Management of cephalic arch stenosis in hemodialysis access: Updated systematic review and meta-analysis

INTRODUCTION

Cephalic arch stenosis (CAS) is often recurrent, resistant to treatment and the intervention outcome is not well validated so far. We purposed to assess the clinical outcomes of CAS treatment in patients with hemodialysis access.

METHODS

Electronic bibliographic sources were searched up to December 4 2023 to identify studies reported outcome after treating CAS. Direct and indirect evidence was combined to compare odds ratios (OR) and surfaces under the cumulative ranking curves across the different treatment modalities through meta-analysis and network meta-analyses (NMA). This systematic review was conducted in accordance with the PRISMA-P. The review is registered in PROSPERO (CRD42022296513).

RESULTS

Four randomized controlled trials (RCTs) and 15 non-RCTs were included in the analysis. The study population differed in fistula type, restenosis or thrombosis, and significant heterogeneity was observed among the publications. The risk of bias was low to serious. Meta-analysis found no significant difference between DCB and PTA in primary patency at 6 and 12 months (OR 1.16 and 0.60, respectively; low certainty of evidence). Favorable result with STG compared to stent or PTA at 3, 6, and 12 month was observed (OR 4.28, 5.13, and 13.12, and 4.28, 5.13, 13.12, respectively; low certainty of evidence). Regarding primary patency, the treatment rankings, from highest to lowest, were STG (92.7%), transposition (76.0%), stent (67.5%), DCB (46.3%), and PTA (64.5%) at 12 months.

CONCLUSION

Despite data limitations, the low-quality evidence suggests that STG may merit consideration as a primary treatment option when all alternatives are applicable, given their potential for better primary patency and higher treatment ranking.

Contemporary review of management techniques for cephalic arch stenosis in hemodialysis

The type of hemodialysis access and its preservation impact the quality of life and survival of patients undergoing hemodialysis. Vascular access complications are among the top causes of morbidity, hospitalization, and catheter use, with significant economic burden. Poor maturation and stenosis continue to be key impediments to upper arm arteriovenous fistula feasibility. Cephalic arch is a common location for vascular access dysfunction due to its distinctive anatomy, complex valves, and biochemical alterations attributable to renal failure. Understanding cephalic arch stenosis is critical due to its high prevalence and treatment failure. The appropriate management option is highly debatable and mostly dependent on patient characteristics and interventionist's preference. Current options include, percutaneous transluminal balloon angioplasty, stent grafts, bare metal stents, cutting balloon angioplasty, endovascular banding, and surgical procedures. This article discusses the etiologies of cephalic arch stenosis as well as currents trends in management including endovascular and surgical options.

Surgical Referral for Hemodialysis Access Maintenance

Hemodialysis access is the lifeline for end-stage renal disease patients. However, dialysis access is associated with a host of complications, including thrombosis, recurrent stenosis, infection, aneurysmal changes and bleeding. Although endovascular therapy remains the first-line treatment owing to its less invasive nature, there are certain situations where surgical referral is recommended or even necessary. Regardless, management of dialysis access complications requires a multidisciplinary approach. Interventional radiologists should be familiar with the appropriate timing for surgical referral to better serve the complex patient population.

Treatment for cephalic arch stenosis with cephalic vein to external jugular vein bridging graft

AIM

Percutaneous transluminal angioplasty or cephalic vein transposition to the axillary vein is mainly used for treatment of cephalic arch stenosis, a common complication of brachiocephalic fistulas. However, the results of such interventions have been disappointing.

METHODS

We used a polytetrafluoroethylene prosthesis with a 6 mm diameter to bridge the cephalic vein and the ipsilateral external jugular vein, and successfully created a new drainage outlet and established immediate restoration of flow through brachiocephalic fistulas.

RESULTS

This surgery allowed the cephalic venous arch and subclavian vein, which are vulnerable to stenosis, to be bypassed altogether and the puncture segment could be elongated by about 20 cm.

CONCLUSION

It is a safe and effective alternative to traditional methods of treatment for cephalic arche stenosis.

