Lesion Type Analysis of Hemodialysis Patients Who Underwent Endovascular Management for Symptomatic Central Venous Disease

Successful management of fatal cardiac tamponade resulting from intravascular intervention for central vein occlusion in hemodialysis patients: A case report

This case report highlights the successful management of fatal cardiac tamponade caused by intravascular intervention for central vein occlusion in hemodialysis patients. Prompt diagnosis and treatment are essential for patient prognosis in such cases. We present a case involving a challenging surgical procedure to address multiple complications, emphasizing the importance of early detection and appropriate interventions. The patient, who had a history of long-term central venous catheter use for hemodialysis, was diagnosed with central vein stenosis in addition to superior vena cava occlusion, hemodialysis catheter rupture, hypertension, and end-stage renal disease. Urgent ultrasound examination during surgery revealed pericardial effusion, prompting immediate pericardial drainage for stabilization. To overcome the complex challenges, we successfully performed an innominate vein-right atrial appendage bypass to restore vascular access and salvage the patient's life. The timely use of echocardiography for diagnosis and pericardial drainage contributed to stabilizing the patient's vital signs, providing an opportunity for subsequent surgical intervention. The innominate vein-right atrial appendage bypass procedure successfully relieved central vein stenosis and saved the patient's life. Although this surgical technique is not widely documented in hemodialysis patients with central venous involvement, it show cases the potential benefits for clinicians managing vascular access in this patient population. This case report underscores the need for awareness among clinicians regarding the risk of cardiac tamponade associated with intravascular intervention for central vein stenosis in hemodialysis patients. Minimizing central venous catheterization and prioritizing autogenous arteriovenous fistulas are crucial principles in preparing vascular access for hemodialysis patients. Early detection, timely interventions, and consideration of alternative surgical techniques can improve outcomes and prevent life-threatening complications.

Fatal superior vena cava rupture complicating dialysis catheter exchange

Central vein stenosis (CVS) is a common and challenging complication in hemodialysis patients with chronic central venous catheters (CVCs). CVS often remains asymptomatic and is discovered incidentally during follow-up imaging. CVS symptoms include arm swelling, venous hypertension, impaired dialysis flow rates, and development of collateral veins. However, these symptoms can be nonspecific and overlap with other conditions, making the diagnosis challenging. Timely recognition and appropriate intervention are crucial to prevent complications and optimize patient outcomes. Diagnostic tools commonly used include duplex ultrasonography and venography to assess the degree and location of stenosis. Management strategies for CVS encompass a multidisciplinary approach involving nephrologists, interventional radiologists, and vascular surgeons. Initial conservative measures may include anticoagulation therapy, along with pharmacological interventions such as antiplatelet agents and thrombolytics. The endovascular approach is the first line for managing CVS by using balloon angioplasty either alone or in combination with stent placement, but CVS typically recurs frequently, requiring repeated interventions with an increased risk of complications. Additionally, alternative vascular access options such as arteriovenous fistulas or grafts may be considered. In this report, we describe a case of a 25-year-old woman who presented with an extensive history of multiple dialysis access failure for left internal jugular vein central venous tunneled catheter exchange. The procedure was complicated by a fatal superior vena cava rupture likely related to the dislodgment of the guidewire causing perforation into the pericardium space with subsequent cardiopulmonary collapse. The post-mortem autopsy showed severe organized stenosis of SVC and transmural defect above the SVC/atrial junction.

ACR Appropriateness Criteria® Central Venous Access Device and Site Selection

The use of central venous access devices is ubiquitous in both inpatient and outpatient settings, whether for critical care, oncology, hemodialysis, parenteral nutrition, or diagnostic purposes. Radiology has a well-established role in the placement of these devices due to demonstrated benefits of radiologic placement in multiple clinical settings. A wide variety of devices are available for central venous access and optimal device selection is a common clinical challenge. Central venous access devices may be nontunneled, tunneled, or implantable. They may be centrally or peripherally inserted by way of veins in the neck, extremities, or elsewhere. Each device and access site presents specific risks that should be considered in each clinical scenario to minimize the risk of harm. The risk of infection and mechanical injury should be minimized in all patients. In hemodialysis patients, preservation of future access is an additional important consideration. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Left brachiocephalic venous occlusion with spontaneous arteriovenous fistula presenting with severe edema in left upper extremity and face: A case report

INTRODUCTION AND IMPORTANCE

The coexistence of central venous occlusion and arteriovenous fistulas (AVF) is rare among non-dialysis patients. Herein, we describe a case of left brachiocephalic venous occlusion with spontaneous AVF, presenting with severe edema in left upper extremity and face.

