Uncommon Surgical Management by AVF between the Great Saphenous Vein and Anterior Tibial Artery for Old Radiocephalic AVF Failure

Introduction: Autologous native arteriovenous fistula (AVF) created in the non-dominant arm is the gold standard vascular access for dialysis in end-stage renal disease, but the post-surgical vascular access dysfunction causes a reduction in the patient’s quality of life. Creating a functional upper extremity permanent arteriovenous access is limited by the upper limb’s vascular resources, so good management of a complicated arteriovenous fistula may improve patient outcomes. This article highlights the importance of new surgical options in treating complicated AVFs. Case report: We present the case of a patient with a 17-year-old complex radio-cephalic arterio-venous fistula and a series of surgical interventions performed for life salvage in the first place and functional vascular access in the second place. Furthermore, we describe a successfully created uncommon type of fistula in the lower extremity between the great saphenous vein and the anterior tibial artery as the last possible access for hemodialysis in this patient. Results: The patient underwent the first successful dialysis using the newly created lower limb fistula 1 month after the surgery. Conclusion: Applying new surgical techniques to manage AVFs gives a unique chance to improve the quality of life and reduce morbidity and mortality in these patients

Negative Impact of the COVID-19 Pandemic on Kidney Disease Management—A Single-Center Experience in Romania

Background: The evolution of the COVID-19 pandemic affected healthcare systems worldwide. The patients with chronic kidney disease (CKD), diabetes, and cardiovascular disease were most affected and had an unfavorable outcome. Methods: We examined the activity of the Nephrology Department from Târgu-Mureș County Emergency Hospital retrospectively, comparing two periods: June 2020–November 2021 (COVID-19 period) and June 2018–November 2019 (non-COVID-19 period). Results: In the COVID-19 period, there were fewer one-day hospitalizations registered, 77.27% more dialysis catheters were installed, and 43.75% more arteriovenous fistulas were performed. An overall increase in the number of patients requiring dialysis during the pandemic was recorded, as of the number of dialysis sessions performed. Moreover, we observed a statistically significant increase in the number of dialysis sessions per patient and a statistically significant increase in the number of hospitalization days in the pandemic interval. Acute kidney injury (AKI) and urosepsis were the diagnoses that increased the most among in-patients during the pandemic, while all other nephrology diagnoses decreased. Conclusions: The COVID-19 pandemic accelerated kidney pathology and worsened the outcomes of nephrology patients in our center. The number of chronic and patient’s access to one-day hospitalization decreased in order to minimalize the exposure and the risk of infection. In contrast, the need for emergency dialysis increased significantly

The Predictive Value of NLR, MLR, and PLR in the Outcome of End-Stage Kidney Disease Patients

Background: Chronic kidney disease (CKD) is a global public health problem with a high mortality rate and a rapid progression to end-stage kidney disease (ESKD). Recently, the role of inflammation and the correlation between inflammatory markers and CKD progression have been studied. This study aimed to analyze the predictive value of the neutrophil–lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) in assessing the outcome of ESKD patients. Methods: A retrospective study which included all patients admitted in the Department of Nephrology of the County Emergency Clinical Hospital, Târgu-Mureș, Romania, between January 2016 and December 2019, diagnosed with ESKD. Results: Mortality at 30 days was clearly higher in the case of the patients in the high-NLR groups (40.12% vs. 1.97%; p < 0.0001), high-MLR (32.35% vs. 4.81%; p < 0.0001), and respectively high-PLR (25.54% vs. 7.94%; p < 0.0001). There was also a significant increase in the number of hospital days and the average number of dialysis sessions in patients with high-NLR (p < 0.0001), high-MLR (p < 0.0001), and high-PLR (p < 0.0001). The multivariate analysis showed that a high baseline value for NLR (p < 0.0001), MLR (p < 0.0001), and PLR (p < 0.0001) was an independent predictor of 30-day mortality for all recruited patients. Conclusions: Our findings established that NLR, MLR, and PLR determined at hospital admission had a strong predictive capacity of all-cause 30-day mortality in ESKD patients who required RRT for at least 6 months. Elevated values of the ratios were also associated with longer hospital stays and more dialysis sessions per patient

