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.

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.

A Case of Severe Thoracoabdominal Impalement by a Steel Bar

A 53-year-old man arrived at the trauma center with a steel bar penetrating from the epigastrium to the right scapula. He was hypotensive and hypoxic, and immediate resuscitation and basic evaluation were performed. An emergency operation was performed due to an unstable hemodynamic state. Multiple injuries were confirmed in the right lower lobe, posterior chest wall, diaphragm, and liver lateral segment. Right lower lobectomy and liver lateral sectionectomy were performed following removal of the bar. The patient recovered without additional hemorrhage after the surgery, and was transferred to a rehabilitation institution with periodic follow-up.

Trapped Stent in the Left Coronary Sinus in a Myocardial Infarction Patient

Stent entrapment is a very rare complication of percutaneous coronary intervention. The interventional approach could be a treatment strategy. However, if it does not work, surgical treatment should be considered. Here, we report a case of surgical treatment of stent entrapment in the left coronary sinus of a 53-year-old male patient.

Surgical Treatment of Ruptured Renal Artery Aneurysm: A Report of 2 Cases

The rupture of a renal artery aneurysm is a rare disease that is difficult to diagnose. Although we usually consider the appropriate treatment to be open laparotomy with aortic aneurysm surgery or stenting with graft insertion through intravascular intervention, thus far, there is no general consensus on the treatment protocol for renal artery aneurysm. Notably, ruptured renal artery aneurysm is a true critical emergency that may result in a fatal outcome. We are reporting two renal artery aneurysm patients who had ruptured and underwent emergency laparotomy.

Floating Thrombus in Aortic Arch

Floating thrombi in the aortic arch are very rare and an unusual source of systemic embolism. Herein, a case of a 3-cm thrombus in the aortic arch is reported. It was a floating, highly mobile thrombus attached to the lesser curvature of the aortic arch. The patients had a hypercoagulable disorder induced by protein C and S deficiency. The thrombus was operatively removed with a favorable outcome.

An Unusual Case of Superior Vena Cava Syndrome Caused by the Intravascular Invasion of an Invasive Thymoma / 결핵및호흡기질환

Superior vena cava syndrome (SVCS) is usually caused by extrinsic compression or invasion of the superior vena cava (SVC) by malignant tumors involving mediastinal structures. Although thymomas are well-known causes of SVCS, cases of SVCS caused by malignant thymomas protruding into adjacent vessels draining the SVC with thrombosis have been very rarely reported worldwide. We experienced a 39-year-old female patient with SVCS that developed after the direct invasion of the left brachiocephalic vein (LBCV) and SVC by an anterior mediastinal mass with a high maximum standardized uptake value on the chest computed tomography (CT) and positron emission tomography-CT. Based on these results, she underwent en bloc resection of the tumor, including removal of the involved vessels, and was eventually diagnosed as having a type B2 thymoma permeating into the LBCV and SVC. We present this case as a very rare form of SVCS caused by an invasive thymoma.

Iatrogenic Perforation of the Left Ventricle during Insertion of a Chest Drain

Chest draining is a common procedure for treating pleural effusion. Perforation of the heart is a rare often fatal complication of chest drain insertion. We report a case of a 76-year-old female patient suffering from congestive heart failure. At presentation, unilateral opacity of the left chest observed on a chest X-ray was interpreted as massive pleural effusion, so an attempt was made to drain the left pleural space. Malposition of the chest drain was suspected because blood was draining in a pulsatile way from the catheter. Computed tomography revealed perforation of the left ventricle. Mini-thoracotomy was performed and the drain extracted successfully.

Iatrogenic Perforation of the Left Ventricle during Insertion of a Chest Drain

Chest draining is a common procedure for treating pleural effusion. Perforation of the heart is a rare often fatal complication of chest drain insertion. We report a case of a 76-year-old female patient suffering from congestive heart failure. At presentation, unilateral opacity of the left chest observed on a chest X-ray was interpreted as massive pleural effusion, so an attempt was made to drain the left pleural space. Malposition of the chest drain was suspected because blood was draining in a pulsatile way from the catheter. Computed tomography revealed perforation of the left ventricle. Mini-thoracotomy was performed and the drain extracted successfully.

A Nasal Myiasis in a 76-Year-Old Female in Korea

On July 2009, 5 fly larvae were discovered inside the nose of a 76-year-old female. She was living in Cheonan-si, and in a state of coma due to rupture of an aortic aneurysm. Surgery was performed on the day of admission, and the larvae were found 4 days later. By observing their posterior spiracle, the larvae were identified as Lucilia sericata. Considering the rapid development of this species, the infection was likely acquired during hospitalization. Further investigation on the hospital environment should be needed to know the origin of the infection.

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.

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.

