A surgical method to be reminded for the treatment of symptomatic ipsilateral central venous occlusions in patients with hemodialysis access: Axillo-axillary venous bypass case report and review of the literature

BACKGROUND

In this case report, we present two chronic hemodialysis patients with upper extremity swelling due to central venous occlusions together with their clinical presentation, surgical management and brief review of the literature.

METHODS

The first patient who was a 63-year-old female patient with a history of multiple bilateral arteriovenous fistulas (AVFs) was referred to our clinic. Physical examination demonstrated a functioning right brachio-cephalic AVF, with severe edema of the right arm, dilated venous collaterals, facial edema, and unilateral breast enlargement. In her history, multiple ipsilateral subclavian venous catheterizations were present for sustaining temporary hemodialysis access. The second patient was a 47-year-old male with a history of failed renal transplant, CABG surgery, multiple AV fistula procedures from both extremities, leg amputation caused by peripheral arterial disease, and decreased myocardial functions. He was receiving 3/7 hemodialysis and admitted to our clinic with right arm edema, accompanied by pain, stiffness, and skin hyperpigmentation symptoms ipsilateral to a functioning brachio-basilic AVF. He was not able to flex his arms, elbow, or wrist due to severe edema.

RESULTS

Venography revealed right subclavian vein stenosis with patent contralateral central veins in the first patient. She underwent percutaneous transluminal angioplasty (PTA) twice with subsequent re-occlusions. After failed attempts of PTA, the patient was scheduled for axillo-axillary venous bypass in order to preserve the AV access function. In second patient, venography revealed right subclavian vein occlusion caused secondary to the subclavian venous catheters. Previous attempts for percutaneously crossing the chronic subclavian lesion failed multiple times by different centers. Hence, the patient was scheduled for axillo-axillary venous bypass surgery.

CONCLUSION

In case of chronic venous occlusions, endovascular procedures may be ineffective. Since preserving the vascular access function is crucial in this particular patient population, venous bypass procedures should be kept in mind as an alternative for central venous reconstruction, before deciding on ligation and relocation of the AVF.

Site of left axillary vein crossing the clavicle: an analysis with computed tomography venography as a guide for vein puncture for device implantation

BACKGROUND

Blind axillary venous access is a convenient but technically difficult approach for cardiac rhythm device lead implantation. We try to explore whether there are rules on the axillary vein course to facilitate blind venous cannulation.

METHODS

In a single-center, retrospective study, we included 155 patients who underwent computed tomography venography (CTV) examination of left axillary vein. All scans were reviewed for the relationship between left axillary vein and clavicle, vein steepness, and depth. Factors probably affecting above indicators were analyzed.

RESULTS

The location of left axillary vein crossing the clavicle was mainly concentrated around the medial 1/3 of clavicle, with mean crossing location of the medial 1/3 of clavicle, which was not correlated with sex, age, abdominal subcutaneous fat thickness, upper thoracic kyphosis angle, or the angle between clavicle and anterior midline (P < 0.05). The average angle between axillary vein and horizontal line was 31.57 ± 11.72°, which was positively associated with age, whereas inversely associated with the angle between clavicle and anterior midline (P < 0.05). The proximal axillary vein ran more and more shallow until becoming the subclavian vein (P < 0.01); and it had a mean depth of 3 cm, which was significantly associated with abdominal subcutaneous fat thickness (P < 0.05).

CONCLUSIONS

The left axillary vein and clavicle had a relatively fixed relationship that axillary vein commonly crossed the medial 1/3 of clavicle. The average angle between axillary vein and horizontal line was 31.57 ± 11.72°, associated with age and the clavicle course. The mean depth of proximal axillary vein was 3 cm, and patients with larger weight had a deeper position of axillary vein.

Axillary vein puncture versus cephalic vein cutdown for cardiac implantable electronic device implantation: A meta-analysis

INTRODUCTION

Cephalic vein cutdown (CVC) and axillary vein puncture (AVP) are both recommended for transvenous implantation of leads for cardiac implantable electronic devices (CIEDs). Nonetheless, it is still debated which of the two techniques has a better safety and efficacy profile.

METHODS

We systematically searched Medline, Embase, and Cochrane electronic databases up to September 5, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary endpoints were acute procedural success and overall complications. The effect size was estimated using a random-effect model as risk ratio (RR) and relative 95% confidence interval (CI).

RESULTS

Overall, seven studies were included, which enrolled 1771 and 3067 transvenous leads (65.6% [n = 1162] males, average age 73.4 ± 14.3 years). Compared to CVC, AVP showed a significant increase in the primary endpoint (95.7 % vs. 76.1 %; RR: 1.24; 95% CI: 1.09-1.40; p = .001) (Figure 1). Total procedural time (mean difference [MD]: -8.25 min; 95% CI: -10.23 to -6.27; p < .0001; I2  = 0%) and venous access time (MD: -6.24 min; 95% CI: -7.01 to -5.47; p < .0001; I2  = 0%) were significantly shorter with AVP compared to CVC. No differences were found between AVP and CVC for incidence overall complications (RR: 0.56; 95% CI: 0.28-1.10; p = .09), pneumothorax (RR: 0.72; 95% CI: 0.13-4.0; p = .71), lead failure (RR: 0.58; 95% CI: 0.23-1.48; p = .26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15-2.23; p = .43), device infection (RR: 0.95; 95% CI: 0.14-6.60; p = .96) and fluoroscopy time (MD: -0.24 min; 95% CI: -0.75 to 0.28; p = .36).

CONCLUSION

Our meta-analysis suggests that AVP may improve procedural success and reduce total procedural time and venous access time compared to CVC.

Ultrasound-guided access to the axillary vein for implantation of cardiac implantable electronic devices: A systematic review and meta-analysis

The aims of our systematic review were to quantify the expected rate of procedural success, early and late complications during CIED implantation using US-guided puncture of the axillary vein and to perform a meta-analysis of those studies that compared the US technique (intervention) versus conventional techniques (control) in terms of complication rates. MEDLINE, ISI Web of Science, and EMBASE were searched for eligible studies. Pooled Odds Ratio (OR) and Pooled Mean Difference (PMD) for each predictor were calculated. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. Thirteen studies were included a total of 2073 patients. The overall success of US-guided venipuncture for CIED implantation was 96.8%. As regards early complications, pneumothorax occurred in 0.19%, arterial puncture in 0.63%, and severe hematoma/bleeding requiring intervention in 1.1%. No cases of hemothorax, brachial plexus, or phrenic nerve injury were reported. As regards late complications, the incidence of pocket infection, venous thromboembolism, and leads dislodgement was respectively 0.4%, 0.8%, and 1.2%. In the meta-analysis (five studies), the intervention group (US-guided venipuncture) had a trend versus a lower likelihood of having a pneumothorax (0.19% vs 0.75%, p = 0.21), pocket hematoma (0.8% vs 1.7%, p = 0.32), infection (0.28% vs 1.05%, p = 0.29) than the control group, but this did not reach statistical significance. The overall QOE was low or very low. In conclusions we found that the US-guided axillary venipuncture for CIEDs implantation was associated with a low incidence of early and late complications and a steep learning curve.

