A 20-Year Analysis of Ruptured Abdominal Aortic Aneurysm Outcomes and Associated Factors in Korea

BACKGROUND

Unlike western countries, which have reported distinct decreases in incidence of ruptured abdominal aortic aneurysm (rAAA) over the last few decades, epidemiologic studies in Korea have not shown significant changes in incidence or mortality of rAAA. The purpose of this study was to analyze the changes in rAAA treatment outcomes and various associated risk factors over the past 2 decades.

METHODS

A 20-year retrospective multicenter review for rAAA cases from the period of January 2000 to December 2020 was undertaken. Preoperative, intraoperative and postoperative clinical data were extracted for patients diagnosed with rAAA. For analysis, outcomes from the early era, defined as patients treated between January 1, 2000, and December 31, 2010, were compared with outcomes from the late era, defined as patients treated between January 1, 2011, and December 31, 2020.

RESULTS

The total in-hospital mortality was 34.1% in the early era compared to 44.8% in the late era. Patients in the late era were older than those in the early era (75.2 ± 10.3 years vs. 70.3 ± 8.9 years; P = 0.009). Treatment with rAAA endovascular aneurysm repair increased from 2.3% in early to 13.8% in late era (P = 0.031). In the early era, more patients were operated by experienced surgeons than the late era (78.1% vs. 45.9%; P = 0.002). The emergency room to operating room time did not show improvement over the 20 years.

CONCLUSIONS

The results indicate that mortality rate of rAAA in Korea has not changed over the last 2 decades. The study suggests the need for national preventive strategies, improved systemic coordination, and potential centralization of vascular services to enhance survival rates for rAAA.

Huge Pseudoaneurysm at the Aortic Bifurcation Misdiagnosed as a Mesenchymal Tumor: A Case Report

Aortic pseudoaneurysms (PA) vary in size and may remain asymptomatic. PAs may be caused by vascular injury, such as trauma or surgery, or other non-traumatic causes, such as Bechet disease, infection, or penetrating atherosclerotic ulcers. The diagnosis of PAs may have been delayed for decades. We present a case of a PA detected incidentally in a male patient who experienced traumatic bowel perforation due to blunt abdominal trauma 30 years before presentation. Computed tomography (CT) displayed a 9.2 cm mass in the pelvis, initially considered a neoplasm of small bowel origin. Further analysis of the CT images suggested a thrombosed PA at the aortic bifurcation, which was confirmed via surgical exploration. Graft interposition was performed using a Dacron 16-8 mm graft and the patient recovered without any complications. This case highlights the importance of a high index of suspicion for the diagnosis of a thrombosed aortic PA.

Outcome after early thrombotic occlusion of arteriovenous fistulas

OBJECTIVE

Arteriovenous fistulas (AVFs) are considered the first choice for venous access in end-stage renal disease patients, however, they are also known to have a high primary failure rate (early thrombosis and maturation failure). Of these, the outcome of thrombosed immature AVFs is not well known. This study aimed to investigate the outcome of AVFs with early thrombosis.

METHODS

Patients who underwent AVF creation from January 2009 to December 2019 at Seoul National University Hospital or Seoul Metropolitan Government - Seoul National University Boramae Medical Center were retrospectively reviewed. Patients who received salvage operations due to early thrombosis within 30 days after access creation were analyzed.

RESULTS

During the study period, a total of 45 patients (radiocephalic 26; brachiocephalic 19) developed early thrombosis and underwent salvage operations. The median age of patients was 61.0 (54.5-69.5) years, and 51.1% were male. The first salvage operation was performed on the median 1.0 (0.0-4.5) day after AVF creation. The most common cause for early thrombosis was venous stenosis (64.4%) and followed by poor arterial inflow (28.9%), especially in radiocephalic AVFs. About 20 AVFs were salvaged to maturation (46.5%). Post-salvage primary patency and secondary patency at 1 year was 72.6% and 100%. In a multivariate logistic regression, significant risk factors for maturation failures were minimum venous outflow diameter ⩽2.5 mm (OR, 4.433; 95% CI, 1.039-18.921; p = 0.044) and lower in patients with hypertension (OR, 0.064; 95% CI, 0.006-0.637; p = 0.019).

CONCLUSIONS

Thrombosed immature AVFs are associated with a high failure rate after salvage operation. However, if the salvage operation is successfully performed, it is associated with an acceptable 1-year outcome.

