietin and ischemic pre- and post-conditioning and stem cell therapy - have been tested to reduce reperfusion injury, ventricular remodeling and serious cardiovascular events, with heterogeneous results: These therapies need confirmation in larger studies to be implemented in clinical practice

Epidemiological analysis of stroke patients with emphasis on access to acute-phase therapies / Análise epidemiológica de pacientes com AVC com ênfase no acesso às terapias de fase aguda

ABSTRACT Background: Stroke is a public health problem. For patients with ischemic stroke, venous thrombolysis and mechanical thrombectomy are effective therapeutic options. However, even after the National Stroke Treatment Guidelines were published in 2012, the number of cases treated is still lower than expected. Objective: To identify the determining factors for obtaining access to acute-phase therapies in the state of Espírito Santo (ES) and investigate the profile of stroke patients treated at the Central State Hospital (HEC). Methods: Retrospective data from the medical records of 1078 patients from May 2018 to December 2019 were analyzed. Results: Among the 1,078 patients, 54.9% were men and the most prevalent age group was 60 to 79 years. Systemic arterial hypertension was the main single risk factor. Regarding treatment modality among the patients who arrived at the HEC within the therapeutic window, 47% received some type of acute-phase therapy. Waking up with the deficit was the main contraindication for venous thrombolysis in these cases. Conclusions: Application of the flowchart established by SESA-ES seemed to be effective for enabling responsiveness of care for stroke victims. Public emergency transport services had a fundamental role in this process. In addition, the care provided by the tertiary stroke center provided excellent access to acute-phase therapies. However, despite the efficiency of the service provided at the HEC, it only reached a maximum of 50% of the ES population. This service model therefore needs to be expanded throughout the state.

RESUMO Antecedentes: O acidente vascular cerebral (AVC) é um problema de saúde pública. Nos casos de AVC isquêmico, a trombólise venosa e a trombectomia mecânica são efetivas opções terapêuticas de fase aguda. Entretanto, mesmo com a Diretriz Nacional de AVC publicada desde 2012, o número de casos tratados ainda é baixo. Objetivo: Apurar os fatores determinantes para o acesso às terapias de fase aguda na realidade espírito-santense e investigar o perfil dos pacientes de AVC atendidos no Hospital Estadual Central de Vitória (HEC). Métodos: O presente estudo analisou dados retrospectivos de prontuários de 1.078 pacientes no período de maio de 2018 a dezembro de 2019. Resultados: Dos 1.078 pacientes, 54,9% eram homens e a faixa etária mais prevalente foi a de 60 a 79 anos. A hipertensão arterial sistêmica foi o principal fator de risco isolado. Quanto ao tratamento, identificou-se que entre os pacientes que chegaram ao HEC na janela terapêutica 47% receberam terapia de fase aguda e que acordar com o déficit foi a principal contraindicação para trombólise venosa nesses casos. Conclusões: As análises demonstraram que a aplicação do fluxograma estabelecido pela Secretaria de Estado da Saúde do Espírito Santo parece ser eficaz na agilidade de atendimento das vítimas de AVC e que o Serviço de Atendimento Móvel de Urgência tem um papel fundamental nesse processo. Além disso, a assistência de um centro terciário de AVC permite acesso às terapias de fase aguda com excelência. Todavia, mesmo que o modelo de serviço prestado no HEC seja eficiente, ele atinge no máximo 50% da população do ES, sendo necessária a sua ampliação.

Robotic-assisted nephrectomy with level II IVC thrombectomy using Rummel Tourniquets