Outcomes of endovascular treatment for stenosis occurring after cephalic vein transposition and graft interposition

OBJECTIVE

To evaluate the outcome of endovascular treatment after surgical treatment for cephalic arch stenosis in brachiocephalic fistula and to analyze the factors influencing patency.

METHODS

We conducted a retrospective review of patients undergoing cephalic transposition (CVT) or graft interposition (GIP) for cephalic arch stenosis (CAS) from January 1, 2017, to December 31, 2019. A total of 73 patients with restenosis were included in this study. Patients were classified into cephalic transposition (BCF-CVT) (n=49) and graft interposition (BCF-GIP) (n=24) groups. We calculated the postintervention primary and secondary patency of endovascular treatment by using the Kaplan-Meier analysis and analyzed variables associated with loss of postintervention patency.

RESULTS

Six-month and 12 month postintervention primary patency rates of endovascular treatment for restenosis were 56.7% and 15.6% and secondary patency rates were 89.7% and 72.1%, respectively. In BCF-CVT group, six month, and 12 month postintervention primary patency was 56.8% and 17.6% and secondary patency was 93.3% and 79.4%, respectively. In BCF-GIP group, six-month, and 12 month postintervention primary patency was 56.5% and 8.7% and secondary patency was 85.7% and 56.3%, respectively. There was no significant difference in postintervention primary patency between the two groups (p=0.79). However, BCF-CVT group demonstrated higher postintervention secondary patency (p=0.034). BCF-GIP group had a higher number of stenosis sites (p<0.01). There was no significant predictor of reduced postintervention primary patency. The only adverse variable of postintervention secondary patency was BCF-GIP (Hazard ratio 3.14; 95% CI 1.06 to 9.34, p <0.05).

CONCLUSION

Endovascular treatment is still the acceptable option for stenosis occurring after surgical treatment for CAS. CVT provides higher postintervention secondary patency than GIP.

ASDIN white paper: Management of cephalic arch stenosis endorsed by the American Society of Diagnostic and Interventional Nephrology

Brachiocephalic arteriovenous fistulas (AVF) makeup approximately one third of prevalent dialysis vascular accesses. The most common cause of malfunction with this access is cephalic arch stenosis (CAS). The accepted requirement for treatment of a venous stenosis lesion is ⩾50% stenosis associated with hemodynamically abnormalities. However, the correlation between percentage stenosis and a clinically significant decrease in access blood flow (Qa) is low. The critical parameter is the absolute minimal luminal diameter (MLD) of the lesion. This is the parameter that exerts the key restrictive effect on Qa and results in hemodynamic and functional implications for the access. CAS is the result of low wall shear stress (WSS) resulting from the effects of increased blood flow and the unique anatomical configuration of the CAS. Decrease in WSS has a linear relationship to increased blood flow velocity and neointimal hyperplasia exhibits an inverse relationship with WSS. The result is a stenotic lesion. The presence of downstream venous stenosis causes an inflow-outflow mismatch resulting in increased pressure within the access. Qa in this situation may be decreased, increased, or within a normal range. Over time, the increased intraluminal pressure can result in marked aneurysmal changes within the AVF, difficulties with cannulation and the dialysis treatment, and ultimately, increasing risk of access thrombosis. Complete characterization of the lesion both hemodynamically and anatomically should be the first step in developing a strategy for management. This requires both access flow measurement and angiographic imaging. Patients with CAS present a relatively broad spectrum as relates to both of these parameters. These data should be used to determine whether primary treatment of CAS should be directed toward the anatomical lesion (small MLD and low Qa) or the pathophysiology (large MLD and high Qa).

Clinical predictors of recurrent cephalic arch stenosis and impact of the access flow reduction on the patency rate

OBJECTIVE

Despite the widespread use of conventional percutaneous transluminal angioplasty (PTA), recurrence of cephalic arch stenosis (CAS), and low patency rate after PTA remain challenging problem. We aimed to identify the clinical predictors of recurrence of CAS and evaluate the effect of the access flow reduction on the fistula patency rate in patients with recurrent CAS.

METHODS

In 1118 angiographies of 220 patients with CAS, access circuit patency rates after PTA and potential clinical predictors of recurrence of CAS were assessed. The effect of the banding procedure was evaluated in terms of post-interventional primary patency rate, and the number of interventions per access-year.