Association of high intra-patient variability in tacrolimus exposure with calcineurin inhibitor nephrotoxicity in kidney transplantation

Tacrolimus intra-patient variability (IPV) is a novel predictive marker for long-term kidney transplantation outcomes. We examined the association between IPV and calcineurin inhibitor (CNI) nephrotoxicity and the impact of pharmacogenes on CNI nephrotoxicity and IPV. Among kidney transplant recipients at our hospital between January 2013 and December 2015, the records of 80 patients who underwent 1-year protocol renal allograft biopsy and agreed to donate blood samples for genetic analysis were retrospectively reviewed. The cohort was divided into the low and high IPV groups based on a coefficient variability cutoff value (26.5%). In multivariate analysis, the IPV group was involved in determining CNI nephrotoxicity (HR 4.55; 95% CI 0.05-0.95; p = 0.043). The 5-year graft survival was superior in the low IPV group than in the high IPV group (100% vs 92.4% respectively, p = 0.044). Analysis of the time above therapeutic range (TATR) showed higher CNI nephrotoxicity in the high IPV with high TATR group than in the low IPV with low TATR group (35.7% versus 6.7%, p = 0.003). Genetic analysis discovered that CYP3A4 polymorphism (rs2837159) was associated with CNI nephrotoxicity (HR 28.23; 95% CI 2.2-355.9; p = 0.01). In conclusion, high IPV and CYP3A4 polymorphisms (rs2837159) are associated with CNI nephrotoxicity.

Ectopic Variceal Bleeding from the Hepaticojejunostomy due to Extrahepatic Portal Vein Occlusion: How to Treat?

Atypical variceal bleeding, which primarily stems from extrahepatic portal vein obstruction (EHPVO), is a severe complication of pancreatic hepatobiliary surgery. This review provides insights into this condition's incidence, diagnosis, and management strategies. The treatment modalities for atypical variceal bleeding resulting from EHPVO range from endoscopic intervention to surgical procedures, including direct variceal ligation and shunt surgery. Here, we discuss the efficacy and potential limitations of each treatment approach. Additionally, we explored the utility and therapeutic advantages of the meso-Rex shunt, a particularly promising surgical technique for mitigating the hemodynamic and metabolic impacts of EHPVO.

Technical Tips for Performing Suprahepatic Vena Cava Tumor Thrombectomy in Renal Cell Carcinoma without Using Cardiopulmonary Bypass

Radical nephrectomy with tumor thrombectomy for advanced renal cell carcinoma is an oncologically relevant approach that can achieve long-term survival even in the presence of distant metastases. However, the surgical techniques pose significant challenges. The objective of this clinical review was to present technical recommendations for tumor thrombectomy in the vena cava to facilitate surgical treatment. Transesophageal echocardiography is required to prepare for this procedure. Cardiopulmonary bypass should be considered when the tumor thrombus has invaded the cardiac chamber and clamping is not feasible because of the inability to milk the intracardiac chamber thrombus in the caudal direction. Prior to performing a cavotomy, it is crucial to clamp the contralateral renal vein and infrarenal and suprahepatic inferior vena cava (IVC). If the suprahepatic IVC is separated from the surrounding tissue, it can be gently pulled down toward the patient's leg until the lower margin of the atrium becomes visible. Subsequently, the tumor thrombus should be carefully pulled downward to a position where it can be clamped. Implementing the Pringle maneuver to reduce blood flow from the hepatic veins to the IVC during IVC cavotomy is simpler than clamping the hepatic veins. Sequential clamping is a two-stage method of dividing thrombectomy by clamping the IVC twice, first suprahepatically and then midretrohepatically. This sequential clamping technique helps minimize hypotension status and the Pringle maneuver time compared to single clamping. Additionally, a spiral cavotomy can decrease the degree of primary closure narrowing. The oncological prognoses of patients can be improved by incorporating these technical recommendations.

Treatments for symptomatic class I patients in CEAP classification with saphenous vein reflux: A pilot study

BACKGROUND

For patients with telangiectasia or reticular veins (CEAP [clinical, etiologic, anatomic, pathophysiologic] class C1), less invasive endovenous (EV) treatments have emerged. However, no prospective studies have compared compression stockings (CSs) and EV ablation treatment for C1 symptomatic refluxing saphenous veins. The present prospective study compared the therapeutic results of the two treatment modalities.

METHODS

From June 2020 to December 2021, 46 patients with telangiectasia or reticular veins (<3 mm; class C1) with axial saphenous reflux and venous congestion symptoms were prospectively enrolled. The patients were assigned to CS (n = 21) or EV treatment (n = 25), according to patient preference. Complications, clinical improvement scales (eg, the venous clinical severity score [VCSS]), and quality of life, including the Aberdeen varicose vein symptom severity score (AVSS) and venous insufficiency epidemiological and economic study - quality of life/symptoms (VEINES-QOL/Sym), were evaluated and compared between the two groups at 1, 3, and 6 months after treatment.