ABSTRACT Background: Inferior vena cava (IVC) invasion from renal cell carcinoma (RCC) occurs at a rate of 4-10% (1). IVC thrombectomy (IVC-TE) can be an open procedure because of the need for handling of the IVC (2). The first reported series of robotic management of IVC-TE started in 2011 for the management of Level I - II thrombi with subsequent case reports in recent years (2-5). Materials and Methods: The following is a patient in his 50's with no significant medical history. Magnetic resonance imaging and IR venogram were performed preoperatively. The tumor was clinical stage T3b with a 4.3cm inferior vena cava thrombus. The patient underwent robotic assisted nephrectomy and IVC-TE. Rummel tourniquets were used for the contralateral kidney and the IVC. The tourniquets were created using vessel loops, a 24 French foley catheter and hem-o-lock clips. Results: The patient tolerated the surgical procedure well with no intraoperative complications. Total surgical time was 274 min with 200 minutes of console time and 22 minutes of IVC occlusion. Total blood loss in the surgery was 850cc. The patient was discharged from the hospital on post-operative day 3 without any complications. The final pathology of the specimen was pT3b clear cell renal cell carcinoma Fuhrman grade 2. The patient followed up post-operatively at both four months and six months without disease recurrence. The patient continues annual follow-up with no recurrence. Conclusions: Surgeon experience is a key factor in radical nephrectomy with thrombectomy as patients have a reported 50-65% survival rate after IVC-TE (4).

Radical Nephrectomy in Renal Cell Carcinoma with Venous Tumoral Thrombus: Long-term Outcomes and Overall Survival / Nefrectomía radical en carcinoma de células renales con trombo tumoral venoso: Desenlaces a largo plazo y supervivencia global

Objective To describe the five-year overall survival (OS) and perioperative morbidity of patients with renal cell carcinoma (RCC) with venous tumor thrombus (VTT) treated through radical nephrectomy and thrombectomy. Materials and Methods We evaluated a cohort of 530 patients with a diagnosis of RCC from January 2009 to December 2019, and found VTT in 42 of them; these 42 patients composed the study sample. The patients were stratified according to the Neves Thrombus Classification (NTC). The baseline and perioperative characteristics, as well as the follow-up, were described. The Kaplan-Meier curve and its respective Cox regression were applied to present the 5-year OS and the OS stratified by the NTC. Results The average age of the sample was of 63.19 ± 10.7 years, and there were no differences regarding gender. In total, VTT was present in 7.9% of the patients. According to the NTC, 30.9% of the cases corresponded to level I, 21.4%, to level II, 26.1%, to level III, and 21.4%, to level IV. The 5-year OS was of 88%. For level-I and level-II patients, the 5-year OS was of 100%, and of only 38% among level-IV patients. Complications, mostly minor, occurred in 57% of the cases. Conclusions Radical nephrectomy with thrombectomy is a morbid procedure; however, most complications are minor, and the five-year mortality is null for patients in NTC levels I and II, and low for levels III and IV, and it may be even lower in level-III patients when standardizing transesophageal echocardiogram intraoperatively and routinary extracorporeal bypass. Thus, we recommend considering this surgery as the first-line management in patients with RCC and VTT.

Objetivo Describir la supervivencia global (SG) a los cinco años y la morbilidad perioperatoria de pacientes con carcinoma de células renales (CCR) con trombo tumoral venoso (TTV) tratados por nefrectomía radical y trombectomía. Materiales y Métodos Se evaluó una cohorte de 530 pacientes con diagnóstico de CCR entre enero de 2009 y diciembre de 2019, y se encontró TTV en 42 de ellos; esos 42 pacientes compusieron la muestra de este estudio. Los pacientes fueron estratificados según la clasificación de trombos de Neves (CTN). Se describieron las características basales y perioperatorias de los pacientes, así como el seguimiento. Se aplicaron la curva de Kaplan-Meier y su respectiva regresión de COX para presentar la SG a los 5 años y la SG estratificada por CTN. Resultados La edad promedio de la muestra fue de 63,19 ± 10,7 años, sin diferencia respecto a género. El TTV estuvo presente en el 7,9% de los pacientes. Según la CTN, el 30,9% de los casos correspondía al nivel I, el 21,4%, al nivel II, el 26,1%, al nivel III, y el 21,4%, al nivel IV. La SG a los 5 años fue del 88%. Para los niveles I y II, la SG a los 5 años fue del 100%, y, para el nivel IV del 38%. Las complicaciones, menores en su mayoría, ocurrieron en el 57% de los casos. Conclusiones La nefrectomía radical con trombectomía es un procedimiento mórbido; sin embargo, la mayoría de las complicaciones son menores, y la mortalidad a los 5 años es nula cuando en los pacientes de niveles I y II en la CYN, y baja en los niveles III y IV, y puede ser incluso menor en los pacientes de nivel III al estandarizar el ecocardiograma transesofágico intraoperatorio y el baipás extracorpóreo rutinario. Por ello, recomendamos considerar esta cirugía como manejo de primera línea en pacientes con CCR y TTV.

