Multi-perspective ultrasound evaluation of Carotid Intima-Media thickness in hemodialysis access patients and its possible use to predict clinical outcomes.

BACKGROUND: Hemodialysis (HD) patients present an increased carotid intima-media thickness (CIMT) and calcified plaques, and studies have demonstrated that CIMT is predictor for cardiovascular death in this patient population; hence, the importance of identifying early non-invasive markers of atherosclerosis. We aim to propose a new three-perspective CIMT measuring method in HD population, and to further investigate the possible use and value of this method to predict outcomes. METHODS: A cross-sectional study was conducted, the CIMT was measured with duplex ultrasound during the perioperative access planning. Software provided maximum CIMT in a 10 mm (mm) width of the common carotid artery. CIMT was measured in Right (R) and Left (L) carotid arteries, both in anterior (a), lateral (l), and posterior (p) view. The sum of these values (Ra+Rl+Rp+La+Ll+Lp) was completed and termed as Sixth Carotid Intimal (SCI) score. We stratified either in low (summation <4) or high (>=4) SCI score groups. Demographics, patency rates, complications, and mortality were collected; chi-square test was used for our analysis. RESULTS: A total of 30 patients (mean age 49 years and 56% females) that underwent access creation in the upper arm from 2010 to 2016 were selected and studied. A low SCI score was found 19 patients and 11 had high SCI, no significant difference was observed in demographics, history cardiovascular disease, and clinical outcomes as early thrombosis, and primary, primary-assisted patency at 12 months. Interestingly, during the follow up period of 36 months a significant higher difference in late thrombosis rates occurred (63.6% vs 26.3%, p = .044) and a higher all-cause mortality (54.4% vs 15.7%, p = .025) in patients with SCI score group above 4. CONCLUSIONS: The SCI score method, might offer a screening tool for traditional cardiovascular risk factors in HD patients. In this study, we demonstrate an increased rate in late thrombosis and mortality in those with high SCI. Further research is necessary to better define the role of CIMT in vascular surgical procedures.

Review of surgical treatment of iatrogenic iliofemoral artery injury in the pediatric population after catheterization.

Trauma is the leading cause of death in the pediatric population. Although vascular trauma has an incidence of 6% in civilian population, iatrogenic injuries are the leading cause, and the most frequent injured vessel is the iliofemoral sector. However, little information is available and there are no guidelines about its treatment. Therefore, this review aimed to describe the information available concerning pediatric iatrogenic arterial trauma, focusing on the iliofemoral segment and present 3 cases. We described 11 articles with 171 patients, of whom 61% underwent surgery to treat iatrogenic trauma. Mean age was 3.28 years (standard deviation of 3.5 years), and 54% were female. Most iliofemoral injuries occurred after arterial catheterization for hemodynamic monitorization and therapeutic or diagnostic cardiac catheterization (due to congenital heart diseases, including septal defects, tetralogy of Fallot, aortic coarctation, and patent ductus arteriosus). For acute complications, arterial thrombosis was the leading injury, followed by pseudoaneurysm, hematoma, dissection, transection, avulsion, eversion, and combined lesions.

Efforts for detection of aortic aneurysms and human resources training for the optimization of their treatment.

OBJECTIVE: To review admissions, interventions and in-hospital mortality associated to Abdominal Aortic Aneurysms (AAA), and to analyze the impact of the introduction of a training program and imaging screening at our institution. METHODS: Retrospective study where hospitalizations, procedures and mortality secondary to AAA were recorded. The national databases (ND) from the Secretariat of Health were utilized from 2010 to 2020. In-hospital lethality was calculated and compared with the experience at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ). The statistical analysis was completed with the STATA version 17. RESULTS: According to the ND, 899 (91%) hospital admissions secondary to AAA occurred, while in the INCMNSZ 85 (9%). Most of them belonged to the male gender (68%); 811 (82%) patients underwent open surgical repair, and 173 (18%) to an endovascular exclusion (EVAR), the latter approach was significantly more frequently performed at our institution (p = 0.007). The 30-day hospital mortality was 22.5%; in the ND was 23.9 vs. a 16.4% in the INCMNSZ without significant difference (p = 0.1). CONCLUSIONS: AAA remain unrecognized in our country. The introduction of University programs and imaging screening might impact in the early detection, and to reduce the morbidity and mortality associated to emergency procedures.

