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Purpose: A method of diagnosing the extent and severity of arteriovenous fistula (AVF) stenoses is multislice computed tomographic angiography (MS-CTA). The aim of this prospective study was to assess the accuracy of MS-CTA for the detection and grading of stenoses in AVF in comparison to digital subtraction angiography (DSA), which was used as the gold standard of reference., Methods: Fifteen hemodialysis (HD) patients with dysfunctioning forearm AVF were included. These AVFs were evaluated by both DSA and MS-CTA and were read in a prospective, blinded manner by two radiologists experienced in vascular imaging., Results: ROC analysis revealed areas under the curve of 0.90+/-0.07 for observer I and 0.87+/-0.08 for observer II at a stenosis cut-off level of >or=50% diameter reduction. The combined results for MS-CTA showed sensitivity, specificity and positive and negative predictive values of 82%, 98%, 82% and 98% for stenoses>or=50% and 71%, 99%, 77% and 98% for stenoses>or=75%. Inter-observer agreement for the detection of stenoses>or=50% diameter reduction was 0.70 and 1.0, for MS-CTA and DSA, respectively., Conclusion: MS-CTA can provide good visualization of forearm HD access AVF and has moderate sensitivity, but high specificity for the detection of flow-limiting stenoses.

Background: Many techniques have been introduced for the surgical treatment of the aging neck. In this study the combination therapy of ultrasound-assisted liposuction and limited-incision platysmaplasty for cervicofacial rejuvenation is presented., Methods: Fifteen female patients (age = 43-75 years) were treated for grade II-III (n = 2), III (n = 6), and grade IV (n = 7) cervicomental angle deformity. The outcome of surgery was retrospectively evaluated by a panel., Results: Ultrasonic energy was applied for an average of 2 min (range = 45 s-6.5 min). The mean aspiration volume was 125 ml. No immediate or delayed adjuvant skin reduction was needed in any of the patients. No complications were encountered in this series. After treatment significant improvement of the cervicomental angle was observed., Conclusion: For treatment of all grades of the aging neck we advocate the combination of UAL and limited-incision platysmaplasty. This combination therapy has little morbidity and leads uniformly to significant improvement of the cervicomental angle.

In view of constructing a gastric tube after esophagus resection, the vascular anatomy of the greater curvature of the stomach, especially the connection between the left and right gastro-epiploic arteries, was investigated. The vascular anatomy was studied in 20 embalmed human specimens. After dissection a gastric tube of 4 cm wide was constructed, using the greater gastric curvature. Various lengths of the arterial arcades were measured. In 70% an anastomosis between the right and left gastro-epiploic arteries was present. With the construction of an isoperistaltic gastric tube, in which the left gastro-epiploic artery is left in situ (ligating it at the splenic hilus), there is an 18.7% increase of length of arterial arcade along the gastric tube. Leaving the left gastro-epiploic artery in situ increases the feeding arterial arcaded-length along the gastric tube with 5.0 cm (19%).

Study Design: A comparative study., Objectives: To assess whether in subjects with unilateral chronic ankle instability the dynamic reaction time of the affected ankle differs from the healthy ankle and from ankles of a control group., Background: Reaction time is an essential element in joint protection against sudden unexpected excessive movement requiring fast and coordinated muscle action. During a sudden ankle inversion movement, a reflex action of the evertor muscles is needed to counteract the movement. Adequate neuromuscular response is crucial and a delayed response could contribute to inversion trauma and subsequently to chronic ankle instability. The isokinetic dynamometer acceleration time (ACC-TIME) provides valuable information on dynamic neuromuscular ability., Material and Methods: Patients with unilateral chronic ankle instability (n = 11) and healthy individuals in a control group (n = 11) were tested on an isokinetic dynamometer during 3 sets of 3 reciprocal inversion/eversion movements of both ankles at 30 degrees/s and 120 degrees/s. Analysis of variance models were used to compare the ACC-TIME of the affected ankle to the unaffected ankle of the same subjects and a control group., Results: For the evertor muscles at 30 degrees/s and 120 degrees/s a significantly prolonged ACC-TIME was found when comparing the affected ankles to the contralateral ankles and both ankles of the control group. For the invertor muscles at 120 degrees/s a significantly prolonged ACC-TIME was found when comparing the affected ankle to the unaffected ankles of patients and those of the control group., Conclusions: Because the most important evertor muscles are innervated by the fibular nerve, the significantly prolonged ACC-TIME of the affected ankle is consistent with the finding of a lower motor nerve conduction velocity of the fibular nerve after inversion trauma. The results support the concept of a delayed neuromuscular response as an important factor in the etiology of chronic ankle instability.

