Ali Kordzadeh

Cephalic vein and radial artery diameter in formation of radiocephalic arteriovenous fistula: a systematic review.

Purpose The aim of this study is to determine the optimal range of cephalic vein and radial artery diameter following preoperative duplex imaging to enhance maturation and primary patency of Brescia-Cimino radiocephalic arteriovenous fistula. Methods A systematic review and meta-aggregation of literature from 1966 to January 2015 in English language and adult subjects in Pubmed, OVID, CINHAL and Cochrane database was conducted. Results This search produced a total of thirty-six (n = 36) articles. Following the application of recruitment criteria, only twelve articles (n = 12) were found eligible. Their quality was assessed by Oxford Critical Appraisal skills Programme (CASP) and their recommendation for practice was examined through National Institute for Health and Care Excellence (NICE). Conclusions The current literature suggests that the optimal range of radial artery for maximum performance (maturation and primary patency) of RCAVF is at least 2 mm (level 2, grade a). The cephalic vein diameter of at least 2 mm (non-augmented) can result in best maturation and primary patency outcomes (level 2, grade a) and threshold below 1.5 mm is not advocated (level 2, grade b).

Donor artery aneurysm formation following the ligation of haemodialysis arteriovenous fistula: a systematic review and case reports

Purpose The purpose of this study is to investigate the pathogenesis, presentation and diagnosis of donor artery aneurysm formation following arteriovenous fistula (AVF) ligation and reach a consensus on their management. Methods A systematic review of literature in Ovid, MedLine, Embase, Scopus and CINHAL in the English language from 1951 to 2014 was performed. This was accompanied by two case reports. A total of 12 articles with 23 case reports were identified. Variables including patients demographics, signs, symptoms, fistula type, duration of fistula use, time to aneurysm formation, renal transplantation, diagnostic modality, aneurysm type and size, type of surgery and outcome were reviewed. Results The data demonstrate a male predominance (5:1) and a median age of 47 years (range, 27-75 years). The median duration of access was 54 months (range, 6-300 months). The median time from ligation to aneurysm was 120 months (range, 6-280 months). The commonest aneurysm was of the brachial artery (BA, n = 21, 84%). The commonest type of AVF was radiocephalic (n = 15, 60%) followed by brachiocephalic AVF (n = 9, 36%). The management of choice was aneurysmectomy followed by interposition vein grafting (n = 12, 50%) with a median reported patency of 12 months (range, 1-38 months). This was followed by polytetrafluoroethylene (PTFE) grafting (n = 6, 25%) with a median reported patency of 6 months (range, 1-48 months). Conclusions The pathogenesis of donor artery aneurysms remains contentious. This review suggests that duplex is the investigative modality of choice and aneurysmectomy with interposition grafting is preferred over bypass.

Neutrophil to lymphocyte ratio (NLR) of five predicts 30-day morbidity in ruptured abdominal aortic aneurysms (rAAA): A retrospective cohort study

BACKGROUNDnIn recent years the role of neutrophil to lymphocyte ratio (NLR) as an independent predictor of mortality and morbidity has gained significant attention in colorectal, upper gastrointestinal and cancer surgery. To date, no study has examined this in ruptured abdominal aortic aneurysms (rAAAs). This study aims to assess the role of NLR as a prognostic marker of 30-day (30d) morbidity and mortality in patients undergoing repair of rAAAs.nnnMETHODSnData from 80 consecutive patients with a diagnosis of rAAAs from November 2007 to June 2014 were included. Receiver operating characteristic curve analysis was used to identify the optimal value for NLR in relation to 30d mortality and morbidity. Univariate and multivariate logistic regression analysis were used to determine the role of NLR after stratification by several clinical factors.nnnRESULTSn25 patients (31.2%) had a low NLR (LNLR) and 55 patients (68.8%) had a high NLR (HNLR). Elevated NLR was significantly associated with low Hemoglobin and it was not associated with gender, age, AAA Size, history of HTN, COPD, smoking and renal failure. Patients with HNLR had higher 30d morbidity compared with the LNLR group (35 vs. 6 p = 0.001) but no difference in intraoperative blood loss, length of hospital, ITU stay and 30d mortality. High NLR through multivariate analysis was an independent prognostic factor for 30d morbidity [OR = 4.28, 95% (1.27-14.42), p = 0.02].nnnCONCLUSIONnA preoperative NLR >5 is an independent predictive marker of 30d morbidity in rAAAs. This appears to be in line with earlier literature demonstrating similar outcome in the elective group of abdominal aortic aneurysm.