Superdrainage Using the Cephalic Vein Due to Unsuitable Internal Thoracic Vein for Microvascular Anastomosis in Esophageal Reconstruction Using Pedicled Jejunum

The progress and popularization of microvascular surgical techniques may improve the outcomes of esophageal reconstruction using non-gastric tube (GT) grafts. A pedicled jejunum (PJ) with microvascular anastomoses is frequently selected as a reconstructed conduit for esophageal reconstruction when the GT is unavailable, and the internal thoracic (IT) vein is frequently selected as a recipient blood vessel for microvascular anastomosis. However, the IT vein may be inadequate for microvascular anastomosis because of its absence or underdevelopment. Since it is difficult to preoperatively predict such rare cases, it becomes necessary to urgently and rapidly prepare an alternative blood vessel. Herein, we present surgical procedures for superdrainage using the cephalic vein (CeV). Due the superficial nature of the CeV, it is both easy to identify and collect sufficient length. Thus, the CeV is very useful as an urgent substitute blood vessel when the IT vein is unavailable for microvascular anastomosis in esophageal reconstruction.

Axillary vein access for antiarrhythmic cardiac device implantation: a literature review

The current narrative review provides an update of available knowledge on venous access techniques for cardiac implantable electronic device implantation, with a focus on axillary vein puncture. Lower procedure-related and lead-related complications have been reported with extrathoracic vein puncture techniques compared with intrathoracic accesses. In particular, extrathoracic lead access through the axillary vein seems to be associated with lower complication incidence than subclavian vein puncture and higher success rate than cephalic vein cutdown. In literature, many techniques have been described for axillary vein access. The use of contrast venography-guided puncture has facilitated the diffusion of the axillary vein approach for device implantation. Venography may be particularly useful in specific demographic and clinical device implantation contexts. Ultrasound-guided or microwire-guided vascular access for lead positioning can be considered a valid alternative to venography, although current applications for axillary vein puncture need further evaluations.

Cephalic vein approach for the implantable central venous access: A retrospective review of the single institution's experiences; Cohort Study

Long-term venous access is usually required in patients receiving chemotherapy. We hypothesized that, out of the various central line approach techniques, the cephalic vein cut-down technique can be a safe and simple alternative in terms of surgical safety, feasibility, cost-effectiveness, and functional outcomes.We retrospectively reviewed the medical records of 569 patients who underwent implantable central venous access between January 2012 and December 2014 at our hospital.We classified our cohort according to access routes, as follows: 230 patients underwent subclavian vein access, 134 patients underwent internal jugular vein access, 25 patients underwent external jugular vein access, and 119 patients underwent cephalic vein access. The cephalic vein group had a significantly longer operation time than the subclavian group (P < .01); however, there was no difference in operation time between the internal jugular vein and cephalic vein groups (P = .59). The procedure-related complications and functional outcomes of the implanted venous port during chemotherapy were comparable between the cephalic group and other groups. Additionally, body mass index, operation time, and age did not correlate with catheter dysfunction in the multivariate logistic regression analysis (P = .53; P = .66; P = .19, respectively).We suggest that a cut-down central venous catheter insertion through the cephalic vein can be performed easily and safely with no differences in surgical and clinical outcomes compared to those of conventional percutaneous approaches. Moreover, the cephalic vein approach requires no specialized equipment, including percutaneous vascular kits, tunneling instruments, and intraoperative ultrasonography. Therefore, this technique might incur less medical expenses than conventional approaches and would be helpful for both patients and surgeons.

Vein Management for Cardiac Device Implantation

Transvenous approaches for pacemaker and defibrillator lead insertion offer numerous advantages over epicardial techniques. Although the cephalic, axillary, and subclavian veins are most commonly used in clinical practice, they each offer their own set of advantages and disadvantages that leave their usage dependent on patient anatomy and physician preference. Alternative methods using the upper and lower venous circulation have been described when these veins are not available or practical for lead insertion. Until current technology is superseded by leadless pacing systems, the search for the optimal lead insertion technique continues.

Permanent Pace Maker Implantation Through Axillary Vein Approach

BACKGROUND

Device implantation is an integral part of interventional cardiology particularly electrophysiology. In this study, we are going to shear our experience of device implantation technique at electrophysiology department Hayatabad Medical Complex, Peshawar.

METHODS

The study was conducted from June 2011 to December 2015. Axillary vein was used to implant the devices but in some cases when this rout was not convenient due to any reason then subclavian vein was entered through the Seldinger technique. Fluoroscopy time was less than 10 minutes and total procedure time was not more than 45 minutes. Electric cautery was used only in two cases. Pressure dressing was used in a few cases.

RESULTS

Total numbers of permanent pacemakers (PPM) remain 800 during the study period. There were 450 single chamber pacemakers and 350 dual chambers pacemakers. No case of any major bleeding was documented and in very few cases there was mild ooze from the procedure site after the operation which was tackled with pressure dressing. Four cases of pneumothorax were noted during the study period and in three cases chest intubation were done and one patient was kept on conservative management. Patient were followed after one moth of discharge from the hospital and then yearly. Eight cases of lead dislodgment were documented during the study period.

CONCLUSIONS

Axillary vein approach for implantation of permanent pacemakers is a safe and less time-consuming technique.

POSTOPERATIVE ARTERIAL RELAXATION AND INTRAOPERATIVE VENOUS DILATION AS INTERCONNECTED PROGNOSTIC FACTORS FOR THE MATURATION OF ARTERIOVENOUS FISTULAS

AIM

To investigate if immediate arterial distention can be used as a predictive factor for the development of a good fistula.

MATERIAL AND METHODS

Over a 5-months period (January- May 2015) all the patients who underwent an arteriovenous fistula between the radial artery and the cephalic vein of the forearm at the Second Surgical Clinic of the Iasi Regional Cancer Institute and were willing to participate were enrolled in the study. The diameters of the vessels were measured 1 hour and 8 weeks after surgery.

RESULTS

We found statistically significant differences for all measured diameter variations between the calcified artery and normal artery groups (p < 0.001 for the arterial distention at 1 hour and 8 weeks after surgery and p = 0.002 for the venous distention 8 weeks after surgery). A linear regression also showed that the degree of arterial distention immediately after surgery and the venous distention 8 weeks after surgery were statistically correlated.

CONCLUSIONS

Arterial distention immediately after surgery and therefore the lack of it due to the presence of arterial calcifications can be used to predict whether or not a good fistula can be achieved at a 1% statistical significance level.

An Initiative Technique to Facilitate Axillary Vein Puncture During CRT Implantation

OBJECTIVES

The aim of the study was to describe a new technique to minimize requirement of contrast and the time to puncture the axillary vein during implantation of cardiac resynchronization therapy (CRT) devices.

