Youngjin Han

Clinical Outcomes of Anticoagulation Therapy in Patients With Symptomatic Spontaneous Isolated Dissection of the Superior Mesenteric Artery

AbstractThe aim of this study was to determine the clinical outcomes of long-term anticoagulation therapy in patients with symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) and to evaluate whether conservative treatment with anticoagulation therapy is a safe and effective treatment modality for these patients.In this single center, observational cohort study, data from a prospectively recruiting symptomatic SIDSMA registry, including demographics, risk factors of interest, clinical characteristics and outcomes, and initial and follow-up computed tomography angiography (CTA) findings, were analyzed retrospectively.During an 8-year period, a total of 52 consecutive patients who underwent conservative treatment with the use of long-term anticoagulation were included in this study. Clinical symptoms resolved within 11 days in all except 4 patients (7.7%); 3 received endovascular treatment for persistent symptoms and 1 received surgical repair. The mean duration of anticoagulation therapy was 9 (range: 3–60) months. A follow-up CTA showed complete remodeling in 20 (41.7%) patients, and the mean diameter and the incidence of false lumen thrombosis were also decreased significantly. There was no anticoagulation therapy-related mortality or morbidity except 2 (4.2%) minor bleeding complications, and no symptomatic recurrence or aggravation of the dissection occurred during the mean follow-up period of 47.5 (range: 10–97) months.The present study showed that long-term anticoagulation therapy could result in a high rate of complete remodeling during the natural course of symptomatic SIDSMA. Conservative treatment with long-term anticoagulation therapy could be an optimal treatment strategy for symptomatic SIDSMA.

Impact of graft composition on the systemic inflammatory response after an elective repair of an abdominal aortic aneurysm

Purpose The present study aimed to evaluate the risk factors and the role of graft material in the development of an acute phase systemic inflammatory response, and the clinical outcome in patients who undergo endovascular aneurysm repair (EVAR) or open surgical repair (OSR) of an abdominal aortic aneurysm (AAA). Methods We retrospectively evaluated the risk factors and the role of graft material in an increased risk of developing systemic inflammatory response syndrome (SIRS), and the clinical outcome in patients who underwent EVAR or OSR of an AAA. Results A total of 308 consecutive patients who underwent AAA repair were included; 178 received EVAR and 130 received OSR. There was no significant difference in the incidence of SIRS between EVAR patients and OSR patients. Regardless of treatment modality, SIRS was observed more frequently in patients treated with woven polyester grafts. Postoperative hospitalization was significantly prolonged in patients that experienced SIRS. In multivariate analyses, the initial white blood cell count (P = 0.001) and the use of woven polyester grafts (P = 0.005) were significantly associated with an increased risk of developing SIRS in patients who underwent EVAR. By contrast, the use of woven polyester grafts was the only factor associated with an increased risk of developing SIRS in patients who underwent OSR, although this was not statistically significant (P = 0.052). Conclusion The current study shows that the graft composition plays a primordial role in the development of SIRS, and it leads to prolonged hospitalization in both EVAR and OSR patients.

Comparison of surgical and endovascular salvage procedures for juxta-anastomotic stenosis in autogenous wrist radiocephalic arteriovenous fistula.

BACKGROUND Although dysfunctional radiocephalic arteriovenous fistulas (RCAVFs) are typically treated surgically, the endovascular approach is also considered suitable. The aim of this retrospective study was to compare the cumulative patency rates following surgical and endovascular salvaging of dysfunctional RCAVFs, and to evaluate whether the maturity of vascular access sites at the time of treatment influenced the outcomes. METHODS A total of 60 patients underwent surgical or endovascular salvage treatment for juxta-anastomotic stenosis of autogenous wrist RCAVFs: 35 patients underwent proximal neo-anastomosis and 25 underwent percutaneous transluminal angioplasty (PTA). RESULTS Clinical and anatomical success rates were, respectively, 100% and 97.1% in the surgery group, and 100% and 96.0% in the angioplasty group (P = 0.81). The post-treatment restenosis rate was higher in the angioplasty group (n = 11, 46.0%) than in the surgery group (n = 8, 22.8%), without reaching statistical significance (P = 0.15). In a Kaplan-Meier analysis, the primary and assisted primary patency rates were significantly higher in the surgery group (P = 0.036 and P = 0.026, respectively), but there was no significant difference in secondary patency rates between the groups (P = 0.52). When stratified by RCAVF maturity at the time of treatment, no significant difference was noted in primary patency rates between the treatment groups. After adjusting for other variables, the relative risk of restenosis was significantly higher in the angioplasty group (hazard ratio 2.56; 95% confidence interval 1.02-6.46; P = 0.046). CONCLUSIONS Post-treatment primary and assisted primary patency rates after proximal neo-anastomosis were significantly higher than after PTA, and RCAVF maturity did not influence the outcomes.