RESULTS

No major complications occurred in either group. The median VCSS was 2.0 (interquartile range [IQR], 1.0-2.0), 1.0 (IQR, 0.5-2.0), 1.0 (IQR 0.0-1.0), and 0.0 (IQR 0.0-1.0) at baseline and 1, 3, and 6 months after treatment in the CS group, respectively. The corresponding VCSSs were 3.0 (IQR, 1.0-3.0), 1.0 (IQR, 0.0-1.0), 0.0 (IQR, 0.0-0.0), and 0.0 (IQR, 0.0-0.0) in the EV group. The median AVSS was 4.4 (IQR, 3.0-5.5), 2.1 (IQR, 1.3-4.6), 1.0 (IQR, 0.0-2.8), and 0.0 (IQR, 0.0-1.8) at baseline and 1, 3, and 6 months after treatment in the CS group, respectively. The corresponding scores were 6.2 (IQR, 3.8-12.3), 1.6 (IQR, 0.6-2.8), 0.0 (IQR, 0.0-2.6), and 0.0 (IQR, 0.0-0.4) in the EV group. The mean VEINES-QOL/Sym score was 92.7 ± 8.1, 100.4 ± 7.3, 104.3 ± 8.2, and 106.0 ± 9.7 in the CS group at baseline and 1, 3, and 6 months after treatment, respectively. The corresponding scores were 83.6 ± 8.0, 102.9 ± 6.6, 107.9 ± 3.9, and 109.6 ± 3.7 in the EV group. Both groups showed considerable improvement in the VCSS, AVSS, and VEIN-SYM/QOL scores, and no significant between-group differences were observed for ≤6 months. Among the severely symptomatic patients (pretreatment VEINES-QOL/Sym score ≤90), the EV group exhibited more marked improvement (P = .029 for the VCSS and P = .030 for the VEINES-QOL/Sym score).

CONCLUSIONS

Both CSs and EV treatment provided clinical and quality of life improvement in symptomatic C1 patients with refluxing saphenous veins, with no significant between-group differences. However, a subgroup analysis revealed that EV treatment provided statistically significant improvement in the severe symptomatic C1 group.

Outcomes of vein reconstruction using bovine pericardial patch

BACKGROUND

The bovine pericardium is a good alternative material to the autogenous vein in vascular reconstruction. This study aimed to evaluate the results of angioplasty in venous reconstruction using bovine pericardium and identify the risk factors for significant complications.

MATERIAL AND METHODS

A retrospective review was performed of the demographic data, clinical characteristics, and complications of patients who underwent vessel repair using bovine pericardium between February 2012 and December 2020. Univariate analysis was used to compare complication frequencies within several categories.

RESULTS

There were 36 cases of patch angioplasty using bovine pericardium. The median age was 65 years; 61% of them were men. Of the 36 venous repairs, 31 (86.1%) were from cancer surgery and five (13.9%) were from iatrogenic injury. Patch shape was used in 27 cases (75.0%), while tube shape was used in nine cases (25.0%). The incidence of occlusion and partial thrombus was five (13.9%) and three (8.3%) cases, respectively. Of the nine tube-shaped angioplasties, four (44.4%) required reoperation due to early thrombosis (three cases) and hematoma (one case).

CONCLUSION

The use of a bovine pericardial patch in the reconstruction of a damaged vein from tumor invasion or iatrogenic injury is feasible. However, the complication rate of vessel patency remains substantial, especially in cases of iatrogenic injury or when a tube-shaped form is used for repair.

Late Type III Endoleak after Loss of Component Overlap after EVAR with AFX2 Device: A Case Report

Addressing the high incidence of late type III endoleaks in previous AFX models, Endologix upgraded the device material and updated its recommendation regarding component overlap. However, whether upgraded AFX2 models are safe for endoleaks remains controversial. Here we report a case of a 67-year-old male with an AFX2-implanted abdominal aortic aneurysm experiencing a delayed type IIIa endoleak. Aneurysmal sac enlargement occurred 36 months post-endovascular aneurysm repair (EVAR), with a computed tomography scan at 52 months revealing component overlap loss and a significant type IIIa endoleak. We performed endograft explantation and endoaneurysmal aorto-bi-iliac interposition grafting. Our findings suggest that sufficient component overlap is necessary when using an AFX2 endograft outside the manufacturer's instructions for use to prevent late type IIIa endoleaks. Moreover, patients who undergo EVAR with AFX2 for tortuous large aortic aneurysms should be carefully monitored for conformational changes.

Validation of I71.3 code for ruptured abdominal aortic aneurysm in Korea: misplaced diagnosis in claims data

Purpose

Studies in western countries have shown a decline in the incidence of ruptured abdominal aortic aneurysm (rAAA) with advancements in endovascular repair and screening. However, according to health insurance data in Korea based on rAAA code (I71.3), overall rAAA has been increasing. This study aimed to validate the I71.3 code for rAAA and attempt to define the true incidence of rAAA in Korea.

Methods

A 20-year multicenter retrospective review of rAAA was undertaken from the period of January 1, 2000 to December 31, 2020. All patients were diagnosed with the rAAA code I71.3 in each of the 4 hospitals. The CT images and surgical records of these patients were reviewed to differentiate true rAAA and misdiagnosis. Further data on true rAAA patient outcomes including mortality and treatment success were also collected.

