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Fitzgibbon JJ, Heindel P, Hentschel DM, Ozaki CK, Hussain MA. Contemporary outcomes of distal radial artery ligation for access related hand ischemia. J Vasc Access 2023:11297298231195910. [PMID: 38142276 DOI: 10.1177/11297298231195910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023] Open
Abstract
OBJECTIVES Access related hand ischemia (ARHI) is a rare albeit morbid complication of hemodialysis access creation. Distal radial artery ligation (DRAL) has been described as a strategy to improve perfusion to the hand while maintaining the access. The objective of this study was to report longitudinal outcomes of DRAL for ARHI. METHODS Retrospective cohort study (2015-2021) of all patients who underwent DRAL for ARHI at a tertiary care vascular center. Subjects were identified using the Mass General Brigham clinical data warehouse and data collection was supplemented with chart adjudication. Outcomes captured included 30-day complications and improvement in ARHI-related symptoms at 1 year. RESULTS Thirty-one patients were included. Mean (SD) age was 59.9 (14.5) and 67.7% were male. Wrist radial-cephalic (74.2%) and proximal radial-cephalic (9.7%) configurations were most common. ARHI severity was: 9.7% stage 1 (retrograde flow without symptoms); 38.7% stage 2 (pain during exercise or dialysis); 41.9% stage 3 (pain at rest); and 9.7% stage 4 (tissue loss). High flow was present in 35.5% of patients at baseline with median (IQR) flow of 1670 ml/min (1478-1954). After DRAL, median (IQR) flow reduction in the high flow group was 953 ml/min (645-993); concurrent precision banding was performed in 29% to reduce flow. The 30-day risk of complication was 3.2% (n = 1 access thrombosis). During follow-up, 82.1% showed improvement in symptoms and 3.6% of patients needed an additional procedure for ARHI. Carpal tunnel surgery was required for improvement in 7.1% of patients and was suspected as the culprit of symptoms in 7.1%. CONCLUSION Distal radial artery ligation for ARHI is safe and can improve ischemic symptoms in most patients while salvaging access function. Precision banding can serve as a useful adjunct in high flow accesses. Carpal tunnel syndrome should be considered as part of the differential diagnosis of hand pain in this population.
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Affiliation(s)
- James J Fitzgibbon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Patrick Heindel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Dirk M Hentschel
- Division of Renal Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Charles Keith Ozaki
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
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Al-Adl AS, Ali HAEM. Identification of small diameter nerve fiber damage in hemodialysis patients' hands using the cutaneous silent period. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2023; 59:107. [DOI: 10.1186/s41983-023-00704-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/04/2023] [Indexed: 09/02/2023] Open
Abstract
Abstract
Background
The arteriovenous fistula is the most effective vascular access option for hemodialysis patients. An important and largely unreported concern detected at follow-up is the complaints of tingling or numbness in the hands of those patients. Furthermore, the cutaneous silent period qualifies as a straightforward evaluation of small nerve fiber function. This study aims to evaluate the function of small-diameter nerve fibers in the hands of patients undergoing continuous hemodialysis (HD) on the side with the arteriovenous fistula (AVF) and on the contralateral side.
Results
A cross-sectional study of 40 randomly chosen patients with chronic kidney disease on regular hemodialysis three times weekly the cutaneous silent period (CSP) was recorded on the hand with and without AV fistula. The cutaneous silent period (CSP) CSP was elicited by electrical square pulse stimulation using standard bipolar electrodes. The average cutaneous silent period onset and end latencies demonstrated significant prolongation in the hemodialysis patient group (arteriovenous fistula and non-arteriovenous fistula) compared with the control group. Correlation between cutaneous silent period with hemodialysis duration and adequacy of hemodialysis (KT\V). There was a statistically negative correlation observed between cutaneous silent period onset latency on the arteriovenous side and a positive correlation with KT\V on non-arteriovenous fistula. side.
Conclusions
Hemodialysis patients recommended to undergo regular neurophysiological testing to check for small nerve fiber affection. In particular, measuring the cutaneous Silent period that provides a quick and noninvasive way to rule out small A-delta nerve malfunction. In addition, less nerve injury results from hemodialysis's increased efficiency.
