Alternative grafts for brachioaxillary hemodialysis access: 1-year comparative results

BACKGROUND: Many chronic renal patients lack autologous veins in the upper limbs suitable for construction of arteriovenous fistulas for hemodialysis. Alternative fistula options for these patients should be evaluated and compared.OBJECTIVE: To compare different types of grafts used for brachioaxillary access in hemodialysis patients in terms of their patency and complication rates.METHOD: Forty-nine patients free from arterial system abnormalities and with no venous options for creation of arteriovenous fistulae in the arm and/or forearm underwent brachioaxillary bypass with implantation of autologous saphenous vein, polytetrafluoroethylene (PTFE), or PROPATEN(r) grafts. Patients were assessed by Doppler ultrasonography at 3, 6, and 12 months after surgery. RESULTS: The four first saphenous vein grafts had failed by 3 or 6 months after surgery. The autologous saphenous vein group was discontinued at the beginning of the study because of extreme difficulty in achieving puncture and hematoma formation. Failure rates of PTFE and PROPATEN(r) grafts did not differ after 3 (p = 0.559), 6 (p = 0.920), or 12 months (p = 0.514). A log-rank test applied to cumulative survival of grafts at 1 year (0.69 for PTFE, 0.79 for PROPATEN(r)) detected no significant differences (p = 0.938). There were no differences in complications resulting in graft failure between the two types of prosthetic graft.CONCLUSION: Autologous saphenous vein grafts do not appear to be a good option for brachioaxillary hemodialysis access because of difficulties with achieving puncture. Brachioaxillary fistulae constructed using PTFE or PROPATEN(r) grafts exhibited similar patency and complication rates. Further studies with large samples size are warranted to confirm our findings.

CONTEXTO: Há inúmeros pacientes renais crônicos sem veias autólogas nos membros superiores para confecção de fístulas arteriovenosas para realização de hemodiálise. As opções de fístula nestes pacientes devem ser avaliadas e comparadas.OBJETIVO: Comparar diferentes enxertos para acesso braquioaxilar em pacientes hemodialíticos, em relação a permeabilidade e taxas de complicação. MÉTODO: Um grupo de 49 pacientes, sem alterações no sistema arterial e sem opções venosas para criação de fístula arteriovenosa no braço e/ou antebraço, foi submetido a procedimentos cirúrgicos para implante de diferentes enxertos: veia safena autóloga, enxertos de PTFE e PROPATEN(r).RESULTADOS: Os quatro primeiros implantes de veia safena falharam no terceiro e no sexto mês após a cirurgia. Interrompeu-se o uso de veia safena autóloga no início do estudo pela extrema dificuldade de punção e pela formação de hematoma. Não houve diferenças nas taxas de falha dos enxertos de PTFE e PROPATEN(r) após três (p = 0,559), seis (p = 0,920) e 12 meses (p = 0,514) de seguimento. O teste de Logrank aplicado à sobrevida cumulativa dos enxertos por um ano (0,68 para PTFE; 0,79 para PROPATEN(r)) não relevou diferenças (p = 0,938). Não foram encontradas diferenças entre os enxertos prostéticos em relação ao tipo de complicação que determinou as falhas.CONCLUSÃO: O enxerto de veia safena autóloga parece não ser é uma boa opção para acesso braquioaxilar em hemodialíticos, já que implica em dificuldade na punção. Os enxertos de PTFE e PROPATEN(r) em fistula braquioaxilar resultaram em permeabilidade e taxas de complicações similares. Estudos com amostras maiores são necessários para confirmar nossos achados.

Anomalous origin of the deep brachial artery (profunda brachii) observed in bilateral arms: case report / Origem anômala da artéria braquial profunda (profunda brachii) observada em braços bilaterais: relato de caso

During an ordinary dissection, a cadaver showed a bilateral anomalous origin of the deep brachial artery, where this vessel appeared like a branching of the subscapular artery with common trunk, which included the posterior circumflex humeral artery. The course and distribution of the deep brachial artery in the back compartment were relatively consistent with previous reports. Arterial variations can be damaged through iatrogenic means if not properly documented. The knowledge of this case is very important in clinical medicine and in surgeries in this compartment to prevent any injury.