Thrombectomy in a severe case of iliofemoral venous thrombosis involving the deep femoral vein via a single percutaneous access from the jugular vein: case report and description of the technique / Trombectomia em caso grave de trombose venosa iliofemoral afetando a veia femoral profunda pela técnica de punção e sessão única realizada pela veia jugular: relato de caso e descrição da técnica

ABSTRACT: Iliac vein thrombectomy is usually performed via access through veins located in the lower limbs, which makes it impossible to treat the deep femoral vein, which in turn is an important inflow route to the iliac vein stent. We describe a clinical case and the previously unpublished technique of percutaneous thrombectomy, angioplasty, and stent implantation performed in a single session and with a single access, obtained via the internal jugular vein.

RESUMO: A trombectomia mecânica venosa ilíaca geralmente é realizada por acesso em veias localizadas nos membros inferiores, o que impossibilita o tratamento da veia femoral profunda, que, por sua vez, é uma importante via de influxo ao stent venoso ilíaco. Descrevemos um caso clínico em que foi aplicada a técnica inédita de trombectomia percutânea, angioplastia e implante de stent, realizada por sessão e acesso único, obtido na veia jugular interna.

Application of non-contrasted computed tomography and diffusion-weighted imaging protocols for endovascular treatment selection in patients with late-presenting or wake-up strokes / Aplicação de tomografia computadorizada sem contraste e protocolos de imagem ponderada em difusão para seleção de tratamento endovascular em pacientes com acidente vascular cerebral em fase tardia ou ao despertar

ABSTRACT Background: Among patients with acute ischemic stroke with a mismatch between deficit severity and infarct volume, thrombectomy performed within a 6-24 hours time window has efficacy and safety similar to treatment within 6 hours. However, whether magnetic resonance imaging with T2 diffusion-weighted imaging (DWI) is feasible remains to be validated. Objective: To investigate prognosis among stroke patients receiving endovascular treatment (EVT) within 6 hours and 6-24 hours using non-contrasted computed tomography (NCCT) and DWI. Methods: Overall, 209 anterior-circulation ischemic stroke patients with large-vessel occlusion who underwent EVT were divided into ≤ 6 hours and 6-24 hours groups. Patients presenting symptoms within 6 hours were treated if their NIHSS score was ≥ 7 and ASPECTS score was ≥ 5, whereas those with wake-up stroke (WUS) or presenting symptoms 6-24 hours after last seen well (WUS/late-presenting stroke, LPS) were managed if their NIHSS score was ≥ 7 and ASPECTS score was ≥ 5. Results: The percentages of patients undergoing intracranial stenting and intracranial ballooning without stenting significantly differed between two groups (p < 0.001). Grades 0, 1, 2a and 2b recanalization rates did not differ between the 6 hours and 6-24 hours groups (all p > 0.05). Grade 3 recanalization rate in the 6 hours group was significantly lower than in the 6-24 hours group (p = 0.043). The 3-month Rankin Scale score did not significantly differ between the two groups (p = 0.629). Conclusions: EVT is a safe and effective treatment for patients with WUS and LPS selected through NCCT and DWI-based simple imaging.

