Factors Affecting the Early Maturation of Arteriovenous Fistulae Created at a Tertiary Centre in Oman

Objectives

This study aimed to determine the risk factors associated with the failure of arteriovenous fistulae (AVF) maturation.

Methods

This retrospective cohort study was conducted from January 2014 to December 2018 in Sultan Qaboos University Hospital, Muscat, Oman. Patients were followed-up 3 months after surgery, and their electronic medical records were accessed for demographic and clinical data. Univariate analysis was used to determine the risk factors associated with early AVF maturation and multivariant analysis was used to determine the predictive factors for AVF failure.

Results

A total of 269 patients were included. Female gender was a significant factor affecting AVF maturity (P = 0.049), while age (P = 0.626), diabetes (P = 0.954), hypertension (P = 0.378), dyslipidaemia (P = 0.907), coronary artery disease (P = 0.576), cerebrovascular accident (P = 0.864), congestive heart failure (P = 0.685), previous central venous catheterisation (P = 0.05), fistula type (P = 0.863) and fistula site (P = 0.861) did not affect AVF maturation. Binary logistic regression showed that all the risk factors were insignificant. Failure of early AVF maturation affected 11.5% in the cohort.

Conclusion

This study found that the proportion of early AVF maturation at our hospital is at par with that in the international literature. Failure of AVF maturation was significantly associated with the female gender. These findings can help nephrologists and vascular surgeons prognosticate AVF maturation rates. However, a larger study is needed for definitive conclusions.

A Central Venous Catheter Line Misadventure: "Doctor why do I have a humming sound in my ear?"

We report a 32-year-old female patient who was referred to a tertiary care hospital in Muscat, Oman, in 2021 with an iatrogenic arteriovenous fistula (AVF) that presented as a neck swelling which developed few weeks after an attempt of central venous catheterisation through the right internal jugular vein. The fistula was corrected surgically with a successful outcome. AVF is an abnormal communication between an artery and vein which can occur as a congenital anomaly, after trauma or iatrogenic following central venous catheter or endovenous thermal ablation.

Congenital Vascular Malformations: A Quick Recap

We present a glimpse of vascular malformations seen at Sultan Qaboos University Hospital from July 2014 to December 2019. The cases are sporadic in nature. Molecular genetic studies can be conducted in patients with a family history of vascular malformations. Cultural practices relating to dress codes may lead to delays in presentation. A diagnostic/management algorithm about vascular malformations would help healthcare professionals diagnose, counsel, and refer appropriately, and a national registry would further enhance research and patient support groups.

Our early experience with mesenteric ischemia in COVID-19 positive patients

Abstract: Literature has been published stating that thrombosis is occurring at higher rates in patients who are positive for COVID-19. This experience is more with limb ischemia. Reports of mesenteric ischemia are coming in from different parts of the globe. We share our early experience of managing two patients with acute mesenteric ischemia.

"Virtual Interdisciplinary COVID-19 Team": A Hospital Pandemic Preparedness Approach

The COVID-19 pandemic continues to move at record speed. Health systems and hospitals worldwide face unprecedented challenges to effectively prepare and respond to this extraordinary health crisis and anticipated surge. Hospitals should confront these unparalleled challenges with a comprehensive, multidisciplinary, coordinated, and organized strategy. We report our experience with the systematic application of the "4S" principle to guide our institutional preparedness plan for COVID-19. We used an innovative "virtual interdisciplinary COVID-19 team" approach to consolidate our hospital readiness.

Outcomes of Early versus Delayed Endovascular Repair of Blunt Traumatic Aortic Injuries

Objectives

Thoracic endovascular aortic repair (TEVAR) has surpassed open surgical repair in the management of blunt traumatic aortic injuries (BTAIs) over the past two decades. It is a less morbid procedure associated with lower mortality. We sought to determine the outcomes of early versus delayed TEVAR of BTAI in our population.

