Jerzy Garcarek

Creation of arteriovenous fistulae for hemodialysis in octogenarians.

Elderly patients, defined as octogenarians and nonagenarians, are an increasing population entering renal replacement therapy. Advanced age appears as an exclusive factor negatively influencing dialysis practice. Elderly patients are referred late for the initiation of hemodialysis and more likely are offered catheters rather than arteriovenous fistulae (AVF), which increase mortality and negatively affect quality of life. We present our approach to the creation of vascular access for hemodialysis in this demanding population. In 2006–2012, 39 patients aged 85.9 ± 2.05 with end‐stage renal disease, mainly resulting from ischemic nephropathy, were admitted to the Department of Nephrology to establish permanent vascular access for hemodialysis: preferably AVF. Temporary dialysis catheters were implanted in uremic emergency to bridge the time to fistula creation/maturation. AVF was attempted in 87.2% of the patients. Primary AVF function was achieved in 54% of the patients. Cumulative proportional survival of AVF at months 12 and 24 was 81.5%. Ninety‐four percent of AVF were localized on the forearm: 74% in the distal and 20% in the proximal part. Mean duration of hemodialysis therapy was 20.80 ± 19.45 months. The mean time of AVF use was 15.9 ± 20.2 months. Until present, 38% have been dialyzed using AVF for 31.0 ± 18.8 months. Five patients died with functioning fistula. Eight patients initiated hemodialysis therapy with fistula. During further observation, the use of AVF increased to 62%. Elderly patients should not be denied creation of AVF as a rule. The outcome of AVF benefits more from acknowledging individual vascular conditions rather than age of the patient.

Combined autologous bone marrow mononuclear cell and gene therapy as the last resort for patients with critical limb ischemia.

Introduction Our study was designed to investigate the safety and efficacy of combined autologous bone marrow mononuclear cell (MNC) and gene therapy in comparison to conventional drug therapy in patients with critical limb ischemia (CLI). Material and methods Thirty-two patients with CLI persisting for 12–48 months (average time 27.5 months) were randomized into 2 groups, each group consisting of 16 patients. In the first group, administration of autologous bone marrow MNC and vascular endothelial growth factor (VEGF) plasmid was performed. The patients from the second group were treated pharmacologically with pentoxifylline. Ankle-brachial index (ABI) was measured and angiography was performed before and finally 3 months after treatment. The pain was evaluated using the Visual Analog Scale (VAS) before and after 3 months. Results Ankle-brachial index improved significantly from 0.29 ±0.21 to 0.52 ±0.23 (p < 0.001) in 12 patients (75.0%) 3 months after the experimental therapy in group 1. In this group angiography showed the development of collateral vessels. Ischemic ulcers healed completely in 11 patients (68.75%). In group 2 the ABI did not improve in any patient; moreover the complete healing of skin ulcers was not found in any of the patients of this group. Amputation was performed in 4 (25.0%) patients in group 1, and in 8 patients (50%) from group 2. Conclusions These data after 3-month follow-up indicate that intramuscular injection of MNC combined with gene therapy in patients with chronic CLI is safe, and a more feasible and effective method of treatment than the conventional therapy. However, both therapies are limited by the degree of microcirculation damage.

Balloon angioplasty for disruption of tunneled dialysis catheter fibrin sheath

Purpose Management of failing tunneled hemodialysis catheters, sometimes the only vascular access for hemodialysis, presents a difficult problem. In spite of various techniques having been developed, no consensus has been reached about the preferred technique, associated with the longest catheter patency. Methods We report disruption of the fibrin sheath covering dysfunctional tunneled hemodialysis catheter by means of angioplasty, followed by over guidewire catheter exchange. Results Following the procedure, the catheter placed in the recovered lumen of the vessel presented correct function. Conclusions The described procedure allowed maintenance of vascular access in our patient. Additionally, dilatation of the concomitant central vein stenosis opens an option for another attempt for arteriovenous fistula creation.

Imaging difficulties in Takayasu arteritis - case report and review of the literature.

Summary Background: Takayasu arteritis is an inflammatory disease of large-diameter arteries. Aorta and its branches are most frequently affected. Takayasu arteritis occurs mainly in young women and, if left untreated, leads to fatal complications. Digital subtraction angiography (DSA) is considered the gold standard in imaging of Takayasu arteritis. Case Report: A thirty-five-year-old woman was admitted to the hospital with transient loss of consciousness, effort-associated vertigo, upper limb weakness and temporary vision problems. On admission, there was no pulse on the left radial artery while there were bruits over subclavian arteries. Imaging of the aortic arch (computed tomography angiography, DSA) revealed stenoses of its main branches, indicating Takayasu arteritis. Conclusions: Computed tomography angiography (CTA) performed with a 64-slice unit revealed high effectiveness in localization of vascular wall and lumen pathologies resulting from Takayasu arteritis. Thanks to this fast diagnostic method, it is now possible to perform successful monitoring of patients with Takayasu arteritis and to plan possible interventional treatment.

Balloon Dilatation for Removal of an Irretrievable Permanent Hemodialysis Catheter: The Safest Approach.

Long-term hemodialysis catheter dwell time in the central vein predisposes to fibrin sheath development, which subsequently causes catheter malfunction or occlusion. In very rare cases, the catheter can be overgrown with fibrin and rigidly connected with the vein or heart structures. This makes its removal almost impossible and dangerous because of the possibility of serious complications, namely vein and heart wall perforation, bleeding, or catheter abruption in deep tissues. We describe two cases in which standard retrieval of long-term catheters was not possible. Balloon dilatation of catheter lumens was successfully used to increase the catheter diameter with simultaneous tearing of the fibrin sheath surrounding it. This allowed the catheter to be set free safely. Based on this experience, we present recent literature and our point of view.

