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Liu W, Wu M, Wang X, Huang XK, Cai WJ, Ding TY, Duan LL, Qiao R, Wu YG. Recanalization of thrombosed aneurysmal hemodialysis arterovenous fistulas using a hybrid technique based on data from a single center. BMC Nephrol 2022; 23:185. [PMID: 35568810 PMCID: PMC9107707 DOI: 10.1186/s12882-022-02820-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/10/2022] [Indexed: 11/19/2022] Open
Abstract
Objective To explore the technical specifications and clinical outcomes of thrombosed aneurysmal haemodialysis arteriovenous fistula (AVF) treated with ultrasound-guided percutaneous transluminal angioplasty combined with minimal aneurysmotomy. Methods This case series study included 11 patients who had thrombosed aneurysmal AVF and underwent salvage procedures over a 13-month period. All procedures were performed under duplex guidance. Minimal aneurysmotomy was performed, along with manual thrombectomy and thrombolytic agent infusion, followed by angioplasty to macerate the thrombus and sufficiently dilate potential stenoses. A successful procedure was defined as immediate restoration of flow through the AVF. Results The 11 patients (four males and seven females) had a mean age of 49.6 years ± 11.9 years. Six patients (54.5%) had two or more aneurysms. The mean aneurysm maximal diameter was 21.5 mm (standard deviation: ± 5.0 mm), and the mean thrombus length was 12.9 cm (8–22 cm). Ten (83.3%) of the 12 procedures were technically successful. The mean duration of operation was 150.9 minutes (standard deviation: ± 34.2 minutes), and mean postoperative AVF blood flow was 728.6 ml/min (standard deviation: ± 53.7 mi/min). The resumption of hemodialysis was successful in all 11 cases, with a clinical success rate of 100%. The primary patency rates were 90.0% and 75.0% at three and four months over a mean follow-up time of 6.3 months (3–12 months). The secondary patency rates were 90.4% at three and four months. Conclusion A hybrid approach combining ultrasound-guided percutaneous transluminal angioplasty and minimal aneurysmotomy might be a safe and effective method for thrombosed aneurysmal AVF salvage.
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Affiliation(s)
- Wei Liu
- Department of Nephropathy, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, P.R. China.,Department of Nephropathy, Anqing Municipal Hospital, Anqing, Anhui, 246000, P.R. China
| | - Meng Wu
- Department of Nephropathy, Anqing Municipal Hospital, Anqing, Anhui, 246000, P.R. China
| | - Xu Wang
- Department of Nephropathy, Anqing Municipal Hospital, Anqing, Anhui, 246000, P.R. China
| | - Xiao-Kang Huang
- Department of Nephropathy, Anqing Municipal Hospital, Anqing, Anhui, 246000, P.R. China
| | - Wen-Jiao Cai
- Department of Nephropathy, Anqing Municipal Hospital, Anqing, Anhui, 246000, P.R. China
| | - Teng-Yun Ding
- Department of Ultrasonography, Anqing Municipal Hospital, Anqing, Anhui, 246000, P.R. China
| | - Liang-Liang Duan
- Department of Nephropathy, Anqing Municipal Hospital, Anqing, Anhui, 246000, P.R. China
| | - Rui Qiao
- Department of Cardiology, Anqing Municipal Hospital, Anqing, Anhui, 246000, P.R. China
| | - Yong-Gui Wu
- Department of Nephropathy, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, P.R. China. .,Center for Scientific Research, Anhui Medical University, Hefei, Anhui, 230022, P.R. China.
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Kovács L, Molnár T, Cserényi L, Raskó E, Ruzsa Z, Sikorszki L. [Successful treatment of brachial artery aneurysm causing embolization after brachiocephalic arteriovenous fistula]. Magy Seb 2022; 75:12-16. [PMID: 35333759 DOI: 10.1556/1046.2021.10003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/14/2021] [Indexed: 06/14/2023]
Abstract
Introduction: The brachial artery aneurysm is a rare condition that accounts for 5% of peripheral aneurysms. Most are pseudoaneurysms that develop as a result of iatrogenic exposure or trauma. True brachial aneurysm can develop after an occluded dialysis fistula. The causes leading to this development are unclear, but steroid-containing and immunosuppressive drugs used after kidney transplantation, as well as increased flow during fistula function and increased mechanical effects on the vessel wall, may play a role. The authors report the case of a 43-year-old patient who underwent two kidney transplants and was hospitalized for acute left arm ischemia. Imaging studies (angiography, CT angiography) confirmed left brachial aneurysm and dilatation of the thrombotic venous stem of the previous brachiocephalic arteriovenous (AV) fistula, and peripheral embolization. The patient was successfully treated in our hospital with the involvement of several subspecialties. The outflow pathway was opened by minimally invasive catheter thrombolysis, the source of embolism was eliminated by conventional vascular surgery, aneurysm ligation, resection of occluded dilated venous stem, and autologous venous saphenous bypass. By describing the case, the authors would like to draw attention to the complex mindset leading to successful treatment.