Presenting Baseline Coagulation of Infra Renal Ruptured Abdominal Aortic Aneurysm: A Systematic Review and Pooled Analysis

BACKGROUNDnThe incidence of coagulopathy in patients presenting with rAAA is not clear. The lack of high-quality evidence has led to various speculations, reliance on anecdotal experience, and suggestions about their appropriate haemostatic resuscitation. The aim of this systematic review is to establish the baseline coagulation status of infra renal ruptured abdominal aortic aneurysms (rAAA) against defined standards and definitions.nnnMETHODSnAn electronic search of literature in Medline, CINHAL, Scopus Embase, and Cochrane library was performed in accordance with the PRISMA guidelines. Quality assessment of articles was performed using the Oxford critical appraisal skills programme (CASP) and their recommendation for practice was examined through National Institute for Health and Care Excellence (NICE). Information on platelet count, international normalisation ratio (INR), activated partial prothrombin time (aPTT), prothrombin time (PT) fibrinogen and D-dimer was extracted, and pooled analysis was performed in accordance with the definition of coagulopathy and its subtypes. Pooled prevalence of coagulopathies and 95% CI were estimated with a variance weighted random effects model.nnnRESULTSnSeven studies, comprising 461 patients were included in this systematic review. Overall weighted prevalence of coagulopathy was 12.3% (95% CI 10.7-13.9), 11.7% for INR (95% CI 1-31.6), 10.1% for platelet count (95% CI 1-26.8), and 11.1% for aPTT (95% CI 0.78-31). Fibrinogen serum concentration level was normal in 97%, and 46.2% (nxa0=xa055) of patients had elevated D-dimer. Only 6% of the entire population demonstrated significant coagulopathy. DIC was noted in 2.4% of the population.nnnCONCLUSIONnThis first systematic review of literature on baseline coagulation of rAAAs suggests that the majority of these patients do not present with coagulopathy and only a minor proportion of patients present with significant coagulopathy.

The Clinical Implication of Blood Product Transfusion on Morbidity and Mortality of Ruptured Abdominal Aortic Aneurysm.

Background: Transfusion of blood products occurs frequently in ruptured abdominal aortic aneurysm surgery (rAAA). The aim of this study is to establish the impact of packed red blood cell (PRBC), fresh frozen plasma (FFP), and platelet (PLT) transfusion on the 30-day mortality and morbidity (thrombotic versus non thrombotic complications) of rAAAs. Methods: A retrospective study of 90 consecutive rAAAs from November 2007 to June 2015 was conducted. Multivariable regression models were produced to determine blood products associated with 30-day morbidity and mortality post-rAAA. Results: The overall mortality was 14.6%. At multivariable analyses, transfusion with FFP (>3 units) was independently associated with an increased risk of mortality (odds ratio [OR]: 11.27, 95% confidence interval [CI]: 1.13-96.72, P = .027). The overall morbidity was 26.8%, and subgroup analysis (thrombotic vs nonthrombotic complications) demonstrated transfusion of PLTs (>1 pool) to be independently associated with thrombotic events (OR: 4.3, 95% CI: 1.37-13.6, P = .012). Thrombotic events were responsible for 50% (n = 11 of 22) of all morbidities and mortalities (n = 6 of 12). Conclusion: Transfusion of FFP and PLTs may be associated with an increased risk of postoperative morbidity and mortality. The use of these blood components should be considered in the context of the patient’s clinical and laboratory data as opposed to a fixed ratio to PRBCs. This may result in the reduction in thrombotic complications emerging in rAAA cohort.

Nonunion of the tibial facture as a consequence of posterior tibial artery pseudoaneurysm.

Pseudoaneurysm of the posterior tibial artery (PTA) is uncommon, and they mainly occur following high-velocity trauma, open fractures and can be iatrogenic in nature. To the best of our knowledge, this is the first reported and successfully treated case of PTA pseudoaneurysm identified as a consequence of tibia fracture nonunion in an otherwise healthy young individual 6 months following the original incident with a novel intraoperative technique.

Role of 3D in minimally invasive esophagectomy.

PurposeTwo-stage minimally invasive esophagectomy (MIE) has gained popularity in the surgical treatment of esophageal cancer. MIE’s limitation is embedded in the construction of intrathoracic anastomosis. Various anastomotic techniques have been reported; however, the mechanical one remains the most commonly adopted. This pilot study aims to describe an efficient, safe, and reproducible way of performing a hand-sewn intrathoracic esophagogastric anastomosis in conjunction with short-term results using 2D and 3D thoracoscopic approaches.MethodsA total of nxa0=xa013 patients (mean age 67.4) underwent MIE for distal esophageal or gastroesophageal junction adenocarcinoma between January and September 2016. Resection was performed in prone position, and the esophagogastric anastomosis was constructed in an end-to-side manner in two layers with barbed knotless suture. A 2D thoracoscopic approach was used in nxa0=xa010 patients (77%) and a 3D approach in nxa0=xa03 (23%).Resultsnxa0=xa08 patients (61.5%) had neo-adjuvant chemotherapy and nxa0=xa05 (38.5%) had primary surgery. The mean operating time was 420xa0min, and the average length of stay was 10xa0days with no associated mortality. nxa0=xa01 (7.7%) developed a radiological leak that did not require an intervention. Thoracoscopic approach with the glasses-based 3D optical system using the angulating-tip 100° camera provided a far superior view for precise lymphadenectomy in combination to an efficient and safe construction of the anastomosis.ConclusionThe barbed knotless suturing technique in MIE is an efficient and safe method of constructing the esophagogastric anastomosis with promising short-term outcomes. A 3D thoracoscopic approach appears to be superior in performing the anastomosis to that of a 2D technique.