Results

A total of 305 rAAA (I71.3) codes were identified in the 4 centers. However, medical record review showed true rAAA in only 131 (43.0%). The remaining 174 cases (57.0%) were misdiagnosed. Impending ruptures were the most common misdiagnoses (37.9%). The total in-hospital mortality including deaths before treatment was 38.9% (n = 51), while mortality of treated patients was 24.4% (n = 15).

Conclusion

The analysis of I71.3 code for rAAA showed that only 43.0% were true rAAA and the remaining 57.0% were misdiagnosed. This indicates that the I71.3 code is overestimated in National Health Insurance-based data and that the true incidence of rAAA could be much lower.

A multicenter, randomized, open-labelled, non-inferiority trial of sustained-release sarpogrelate versus clopidogrel after femoropopliteal artery intervention

Optimal antiplatelet therapy after endovascular therapy (EVT) for peripheral artery disease is controversial. This trial aimed to evaluate whether sarpogrelate plus aspirin was non-inferior for preventing early restenosis after femoropopliteal (FP) EVT compared to clopidogrel plus aspirin. In this open-label, prospective randomized trial, 272 patients were enrolled after successful EVT for FP lesions. Patients in each group received aspirin 100 mg and clopidogrel 75 mg or sarpogrelate 300 mg orally once per day for 6 months. The primary outcome was target lesion restenosis at 6 months, tested for noninferiority. Patient characteristics and EVT patterns were similar, except for increased inflow procedures in the sarpogrelate group and increased outflow procedures in the clopidogrel group. The sarpogrelate group showed a tendency of less restenosis at 6 months than the clopidogrel group (13.0% vs. 19.1%, difference 6.1 percentage points, 95% CI for noninferiority - 0.047 to 0.169). Secondary endpoints related to safety outcomes were rare in both groups. Risks of target lesion restenosis of the two intervention arm were uniform across most major subgroups except for those with coronary artery disease. In conclusion, Sarpogrelate plus aspirin is non-inferior to clopidogrel plus aspirin in preventing early restenosis after FP EVT. Larger multi-ethnic trials are required to generalize these findings. Trial registration: National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier: NCT02959606; 09/11/2016).

Venous Reconstruction in Extremity Soft Tissue Sarcoma Is Not Essential

OBJECTIVE

Limb salvage is an important concern following complete oncologic resection for extremity soft tissue sarcoma (STS). Vascular reconstruction is essential for limb salvage. The purpose of this study was to evaluate the outcomes of vascular reconstruction in patients with extremity STS.

METHODS

This is a retrospective, multi-center, case series of consecutive patients who underwent vascular reconstruction during extremity STS resection at 2 major centers in Korea. Demographics, reconstruction methods, type of conduit, surgical complications, graft patency, limb salvage rate, and patient survival were reviewed.

RESULTS

From March 2005 to December 2020, 43 patients underwent vascular reconstructions during STS resection. Among the patients, 22 (51.2%) received arterial only, and 21 (48.8%) received simultaneous arterial and venous reconstructions. For the types of conduits, autologous saphenous veins (56.2%), artificial grafts (26.3%), and cryopreserved allografts (15.8%) were used. During a median follow-up of 23.8 months (interquartile range; 7.7-54.5), the overall primary patency of the reconstructed vessels was significantly higher in arteries than in veins (82.5% vs 56.3% at 12 months, P < .001). According to the type of conduit, the primary patency rate of autogenous vein seemed higher in venous reconstruction, however, there was no statistical significance in both arterial and venous reconstruction. There was no significant difference in primary arterial patency rate (P = .132) or incidence of surgical complications including postoperative edema or wound problem whether or not simultaneous venous reconstruction was performed with arterial reconstruction. The overall limb salvage rate and patient survival were 97.4%, 95.1%, and 89.4% and 91.9%, 81.7%, and 65.4% at 12, 24, and 36 months, respectively.

CONCLUSIONS

Patency rates were poorer in venous reconstruction than in arterial reconstruction. In terms of arterial patency and postoperative complication, the role of simultaneous arterial and venous reconstruction seems not essential, however, it needs to be evaluated in future studies.

The appearance of C1q deposition in transplanted kidney allografts and its clinical and histopathologic features

Background

C1q nephropathy is an uncommon type of glomerulonephritis characterized by extensive and dominant C1q mesangial deposition in the absence of systemic lupus erythematosus. However, there are limited studies about C1q deposition in renal allografts. This study aimed to report the prevalence of C1q deposition in transplanted kidney allograft biopsies and describe its clinical and histopathologic features.

Methods

Between January 2005 and December 2018, a total of 1,742 kidney transplantations were performed at Seoul National University Hospital. All renal allograft biopsies (n=10,217) of these patients were retrospectively screened for C1q deposition. C1q deposition was detected in the renal allograft biopsies of 104 patients (6.0%). Only 28 cases (1.6%) had intense (≥2+) C1q dominance and were reviewed in this study.

