Impact of Incidental Findings During the Evaluation of Live Kidney Donors on Post-Transplant Outcomes: A Single Center Analysis.

BACKGROUND: A careful assessment of a living donor is mandatory to minimize the short- and long-term risk related to kidney donation. In this study, we evaluated the incidence of incidental findings (IFs) in a large population of potential living kidney donors. Moreover, this study evaluated if the presence of IFs could influence the chance of living kidney donation and post-transplant outcomes. METHODS: One hundred and sixty consecutive potential prospective living kidney transplant donors, who underwent a multidetector computed tomography angiography (MDCTA), were included in the study. An IF was defined as an incidentally discovered mass or lesion, detected by computed tomography angiography during the imaging evaluation of potential living donors. Clinical outcomes of living donors with IF were compared with those without IF. RESULTS: In 10 patients (6.2%) an incidental finding was detected at MDCTA assessment. Among the 10 patients presenting with an IF, 7 patients (4.3%) were excluded from the living donation: 2 patients with an adrenal lesion, 3 patients with cancer, and 2 patients with a large (>8 cm) renal cyst. Graft and patient survival of kidney transplant recipients of donors with IFs were not significantly different to those receiving a kidney from living donors without IFs. CONCLUSIONS: Incidental findings are frequently discovered during living kidney donor evaluation. Whereas most are asymptomatic or not clinically relevant, predonation screening could identify potentially life-threatening diseases at an earlier stage, allowing for a more radical treatment.

Mid-term sustained relief from headaches after balloon angioplasty of the internal jugular veins in patients with multiple sclerosis.

OBJECTIVES: Multiple sclerosis (MS) patients frequently suffer from headaches and fatigue, and many reports have linked headaches with intracranial and/or extracranial venous obstruction. We therefore designed a study involving MS patients diagnosed with obstructive disease of internal jugular veins (IJVs), with the aim of evaluating the impact of percutaneous transluminal angioplasty (PTA) on headache and fatigue indicators. METHODS: 286 MS patients (175 relapsing remitting (RR), 75 secondary progressive (SP), and 36 primary progressive (PP)), diagnosed with obstructive disease of IJVs, underwent PTA of IJVs during the period 2011-2015. This included 113 headache positive patients (82 RR, 22 SP, and 9 PP) and 277 fatigue positive patients (167 RR, 74 SP, and 36 PP). Migraine Disability Assessment (MIDAS), and the Fatigue Severity Scale (FSS) were evaluated: before PTA; 3-months after PTA; and at final follow-up in 2017. Patients were evaluated with Doppler sonography of the IJVs at 1, 6 and 12 months after PTA and yearly thereafter. Non-parametric statistical analysis was performed using a combination of the Friedman test and Spearman correlation analysis. RESULTS: With the exception of the PP patients there were significant reductions (all p < 0.001) in the MIDAS and FSS scores in the 3-month following PTA. The improvement in MIDAS score following PTA was maintained throughout the follow-up period in both the RR (p < 0.001; mean of 3.55 years) and SP (p = 0.002; mean of 3.52 years) MS cohorts. With FSS, significant improvement was only observed at 2017 follow-up in the RR patients (p < 0.001; mean of 3.37 years). In the headache-positive patients, post-PTA MIDAS score was significantly negatively correlated with the change in the blood flow score in the left (r = -0.238, p = 0.031) and right (r = -0.250, p = 0.023) IJVs in the RR patients and left IJV (r = -0.727, p = 0.026) in the PP patients. In the fatigue-positive cohort, post-PTA FSS score was also significantly negatively correlated with the change in blood flow in the right IJV in the PP patients (r = -0.423, p = 0.010). In addition, the pre and post-PTA FSS scores were significantly positively correlated in the fatigue-positive RR (r = 0.249, p = 0.001) and SP patients (r = 0.272, p = 0.019). CONCLUSIONS: The intervention of PTA was associated with a large and sustained (>3 years) reduction in MIDAS score in both RR and SP MS patients. While a similar initial post-PTA reduction in FSS score was also observed, this was not maintained in the SP and PP patients, although it remained significant at follow-up (>3 years) in the RR MS patients. This suggests that venoplasty might be a useful intervention for treating patients with persistent headaches and selected concomitant obstructive disease of the IJVs.

Factors influencing the hemodynamic response to balloon angioplasty in the treatment of outflow anomalies of internal jugular veins.

OBJECTIVE: Percutaneous transluminal angioplasty (PTA) of the internal jugular veins (IJVs) has been proposed in recent years to treat chronic cerebrovascular venous insufficiency, with discordant results. Moreover, very little is known about the efficacy of PTA in restoring a normal cerebral venous outflow. The aim of this study was to investigate the anatomic factors and patient characteristics that might influence the efficacy of PTA of the IJV. METHODS: There were 797 consecutive patients with venous outflow anomalies who underwent standardized, operator-independent catheter venography and PTA of the IJVs. Before and after PTA, morphologic and hemodynamic anomalies of the IJVs were documented. The primary end point of the study was to evaluate the morphologic factors influencing the efficacy of angioplasty in improving IJV outflow. RESULTS: PTA resulted in an increased outflow through the IJVs in most patients. However, younger individuals with transverse endoluminal defects and higher pre-PTA flows are more likely to respond well to PTA compared with those who exhibit hypoplasia, stenosis, or longitudinal endoluminal defects. CONCLUSIONS: This study identified the factors that influence and could predict the efficacy of PTA in the treatment of IJV anomalies.