BACKGROUND

One of the challenges to the wide applications of CRT has been the technical difficulty encountered while obtaining venous access utilizing axillary venous puncture. This is mainly due to vague anatomical land marks. The axillary vein is the preferred access point because of fewer associated risks and better lead protection in the future.

METHODS

We introduced a 0.035 mm guidewire retrogradely from the femoral vein up to the left axillary vein. A single anteroposterior scene at 7.5 frames/second was captured while the guidewire was in the vein. The scene was kept as a roadmap for the axillary vein puncture during the implantation procedure.

RESULTS

The axillary vein was accessed in all patients (100%) and the time to axillary vein puncture was <1 minute in 36 patients (41%) and between 1-5 minutes in the remaining patients. There were no related vascular complications and no contrast venography was required.

CONCLUSION

The use of retrograde axillary vein wiring simplifies axillary venous puncture and minimizes the need for contrast media during CRT device implantation without compromising visualized anatomy.

Prosthetic axillary-axillary arm loop arteriovenous graft for hemodialysis

AIM

In this study we present our experience with an alternative technique of vascular access for hemodialysis in which a prosthetic graft was placed as subcutaneous arm loop and anastomosed to the axillary artery and vein.

METHODS

Patients included in this study were those with end stage renal disease (ESRD) requiring hemodialysis access who did not have suitable vein to perform autogenous AVF in both upper limbs and Duplex examination revealed unsuitable brachial artery to perform prosthetic brachial-axillary access.

RESULTS

Forty-one patients with ESRD underwent axillary-axillary arm loop AVG for hemodialysis. The primary patency rate at 1 year was 63.4% and at 2 years was 21.8%. The secondary patency rate at 1 year was 75.6% and at 2 years was 43.5%.

CONCLUSION

Axillary-axillary arm loop AVG provides an acceptable option of vascular access for hemodialysis which can be used to recruit all possible configurations in the upper limb before shifting to chest wall options.

[Combined methods of treatment the congenital arterio-venous fistulas of peripheral vessels]

A 10-year experience and results of combined methods of surgical treatment of arterio-venous fistulas of peripheral vessels in 50 patients were analyzed. The patients were systematized on the basis of existing classifications, clinical manifestations of the disease, methods of invasive (ultrasound dopplerography and duplex scanning) and invasive (angiography) examinations. According to many authors no one of conventional methods of surgical treatment of arterio-venous fistulas which are used singly can be effective and must not be recommended as the most optimal. Stepwise employing of traditional operations and endovascular techniques are the main conditions for preventive measures of ischemic disorders in the limbs.

Is ultrasound follow-up necessary in humero-axillary prosthetic arteriovenous fistulas for haemodialysis?

AIM

To evaluate through a specific trial on vascular access fistulas (T-VAF), the impact of intensive follow-up controls on the permeability of humero-axillary fistulas (Hax-AVF).

PATIENTS AND METHOD

Retrospective study. Between January 2005 and December 2009, 108 Hax-AVF were implanted. From June 2007 a T-AVF was established. A preoperative duplex was performed and a follow-up control carried out a month after the intervention and subsequently every 3 months.

RESULTS

An analysis was made of the permeability of 57 Hax-AVF carried out between June 2007 and December 2009 (T-AVF Group), in comparison to 51 interventions performed during the previous 30 months (Control Group). No differences in the permeability achieved were found at 12 and 24 months, with a secondary permeability at 12 months of 49% in the T-AVF Group and 52% in the Control Group. The percentage of patients needing to be re-operated was inferior in the T-AVF Group (35%) than in the Control Group (67%) p=0.02. The re-operation per patient average was lower in the T-AVF Group than in the Control Group (0.49 vs. 1.18 p=0.01). The patients of the TAVF Group underwent a lesser number of re-operations for obstruction as opposed to the Control Group (0.42 vs 1.04 p=0.01).

CONCLUSIONS

In our experience, the intensive follow-up controls did not improve the permeability of the Hax-AVF, although re-operations due to obstruction did diminish. The follow-up of these access fistulas should be clinical based on hemodialysis data, leaving ultrasonographic evaluation for those cases where a malfunction is suspected.

Balloon angioplasty vs nitinol stent placement in the treatment of venous anastomotic stenoses of hemodialysis grafts after surgical thrombectomy

OBJECTIVE

Most arteriovenous hemodialysis grafts fail ≤18 months after implantation, most commonly due to intimal hyperplasia at the venous anastomosis. This open prospective study compared balloon angioplasty vs nitinol stent placement in the treatment of venous anastomotic stenosis after thrombectomy of prosthetic brachial-axillary accesses.

METHODS

Between February 2007 and December 2010, 61 patients with an initial thrombosis of a prosthetic brachial-axillary access were admitted to our hospital. Of these patients, 28 (46%), treated before June 2008, underwent thrombectomy plus balloon angioplasty of the venous anastomosis (group A), whereas the remaining 33 (54%) patients, who were treated after July 2008, underwent graft thrombectomy plus angioplasty with self-expanding nitinol stent placement (group B). Primary, primary-assisted, and secondary patency rates were calculated using Kaplan-Meier analysis and compared between the two groups with the log-rank test.

RESULTS

Primary patency was 32% at 3 months, 24% at 6 months, and 14% at 12 months in group A, and the respective values were 85%, 63% and 49% in group B. Primary patency was significantly better in group B than in group A (P < .001; log-rank test). Cumulative median patency was 60 days in group A and 260 days in group B. Patient age, sex, comorbidities, graft material, and graft age did not have prognostic significance. Primary-assisted and secondary patency rates were significantly higher in group B.

CONCLUSIONS

Graft thrombectomy plus angioplasty with self-expanding nitinol stent placement provides significantly higher patency rates compared with thrombectomy plus plain balloon angioplasty of the venous anastomosis.

Comparison between autogenous brachial-basilic upper arm transposition fistulas and prosthetic brachial-axillary vascular accesses for hemodialysis

AIM

The aim of this paper was to compare the outcomes of patients undergoing autogenous brachial-basilic upper arm transposition fistulas (BBAVF) with prosthetic brachial-axillary vascular accesses (BAPTFE) at immediate and medium follow-up.

METHODS

Retrospective analysis of the aforementioned accesses performed in a single-center from 2003 to 2007. Transposition was used in all BBAVF performed. Conic prostheses were used in the BAPTFE. Primary and secondary patency, patient survival, types of complications and its rates were assessed during follow-up.

RESULTS

Thirty-six BBAVF and 40 BAPTFE were performed. Both groups were well matched for age, gender and comorbidity. BBAVF primary patency was 93.5%, 50.4%, 45.8% and 45.8% compared to 80.6%, 64.3%, 46.2% and 31.6% of the BAPTFE group at 1, 12, 24 and 36 months of follow-up (P=0.719). BBAVF secondary patency was 93.5%, 50.4%, 45.8% and 45.8% compared to 80.6%, 67.7%, 54.2% and 35.1% of the BAPTFE at the same periods (P=0.902). Patient survival was 97.2%, 97.2%, 93.2% and 86.5 for BBAVF in contrast to 97.2%, 94.4%, 84.1% and 79.9% for BAPTFE in the same months (P=0.386). 13.8% of the BBVAF had accessibility problems while only 5% of the BAPTFE presented them (P=0.174). Infection was more frequent in BAPTFE (0% vs 10%), being the only complication near the statistical signification (P=0.071).