OBJETIVO: Revisar los ingresos, procedimientos y defunciones intrahospitalarias asociadas a aneurismas aórticos abdominales (AAA) y analizar el impacto de la introducción de programas de formación de recursos humanos y tamizaje ultrasonográfico. MÉTODOS: Estudio retrospectivo, se analizaron las bases de datos nacionales obtenidas del portal datos abiertos de la Dirección General de Información en Salud (DGIS) del año 2010 al 2020. Se calculó la letalidad intrahospitalaria anual y comparamos la experiencia del Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ). El análisis estadístico se realizó en el programa STATA versión 17. RESULTADOS: De acuerdo con la base nacional (BN), se registraron 899 (91%) ingresos, mientras que en el INCMNSZ 85 (9%). La mayoría pertenecía al sexo masculino (68%), un total de 811 (82%) pacientes fueron sometidos a cirugía abierta, mientras que 173 (18%) a terapia endovascular (EVAR), siendo este abordaje más frecuente en nuestra institución (p = 0.007). La mortalidad intrahospitalaria fue del 22.5%, en la BN fue del 23.9%, mientras que en el INCMNSZ fue del 16.4%, sin que encontráramos diferencia significativa (p = 0.1). CONCLUSIONES: Los AAA continúan siendo poco reconocidos en nuestro país. La introducción de programas universitarios de especialidad y el tamizaje podría impactar en la reducción de la morbimortalidad.

Congenital pelvic kidney perfusion during infrarenal aortic aneurysm repair.

Purpose: This case report describes a patient with a pelvic kidney associated with an aortoiliac aneurysm amenable to open repair. Methods: We chose the selective cold renal perfusion to preserve renal function. Results: Other techniques such as transient or permanent extra-anatomic bypass, extracorporeal circulation and proximal aortic double clamping are also described in this report. Conclusions: Choosing the renal perfusion technique depended on the anatomical evaluations of the kidney and the renal artery location during the preoperative period.

Acute Venous Disease Anomalies in Critically Ill COVID-19 Patients.

INTRODUCTION: Other entities besides deep vein thrombosis (DVT) affecting the venous system, such as superficial vein phlebitis (SVP) and superficial vein thrombophlebitis (SVT), receive poor attention in the literature. However, both entities may propagate proximally into the deep venous system and progress to a DVT. To our knowledge, the relevance of other venous findings such as SVP or SVT in coronavirus disease 2019 (COVID-19) patients has not been evaluated. This work aimed to assess the clinical, biochemical, and hematological variables associated with the incidence of acute venous diseases, such as DVT, SVP, and SVT, in a cohort of 74 critically ill COVID-19 patients and their association with mortality. METHODS: Given the high thrombotic risk, all patients underwent venous imaging with bedside ultrasound. Clinical variables were obtained from medical records. Comparisons were made by the chi-square test or Fisher's exact test. We constructed Kaplan-Meier curves and used Cox proportional hazard models to calculate hazard ratios for dichotomized risk factors to identify predictors of mortality. SPSS version 21.0 (IBM Corp., Armonk, NY) was used for statistical analysis. RESULTS:  SVP occurred in 28 patients (37.8%), DVT in 22 patients (29.7%), and 28 patients died (37.8%). Elevated D-dimer was associated with DVT but not with SVP. Neither SVP nor DVT was associated with mortality. After adjusting for age, elevated troponins (OR: 2.4, 95% CI: 1.1-5.4), platelets < 244 cell/mm3 (2.4, 1.1-5.6), and IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) bleeding score > 7 (2.8, 1.3-6.3) were predictors of mortality. CONCLUSIONS: Acute venous findings such as SVP and DVT are highly prevalent and independent of mortality in critically ill COVID-19 patients. These entities are not related, although they may occur synchronically. DVT is frequently presented as an asymptomatic distal bilateral finding associated with elevated D-dimer, decreased ferritin, and higher vasoactive drug use but independent from chronic venous disease. Interestingly, elevated troponins, decreased platelets, and a prognostic value > 7 of the IMPROVE bleeding score were predictors of mortality in this group of critically ill COVID-19 patients.

