No contraindication to internal jugular central venous catheter insertion in patients at increased risk of bleeding: Results from a prospective observational study in a internal medicine department.

Implantation of centrally inserted central venous catheter (CICC) may be complicated by bleedings particularly in patients with severe coagulopathy or taking antithrombotic drugs. It has been shown that the application of the Italian Group for Venous Access Devices (GAVeCeLT) bundle reduces the incidence of bleeding in patients admitted to intensive care units (ICU), but its effectiveness has never been demonstrated in different contexts. In this study we evaluated the incidence of bleeding after urgent internal jugular CICC (J-CICC) implantation in patients with increased or no risk of bleeding complications when recommended preventive strategies are applied systematically. We included 185 patients admitted to Internal Medicine Units who underwent urgent J-CICC implantation from April 2016 to December 2018. The incidence of major and minor bleeding immediately after the procedure and in the following 30 days was recorded. None of the enrolled patients showed major bleeding. The incidence of minor bleedings was 2.1% (95% IC: 0.03-4.2) with two patients requiring line removal and repositioning (1.1%; 95% IC: -0.45 to 2.6). Bleeds were not correlated with age or sex, although they all occurred in female subjects. The incidence of bleeds was not increased in patients with increased risk of bleeding compared with those without (5.0% vs 1.3%; p = 0.16). The use of anti-thrombotic medications was significantly associated with increased risk of minor bleedings (p = 0.03). In this study we demonstrated that the application of the GAVeCeLT suggested bundle can minimize the number of bleeding complications even in patients hospitalized in Internal Medicine Units. Further data are needed in patients taking antithrombotic drugs who appear to be more prone to minor bleeding, however the benefit of completing the procedure appears to significantly outweigh the risk of mechanical complications.

[CEUS, a world to discover. Three clinical cases and literature review].

Currently, CEUS (Contrast-Enhanced UltraSound) is used in the evaluation of different organs and systems. It offers valuable information about vascular disease, both on a macro- and a micro-vascular level, and has a series of well-established applications in the monitoring of adult patients; official guidelines and recommendations are also available. Its use in a nephrological setting is constantly growing thanks to the lack of nephrotoxicity of the contrast agent, the absence of ionizing radiation and the possibility of characterizing focal pathologies, for diagnosis and in clinical practice. We describe here 3 clinical cases relating to renal diseases and we review the relevant literature with a specific focus on the use of CEUS in a nephro-urological setting.

[Peripheral hypoperfusion syndrome and monomielic syndrome: from diagnosis to treatment. Case report with review of the literature].

Arteriovenous access ischemic steal is a fairly uncommon complication associated with the creation of a vascular access for hemodialysis, which can sometimes cause potentially devastating complications, with permanent disability. Several old names for this syndrome have now been replaced by two new denominations: Hemodialysis Access-Induced Distal Ischemia (HAIDI) and Distal Hypoperfusion Ischemic Syndrome (DHIS). Clinically, we distinguish between the Peripheral Hypoperfusion Syndrome, which can cause gangrene of the fingers, and the Monomelic Syndrome, characterized by low incidence and by the presence of neurological dysfunctions. Risk factors include diabetes mellitus, atherosclerotic vascular disease, old age, female gender, tobacco use and hypertension. We report the case of a patient with HAIDI in order to increase awareness on this syndrome's early diagnosis and proper management. After describing the case, we also include a literature review.

[Management of the incidental renal masses].

The diagnosis of renal masses has increased in the last decades owing to the widespread use of imaging (ultrasound, computed tomography and magnetic resonance). Majority of the renal masses are detected incidentally on routine ultrasound examination. Solid masses detected on ultrasound require further imaging evaluation with CT and/or MRI for suitable characterization. US-guided renal biopsy is a safe, effective and accurate method for evaluating the small renal masses with ambiguous radiologic findings. Navigation technology and multimodality image fusion represent an important development in interventional radiology, especially for performing difficult percutaneous biopsies and ablations of small renal masses. Multidisciplinary approach is required which results from experience and knowledge and in hard cases the use of serial imaging can be helpful.

Buttonhole Cannulation of the AV Fistula: A Critical Analysis of the Technique.