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Ghoshal S. Renal and Electrolyte Disorders and the Nervous System. Continuum (Minneap Minn) 2023; 29:797-825. [PMID: 37341331 DOI: 10.1212/con.0000000000001286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Neurologic complications are a major contributor to death and disability in patients with renal disease. Oxidative stress, endothelial dysfunction, accelerated arteriosclerosis, and uremic inflammatory milieu affect both the central and peripheral nervous systems. This article reviews the unique contributions of renal impairment to neurologic disorders and their common clinical manifestations as the prevalence of renal disease increases in a globally aging population. LATEST DEVELOPMENT Advances in the understanding of the pathophysiologic interplay between the kidneys and brain, also referred to as the kidney-brain axis, have led to more widespread recognition of associated changes in neurovascular dynamics, central nervous system acidification, and uremia-associated endothelial dysfunction and inflammation in the central and peripheral nervous systems. Acute kidney injury increases mortality in acute brain injury to nearly 5 times that seen in matched controls. Renal impairment and its associated increased risks of intracerebral hemorrhage and accelerated cognitive decline are developing fields. Dialysis-associated neurovascular injury is increasingly recognized in both continuous and intermittent forms of renal replacement therapy, and treatment strategies for its prevention are evolving. ESSENTIAL POINTS This article summarizes the effects of renal impairment on the central and peripheral nervous systems with special considerations in acute kidney injury, patients requiring dialysis, and conditions that affect both the renal and nervous systems.
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Joo Y, Moon J, Lee YJ, Bang YS, Yi J, Jang JN, Su MY, Kim YU. A new diagnostic morphological parameter for the Carpal tunnel syndrome: The palmaris longus tendon cross-sectional area. Medicine (Baltimore) 2022; 101:e30906. [PMID: 36221400 PMCID: PMC9542913 DOI: 10.1097/md.0000000000030906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Carpal tunnel syndrome (CTS) is correlated with increased intracarpal canal pressure (ICP). The effect of palmaris longus tendon (PLT) loading on ICP is documented in previous researches. PLT loading induces the greatest absolute increase in ICP. Therefore, to analyze the connection between the PLT and CTS, we newly made the measurement of the PLT cross-sectional area (PLTCSA). We assumed that PLTCSA is a reliable diagnostic parameter in the CTS. PLTCSA measurement data were acquired from 21 patients with CTS, and from 21 normal subjects who underwent wrist magnetic resonance imaging (W-MRI). We measured the PLTCSA at the level of pisiform on W-MRI. The PLTCSA was measured on the outlining of PLT. The two different cutoff values in the analysis were determined using receiver operating characteristic (ROC) analysis. The mean PLTCSA was 2.34 ± 0.82 mm2 in the normal group and 3.97 ± 1.18 mm2 in the CTS group. ROC curve analysis concluded that the best cutoff point for the PLTCSA was 2.81 mm2, with 76.2% sensitivity, 71.4% specificity, and area under the curve of 0.88 (95% CI, 0.78-0.98). PLTCSA is a sensitive, new, objective morphological parameter for evaluating CTS.
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Affiliation(s)
- Young Joo
- Department of Anesthesiology and Pain Medicine, CHA Ilsan Medical Center, CHA University, Goyang, Republic of Korea
| | - JeeYoun Moon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University School of Medicine, Seoul, Republic of Korea
| | - Yoon Jin Lee
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Yun-Sic Bang
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Jungmin Yi
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Incheon, Republic of Korea
| | - Jae Ni Jang
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Incheon, Republic of Korea
| | - Min-Ying Su
- Department of Radiological Sciences, University of California, Irvine, CA, USA
| | - Young Uk Kim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Incheon, Republic of Korea
- Department of Radiological Sciences, University of California, Irvine, CA, USA
- * Correspondence: Young Uk Kim, Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary’s Hospital, Simgokro, 100 Gil 25, Seo-Gu, Incheon City, Republic of Korea (e-mail: )
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Gu F, Yu J, Mi J. Radial arteriovenous fistula complicated with ischemic steal syndrome after transradial cardiac catheterization: a case report and literature review. BMC Surg 2022; 22:106. [PMID: 35313862 PMCID: PMC8939090 DOI: 10.1186/s12893-022-01562-7] [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: 12/08/2021] [Accepted: 03/15/2022] [Indexed: 11/27/2022] Open
Abstract
Background The radial arteriovenous fistula (AVF) is a rare complication occurring after transradial cardiac catheterization. Patients with AVF typically present with signs of venous dilation, such as swelling or palpable thrills. However, neurological complications secondary to radial AVFs are rare. This paper reported a rare case of ischemic steal syndrome that occurred 11 months after the transradial cardiac catheterization, most likely as a consequence of radial arteriovenous fistula. Case presentation This paper described a case of a 73-year-old female, who complained of right forearm swelling and radial 1–3 fingers numbness for several months after the catheterized stent surgery through radial approach. Upon Clinical examination, this patient presented with a slight bump and palpable thrill at the distal third of right forearm, and the sensory of radial 1–3 fingers and pinch force was compromised. The Ultrasonography and computed tomography angiography (CTA) of the upper extremity revealed AVF between the right radial artery and the adjacent vein. Microsurgery was performed successfully to ligate the fistula and reconstruct the radial artery. The numbness has gradually improved about 1 week after the surgery, with no recurred swelling. The two-point pinch force and digital sensitivity recovered at the 20-month follow-up. What’s more, due to the scarcity of cases, the optimal therapy for iatrogenic radial AVF is controversial. Accordingly, we provided a literature review of previous reports of catheter-related radial AVFs and proposed an algorithm to manage them. Conclusions We believe that once an AVF is diagnosed, early treatment options such as compression or surgery are necessary to relieve symptoms and prevent further complications. Otherwise, serious complications can occur, including the ischemic steal syndrome.