CASE PRESENTATION

A 90-year-old woman presented to our hospital with gradually worsening edema in her left arm and face for eight years. Contrast-enhanced computed tomography revealed left brachiocephalic venous occlusion and severe edema in her left upper extremity and face. Computed tomography also revealed abundant collateral veins; thus, it seemed unnatural for severe edema to occur with such well-developed collateral pathways. Therefore, the presence of AVF was suspected. After careful re-examination of the patient, a continuous murmur was heard in the post-auricular region. Magnetic resonance imaging and angiogram revealed a dural AVF. Considering the patient's age and treatment difficulty for the dural AVF, we performed a stent insertion into the left brachiocephalic vein. After the procedure, edema in her left upper extremity and face improved dramatically.

CLINICAL DISCUSSION

In cases of persistent swelling of the upper extremities or face, there could be a factor that increases venous inflow. Therefore, any condition that may increase venous inflow must be aggressively investigated and therapeutic interventions should be applied to treat such conditions.

CONCLUSION

Central venous occlusion and AVF is a possible underlying cause for severe refractory edema in the upper extremity and face. Therefore, both AVF and brachiocephalic occlusion should be assessed for treatment indications under these conditions.

Heme Oxygenase 1/Peroxisome Proliferator-Activated Receptor Gamma Pathway Protects Intimal Hyperplasia and Mitigates Arteriovenous Fistula Dysfunction by Regulating Oxidative Stress and Inflammatory Response

Purpose

An arteriovenous fistula (AVF) is the preferred vascular access mode for maintenance hemodialysis, and access stenosis and thrombosis are the primary causes of AVF dysfunction. This study is aimed at exploring the molecular mechanisms underlying AVF development and the roles of the heme oxygenase 1/peroxisome proliferator-activated receptor gamma (HO-1/PPAR-γ) pathway in AVF.

Method

AVF model mice were established, and the vascular tissues from the arteriovenous anastomosis site were sent for mRNA sequencing. Differentially expressed mRNAs (DEmRNAs) were screened and subjected to functional analysis. Thereafter, the mice with HO-1 knockdown and coprotoporphyrin IX chloride (COPP) pretreatment were used to investigate the roles of the HO-1/PPAR-γ pathway in AVF.

Results

By sequencing, 2514 DEmRNAs, including 1323 upregulated and 1191 downregulated genes, were identified. These DEmRNAs were significantly enriched in the PPAR signaling pathway, AMPK signaling pathway, glucagon signaling pathway, IL-17 signaling pathway, and Toll-like receptor signaling pathway. High expression of HO-1 and PPAR-γ reduced endothelial damage and intimal hyperplasia during AVF maturation. After AVF was established, the levels of transforming growth factor-β (TGF-β), interleukin-1β (IL-1β), interleukin-18 (IL-18), and reactive oxygen species (ROS) were significantly increased (P < 0.05), and HO-1 normal expression and COPP pretreatment evidently decreased their levels in AVF (P < 0.05). Additionally, AVF significantly upregulated HO-1 and PPAR-γ and downregulated MMP9, and COPP pretreatment and HO-1 normal expression further upregulated and downregulated their expression.

Conclusion

The HO-1/PPAR-γ pathway may suppress intimal hyperplasia induced by AVF and protect the intima of blood vessels by regulating MMP9 and ROS, thus mitigating AVF dysfunction.

Reduction in hemodialysis catheter-related bloodstream infections after implementation of a novel care program

BACKGROUND

Catheter-related bloodstream infection (CRBSI) due to dialysis is the major factor causing morbidity and mortality factor for patients undergoing hemodialysis and is associated with additional costs for these patients. This study investigated the effect of a novel care program in terms of reducing CRBSIs for hemodialysis patients with nontunneled (temporary) catheters inserted in their femoral veins.

METHODS

This study included dialysis patients (inpatients and outpatients) from July 2018 to September 2019, covering two periods, pre-intervention (baseline period) and intervention with a novel care program (novel care period). The novel care program was initiated on December 1, 2018. The CRBSI rates (/1000 catheter-days) for the baseline and novel care periods were compared, and the characteristics of the pathogens were determined.

FINDINGS

Of a total of 72 patients, 33 were from the baseline period and 39 were from the novel care period. Patients in the baseline and novel care periods had the catheter inserted in their femoral veins for a median of 20 and 29 days, respectively. The CRBSI rate decreased by 82.63%, from 8.52/1000 catheter-days in the baseline period to 1.48/1000 catheter-days in the novel care period (p = 0.036). The most common organisms involved in CRBSIs were coagulase-negative staphylococcus and Burkholderia cepacia (26% for both).

DISCUSSION

The novel care program reduced the incidence of CRBSIs in patients with temporary catheters inserted in their femoral veins.