Results

Among the 28 cases, only four (14.3%) had accompanying proliferative glomerulonephritis. Most did not have any other glomerular changes on light microscopy. No patients had nephrotic-range proteinuria at the time of biopsy. A follow-up biopsy was undertaken in 15 of the cases (53.6%). In these follow-up biopsies, C1q deposition either completely disappeared (n=13, 86.7%) or showed diminished staining (n=2, 13.3%).

Conclusions

The prevalence of dominant or codominant C1q deposition in transplanted renal allograft biopsies was 1.6%. Most cases did not have any other accompanying glomerular changes. The follow-up biopsies of these allografts showed spontaneous disappearance or diminished staining of C1q deposition. These findings suggest that C1q deposition found in renal allografts is most likely clinically benign, although this possibility should be confirmed in further large-scale studies.

Effects of tacrolimus intrapatient variability and CYP3A5 polymorphism on the outcomes of pediatric kidney transplantation

BACKGROUND

The intrapatient variability (IPV) of tacrolimus (Tac) is associated with the long-term outcome of kidney transplantation. The CYP3A single-nucleotide polymorphism (SNP) may affect the IPV of Tac. We investigated the impact of IPV and genetic polymorphism in pediatric patients who received kidney transplantation.

METHODS

A total of 202 pediatric renal transplant recipients from 2000 to 2016 were analyzed retrospectively. The IPV was calculated between 6 and 12 months after surgery. Among these patients, CYP3A5 polymorphism was analyzed in 67 patients.

RESULTS

The group with high IPV had a significantly higher rate of de novo donor-specific human leukocyte antigen antibodies (dnDSA) development (35.7% vs. 16.7%, p = .003). The high IPV group also had a higher incidence of T-cell-mediated rejection (TCMR; p < .001). The high IPV had no significant influence on Epstein-Barr virus, cytomegalovirus, and BK virus viremia but was associated with the incidence of posttransplant lymphoproliferative disorders (p = .003). Overall, the graft survival rate was inferior in the high IPV group (p < .001). The CYP3A5 SNPs did not significantly affect the IPV of Tac. In the CYP3A5 expressor group, however, the IPV was significantly associated with the TCMR-free survival rate (p < .001).

CONCLUSION

The IPV of Tac had a significant impact on dnDSA development, occurrence of acute TCMR, and graft failure in pediatric patients who received renal transplantation. CYP3A5 expressors with high IPV of Tac showed worse outcomes, while the CYP3A5 polymorphism had no impact on IPV of Tac.

Inadvertent Stenting and Percutaneous Aspiration for Treatment of Adventitial Cystic Disease in the Popliteal Artery: A Case Report

Adventitial cystic disease (ACD) is a rare, non-atherosclerotic disease that mainly affects the popliteal artery. Treatment is primarily surgical as endovascular approaches are affected by high recurrence rates. However, some studies have reported successful endovascular treatments of popliteal ACD cases. A 55-year-old female presented with right calf claudication. Computed tomography angiography revealed segmental occlusion of the right distal superficial femoral artery. Subsequently, a drug-eluting stent was successfully deployed. However, an unusual adventitial cystic lesion occluding the lumen that was characteristic of ACD was detected during a postoperative imaging review. It was aspirated using an ultrasound-guided percutaneous needle and drained using a pigtail catheter for 24 hours. Follow-up images after 39 months showed a patent artery with no recurrence of any cystic lesions, highlighting successful ACD treatment via stenting, ultrasound-guided aspiration, and cyst drainage. Stenting and cyst aspiration can be an alternative option for selected patients with ACD.

Vein Graft Aneurysm after Aorto-Renal Bypass for Childhood Renovascular Hypertension Due to Fibromuscular Dysplasia

Renovascular hypertension (RVHT) is a major cause of surgically correctable secondary hypertension. Refractory hypertension despite multiple antihypertensive drugs requires angioplasty, surgical revascularization, or even nephrectomy. Herein, we report a pediatric patient who had been treated with angioplasty, nephrectomy, and aortorenal bypass surgery for RVHT due to fibromuscular dysplasia and re-do endoaneurysmal graft replacement for a vein graft aneurysm. This case highlights the various treatment modalities for RVHT and the recurrent nature of the disease with a rare presentation of a vein graft aneurysm after aortorenal bypass.

Campaign for the optimal treatment of varicose veins: welcoming the declaration of the Code of Ethics issued by the Korean Society for Phlebology

Background: Varicose veins (VV) is a common chronic venous disorder that is often left untreated due to its minor symptoms. However, recent developments in minimal invasive surgery has resulted in a rapid increase of VV treatment cases. Unfortunately, there have been some ethical issues regarding the high cost of intervention and non-professional treatment administered for VV at some private clinics.Current Concepts: Most endovenous therapies for VV are not reimbursed by the national health insurance but are only covered by personal health insurance plans in Korea. Rapid increase in the coverage costs for VV treatment has led to conflicts between the insurance companies and doctors in several cases. Recently, the Korean Society for Phlebology declared the Code of Ethics to support evidence-based treatment and warn against unethical practices related to interventions for VV.Discussion and Conclusion: The Korean Society for Vascular Surgery and Korean Society for Phlebology have just launched a campaign for the optimal treatment of VV on their YouTube channel, which shares accurate information regarding VV treatment to inform patients and doctors. To strengthen doctor-patient relationship and to avoid falling prey to unethical practitioners, it is critical to educate and update patients and healthcare service providers regarding the options available for VV treatment.

