Effect of timing of thrombectomy on survival of thrombosed arteriovenous hemodialysis grafts.

BACKGROUND: The use of an arteriovenous (AV) graft for hemodialysis is associated with a relatively high rate of thrombosis. Unfortunately, the urgent thrombectomy is not always readily available. Our aim was to investigate a possible association between the timing of thrombectomy and the patency rates of AV grafts. METHODS: A retrospective single-center study on patients who underwent thrombectomy of clotted AV grafts was conducted. According to the time of thrombectomy, all patients were divided into 4 groups. RESULTS: Primary graft patency at 6 months after thrombectomy was 28.3%, with no significant difference between the study groups (P = .161). Secondary graft patency at 6 months was significantly worse in the group that underwent thrombectomy between the third and fifth days than in the whole cohort: 15.4% versus 45.6% (P = .038). CONCLUSIONS: Timing of thrombectomy of a clotted AV graft may have a significant impact on the graft survival.

Long-term follow-up of patients after carotid stenting with or without distal protective device in a single tertiary medical center.

OBJECTIVE: To evaluate the immediate and long-term clinical outcomes after carotid artery stenting (CAS) with and without protection devices (PDs), compared with carotid endarterectomy (CEA). METHODS: A total of 116 patients with symptomatic carotid stenosis underwent CAS; 56 patients (48.3%) underwent CAS-PD; and 137 patients underwent CEA. RESULTS: There were more ipsilateral transient ischemic attacks (TIAs) in the CEA group than in CAS-PD and CAS + PD (4 [3%] vs 1 [1.6%] and 0 respectively, P = 0.02). In the CAS-PD group there were more vertebrobasilar TIAs, ipsi- and contralateral strokes, myocardial infarctions, and death rates in the 30-day postprocedural period. After 8-year follow-up, there were 18 (30%) death cases in the CAS-PD group, 10 death cases (17%) in the CAS + PD patients, and 15 death cases (11%) in the CEA group of patients (P = .02). CONCLUSION: Our data show that CAS + PD was associated with lower rate of vascular complications and mortality compared with CAS-PD and CEA.

Management of symptomatic vertebral hemangioma: follow-up of 6 patients.

STUDY DESIGN: Retrospective study. OBJECTIVE: To analyze our experience in the treatment of symptomatic vertebral hemangioma, review the relevant literature, and propose a management algorithm. SUMMARY OF BACKGROUND DATA: Hemangioma is one of the commonest benign neoplasms affecting the vertebral column. These usually dormant lesions may become symptomatic by causing pain, neurologic deficit, or both. Several treatment modalities are available in the management of such symptomatic conversion. METHODS: The clinical and radiographic data of 6 patients diagnosed with symptomatic vertebral hemangioma and treated at our medical center over a period of 10 years were reviewed and analyzed retrospectively. RESULTS: Six patients were diagnosed with symptomatic vertebral hemangioma between 1998 and 2008. The lesions occupied the thoracic, lumbar, or multiple segments. Our patients presented with either simple or radicular back pain. One patient had muscle weakness, 3 revealed sensory impairment, and the remaining 2 were neurologically intact. Four patients underwent preoperative transarterial embolization followed by laminectomy and vertebroplasty of the affected level and 2 patients were treated with vertebroplasty alone. A 35-year-old woman presented during pregnancy. Her clinical course during evaluation was complicated by an acute pulmonary embolic event that necessitated installation of an inferior vena cava filter. All patients had an overall uneventful postoperative course and reported symptomatic relief to varying degrees, at an average follow-up period of 35 months. CONCLUSIONS: Symptomatic hemangioma involving the vertebral column may pose a therapeutic challenge, often requiring the active involvement of several disciplines. A review of the relevant literature, however, discloses only few management algorithms for such lesions. The coupling of preoperative transarterial embolization followed by vertebroplasty, with or without surgical decompression depending on the patients' presenting symptoms, is a relatively safe treatment and may offer long-term symptomatic relief in these patients. Other aspects of treatment are further discussed.

Thoracic empyema in high-risk patients: conservative management or surgery?

