Enoxaparin Sodium Biosimilar in the Prophylactic Treatment of Veinous Thromboembolism and Thromboembolic Disease: Prophyvar Study

Objectives: Varenox is the first locally manufactured and approved biosimilar in Algeria. It is an enoxaparin sodium (ES) with established good analytical characterization and manufacturing quality control. The aim of the PROPHYVAR study was to generate real-life data in routine practices and to assess the safety and tolerability in the prophylaxis of venous thromboembolism (VTE). Method(s): This is an observational, prospective, multicenter study, conducted between April 2021 and May 2022. The primary safety outcome was the incidence of Adverse Events (AEs) related to the study drug. A sample size of 500 patients was calculated to estimate the proportion of patients with AEs. Assuming that approximately 10% will be lost to follow-up or not evaluable, 550 patients were needed to describe the impact of Varenox use. Result(s): The study was conducted in 25 different sites in Algeria, in 4 therapeutic areas: ICU, orthopedic surgery, obstetrics and nephrology;550 patients were included and received at least one injection of Varenox. The mean age was 47 years, women in majority (62.5%). The patients were overweight or obese (53%), with a history of arterial hypertension (25%), diabetes (7.5%) and renal failure (6.4%). Reasons for hospitalization were mainly fracture (15.5%), pregnancy (8.3%), COVID-19 (7%) or cancer (7%). The majority of patients were treated at prophylactic dose of 0.4ml (80%) or 0.6ml (10%). The median duration of follow-up was 24 days. A total of 38 patients experienced at least one AE (6.9%, CI95=[4.9%;9.4%]). Related AEs were reported in 10 patients (1.8%), mainly in nephrology (N=7 arterio-venous fistula). VTE events were reported in 6 patients (1.1%, CI95=[0.2%;2%]). Conclusion(s): This study suggests that Varenox is safe in the prophylaxis of VTE. To our knowledge this is the first large study describing the use of ES in current medical practice in Algeria.Copyright © 2023

Did stopping ultrasound surveillance during COVID-19 result in an increase of the dialysis access thrombosis rate?

PURPOSE: The COVID-19 pandemic resulted in cessation and subsequent reduction of routine care including the outpatient ultrasound surveillance of AVF. This un-planned service disruption allowed evaluation of effectiveness of US surveillance in reducing AVF/AVG thrombosis. METHODS: This study was a secondary data analysis of monthly access patency for all in-centre patients receiving haemodialysis using an AVF or AVG over a 2-year period (April 2019-March 2021). The study included 298 patients with age, access type, patency and COVID status measured as variables. Thrombosis rates for the 12 months prior to COVID-19 and then during the first 12 months of the pandemic were also measured. Statistical analysis to assess mean and standard deviation for relevant variables was used. A p-value of <0.05 was deemed significant. RESULTS: At the end of the study an increase in thrombosis rate (%) in the non-surveillance year was observed ((1.20) thrombosis/patient/year in the surveillance group vs (1.68) thrombosis/patient/year in the non-surveillance group). Monthly mean of thrombosed access during surveillance (M = 3.58, 95% CI 2.19-4.98, SD = 2.193) and non-surveillance (M = 4.92, 95% CI 3.52-6.31, SD = 2.19); t(7148) = 2.051, p = 0.038. CONCLUSION: Reduction in routine Ultrasound surveillance following the COVID-19 pandemic was associated with a significant increase in access thrombosis rate. Further research is needed to unpick whether the associations seen were directly due to service changes, associated with COVID-19 or other factors during the pandemic. This association was independent of SARS-CoV-2 infection status. Clinical teams should consider alternative service delivery options including out-reach, bedside surveillance to balance risks of access thrombosis versus reducing the risk of nosocomial infection with hospital visits.

The Challenge Of Covid19 In The Management Of Vascular Access For Hemodialysis In An Universitary Hospital.

