Complications of arteriovenous hemodialysis access: Recognition and management

English language citations reporting complications of arteriovenous access for hemodialysis are critically reviewed and discussed. Venous hypertension, arterial steal syndrome, and high-output cardiac failure occur as a result of hemodynamic alterations potentiated by access flow. Uremic and diabetic neuropathies are common but may obfuscate recognition of potentially correctable problems such as compression or ischemic neuropathy. Mechanical complications include pseudoaneurysm, which may develop from a puncture hematoma, degeneration of the wall, or infection. Dysfunctional hemostasis, hemorrhage, noninfectious fluid collections, and access-related infections are, in part, manifestations of the adverse effects of uremia on the function of circulating hematologic elements. Impaired erythropoiesis is successfully managed with hormonal stimulation; perhaps, similar therapies can be devised to reverse platelet and leukocyte dysfunction and reduce bleeding and infectious complications

Isolated blunt abdominal aortic injury without concomitant abdominal injuries treated with endovascular stent grafting

Blunt injury of the abdominal aorta is a rare event, seen in only 0.07% to 0.17% of all blunt traumas. These injuries are frequently associated with other intra-abdominal injuries, with high rates of morbidity and mortality. We present a case of isolated blunt abdominal aortic trauma to the infrarenal aorta without concomitant abdominal or spinal injuries. The patient was treated with endovascular aortic stent grafting and is without complications 12 months after the procedure

The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum

The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines for the care of patients with varicose veins of the lower limbs and pelvis. The document also includes recommendations on the management of superficial and perforating vein incompetence in patients with associated, more advanced chronic venous diseases (CVDs), including edema, skin changes, or venous ulcers. Recommendations of the Venous Guideline Committee are based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system as strong (GRADE 1) if the benefits clearly outweigh the risks, burden, and costs. The suggestions are weak (GRADE 2) if the benefits are closely balanced with risks and burden. The level of available evidence to support the evaluation or treatment can be of high (A), medium (B), or low or very low (C) quality. The key recommendations of these guidelines are: We recommend that in patients with varicose veins or more severe CVD, a complete history and detailed physical examination are complemented by duplex ultrasound scanning of the deep and superficial veins (GRADE 1A). We recommend that the CEAP classification is used for patients with CVD (GRADE 1A) and that the revised Venous Clinical Severity Score is used to assess treatment outcome (GRADE 1B). We suggest compression therapy for patients with symptomatic varicose veins (GRADE 2C) but recommend against compression therapy as the primary treatment if the patient is a candidate for saphenous vein ablation (GRADE 1B). We recommend compression therapy as the primary treatment to aid healing of venous ulceration (GRADE 1B). To decrease the recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy (GRADE 1A). For treatment of the incompetent great saphenous vein (GSV), we recommend endovenous thermal ablation (radiofrequency or laser) rather than high ligation and inversion stripping of the saphenous vein to the level of the knee (GRADE 1B). We recommend phlebectomy or sclerotherapy to treat varicose tributaries (GRADE 1B) and suggest foam sclerotherapy as an option for the treatment of the incompetent saphenous vein (GRADE 2C). We recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP class C2; GRADE 1B), but we suggest treatment of pathologic perforating veins (outward flow duration ≥500 ms, vein diameter ≥3.5 mm) located underneath healed or active ulcers (CEAP class C5-C6; GRADE 2B). We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together (GRADE 2B)

Correction to: Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years

Simultaneous rTMS and psychotherapy in major depressive disorder : Clinical outcomes and predictors from a large naturalistic study

Background: Repetitive transcranial magnetic stimulation (rTMS) is considered an efficacious non-invasive neuromodulation treatment for major depressive disorder (MDD). However, little is known about the clinical outcome of combined rTMS and psychotherapy (rTMS + PT). Through common neurobiological brain mechanisms, rTMS + PT may exert enhanced antidepressant effects compared to the respective monotherapies. Objective: The current naturalistic study aimed to evaluate feasibility and clinical outcome of rTMS + PT in a large group of MDD patients. The second aim was to identify clinical predictors of response and remission. Methods: A total of 196 patients with MDD were treated with at least 10 sessions of simultaneous rTMS and PT. rTMS was applied over the DLPFC, either 10 Hz left or 1 Hz right. Psychotherapy was based on principles of cognitive behavioral therapy (CBT). Symptoms were measured using the BDI each fifth session until end of treatment and at 6-month follow-up. Comparisons were made between responders and non-responders, as well as between the 10 Hz and 1 Hz protocol. Additionally, baseline variables and early BDI change were evaluated as predictors of response/remission. Major findings and conclusions: 1) Combining rTMS and PT resulted in a 66% response and a 56% remission rate at the end of treatment with 60% sustained remission at follow-up. Compared to previous findings in RCTs, these rates are relatively high; 2) No differences were found between the 10 Hz and 1 Hz TMS regarding clinical outcome; 3) Clinical baseline variables were not predictive of treatment outcomes; 4) Early symptom improvement (at session 10) was highly predictive of response, and may therefore be used to guide rTMS + PT continuation; 5) Based on the current findings in a large naturalistic study, future studies employing a more standardized method are warranted to draw solid conclusions on the unique effect of rTMS + PT