Acute Mesenteric Ischemia Prior to Emergency Cardiac Surgery for Infective Endocarditis: Can We Design a Strategy to Improve Outcomes?

Infective endocarditis (IE) can be complicated by systemic embolization. Unfortunately, in some situations, it requires radical and urgent therapeutic approaches. Herein, we describe a case of IE complicated by acute mesenteric ischemia (AMI) due to septic embolism prior to emergent cardiac surgery. A previously healthy 38-year-old woman was admitted to our emergency department with a diagnosis of mitral valve IE. She presented with tachycardia and was tachypneic. In addition, a systolic murmur in the mitral area and Janeway lesions were documented. Transthoracic and transesophageal echocardiography confirmed large mobile vegetations on the mitral valve and the presence of mitral regurgitation. A thoracic computed tomography scan showed splenic and bilateral renal infarctions. Emergency mitral valve replacement was scheduled. Prior to surgery, AMI developed because of occlusion of the superior mesenteric artery (SMA). Endovascular treatment was performed with percutaneous aspiration, thrombectomy, and in situ fibrinolysis, yielding satisfactory results. Ten hours later, she underwent cardiac surgery. AMI developed postoperatively due to re-occlusion of the SMA, requiring an open laparotomy with mesenteric revascularization and extensive resection of the necrotic bowel. The patient died 18 days after hospitalization. In the IE setting, AMI is a very rare, potentially life-threatening complication. This case highlights the importance of recognizing this complication and designing a better therapeutic strategy to reduce the associated mortality rate.

Usefulness of preoperative three-dimensional volumetric analysis of carotid body tumors.

PURPOSE: The Shamblin classification is the commonest method to predict complications and outcomes during carotid body tumor (CBT) resection. The aim of this study is to describe the utility of the three-dimensional volumetric reconstruction (3DVR) analysis of the CBT and its relationship with postoperative outcomes. METHODS: Preoperative computed tomography angiography (CTA) was obtained to perform 3DVR of the CBT. Imaging data were analyzed and correlated with surgical outcomes: estimated blood loss (EBL), surgical time (ST), and hospital length of stay (HLOS). The Pearson test was used to determine the correlation between volume and postoperative outcomes. RESULTS: Fifty-seven patients were studied, 13 had Shamblin type I tumors with a mean 3DVR of 7.69 cm3 (standard deviation [SD 8.27]), 21 were type II with a mean 3DVR of 15.57 cm3 (SD 8.40), and 23 were type III with a mean 3DVR of 30.58 cm3 (SD 20.16). EBL mean was 559 milliliters (mL) (standard error [SE] 80.44), the mean ST of resection was 202 min (SD 67), and the mean HLOS was 5.8 days (SD 3.23). The Pearson test showed a correlation of r = 0.69 (p < 0.0001) between 3DVR and EBL, a r = 0.4 (p = 0.05) was obtained between 3DVR and ST, and finally, a r = 0.3 (p = 0.05) between 3DVR and HLOS was obtained. CONCLUSION: The preoperative 3DVR determination of CBTs allows to analyze possible predictors of surgical outcomes. We found a positive correlation between the 3DVR volume and EBL. Further research is necessary to validate this method in the evaluation of these rare neoplasms.

Predictive value of computed tomographic screening of aortic aneurysms in the Mexican population older than 55 years. / Valor predictivo del tamizaje con tomografía computarizada en la detección de aneurismas aórticos en la población mexicana mayor de 55 años.