We retrospectively analyzed the data of 119 patients who were treated for empyema thoracis from 1999 to 2007. There were 87 men with a mean age of 63.9 years (range, 19-79 years) and 32 women with a mean age 55.2 years (range, 26-78 years). The empyema was right-sided in 73 patients and left-sided in 46. The etiology was parapneumonic in 43.7% of cases, postoperative in 42.0%, posttraumatic in 11.8%, and due to other causes in 2.5%. Eight (6.7%) patients underwent surgery on admission because of unstable clinical status; all 8 survived. Fibrinolysis was used in 111 (93.3%) patients; of these, 88 (73.9%) were successfully treated by intrapleural urokinase instillation, and 23 (19.4%) failed treatment and underwent surgery. All 88 patients who had successful fibrinolytic therapy survived, they accounted for 1.8% of the morbidity. In the 23 patients who underwent surgery after failed treatment, there were 3 deaths, accounting for 2.7% overall mortality and 6.3% morbidity. Treating thoracic empyema in patients with significant comorbidities is challenging. Intrapleural urokinase administration might be beneficial in high-risk patients, but in those without significant comorbidities, early surgery may be considered.

Selection of patients with severe pelvic fracture for early angiography remains controversial.

BACKGROUND: Patients with severe pelvic fractures represent about 3% of all skeletal fractures. Hemodynamic compromise in unstable pelvic fractures is associated with arterial hemorrhage in less than 20% of patients. Angiography is an important tool in the management of severe pelvic injury, but indications and timing for its performance remain controversial. METHODS: Patients with major pelvic fractures [Pelvic Abbreviated Injury Score (AIS) >or= 3] admitted to two high volume Trauma Centers from January 2000 to June 2005 were identified and divided into two groups: Group I patients did not undergo angiography, Group II patients underwent angiography with/without embolization. Demographics, hemodynamic status on admission, concomitant injuries, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), pelvic AIS, blood requirement before and after angiography, arterial blood gases and mortality were evaluated. Patients with an additional reason for hemodynamic instability were excluded. RESULTS: Charts of 106 patients were retrospectively reviewed. Twenty nine patients (27.4%) underwent angiography. Bleeding vessel embolization was performed in 20 (18.9%) patients. Patients who underwent angiography had a significantly higher pelvic AIS and a lower Base Excess level on admission. A blood transfusion rate of greater than 0.5 unit/hour was found to be a reliable indicator for early angiography. CONCLUSION: A high pelvic AIS, amount of blood transfusions and decreased BE level should be considered as an indicators for early angiography in patients with severe pelvic injury.

Carotid artery stenting in high risk patients with carotid artery stenosis not eligible for endarterectomy: clinical outcome after 5 years.

BACKGROUND: Carotid artery stenting is used as an alternative to surgical endarterectomy. OBJECTIVES: To determine the outcome of CAS in a retrospective cohort of patients. METHODS: Between July 1999 and March 2003, 56 consecutive patients with carotid artery stenosis who were considered ineligible for surgery were treated (45 males, 11 females, mean age 69). All underwent the procedure prior to the introduction of distal protective devices in Israel. RESULTS: Intraprocedural complications included transient neurological findings in 5 patients (8%), cerebrovascular accident in 2 (3%), hemodynamic changes in 11 (18%), and 4 procedural failures. Post-procedural complications included transient ischemic attack in 3 patients and cardiovascular accident in 6 (10%). At 30 days follow-up, three patients (5%) remained with signs of CVA. Two patients (3%) died during the post-procedural period and 16 (28%) during the 5 year follow-up, one due to recurrent CVA and the remainder to non-neurological causes. Five-year carotid Doppler follow-up was performed in 25 patients (45%), which revealed normal stent flow in 21 (84%), 50-60% restenosis in 3 (12%) and > 70% restenosis in one patient (4%). CONCLUSIONS: This study confirms that stent procedures are beneficial for symptomatic carotid stenosis in patients not eligible for surgery.

Hypothenar hammer syndrome: apropos of six cases and review of the literature.