CONCLUSION

BBAVF offer patency and accessibility rates similar to BAPTFE, but lower infectious complications. Thus, we consider them as the preferred hemodialysis access when fistulas using the cephalic vein have failed or are not possible.

[Trauma of the brachial plexus and associated vascular injury--a case report]

Acute vascular trauma in the axillary region is usually associated with brachial plexus injury and presents a great challenge to surgeon and formidable obstacle to restore a useful limb function. Interdisciplinary operative and postoperative approach is mandatory providing an optimal care of these severe patients. Here we present a case of neurovascular trauma that affected axillary artery and vein, complete transection associated with complete transection of the brachial plexus. Immediately after admission emergency surgery was performed and in postoperative follow up, after several operations and rehabilitation that continued for 24 months, entire functional recovery was achieved without any disabling consequences.

An approach to ablate and pace:AV junction ablation and pacemaker implantation performed concurrently from the same venous access site

BACKGROUND

Atrioventricular junction (AVJ) ablation combined with permanent pacemaker implantation (the "ablate and pace" approach) remains an acceptable alternative treatment strategy for symptomatic, drug-refractory atrial fibrillation (AF) with rapid ventricular response. This case series describes the feasibility and safety of catheter ablation of the AVJ via a superior vena caval approach performed during concurrent dual-chamber pacemaker implantation.

METHODS

A total of 17 consecutive patients with symptomatic, drug-refractory, paroxysmal AF underwent combined AVJ ablation and dual-chamber pacemaker implantation procedure using a left axillary venous approach. Two separate introducer sheaths were placed into the axillary vein. The first sheath was used for implantation of the pacemaker ventricular lead, which was then connected to the pulse generator. Subsequently, a standard ablation catheter was introduced through the second axillary venous sheath and used for radiofrequency (RF) ablation of the AVJ. After successful ablation, the catheter was withdrawn and the pacemaker atrial lead was advanced through that same sheath and implanted in the right atrium.

RESULTS

Catheter ablation of the AVJ was successfully achieved in all patients. The median number of RF applications required to achieve complete AV block was three (range 1-10). In one patient, AV conduction recovered within the first hour after completion of the procedure, and AVJ ablation was then performed using the conventional femoral venous approach. There were no procedural complications.

CONCLUSION

Catheter ablation of the AVJ can be performed successfully and safely via a superior vena caval approach in patients undergoing concurrent dual-chamber pacemaker implantation.

Using arteriovenous fistulae as a dual access for hemodialysis and total parenteral nutrition administration is feasible with a good outcome: a case series

End stage renal failure patients requiring long term total parenteral nutrition (TPN) often have multiple central line placements due to line infection or occlusion. Sometimes this can cause central venous stenosis or even occlusion. We present three cases in this consecutive series, in which we have successfully used arteriovenous fistulae for both hemodialysis and long term TPN administration as an alternative route without any complications. We therefore think that native AVF and grafts can be used as dual access for hemodialysis and TPN administration provided careful case selection, counselling and follow-up.

Percutaneous placement of a constrained stent for the treatment of dialysis associated arteriovenous graft steal syndrome

Though rare, dialysis associated steal syndrome (DASS) can cause debilitating symptoms. Surgical revision of the dialysis access is typically required. We describe a percutaneous technique to alleviate steal syndrome utilizing a constrained stent within an arteriovenous graft. A brief review of the incidence, pathophysiology, and standard treatment of DASS is also provided.

Navigation by Parallax in Three-Dimensional Space During Fluoroscopy: Application in Guide Wire-Directed AxillarySubclavian Vein Puncture

BACKGROUND

Fluoroscopy is range ambiguous--the relative positions in three-dimensional space of two structures with superimposed silhouettes cannot be ascertained. The parallax effect can be used to overcome this problem, and was used to develop a technique of axillary/subclavian vein puncture.

METHOD

Patients requiring axillary/subclavian vein puncture were considered for the new technique. The vein was marked by a guide wire placed inside. In the postero-anterior (P-A) caudal projection, the needle was advanced dorsally from medial to the coracoid process at an arbitrary angle until its tip overlay the guide wire over the first intercostal space. Depending on whether the needle tip appeared caudad or cephalad of the guide wire in the P-A projection, the needle was advanced farther into or withdrawn back from the body, with its tip maintained over the guide wire in the P-A caudal projection at all times. Maneuvering of the needle stopped when the needle tip overlay the guide wire in both the P-A caudal and P-A projections or blood was aspirated.

RESULT

Forty-one separate successful punctures were performed in 20 patients. No complications were recorded. Each puncture took no more than 1 minute, and the image intensifier needed to swing between the P-A caudal and the P-A projections only twice.

CONCLUSIONS

The new technique was effective, efficient, and safe when implemented in clinical practice, justifying the parallax principles on which it is based. The parallax principles may be applied to other invasive medical procedures with due modifications.

The Effect of the Keyhole Technique on Diabetic Patients Undergoing Autologous Brachiobasilic Transposition of an Arteriovenous Fistula

PURPOSE

Our aim was to investigate the efficiency of the keyhole transposed brachiobasilic technique in patients with diabetes mellitus and compare the effect of different arteriovenous fistula techniques on the development of complications.

MATERIALS AND METHODS

Thirty-eight diabetic, chronic renal failure patients (group 1) had transposed brachiobasilic arteriovenous fistula creations, and 49 diabetic patients (group 2) had other types of fistula creations and histories of multiple fistula attempts. The 2 groups were compared for age, sex, weight, the presence of hypertension and/or diabetes mellitus, other risk factors, arteriovenous fistula patency, and possible complications.

RESULTS

The 2 groups were not different statistically regarding the demographic data including age, sex, weight, the presence of hypertension and/or diabetes mellitus, other risk factors, and mean operation time. The median follow-up after surgery in both groups was 8 months. The primary patency in group 1 was 97.4% in the early period (6 weeks after surgery) and 94.7% in the late period (mean duration of 8 months after surgery). In the second group, these rates were 73% and 62%, respectively (P < .05). The secondary patency rates were 84.2% in group 1 and 53% in group 2 (P < .05). In group 2, the primary and secondary patencies of brachiocephalic and radiocephalic fistulas were significantly lower than the patencies of group 1. The incidence of complications was significantly less in group 1 than in group 2 (P < .05).

CONCLUSION

Although the groups were small in size, the success rate with the keyhole transposed brachiobasilic technique in patients with diabetes was extremely gratifying, and this report can be considered to document the first attempt of a hemodialysis-access procedure.

