ABSTRACT
Avascular osseo-necrosis is one of the rare complications that has never been reported in pediatric mandibular distraction. However extensive periosteal stripping, developing tooth buds and aberrations related to the inferior alveolar canal in malformed syndromic mandible may lead to compromised vascularity to the osteotomised segments leading to avascular necrosis after monofocal mandibular distraction. The aim of the current case report is to describe this rare complication after pediatric MMDO and discuss in detail the possible etio-pathologic mechanisms and provide an insight for the management strategies.Copyright © 2021 The Authors
ABSTRACT
BACKGROUND: Currently, AVFs are created by vascular surgeons urologists and nephrologists. Nephrologists may be better placed to create AVFs and conduct follow-up as they re well versed with the usage of AVF. AIM OF THE STUDY: This observational prospective study aims to find the outcome of AVFs created by nephrologists over two years in a tertiary level hospital. METHOD(S): All the patients in whom an AVF was created by nephrologists between March 2020 and August 2022 were included. On the day of surgery vitals were recorded and vein mapping was done. Side-to-side anastomosis with 6-0 proline between artery and vein were performed under local anesthesia in a single sitting. Patients were observed for post-op complications. During the COVID-19 pandemic, RT PCR was only performed in suspected in suspected patients indentified during screening. All patients staff and surgeons wore N-95 masks in addition to usual sterile measures. Patients were followed up at 6th week and 12th week post-AVF construction to do clinical examination and evaluate blood flow diameter of AVF by high-quality Doppler. Patients were asked to use AVF for dialysis after 6th week of creation after they have matured. AVF maturation was defined radiologically as a combination of blood flow of 600 ml/min and diameter of 6 mm or more and clinically usable. Else it was considered immature. Primary failure was defined as AVFs that had not matured till 12th week of creation. All the data were analyzed by appropriate statistical tools using the SPSS software RESULTS: A total of 1323 fistulae (including 376 during COVID-19 pandemic) were created in 1102 patients. Of them 928 (84.21%) were males, and 537 (48.72%) of the patients were having underlying diabetes mellitus. A total of 1008 (76.19%) were radio-cephalic while 262 (19.8%), 19 (1.43%) were brachio-cephalic, and brachio-basilic respectively. 1013 (76.56%) fistulae were left sided. 944 (85.66%) were already on hemodialysis while 158 (14.33%) were planned for elective initiation after fistula maturation. Of the 1102 patients, 150 patients required fistula creation twice, 17 patients thrice, and 4 patients underwent fistula creation four times. Out of 556 (50.45%) patients who completed three months follow-up, 65 patients (11.69%) expired. Primary failure was observed in 107 (19.21%) fistulae and 24 (4.30%) patients developed local site infection. 8 (1.43%) and 4 (0.71%) patients developed fistula rupture and aneurysms respectively requiring admission for AVF closure. Mean AVF blood flow and diameter were 674.92 +/- 317.40 and 5.42 +/- 1.33 at 6th week and 983.60 +/- 289.41 and 9.36 +/- 54.58 at 12th week respectively. During the COVID-19 pandemic, out of 376, 15 (7.1%) patients were found to be COVID-19 positive during follow-up, and only 2 out of 18 staff and 4 nephrologists were found to COVID-19 positive. CONCLUSION(S): Nephrologists are well positioned to create AVFs successfully. However, collaboration with vascular surgeons and radiologists will further improve the success rate and management of complications. AVF creation is safe during pandemics and should be continued.