INTRODUCTION: Chronic kidney disease prevalence has been increasing worldwide, with an increasing need to deliver an effective treatment. During the first months of the coronavirus disease 2019 (COVID-19) pandemic healthcare systems around the world were under stress. Therefore, the aim of this study is to report a single center experience with arteriovenous fistula (AVF) creation while also evaluating the impact of COVID-19. METHODS: Procedures for AVF creation in a tertiary hospital between March 2017 and December 2020 were included in this study and their case records were retrospectively analyzed and data retrieved. RESULTS: A total of 582 procedures were performed and a total of 568 accesses were created (506 being made pre-COVID onset and 62 post-COVID onset). The period between the referral to the vascular surgery consultation was significantly longer for the COVID group [18 (23) days vs 28 (44) days; p<0,001] while the period between the consultation to the surgery was significantly shorter [76 (77) days vs 40 (57) days; p<0,001]. This resulted in significantly less time between referral to surgery in the COVID group [103 (77) days vs 88 (55) days; p=0,008]. CONCLUSION: The ability of hospitals to adapt their resources was paramount to mitigate COVID impact. In the institution where the study took place, the time from referral to consultation was increased significantly during the first months of COVID but the time from consultation to surgery was significantly reduced. Overall, these results show that there was a successful effort to expedite the creation of a vascular access.

Distribution, Preparedness and Management of Ukrainian Adult Refugees on Dialysis- an International Survey by the Renal Disaster Relief Task Force of the European Renal Association

Introduction: During armed conflicts dialysis patients may experience limitations or interruptions of therapy leading to severe life-threatening complications due to medical and logistical challenges. Before the Russian-Ukrainian war, there were approximately 10,000 adults requiring dialysis in Ukraine. Some patients decided to flee their place of residence and look for opportunities to continue dialysis in another location in Ukraine or abroad. To better understand the needs of conflict-affected kidney failure patients and to provide data which could support equitable and evidence-based prioritization of resources, the Renal Disaster Relief Task Force of the European Renal Association conducted a survey on distribution, preparedness and management of adults requiring dialysis displaced due to the war in Ukraine. Method(s): Cross-sectional online survey was conducted to assess the status of dialysis patients who were displaced across European countries since the beginning of the conflict in February 2022. The survey was sent to all national nephrology societies across Europe with a request to disseminate it to all dialysis centers in their countries. Data were collected between May and August 2022. Fresenius Medical Care (FMC) shared a limited set of aggregated data without direct center participation. Result(s): We received data on 602 patients (290 collected through the survey and 312 from FMC), who were dialyzed in 24 countries. Most patients were dialyzed in Poland (45.0%), followed by Slovakia (18.1%), Czech Republic (7.8%), Romania (6.3%), Germany (4.7%) and Hungary (3.5%). Most patients were originally dialyzed in Kyiv (north-central), Kharkiv (northeast), Odesa (southwest) and Zaporizhzhia (southeast). Before reaching the current reporting center, 34.6% of patients were treated in at least one other center since leaving their regular unit. Mean age was 48.1+/-13.4 years, 43.5% were females. Before patients left Ukraine, 95.7% had been on hemodialysis (HD), 2.5% on continuous ambulatory peritoneal dialysis (PD) and 1.8% on automated PD. HD session frequency was reduced under war conditions in 23.5% of patients. Eighty-eight percent of HD patients had a patent arteriovenous fistula, 7.3% were HBs antigen positive, 16.1% had anti-HCV antibodies, 0.6% anti-HIV antibodies and 27.3% anti-HBc antibodies. In terms of patient preparedness for displacement, 63.9% carried medical records with them, 63.3% had a list of medications, 60.4% had medications themselves and 44.0% had a dialysis prescription. Overall, 26.1% of patients were admitted to the dialysis unit in the possession of all these factors while 16.1% presented with none. After leaving Ukraine, 33.9% of patients were hospitalized. Of the 88.5% of patients tested in the reporting center for COVID-19 1.9% was positive. Communication and language problems were reported by 43.8% of responding physicians. Conclusion(s): Up to the end of August 2022, less than 10% of Ukrainian dialysis patients decided to flee their country since the start of the Russian-Ukrainian conflict and the majority of them chose as their place for dialysis a country neighboring Ukraine. Preparedness for displacement varied and was incomplete in most patients. Results from our survey may inform evidence-based policies and interventions to prepare for and respond to special needs of vulnerable kidney failure populations during armed conflicts and other emergencies. No conflict of interestCopyright © 2023

Arterio-Venous Fistula Creation by Nephrologists and Its Outcome in a Tertiary Level Hospital over Two Years Including Covid-19 Pandemic Period

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.

