A case report on the placement of a temporal dialysis catheter in the femoral artery for emergency dialysis.

Background: Ensuring vascular access is essential for dialysis patients. This can be achieved through an arteriovenous anastomosis (fistulae), a central venous catheter, or an arteriovenous graft. However, in some cases vascular access to the patient's blood is not possible. Case Presentation: A multi-vascular male patient, who had been undergoing dialysis for 17 years, was presented to our renal department. There was no possibility of vascular access to the patient's venous network for dialysis. A peritoneal dialysis catheter was inserted, but it was malfunctioning. An attempt was made to place a HeRO AV Graft, but it did not succeed due to contraindications from the patient's venous network, as shown by the computed tomography. While trying to solve the problem in order to dialyze the patient during his hospitalization, he experienced severe shortness of breath with tachypnea (pulmonary edema), along with acidosis and hyperkalemia. A temporal dialysis catheter was urgently inserted into the left femoral artery and isolated ultrafiltration was performed, and by removing 1500 ml of ultrafiltration, the patient improved significantly. During the subsequent days, he underwent another 11 dialysis sessions using the femoral artery catheter. While he was hospitalized and being dialyzed via the femoral artery, a successful effort was made to catheterize the right external jugular vein, from which he continues to be dialyzed today. Conclusion: The patient's treatment through the placement of a temporal dialysis catheter in the femoral artery enabled him to survive. It is our belief that such a solution could be helpful in similar cases.

Histology and Immunohistochemistry of Radial Arteries Are Suggestive of an Interaction between Calcification and Early Atherosclerotic Lesions in Chronic Kidney Disease.

Background and Objectives: recent studies suggest an implication of immune mechanisms in atherosclerotic disease. In this paper, the interaction between inflammation, calcification, and atherosclerosis on the vessel walls of patients with chronic kidney disease (CKD) is described and evaluated. Materials and Methods: patients with stage V CKD, either on pre-dialysis (group A) or on hemodialysis (HD) for at least 2 years (group B), in whom a radiocephalic arteriovenous fistula (RCAVF) was created, were included in the study. The control group included healthy volunteers who received radial artery surgery after an accident. The expressions of inflammatory cells, myofibroblasts, and vascular calcification regulators on the vascular wall were estimated, and, moreover, morphometric analysis was performed. Results: the expressions of CD68(+) cells, matrix carboxyglutamic acid proteins (MGPs), the receptor activator of nuclear factor-kB (RANK) and RANK ligand (RANKL), and osteoprotegerin (OPG), were significantly increased in CKD patients compared to the controls p = 0.02; p = 0.006; p = 0.01; and p = 0.006, respectively. In morphometric analysis, the I/M and L/I ratios had significant differences between CKD patients and the controls 0.3534 ± 0.20 vs. 0.1520 ± 0.865, p = 0.003, and 2.1709 ± 1.568 vs. 4.9958 ± 3.2975, p = 0.03, respectively. The independent variables correlated with the degree of vascular calcification were the intensity of CD34(+), aSMA(+) cells, and OPG, R2 = 0.76, p < 0.0001, and, with intima-media thickness (IMT), the severity of RANKL expression R2 = 0.3, p < 0.0001. Conclusion: atherosclerosis and vascular calcification in CKD seem to be strongly regulated by an immunological and inflammatory activation on the vascular wall.

Thrombosed Aneurysm of Superficial Epigastric Vein Simulating Inguinal Hernia: Report of Two Cases.

AIM: Presentation of two cases of superficial epigastric vein aneurysm simulating inguinal hernia. To our knowledge, only one other case is reported in the literature. Case presentation. The first case was a 34-year-old female with left inguinal pain and swelling which was clinically diagnosed as inguinal hernia. The second case was a 28-year-old female with inguinal pain and swelling, depicted with triplex ultrasonography and computed tomography, and was suspected to have inguinal hernia or enlarged inguinal lymph node. During the surgical exploration, both patients were found to have thrombosed aneurysm of the superficial epigastric vein. During the surgical exploration, both patients were found to have thrombosed aneurysm of the superficial epigastric vein. The superficial epigastric vein was ligated, and the venous aneurysms (6 × 4 × 3 and 2 × 3 × 2.5 cm, respectively) were excised. Histological examination of the thrombosed aneurysm showed complete replacement of the vascular wall by fibrous tissue, thrombosis, and an inflammatory reaction. There were no postoperative complications, and both patients were discharged on the second postoperative day. The 3-month and 1-year follow-up examination, respectively, was uneventful. CONCLUSION: Although venous aneurysms in the inguinal area are rare, they should be included in the differential diagnosis of a groin swelling.