The independent association of preoperative serum albumin on the functional maturation of radiocephalic arteriovenous fistulae

Purpose The aim of this study is to test the null hypothesis that preoperative albumin along with other preoperative confounders have no impact on the functional maturation of radiocephalic arteriovenous fistulae (RCAVF). Methods A retrospective cohort study of n = 195 individuals undergoing RCAVF formation from July 2013 to December 2015 was conducted. The null hypothesis was assessed through chi squared test. Independent association of each variable was evaluated through univariate and multivariate logistic regression model. Pearsons correlation test was also performed between scale variables to establish their causal link. Results Preoperative hypoalbuminaemic group of individuals demonstrated significant failure of maturation (49.3% vs. 27.2%, p = 0.002). At multivariate analysis, hypoalbuminemia remained an independent marker of fistula failure (OR 0.40, 95% CI 0.21-0.76, p = 0.004) and demonstrated a weak but a positive correlation at the endpoint of maturation (R = 0.223, p = 0.002). Conclusions Preoperative hypoalbuminemia (<35 mg/dL) is independently associated with 40% reduction in the functional maturation of RCAVF. Stratification of this readily available biomarker prior to RCAVF formation may require consideration subjected to further research.

Independent association of arteriovenous ratio index on the primary functional maturation of autologous radiocephalic arteriovenous fistula

Objective: It has been hypothesized that a novel measurement technique of arteriovenous ratio (AVR) index obtained from inflow (radial artery diameter) to that of outflow (cephalic vein diameter) and its application through the Bernoulli effect has no impact on the primary functional maturation (FM) of autogenous radiocephalic arteriovenous fistula (RCAVF). Methods: A prospective consecutive single‐center cohort study with intention to treat of 324 patients undergoing RCAVF during a period of 4 years was conducted. Variables of demographics, anatomic factors, laterality, comorbidities, anesthesia type, presence of intraoperative thrill, angle of anastomosis, and AVR index were assessed through univariate and multivariate logistic regression analysis on the end point of FM. The AVR was subjected to three decimal points to ensure maximal accuracy for best sensitivity and 1 − specificity by receiver operating characteristic curve. The χ2 (subgroup) analyses were undertaken to investigate the differences in FM incidence within different ranges of AVR. Test of probability (P value) was considered to be significant with P < .05. Effect sizes were reported as odds ratio with their measure of uncertainty at 95% confidence intervals. Results: Among all variables, the AVR index remained the only independent factor associated with FM (66%; n = 214/324) of RCAVFs (P = .001; 95% confidence interval, 0.08–0.26). AVR of 1 to 1.06 was associated with 100% FM in RCAVFs. Decrease or increase of this index was associated with stepwise reduction in FM of RCAVFs (P < .05). Conclusions: The suggested novel measurement technique (AVR index) is an independent predictor of FM in RCAVFs. This study implies that minimal diameter (ie, inflow artery dimeter to outflow cephalic vein diameter) mismatch (AVR, 1–1.06) irrespective of other variables remains crucial for optimal hemodynamics (pressure and velocity) of RACVFs and their primary FM.

Revision Using Distal Inflow for the Treatment of Dialysis Access Steal Syndrome: A Systematic Review

The aim of this systematic review is to establish the efficacy of revision using distal inflow (RUDI) on the primary endpoints of complete dialysis access steal syndrome (DASS) resolution and arteriovenous fistula (AVF) longevity. An electronic search of literature from 1966 to 2017 in CINAHL, Medline, Embase and the Cochrane library according to PRISMA standards was conducted. Quality evaluations and recommendations for practice were examined. Data on power, age, gender, comorbidities, arterial inflow, conduit material, fistulae type, follow-up, failure incidence, ischaemia grade, modality of diagnosis, morbidity and mortality were subjected to pooled analysis of prevalence at a 95% confidence interval (CI). Eleven studies involving 130 individuals with a median age of 57 [interquartile ranges (IQR), 54–65] and equal gender distribution were conducted. Of the patients with diabetes mellitus (67.3%), the most common type of AVF with DASS was brachiocephalic AVF (73.7%). Overall, the prevalence of success was 82.0% (95%CI, 74.4%–89.6%) over 12 months (IQR, 1–40 months). Grade 3 ischaemia was the most common type of DASS (49.2%). Grade 4 had the worst outcomes compared with grades 2 and 3. The overall morbidity was 3% with no mortality. Overall, RUDI is an effective treatment for various grades of DASS and their longevity.