Staple aneurysmorrhaphy to salvage autogenous arteriovenous fistulas with aneurysm-related complications.

OBJECTIVE: Aneurysm-related complications could lead to loss of a functioning arteriovenous fistula (AVF). We report our midterm and long-term results with the staple aneurysmorrhaphy technique to repair and preserve aneurysmal AVFs. METHODS: We retrospectively reviewed our surgical treatment of patients with aneurysmal autogenous AVF complicated by skin erosion, bleeding, infection, pain, and difficulty with needle access from 2007 through 2014. We identified 52 patients, 40 (77%) of whom underwent repair with the staple aneurysmorrhaphy technique. The operation involved mobilizing the entire aneurysmal segments. A TA (Covidien, Norwalk, Conn) or Endo GIA (Covidien, Mansfield, Mass) stapler was used to resect the redundant aneurysm wall to create a 6- to 8-mm-diameter conduit. A subcutaneous skin flap was created after excising compromised skin. The remodeled vein was repositioned underneath the subcutaneous flap, with the staple line rotated laterally to avoid needle puncture. RESULTS: We attempted staple aneurysmorrhaphy in 40 patients with complicated AVF aneurysms, of which 38 repairs (95%) were successful. Median patient age was 66 years (range, 29-88 years). Median AVF age was 63 months (range, 12-136 months). Median follow-up was 20 months (range, 5-81 months). At 1 year, primary patency was 67%, assisted primary patency was 88%, and secondary patency was 91%. At 2 years, primary patency was 59%, assisted primary patency was 84%, and secondary patency was 91%. At 3 years, primary patency was 46%, assisted primary patency was 69%, and secondary patency was 85%. Surgery was performed under local-regional anesthesia in 28 patients (70%) and under general anesthesia in the remaining 12 (30%). Proximal venous outflow stenoses were detected in 19 of 40 AVFs (48%) preoperatively and in 11 of 38 AVFs (29%) postoperatively. Aneurysm recurrence occurred in two repaired AVFs. CONCLUSIONS: Our experience with staple aneurysmorrhaphy shows that it is an effective, safe, and durable procedure to preserve a functioning autogenous AVF with complicated aneurysmal degeneration. Key principles are to reduce the vein to normal adjacent diameter and to provide healthy skin coverage. The remodeled AVF has a low aneurysm recurrence rate and maintains the beneficial properties of superior patency and low infection. It is important to aggressively monitor for and treat proximal outflow venous stenoses to prevent aneurysm recurrence. The surgery can be done safely under local anesthesia in selected patients.

Sequelae of World War II: an outbreak of chronic cutaneous nontuberculous mycobacterial infection among Satowanese islanders.

BACKGROUND: After World War II, residents of Satowan (population, 650 persons), an outer island in the state of Chuuk, Federated States of Micronesia, noted a high prevalence of a chronic, progressive skin disease known locally as "spam." METHODS: Island residents who had chronic, progressive verrucous or keloidal plaques for >3 months were considered case patients. Tissue specimens were obtained for culture, histopathological analysis, mycobacterial polymerase chain reaction (PCR), and comparison with the hsp65 gene of Mycobacterium marinum. We performed a case-control study involving all cases and randomly selected control individuals from the community. RESULTS: A total of 39 case patients were identified, with a median age of 26.0 years (range, 8-82 years); 74.4% were male, and the mean duration of disease was 12.5 years. A total of 98 control individuals were enrolled. Results of all 19 mycobacterial tissue cultures were negative, and histopathological analysis of all 9 lesions showed suppurative granulomatous inflammation with negative results of mycobacterial and fungal stains. In 7 of 9 paraffin-embedded samples, nontuberculous mycobacterial DNA was detected by PCR, and 2 sequenced products had 95% and 87% identity to M. marinum. All case patients were taro farmers (odds ratio, undefined; P < .01), and among taro farmers, when the analysis was controlled for sex, contact with water-filled World War II-era bomb craters was associated with infection (odds ratio, 8.2; P < .01). CONCLUSIONS: "Spam disease" is a chronic, progressive skin disease of high prevalence on Satowan and is associated with taro farming and contact with World War II-era bomb craters. Histopathological and PCR data demonstrate a nontuberculous mycobacterial infection as the cause.