RESUMO Antecedentes: Entre pacientes com acidente vascular cerebral isquêmico (AVCI) agudo com divergência entre gravidade do déficit e volume do infarto, a trombectomia em 6 a 24 horas tem eficácia e segurança semelhantes ao tratamento em até 6 horas. Entretanto, a viabilidade da imagem ponderada em T2 com difusão (DWI) da ressonância magnética necessita validação. Objetivo: Investigar o prognóstico de pacientes com AVCI que recebem tratamento endovascular (EVT) em até 6 horas e de 6-24 horas usando tomografia computadorizada sem contraste (NCCT) e DWI. Métodos: Duzentos e nove pacientes com AVCI de circulação anterior submetidos a EVT foram divididos em ≤ 6 horas e 6-24 horas. Pacientes com sintomas até 6 horas foram tratados se NIHSS ≥ 7 e ASPECTS ≥ 5; aqueles com AVCI ao despertar (WUS) ou com sintomas entre 6-24 horas da última vez em que foram vistos bem (WUS/AVC de fase tardia, LPS) foram tratados se NIHSS ≥ 7 e ASPECTS ≥ 5. Resultados: As porcentagens de pacientes submetidos a implante de stent intracraniano e angioplastia intracraniana sem stent diferiram entre os dois grupos (p <0,001). As taxas de recanalização 0, 1, 2a e 2b não diferiram entre 6 horas e 6-24 horas (p> 0,05). A taxa de recanalização de grau 3 no grupo 6 horas foi menor do que 6-24 horas (p = 0,043). Pontuação na Escala Rankin (3 meses) não foi diferente (p = 0,629). Conclusões: EVT é um tratamento seguro e eficaz para pacientes com WUS e LPS selecionados por meio de imagens baseadas em NCCT e DWI.

Aneurisma trombosado de arteria comunicante anterior asociado a síntomas visuales / Thrombosed anterior communicating artery aneurysm associated with visual symptoms

Introducción: Los aneurismas de la arteria comunicante anterior (AComA) se presentan frecuentemente como causa de hemorragia subaracnoidea espontánea (HSAE), en casos raros se asocian a síntomas visuales por compresión mecánica o ruptura y su tratamiento quirúrgico a menudo representa un desafío. Descripción del caso: Se presenta el caso clínico de una paciente adulta con disminución de la agudeza visual del ojo derecho a predominio temporal, y hallazgos en RMN cerebral y angiografía compatibles con un aneurisma grande de AcomA, asociado a trombosis parcial; se realizó clipaje y trombectomía del aneurisma, la panangiografia de control evidenció exclusión completa de la lesión con posterior resolución del déficit visual. Discusión: El déficit visual por un aneurisma de la AcoA se puede generar por varios mecanismos, uno de ellos es la ruptura del aneurisma hacia el nervio óptico, con la subsecuente formación de un hematoma, adherencias y fibrosis; el otro mecanismo es la compresión mecánica de un aneurisma gigante no roto. El manejo quirúrgico a menudo implica técnicas complejas microquirúrgicas para intentar resolver el efecto de masa y excluir el aneurisma. La terapia endovascular es otra alternativa de tratamiento, pero tiene desventajas respecto a la cirugía. Conclusión: Los aneurismas de la AComA en raros casos se pueden asociar a síntomas visuales, debido a que por lo general se romepen cuando son pequeños, y no alcanzan a tener el tamaño suficiente para generar compresión de la vía óptica. Las técnicas microquirúrgicas ofrecen un método efectivo para disminuir el efecto de masa y mejorar los síntomas visuales

Introduction: Aneurysms of the anterior communicating artery (AComA) frequently present as a cause of spontaneous subarachnoid hemorrhage (HSAE), in rare cases they are associated with visual symptoms due to mechanical compression or rupture and their surgical treatment often represents a challenge. Description of the case: We present the clinical case of an adult patient with a decrease in visual acuity due to the right eye with a temporal predominance and findings on brain MRI and angiography compatible with a large AcomA aneurysm associated with partial thrombosis; clipping and thrombectomy of the aneurysm were performed, the control panangiography showed complete exclusion of the lesion. With subsequent resolution of the visual deficit. Discussion: The visual deficit due to an AcoA aneurysm can be generated by several mechanisms, one of them is the rupture of the aneurysm towards the optic nerve, with the subsequent formation of a hematoma, adhesions and fibrosis; The other mechanism is mechanical compression of a giant, unruptured aneurysm. Surgical management often involves complex microsurgical techniques to try to resolve the mass effect and exclude the aneurysm. Endovascular therapy is another treatment alternative, but it has disadvantages compared to surgery. Conclusion: AComA aneurysms in rare cases can be associated with visual symptoms, because they generally rupture when they are small, and are not large enough to generate compression of the optic pathway. Microsurgical techniques offer an effective method to alleviate the mass effect and improve visual symptoms