As a consequence of the central role of the arteriovenous fistula for dialysis (AVF) in the clinical management of the dialysis patient the necessity to limit the puncture-related complications to extend as much as possible the life of the vascular access. Accordingly, the AVF needling technique has gained growing attention. Alongside the traditional rope ladder (RL) puncture method, the buttonhole technique (BH) is increasingly popular; this technique employs the same cannulation sites of AVF in every dialysis associated with the use of dull needles to minimize vessels damage. The BH technique, utilized only for native AVF, is considered an appropriate alternative to the RL and is now recommended by several scientific societies for its reported benefits such as: AVF greater ease of cannulation, less pain, faster hemostasis and less tendency to the creation of aneurysms and hematomas. The use of BH is especially recommended in cases in which the RL is problematic with short or winding venous sections and in home dialysis in which the patient performs the needling. However recent evidence in literature, countering these theoretical advantages, indicates that the BH technique appears to be closely related to an increased risk of local and systemic infections. Furthermore, the purported benefits of BH have not held up under closer examination.

[Clinical, ultrasound and treatment of aneurysms and pseudoaneurysms in hemodialysis vascular access]. / Clinica, ecografia e trattamento degli aneurismi e pseudoaneurismi nell'accesso vascolare dell'emodializzato.

Aneurysms (AN) and pseudoaneurysms are among the complications of vascular access. AN is a focal area of expansion, concentric or eccentric, with the wall consistency the same as all elements of the vessel wall (intima, media and adventitia). Pseudoaneurysm, or false aneurysm, is a blood harvesting without vascular wall, it is characterized by a reactive capsule of connective tissue that delimits it. The K/DOQI guidelines recommend a regular program of monitoring and surveillance of the vascular access. Color-Doppler ultrasound is considered a valuable tool in the preoperative evaluation and in the follow-up. The echo-color-Doppler surveillance plays an important role in diagnosis of aneurysm. It allows monitoring the evolution of the aneurysm, studying vessels walls, thickened because of intimal hyperplasia and to identify the presence of thrombotic material and/or calcification of the wall. Early identification of complications and the adoption of corrective measures will extend the life of the vascular access, with benefit for the patient. Moreover, it will reduce health care costs.

Aneurysms and pseudoaneurysms in dialysis access.

Aneurysms are a common and often difficult complication seen with arteriovenous vascular access for haemodialysis. The purpose of this narrative review is to define and describe the scale of the problem and suggested therapeutic strategies. A narrative review of the published literature illustrated by individual cases is presented with the aim of summarising the relevant literature. The definitions of aneurysm are inconsistent throughout the literature and therefore systematic review is impossible. They vary from qualitative descriptions to quantitative definitions using absolute size, relative size and also size plus characteristics. The incidence and aetiology are also ill defined but separation into true aneurysms and false, or pseudoaneurysms may be helpful in planning treatment, which may be conservative, surgical or radiological. The lack of useful definitions and classification along with the multitude of management strategies proposed make firm evidence based conclusions difficult to draw. Further robust well designed studies are required to define best practice for this common problem.

[Radiofrequency in the treatment of the renal neoplasias]. / La radiofrequenza nel trattamento delle neoplasie renali.

The tumors of the kidney are around the 3% of the neoplasia in adult patients and, at the postmortem examination, the renal neoplasias has a frequency of 1/300 for tumors diameter of 1 to 2 cms. In the treatment of the small neoplasias, techniques of nephron sparing and enucleation are used. These techniques have shown the same therapeutic effectiveness of the radical nephrectomy in patients with tumors smaller than 4 centimeters, with reduction of morbidity. However, there are few clinical situation in which the surgery has a high risk: patients with solitary kidney, chronic renal failure, multiple localizations involving also contralateral kidney, in patients with other malignancies and in von Hippel-Lindau Syndrome. Recently, percutaneous mininvasive techniques have been applied (ex. thermoablation): these techniques allow to reduce the duration of general anesthesia, they offer the possibility to use spinal anaesthesia (besides deep sedation and general anaesthesia) with reduction in mortality during surgery. The most commonly used among interstitial therapies is the radiofrequency (RF), which changes electromagnetic waves into heat. RF used both tomography and ultrasound-guided. The latter is the most recommended because it allows to follow the procedure in real-time. The treatment of renal tumors with RF, in which surgery is inadvisable, is safe and effective especially in peripheral and/or exophytic lesions lower than 4 cm. However the larger tumors can also be treated successfully with combined therapy or multiple sessions.