RESULTS

At 3, 6, and 12 months after the first PTA on CAS, the post-interventional access circuit primary patency rates were 68.8%, 40.5%, and 25.1%, respectively. High CV to CA ratio (the ratio of the maximal diameter of the distal cephalic vein to the diameter of the cephalic arch) (Hazard ratio (HR), 1.437; 95% confidence interval (CI), 1.036-1.992) and involvement of the proximal segment of cephalic arch (HR, 1.828; 95% CI, 1.194-2.801) were significant predictors of recurrent CAS. For those with recurrent CAS (>3 times/year) and an access flow rate >1.5 L/minute, endovascular banding procedure was performed. The banding procedure significantly reduced the number of interventions per access-year (t = 3.299, p = 0.005 and t = 2.989, p = 0.007, respectively). Post-interventional access circuit primary patency rate after banding was significantly higher than that before banding (p = 0.01).

CONCLUSIONS

High CV to CA ratio and involvement of the proximal segment of the cephalic arch are independent clinical predictors of recurrent CAS. Endovascular banding might delay recurrence of CAS in patients with high CV to CA ratio and high access flow.

Double Mesh Nitinol Stent Versus Self-expanding Stent-graft in Recurrent/Resistant Cephalic Vein Arch Stenoses in Dialysis Fistulae: A Comparative Study

PURPOSE

To compare the double mesh nitinol stent (DNS) versus the self-expanding stent-graft (SES) in recurrent/resistant cephalic vein arch stenosis in dialysis fistulae.

MATERIALS AND METHODS

17 cases with recurrent/resistant stenosis of the cephalic vein arch treated with a DNS were compared retrospectively with 18 cases treated with an SES. Stenting was performed either for significant recoil post-angioplasty with high-pressure balloons or in recurrent stenoses. Patients were followed up with Doppler ultrasound in our vascular access surveillance programme. Primary and assisted primary patency rates at 3, 6 and 12 months were estimated by Kaplan-Meier analysis.

RESULTS

Both stents showed 100% technical success immediately post-stenting, defined as residual stenosis < 30%. 3, 6 and 12 month primary patency of the DNS was 82.4%, 69.7% and 28.1% versus 88.9%, 77.8% and 72.2% for the SES. The DNS had a mean primary patency of 242.4 days compared to 896.3 days for the SES (p = 0.021). 12 month assisted primary patency was 88.2% (DNS) and 100% (SES). The DNS had a mean assisted primary patency of 812 days compared to 1390.3 days for the SES, though this did not reach statistical significance. No stent fractures were identified at 2 years in either group.

CONCLUSION

Both stents had 100% technical success with no stent fractures. SES showed statistically significant higher primary patency. Assisted primary patency was also higher, though this did not reach statistical significance.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Surgical Treatment of Cephalic Arch Problems in Arteriovenous Fistulas: A Center Experience

BACKGROUND

Cephalic arch problems, mainly stenosis, are a common cause of arteriovenous fistulas (AVFs) failure, and the most effective treatment is yet to be clearly defined. Restenosis usually occurs soon, and multiple interventions become necessary to maintain patency and functionality. The authors present the experience of their center with cephalic vein transposition in a group of patients with different problems involving the cephalic arch.

METHODS

After consultation of the medical records, an observational retrospective analysis was performed to evaluate the outcomes of surgical treatment in cephalic arch problems of AVFs treated at the author's center between January 2013 and December 2015. The considered outcomes were endovascular intervention rate, thrombosis rate, and primary and secondary patencies.