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Affiliation(s)
- Fengming Gu
- Medical College, Soochow University, Suzhou, Jiangsu, China
| | - Jiong Yu
- Department of Sports Medicine, Wuxi 9th People's Hospital Affiliated to Soochow University, 999 Liangxi Road, Wuxi, 214062, Jiangsu, China
| | - Jingyi Mi
- Department of Sports Medicine, Wuxi 9th People's Hospital Affiliated to Soochow University, 999 Liangxi Road, Wuxi, 214062, Jiangsu, China.
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Dukkipati R, Richler A, Shah A, de Virgilio C. Median Nerve and Ulnar Nerve Entrapment with Cubital Tunnel Syndrome in a Hemodialysis Patient Following Creation of an Arteriovenous Fistula. Case Rep Nephrol Dial 2021; 11:275-280. [PMID: 34703827 PMCID: PMC8460880 DOI: 10.1159/000518001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/19/2021] [Indexed: 11/19/2022] Open
Abstract
Neurological and vascular complications associated with creation of arteriovenous access need to be recognized promptly to deliver appropriate interventions for relief of symptoms and avoid loss of function of the involved extremity. We present here a 55-year-old female with end-stage renal disease on hemodialysis secondary to diabetic nephropathy who had a surgical creation of first stage of the brachial artery-basilic vein fistula in the left arm. She subsequently developed pain and weakness of the left arm which was diagnosed as median and ulnar nerve entrapment. She was treated with surgical nerve release and neurolysis and her symptoms improved.
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Affiliation(s)
- Ramanath Dukkipati
- Harbor-UCLA Medical Center, Torrance, California, USA.,Lundquist Research Institute, Torrance, California, USA.,UCLA School of Medicine, Westwood, California, USA
| | - Aaron Richler
- Harbor-UCLA Medical Center, Torrance, California, USA.,UCLA School of Medicine, Westwood, California, USA
| | - Anuja Shah
- Harbor-UCLA Medical Center, Torrance, California, USA.,Lundquist Research Institute, Torrance, California, USA.,UCLA School of Medicine, Westwood, California, USA
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Kim JH, Ye BM, Kim MJ, Kim SR, Kim IY, Kim HJ, Han M, Song SH, Seong EY, Lee SB, Lee DW. Median nerve swelling is an independent risk factor of carpal tunnel syndrome in chronic hemodialysis patients. Ther Apher Dial 2021; 25:607-612. [PMID: 33629794 DOI: 10.1111/1744-9987.13636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 02/10/2021] [Accepted: 02/23/2021] [Indexed: 11/29/2022]
Abstract
Carpal tunnel syndrome (CTS) has a wide variety of underlying causes and occurs in association with dialysis. Early diagnosis is essential to prevent permanent nerve damage and functional sequelae. We evaluated the association between CTS and cross-sectional area (CSA) of the median nerve in chronic hemodialysis (HD) patients. Patients with end-stage renal disease on maintenance HD via arteriovenous fistula were enrolled. We divided 43 patients into two groups; patients diagnosed with CTS (n = 19) and patients without CTS (n = 24). The median nerve CSA was measured at the wrist (CSA-W) and forearm (CSA-F) by ultrasonography. Median nerve swelling was assessed by the wrist-to-forearm ratio (WFR). There were no significant differences in the underlying causes of chronic kidney disease and adequacy of dialysis between the two groups (p = NS). The patients with CTS showed significantly higher WFR than the patients without CTS (p = 0.001). Univariate Cox regression analysis revealed that WFR >1.25 (odds ratio, 6.30; 95% confidence interval, 1.44-27.45; p = 0.014) was associated with CTS in HD patients. The factors traditionally associated with CTS such as age, sex, diabetes, vintage of HD, β2-MG, intact PTH, and Kt/V were not associated with CTS. After adjustment for age and sex, we found a strong correlation between CTS and the WFR >1.25 (odds ratio, 10.8; 95% confidence interval, 1.85-62.4; p = 0.008). High WFR was associated with the development of CTS, and median nerve swelling was an independent risk factor of CTS in chronic HD patients.
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Affiliation(s)
- June Hyun Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Byung-Min Ye
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Min Jeong Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Seo Rin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Il Young Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Hyo Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Hospital, Busan, South Korea
| | - Miyeun Han
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Hospital, Busan, South Korea
| | - Sang Heon Song
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Hospital, Busan, South Korea
| | - Eun Young Seong
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Hospital, Busan, South Korea
| | - Soo Bong Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Dong Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea.,Division of Nephrology, Pusan National University Yangsan Hospital, Yangsan, South Korea
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