The Predictive Role of NLR and PLR in Outcome and Patency of Lower Limb Revascularization in Patients with Femoropopliteal Disease

Background: Peripheral arterial disease (PAD) changes the arterial structure and function, and is the most common manifestation of the atherosclerotic process, except for the coronary and cerebral arterial systems. Inflammation is well known to have a role in the progression of atherosclerosis and, by extension, in PAD. Among the recently studied markers in the literature, we list the neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR). This study aims to analyze the preoperative role of NLR and PLR in the medium-term outcome of patients surgically revascularized for femoropopliteal disease. Methods: A retrospective study included patients admitted to the Vascular Surgery Clinic of the County Emergency Clinical Hospital of Târgu-Mureș, Romania, between January 2017 and December 2019, diagnosed with femoropopliteal disease and having presented an indication for surgical revascularization. The patients included in the study were classified according to the 12 months primary patency in two groups: “patency” and “nonpatency”. Results: Depending on the Rutherford classification (RC), there was a higher incidence of stages II and III in the patency group and a higher incidence of stage V in the nonpatency group. Depending on the optimal cut-off value according to ROC for the 12 months primary patency, obtained from Youden’s index (3.95 for NLR (82.6% sensitivity and 89.9% specificity), and 142.13 for PLR (79.1% sensitivity and 82.6% specificity)), in all high-NLR and high-PLR groups, there was a higher incidence of all adverse outcomes. Moreover, a multivariate analysis showed that a high baseline value for NLR and PLR was an independent predictor of all outcomes for all recruited patients. Furthermore, for all hospitalized patients, RC 5 was an independent predictor of poor prognosis. Conclusions: Our findings establish that a high value of preoperative NLR and PLR determined at hospital admission is strongly predictive of primary patency failure (12 months after revascularization). Additionally, elevated ratio values are an independent predictor for a higher amputation rate and death for all patients enrolled in the study, except for mortality in RC 2, and both amputation and mortality in RC 5

The Predictive Value of Systemic Inflammatory Markers, the Prognostic Nutritional Index, and Measured Vessels’ Diameters in Arteriovenous Fistula Maturation Failure

Background: An arteriovenous fistula (AVF) is the first-line vascular access pathway for patients diagnosed with end-stage renal disease (ESRD). In planning vascular access, it is necessary to check the diameters of the venous and arterial components for satisfactory long-term results. Furthermore, the mechanism underlying the maturation failure and short-term patency in cases of AVFs is not fully known. This study aims to verify the predictive role of inflammatory biomarkers (the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic inflammatory index (SII), and C-reactive protein (CRP)), Ca-P product, the prognostic nutritional index (PNI), and the diameters of the venous and arterial components in the failure of AVF maturation. Methods: The present study was designed as an observational, analytical, and retrospective cohort study with a longitudinal follow-up, and included all patients with a diagnosis of ESRD that were admitted to the Vascular Surgery Clinic of the Targu Mures Emergency County Hospital, Romania, between January 2019 and December 2021. Results: The maturation of AVF at 6 weeks was clearly lower in cases of patients in the high-NLR (31.88% vs. 91.36%; p < 0.0001), high-PLR (46.94% vs. 85.55%; p < 0.0001), high-SII (44.28% vs. 88.89%; p < 0.0001), high-CRP (46.30% vs. 88.73%; p < 0.0001), high-Ca-P product (40.43% vs. 88.46%; p < 0.0001), and low-PNI (34.78% vs. 91.14%; p < 0.0001) groups, as well as in patients with a lower radial artery (RA) diameter (40% vs. 94.87%; p = 0.0009), cephalic vein (CV) diameter (44.82% vs. 97.14%; p = 0.0001) for a radio-cephalic AVF (RC-AVF), and brachial artery (BA) diameter (30.43% vs. 89.47%; p < 0.0001) in addition to CV diameter (40% vs. 94.59%; p < 0.0001) for a brachio-cephalic AVF (BC-AVF), respectively. There was also a significant increase in early thrombosis and short-time mortality in the same patients. A multivariate analysis showed that a baseline value for the NLR, PLR, SII, CRP, Ca-P product, and PNI was an independent predictor of adverse outcomes for all of the recruited patients. Furthermore, for all patients, a high baseline value for vessel diameter was a protective factor against any negative events during the study period, except for RA diameter in mortality (p = 0.16). Conclusion: Our findings concluded that higher NLR, PLR, SII, CRP, Ca-P product, and PNI values determined preoperatively were strongly predictive of AVF maturation failure, early thrombosis, and short-time mortality. Moreover, a lower baseline value for vessel diameter was strongly predictive of AVF maturation failure and early thrombosis