Methods

We conducted a retrospective analysis of a prospectively collected registry that looked at patients presenting with an image-proven diagnosis of BTAI at three tertiary health care facilities in Muscat, Oman. Forty consecutive patients were identified between January 2012 and July 2017, of which four were excluded for incomplete data. The remaining 36 patients were divided based on the timing of repair into early (< 7 days) or delayed (³ 7 days) repair. In both cohorts, variables analyzed included patient demographics, mechanism of injury, injury severity score, need for blood products transfusion, use of anti-impulse medications, anticoagulation, intensive care unit (ICU) stay, and total hospital stay. Primary endpoints included: in-hospital mortality, TEVAR-related morbidity, and the need for reintervention.

Results

Our study subjects were young with a mean age of 33.5±14.8 and 29.9±11.0 years in the early and delayed repair cohorts, respectively. Motor vehicle collisions accounted for the majority of cases (82.6% and 76.9% in early and delayed repair, respectively). Thoracic injuries were the most commonly associated injuries in both early and delayed repair cohorts. Compared to early repair, the delayed repair cohort had a higher incidence of exploratory laparotomies, but the difference was not statistically significant (p = 0.161). There were four incidences of cerebrovascular accidents (CVAs) post-TEVAR; three in the early repair cohort and one in the delayed repair cohort (p = 1.000). There was no statistically significant correlation between left subclavian total or partial coverage and the incidence of CVA (p = 0.220) and type 1 (p = 0.466) or type 2 endoleak (p = 0.102). The early repair cohort had a longer but not statistically significant ICU stay (7.8±6.8 vs. 5.3±10.7, p = 0.386). Prolonged ICU stay was associated with more blood transfusion requirement (p < 0.001), and higher respiratory (p = 0.010) and gastrointestinal complications (p = 0.026).

Conclusions

The short-term outcomes for TEVAR of BTAI continue to show its feasibility in managing BTAI in severely injured patients. There was no clear statistical significance in mortality and morbidity comparing early versus delayed repair. However, our experience is based on a small sample size and short median follow-up but provides a good platform for further analysis.

Dissecting Aneurysm of the Internal Carotid Artery as a Complication of Facial Bone Trauma

The involvement of the internal carotid artery in dissecting aneurysm is rarely reported in the literature and may occur as a complication of trauma, surgery, and other medical conditions. We report a case of a 22-year-old male who was involved in a motor vehicle accident with associated multiple orthopedic and maxillofacial fractures. During surgical management, the patient was incidentally diagnosed with a dissecting aneurysm involving the right internal carotid artery.

Laparoscopic Adrenalectomy for Large Adrenocortical Carcinoma

Background:

Adrenocortical cancer (ACC) is a rare disease that is difficult to treat. Laparoscopic adrenalectomy (LA) is performed, even for large adrenocortical carcinomas. However, the oncological effectiveness of LA remains unclear. This review presents the current knowledge of the feasibility and oncological effectiveness of laparoscopic surgery for ACC, with an analysis of data for outcomes and other parameters.

Database:

A systematic review of the literature was performed by searching the PubMed and Medline databases for all relevant articles in English, published between January 1992 and August 2014 on LA for adrenocortical carcinoma.

Discussion:

The search resulted in retrieval of 29 studies, of which 10 addressed the outcome of LA versus open adrenalectomy (OA) and included 844 patients eligible for this review. Among these, 206 patients had undergone LA approaches, and 638 patients had undergone OA. Among the 10 studies that compared the outcomes obtained with LA and OA for ACC, 5 noted no statistically significant difference between the 2 groups in the oncological outcomes of recurrence and disease-free survival, whereas the remaining 5 reported inferior outcomes in the LA group. Using a paired t test for statistical analysis, except for tumor size, we found no significant difference in local recurrence, peritoneal carcinomatosis, positive resection margin, and time to recurrence between the LA and OA groups. The overall mean tumor size in patients undergoing LA and OA was 7.1 and 11.2 cm, respectively (P = .0003), and the mean overall recurrence was 61.5 and 57.9%, respectively. The outcome of LA is believed to depend to a large extent on the size and stage of the lesion (I and II being favorable) and the surgical expertise in the center where the patient undergoes the operation. However, the present review shows no difference in the outcome between the 2 approaches across all stages. A poor outcome is likely to result from inadequate surgery, irrespective of whether the approach is open or laparoscopic.

