Surgeons avoid creating arteriovenous fistulae in obese patients owing to deep vessels, cannulation complications, and inconsistent outcomes. We describe placing an arteriovenous polytetrafluoroethylene (PTFE) graft between the brachial artery and axillary vein to avoid these complications. A 39-year-old super-obese woman with end-stage renal disease had undergone several hemodialysis access procedures on both arms. We traced the course of the arteriovenous graft course with the patient sitting and lying down. The ideal course was more accurate with the patient sitting; thus, the patient sat when the course was drawn, before lying on the operating bed. The PTFE graft was placed between the right brachial artery and axillary vein, according to the course in the opposite arm. No anastomotic dehiscence or pseudoaneurysm has taken place during 2 years of follow-up.In super-obese patients, the ideal course for arteriovenous grafts should be drawn while they are sitting, avoiding skin folds. This tip could avoid anastomotic dehiscence and pseudoaneurysm between the axillary vein and a PTFE graft.

Although development of surgical technique and critical care, ruptured abdominal aortic aneurysm still carries a high mortality. In order to obtain good results, various efforts have been attempted. This paper reviews initial management of ruptured abdominal aortic aneurysm and discuss the key point open surgical repair and endovascular aneurysm repair.
Aneurysm ; Aorta ; Aortic Aneurysm, Abdominal* ; Critical Care ; Mortality ; Rupture

BACKGROUND: Upper limb ischemia is less common than lower limb ischemia, and relatively few cases have been reported. This paper reviews the epidemiology, etiology, and clinical characteristics of upper limb ischemia and analyzes the factors affecting functional sequelae after treatment. METHODS: The records of 35 patients with acute and chronic upper limb ischemia who underwent treatment from January 2007 to December 2012 were retrospectively reviewed. RESULTS: The median age was 55.03 years, and the number of male patients was 24 (68.6%). The most common etiology was embolism of cardiac origin, followed by thrombosis with secondary trauma, and the brachial artery was the most common location for a lesion causing obstruction. Computed tomography angiography was the first-line diagnostic tool in our center. Twenty-eight operations were performed, and conservative therapy was implemented in seven cases. Five deaths (14.3%) occurred during follow-up. Twenty patients (57.1%) complained of functional sequelae after treatment. Functional sequelae were found to be more likely in patients with a longer duration of symptoms (odds ratio, 1.251; p=0.046) and higher lactate dehydrogenase (LDH) levels (odds ratio, 1.001; p=0.031). CONCLUSION: An increased duration of symptoms and higher initial serum LDH levels were associated with the more frequent occurrence of functional sequelae. The prognosis of upper limb ischemia is associated with prompt and proper treatment and can also be predicted by initial serum LDH levels.
Angiography ; Brachial Artery ; Embolism ; Epidemiology ; Follow-Up Studies ; Humans ; Ischemia* ; L-Lactate Dehydrogenase ; Lower Extremity ; Male ; Prognosis ; Retrospective Studies ; Thrombosis ; Upper Extremity*

Arterial thoracic outlet syndrome (TOS) causes ischemic symptoms; it is the rarest type, occurring in 5% of all TOS cases. This paper is a case report of a 38-year-old male patient diagnosed with arterial TOS, displaying symptoms of acute critical limb ischemia caused by thromboembolism. Brachial artery of the patient has been diffusely damaged by repeated occurrence of thromboembolism. It was thought to be not enough only decompression of subclavian artery to relieve the symptoms of hand ischemia; therefore, bypass surgery using reversed great saphenous vein was performed.
Adult ; Brachial Artery ; Decompression ; Extremities ; Hand ; Humans ; Ischemia ; Male ; Saphenous Vein ; Subclavian Artery ; Thoracic Outlet Syndrome* ; Thromboembolism ; Vascular Grafting

BACKGROUND: The inferior vena cava filter (IVCF) is very effective for preventing pulmonary embolism in patients who cannot undergo anticoagulation therapy. However, if a filter is placed in the body permanently, it may lead to other complications. METHODS: A retrospective study was performed of 159 patients who underwent retrievable Cook Celect IVCF implantation between January 2007 and April 2015 at a single center. Baseline characteristics, indications, and complications caused by the filter were investigated. RESULTS: The most common underlying disease of patients receiving the filter was cancer (24.3%). Venous thrombolysis or thrombectomy was the most common indication for IVCF insertion in this study (47.2%). The most common complication was inferior vena cava penetration, the risk of which increased the longer the filter remained in the body (p=0.032, Exp(B)=1.004). CONCLUSION: If the patient is able to retry anticoagulation therapy and the filter is no longer needed, the filter should be removed, even if a long time has elapsed since implantation. If the filter cannot be removed, it is recommended that follow-up computed tomography be performed regularly to monitor the progress of venous thromboembolisms as well as any filter-related complications.
Follow-Up Studies ; Humans ; Pulmonary Embolism ; Retrospective Studies ; Thrombectomy ; Thromboembolism ; Vena Cava Filters* ; Vena Cava, Inferior* ; Venous Thrombosis