Increased Epicardial Adipose Tissue (EAT), Left Coronary Artery Plaque Morphology, and Valvular Atherosclerosis as Risks Factors for Sudden Cardiac Death from a Forensic Perspective

Background: In sudden cardiac deaths (SCD), visceral adipose tissue has begun to manifest interest as a standalone cardiovascular risk factor. Studies have shown that epicardial adipose tissue can be seen as a viable marker of coronary atherosclerosis. This study aimed to evaluate, from a forensic perspective, the correlation between body mass index (BMI), heart weight, coronary and valvular atherosclerosis, left ventricular morphology, and the thickness of the epicardial adipose tissue (EAT) in sudden cardiac deaths, establishing an increased thickness of EAT as a novel risk factor. Methods: This is a retrospective case–control descriptive study that included 80 deaths that were autopsied, 40 sudden cardiac deaths, and 40 control cases who hanged themselves and had unknown pathologies prior to their death. In all the autopsies performed, the thickness of the epicardial adipose tissue was measured in two regions of the left coronary artery, and the left ventricular morphology, macro/microscopically quantified coronary and valvular atherosclerosis, and weight of the heart were evaluated. Results: This study revealed a higher age in the SCD group (58.82 ± 9.67 vs. 53.4 ± 13.00; p = 0.03), as well as a higher incidence in females (p = 0.03). In terms of heart and coronary artery characteristics, there were higher values of BMI (p = 0.0009), heart weight (p < 0.0001), EAT of the left circumflex artery (LCx) (p < 0.0001), and EAT of the left anterior descending artery (LAD) (p < 0.0001). In the multivariate analysis, a high baseline value of BMI (OR: 4.05; p = 0.004), heart weight (OR: 5.47; p < 0.001), EAT LCx (OR: 23.72; p < 0.001), and EAT LAD (OR: 21.07; p < 0.001) were strong independent predictors of SCD. Moreover, age over 55 years (OR: 2.53; p = 0.045), type Vb plaque (OR: 17.19; p < 0.001), mild valvular atherosclerosis (OR: 4.88; p = 0.002), and moderate left ventricle dilatation (OR: 16.71; p = 0.008) all act as predictors of SCD. Conclusions: The data of this research revealed that higher baseline values of BMI, heart weight, EAT LCx, and EAT LAD highly predict SCD. Furthermore, age above 55 years, type Vb plaque, mild valvular atherosclerosis, and left ventricle dilatation were all risk factors for SCD

Increased Epicardial Adipose Tissue (EAT), Left Coronary Artery Plaque Morphology, and Valvular Atherosclerosis as Risks Factors for Sudden Cardiac Death from a Forensic Perspective