Objective: To determine the prevalence of aortic aneurysm (AA) in tomographic studies in the population at risk. Methods: An observational, cross-sectional study that consisted in systematically reviewing computed tomographies (CT) of the chest and abdomen was carried out at our institution. These studies were performed for different clinical indications, we selected studies of patients older than 55 years from January 1, 2014 to December 31, 2016. Descriptive statistics was completed in the studied population and linear regression model was performed to determine the relationship of AA findings and the patient's age. Results: A total of 4809 patients were included in this study, 2707 (56%) were females. The mean age of the study population was 69 ± 9 years. The prevalence of aortic aneurysms was 5.63% (271) with a predominance in the male gender (9.5% vs. 2.9%). Of the total, 138 (2.8%) were located in the thoracic aorta and 133 (2.7%) were in the abdominal aorta. Linear regression model demonstrated a Y = 8.3 + 0.154, r2 = 0.03 (p = 0.001). Conclusions: Imaging screening with CT for aortic aneurysms has had a favorable impact in our institution and this reinforces the need to educate radiologists in the intentional search for this pathology. There is a positive correlation between the patient´s age and aortic diameter.

Analysis of the MELD Score Impact in the Outcome of Endovascular Portal Vein Reconstruction.

INTRODUCTION: Endovascular therapy represents a less invasive alternative to open surgery for reconstruction of the portal vein (PV) and the spleno-mesenteric venous confluence to treat Portal hypertension. The objective of this study is to determine if the Model for End-Stage Liver Disease (MELD) score is a useful method to evaluate the risk of morbidity and mortality during endovascular approaches. MATERIAL AND METHODS: Patients that underwent endovascular reconstruction of the PV or spleno-mesenteric confluence were identified retrospectively. Data were collected from November 2011 to August 2016. The MELD score was calculated using international normalized ratio, serum billirubin and creatinine. Patients were grouped into moderate (≤ 15) and high (> 15) MELD. Associations of the MELD score on the postprocedural morbidity, mortality and vessels patency were assessed by two-sided Fisher's exact test. RESULTS: Seventeen patients were identified; MELD score distribution was: ≤ 15 in 10 patients (59%) and > 15 in 7 (41%). Even distribution of severe PV thrombosis was treated in both groups, performing predominately jugular access in the high MELD score group (OR 0.10; 95%; CI 0.014-0.89; p = 0.052) in contrast to a percutaneous transhepatic access in the moderate MELD score group. Analysis comparing moderate and high MELD scores was not able to demonstrate differences in mortality, morbidity or patency rates. CONCLUSION: MELD score did not prove to be a useful method to evaluate risk of morbidity and mortality; however a high score should not contraindicate endovascular approaches. In our experience a high technical success, good patency rates and low complication rates were observed.

Surgical Interventions for Organ and Limb Ischemia Associated With Primary and Secondary Antiphospholipid Antibody Syndrome With Arterial Involvement.

OBJECTIVE: The association of antiphospholipid antibody syndrome (APS) and hypercoagulability is well known. Arterial compromise leading to ischemia of organs and/or limbs in patients with APS is uncommon, frequently unrecognized, and rarely described. We evaluated our institutional experience. METHODS: Retrospective review was conducted. From August 2007 to September 2016, 807 patients with diagnosis of APS were managed in our Institution. Patients with primary and secondary APS who required interventions were examined. Demographics, comorbidities, manifestations, procedures, complications, and other factors affecting outcomes were recorded. RESULTS: Fourteen patients (mean age 35 years old, standard deviation ±14) were evaluated and treated by our service. Six (43%) of them had primary APS and 8 (57%) had secondary APS; 11 (79%) were female. Two (14%) experienced distal aorta and iliac arteries involvement, 3 (21%) visceral vessels disease, 2 (14%) in upper and 7 (50%) in the lower extremity vasculatures. Thirteen (93%) patients underwent direct open revascularization and 1 with hand ischemia (Raynaud disease) underwent sympathectomy. During the mean follow-up period of 48 months, reinterventions included a revision of the proximal anastomosis of an aortobifemoral bypass graft, 1 (7%) abdominal exploration for bleeding, 1 (7%) graft thrombectomy, and 4 (29%) amputations (2 below the knee, 1 above the knee, and 1 transmetatarsal). One (7%) death occurred secondary to sepsis in a patient who had acute mesenteric ischemia. Significant differences in clinical manifestations and outcomes were not observed among patients with primary and secondary APS. All patients remained on systemic anticoagulation. CONCLUSION: APS is a prothrombotic disorder that may lead to arterial involvement with less frequency than the venous circulation but has significant morbidity and limb loss rate. Arterial reconstruction seems feasible in an attempt to salvage organs and limbs; however, research is necessary to establish the optimal anticoagulation regime and long-term management following surgical interventions.