Giant Posttraumatic Angiolipoma of the Forearm: A Case Report and Review of the Literature.

Angiolipoma is a type of lipoma, a benign soft tissue tumor. It is distinguished by the excessive degree of vascular proliferation and the presence of mature adipocytes. It occurs commonly on the trunk and extremities. Angiolipomas larger than 4 cm are classified as "giant," and due to their size, histological evaluation is necessary to exclude malignancy. We report a case of a male patient who suffered from a giant noninfiltrating intramuscular angiolipoma which formed after venipuncture in the antecubital fossa. Clinical examination showed a palpable painless soft mass. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a giant angiolipoma on the right forearm. Surgical removal of the mass was performed, and the biopsy was negative for malignancy. To the best of our knowledge, this is the first report in the literature of posttraumatic intramuscular angiolipoma. Physicians and orthopedic/general surgeons should be aware of the possibility of soft tissue masses in a posttrauma situation.

Abdominal rectus muscle pyomyositis: Report of a case and review of the literature.

Pyomyositis is an uncommon primary bacterial infection of skeletal muscles, usually caused by Staphylococcus aureus. Predisposing factors for pyomyositis include immunodeficiency, trauma, injection drug use, concurrent infection and malnutrition. The diagnosis, staging of the disease and differential diagnosis are established by ultrasound, CT and MRI. Treatment involves surgical drainage and antibiotic therapy. We report a case of abdominal rectus muscle pyomyositis, which constitutes, as far as we know, the second reported in bibliography, while Prevotella disiens is firstly reported as causative agent.

Left Brachiocephalic Vein Stenosis due to the Insertion of a Temporal Right Subclavian Hemodialysis Catheter.

Central vein stenosis/occlusion is a common well-described sequel to the placement of hemodialysis catheters in the central venous system. The precise mechanisms by which central vein stenosis occurs are not well known. Current concepts in central vein stenosis pathophysiology focus on the response to vessel injury model, emphasizing the process of trauma. A case of left brachiocephalic vein stenosis due to the insertion and function of a temporary right subclavian hemodialysis catheter is presented. The purpose of the manuscript is to emphasize that, with the introduction of a temporary subclavian hemodialysis catheter via the right subclavian vein apart from causing concurrent stenosis/infarction of the right subclavian and right brachiocephalic vein, it is also possible to cause stenosis of the left brachiocephalic vein (close to its contribution to the superior vena cava) although the catheter tip is placed in the correct anatomical position in the superior vena cava.

Fournier's Gangrene: Lessons Learned from Multimodal and Multidisciplinary Management of Perineal Necrotizing Fasciitis.

BACKGROUND: Fournier's gangrene (FG) is a rapidly evolving necrotizing fasciitis of the perineum and the genital area, the scrotum as it most commonly affects man in the vast majority of cases. It is polymicrobial in origin, due to the synergistic action of anaerobes and aerobes and has a very high mortality. There are many predisposing factors including diabetes mellitus, alcoholism, immunosuppression, renal, and hepatic disease. The prognosis of the disease depends on a lot of factors including but not limited to patient age, disease extent, and comorbidities. The purpose of the study is to describe the experience of a general surgery department in the management of FG, to present the multimodal and multidisciplinary treatment of the disease, to identify predictors of mortality, and to make general surgeons familiar with the disease. METHODS: The current retrospective study is presenting the experience of our general surgery department in the management of FG during the last 20 years. The clinical presentation and demographics of the patients were recorded. Also we recorded the laboratory data, the comorbidities, the etiology, and microbiology and the therapeutic interventions performed, and we calculated the various severity indexes. Patients were divided to survivors and non-survivors, and all the collected data were statistically analyzed to assess mortality factors using univariate and then multivariate analysis. RESULTS: In our series, we treated a total of 24 patients with a mean age 58.9 years including 20 males (83.4%) and 4 females (16.6%). In most patients, a delay between disease onset and seeking of medical help was noted. Comorbidities were present in almost all patients (87.5%). All patients were submitted to extensive surgical debridements and received broad-spectrum antibiotics until microbiological culture results were received. Regarding all the collected data, there was no statistically significant difference between survivors and non-survivors except the presence of malignancy in non-survivors (p = 0.036) and the lower hemoglobin (p < 0.001) and hematocrit (p = 0.002) in non-survivors. However, multivariate analysis did not reveal any predictor of mortality. CONCLUSION: Early diagnosis, aggressive thorough surgical treatment, and administration of the proper antibiotic treatment comprise the cornerstone for the outcome of this disease. In small populations like in the present study, it is difficult to recognize any predictors of mortality and even the severity indexes, which take into account a lot of data cannot predict mortality.