[The use of intravascular nitinol stents in the treatment of subclavian vein compression for thoracic outlet syndrome]

AIM

The purpose of this study is to evaluate the multimodal treatment (thrombolysis, anticoagulation and surgical decompression) of subclavian-axillary vein thrombosis (Paget-Schroetter syndrome) and possibility of shortening of time of therapy.

MATERIAL AND METHODS

In this paper 23 patients with Paget-Schroetter syndrome in Department of Vascular, General and Transplantological Surgery is presented. Thrombolysis with rt-PA, anticoagulation with heparin and intra venous angioplasty with the use intravascular stent, and operation with resection of the first rib in the treatment of subclavian vein thrombosis was used. During the follow up period the patients were divided into two groups: group I (13 patients) with traditional surgical decompression after 3-4 months (potential risk of hemorage) and group II (10 patients) with early surgical treatment (median 8 days). Long-term follow-up was obtained by chart review and asking patients to complete the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire that was developed by the American Academy of Orthopedic Surgeons.

RESULTS

Complete revascularization with venous thrombolysis was achived in all patients. Decompresion with transaxillary resection of first rib and venous revascularization were performed in the same procedure in all patients. Statistical difference were not found in both groups. Most patients report no disability of upper limb at work and sport activity.

CONCLUSIONS

Multimodal treatment of Paget-Schroetter syndrome (thrombolysis, the use of intravascular stents and early thoracic outlet decompression) can be used as a optimal of therapeutic method to subclavian vein thrombosis. The advantages of immediate surgical treatment are a promotion of rapid resumption of athletic activities.

Ultrasound-Guided Venous Access for Permanent Pacemaker Leads

BACKGROUND

Existing methods of venous access for permanent pacemaker leads have disadvantages. We documented learning times for ultrasound-guided lead implantation and compared them with cephalic venotomy technique.

METHODS

Two implanters learnt ultrasound-guided technique by implanting consecutive pacemaker patients. When procedural times stabilized, we reverted to our normal cephalic approach. We measured lead placement time and screening time from skin incision until all leads were placed in superior vena cava were measured.

RESULTS

Initial strategy adopted was ultrasound for 60, then cephalic for 38 patients. There were no significant differences between groups in baseline characteristics or number of leads implanted. Lead placement and screening times were significantly shorter for ultrasound, despite inclusion of all learning cases. There was a high success rate for both strategies (88% ultrasound, 87% cephalic). There was significantly greater use of pressure dressings with ultrasound, but no difference in pocket hematoma or pneumothorax. There was a trend for more predictable lead implant times with ultrasound and fluoroscopy times were shorter and more predictable. Independent predictors of lead placement time were body mass index, operator, initial strategy (ultrasound vs cephalic), and procedure number.

CONCLUSION

Ultrasound-guided venepuncture for placement of permanent pacing leads is quick to learn and achieves faster lead placement times with shorter and more predictable fluoroscopy time when compared with the cephalic venotomy technique.

Preoperative Radiological Assessment for Vascular Access

There is increasing evidence that routine preoperative duplex scanning ultrasound cannot only increase the utilisation of native AVF for dialysis access but also allow proper selection of a target vessel with adequate luminal diameter to improve outcome. A minimum arterial diameter of 2mm is associated with successful fistula formation. A threshold for minimal venous diameter is difficult to establish. Most clinical studies use a value of 2.5mm for AVF and 4mm for prosthetic grafts. Traditional contrast venography is mandatory where there is suspicion of central vein stenosis. In predialysis patients where there is a risk of contrast nephropathy MR venography is emerging as a possible alternative.

The Brachial Artery-basilic Vein Arterio-venous Fistula in Vascular Access for Haemodialysis—A Review Paper

AIMS

To review the available literature regarding patency rates and complications of the brachial-basilic arterio-venous fistula (BBAVF) and to discuss this with relation to the current dialysis outcomes quality initiative guidelines.

METHODS

An internet based literature search was performed using Pubmed, Medline and Medscape databases to identify all published reports of the BBAVF in the English language from which the full articles were retrieved and cross-referenced.

RESULTS

Of 136 papers identified, 28 were directly relevant to this review including four prospective studies (one randomised trial, three non-randomised trials) and 24 retrospective studies. First described by Dagher in 1976, the BBAVF has since been modified to a two-stage procedure with initial fistula formation followed by superficialisation of the basilic vein 6 weeks later. It can be formed successfully in 95% of cases. Mean 1-year primary and secondary patency rates were 72 and 74.6%, respectively. Complications included haematoma (3.8%), stenosis (2.3%), thrombosis (9.7%), transient arm oedema (3.7%), steal syndrome (2.9%) and aneurysm/pseudoaneurysm formation (1.9%). The BBAVF had a lower rate of infection than prosthetic fistulas (3.6 vs. 16%).

CONCLUSIONS

The BBAVF has good primary and secondary patency rates with lower rates of infection than prosthetic fistulas making it a preferred secondary access procedure.

Occluded Brescia–Cimino Hemodialysis Fistulas: Endovascular Treatment with Both Brachial Arterial and Venous Access Using the Pull-Through Technique

We retrospectively evaluated the usefulness of both arterial and venous access with the pull-through technique in endovascular treatment of totally occluded Brescia-Cimino fistulas. We treated 26 patients (17 men, 9 women; age range 43-82 years, mean age 66 years) with occluded Brescia-Cimino fistulas. First, the occluded segment was traversed from the antegrade brachial arterial access using a microcatheter-guidewire system. Second, the vein was retrogradely punctured after confirmation of all diseased segments, and a 0.014- or 0.016-inch guidewire was pulled through the venous access when the occluded segment was long. All interventions including thrombolysis, thromboaspiration, angioplasty, and stent placement were performed via the venous access. The occlusion was successfully crossed via the brachial arterial access in 23 patients (88%). In 2 patients it was done from the venous approach. In the remaining patient it was not possible to traverse the occluded segment. The pull-through technique was successful in all 19 attempts. Clinical success was achieved in 96%, the primary patency rates at 6, 12, and 18 months were 83%, 78%, and 69%, the primary assisted patency rates were 92%, 92%, and 72%, and the secondary patency rates were 92%, 92%, and 92%, respectively. Minor complications in 5 patients included venous perforation in 2 (8%), venous rupture in 1 (4%), and regional hematoma in 2 (8%). Our study suggests that endovascular treatments with both arterial and venous access using the pull-through technique are highly effective in restoring function in totally occluded Brescia-Cimino fistulas.

Placement of the VenaTech LP Caval Filter in the Elderly: Feasibility and Clinical Benefits of Insertion Via the Arm

PURPOSE

To evaluate routine use of access sites in the arm for percutaneous caval filter placement (PCFP) in elderly patients. Neck arthritis, patient anxiety, access site thrombosis or fecal/urinary incontinence complicating jugular or femoral access may require alternative access sites in this population.

METHODS

Access via the right arm was chosen for PCFP (VenaTech LP). The indication for PCFP was deep vein thrombosis, a history of pulmonary embolism, and a contraindication to anticoagulant therapy. Ultrasound-guided puncture was performed after diameter measurement of the arm veins (ØAV). The filter was inserted with standard imaging procedures. Procedural difficulty was graded and compared with ØAV and the angle from the arm vein to the superior vena cava (alphaAV/SVC).