Blood pressure behavior during mechanical thrombectomy and drugs used for conscious sedation or general anesthesia / Comportamento da pressão arterial durante trombectomia mecânica e drogas utilizadas para sedação consciente ou anestesia geral

ABSTRACT Background: The optimal blood pressure (BP) during mechanical thrombectomy for acute ischemic stroke is currently unclear. Objective: To investigate BP behavior during mechanical thrombectomy in patients with acute ischemic stroke and its relationship with drugs used for sedation or general anesthesia. Additionally, we investigated the association between BP oscillation during mechanical thrombectomy and recanalization status, and with functional outcome at discharge. Methods: Consecutive patients treated with mechanical thrombectomy for acute ischemic stroke were evaluated in a tertiary hospital from December/2009 to December/2015. Maximum, minimum, and mean systolic and diastolic BP, and mean arterial pressures were collected during the procedure. Sedative drugs were also reviewed. Results: Fifty-three patients with a mean age of 71.9 years (60.4% men) were treated with mechanical thrombectomy. The mean reduction in systolic BP and mean arterial pressure from hospital admission to mechanical thrombectomy were respectively 42 and 36 mmHg. During the procedure, oscillations were 50.4 mmHg for systolic, and 33.2 mmHg for diastolic BP. Patients treated with neuromuscular blocking drugs had more oscillation in systolic BP from hospital admission to procedure (51.1 versus 26.2 mmHg, P=0.06). The use of cisatracurium (43.9 versus 29.6 mmHg, P=0.02) and succinylcholine (44.7 versus 29.3 mmHg, P=0.01) were associated with a significant drop in BP during the procedure. Conclusions: Significant BP oscillation occurs during mechanical thrombectomy. Drugs used for conscious sedation or general anesthesia, specifically neuromuscular blocking agents, might have an influence upon BP levels.

RESUMO Antecedentes: Atualmente, a pressão arterial ideal durante a trombectomia mecânica em pacientes com acidente vascular cerebral isquêmico agudo não é clara. Objetivo: Investigar o comportamento da pressão arterial durante a trombectomia mecânica em pacientes com acidente vascular cerebral isquêmico agudo e sua relação com os medicamentos utilizados para sedação ou anestesia geral. Adicionalmente, investigar a associação entre a oscilação da pressão arterial durante a trombectomia mecânica e a capacidade de recanalização, além do status funcional no momento da alta hospitalar. Métodos: Avaliação de pacientes tratados com trombectomia mecânica por acidente vascular cerebral isquêmico agudo em um hospital terciário de dezembro/2009 a dezembro/2015. Valores máximos, mínimos e médios da pressão arterial sistólica, pressão diastólica e pressão arterial média foram coletados durante o procedimento. Drogas sedativas utilizadas também foram revisadas. Resultados: Um total de 53 pacientes com idade média de 71,9 anos (60,4% homens) foram tratados com trombectomia mecânica. A redução média da pressão arterial sistólica e da pressão arterial média desde a internação até a trombectomia mecânica foi respectivamente de 42 mmHg e 36 mmHg. Durante o procedimento, as oscilações da pressão arterial foram de 50,4 mmHg para pressão sistólica e 33,2 mmHg para pressão diastólica. Os pacientes tratados com bloqueadores neuromusculares apresentaram uma tendência a maior oscilação da pressão arterial sistólica desde a internação até o procedimento (51,1 mmHg versus 26,2 mmHg, P = 0,06). O uso de cisatracúrio (43,9 mmHg versus 29,6 mmHg, P = 0,02) e succinilcolina (44,7 mmHg versus 29,3 mmHg, P = 0,01) foram associados a uma queda significativa da pressão arterial durante o procedimento. Conclusões: Durante a trombectomia mecânica ocorre oscilação significativa da pressão arterial. Os medicamentos usados para sedação consciente ou anestesia geral, especificamente bloqueadores neuromusculares, podem ter influência nos níveis de pressão arterial.