Endovascular exclusion of a large spontaneous aortocaval fistula in a patient with a ruptured aortic aneurysm

A primary aortocaval fistula (ACF) is present in less than 1% of all abdominal aortic aneurysms (AAA). The case of a 62-year-old patient with a ruptured AAA and ACF was reported. A stent-graft was implanted into the abdominal aorta. An inferior vena cava filter was inserted to prevent pulmonary embolism. The patient made a smooth recovery. The follow-up computed tomographic scan three months later did not reveal any evidence of endoleaks or that the fistula was still present. Hemodynamic changes with regard to transient acute liver impairment were discovered (renal and liver parameters were presented). Endovascular exclusion appears to be an effective option in the treatment of an aortocaval fistula in comparison to conventional open repair.

Biological Properties of Low-Toxic PLGA and PLGA/PHB Fibrous Nanocomposite Scaffolds for Osseous Tissue Regeneration. Evaluation of Potential Bioactivity

The aim of the study was to evaluate the biocompatibility and bioactivity of two new prototype implants for bone tissue regeneration made from biodegradable fibrous materials. The first is a newly developed poly(l-lactide-co-glycolide), (PLGA), and the second is a blend of PLGA with synthetic poly([R,S]-3-hydroxybutyrate) (PLGA/PHB). The implant prototypes comprise PLGA or PLGA/PHB nonwoven fabrics with designed pore structures to create the best conditions for cell proliferation. The bioactivity of the proposed implants was enhanced by introducing a hydroxyapatite material and a biologically active agent, namely, growth factor IGF1, encapsulated in calcium alginate microspheres. To assess the biocompatibility and bioactivity, allergenic tests and an assessment of the local reaction of bone tissue after implantation were performed. Comparative studies of local tissue response after implantation into trochanters for a period of 12 months were performed on New Zealand rabbits. Based on the results of the in vivo evaluation of the allergenic effects and the local tissue reaction 12 months after implantation, it was concluded that the two implant prototypes, PLGA + IGF1 and PLGA/PHB + IGF1, were characterized by high biocompatibility with the soft and bone tissues of the tested animals.

Embolization of a True Giant Splenic Artery Aneurysm Using NBCA Glue - Case Report and Literature Review.

Summary Background Although splenic artery aneurysms (SAAs) are common, their giant forms (more than 10 cm in diameter) are rare. Because of the variety of forms and locations of these aneurysms, there are a lot of therapeutic methods to choose. In our case of a giant true aneurysm we performed an endovascular embolization with N-butyl-cyano-acrylate (NBCA) glue. To our knowledge it is the first reported case of this method of treatment of true giant SAA. Case Report A 74-year-old male patient with symptomatic giant SAA (13 cm) was urgently admitted to our hospital for the diagnostic and therapeutic procedures. Due to the general health condition, advanced age and the large size of the aneurysm we decided to perform an endovascular treatment with N-butyl-cyano-acrylate (NBCA) glue. Conclusions The preaneurysmal part of splenic artery was occluded completely with exclusion of the aneurysm. No splenectomy was needed. The patient was discharged in good general condition Embolization with NBCA can be an efficient method to treat the giant SAA.

Vascular access should be tailored to the patient

A cornerstone of hemodialysis treatment is the creation of a functional and durable dialysis vascular access. Every patient with chronic kidney disease should have a plan of renal replacement therapy and access site protection. Factors having a crucial impact on vascular access selection include age, comorbidity, vessel quality, prognosis, dialysis urgency, and surgeons preferences. Our medical group have reviewed these factors in our patients and, based on recently published data, developed a clinical decision tree for dialysis access in the chronic kidney disease patient. Vascular access care should be patient-centered with the aim to maximize patient survival without loss of vascular access options; and not focused only the primary patency rates of dialysis access procedures.

OwN CLINICAL ObSERvAtIONS Of tREAtmENt OutCOmE IN ACutE tyPE b AORtIC dISSECtION

UNLABELLED The aim of the study was to analyse early results of treatment of acute type B aortic dissection. MATERIAL AND METHODS 59 patients, treated between 1998 and 2011, were divided into four groups. Group I comprised ten patients in whom hybrid procedures were performed: extra-anatomical by-pass graft from the brachio-cephalic trunk to the left carotid artery in six patients, transposition of the left carotid artery to the right one in two patients, and reversed Y prosthesis from the brachio-cephalic trunk to both carotids in the remaining 2 patients, to facilitate stent-grafting. Group II comprised 13 patients in whom endovascular procedures were performed (stent-grafting). Group III comprised 21 patients in whom conventional surgery was done. Group IV comprised 15 patients who were treated conservatively. RESULTS In group I, a very good clinical outcome, without complications, was achieved in six patients (60% of cases). The total mortality rate was 40%. One patient died on the operation table, following stent-grafting, due to the rupture of the aortic arch. Two patients died as a result of brain damage (cerebral aneurysm rupture in one, and ischemic stroke in the other). In one patient, an aorto-oesophageal fistula developed. In group II, one patient died during endovascular procedure. Another patient suffered from type 1 endoleak, requiring repeated endovascular surgery. In group III, 15 patients (72%) died. Moreover, four patients required acorrective cardiac surgery (Bentall procedure)which in three patients resulted in death. Thus, the total mortality rate in this group was as high as 85%. In group IV, the mortality rate was 13%. CONCLUSIONS We noticed a clear superiority of endovascular procedures over conventional surgeries-for acute type B aortic dissection. Hybrid procedures for acute, complicated type B aortic dissection evidently reduce mortality and postoperative morbidity. Uncomplicated acute type B aortic dissections should be treated conservatively at intensivecare units.