RESULTS

Over 2 years, 16 patients (14 women, 2 men) with an average age of 90 years (range 79-97 years) were included in the study. The average ØAV value of the basilic or brachial veins was 4.2 mm (range 3.0-5.1 mm). The minimal ØAV for successful access was determined after the first 15 patients. No hematoma occurred at the puncture sites. The average alphaAV/SVC value was 62 degrees (range 29 degrees -90 degrees ). Arm access was possible in 12 of 16 patients (75%) with ØAV >or= 3.5 mm and alphaAV/SVC >or= 29 degrees . Every procedure via the arm was graded "easy" by the operator, regardless of angulation values. Femoral access was used in one case due to the impossibility of traversing the heart (patient no. 2), and jugular access was used in 3 of 16 (19%) patients due to puncture failure (patient no. 4), small ØAV (3 mm) (patient no. 6), and stenosis of the distal right subclavian vein (patient no.16), respectively.

CONCLUSION

PCFP via the arm can be routinely accomplished in patients older than 75 years, provided ØAV >or= 3.5 mm, and alphaAV/SVC >or= 29 degrees .

Occlusion of subclavian-innominate veins: the increasing problem of receiving improper care

Acute upper vein obstruction necessitates emergency treatment and always requires surgery. However, it is not treated appropriately most of the time. Leaving this condition untreated, or treating it incorrectly, can result in permanent disability of the patient, as well as malpractice and negligence lawsuits against the treating physicians. Thus, all physicians must be familiar with the proper care of acute upper vein obstruction. We provide in this article an easy-to-follow algorithm and an outline of steps for successful treatment. We also discuss two situations that should not be confused: 1) the acute event involving the axillary-subclavian-innominate vein, which is called effort thrombosis or Paget-Schroetter syndrome, and 2) the chronic, more extensive obstruction caused by the intravenous placement of intraluminal devices.

Axillary to saphenous vein bypass for treatment of central venous obstruction in patients receiving dialysis

OBJECTIVE

Venous hypertension due to subclavian or innominate vein stenosis coexisting with a functioning arteriovenous access in the ipsilateral arm is a complex problem in patients undergoing hemodialysis. Therapeutic solutions must optimally relieve symptoms, permit use of the angioaccess, and carry minimal surgical risk. The purpose of this study was to evaluate a simple surgical option, bypassing central venous obstruction to the great saphenous vein.

METHODS

Eight patients undergoing hemodialysis with severe symptoms and signs of venous hypertension due to subclavian or innominate vein obstruction and ipsilateral arteriovenous fistula or graft underwent axillosaphenous bypass via a subcutaneous 8-mm polytetrafluoroethylene bridge graft.

RESULTS

No intraoperative or immediate postoperative morbidity was observed. Early and 6-month patency rates were 100% and 87.5%, respectively. All patients reported improvement of symptoms, and the angioaccess was usable in all cases. Average follow-up was 21.5 months. One patient had a relapse at 5 months, which necessitated revision of the graft-saphenous vein anastomosis.

CONCLUSION

Bypassing a central vein occlusion to the saphenous vein relieves symptoms of venous hypertension and prolongs use of the hemodialysis angioaccess.

Outcome after autogenous brachial-axillary translocated superficial femoropopliteal vein hemodialysis access

OBJECTIVE

The optimal configuration for patients with "complex" or "tertiary" hemodialysis access needs remains undefined. This study was designed to examine the utility of the autogenous brachial-axillary translocated superficial femoropopliteal vein access (SFV ACCESS) in this subset of patients.

METHODS

Patients presenting for permanent hemodialysis access without a suitable upper extremity vein for autogenous access identified by duplex ultrasound mapping and those with repeated prosthetic access failures were considered candidates for SFV ACCESS. Ankle-brachial indices were obtained, and duplex scanning of the superficial femoropopliteal and saphenous veins was performed. Patients deemed candidates for SFV ACCESS also underwent preoperative upper extremity arteriography and venography. A retrospective review of the complete medical record was performed, and a follow-up telephone or personal interview was conducted.

RESULTS

Thirty patients (mean age +/- SD, 54 +/- 15 years; male, 33%; white, 37%; with diabetes, 50%; obese, 21%) underwent SFV ACCESS among approximately 650 access-related open surgical procedures during the study period. The patients had been receiving dialysis for 4 +/- 5 years (range, 0-24 years), and had 3 +/- 3 (range, 0-17) prior permanent accesses, whereas 90% were actively dialyzed through tunneled catheters. In-hospital 30-day mortality was 3%, and the hospital length of stay was 7 +/- 7 days. Fifty-seven percent of the patients experienced some type of perioperative complication, and 38% required a remedial surgical procedure. Hand ischemia developed in 43% of the patients (severity grade: 1, 10%; 2, 7%; 3, 27%), and a distal revascularization, interval ligation was performed in all those with grade 3 ischemia. Thigh wound complications or hematomas developed in 23% of the patients, and arm wound complications or hematomas developed in 17%. The incidence of thigh wound complications was significantly greater (57% vs 9%; P =.03) in obese patients, but the other perioperative complications analyzed could not be predicted on the basis of age, gender, or comorbid conditions. The SFV ACCESS was cannulated 7 +/- 1 weeks postoperatively. The primary, primary assisted, and secondary patency rates were 96% +/- 4%, 100% +/- 0%, and 100% +/- 0%, respectively, at 6 months; 79% +/- 8%, 91% +/- 6%, and 100% +/- 0%, respectively, at 12 months; and 67% +/- 13%, 86% +/- 9%, and 100% +/- 0%, respectively, at 18 months (life table analysis; % +/- SE).

CONCLUSIONS

The intermediate term functional patency rate after SFV ACCESS is excellent, although the magnitude of the procedure and the complication rate are significant. SFV ACCESS should only be considered in patients with limited access options.

Locating the axillary vein and preserving the medial pectoral nerve

The exposure for an axillary dissection has become more limited as surgical treatment for breast cancer has evolved from a radical mastectomy to a limited axillary dissection. Exposure of the axillary vein is made more difficult by the smaller incisions, by preservation of intercostobrachial nerves, and by the induration resulting from a previous sentinel node biopsy. To assist in the identification of the axillary vein, I describe the course of a visible but small vein adjacent to the medial pectoral nerve. The vein can be easily identified at the lateral edge of the pectoralis major. It, frequently together with the medial pectoral nerve, traverses in a craniomedial direction and leads to either the lateral thoracic vein (near its junction with the axillary vein) or directly to the axillary vein. Dissection of this vessel identifies the axillary vein, preserves the medial pectoral nerve and allows a more complete and safe level II dissection.

