Double-Barrel Technique With Reversed Gore Excluder Stent Graft Limb for Common Iliac Aneurysm Exclusion in a Patient With Prior Aortic Surgical Repair

Surgical repair of a common iliac artery aneurysm (CIA) after previous open aortic reconstruction is associated with significant morbidity and mortality. Endovascular repair is considered less invasive than surgery. However, if preservation of the internal iliac artery (IIA) is required, the applicability of endovascular techniques may represent a challenge and a limitation to the use of standard aortic endografts or iliac branch devices. In these cases, the off-label use of endovascular devices may be an effective alternative. Herein, we report a successful hybrid approach to treat CIA using a reversed iliac limb endograft coupled with a double-barrel technique with femoro-femoral crossover bypass in a patient who had previously undergone open aortic reconstruction.

[The Cannulation of the Arteriovenous Fistula in the Presence of a Stent: Precautions, Risks, and Possibilities]

A proper management and tailored interventions represented two fundamental steps to ensure a long-term use of the arteriovenous fistula (AVF). AVF failure can be attributed to various factors, with stenosis being the most common cause. Different techniques are employed for treating complications, but percutaneous endovascular procedures are the most widely used. In addition to angioplasty (PTA), the possibility of utilizing stents, particularly stent grafts (SG), has further improved outcomes. However, the insertion of these devices involves commitment to a segment of the vessel, which may vary in length, making the indication necessitate a careful evaluation. The positioning of a stent graft indeed limits the space for needle insertion, and on the other hand, the cannulation of the device is considered off-label according to technical specification. This work addresses the issue of puncturing these devices. Alongside a rapid overview, we describe a clinical case of continuous cannulation of a multiply stented AVF, for over 9 years, which opens up the discussion about the possibility of long-term cannulation through proper planning.

Hybrid arteriovenous graft for hemodialysis vascular access in a multicenter registry

OBJECTIVE

The aim of our study was to identify patients' characteristics that predicted a higher chance of arteriovenous graft patency in patients undergoing Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) implantation for hemodialysis access. The GHVG is a polytetrafluroethylene (PTFE) prosthesis with a nitinol-reinforced section (NRS) at the venous end.

METHODS

All consecutive patients undergoing GHVG implantation for hemodialysis access at 10 tertiary referral centers between December 2013 and January 2018 were included in the study and compared with a control group of patients undergoing standard PTFE graft implantation. Selection of patients for hybrid graft implantation was based on the impossibility of autogenous vascular access creation.

RESULTS

There were 145 patients included in the GHVG group and 218 in the PTFE group. In the GHVG and the PTFE groups, the mean age was 67 ± 13 years and 65 ± 13 years, and male patients totaled 52% and 46%, respectively. The technical success was 99%. The mean duration of the intervention was 100 minutes (median, 95 minutes; interquartile range, 80-120 minutes). The brachial-axillary configuration was used in the majority of cases (n = 78 [54%]). The 5-cm NRS length was prevalent (n = 108 [75%]). The median NRS oversize was 14% (interquartile range, 0%-21%). Mean follow-up was 13 months (range, 0-55 months). Seventy-one patients (49%) underwent at least one reintervention. Primary, assisted primary, and secondary patency estimates at 12 months were 44% ± 5%, 47% ± 5%, and 65% ± 4% for the GHVG group and 41% ± 4%, 53% ± 4%, and 75% ± 3% for the control group, respectively (P = NS). One-year survival was 90% ± 3%. On multivariable Cox regression analysis, hypotension (P < .001; hazard ratio [HR], 5.8; confidence interval [CI], 2.6-13) and diabetes (P = .024; HR, 1.9; CI, 1.1-3.2) were significant predictors of GHVG loss. A larger graft size was protective against GHVG loss (P = .042; HR, 0.73; CI, 0.54-0.99). The 10-cm-long graft showed a tendency toward improved patency but did not reach statistical significance (P = .074; HR, 0.48; CI, 0.21-1.07).

CONCLUSIONS

Diabetes and hypotension were predictors of loss of hybrid arteriovenous access. Smaller diameters of NRS were more prone to thrombosis, whereas the 10-cm length seemed to perform better than the 5-cm one.

Extra-anatomic lateral bypass combined with embolization of the femoral stump for management of groin infection and bleeding due to metastatic carcinoma of the penis

We report a possible treatment strategy for a patient with squamous cell carcinoma of the penis in hemorrhagic shock, due to erosion of the right femoral artery by metastatic inguinal lymph nodes. Because of coexistent groin infection and the inability to perform radical excision, the patient was treated with a lateral extra-anatomic iliac femoral prosthetic bypass; to prevent further bleeding, the femoral stump was embolized percutaneously. The patient was discharged home and did not experience any vascular complications during the follow-up, until death due to pulmonary metastasis.

Mucosal cell proliferation in patients with hyperplastic colorectal polyps

BACKGROUND

Morphologic, histochemical, and cytoproliferative characteristics differentiate hyperplastic polyps from adenomas. Even so, these polyps are indicators of populations with a high colorectal cancer risk. Since changes in mucosal cell proliferation are highly predictive biomarkers of the adenomacarcinoma sequence, this study examined the cytoproliferative profiles of mucosa bearing hyperplastic polyps, in a search for the significance of such lesions in bowel carcinogenesis.

METHODS

Proliferative activity demonstrated by immunohistochemical detection of the in vitro uptake of bromodeoxyuridine was evaluated in the rectal mucosa of 26 patients with hyperplastic polyps, 35 with adenomas < 1 cm, 60 with adenomas > 1 cm, 10 with adenomas + synchronous hyperplastic polyps, and 400 controls.

RESULTS

An upward shift of the major DNA synthesis zone to the intermediate and surface crypt compartments was found in all four patients groups. Significant hyperproliferation, on the other hand, was only observed in patients with large adenomas or hyperplastic polyps, or small adenomas and synchronous hyperplastic polyps.

CONCLUSIONS

These findings suggest that hyperplastic polyps are morphologic indicators of tumor initiation in the rectal mucosa and its ensuing hyperproliferation. Abnormalities in the distribution of proliferation in the mucosa do not appear to be specifically associated with the morphogenesis of hyperplastics polyps.