Surgical Treatment of Residual Distal Intimal Flap during Eversion Carotid Endarterectomy.

BACKGROUND: Eversion carotid endarterectomy (ECEA) is an effective surgical technique for the treatment of internal carotid artery (ICA) stenosis. However, a residual distal intimal flap may determine a higher rate of neurological complications. The treatment of DIF may be challenging, and no definitive approach has been described. We describe a simple surgical option for the treatment of DIF. METHODS: After internal ECEA has been performed, stitches are positioned at the side of intimal flap. Suture sequence is performed from internal-external-external-internal artery wall including the everted ICA, maintaining the suture thread inside the vessel. Once the ICA is correctly repositioned, the suture thread is pulled out. Once the standard carotid anastomosis has been performed, the flap is finally tacked. RESULTS: Fifteen patients have undergone surgical repair of DIF with the modified technique. No patients developed neurological complications after the surgical procedure, and all patients are still alive at last follow-up visit. CONCLUSIONS: This simple technique seems a safe and feasible surgical option to correct DIF, avoiding challenging surgical procedures that may increase operative and clamping time.

Everolimus-Eluting Stent for Patients With Critical Limb Ischemia and Infrapopliteal Arterial Occlusive Disease.

BACKGROUND: Critical limb ischemia (CLI), despite revascularization, may result in minor or major amputations with devastating psychological effects and a negative impact on patient survival. Randomized clinical trials demonstrated that drug-eluting stents improve 1-year primary patency and decrease target lesion revascularization, compared to standard angioplasty and bare-metal stents, in patients with short occlusive below-the-knee lesions. OBJECTIVES: This prospective clinical study was designed to evaluate if one straight-line flow revascularization to the foot, using Xience-Prime Everolimus-Eluting Stent (EES), is an effective treatment of patients in Rutherford-Becker category 4 to 5 with distal popliteal and proximal tibial arteries long occlusive lesions up to 10 cm. METHODS: All patients with angiographic documented segment P3 of popliteal artery and proximal tibial arteries stenosis >70%, and lesion length between 20 mm and 100 mm, meeting the inclusion criteria, were included in the Etna Registry. The end points assessed were 1- and 3-year primary patency, major amputation-free survival, target lesion revascularization, and wound healing rates. RESULTS: Between June 2011 and April 2014, 122 patients were included in the study, with mean lesion length of 52.7 mm (range: 20-100 mm). The 1- and 3-year primary patency rates were 88.9% and 80.1%, respectively. The survival, major amputation-free survival, and target lesion revascularization rates were 88.1%, 93%, and 91.5% at 1-year and 70.4%, 89.3%, and 85.1% at 3-year follow-up, respectively. Primary patency influenced major amputation rate, which was 60% in patients with no target artery patency versus 5.4% in patients with patency ( P = .022). At 1-year follow-up, 78 (88.6%) of 88 patients improved 1 or more of their Rutherford-Becker category, and 48 (80%) of 69 patients had wound healing. CONCLUSIONS: The results of our study suggest that a conservative approach, with EES, seems feasible in selected patients with CLI and infrapopliteal artery occlusive disease.

Better prognosis of elderly patients with infectious endocarditis in the era of routine echocardiography and nonrestrictive indications for valve surgery.

OBJECTIVE: It has been reported that endocarditis in the elderly may have a poor outcome. Our aim was to assess the different features and prognosis, if any, in the present time. METHODS: Of 103 patients with proven endocarditis, 31 were 65 years or older and 72 were younger than 65 years. Degenerative heart disease was seen more frequently in the elderly (22.5% vs 2.7%, P =.003). Drug abuse and immunodeficiency virus infection were more common in the younger group, as was tricuspid endocarditis (26.3% vs 0%, P <.001). At clinical presentation cardiac failure (41.9 vs 19.4%, P =.02) and leukocytosis (61.2% vs 40.2%, P =.049) were seen more frequently in the elderly. RESULTS: Despite other similar clinical features, it took longer to diagnose older patients (7.2 +/- 6.2 vs 3.2 +/- 3.5 days, P <.001). Enterococcus infected the aged more often (32.2% vs 13.1%, P =.001). During hospitalization, heart failure and embolization tended to be more common in the elderly and the younger group, respectively. There were no significant differences in the incidence of anatomic complications, the need for operation, and overall mortality. CONCLUSION: Although a worse prognosis has been reported in elderly patients with infective endocarditis, the early use of transesophageal echocardiographic examinations and equal therapeutic options provides a similar outcome when compared with younger subjects.