Hypothenar hammer syndrome (HHS) is a rather rare condition and is a term used to describe an aneurysm or thrombosis of the ulnar artery. It is considered an occupational or recreational injury and is usually a result of a repetitive trauma to the hypothenar region where the unique anatomy of the Guyon canal allows arterial injury. HHS is one of the less common causes of symptomatic ischemia of the upper extremity. The aim of this article is to describe our experience with six patients. Presenting signs, symptoms, differential diagnoses, and literature review of this probably underdiagnosed syndrome are described. There are two pathologic entities: the aneurysmal type and the thrombotic type. Although most authors recommend watchful observation for the thrombotic type, reconstructive surgery is the treatment of choice for the aneurysmal type.

Lumbar disk replacement with the ProDisc prosthesis.

Twenty-two ProDisc II prostheses (Spine Solutions, New York, New York) were implanted in 21 patients with degenerative disk disease at L5-S1 (19 disks) and L4-L5 (3 disks). After mean follow-up of 3.1 years (range, 17-49 months), pain intensity in all but 3 patients had improved from an average of 7.7 preoperatively to 4.6 postoperatively (P< .001) on a visual analog scale. Average Oswestry Disability Index score improved from 61 to 35 (P< .001). Radiographic reconstruction of the disk space height was achieved in all cases. Previous diskectomy at the implanted level and disk degeneration adjacent to previous fusion negatively influenced the results.

Arteriovenous malformation after uterine curettage: a report of 3 cases.

BACKGROUND: Acquired uterine arteriovenous malformation is a rare but potentially life threatening condition and, as such, must be considered in the differential diagnosis of cases of abrupt, profuse vaginal bleeding following uterine curettage. The condition can easily be confused with retained products of conception and gestational trophoblastic disease. CASES: One case was managed surgically, while 2 others were treated with selective embolization. CONCLUSION: A positive medical history, the clinical presentation and features for the the ultrasonic appearance are the main features for the correct differential diagnosis and treatment of traumatic arteriovenous malformation resulting from uterine curettage.

Intradiscal cement leak following percutaneous vertebroplasty.

STUDY DESIGN: A retrospective study to detect patients with cement leakage into the disc space following vertebroplasty. OBJECTIVE: To determine the frequency, causes, and clinical significance of cement leakage into the disc space. SUMMARY OF BACKGROUND DATA: Much has been written about cement leakage into the epidural space following vertebroplasty but only little about intradiscal leakage. METHODS: A total of 66 patients with 1 cemented osteoporotic, fractured vertebra between T5 and L5 were followed for at least 2 years. Two of the senior authors (Y.M. and A.P.) evaluated independently cement leakage into the disc space, possible causes were investigated, and the clinical results were evaluated according to patient self-assessment. RESULTS: Detected in 27 patients, cement leakage into the disc space did not negatively affect patient satisfaction with the procedure. In 7 of these patients, leakage occurred through an intravertebral vacuum cleft and, in 8, through a perforation of the endplate created by the needle tip. In only 2 patients was cement found to cross the height of the vertebral body and leak into the contralateral disc. CONCLUSIONS: Apart from iatrogenic endplate perforation, cement extravasation into the disc space was always found to occur through the fractured endplate or a vacuum cleft. Placing the needle tip far from the fractured endplate and using more solid cement appear to decrease the risk of leakage.

[Comparative morbidity for different accesses in percutaneous nephrolithotripsy].

BACKGROUND: Over the last decades percutaneous nephrolithotripsy (PCNL) has been developed as an alternative for open renal operations in the treatment of complex renal stones. Currently, different approaches are used for the collecting system. OBJECTIVES: To estimate the overall morbidity of different approaches to the collecting system during PCNL; to compare the complication rates for PCNL through the upper pole of the kidney with lower pole access and multiple access approaches. METHODS: We retrospectively reviewed 174 patients (178 renal units) who underwent PCNL. They formed three groups according to surgical access: upper pole (n = 107), lower pole (n = 51) and multiple (n = 20). Inter-group data on procedure related complications were compared. RESULTS: Postoperative fever was more frequent in the upper pole group (34%) compared to the other two groups (25% each, p < 0.49). There was a higher rate of pulmonary complications in the upper pole and multiple access groups (21% and 20%, respectively) compared with the lower pole group (2%, p=0.007). The rate of bleeding and need for blood transfusion was significantly higher in the multiple access group than in the other groups (20% vs 5% and 6%, respectively, p < 0.05). CONCLUSIONS: The upper and multiple access approaches were associated with a higher overall incidence of pleural effusion compared with the lower pole access. The incidence of bleeding and transfusion rates were similar using the upper and lower pole accesses but higher in the multiple access group. Provision of an enhanced surgical field and greater maneuverability together with 'the treatable nature of the associated complications favor an upper pole access, especially for removing a large stone burden.