Spontaneous rupture of a giant renal angiomyolipoma-Wunderlich's syndrome: Report of a case.

INTRODUCTION: Herein we present a rare case of pontaneous rupture of a giant renal angiomyolipoma (AML), with symptoms of hypovolemic shock (Wunderlich's syndrome), which was managed by urgent total nephrectomy. PRESENTATION OF CASE: A 53 year old female was transferred to the emergency room with progressive acute painful swelling of the left lateral abdominal area, duration of 5h. An emergent ultrasonic examination, revealed a heterogeneous-solid mass with maximum diameter of 23cm, with probable origin from the left kidney. Due to worsening of the clinical status (hypovolemic shock), loss of consciousness and acute drop of haematocrit level to 17.8%, the patient was urgently intubated in the emergency room and transferred to the operating theater. A giant haemorrhagic mass was found originating from the left kidney, which removed en-block with the left kidney. The patient was transferred to the intensive care unit. Her recovery was uneventful. The histopathologic examination revealed a giant renal angiomyolipoma (25×18×8cm) with extensive bleeding. DISCUSSION: Enlarged renal AMLs can rupture. This can be sudden and painful with manifestations of hypovolemic shock. The management of AMLs has been correlated with symptoms. Patients with life-threatening retroperitoneal haemorrhage, require urgent exploration as retroperitoneal bleeding can lead to severe complications, increasing morbidity. CONCLUSION: In case of giant angiomyolipoma with intratumoral haemorrhage, and symptoms of Wunderlich's syndrome, partial or total nephrectomy is a good treatment option in order to save the patient's life.

Giant extra gastrointestinal stromal tumor of lesser omentum obscuring the diagnosis of a choloperitoneum.

INTRODUCTION: Herein we present an extremely rare case of a giant extra gastrointestinal stromal tumor (EGIST) of the lesser omentum obscuring the diagnosis of a choloperitoneum. PRESENTATION OF CASE: A 79 years old female was admitted to our hospital with symptoms of vomiting and epigastric pain. Abdominal computer tomography revealed a sizable formation that was diagnosed as a tumor of the pancreas. In laparotomy, a choloperitoneum was diagnosed as the cause of patient's symptoms. A tumor adherent firmly to the lesser curvature of stomach was also discovered. Cholecystectomy and subtotal gastrectomy were performed. Histologically, the tumor was diagnosed as a EGIST of the lesser omentum. The patient did not receive any adjuvant therapy and after two years of follow up she is without any recurrence. DISCUSSION: Omental EGISTs may remain clinically silent despite the large tumor's size. It is difficult to differentiate a EGIST in the lesser omentum from a GIST of the lesser curvature of the stomach, despite the use of advanced radiological imaging techniques. Our case of a giant EGIST of lesser omentum obscuring the diagnosis of acute choloperitoneum is the only one reported in literature. CONCLUSION: EGISTs that arise from the omentum are very rare and complete surgical resection is the only effective treatment approach. Adjuvant therapy following resection of localized disease has become standard of care in high risk cases.

Hemodialysis catheter malposition induced by a brachiocephalic vein stenosed stent.

Malposition of a central venous hemodialysis catheter, mainly due to central vein stenosis or thrombosis, is not an uncommon complication. Herein, we present a rare cause of a left external jugular vein hemodialysis catheter, malpositioned into the ipsilateral internal jugular-subclavian venous route, due to a stenosed stent that has been placed into the ipsilateral brachiocephalic vein.

Unusual malpositioning of hemodialysis catheter into the hepatic veins.

Malpositioning of long-term hemodialysis catheter is a known complication that may lead to a gradual decline in blood flow. We report two rare catheter malpositions in the hepatic veins in two patients with end-stage renal disease in whom a dialysis catheter was inserted through the left external jugular vein and the right external jugular vein. Because of gradual reduction of catheters' blood flow, an angiography was performed, which confirmed catheters' tip positioning into the hepatic veins. The catheters were replaced in the correct site.

Mycotic abdominal aortic aneurysm infected by Vibrio mimicus: report of a case.

This report describes a case of a mycotic aneurysm of the infrarenal abdominal aorta infected by Vibrio mimicus, which is the only such case ever reported in the literature. The 80-year-old male patient was first treated for gastroenteritis for 7 days. Two months later, he was admitted to the hospital and the aneurysm was diagnosed by three-dimensional computed tomography. The aneurysm was excised and the restoration was done using a 16-mm Dacron straight graft. The cultivation of the excised aneurysm and the inflammatory fluid was positive for V. mimicus. The postoperative period was free of complications and the patient has remained asymptomatic during the 4-year follow-up.