Percutaneous Mechanical Thrombectomy of Submassive Pulmonary Embolism and Extensive Deep Venous Thrombosis for Early Thrombus Removal

Traditional treatment with anticoagulation in nonfatal submassive pulmonary embolism can result in serious sequelae of chronic thromboembolic pulmonary hypertension or poor exercise tolerance, and functional impairment. To prevent long-term complications in previously healthy young patients, other treatment options to actively resolve existing thrombi should be considered. Despite recommendations for use in only severe clinical presentations, endovascular interventional techniques could serve as suitable treatment options for such patients. Here we report the case of a previously healthy 23-year-old female with submassive pulmonary embolism and extensive deep vein thrombosis in the inferior vena cava down to the right popliteal vein. The patient was initially treated with catheter-directed thrombolysis. However, she continued to show extensive venous thrombosis and pulmonary embolism. Percutaneous thrombectomy and aspiration using an AngioJet successfully removed the main pulmonary artery embolism and venous thrombus. The patient's recovery was uneventful, and 3-month follow-up showed no signs of recurrence or discomfort.

Perioperative hemodynamic instability in pheochromocytoma and sympathetic paraganglioma patients

For pheochromocytoma and sympathetic paraganglioma (PPGL), surgery can be used as a curative treatment; however, the life-threatening risk of perioperative hemodynamic instability (HI) presents challenges. This study aimed to analyze the incidence and predictive factors of perioperative HI. The electronic medical records of 114 consecutive patients who underwent surgery for PPGLs at our institution were retrospectively reviewed. HI was defined as one or more episodes of systolic blood pressure > 200 mmHg or mean blood pressure < 60 mmHg during surgery. The factors predictive of perioperative HI were determined using both univariate and multivariate analyses. Intraoperative HI occurred in 79 (69.3%) patients. In multivariate analysis, α-adrenergic receptor blocker duration (days) (odds ratio, 1.015; 95% confidence interval, 1.001–1.029) was a predictor for intraoperative HI. Postoperative hypotension occurred in 36 (31.6%) patients. Higher urine epinephrine levels, and greater preoperative highest heart rate (HR) were predictive factors for postoperative hypotension in PPGL patients. Caution should be taken in perioperative management for PPGL, especially with long duration of α-adrenergic receptor blocker use, higher urine epinephrine levels, and greater preoperative highest HR.

Editor's Choice - Paclitaxel Coated Balloon Angioplasty vs. Plain Balloon Angioplasty for Haemodialysis Arteriovenous Access Stenosis: A Systematic Review and a Time to Event Meta-Analysis of Randomised Controlled Trials

OBJECTIVE

A systematic review and meta-analysis of randomised controlled trials (RCTs) was performed to determine the effectiveness and safety of drug coated balloon (DCB) angioplasty compared with uncoated plain balloon (PB) angioplasty in treating arteriovenous access stenosis.

METHODS

MEDLINE, Embase, Scopus, and the Cochrane Central Register of Controlled Trials were searched for RCTs comparing paclitaxel coated DCB and PB angioplasty for arteriovenous access stenosis. The last date of the literature search was 31 December 2020. Risk of bias of the retrieved studies was assessed with the Cochrane Collaboration tool for assessing risk of bias (RoB 2.0). The random effects model was used to estimate the risk of loss of target lesion patency (six and 12 months) and circuit patency (six and 12 months). Procedure related adverse events and mortality rate were also compared. Patency results were pooled using the time to event meta-analytical method and the quality of evidence was assessed according to the GRADE approach.

RESULTS

Sixteen eligible trials, including 1 682 lesions, were included in the quantitative analysis for the efficacy and safety of paclitaxel coated DCBs. DCBs were associated with a lower risk of loss of target lesion patency at six months (HR 0.53, 95% CI 0.42 - 0.66) and 12 months (HR 0.60, 95% CI 0.47 - 0.76), and were also associated with improved six and 12 month circuit patency. Overall quality of evidence was moderate to low. Procedural complications were rare, and the risk of death up to 12 months was similar between the two groups (OR 1.03, 95% CI 0.68 - 1.56).

CONCLUSION

Paclitaxel coated DCBs reduced the risk of loss of target lesion patency and circuit patency in arteriovenous access stenosis compared with PBs. Considering the heterogeneity of the included trials, there is a need to investigate optimal treatment regimens regarding drug dose and agent of the DCB and the treatment procedure.