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Affiliation(s)
- Lajos Kovács
- 1 Bács-Kiskun Megyei Kórház, a Szegedi Tudományegyetem Általános Orvostudományi Kar Oktatókórháza, Általános Sebészeti Osztály, Kecskemét, Magyarország (osztályvezető főorvos: prof. dr. Sikorszki László)
| | - Tamás Molnár
- 1 Bács-Kiskun Megyei Kórház, a Szegedi Tudományegyetem Általános Orvostudományi Kar Oktatókórháza, Általános Sebészeti Osztály, Kecskemét, Magyarország (osztályvezető főorvos: prof. dr. Sikorszki László)
| | - László Cserényi
- 1 Bács-Kiskun Megyei Kórház, a Szegedi Tudományegyetem Általános Orvostudományi Kar Oktatókórháza, Általános Sebészeti Osztály, Kecskemét, Magyarország (osztályvezető főorvos: prof. dr. Sikorszki László)
| | - Endre Raskó
- 1 Bács-Kiskun Megyei Kórház, a Szegedi Tudományegyetem Általános Orvostudományi Kar Oktatókórháza, Általános Sebészeti Osztály, Kecskemét, Magyarország (osztályvezető főorvos: prof. dr. Sikorszki László)
| | - Zoltán Ruzsa
- 2 Bács-Kiskun Megyei Kórház, a Szegedi Tudományegyetem Általános Orvostudományi Kar Oktatókórháza, Invazív Kardiológiai Osztály, Kecskemét, Magyarország (osztályvezető főorvos: dr. Ruzsa Zoltán)
| | - László Sikorszki
- 1 Bács-Kiskun Megyei Kórház, a Szegedi Tudományegyetem Általános Orvostudományi Kar Oktatókórháza, Általános Sebészeti Osztály, Kecskemét, Magyarország (osztályvezető főorvos: prof. dr. Sikorszki László)
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Alejandro G, Adolfo FG, Hugo TA. Digital embolization from a thrombosed aneurysmal hemodialysis arteriovenous fistula. Nefrologia 2021; 41:593-594. [PMID: 36165143 DOI: 10.1016/j.nefroe.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/15/2020] [Indexed: 06/16/2023] Open
Affiliation(s)
| | | | - Tabares Aldo Hugo
- Vascular Medicine Service, Argentina; Instituto Universitario de Ciencias Biomédicas de Córdoba, Argentina
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4
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Alejandro G, Adolfo FG, Hugo TA. Digital embolization from a thrombosed aneurysmal hemodialysis arteriovenous fistula. Nefrologia 2021. [DOI: 10.1016/j.nefro.2020.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Raulli SJ, Cheng TW, Farber A, Eslami MH, Kalish JA, Jones DW, Rybin DV, Nuhn M, Gautam A, Siracuse JJ. Intraoperative Heparin Use during Upper Extremity Arteriovenous Access Creation Does Not Affect Outcomes. Ann Vasc Surg 2018; 55:216-221. [PMID: 30217706 DOI: 10.1016/j.avsg.2018.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND There are conflicting data about the effect of heparin use on perioperative outcomes during upper extremity arteriovenous (AV) access creation. Our goal was to assess the effect of the use and degree of intraoperative heparin on perioperative outcomes after AV access creation. METHODS All upper extremity AV access cases performed at a tertiary academic medical center between 2014 and 2017 were reviewed. Patient and procedural details including intraoperative heparin use and dosing as well as protamine use were analyzed. Full heparin dose was defined as 80-100 U/kg and partial heparin dose as less than 80 U/kg. Perioperative arterial thrombosis or distal embolism, hematoma, and early loss of primary patency within 30 days were evaluated. Multivariate analysis was performed to assess the effect of heparin use. RESULTS There were 550 AV access cases identified: brachiocephalic (37.5%), brachiobasilic (29.3%), and radiocephalic fistulas (12.9%), and AV grafts (16.9%). Average patient age was 62.6 years and 58.9% were male. Full heparinization was used in 21.3%, partial heparinization in 58.7%, and no heparin was used in 20% of cases. Protamine was used in 94.9% of full heparin cases and 51.4% of partial heparin cases. No perioperative arterial thrombosis or distal embolism was observed. Perioperative wound hematoma rate was 3.4%, 3.1%, and 0.9% in full heparin, partial heparin, and no heparin cohorts, respectively (P = 0.42). Early loss of primary patency was 11.1%, 7.7%, and 6.4% for full heparin, partial heparin, and no heparin cases, respectively (P = 0.39). There were no differences in return to the operating room or perioperative survival. On multivariable analysis, full heparin use (odds ratio [OR] 3.82, 95% confidence interval [CI] 0.41-35.9, P = 0.24) and partial heparin (OR 4.03, 95% CI 0.5-32.6, P = 0.19) use were not significantly different from no heparin cases with respect to 30-day perioperative hematoma rate. Full heparin (OR 1.76, 95% CI 0.65-4.78, P = 0.26) and partial heparin (OR 1.13, 95% CI 0.46-2.75, P = 0.79) were not significantly different from no heparin cases with respect to early loss of primary patency. CONCLUSIONS Intraoperative heparin use, at full or partial doses, did not affect perioperative outcomes after AV access creation. Overall complication event rate was low for all groups. AV access can be safely performed without intraoperative heparin use.