RESULTS

Seven patients were treated by venovenostomy with transposition of the cephalic arch and anastomosis to the axillary vein. The average patient age was 72 years (59-81), and most patients were female (71%) and diabetic (71%). All accesses were brachiocephalic AVFs with a mean duration of 4 years (1-7). The underlying problems were intrinsic cephalic arch stenosis (n = 5), entrapment of the cephalic vein (n = 1), and clinically significant vein tortuosity at the cephalic arch (n = 1). These last 2 problems conducted to a surgical approach as first-line therapy instead of endovascular intervention, the initial treatment in the other 5 cases (all with high-pressure balloons, with cutting balloon in one case). Previous thrombotic episodes were reported in 57% of the patients. The mean access flow before surgical intervention was 425 mL/min (350-1,500). No complications related with the surgical procedure were reported. One patient underwent surgical thrombectomy after AVF thrombosis, followed by transposition of the vein. In another case, a simultaneous flow reduction was performed. Most of the patients on dialysis (5/6) used the AVF after surgery. After a mean follow-up period of 9 months (1-22), surgical treatment was associated with a reduction in endovascular intervention rate (1.9 interventions per patient-year presurgery versus 0.4 postsurgery; P < 0.05) and thrombosis rate (0.93 thrombotic episodes per patient-year presurgery versus 0.17 postsurgery; P < 0.05). The problems leading to endovascular reintervention were as follows: new venous anastomosis stenosis (57%), axillary vein stenosis (29%), and swing-point stenosis (14%). Primary and secondary patencies at 6 months were 57% and 71%, respectively.

CONCLUSIONS

In this group of patients with cephalic arch problems and multiple previous procedures, surgical treatment was associated with a reduction in endovascular intervention and thrombosis rate but did not avoid reintervention. Facing the complexity and multiplicity of the cephalic arch complications, treatment should be individually decided.

Cephalic Arch Stenosis in Autogenous Brachiocephalic Hemodialysis Fistulas: Results of Cutting Balloon Angioplasty

Purpose

Cephalic arch stenosis is a known cause of hemodialysis access failure in patients with brachiocephalic fistulas (BCFs). Outcomes of endovascular treatment are affected by resistance of the stenosis to balloon dilation, a high vein rupture rate and the development of early restenosis. The purpose of this retrospective study was to report outcomes after cutting balloon angioplasty (CBA) of cephalic arch stenosis.

Methods

In our vascular access database we identified 74 dysfunctional BcFs of which 30 (41%) were caused by cephalic arch stenosis. Seventeen fistulas in 17 patients (13 males and four females; median age 62 yrs; range 52–86) were treated with CBA (June 2005 to January 2008). Twenty-five procedures were performed. In 15 procedures, a cutting balloon was used alone and in 10 procedures CBA was followed by standard or high-pressure balloon angioplasty. Restenosis rates were calculated and patency rates were estimated with the Kaplan-Meier method.

Results

Primary patency rates (±SEE) at 3, 6, 12 and 15 months were 94% (±6%), 81% (±10%), 38% (±14%) and 22% (±15%), respectively. Assisted primary patency rates (±SEE) at the same intervals were 100% (±0%), 94% (±6%), 77% (±12%) and 63% (±13%), respectively. The mean interval between radiological interventions was 13 months (SD=8) and the mean number of interventions required per patient-year of dialysis was 0.9.

Conclusion

Treatment of cephalic arch stenosis with CBA did not improve patency compared to published results of conventional PTA, but our results indicate that CBA may lower the frequency of required re-interventions.

Cephalic vein transposition is a durable approach to managing cephalic arch stenosis

INTRODUCTION

The proximal cephalic vein that enters the axillary vein (cephalic arch) is a common site of stenosis in patients with upper extremity arteriovenous fistulas for hemodialysis (HD). In this study, we present the outcomes of a series of cephalic vein transposition, to determine its utility in the setting of refractory arch stenosis.

METHODS

We conducted a retrospective review of patients undergoing cephalic vein transposition to manage refractory cephalic arch stenosis from January 1, 2008 to August 31, 2015. Demographics, past medical history, access history of the patients as well as procedural details of the surgery to the stenotic segment, patency of the access, and the need for subsequent interventions were recorded.

RESULTS

Twenty-three patients underwent a cephalic vein transposition during the study period. The patients undergoing cephalic transposition had their current access for an average of 3.0 ± 2.6 years and had an average of 2.3 ± 0.9 interventions on the access prior to the surgery. Complications from the surgery were uncommon (8.7%) and no patient required a temporary tunneled dialysis catheter. The re-intervention rate was 0.2 ± 0.2 interventions per patient per year. At two years, primary patency was 70.9% and cumulative patency was 94.7% for the patients with cephalic transposition.