Durante dissecação em prática usual, um cadáver apresentou origem anômala da artéria braquial profunda, na qual este vaso apareceu como um ramo da artéria subescapular com um tronco comum, que incluiu a artéria circunflexa posterior do úmero. O curso e a distribuição da artéria braquial profunda no compartimento posterior foram relativamente coincidentes com relatos prévios. Variações arteriais podem ser danificadas de maneira iatrogênica se não forem adequadamente documentadas. O conhecimento desse caso é muito importante na prática clínica e em cirurgias nesse compartimento para prevenção de qualquer injúria.

Cateterismo cardíaco por acceso radial percutáneo en pacientes con disección humeral previa / Transradial percutaneous approach for cardiac catheterization in patients with previous brachial artery cutdown

La punción percutánea de la arteria radial para la realización de procedimientos por cateterismo ha ganado mayor aceptación en los últimos tiempos. Esto sucedió como consecuencia de haber alcanzado resultados similares a los obtenidos mediante el acceso femoral, con los beneficios de una menor tasa de complicaciones y mayor confort de los pacientes. Recientemente, su utilización tomó un impulso adicional, por estar asociada a mejor pronóstico en síndromes coronarios agudos. En el presente trabajo hemos evaluado si la factibilidad, resultados y ventajas relacionadas al acceso percutáneo de la arteria radial en procedimientos por cateterismo, se aplican también a quienes presentan disección previa de la arteria humeral. Sobre un total de 1 356 accesos radiales percutáneos, 53 fueron en pacientes con disección previa de la arteria humeral, obteniéndose éxito del acceso en el 96.2% (51/53) de las punciones. A través de estos accesos se realizaron 71 procedimientos por cateterismo, con 93.6% (44/47) de éxito del procedimiento en las intervenciones diagnósticas y 100% (24/24) en las terapéuticas. En este grupo no ocurrieron complicaciones mayores. Las complicaciones menores sucedieron en el 1.4% (1/71) de los casos y no se registraron nuevas complicaciones en el seguimiento a siete días. Si bien el grupo es pequeño, consideramos que resulta suficiente para mostrar que las punciones percutáneas de la arteria radial para la realización de procedimientos por cateterismo, en pacientes con disección previa de la arteria humeral, son factibles y permiten elevadas tasas de éxito con baja frecuencia de complicaciones.

The percutaneous punction of the radial artery for catheterization procedures has gained acceptance lately. This was a consequence of achieving results similar to the femoral approach, with the benefits of a lower rate of complications and increased comfort for the patients post procedure. Recently it has gained an additional impulse with the better prognosis obtained in acute coronary syndromes. In this trial we have evaluated if the feasibility, results and advantages related with the use of the radial artery percutaneous approach to perform catheterization procedures, continues when used in patients who have had a previous brachial artery cutdown. Out of a total of 1356 percutaneous radial accesses, 53 were in patients with previous brachial artery cutdown. Through this access 71 catheterization procedures were performed, achieving access success in 96.2% (51/53) of the punctions. Once the access success was obtained, 93.6% (44/47) of the diagnostic procedures and 100% (24/24) of the therapeutics procedures were successful. During hospitalization, in this group of patients, no major adverse cardiac events occurred and there was a 1.4% (1/71) rate of minor events. At seven days follow up, no new complications were recorded. Although this is a small group, we believe that it is enough to show that percutaneous punctions of the radial artery to perform catheterization procedures, in patients with previous brachial artery cutdown, are feasible, allowing high access and procedure success rates, with a low frequency of complications.

Brachiobasilic fistula with anterior transposition, a workable solution in difficult clinical situations

This study was undertaken to assess the role of brachio-basilic fistulae with anterior transposition in patients with unsuitable veins for formation of conventional AV fistulae or after failure of multiple fistulae. Descriptive study. Armed Forces Institute of Urology and Military Hospital Rawalpindi, from November 2007 to October 2009. Patients of CKD with unsuitable veins for the formation of conventional AV fistula and those with failed Radiocephalic and Brachiocephalic fistulae in whom Brachio-basilic fistula was formed, were included in the study. Patients unfit for general anesthesia and those with upper arm Prosthetic grafts were excluded. The patients were interviewed, examined with particular attention to vascular access and a complete data about their hemodialysis and previous vascular access was collected. Transposed Brachio-basilic fistulae were created in 38 patients of End Stage Renal Disease [ESRD] during study period; out of which 1 patient was lost during followup and the rest 37 were followed prospectively. The median duration of follow-up was 13.56 months [SD +6.03] with a range of 3 to 23 months. In 92% of cases transposed Brachio-basilic fistula was created after failure of one or more conventional fistulae. Complications were noted in 16.2% cases which included primary failure, wound infection, arm swelling and distal ischemia as a result of steal phenomena [Table]. Three patients died during this period. Life of fistulae ranged from primary failure to as long as 23 months. Transposed brachio-basilic fistula is a viable option for patients who do not have suitable vasculature for formation of conventional fistula but especially for those after failure of fistulae at other sites