Simultaneous rTMS and psychotherapy in major depressive disorder : Clinical outcomes and predictors from a large naturalistic study

Background: Repetitive transcranial magnetic stimulation (rTMS) is considered an efficacious non-invasive neuromodulation treatment for major depressive disorder (MDD). However, little is known about the clinical outcome of combined rTMS and psychotherapy (rTMS + PT). Through common neurobiological brain mechanisms, rTMS + PT may exert enhanced antidepressant effects compared to the respective monotherapies. Objective: The current naturalistic study aimed to evaluate feasibility and clinical outcome of rTMS + PT in a large group of MDD patients. The second aim was to identify clinical predictors of response and remission. Methods: A total of 196 patients with MDD were treated with at least 10 sessions of simultaneous rTMS and PT. rTMS was applied over the DLPFC, either 10 Hz left or 1 Hz right. Psychotherapy was based on principles of cognitive behavioral therapy (CBT). Symptoms were measured using the BDI each fifth session until end of treatment and at 6-month follow-up. Comparisons were made between responders and non-responders, as well as between the 10 Hz and 1 Hz protocol. Additionally, baseline variables and early BDI change were evaluated as predictors of response/remission. Major findings and conclusions: 1) Combining rTMS and PT resulted in a 66% response and a 56% remission rate at the end of treatment with 60% sustained remission at follow-up. Compared to previous findings in RCTs, these rates are relatively high; 2) No differences were found between the 10 Hz and 1 Hz TMS regarding clinical outcome; 3) Clinical baseline variables were not predictive of treatment outcomes; 4) Early symptom improvement (at session 10) was highly predictive of response, and may therefore be used to guide rTMS + PT continuation; 5) Based on the current findings in a large naturalistic study, future studies employing a more standardized method are warranted to draw solid conclusions on the unique effect of rTMS + PT

Mandibular subluxation for distal internal carotid exposure: Technical considerations

AbstractPurpose: Carotid endarterectomy (CEA) has become one of the most commonly performed vascular procedures, because of the beneficial outcome it has when compared with medical therapy alone and because of the anatomic accessibility of the artery. In cases of distal carotid occlusive disease, high cervical carotid bifurcation, and some reoperative cases, access to the distal internal carotid artery may limit surgical exposure and increase the incidence of cranial nerve palsies. Mandibular subluxation (MS) is recommended to provide additional space in a critically small operative field. We report our experience to determine and illustrate a preferred method of MS. Methods: Techniques for MS were selected based on the presence or absence of adequate dental stability and periodontal disease. All patients received general anesthesia with nasotracheal intubation before subluxation. Illustrations are provided to emphasize technical considerations in performing MS in 10 patients (nine men and one woman) who required MS as an adjunct to CEA (less than 1% of primary CEAs). Patients were symptomatic (n = 7) or asymptomatic (n = 3) and had high-grade stenoses demonstrated by means of preoperative arteriography. Results: Subluxation was performed and stabilization was maintained by means of: Ivy loop/circumdental wiring of mandibular and maxillary bicuspids/cuspids (n = 7); Steinmann pins with wiring (n = 1); mandibular/maxillary arch bar wiring (n = 1); and superior circumdental to circummandibular wires (n = 1). MS was not associated with mandibular dislocation in any patient. No postoperative cranial nerve palsies were observed. Three patients experienced transient temporomandibular joint discomfort, which improved spontaneously within 2 weeks. Conclusion: Surgical exposure of the distal internal carotid artery is enhanced with MS and nasotracheal intubation. We recommend Ivy loop/circumdental wiring as the preferred method for MS. Alternative methods are used when poor dental health is observed. (J Vasc Surg 1999;30:1116-20.