Risk factors for acute kidney injury after radical nephrectomy and inferior vena cava thrombectomy for renal cell carcinoma

OBJECTIVE The objectives of the present study are to estimate the incidence of postoperative acute kidney injury (AKI) after radical nephrectomy with inferior vena cava (IVC) thrombectomy for renal cell carcinoma (RCC) based on the Acute Kidney Injury Network (AKIN) criteria, to investigate the risk factors for postoperative AKI, and to define the association between postoperative AKI and clinical outcome in patients undergoing such a surgery. METHODS We retrospectively analyzed 76 patients (22 women; mean age, 56.9 years; range, 29-83 years) with RCC and IVC thrombus who underwent radical nephrectomy and IVC thrombectomy at our institute between January 2003 and December 2011. Postoperative AKI was diagnosed after surgery based on the AKIN criteria. Logistic regression was used to model the association between preoperative factors and the risk of AKI after surgery. The relationship between postoperative AKI and clinical outcomes, including chronic kidney disease (CKD), mortality, and days in hospital, was investigated. RESULTS Postoperative AKI was diagnosed in 41 patients (53.9%) based on the AKIN criteria (stage 1, n = 34; stage 2, n = 2; and stage 3, n = 5). Multivariate analysis demonstrated an independent association between postoperative AKI and male gender (odds ratio 4.79, 95% confidence interval: 1.13-20.39; P = .034), and IVC clamping time lasting more than 20 minutes (odds ratio 6.60, 95% confidence interval: 1.48-29.42; P = .013). Development of AKI was associated with an increased rate of postoperative CKD (43.9% vs 20.0%; P = .031) and prolonged hospitalization (17.7 vs 12.2 days; P = .047). Only one patient who had postoperative AKI required renal replacement therapy. There was no 30-day mortality during the study period and no difference in mortality between AKI and non-AKI patients (4.9% vs 5.7%; P = .859). CONCLUSIONS The incidence of postoperative AKI in patients with RCC and IVC thrombus was considerable. Intraoperative management seems to influence the risk of AKI after surgery; particularly, the longer the IVC clamping time, the higher the risk of postoperative AKI. Postoperative AKI was associated with postoperative CKD (P = .031), prolonged hospitalization (P = .047), and increased long-term mortality (1 year after surgery).

Renal vein extension during living-donor kidney transplantation in the era of hand-assisted laparoscopic living-donor nephrectomy.

Background To evaluate retrospectively the clinical outcomes of living-donor kidney transplantations (LDKTs) using renal vein extension (RVE) for donor kidneys with short renal veins. Methods Between January 2007 and December 2010, a total of 576 LDKTs were performed with grafts generated by hand-assisted laparoscopic living-donor nephrectomy: 31 (5.4%) transplants with RVE and 545 (94.6%) without an additional vascular procedure for renal vein lengthening. Outcomes were compared in patients who did and did not undergo the RVE procedure during transplantation. Results The 31 transplantation patients that underwent RVE involved procured kidneys with short renal veins: 29 were right-sided kidneys (93.5%) and 2 were left-sided kidneys (6.5%) (P=0.00). The RVE grafts were obtained from allogenic gonadal veins from female donors (n=16, 51.6%) and iliac veins from deceased donors (n=15, 48.4%). There were no postoperative complications related to the RVE procedure. During a follow-up period of 45.6±15.9 months, there were one (3.2%) graft failure among the 31 patients with RVE and four (0.7%) among the 545 patients without RVE. Delayed graft function was noted in one (3.2%) of the RVE patients and 22 (4.0%) of the patients without RVE. There was no statistically significant difference in graft failure (P=0.24) or delayed graft function (P=1.00) between the two groups. Conclusion During LDKT, donor kidneys with exceptionally short renal veins, which may result in unavoidable tension during renal vein anastomosis, may be modified by RVE, thus facilitating a secure anastomosis and reducing postoperative complications.