Objective: To report the authors’ experience in performing thoracic endovascular aortic repair (TEVAR) for zone 2 lesions after traumatic aortic injury (TAI). Materials and Methods: This retrospective review included 10 patients who underwent zone 2 TEVAR after identification of aortic isthmus injury by CT angiography (CTA) upon arrival at the emergency room of a regional trauma center from 2016 to 2019. Patients were classified into two groups: those who underwent left subclavian artery (LSA) embolization concurrently with the main TEVAR procedure, and those in whom LSA embolization was not performed during the main procedure, but was planned as a bailout treatment if type II endoleak was noted on follow-up CTA images. Pre-procedural and procedurerelated factors and post-procedure prognosis were compared between the groups. Results: There were no differences in pre-procedural factors, occurrence of endoleaks, and post-procedure prognosis (including mortality) between patients in the two groups. The duration of the procedure was shorter in the non-LSA embolization group (61 minutes vs. 27 minutes, p = 0.012). During follow-up, type II endoleak did not occur in either group. Conclusion Delaying preventative LSA embolization until stabilization of the patient would be desirable when performing zone 2 TEVAR for TAI, in the absence of endoleak on the completion aortography image taken after complete deployment of the stent graft.

Objective: To report the authors’ experience in performing thoracic endovascular aortic repair (TEVAR) for zone 2 lesions after traumatic aortic injury (TAI). Materials and Methods: This retrospective review included 10 patients who underwent zone 2 TEVAR after identification of aortic isthmus injury by CT angiography (CTA) upon arrival at the emergency room of a regional trauma center from 2016 to 2019. Patients were classified into two groups: those who underwent left subclavian artery (LSA) embolization concurrently with the main TEVAR procedure, and those in whom LSA embolization was not performed during the main procedure, but was planned as a bailout treatment if type II endoleak was noted on follow-up CTA images. Pre-procedural and procedurerelated factors and post-procedure prognosis were compared between the groups. Results: There were no differences in pre-procedural factors, occurrence of endoleaks, and post-procedure prognosis (including mortality) between patients in the two groups. The duration of the procedure was shorter in the non-LSA embolization group (61 minutes vs. 27 minutes, p = 0.012). During follow-up, type II endoleak did not occur in either group. Conclusion Delaying preventative LSA embolization until stabilization of the patient would be desirable when performing zone 2 TEVAR for TAI, in the absence of endoleak on the completion aortography image taken after complete deployment of the stent graft.

Background: When an arteriovenous fistula (AVF) is created using the basilic or deep cephalic vein, it is additionally necessary to transfer the vessels to a position where needling is easy; however, many patients develop wound-related postsurgical complications due to the long surgical wounds resulting from conventional superficialization of a deep AVF or basilic vein transposition. Thus, to address this problem, we performed videoscopic surgery with small surgical incisions. Methods: Data from 16 patients who underwent additional videoscopic radiocephalic superficialization, brachiocephalic superficialization, and brachiobasilic transposition after AVF formation at our institution in 2018 were retrospectively reviewed. Results: Needling was successful in all patients. No wound-related complications occurred. The mean vessel size and blood flow of the AVF just before the first needling were 0.73±0.16 mm and 1,516.25±791.26 mL/min, respectively. The mean vessel depth after surgery was 0.26±0.10 cm. Percutaneous angioplasty was additionally performed in 25% of the patients. Primary patency was observed in 100% of patients during the follow-up period (262.44±73.49 days). Conclusion Videoscopic surgery for AVF dramatically reduced the incidence of postoperative complications without interrupting patency; moreover, such procedures may increase the use of native vessels for vascular access. In addition, dissection using a videoscope compared to blind dissection using only a skip incision dramatically increased the success rate of displacement by reducing damage to the dissected vessels.

BACKGROUND: Patients who are born without spleen or who have impaired splenic function due to disease or splenectomy become vulnerable to sepsis caused by bacteria. Overwhelming post-splenectomy infection (OPSI) occurs at an estimated incidence of 0.23-0.42% per year with a lifetime risk of 5%. The risk of OPSI with encapsulated bacteria is generally considered greatest in the first 2 years after splenectomy but the increased risk remains lifelong. Because vaccination doesn't completely protect against infection with encapsulated bacteria that prevent OPSI, use of prophylactic antibiotics are recommended for prevention of infection after splenectomy.METHODS: A retrospective review of 41 patients who underwent splenectomy from January 1990 to December 2012 in Inje University Busan Paik Hospital were identified through the medical records.RESULTS: Of 41 patients, 100% (41/41) were vaccinated in pneumococcal vaccines, 27% (11/41) were vaccinated in HIB vaccines. Prophylactic antibiotics (penicillin G benzathine IM every 4 weeks) were prescribed in 73% (30/41) of patients. We could not find any septic events.CONCLUSION: Because of the high mortality, the fulminant course, and the refractoriness to common treatment of overwhelming infections caused by encapsulated bacteria, prevention through vaccination and antibiotic prophylaxis is the basis of the management of patients who have had splenectomy or have hyposplenism. Prophylactic antibiotics using Penicillin G benzathine every 4 weeks is effective for preventing septic events in splenectomized patients. But further improvement in coverage of recommended vaccines and continuous prophylactic antibiotics after splenectomy is needed to reduce the risk of serious infection.
Anti-Bacterial Agents ; Antibiotic Prophylaxis ; Bacteria ; Ethylenediamines ; Haemophilus influenzae type b ; Humans ; Incidence ; Medical Records ; Mortality ; Penicillin G Benzathine ; Pneumococcal Vaccines ; Retrospective Studies ; Sepsis ; Spleen ; Splenectomy ; Vaccination ; Vaccines