Flegmasía cerulea dolens. tratamiento con fibrinolisis sistémica / Phlegmasia cerulea dolens. Treatment with systemic fibrinolysis

Resumen La flegmasia cerulea dolens es una complicación rara y poco frecuente de la trombosis venos a profunda. Los principales factores predisponentes son los procesos neoformativos, estados de hiper coagulabilidad, insuficiencia cardíaca congestiva, embarazo, inmovilización prolongada y cirugías. Se caracteriza por edema masivo, dolor intenso y cianosis. Sin tratamiento evoluciona con isquemia, necrosis y amputación del miembro comprometido. No existe consenso en su tratamiento, pero éste debe ser rápido, multidisciplinario y agresivo. La anticoagulación con heparina, la fibrinólisis sistémica, la trombectomía percutánea con fibrinólisis local, la trombectomía quirúrgica, la fasciotomía, la colocación de filtro de vena cava inferior y la amputación son algunos de los tratamientos propuestos.

Abstract Phlegmasia cerulea dolens (FCD) is a rare complication of deep vein thrombosis. Its cause is unknown. The main predisposing factors for the disease are neoformative processes, hypercoagulable states, congestive heart failure, pregnancy, prolonged immobilization, and surgeries on the affected limb. FCD is characterized by massive edema, severe pain, and cyanosis. The diagnosis is clinical. It is associated in most cases with pulmonary embolism and can lead to loss of the compromised limb if not treated in time. So far there is no consensus on its treatment. In clinical practice the use of anticoagulation with heparin, local thrombolysis, systemic fibrinolysis, surgical thrombectomy, fasciotomy, and inferior vena cava filter are described. In irreversible cases amputation is required. We present the case of a patient with FCD, the treatment performed and the evolution.

Trombectomía más fleboextracción: una técnica alternativa en el manejo de la enfermedad hemorroidal externa trombosada / Thrombectomy combined with vein stripping: An alternative technique to treat thrombosed external hemorrhoid disease

Resumen Objetivo: Evaluar los resultados de la trombectomía más fleboextracción como alternativa en el manejo de la enfermedad hemorroidal externa trombosada. Materiales: Estudio observacional, cuantitativo, retrospectivo, transversal y descriptivo de los pacientes que consultaron y se sometieron a la trombectomía más fleboextracción como técnica alternativa en el manejo de la enfermedad hemorroidal externa trombosada en el servicio de coloproctología del Hospital Militar Central desde el primero de enero de 2014 hasta el 31 de diciembre de 2016. Resultados: Se encontró que 197 pacientes consultaron por hemorroides externas trombosadas, el 71 % eran hombres y el promedio de edad para el grupo de manejo conservador fue de 48,5 años, frente al promedio del grupo de manejo quirúrgico, que fue de 43,2 años. El seguimiento promedio posterior al inicio del tratamiento médico o quirúrgico fue de 16 meses. En el grupo de manejo quirúrgico, la tasa de recurrencia fue del 7,2 % y el intervalo de recurrencia fue 29,2 meses. Conclusiones: Los pacientes a quienes se les practicó la técnica de trombectomía más fleboextracción presentaron una menor tasa de retrombosis hemorroidal, menor tasa de dolor y sangrado posoperatorio. La trombectomía hemorroidal con fleboextracción es una técnica bien tolerada en el consultorio, que se puede realizar sin anestesia, a diferencia del estándar de manejo actual con hemorroidectomía externa en elipse, que requiere anestesia local, regional o general, y una sala de procedimientos quirúrgicos que deja un defecto mayor en la piel por el tejido resecado, un mayor tiempo de cicatrización y de dolor posoperatorio.