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Affiliation(s)
- Stephen J Raulli
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Denis V Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Matthew Nuhn
- Division of Transplant Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Amitabh Gautam
- Division of Transplant Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
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Yj A. Digital infarction in a hemodialysis patient due to embolism from a thrombosed brachial arteriovenous fistula. Hemodial Int 2014; 19:E6-9. [PMID: 25545123 DOI: 10.1111/hdi.12256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Acute onset of digital ischemia and infarction is an unusual complication in patients undergoing hemodialysis. This is a report of a patient on regular hemodialysis who presented with acute distal extremity ischemia, progressing to digital infarction and on evaluation was found to have thrombosis of brachial arteriovenous fistula with embolization to the distal arteries causing digital artery occlusion.
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Affiliation(s)
- Anupama Yj
- Department of Nephrology, Nanjappa Hospital, Shimoga, Karnataka, India
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Kim MH, Hwang JK, Chun HJ, Moon IS, Kim JI. Thrombosed hemodialysis access as an unusual source of emboli in the upper extremity of a kidney transplant recipient. Hemodial Int 2013; 18:535-9. [PMID: 24274072 DOI: 10.1111/hdi.12118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Arteriovenous fistula (AVF) is no longer used in kidney transplant recipients. However, there is no consensus regarding whether or not to ligate a well-functioning AVF after successful kidney transplantation, particularly in patients with well and stably functioning kidney transplants. Most AVFs without complications are left in situ and more than one-third of native AVFs close spontaneously. The currently accepted policy toward thrombosed AVFs is retention within the patient's extremity without treatment. These thrombosed AVFs seldom cause serious problems. However, when combined with aneurysmal dilatation of the proximal vein adjacent to the arterial anastomotic area, the AVF could act as the source of distal arterial emboli. This is very similar clinical scenario to that observed in embolization from a peripheral arterial aneurysm. Here we describe a case report of upper extremity ischemia following massage of a thrombosed aneurysmal AVF. The patient was successfully treated with a combination of catheter-directed thromboaspiration, thrombolysis, and surgical repair of the thrombosed AVF. To the best of our knowledge, this is the first report of upper extremity embolism after massage of a thrombosed aneurysmal AVF involving this combined treatment.
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Affiliation(s)
- Mi-Hyeong Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Davies LL, Fitchett JM, Dunsby AM, Champ C, Lewis MH. The thrombosed brachial-cephalic fistula used for renal dialysis--a cautionary note. BMJ Case Rep 2012; 2012:bcr.05.2011.4269. [PMID: 22605843 DOI: 10.1136/bcr.05.2011.4269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Arteriovenous fistulae (AVF) are commonly required for dialysis prior to renal transplantation, and are subsequently left insitu, even if thrombosed. The authors present one of two patients in whom progressive digital ischaemia occurred, and was initially overlooked, many years following formation of an AVF. The patient was surgically explored and clot protruding from the thrombosed vein into the brachial artery was noted. The arterial defect was closed with a vein patch and histological examination of the fistula confirmed clot. The patient recovered satisfactorily and remained well 6 months postoperatively. The authors would suggest that embolisation from a thrombosed AVF does occur, has a significant morbidity and can lead to digital loss. Furthermore, transplant patients are usually long suffering and will often put up with what they describe as 'aches and pains' as part of their illness. The authors suggest those patients suffering with evidence of ischaemia warrant excision of the fistula.
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Affiliation(s)
- Llion L Davies
- General Surgery Department, Royal Glamorgan Hopital, Llantrisant, UK
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Journet J, Bui HT, Capdevila C, Lavaud S, Hadj Henni A, Clément C, Rieu P, Long A. [Digital arterial embolization from a previously thrombosed arteriovenous access: a rare and misdiagnosed complication]. Nephrol Ther 2010; 6:121-4. [PMID: 20181540 DOI: 10.1016/j.nephro.2009.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 12/22/2009] [Accepted: 12/23/2009] [Indexed: 10/19/2022]
Abstract
Surgical removal of a hemodialysis access after thrombosis is generally not performed as it remains clinically well tolerated. However, it may be the source of distal embolization. We report the case of a 43-year-old patient, kidney recipient, who presented with digital ischemia of the right hand. He had a forearm arteriovenous fistula at the right wrist which thrombosed 5 years ago. Digital ischemia was due to thrombus formation at the anastomotic site and migration into the downstream arterial bed. Heparine was initiated together with antiplatelet treatment. The ischemia resolved after a few days, no recidive was observed. Surgical ligation of the arteriovenous fistula was rapidly performed and antiplatelet treatment was maintained after surgery. After a follow-up of 6 months, the patient remained asymptomatic without new embolization. This observation underlines the necessity of clinical monitoring after access thrombosis and preventive surgical ligation might be discussed when the risk of distal embolization is high.
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Affiliation(s)
- Julien Journet
- Service de médecine vasculaire, hôpital Robert-Debré, CHU de Reims, rue du Professeur-Kochman, 51092 Reims cedex, France.
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