Background: In sudden cardiac deaths (SCD), visceral adipose tissue has begun to manifest interest as a standalone cardiovascular risk factor. Studies have shown that epicardial adipose tissue can be seen as a viable marker of coronary atherosclerosis. This study aimed to evaluate, from a forensic perspective, the correlation between body mass index (BMI), heart weight, coronary and valvular atherosclerosis, left ventricular morphology, and the thickness of the epicardial adipose tissue (EAT) in sudden cardiac deaths, establishing an increased thickness of EAT as a novel risk factor. Methods: This is a retrospective case–control descriptive study that included 80 deaths that were autopsied, 40 sudden cardiac deaths, and 40 control cases who hanged themselves and had unknown pathologies prior to their death. In all the autopsies performed, the thickness of the epicardial adipose tissue was measured in two regions of the left coronary artery, and the left ventricular morphology, macro/microscopically quantified coronary and valvular atherosclerosis, and weight of the heart were evaluated. Results: This study revealed a higher age in the SCD group (58.82 ± 9.67 vs. 53.4 ± 13.00; p = 0.03), as well as a higher incidence in females (p = 0.03). In terms of heart and coronary artery characteristics, there were higher values of BMI (p = 0.0009), heart weight (p p p p = 0.004), heart weight (OR: 5.47; p p p p = 0.045), type Vb plaque (OR: 17.19; p p = 0.002), and moderate left ventricle dilatation (OR: 16.71; p = 0.008) all act as predictors of SCD. Conclusions: The data of this research revealed that higher baseline values of BMI, heart weight, EAT LCx, and EAT LAD highly predict SCD. Furthermore, age above 55 years, type Vb plaque, mild valvular atherosclerosis, and left ventricle dilatation were all risk factors for SCD

Polytetrafluorethylene (PTFE) vs. Polyester (Dacron^®) Grafts in Critical Limb Ischemia Salvage

Background: Critical ischemia of the lower limbs refers to the last stages of peripheral arterial disease. It is characterized by resting discomfort or trophic disorders such as ulceration, skin necrosis, or gangrene in the lower limbs. Critical ischemia corresponds to Leriche–Fontaine (LF) stages III-IV and Rutherford stages 4–6. The purpose of this study was to observe the patency and postoperative complications of patients who have had infra-inguinal surgical revascularization and compare the results based on the kind of graft utilized. Methods: The present study was designed as an observational retrospective cohort study, including all patients from 2018 to 2019 diagnosed with severe ischemia of the lower limbs who were hospitalized at the Vascular Surgery Clinic of the County Emergency Clinical Hospital of Targu Mures. Results: Patients with a polytetrafluoroethylene (PTFE) graft had a higher incidence of chronic obstructive pulmonary disease (p = 0.01), stage III LF (70.41% vs. 55.29%), p = 0.03), and a lower incidence of stage IV LF (29.95% vs. 44.71%, p = 0.03). As for complications, the PTFE group showed a lower incidence of bypass thrombosis (29.59% vs. 44.71%; p = 0.03) and graft infection (9.18% vs. 21.18%; p = 0.02), but no statistical significance in the event of bleeding (p = 0.40). Regarding the outcomes, no statistical significance was seen for below-the-knee amputations or death. However, the PTFE group had a lower incidence of above-the-knee amputations (11.22% vs. 24.71%; p = 0.01). At multivariate analysis, the PTFE graft is an independent predictor of primary patency at 6, 12, and 24 months (OR: 2.15, p = 0.02; OR: 1.84, p = 0.04; and OR: 1.89, p = 0.03), as well as a protective factor against bypass thrombosis (OR: 0.52; p = 0.03), graft infection (OR: 0.37; p = 0.02), and above-the-knee amputation (OR: 0.38; p = 0.01).; Conclusions: According to this study’s findings, there were minor differences regarding the long-term patency, bypass thrombosis, graft infections, and above-the-knee amputations. In addition, the PTFE graft group had a higher incidence of primary patency at 6, 12, and 24 months, as well as a lower incidence of bypass thrombosis, graft infection, and above-the-knee amputations

Prognostic Nutritional Index, Controlling Nutritional Status (CONUT) Score, and Inflammatory Biomarkers as Predictors of Deep Vein Thrombosis, Acute Pulmonary Embolism, and Mortality in COVID-19 Patients