Sequential Hybrid Repair of Aorta and Bilateral Common Iliac Arteries Secondary to Chronic Aortic Dissection with Extensive Aneurysmal Degeneration in a Marfan Patient.

Marfan syndrome is a connective tissue disorder associated with aortic dissection, aneurysmal degeneration and rupture. These cardiovascular complications represent the main cause of mortality, therefore repair is indicated. We present a 35-year-old woman who experienced acute onset of chest pain. Her imaging revealed a chronic DeBakey type I dissection with aortic root dilation and descending thoracic aneurysmal degeneration. She underwent a Bentall procedure and endovascular exclusion of the descending thoracic aortic aneurysm. She was closely followed and 2 years later a computed tomography angiography (CTA) revealed the aneurysmal degeneration of the thoracoabominal aorta and bilateral iliac arteries. The patient underwent a composite reconstruction using multi-visceral branched and bifurcated Dacron grafts. At 5 years from her last surgery, a CTA revealed no new dissection or further aneurysmal degenerations. Aortic disease in Marfan patients is a complex clinical problem that may lead to secondary or tertiary aortic reconstructions; close follow-up is mandatory.

Right Thoracoabdominal Approach for Retrocardiac Paraganglioma Resection.

Paragangliomas are rare extra-adrenal tumors of sympathetic or parasympathetic paraganglia origin; of these, mediastinal paragangliomas are 2% of all cases. We present the case of a 21-year-old woman with uncontrolled arterial hypertension who had a functioning 6.5 × 6.2-cm retrocardiac paraganglioma firmly attached to the pericardium. The patient underwent tumor resection via a right thoracoabdominal incision; this surgical approach enabled adequate exposure for complete resection without institution of cardiopulmonary bypass or need for cardiac reconstruction or autotransplantation. Ten months postoperatively, the patient was doing well and was no longer hypertensive.

Concomitant Surgical Treatment of Symptomatic Carotid Artery Disease With a Coexisting Shamblin I Carotid Body Tumor.

Symptomatic carotid artery atherosclerotic disease is an indication for carotid artery endarterectomy. The coexistence of carotid body tumors (CBTs) with symptomatic carotid disease is rarely encountered and adds significant challenges to vascular surgeons, with a reported overall mortality for patients who undergo endarterectomy and tumor excision of 8.8%, as opposed to the 2% for those who had CBT excision only. We describe the case of a 79-year-old female who experienced an acute cerebrovascular accident in the left hemisphere; duplex ultrasound revealed high-grade carotid stenosis in the left side and the presence of a Shamblin I CBT. The risks and benefits of the planned operation were reviewed, and the decision was made to proceed with early carotid endarterectomy and concomitant surgical resection of the tumor using the retrocarotid dissection technique. The patient recovered well, and at 11 months from the combined procedure, her neurological deficits improved significantly.

[Macroscopic hematuria secondary to nutcracker syndrome and successful endovascular treatment]. / Hematuria macroscópica secundaria a síndrome de cascanueces y tratamiento endovascular exitoso.