Successful Direct Adsorption of Lipoproteins (DALI) Apheresis During Pregnancy in an Omani Woman with Homozygous Familial Hypercholesterolemia

We report our experience with Direct Adsorption of Lipoproteins (DALI) apheresis in an Omani pregnant woman affected by homozygous familial hypercholesterolemia. To the best of our knowledge this is the first successful pregnancy treated with DALI apheresis. The patient had a history of coronary artery disease, supra-aortic valvular stenosis and severe carotid artery disease with right carotid artery stenting. She was on a regular biweekly DALI apheresis since 2008. In May 2013, she became pregnant and rosuvastatin and ezetimibe were stopped while she continued on DALI apheresis biweekly. This treatment during pregnancy was successful with no major complications. The average low-density lipoprotein cholesterol reduction during therapy was 50%. She spontaneously delivered a healthy male infant (2,400 g) at 37 weeks. We showed that DALI apheresis therapy was safe during pregnancy with a good outcome for both mother and neonate.

Patient-reported quality of life after abdominal aortic aneurysm surgery: A prospective comparison of endovascular and open repair

PURPOSE

This study evaluated and compared changes over time in health-related quality of life reported by patients with infrarenal abdominal aortic aneurysm (AAA) undergoing elective endovascular (EVAR) and open aneurysm (OR) repair.

METHODS

A prospective, nonrandomized cohort of 76 patients (62 men, 14 women; age range, 42 to 89 years) undergoing elective, infrarenal AAA repair (EVAR, n = 43; OR, n = 33) at two university teaching hospitals during a 15-month period were administered the Medical Outcomes Study Short-Form 36-item (SF-36) health survey preoperatively and then 1 week, 1 month, and 6 months postoperatively. Patient demographics, procedural details, postoperative follow-up data, and SF-36 scores were compared between groups.

RESULTS

Both groups had total SF-36 scores that were significantly lower than preoperative scores at 1 week and 1 month after surgery but were not significantly different from the preoperative scores at 6 months (OR 66.2 +/- 21.1 to 72.3 +/- 19.8, P > .1; and EVAR 61.0 +/- 17.7 to 58.7 +/- 19.4, P > .1). Six-month total SF-36 scores were significantly higher in the OR group compared with the EVAR group (mean 72.3 +/- 19.8 OR vs 58.7 +/- 19.4 EVAR; P = .009). In the postoperative period, a significant drop occurred in mean scores in six of the eight domains of the SF-36 in the OR patients (physical function, PF; role physical, RP; bodily pain, BP; vitality, VT; social function, SF; role emotional, RE) and five domains for EVAR patients (PF, RP, BP, SF, RE). In two domains, RE and PF, scores returned to baseline values significantly sooner in EVAR patients than in OR patients (RE, EVAR 1 month vs OR 6 months; and PF, EVAR 1 month vs OR 6 months). In the VT domain, no significant postoperative drop occurred in the EVAR group, but in the OR group, mean scores were significantly lower at 1 week and 1 month compared with preoperative values. In the domains of general health and mental health, no significant drop occurred in SF-36 score postoperatively in either group.

CONCLUSIONS

Patient reported health-related quality of life after infrarenal AAA repair is significantly impaired in the early postoperative period but returns to baseline by 6 months in patients treated with EVAR and OR. Patients having EVAR had significantly more rapid return to preoperative scores in selected domains of the SF-36. Even though EVAR is associated with shorter and less invasive perioperative hospital course and fewer postoperative complications, EVAR patients had lower quality of life scores 6 months after surgery than OR patients.