CONCLUSIONS

Cephalic vein transposition is safe and effective treatment for cephalic arch stenosis without interrupting utilization of the access. The surgical approach to stenosis of the proximal cephalic vein is effective, requires minimal re-interventions, and should be considered for isolated, refractory cephalic arch stenosis in mature arteriovenous fistulas.

Clinical predictors of recurrent stenosis and need for re-intervention in the cephalic arch in patients with brachiocephalic AV fistulas

INTRODUCTION

Cephalic arch stenosis is one of the most common reasons for repeated endovascular intervention and eventual abandonment of access in hemodialysis patients. There is no prediction model to identify risk factors for recurrent cephalic arch stenosis. We have developed a mathematical model to predict the need for reintervention in brachiocephalic (BC) fistulas with recurrent cephalic arch stenosis.

METHODS

Single-center retrospective analysis of 143 patients with a BC fistula referred to the vascular clinic for access dysfunction who underwent cephalic arch angioplasty were included for the analysis. Twelve-month post-index angioplasty data were analyzed using parametric, non-parametric and multiple regression models using SPSS software.

RESULTS

The mean need for re-intervention in 1 year since first index visit was 2.46 ± 1.404. Statistically significant correlation (p≤0.001) for re-intervention was observed with the severity of stenosis at index visit, access flow, vessel wall diameter proximal to the stenosis, average venous pressure >50% of the delivered blood flow rate and prolonged bleeding for >30 minutes as a reason for referral. Three equations have been derived for calculating the need for re-intervention based on the diameter of the vessel wall proximal to the stenosis.

CONCLUSIONS

Risk stratification of BC fistulas utilizing the above parameters could enable clinicians to identify accesses that are at risk for multiple re-interventions. Early identification of accesses that are at high risk for re-interventions at the cephalic arch might prolong access survival and reduce the cost for intervention by utilizing alternate strategies.

A rare anatomic variant of a single-conduit supraclavicular cephalic arch draining into the external jugular vein presenting with recurrent arteriovenous fistula stenosis in a hemodialysis patient

The cephalic arch is a common location of stenosis, especially in brachiocephalic fistulas. The cephalic arch has a number of anatomic variations. Cephalic arch stenoses are often resistant and have poor primary patency. Here we describe an unusual case of a hemodialysis patient with a single-conduit supraclavicular cephalic arch draining into the external jugular vein presenting with recurrent cephalic arch stenoses and external jugular vein stenosis. In our view, extrinsic compression by the clavicle may contribute to the high rate of recurrence, the lack of complete dilation of even high-pressure balloons, and a theoretically heightened risk of rupture when cutting balloons are used.

Bilateral Chondroepitrochlearis Muscle: Case Report, Phylogenetic Analysis, and Clinical Significance

Anomalous muscular variants of pectoralis major have been reported on several occasions in the medical literature. Among them, chondroepitrochlearis is one of the rarest. Therefore, this study aims to provide a comprehensive description of its anatomy and subsequent clinical significance, along with its phylogenetic importance in pectoral muscle evolution with regard to primate posture. The authors suggest a more appropriate name to better reflect its proximal attachment to the costochondral junction and distal attachment to the epicondyle of humerus, as “chondroepicondylaris”; in addition, we suggest a new theory of phylogenetic significance to explain the twisting of pectoralis major tendon in primates that may have occurred with their adoption to bipedalism and arboreal lifestyle. Finally, the clinical significance of this aberrant muscle is elaborated as a cause of potential neurovascular entrapment and as a possible hurdle during axillary surgeries (i.e., mastectomy).

Stent and Stent-Graft Use in Arteriovenous Dialysis Access

Dialysis access failure is a major cause of mortality and morbidity among dialysis patients. Preservation of access is critical to maintaining hemostasis, avoiding uremia, and managing the complications of kidney failure. While angioplasty remains the most common method of managing arteriovenous (AV) access stenoses, the use of stents and stent grafts to manage venous stenoses associated with AV access has become more prominent. There have been several prospective randomized trials that have demonstrated the benefit of these devices in maintaining the target lesion patency of the treated areas. In this article, the author reviews the data relating to stent and stent-graft use at the venous anastomosis and outflow veins for pseudoaneurysms of grafts, at the cephalic arch, and for central venous stenoses.