A Retrospective 10-Year, Single-Institution Study of Carotid Endarterectomy with a Focus on Elderly Patients

Background and Purpose This study evaluated the outcome following surgery for carotid artery stenosis in a single institution during a 10-year period and the relevance of aging to access to surgery. Methods Between January 2001 and December 2010, 649 carotid endarterectomies (CEAs) were performed in 596 patients for internal carotid artery occlusive disease at our institution; 596 patients received unilateral CEAs and 53 patients received bilateral CEAs. Data regarding patient characteristics, comorbidities, stroke, mortality, restenosis, and other surgical complications were obtained from a review of medical records. Since elderly and high-risk patients comprise a significant proportion of the patient group undergoing CEAs, differences in comorbidity and mortality were evaluated according to age when the patients were divided into three age groups: <70 years, 70-79 years, and ≥80 years. Results The mean age of the included patients was 67.5 years, and 88% were men. Symptomatic carotid stenosis was observed in 65.7% of patients. The rate of perioperative stroke and death (within 30 days of the procedure) was 1.84%. The overall mortality rate was higher among patients in the 70-79 years and >80 years age groups than among those in the <70 years age group, but there was no significant difference in stroke-related mortality among these three groups. Conclusions CEA over a 10-year period has yielded acceptable outcomes in terms of stroke and mortality. Therefore, since CEA is a safe and effective strategy, it can be performed in elderly patients with acceptable life expectancy.

Use of cryopreserved cadaveric arterial allograft as a vascular conduit for peripheral arterial graft infection

Major peripheral arterial graft infection is a potentially devastating complication of vascular surgery, associated with significant mortality and high amputation rates. Autologous saphenous veins are considered optimal arterial conduits for lower extremity revascularization in infected fields, but they are often unavailable or unsuitable in these patients. This study describes two patients with major peripheral graft infection, but without available autologous veins, who underwent graft excision and cryopreserved cadaveric arterial allograft reconstruction. Although long-term graft durability is unclear because of gradual deterioration and degeneration, these findings suggest that cadaveric allografts may be good options for patients with major peripheral graft infection.

Abdominal aortic aneurysm in giant cell arteritis

Aortic complications of giant cell arteritis are a rare cause of abdominal aortic aneurysm. Here, we describe a case of a ruptured aortic aneurysm in a patient with giant call arteritis (GCA) who was preoperatively suspected of having an infectious aortic aneurysm. Intraoperative inspection revealed infectious granulation tissue on the anterior wall of the abdominal aorta. GCA was finally confirmed by pathological diagnosis. Our findings suggest that the surgical and postoperative treatment of nonatheromatous aortic aneurysm should be based on accurate diagnosis.

Renal autotransplantation in open surgical repair of suprarenal abdominal aortic aneurysm

Although the standard treatment of abdominal aortic aneurysm has shifted from open surgery to endovascular repair, open surgery has remained the standard of care for complex aneurysms involving the visceral arteries and in patients unsuitable for endovascular aneurysm repair. Postoperative renal insufficiency may occur after open surgical repair of suprarenal abdominal aortic aneurysm. Methods of minimizing renal ischemic injury include aortic cross-clamping and renal reconstruction techniques. This report describes the use of renal autotransplantation for renal reconstruction during open surgical repair of a suprarenal abdominal aortic aneurysm. This technique was successful, suggesting its feasibility for open suprarenal abdominal aortic aneurysm repair, minimizing renal ischemic injury and optimizing postoperative renal function.

Surgical Treatment of Central Venous Catheter Related Septic Deep Venous Thrombosis

OBJECTIVE/BACKGROUND The aim of this study was to evaluate the clinical features and outcomes of catheter related central venous thrombosis and whether a surgical approach can be an effective treatment modality in selected cases that are refractory to conservative management. METHODS This was a retrospective review of the 46 consecutive patients who were suspected of having central venous catheter related infected deep venous thrombosis and who met the eligibility criteria. RESULTS Conservative management achieved clinical improvement in 26 (56.5%) patients and failed in 20 (43.5%), of whom surgical thrombectomy was performed in 13. The remaining seven patients died before surgery could be performed or their clinical condition was too poor. Apart from one case of wound hematoma (7.7%), post-operative complications that related to the surgical procedure were not observed. Patency of the involved vein was re-established in 12 of the 13 (92.3%) surgically treated patients, and clinical improvement was achieved in 11 (84.6%). In particular, the five patients whose blood cultures revealed Candida species exhibited prompt defervescence after surgical thrombectomy. CONCLUSION Although conservative management is the first therapy of choice in patients with central venous catheter related infected thrombosis, surgical treatment that removes the septic material can be regarded as a last resort in critically ill patients with septic thrombophlebitis that is refractory to conservative management.