Neurovascular injuries following displaced proximal humerus fractures: case reports and review of literature

Displaced fractures of the proximal part of the humerus with injury of the brachial plexus are not very common. We present two cases of displaced proximal fracture of humerus with median nerve damage. Both the cases were having vascular injuries as welt. One case had injury to profunda brachii artery which was ligated while the other presented with absent radial pulse. Neural injuries were treated conservatively with good functional results

The superficial ulnar artery: development and clinical significance

The principal arteries of the upper limb show a wide range of variation that is of considerable interest to orthopedic surgeons, plastic surgeons, radiologists and anatomists. We present here a case of superficial ulnar artery found during the routine dissection of right upper limb of a 50-year-old male cadaver. The superficial ulnar artery originated from the brachial artery, crossed the median nerve anteriorly and ran lateral to this nerve and the brachial artery. The superficial ulnar artery in the arm gave rise to a narrow muscular branch to the biceps brachii. At the elbow level the artery ran superficial to the bicipital aponeurosis where it was crossed by the median cubital vein. It then ran downward and medially superficial to the forearm flexor muscles, and then downward to enter the hand. At the palm, it formed the superficial and deep palmar arches together with the branches of the radial artery. The presence of a superficial ulnar artery is clinically important when raising forearm flaps in reconstructive surgery. The embryology and clinical significance of the variation are discussed.

As principais artérias do membro superior apresentam uma ampla variação, que é relativamente importante a cirurgiões ortopédicos e plásticos, radiologistas e anatomistas.Apresentamosumcaso de artéria ulnar superficial encontrada durante dissecção de rotina de membro superior direito de um cadáver masculino de 50 anos de idade.Aartéria ulnar superficial originava-se da artéria braquial, cruzava o nervo mediano anteriormente e percorria lateralmente esse nervo e a artéria braquial. A artéria ulnar superficial no braço deu origem a um ramo muscular estreito do músculo bíceps braquial. Ao nível do cotovelo, a artéria percorria superficialmente a aponeurose bicipital, onde era cruzada pela veia cubital mediana. Percorria, então, em sentido descendente e medialmente superficial aos músculos flexores do antebraço, e então descendia para entrar na mão. Na palma, essa artéria formava os arcos palmares superficial e profundo junto com os ramos da artéria radial.Apresença de uma artéria ulnar superficial é clinicamente importante ao levantar retalhos do antebraço em cirurgias reconstrutivas.Aembriologia e relevância clínica da variação são discutidas.

Angiografia coronária: técnica transbraquial revisitada / Coronary angiography: transbrachial technique revisited

Objetivo: Demosntrar a experiência na execução da técnica de punção braquial para a realização de coronariopatia. Método: Foram avaliados 106 pacientes ambulatóriais com suspeita de doença coronária submetidos a coronariografia pela técnica transbraquial. Foi pré-selecionado cateter MP2 introduzido através de bainha 5F, e o cateterismo esquerdo e angiográfico realizado da maneira usual. Ao término do exame foi retirada a bainha e a hemostasia realizada por compressão manual. Resultado: A maioria dos exames (76,4 por cento) foi completada com a utilização de um único cateter (MP2). A mediana do tempo de fluoroscopia foi 4,5 min. Em apenas 4 casos a técnica teve que ser substituída, todas ocorreram com um mesmo operador durante a curva de aprendizagem. Observamos a presença de hematoma de pequeno volume em 3 pacientes, logo após o procedimento, áreas discretas de esquimose em 4 e equimoses mais extensas em 6 doentes, não tendo ocorrido complicações graves. Conclusões: A técnica transbraquial mosntrou-se efetiva e segura , facilitando a realização de cateterismo ambulatorial com baixa frequência de complicações.