Current management of Paget-Schroetter syndrome in the UK

INTRODUCTION

Untreated symptomatic patients with Paget-Schroetter syndrome (PSS) can sustain chronic disability from venous obstruction, with arm swelling, pain and early exercise fatigue. This may result in significant loss of occupational productivity and quality of life. For this reason, active management is recommended in the majority of the recent literature. The objective of the this study was to assess current trends of management of PSS in the UK.

METHODS

A 9-part questionnaire was sent to 90 ordinary members of the Vascular Surgical Society of Great Britain and Ireland (VSS-GBI). Names and addresses were selected by highlighting every fourth ordinary member from the UK, in the 2000 VSS-GBI handbook. Ordinary members of the VSS-GBI who were clearly radiologists were excluded.

RESULTS

Of the 90 questionnaires sent, 60 were returned (66.67%). The majority of respondents used both duplex and venography (61%) as the major investigative tools though some employed duplex only (17%). Multimodality treatment (radiological and operative) was the favoured approach. Only 17% still favoured conservative management alone. Thrombolysis was the most common intervention (86.7%) usually followed by elective thoracic outlet decompression. Most favoured a delayed approach for surgery of 6-12 weeks. First rib resection was the most commonly performed operation (58%), usually by the transaxillary approach (55%). Most of the respondents were doubtful of the role of stenting in this condition and did not use it.

CONCLUSIONS

There is no definite consensus on treatment of this condition in the UK. A majority tend to favour a multimodal approach. Thrombolysis is the most common form of treatment employed and first rib resection via the transaxillary approach remains the most popular surgical procedure. The lack of consensus of this potentially disabling condition highlights the need for randomised clinical trials to guide management.

Evaluation of Safety and Efficacy of Pacemaker and Defibrillator Implantation by Axillary Incision in Pediatric Patients

We successfully implanted 11 pacemakers, 6 defibrillators, and 1 biventricular pacemaker in 18 pediatric patients (15 female; 4 to 15 years, average age: 9) using the retropectoral transvenous approach with a hidden axillary incision. The average follow-up period was 24 months (range 49 months). Eight patients had congenital structural heart conditions (d-transposition of great arteries S/P Mustard operation, d-transposition of great arteries S/P arterial switch operation, truncus arteriosus, right ventricular diverticula, ventricular septal defect, hypertrophic cardiomyopathy). Four patients had acquired heart conditions (dilated cardiomyopathy, myocarditis). Excellent sensing and pacing thresholds were achieved in all attempted implantations. There was no pneumothorax. There was one lead dislodgement. One lead fracture distant from the subclavian vein occurred 4 months after implantation. Implantation of pacemakers and defibrillators via axillary incisions can be safe and effective in pediatric patients. This approach avoids skin erosion when implanting large devices such as defibrillators or biventricular devices in small patients with limited muscle mass while achieving superior aesthetic results. The axillary or extrathoracic venous entry site avoids subclavian crush syndrome.

Left Ventricular Endocardial Lead Placement Using a Modified Transseptal Approach

Coronary sinus cannulation and placement of left ventricular (LV) leads can be difficult. Occasionally alternative approaches are required. We report the first case of a modified transseptal LV endocardial lead placement via the left axillary vein for cardiac resynchronization.

Long-term Outcomes of Brachiobasilic Transposition Fistula for Haemodialysis

OBJECTIVES

The transposed basilic vein to brachial artery arteriovenous fistula provides secondary vascular access for haemodialysis. The long-term results of such fistula are assessed in this retrospective series.

MATERIAL AND METHODS

Over a 5-year period 75 brachiobasilic transposition fistulae were performed in 74 patients. There was a median follow up of 14 months.

RESULTS

Primary patency was achieved in 69 (92%) of the fistulae, and secondary patency in 74 (99%) of the fistulae. Successful interventions included angioplasties in four, and saphenous vein interposition in one, whilst three patients had failed thrombectomies. Dialysis was performed using 69 (92%) of the fistulae while 6 (8%) were never used. Of the 75 fistulae 47 (63%) were patent at follow up. Cumulative secondary patency was 66% at 1 year, 52% at 2 years, and 43% at 3 years. Complications developed in 41 (55%), and included thrombosis, infection, stenosis, arm oedema, bleeding, steal syndrome and microaneurysm formation.

CONCLUSIONS

Brachiobasilic transposition fistulae have good long-term patency rates. The complication rate, although high, is lower than that reported for PTFE grafts. Brachiobasilic fistulae should be used in preference to PTFE grafts for secondary access.

[Does venous thrombectomy still play a role in the treatment of Paget-von-Schroetter-Syndrome?]

In a retrospective study we reviewed 24 patients treated by venous thrombectomy for acute thrombosis of the axillary vein during the past 23 years. We performed 25 venous thrombectomies without any complications. Complete recanalisation could be achieved in all cases of acute thrombosis. Whereas similar clinical results can be achieved by thrombolytic therapy, complete recanalisation by thrombolytic therapy is only achieved in 60% of cases.

Paget-Schroetter syndrome therapy: failure of intravenous stents

BACKGROUND

The purpose of this study is to show that intravenous stents (IS) are contraindicated in patients with thrombosis of the axillary-subclavian vein (Paget-Schroetter syndrome).

METHODS

Twenty-two patients had IS placed after balloon dilatation of the venous compression in the thoracic outlet. Each of the patients receiving IS had the diagnosis made less than 6 weeks after vein occlusion, previous thrombolytic therapy, and poststent anticoagulants. (All were performed in outside hospitals. In no case was surgical decompression of the "externally constricted venous tunnel" performed.) The 22 patients receiving IS were compared with a similar group of 384 patients seen less than 6 weeks after thrombosis who were treated with "optimal therapy," ie, thrombolysis and prompt transaxillary resection of the first rib with venous tunnel decompression.

RESULTS

All 22 patients with IS reoccluded their axillary-subclavian vein from 1 day to 6 weeks after insertion. All were retreated with thrombolytic therapy and first rib resection. Ten remained patent and 7 remained occluded but developed adequate collateral circulation. All 17 were asymptomatic. Five remained occluded with minimal collateral circulation. Attempts were made to reopen them a third time. All 5 are receiving long-term anticoagulants. In contrast the 384 patients managed with optimal therapy were significantly improved without retreatment or anticoagulants.

CONCLUSIONS

From our study, there is no indication for use of IS in patients with Paget-Schroetter syndrome; in fact, from our experience it is contraindicated when compared with the optimal therapy group. Other authors corroborate this conclusion in recent review articles.

Treatment of steal syndrome complicating a proximal arteriovenous bridge graft fistula by simple distal artery ligation without revascularization using intraoperative pressure measurements

This case report describes the treatment of a patient with a steal syndrome complicating a brachioaxillary prosthetic bridge graft AV fistula by simple ligation of the brachial artery beyond the fistula. Intraoperative pressure measurements showed concomitant distal revascularization to be unnecessary.