The Role of Endovascular Stents in Dialysis Access Maintenance

Vascular stenosis is most often the culprit behind hemodialysis vascular access dysfunction, and although percutaneous transluminal angioplasty remains the gold standard treatment for vascular stenosis, over the past decade the use of stents as a treatment option has been on the rise. Aside from the 2 Food and Drug Administration-approved stent grafts for the treatment of venous graft anastomosis stenosis, use of all other stents in vascular access dysfunction is off-label. Kidney Disease Outcomes Quality Initiative recommends limiting stent use to specific conditions, such as elastic lesions and recurrent stenosis; otherwise, additional adapted indications are in procedure-related complications, such as grade 2 and 3 hematomas. Published reports have shown the potential use of stents in a variety of conditions leading to vascular access dysfunction, such as venous graft anastomosis stenosis, cephalic arch stenosis, central venous stenosis, dialysis access aneurysmal elimination, cardiac implantable electronic device-induced stenosis, and thrombosed arteriovenous grafts. Although further research is needed for many of these conditions, evidence for recommendations has been clear in some; for instance, we know now that stents should be avoided along cannulation sites and should not be used in eliminating dialysis access aneurysms. In this review article, we evaluate the available evidence for the use of stents in each of the aforementioned conditions leading to hemodialysis vascular access dysfunctions.

Cephalic Arch Stenosis in Dialysis Patients: Review of Clinical Relevance, Anatomy, Current Theories on Etiology and Management

Arteriovenous hemodialysis fistulas (AVFs) serve as a lifeline for many individuals with end-stage renal failure. A common cause of AVF failure is cephalic arch stenosis. Its high prevalence compounded with its resistance to treatment makes cephalic arch stenosis important to understand. Proposed etiologies include altered flow in a fistulized cephalic vein, external compression by fascia, the unique morphology of the cephalic arch, large number of valves in the cephalic outflow tract and biochemical changes that accompany renal failure. Management options are also in debate and include angioplasty, cutting balloon angioplasty, bare metal stents, stent grafts and surgical techniques including flow reduction with minimally invasive banding as well as more invasive venovenostomy with transposition surgeries for refractory cases. In this review, the evidence for the clinical relevance of cephalic arch stenosis, its etiology and management are summarized.

Cephalic arch stenosis: mechanisms and management strategies

Cephalic arch is a frequent site for the development of stenosis in patients with brachiocephalic fistulae. This is in part owing to the anatomic constraints of the cephalic arch region and the exertion of hemodynamic forces at this site caused by the creation of a brachiocephalic fistula. Multiple interventions have been used to correct stenosis and subsequent fistula dysfunction. These include percutaneous balloon angioplasty using conventional and cutting balloons, endovascular stent insertion, and surgical interventions. It is important to emphasize that the stenosis in this region frequently recurs, is more resistant to angioplasty, and shows a higher rate of rupture during the percutaneous balloon angioplasty procedure compared with peripheral lesions at other sites. Because hemodynamic forces have been postulated to be one of the culprits for the development of stenosis, a new technique of flow reduction has been introduced to combat this problem. This article discusses the etiology, pathophysiology, and current management of cephalic arch stenosis.

Surgical Treatment of Cephalic Arch Stenosis by Central Transposition of the Cephalic Vein

Purpose

After creation of a brachiocephalic (BC) arteriovenous fistula (AVF), stenosis of the cephalic vein close to its junction with the axillary vein (cephalic arch stenosis, CAS) can develop. Flow impairment and access thrombosis are the consequences, sometimes complicated by prestenotic aneurysm of the cephalic vein. We here report our experience with cephalic vein transposition (CVT) for CAS.

Methods

From March 2007 through February 2012, symptomatic CAS was detected in 25 patients (13 female) with either dysfunction (n=14) or thrombosis (n=11) of their BC AVF. All were treated by CVT: the vein was ligated and cut distally to the stenotic segment, then tunneled subcutaneously to the medial aspect of the upper arm and anastomosed to the proximal brachial or basilic vein in an end-to-side fashion. Simultaneous thrombectomy of the cephalic vein was performed in 11 patients and aneurysmorrhaphy in 9. In addition, one patient had a proximal new AV anastomosis, another angioplasty of an in-stent restenosis of the access-draining subclavian vein.