Do Not Tunnel the Small Bowel during the Tunneling of a Femoro-Femoral Bypass

A 62-year-old male with a history of femoro-femoral crossover bypass surgery 31 months previously presented with recurrent symptoms of fever and chills, along with a previous positive blood culture. Computed tomography showed vegetation in the bypass graft located in the peritoneal cavity, closely abutting the small bowel and soft tissue lesions in the right proximal thigh and distal calf. Under high suspicion of graft-enteric fistula with metastatic infection, surgery was performed to remove the previous graft and insert a new femoro-femoral bypass graft subcutaneously. Small bowel resection and anastomosis were also performed because the graft penetrated the small bowel mesentery and eroded into the small bowel. The patient had a patent graft without infection for more than 10 years. This case demonstrates the importance of tunneling in femoro-femoral crossover bypass free from the small bowel or other intraperitoneal organs.

Comparison between autogenous brachial-brachial upper-arm elevated direct arteriovenous fistulas and prosthetic brachial-antecubital indirect forearm arteriovenous grafts

OBJECTIVES

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines recommend forearm arteriovenous grafts (AVGs) as an alternative procedure to transposed basilic vein fistulas for providing secondary access during hemodialysis. Recently, autogenous elevated brachial-brachial vein fistulas (BVE) have become increasingly popular. The aim of this study was to compare the outcomes of BVE and forearm loop AVG (AVG) for secondary access in hemodialysis.

METHODS

We retrospectively reviewed the medical records of patients who had received a BVE or forearm AVG at a single center from January 2015 to April 2019. In total, 19 BVE were created via two-stage operations and two via a one-stage operation; 53 forearm AVG's were performed.

RESULTS

The AVG group was twice as likely to suffer loss of primary patency compared with the BVE group (odds ratio [OR], 2.666; 95% confidence interval [CI], 1.108-6.412; p = 0.029) per the multivariate analysis. The primary patency and primary assisted patency of the BVE group were superior those of the AVG group, except for secondary patency (p = 0.02, p = 0.07, p = 0.879, respectively). In subgroup analysis, there were no significant differences in primary, primary assisted, or secondary patency between AVG and BVE when brachial vein was used for AVG outflow. In addition, no significant differences were noted regarding the infection rate (12.5% vs 12.3%, p = 0.331, severity >0), postoperative bleeding rate (14.5% vs 3.5%, p = 0.191, severity >1), early thrombus rate (0.0% vs 10.5%, p = 0.122), and early failure rate (7% vs 4.8%, p = 0.591).

CONCLUSIONS

The primary patency and primary assisted patency rates of BVE were significantly better than those observed in AVGs, but the complication rates were similar. The appropriate procedure to provide vascular access should be determined by the individual patient's condition and the surgical skill of the operating surgeon.

Stump Length Changes after Endovenous Cyanoacrylate Closure or Radiofrequency Ablation for Saphenous Vein Incompetence

Purpose

The aim of this study was to analyze changes in stump length over time in patients with saphenous vein incompetence treated with cyanoacrylate closure (CAC) or radiofrequency ablation (RFA).

Methods

Materials and We retrospectively analyzed data collected from patients with saphenous vein incompetence who underwent either CAC or RFA at Seoul National University Hospital between November 2015 and December 2018. The stump lengths were measured using duplex ultrasonography (DUS) within 1 month and 6 months after treatment. The Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Questionnaire (AVVQ) score were used to assess clinical outcomes.

Results

A total of 97 veins (64 great saphenous veins and 33 small saphenous veins) were analyzed. The stump length was not significantly different between the two groups at <1 month (P=0.311). However, the stump length in the CAC group was significantly longer than that in the RFA group at 6 months (P=0.004). At 6 months, the mean change in stump length was 1.41±2.28 cm in the CAC group and 0.51±0.54 cm in the RFA group (P=0.006). The VCSSs and AVVQ scores significantly improved after both procedures but were not significantly different between the two groups.

Conclusion

DUS at 6 months after treatment showed that the stump length in the CAC group increased more than that in the RFA group. No other factors affected the changes in stump length.

Intravascular Fasciitis in the Femoral Vein with Hypermetabolic Signals Mimicking a Sarcoma: The Role of Preoperative Imaging Studies with Review of Literature

Intravascular fasciitis (IVF) is a very rare disease that is difficult to diagnose preoperatively. Frequently, it can be misdiagnosed as a malignancy or deep vein thrombosis. A 26-year-old man presented with a 6-month history of intermittent cramping pain in the right calf. Duplex ultrasonography, computed tomography, magnetic resonance imaging, and positron emission tomography were performed in various hospitals. The work-up revealed a hypermetabolic mass in the femoral vein, suggestive of a malignancy, such as leiomyosarcoma. The tumor was located inside the femoral vein with no invasion, and the mass was resected en bloc with the vein wall. Intraoperative frozen section biopsy revealed no malignancy, and the final pathological diagnosis was IVF. Herein, we report a case of IVF and discuss the role of imaging studies in its preoperative diagnosis, with an extensive literature review.