Deep vein thrombosis prevention in joint arthroplasties: continuous enhanced circulation therapy vs low molecular weight heparin.

Deep vein thrombosis prevention efficacy using a new, miniature, mobile, battery-operated pneumatic system (continuous enhanced circulation therapy [CECT] system) combined with low-dose aspirin was compared to enoxaparin. One hundred twenty-one patients who underwent total hip or knee arthroplasty were prospectively randomized into 2 groups. The study group was treated by the CECT system starting immediately after the induction of anesthesia. Postoperatively, a daily 100-mg aspirin tablet was added. The control group received 40 mg of enoxaparin per day. Bilateral venography was performed at the fifth to eight postoperative day. In the CECT group, as compared to the enoxaparin group, there was a significantly lower overall rate of DVT and proximal DVT. Safety profiles were similar in both groups. The combination of the CECT device with low-dose aspirin is more effective than enoxaparin in preventing deep-vein thrombosis after lower limb arthroplasties.

Vacuum clefts of the vertebral bodies.

BACKGROUND AND PURPOSE: The appearance of vacuum clefts (VCs) of the vertebral bodies has frequently been considered pathognomonic for avascular necrosis. Until recently, this was considered to be a rare finding that might indicate excessive motion at the fracture site. Our aim in this retrospective study was to determine the occurrence and location of these clefts in patients with osteoporotic vertebral fractures and evaluate the risk factors involved for developing these clefts in such patients. METHODS: The records of 66 patients with 101 painful osteoporotic vertebral fractures who were treated by vertebroplasty in our department were reviewed. All the fractures with VCs were collected. Age, sex, degree of deformity, and extent of degenerative changes in the adjacent disk space were compared with those found in the patients without clefts. RESULTS: VCs were found in 26 fractured vertebrae of 26 patients. They were significantly more common in elderly men who had deformed fractures located at the thoracolumbar junction, when compared with fractures without clefts, especially when degenerative changes were observed in the adjacent disk space. CONCLUSION: This study suggests that VCs, which have long been considered pathognomonic for avascular necrosis (Kümmell disease), are not rare and most probably represent fracture nonunion. Elderly patients who have deformed fractures at the thoracolumbar area have a higher risk for developing clefts, mainly when there is degeneration of the adjacent disk space.

Contrast media augmented apoptosis of cultured renal mesangial, tubular, epithelial, endothelial, and hepatic cells.

RATIONALE AND OBJECTIVE: Nephrotoxicity of contrast media, resulting in apoptosis and acute necrosis of tubular cells, is well documented. No studies concerning mesangial cells apoptosis have been published yet. AIM: Apoptosis of cultured mesangial, tubular, and hepatic cell lines was investigated following exposure to different contrast media. METHODS: Apoptosis was assessed by TUNEL assay and verified by Mayer Hematoxylin staining. RESULTS: Iopromide, Ioxaglate, and Ioxatalamate induced apoptosis in all cell cultures at final concentrations ranged from 0.1% to 10.0%. However, only 1% to 10% Iomeprol elicited a significant apoptosis. Moreover, at 10% concentration, Iomeprol induced significantly less apoptosis than Iopromide, Ioxaglate, or Ioxatalamate. CONCLUSIONS: First, Iomeprol, which has a different physico-chemical properties, proved to be less proapoptotic compared with other contrast compounds. Second, all types of cells similarly respond by apoptosis to contrast media induced injury. However, apoptosis of mesangial cells might generate additional deleterious effects in vivo.

Neonatal periappendicular abscess--updated treatment.

The authors present a case of periappendicular abscess in a 5-day-old full-term neonate. Prompt diagnosis enabled us to deliver conservative treatment followed by interval laparoscopic appendectomy, instead of a risky urgent laparotomy. This is the first description of an advanced imaging-guided drainage procedure, followed by minimal invasive surgery, for the treatment of periappendicular abscess at such a young age.