Abstract Objective: To evaluate the results of thrombectomy combined with vein stripping as an alternative to treat external thrombosed hemorrhoid disease. Materials and methods: This is an observational, quantitative, retrospective, cross-sectional and descriptive study of the patients who underwent thrombectomy combined with vein stripping as an alternative technique to treat thrombosed external hemorrhoid disease at the Coloproctology Service of the Hospital Militar Central from January 1, 2014, to December 31, 2016. Results: It was found that 197 patients consulted due to thrombosed external hemorrhoids. 71% were men. The average age for the conservative treatment group vs. the surgical treatment group was 48.5 vs. 43.2 years, respectively. The average follow-up time after initiation of medical or surgical treatment was 16 months. In the surgical treatment group, the recurrence rate was 7.2% and the recurrence interval was 29.2 months. Conclusions: Patients who underwent thrombectomy combined with vein stripping had a lower recurrence rate of thrombosed hemorrhoids, a lower pain score, and less postoperative bleeding. Hemorrhoid thrombectomy combined with vein stripping is a well-tolerated technique that can be performed at the doctor's office without anesthesia, unlike the current management standard with external elliptical hemorrhoidectomy, which that requires local, regional, or general anesthesia, and a surgical room, leaving a larger skin defect following the resection of the tissue, with longer healing time and greater postoperative pain.

Caracterización de los pacientes con fístulas arterio-venosas para hemodiálisis / Characterization of patients with arteriovenous fistulas for hemodialysis

Introducción: La insuficiencia renal crónica es una enfermedad frecuente que requiere del uso vital de la hemodiálisis, procedimiento común en los pacientes que la padecen, por lo cual resulta necesario disponer de un acceso vascular adecuado. Objetivo: Caracterizar a los pacientes con fístulas arterio-venosas para hemodiálisis en el Hospital Clínico-Quirúrgico "General Freyre de Andrade". Métodos: Se realizó un estudio descriptivo-retrospectivo en 88 pacientes con fístulas arterio-venosas. Se recogieron las siguientes variables: edad, sexo, tipo de acceso vascular, localización, complicaciones inmediatas y tardías, y procedimiento corrector. El período de estudio abarcó desde enero de 2018 hasta enero de 2019. Resultados: Se les realizaron a los pacientes un total de 88 fístulas arterio-venosas. Predominó el sexo masculino (67 por ciento). Prevaleció el grupo de edades de 50 a 59 años (36,4 por ciento). La fístula arterio-venosa humero-cefálica (48,9 por ciento) resultó el procedimiento más realizado. El hematoma, la trombosis y la infección fueron las complicaciones inmediatas con mayor frecuencia (3,4 por ciento). De las complicaciones tardías, predominó la trombosis (3,4 por ciento), mientras que la trombectomía prevaleció como procedimiento corrector (37,5 por ciento). Conclusiones: Como parte del acceso vascular, la fístula humero-cefálica presentó los mejores resultados en cuanto a permeabilidad y durabilidad. Por otra parte, la fístula humero-humeral constituyó una alternativa cuando no se pudieron usar las venas cefálica y basílica a nivel del pliegue del codo(AU)

Introduction: Chronic kidney disease is a frequent condition that demands the vital use of hemodialysis, a common procedure in patients who suffer from it; therefore, it is necessary to have adequate vascular access. Objective: To characterize patients with arteriovenous fistulas for hemodialysis at General Freyre de Andrade Clinical-Surgical Hospital. Methods: A descriptive-retrospective study was carried out in 88 patients with arteriovenous fistulas. The following variables were selected: age, sex, type of vascular access, location, immediate and late complications, and corrective procedure. The study period covered from January 2018 to January 2019. Results: A total of 88 arteriovenous fistulas were approached among all the patients. The male sex predominated (67 percent). The age group 50-59 years (36.4 percent) prevailed. The procedure for creating a humeral cephalic arteriovenous fistula (48.9 percent) was the most performed. Hematoma, thrombosis and infection were the immediate complications with the highest frequency (3.4 percent). Among late complications, thrombosis prevailed (3.4 percent); while thrombectomy prevailed as a corrective procedure (37.5 percent). Conclusions: As part of vascular access, the procedure for creating humeral cephalic fistula presented the best outcome in terms of patency and durability. On the other hand, the procedure for creating the humeral fistula was an alternative when the cephalic and basilic veins could not be used at the level of the elbow crease(AU)