Better Efficacy of Balloon Assisted Maturation in Radial-Cephalic Arteriovenous Fistula for Hemodialysis

Purpose

Native arteriovenous fistula (AVF) is the first choice for hemodialysis access; however, the maturation failure rate remains high. Hence, balloon-assisted maturation (BAM) is increasingly being used to overcome maturation failure. This study evaluated the outcomes of BAM and compared the differences between radial-cephalic (RC) and brachial-cephalic (BC) AVF.

Methods

Materials and Between January 2013 and December 2017, 1,622 new AVFs were created. BAM was considered if the AVF did not satisfy the criteria for hemodynamic maturation (6-mm diameter and 500-mL/min flow rate within 8 weeks after the operation).

Results

Of the 1,622 AVFs, BAM was performed in 142 patients (8.75%). There were 92 RC and 50 BC AVFs. Multivariate analyses revealed that ipsilateral central vein catheter history was the sole risk factor for maturation failure after BAM. One-year functional primary patency (FPP) and functional secondary patency (FSP) in RC AVFs were higher than those in BC AVFs without statistical significance (FPP, RC vs. BC: 70.9% vs. 50.9%, P=0.099; FSP, 95.5% vs. 81.1%, P=0.146). Further, based on the multivariate analysis, the independent risk factors for FPP in the RC and BC AVFs were the number of BAMs (odds ratio [OR], 3.05; 95% confidence interval [CI], 1.11-8.37; P=0.03) and age (OR, 1.04; 95% CI, 1.00-1.07; P=0.04), respectively.

Conclusion

BAM is a relatively good salvage method with tolerable patency. However, the risk factors for patency and the outcomes of BAM differ between RC and BC AVFs.

Combined application of rapamycin and atorvastatin improves lipid metabolism in apolipoprotein E-deficient mice with chronic kidney disease

Atherosclerosis arising from the pro-inflammatory conditions associated with chronic kidney disease (CKD) increases major cardiovascular morbidity and mortality. Rapamycin (RAPA) is known to inhibit atherosclerosis under CKD and non-CKD conditions, but it can cause dyslipidemia; thus, the co-application of lipid-lowering agents is recommended. Atorvastatin (ATV) has been widely used to reduce serum lipids levels, but its synergistic effect with RAPA in CKD remains unclear. Here, we analyzed the effect of their combined treatment on atherosclerosis stimulated by CKD in apolipoprotein E-deficient (ApoE^−/−) mice. Oil Red O staining revealed that treatment with RAPA and RAPA＋ ATV, but not ATV alone, significantly decreased the atherosclerotic lesions in the aorta and aortic sinus, compared to those seen in the control (CKD) group. The co-administration of RAPA and ATV improved the serum lipid profile and raised the expression levels of proteins involved in reverse cholesterol transport (LXRα, CYP7A1, ABCG1, PPARγ, ApoA1) in the liver. The CKD group showed increased levels of various genes encoding atherosclerosis-promoting cytokines in the spleen (Tnf-α, Il-6 and Il-1β) and aorta (Tnf-α and Il-4), and these increases were attenuated by RAPA treatment. ATV and RAPA＋ATV decreased the levels of Tnf-α and Il-1β in the spleen, but not in the aorta. Together, these results indicate that, in CKD-induced ApoE^−/− mice, RAPA significantly reduces the development of atherosclerosis by regulating the expression of inflammatory cytokines and the co-application of ATV improves lipid metabolism.

Renal transplantation in patients with an augmentation cystoplasty

Background

The effects of renal transplantation in patients with augmentation cystoplasty are still controversial. We retrospectively analyzed nine patients who underwent renal transplantation after augmentation cystoplasty.

Methods

A total of nine patients who underwent augmentation cystoplasty prior to renal transplantation between January 1990 and May 2020 were reviewed. Basic information on augmentation cystoplasty, transplant procedures, and long-term outcomes of renal transplantation were analyzed.

Results

The bowel segments utilized for augmentation cystoplasty were the stomach in two patients (one patient needed revision using the ileum), the ileum in four patients, the ileocolic pouch in one patient, the sigmoid in one patient, and the ureter in one patient. All the cystoplasties were performed prior to renal transplantation. The mean follow-up period after transplantation was 161 months (range, 2–341 months). Two patients had an episode of acute rejection each; however, their graft functions were well-maintained. Five patients had recurrent urinary tract infections, and three of these patients progressed to allograft failure. One patient died from bladder cancer with a functioning graft. Five of nine patients showed well-maintained graft function.

Conclusions

Renal transplantation after bladder augmentation surgery is a major operation requiring a high level of surgical skill. Based on our long-term experiences, we recommend diligent postoperative monitoring for urinary tract infections, optimal catheter use, and use of appropriate antibiotic prophylaxis to avoid severe complications.