Results

After CVT, two acute complications (8%) occurred: access thrombosis (one) and bleeding (one). During follow-up (1 to 54 months, median 13 months, 34.5 patient-years), six patients died with functioning AVF, three were successfully transplanted. Primary (secondary) 1-year patency was 79% (90%), with a reintervention rate of 0.1/patient/year.

Conclusions

Primary 1-year access patency rates after CVT compare favorably with those after interventional treatment, and reintervention rates are lower. Frequently occurring prestenotic aneurysms could be repaired simultaneously. CVT should therefore be regarded as the treatment of choice for CAS.

Access Flow Reduction and Recurrent Symptomatic Cephalic Arch Stenosis in Brachiocephalic Hemodialysis Arteriovenous Fistulas

Background

Recurrent cephalic arch stenosis (CAS) has been linked to high flow and has a high rate of recurrence following angioplasty. This study investigates the effectiveness of access flow reduction in decreasing rapidly recurrent symptomatic CAS.

Methods

A retrospective study of patient records from February 2005 to April 2009 was conducted. Patients with brachiocephalic fistulas who had undergone two or more instances of cephalic arch angioplasty within 3 months, and thereafter underwent flow reduction via banding of the access inflow (n=33) were included. A before-and-after analysis was conducted: the rates of cephalic arch angioplasty were calculated for each patient before and after the banding procedure, and compared via a paired t-test.

Results

At 3, 6, and 12 months, the cephalic arch primary lesion patency was 91%, 76%, and 57%. The cephalic arch intervention rate was reduced from 3.34 to 0.9 per access-year (t=7.74, p<.001). The average follow-up time was 14.5 months (range, 4.8–32).

Conclusion

Flow reduction of a brachiocephalic arteriovenous hemodialysis fistula may effectively diminish the incidence of symptomatic CAS.

Nerve loop around the axillary vessels by the roots of the median nerve a rare variation in a south Indian male cadaver: a case report

INTRODUCTION

Median nerve is normally formed by the union of medial and lateral root arising from the medial and the lateral cords of the brachial plexus respectively. However, variations in the formation and its relation with the axillary vessels are not uncommon. Therefore, knowledge of the variations in the nerve formation and course is useful for the clinicians during surgery and for differential diagnosis of uncommon clinical conditions.

CASE PRESENTATION

During the routine dissection in the department of anatomy, Kasturba Medical Collage, Manipal, India, we found unique anatomical variations in the formation and the course of the roots of the median nerve forming the neural loops around the axillary artery and vein.

CONCLUSION

Here we report the detailed description of these variations along with its clinical, embryological relevance and review of literature.

Characteristic differences in cephalic arch geometry for diabetic and non-diabetic ESRD patients

BACKGROUND

Fistula access in chronic haemodialysis patients is recommended. The first and second choice for location of fistula placement is radial-cephalic followed by the brachiocephalic fistula. Fistula access using the cephalic vein often results in cephalic arch stenosis that is less common in diabetics for unclear reasons. The objective of the current study is to determine if geometry of the cephalic arch differs between diabetics and non-diabetics.

METHODS

In a retrospective design, 57 patients with brachiocephalic fistula access had radiology films of the cephalic arch reviewed for geometric analysis. Twelve patients were excluded from final analysis because of stent placement in the cephalic arch. Measurements made included diameter of the cephalic vein, minimum radius of curvature and angle of the arch. Demographics were statistically analysed to determine the association with the geometric measurements.

RESULTS

Global and local measurements showed evidence of two arch types. Wider arch angles and larger R/d were associated with diabetes by univariate (P < 0.05) and multivariate analyses (P < 0.05). A wider arch angle was also associated with a history of right permcath access by multivariable analysis (P = 0.042).

CONCLUSIONS

Based on this study, it was found that there are two distinct types of cephalic arch geometries. Patients having diabetes mellitus show a significant probability of having a larger R/d ratio and wider arch angle. This study has given insight into structural alterations in geometry of the cephalic arch of diabetics with brachiocephalic fistula access.