Objectives: To report the experience using the transbrachial approach for coronary angiography. Methods: 106 patients were studied with possible diagnosis of coronary artery disease using transbrachial catheterization. A preselected catheter (MP2) was introduced through a 5 F sheath and left heart catheterization and angiography performed in the usual manner. At the end of the procedure, the sheath was removed and hemostasis accomplished by manual compression. Results: Most procedures (76.4%) were performed with a single catheter (MP2). The median fluoroscopy time was 4.5 min. In only 4 cases, during the learning curve of one operator, a different technique had to be performed. Three patients suffered small hematomas, 4 patients presented with small and 6 with moderate ecchymosis; there were no severe complications. Conclusions: The transbrachial technique is effective and safe; it has facilitated outpatient catheterization with a low rate of complications.

Brachio-infraclavicular axillary interposition graft as a successful tertiary vascular access procedure for hemodialysis

This study describes experience with brachio-axillary interposition graft for hemodialysis as a successful tertiary vascular access procedure. The purpose of the study is to assess the role of this procedure in the dialysis access algorithm. Between May [1995] and March [2000], fourteen grafts were placed in 14 patients, with exhausted venous arm sites. No significant post-operative complications occurred, the secondary patency rate after 1 and 2 years was 85.7% and 77% respectively, which were much better than conventional arm bridge fistula 50-70% after one year, Really, this procedure opened the closed doors infront of those miserable patients with chronic renal failure and exhausted all venous arm sites and good enough that the proposed two main problems with this procedure which were heart failure and steal phenomena did not occur with a significant importance. No single case of heart failure occurred in this series also, steal phenomena occurred only in one case with mild degree that there was no need for intervention, So, it might prove reasonable to use this graft earlier in an effort to eliminate the painful, costly and inconvenient multiple revisions frequently required with more conventional grafts

Are lower limb arteriovenous grafts the final solution for hemodialysis?

In this study, 14 patients on hemodialysis [HD] therapy for prolonged time [>5 years] with unavailable both upper limbs for various reasons required the use of lower limbs for access construction. PTFE arteriovenous loop constructed between upper thigh femoral vessels was the procedure of choice. The early postoperative complications such as acute ischemia and severe venous hypertension led to an early access loss. It was concluded that lower limb synthetic graft placement may be considered as a final option for hemodialysis access placement with a special consideration to its potentially serious complications

Vascular access for hemodialysis in the pediatric population

In this study, retrospective data of 106 patients with a total of 120 procedures over a seven-year period were collected. Patients were divided into groups according to the procedure that was selected for them. The primary radiocephalic group [52 patients] had 80% primary success rate and 75% long-term patency rate. Brachial artery based group [42 patients] showed 86% primary success rate, 64% long-term patency rate and 15% revision rate. Basilic vein transposition group [nine patients] showed 88% primary success and long-term patency rate

Tratamiento de la isquemia grave luego de fístula arteriovenosa mediante ligadura arterial y by pass / Treatment of severe ischemia after arterio-venous fistula by artery ligation and bypass

Se realiza una revisión de la incidencia, patogenia y tratamiento de la isquemia severa del miembro superior luego de realizada una fístula arteriovenosa (FAV), en relación con dos casos tratados mediante ligadura arterial distal a la anastomosis y bypass. La incidencia global de esta complicación es baja, aunque significativamente mayor para las FAV en situación proximal que para las realizadas en el puño. Se consigna un alto porcentaje de amputaciones en las distintas series consultadas. En el tratamiento tiene importancia la conservación de la FAV en pacientes que van agotando las posibilidades de realizarlas. La revisión de los distintos procedimientos quirúrgicos utilizados para su tratamiento destaca los buenos resultados obtenidos con la ligadura arterial distal a la anastomosis y revascularización con un puente entre arteria proximal y distal

Transposición venosa basílica como vía de acceso vascular para la hemodiálisis crónica: fístula arteriovenosa basílico humeral / Transposition of basilic vein as vascular access for chronic hemodialysis, with construction of an arteriovenous fistula

La transposición venosa basílica a manera de fístula arteriovenosa es una excelente alternativa como acceso vascular secundario. La naturaleza "autógena" del procedimiento, su baja mortalidad y excelente permeabilidad alejada (81% en nuestras series), lo convierten en una alternativa recomendable. Es importante destacar el valor de la venografía, como paso previo a la realización de cualquier vía definitiva de angio-acceso. Ella permite seleccionar adecuadamente el procedimiento indicado. Se detalla la metodología terapéutica