BACKGROUND: Nutcracker syndrome is a rare entity, and in the majority of cases is the result of extrinsic compression of the left renal vein between the superior mesenteric artery and the aorta, associated with functional stenosis. OBJECTIVE: To present the case of a 19-year-old female with no significant medical history with confirmed diagnosed of nutcracker syndrome treated successfully by endovascular means. CLINICAL CASE: She was referred to the Vascular Surgery Department with a 6-month history of macroscopic haematuria, after other aetiologies were ruled out. Abdominal computed tomography angiography revealed compression of the left renal vein; the patient underwent endovascular treatment, and a 12×16 mm balloon expandable stent was placed with immediate angiographic improvement, decreased pressure gradients and progressive resolution of haematuria. At one year, she remains symptom-free. CONCLUSION: Nutcracker syndrome is uncommon, and a high index of suspicion is needed. Macroscopic haematuria is not always present, and in our case stent placement demonstrated effectiveness in the resolution of symptoms at 12 months' follow--up. We also present a brief review of the literature.

Axillo-iliac arteriovenous hemodialysis graft creation with an early cannulation device.

Exhaustion of superficial veins coupled with the presence of intrathoracic central venous occlusions remains a significant obstacle for hemodialysis access creation; complex arteriovenous graft (AVG) configurations have been described. The axillary-iliac AVG was first reported in 1987, and few authors have explored this access. We evaluated our experience with this AVG configuration utilizing the early cannulation (EC) graft Flixene™ (Atrium ™, Hudson, NH, USA). Eight patients (75 % men; mean age 37 ± 10 years) with End-Stage Renal Disease (ESRD) underwent axillo-iliac AVG creation with Flixene™ grafts; all had exhausted peripheral veins, occluded thoracic central veins, and inadequate femoral veins. Inflow from the axillary artery and outflow in iliocaval system was assessed prior to access creation. An axillary-to-common iliac AVG was constructed using a 6 mm (mm) EC graft and tunneled in the chest and abdominal wall. Eight grafts were implanted; all were patent after placement. Seven (88 %) were successfully used for hemodialysis within 72 h and one (12 %) within 96. During the mean follow-up of 6 months, 5 (62 %) patients underwent thrombectomy, 1 (12 %) of them had balloon angioplasty at the vein anastomosis, and 2 (25 %) grafts were removed secondary to infection. The remaining grafts are still functioning. Complications as high-output heart failure, steal syndrome and venous hypertension were not observed. Construction of axillo-iliac AVG with EC grafts in the setting of exhausted veins, occluded intrathoracic central veins and hostile groins, is a viable arteriovenous access alternative while avoiding central venous catheters.

Left subclavian-carotid bypass in a 38-year old female with brain ischemic symptoms secondary to Takayasu's arteritis: A case report.

INTRODUCTION: Takayasu's arteritis (TA) is a rare form of vasculitis that affects the aorta, its branches and pulmonary arteries. TA is primarily treated by pharmacologic therapy; however revascularization procedures may be required to treat organ ischemia. Evidence-based consensus regarding the indications for surgical or endovascular therapy for patients with supra-aortic vessels lesions remains unclear. PRESENTATION OF CASE: We herein present a female patient with known TA since 2000, who experienced progressive and frequent episodes of amaurosis fugax in the left eye for 4 months. Computed tomography angiography (CTA) revealed focal stenotic segments in the right common carotid artery (CCA) and internal carotid artery (ICA) and near occlusion of the proximal left CCA. We opted to treat the left side first with open revascularization, and a subclavian-carotid bypass was performed using a 6 millimeters (mm) externally supported ePTFE graft. Patient recovered well from the surgery, her neurological exam was normal and she was discharged home in stable condition in postoperative day three. At three months she remains symptoms-free and her bypass is patent. DISCUSSION/CONCLUSION: This case illustrates the clinical presentation of TA affecting both carotid arteries; open revascularization via carotid subclavian bypass grafting was successfully performed with minimal morbidity, complete resolution of symptoms and improvement of the patient's quality of life. Revascularization procedures when indicated should be performed while the disease is inactive and close surveillance is mandatory.