Improved patency of prosthetic arteriovenous grafts with an acute anastomotic angle and flow diffuser

OBJECTIVE

Conventional end-to-side anastomosis to establish venous outflow for prosthetic arteriovenous grafts often requires operative patch angioplasty within 1 year because of venous stenosis. Rather than conventional venous anastomosis, a modified end-to-side anastomosis at a 15-degree angle with a flow diffuser was constructed. Such diffusers allow decreased flow velocity and increased pressure, inhibiting boundary layer separation.

METHODS

Ten brachial artery to axillary vein 6 mm straight se-polytetrafluoroethylene prosthetic arteriovenous grafts were created with this technique. Patients included 6 men and 4 women (mean age, 66.4 years; range, 54-80 years), all with renal failure and a history of diabetes. The degree of stenosis at the venous anastomosis was determined with duplex scanning at intervals of 6 months. Analysis of survival and cumulative primary patency estimates were determined with the Kaplan-Meier method.

RESULTS

Primary cumulative patency estimate of 100% for the modified group at 18 and 24 months was significantly greater than that for age-matched historic control fistulas with the conventional end-to-side anastomosis (n = 20): 18 months, 32%; 24 months, 32% (P <.05). Although venous stenosis could not be quantitated for thrombosed conventional fistulas, modified anastomoses had minimal stenosis at 24 months: mean area reduction, 30% (range, 20%-45%).

CONCLUSION

Incorporation of a flow diffuser and a 15-degree anastomotic angle significantly increases patency of prosthetic brachial artery to axillary vein grafts.

Brachiobasilic arteriovenous fistula: different surgical techniques and their effects on fistula patency and dialysis-related complications

OBJECTIVE

Easy access to the vascular system is vital in patients with chronic renal failure undergoing long-term hemodialysis. Such patients often require multiple operations, and options for secondary or tertiary access procedures become increasingly limited. Brachiobasilic arteriovenous fistula offers excellent access in such difficult cases and is increasingly preferred over prosthetic grafts. Many surgical techniques have been described to create such fistulas. The purpose of this study was to determine the difference in long-term patency and dialysis-related complications among various techniques.

METHODS

Seventy brachiobasilic arteriovenous fistulas were constructed in 70 patients. This was the secondary or tertiary access in 88.6% of patients. The basilic vein was transposed in 30 patients and elevated in 40 patients; twenty veins were elevated with a one-stage technique, and 20 were elevated with a two-stage (delayed elevation) technique.

RESULTS

The early failure rate was 5.7% in the entire group. Sixty-six fistulas (94.3%) were successfully used for dialysis. Mean follow-up was 25.8 months (range, 4-36 months). Four fistulas (5.7%) required additional procedures during follow-up, 2 in the transposed vein group and 2 in the elevated vein group. Cumulative secondary patency rate, measured with the Kaplan-Meier survival method, was 86.7%, 90%, and 84.2% at 1 year for the transposed, one-stage, and two-stage elevation procedures, respectively, compared with 82.8%, 70%, and 68.4% at 2 years. The difference was statistically nonsignificant. Forty-two complications developed in 29 (43.9%) fistulas. Thirteen fistulas (19.7%) had more than one complication. Twelve complications in 10 fistulas (35.7%) were recorded in the transposition group, 15 complications in 9 fistulas (47.4%) in the one-stage elevation group, and 15 complications in 10 fistulas (52.6%) in the two-stage elevation group. The total complication rate was higher in the elevated fistulas (71.4% vs 28.6%); the difference was statistically highly significant (P <.001). The most common complication was arm edema (21.2%; n = 14), followed by puncture site-related hematoma (16.7%; n = 11) and thrombosis (16.7%; n = 11). Hematoma was statistically more common (P <.05) in the elevated vein group (26.3% vs 3.6%). The difference in thrombosis between the transposition and elevation groups (23.7% vs 7.1%) was not significant. Hematoma preceded thrombosis in 63.7% (7 of 11) of the fistulas, and it was the major predisposing factor for fistula failure. Transposed vein was easier to manage by dialysis staff. All nurses were satisfied with the transposed veins, but only 53.3% were satisfied with the elevated veins; the difference was statistically highly significant (P <.001).

CONCLUSION

Available techniques for creating brachiobasilic arteriovenous fistula are associated with good patency rate, and most related complications can be treated conservatively without loss of the fistula. Among the various procedures, transposition has a lower complication rate and is favored by the dialysis staff dealing with such fistulas.

Free flap transfer to the dorsum of the rat: a new technique to avoid autocannibalization in free flap studies

In this report the authors describe a new method that avoids autocannibalization by free transfer of a flap to the dorsum of the rat by means of a simple exposure technique. A total of 22 Wistar rats of both sexes (weight, 200-290 g) were used in this experiment. An anatomic study performed in 12 rats revealed that a wide exposure could be created in the axillary fossa by retracting the inferior tip of the scapular bone superiorly (after severing its attachments with the deep extrinsic back muscles), the latissimus dorsi muscle laterally, and the serratus anterior muscle medially. Furthermore, after obtaining vessel diameter measurements, it was ascertained that the subscapular and the lateral thoracic vessels could serve as the recipient vessels. Based on the anatomic study, a total of 10 conventional groin cutaneous flaps, measuring 2 x 3 cm in size, were harvested based on the femoral vessels and transferred to the dorsum of the same animal by the exposure method as just described, with microvascular anastomoses performed between the femoral vessels of the flap and either the subscapular artery and the lateral thoracic vein (N = 5) or the lateral thoracic artery and vein (N = 5). Results showed that 9 of the 10 transplanted flaps were totally viable on postoperative day 7, giving a success rate of 90%, with one failing flap belonging to the latter group. The authors conclude that by this simple method of recipient vessel exposure in the axillary fossa, free flap transfer to the dorsum of the rat is a simple and reproducible technique by microvascular anastomoses performed between the pedicle vessels of a flap and the subscapular artery and the lateral thoracic vein. This model offers the unique advantage of a dorsally located flap that is protected by autocannibalization. Moreover, daily observation and monitoring of the flap are easy and practical without the need to have the animal wear protective material such as vest.

Endoluminal repair of axillary artery and vein rupture after reduction of shoulder dislocation. A case report

A case of endoluminal repair of vein and artery axillary rupture after reduction of shoulder dislocation in an 83-year-old woman is reported. The lesions were repaired successfully with two cover stents (JOSTENT and Passager). Endovascular treatment of such vascular injuries seems to be feasible and safe, though further investigation is warranted.

Simultaneous bilateral upper extremity venous thrombosis in a factor V Leiden heterozygote: a case report and review

Primary upper extremity deep venous thrombosis (DVT), or effort thrombosis, typically occurs in young, healthy individuals with a history of repetitive upper extremity movement while secondary upper extremity DVT is associated with a number of predisposing factors. The role of factors such as hypercoagulability in the development of effort thrombosis is less well described. This report describes a previously healthy 21-year-old man who presented with simultaneous bilateral upper extremity DVT after hours of pushing and lifting a heavy wheelbarrow. Treatment included thrombolytic therapy followed by delayed venolysis and vein patch angioplasty. Hypercoagulable screening revealed factor V Leiden heterozygous characteristics.