Background: Numerous tools, including nutritional and inflammatory markers, have been evaluated as the predictors of poor outcomes in COVID-19 patients. This study aims to verify the predictive role of the prognostic nutritional index (PNI), CONUT Score, and inflammatory markers (monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic inflammatory index (SII), Systemic Inflammation Response Index (SIRI), and Aggregate Index of Systemic Inflammation (AISI)) in cases of deep vein thrombosis (DVT) and acute pulmonary embolism (APE) risk, as well as mortality, in COVID-19 patients. Methods: The present study was designed as an observational, analytical, retrospective cohort study, and included 899 patients over the age of 18 who had a COVID-19 infection, confirmed through real time-polymerase chain reaction (RT-PCR), and were admitted to the County Emergency Clinical Hospital and Modular Intensive Care Unit of UMFST “George Emil Palade” of Targu Mures, Romania between January 2020 and March 20212. Results: Non-Surviving patients were associated with a higher incidence of chronic kidney disease (p = 0.01), cardiovascular disease (atrial fibrillation (AF) p = 0.01; myocardial infarction (MI) p = 0.02; peripheral arterial disease (PAD) p = 0.0003), malignancy (p = 0.0001), tobacco (p = 0.0001), obesity (p = 0.01), dyslipidemia (p = 0.004), and malnutrition (p p < 0.0001). The presence of PAD, malignancy, and tobacco, were also independent predictors of all outcomes. Conclusions: According to our findings, higher MLR, NLR, PLR, SII, SIRI, AISI, CONUT Score, and lower PNI values at admission strongly predict DVT risk, APE risk, and mortality in COVID-19 patients. Moreover, PAD, malignancy, and tobacco, all predicted all outcomes, while CKD predicts APE risk and mortality, but not the DVT risk

The Predictive Role of Systemic Inflammatory Markers in the Development of Acute Kidney Failure and Mortality in Patients with Abdominal Trauma

Background: Abdominal trauma is defined as a variety of injuries to the abdominal wall, solid or hollow intra-abdominal organs, and various intra-abdominal vessels. Recently, there has been a significant amount of interest in the establishment of a reliable biomarker that can predict the outcome in patients with an abdominal injury. The purpose of this study is to confirm the predictive role of inflammatory biomarkers and underlying risk factors and the risk of acute kidney insufficiency (AKI) developing and mortality in abdominal trauma patients; Materials and methods: The current study was intended as an observational, analytical, retrospective cohort study and included all patients over 18 years of age with a diagnosis of abdominal trauma confirmed through a CT scan admitted to the County Emergency Clinical Hospital of Targu-Mureș, Romania between January 2017, and December 2021; Results: Non-survivor patients had a greater age (p = 0.02), as well as a higher prevalence of ischemic heart disease (IHD) (p = 0.007), history of myocardial infarction (MI) (p = 0.002), peripheral arterial disease (PAD) (p = 0.01), chronic kidney disease (CKD) (p = 0.01), and all risk factors (p = 0.0004 and p p = 0.003) and hemoperitoneum (p = 0.008). Multivariate analysis showed a high baseline value for all inflammatory biomarkers that are independent predictors of adverse outcomes for all recruited patients. Furthermore, for all hospitalized patients, the history of MI (p = 0.03; p = 0.001; and p = 0.003), PAD (p = 0.01; p = 0.01; and p = 0.002), obesity (for all p p p = 0.01; and p = 0.001), and kidney injury (p = 0.02; p = 0.004; and p = 0.01) were independent predictors of all outcomes. Moreover, IHD (p = 0.008 and p = 0.02), tobacco (p p = 0.02), and hemoperitoneum (p = 0.009 and p = 0.01) were predictors of mortality and composite endpoint, but not for AKI risk, as well as atrial fibrillation [AF] (p = 0.04) as predictors of the composite endpoint Conclusions: Higher monocyte to lymphocyte ratio (MLR), platelets to lymphocyte ratio (PLR), systemic inflammatory index (SII), neutrophil to lymphocyte ratios (NLR), aggregate inflammatory systemic index (AISI), and systemic inflammatory response index (SIRI) levels at admission, according to our data, highly predict AKI risk and death