Objective: The construction of an autogenous radial-cephalic direct wrist arteriovenous fistula (RCAVF) is the primary and best option for vascular access for hemodialysis. However, 10%-24% of RCAVFs thrombose directly after operation or do not function adequately due to failure of maturation. In case of poor arterial and/or poor venous vessels for anastomosis, the outcome of RCAVFs may be worse and an alternative vascular access is probably indicated. A prosthetic graft implant may be a second best option. Therefore, a randomized multicenter study comparing RCAVF with prosthetic (polytetrafluoroethylene [PTFE]) graft implantation in patients with poor vessels was performed., Methods: A total of 383 consecutive new patients needing primary vascular access were screened for enrollment in a prospective randomized study. According to defined vessel criteria from the preoperative duplex scanning, 140 patients were allocated to primary placement of an RCAVF and 61 patients to primary prosthetic graft implantation. The remaining 182 patients were randomized to receive either an RCAVF (n = 92) or prosthetic graft implant (n = 90). Patency rate was defined as the percentage of AVFs that functioned well after implantation., Results: Primary and assisted primary 1-year patencies were 33% +/- 5.3% vs 44% +/- 6.2% (P = .03) and 48% +/- 5.5% vs 63% +/- 5.9% (P = .035) for the RCAVF and prosthetic AVF, respectively. Secondary patencies were 52% +/- 5.5% vs 79% +/- 5.1% (P = .0001) for the RCAVF and prosthetic AVF, respectively. Patients with RCAVFs developed a total of 102 (1.19/patient-year [py]) vs 122 (1.45/py; P = .739) complications in the prosthetic AVFs. A total of 43 (0.50/py) interventions in the RCAVF group and 79 (0.94/py) in the prosthetic graft group were needed for access salvage (P = .077)., Conclusions: Although there were more interventions needed for access salvage in the patients with prosthetic graft implants, we may conclude that patients with poor forearm vessels do benefit from implantation of a prosthetic graft for vascular access.

Objective: To improve the precision of the estimates of primary failure rates and primary and secondary 1 year patency of radial-cephalic arteriovenous fistulas (RCAVF) for hemodialysis., Design: Meta-analysis., Materials and Methods: A Medline search was performed of the English language medical literature between January 1970 and October 2002. Key words that were searched included radiocephalic fistula, arteriovenous shunt, Brescia-Cimino fistula and patency. Primary failure, primary and secondary patency rates were analysed using the standard mixed effects model, which allows for variability between the different studies., Results: Eight prospective and 30 retrospective studies were included. The analysis showed a pooled estimated primary failure rate of 15.3% (95% CI: 12.7-18.3%). In addition, the pooled estimated primary and secondary patency rates of 62.5% (95% CI: 54.0-70.3%) and 66.0% (95% CI: 58.2-73.0%), respectively, were calculated. Subgroup analysis concerning various study characteristics, including study year, gender and age, did not reveal statistically significant differences., Conclusion: Although, the autogenous RCAVF is considered to be the primary choice for vascular access, this meta-analysis indicates a high primary failure rate and only moderate patency rates at 1 year of follow-up.

The purpose of this study was to investigate tumor angiogenesis in a series of benign and malignant pheochromocytomas and to determine whether there is a correlation between angiogenesis and the presence of distant metastases. In this study, the CD31 monoclonal antibody was selected to measure intratumoral microvessel density. Nineteen patients with malignant pheochromocytomas and nineteen patients with benign pheochromocytomas who underwent operation were studied. In order to quantify intratumoral microvessel density, the total number of pixels of CD31-positive reactivity was assessed and expressed as a percentage of the total tissue area in the analyzed field. Analysis of variance revealed a statistically significant correlation between malignancy and intratumoral microvessel density (p = 0.0009). Although there was a considerable variability in the intratumoral microvessel density from tumor to tumor within both the benign and the malignant group, a percentage of more than 28.5% anti-CD31 stained area was found only in malignant tumors. In conclusion, this study shows that the mean intratumoral microvessel density in malignant pheochromocytomas is increased approximately twofold as compared with benign tumors. However, the clinical significance of this prognostic marker is rather weak, because only 4 of the 19 malignant pheochromocytomas had microvessel density higher than this threshold of 28.5%.

Background: One of the a main reasons for the long learning curve associated with totally extraperitoneal (TEP) laparoscopic hernia repair is an insufficient understanding of the dissection of the proper preperitoneal space. In this study, we investigated the conditions required for the correct anatomical approach to the preperitoneal space., Methods: The anatomo-surgical conditions for dissection of the correct preperitoneal space were evaluated in 10 video studies of TEP repairs. In addition, we also investigated the preperitoneal tissue layers in 10 embalmed human bodies., Results: The proper preperitoneal space can only be approached after cleavage of the ventral component of a bilaminar preperitoneal fascia complex, also known as the posterior lamina of the transversalis fascia. The cleavage can be accomplished spontaneously by a fully expanded balloon correctly introduced into the plane between the rectus muscle and the posterior lamina of the transversalis fascia., Conclusions: The anatomy of the preperitoneal tissues in the inguinal region is complex. To gain expertise in laparoscopic totally extraperitoneal (TEP) hernia repair, the presence of a bilaminar fascia complex and the importance of the cleavage of the posterior lamina of transversalis fascia must be appreciated.