Clinical Analysis of Disease Recurrence for the Patients with Secondary Spontaneous Pneumothorax / 대한흉부외과학회지

BACKGROUND: Secondary spontaneous pneumothorax is caused by various underlying lung diseases, and this is despite that primary spontaneous pneumothorax is caused by rupture of subpleural blebs. The treatment algorithm for secondary pneumothorax is different from that for primary pneumothorax. We studied the recurrence rate, the characteristics of recurrence and the treatment outcomes of the patients with secondary spontaneous pneumothorax. MATERIAL AND METHOD: Between March 2005 to March 2007, 85 patients were treated for their first episodes of secondary spontaneous pneumothorax. We analyzed the characteristics and factors for recurrence of secondary spontaneous pneumothorax by conducting a retrospective review of the medical records. RESULT: The most common underlying lung disease was pulmonary tuberculosis (49.4%), and the second was chronic obstructive lung disease (27.6%). The recurrence rate was 47.1% (40/85). The second and third recurrence rates were 10.9% and 3.5%, respectively. The mean follow up period was 21.1+/-6.7 months (range: 0~36 month). For the recurrence cases, 70.5% of them occurred within a year after the first episode. The success rates according to the treatment modalities were thoracostomy 47.6%, chemical pleurodesis 74.4%, bleb resection 71% and Heimlich valve application 50%. Chemical pleurodesis through the chest tube was the most effective method of treatment. The factor that was most predictive of recurrence was 'an air-leak of 7 days or more' at the first episode. (p=0.002) CONCLUSION: The patients who have a prolonged air-leak at the first episode of pneumothorax tend to have a higher incidence of recurrence. Further studies with more patients are necessary to determine the standard treatment protocol for secondary spontaneous pneumothorax.

Surgical Treatment for Descending Necrotizing Mediastinitis / 대한흉부외과학회지

BACKGROUND: Descending necrotizing mediastinitis (DNM) is a serious disease originating in odontogenic or oropharyngeal infection with high mortality despite adequate antibiotics and aggressive surgery. We analyzed results of treatment for DNM. MATERIAL AND METHOD: We studied 8 cases diagnosed as DNM from 1998 to 2007. All patients received emergent surgical drainage and debridement with broad spectrum antibiotics just after diagnosis. Antibiotics were changed after bacterial susceptibility testing. The surgical approach included 2 cases of cervicotomy, 6 cases of cervicotomy, and a thoracotomy. RESULT: The interval between symptom onset and hospitalization was 4.6+/-1.8 days (1~9 day). DNM originated in 4 cases of odontogenic infection (50%), 2 cases of oropharyngeal infection (25%), and 2 cases of unknown origin (25%). Causative organisms were found in 6 cases; Streptococcus in 4 cases, Staphylococcus in 1 case, and Klebsiella in 1 case. The Endo DNM classification was type I (2 cases), IIA (3 cases), and IIB (3 cases). The incidence of thoracotomy was 75%. The surgical mortality rate was 25% (2/8). The cause of death was multiple organ failure caused by septic shock. All mortality cases received only cervicotomy and aggravated infections after initial drainage. CONCLUSION: Early diagnosis, immediate surgical drainage, and adequate antibiotics, including covered anaerobes, are required. Thoracotomy should be performed with cervicotomy even for localized DNM.

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.

The Proteasome Inhibitor MG132 Sensitizes Lung Cancer Cells to TRAIL-induced Apoptosis by Inhibiting NF-kappaB Activation / 결핵및호흡기질환

BACKGROUND: TRAIL (TNF-related apoptosis inducing ligand) is a newly identified member of the TNF gene family which appears to have tumor-selective cytotoxicity due to the distinct decoy receptor system. TRAIL has direct access to caspase machinery and induces apoptosis regardless of p53 phenotype. Therefore, TRAIL has a therapeutic potential in lung cancer which frequently harbors p53 mutation in more than 50% of cases. However, it was shown that TRAIL also could activates NF-kappaB in some cell lines which might inhibit TRAIL-induced apoptosis. This study was designed to investigate whether TRAIL can activate NF-kappaB in lung cancer cell lines relatively resistant to TRAIL-induced apoptosis and inhibition of NF-kappaB activation using proteasome inhibitor MG132 which blocks I kappa B alpha degradation can sensitize lung cancer cells to TRAIL-induced apoptosis. METHODS: A549 (wt p53) and NCI-H1299 (null p53) lung cancer cells were used and cell viability test was done by MTT assay. Apoptosis was confirmed with Annexin V assay followed by FACS analysis. To study NF-kappaB-dependent transcriptional activation, a luciferase reporter gene assay was used after making A549 and NCI-H1299 cells stably transfected with IgGkappa-NF-kappaB luciferase construct. To investigate DNA binding of NF-kappaB activated by TRAIL, electromobility shift assay was used and supershift assay was done using anti-p65 antibody. Western blot was done for the study of I kappa B alpha degradation. RESULTS: A549 and NCI-H1299 cells were relatively resistant to TRAIL-induced apoptosis showing only 20~30% cell death even at the concentration 100 ng/ml, but MG132 (3microM) pre-treatment 1 hour prior to TRAIL addition greatly increased cell death more than 80%. Luciferase assay showed TRAIL-induced NF-kappaB transcriptional activity in both cell lines. Electromobility shift assay demonstrated DNA binding complex of NF-kappaB activated by TRAIL and supershift with p65 antibody. I kappa B alpha degradation was proven by western blot. MG132 completely blocked both TRAIL-induced NF-kappaB dependent luciferase activity and DNA binding of NF-kappaB. CONCLUSION: This results suggest that inhibition of NF-kappaB can be a potentially useful strategy to enhance TRAIL-induced tumor cell killing in lung cancer.

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.