Chronic Kidney Disease Patients: Collateral Damage Due to Suspension of Vascular Access Services

This study was conducted at the Department of Vascular Surgery at Combined Military Hospital Lahore from December 2019 to June 2020. The mortality of patients on the waiting list for vascular access in our institution three months after implementing strict policies for elective surgeries (30th March 2020 to 29th June 2020) was compared with the preceding three months. The mortality of patients in the pre-COVID-19 periods on the waiting list for HD was 11 (7.9%) in the pre-COVID-19 period, while this increased to 5 (12.5%) in the post-COVID-19 period. COVID-19 related suspension of vascular access services negatively influences CKD patients waiting for permanent vascular access. © 2022, Army Medical College. All rights reserved.

Central Vein Stenosis in Hemodialysis Patients during COVID Pandemic: A Case Series Analysis

End-stage kidney disease (ESKD) patients who were on maintenance hemodialysis require a stable, permanent vascular access as a lifeline. Venous mapping during prearteriovenous fistula (AVF) construction does not include central vein assessment. The guidelines on angiographic assessment of central veins during pre-AVF construction are yet to be streamlined. Moreover, during COVID pandemic, assess difficulty in catheterization laboratory and interventional radiology created devastating situation. We report 15 ESKD cases of central venous stenosis presented during the COVID pandemic time from February 2020 to July 2021. Patients' basic details were collected and initial clinical examination findings were recorded;they were subjected to Doppler and fistulogram. After the combined decision of nephrologist, interventional cardiologist, and vascular surgeon, the management (fistula closure/repair) was planned. Of 15 patients, 13 were males. Basic disease is chronic glomerulonephritis in 9, diabetic nephropathy in 4, and chronic interstitial nephritis in 2. Average number of central vein cannulation prior to AVF creation was 2.6. The median time to the development of symptoms after fistula creation was 13 months. Major initial symptoms were swelling of the upper limb in 4, dilatation of outflow veins in 5, swelling and dilatation in 2, poor flow during dialysis in 3, and dilatation of neck and chest vein in 1. Arm elevation test was positive in most of the cases. On Doppler assessment, dilated veins (> 12 mm) with high outflow (> 2000 ml/min) in 5, 4 patients showed low flow (< 400 ml/min), and six patients showed normal findings. In fistulogram, the common location of stenosis/thrombosis was brachiocephalic vein (BV) in 5 and subclavian vein (SC) in 3, BV vein + SC vein in 4, and superior vena cava in 3. Out of 15, 3 underwent balloon dilatation, 7 underwent fistula closure, 1 no intervention done, 3 lost to follow-up, and 1 expired. This is the first case series of central vein stenosis (CVS) brought in light during COVID pandemic. CVS is a serious issue, which might result in permanent vascular access failure. Further study is needed on impact of previous central vein catheterization leading to stenosis and role of pre-AVF creation angiographic assessment to avoid this type of devastating AVF complication.

Off Label Picc as a Femoral Catheter in an Almost Noncannulated Patient

Introduction: 39-year-old patient presented with rapid progressive metastatic (lung, bone) sarcoma. He was in a life-threatening situation on peritoneal dialysis, with cardiomyopathy and ongoing infectious endocarditis. He had multiple cannulations with the introduction of dialysis catheters (jugular, axillary, femoral veins), AV fistulas on both shoulders for hemodialysis followed by calcification of these fistulas and he had tumour thrombosis of the right femoral vein. He should receive chemotherapy, but unfortunately, he tested positive for COVID-19. He developed massive bilateral covid related pneumonia. Subsequently, he fell down and broke his right arm (traumatic humerus fracture with dislocation). Method(s): According to the guidelines from GAVACELT, in covid patients, PICC is recommended as a safe and simple central venous access (CVA). This patient needed a safe CVA, because of intravenous application of antibiotics to treat the endocarditis. We were not able to use the upper part of the body to insert the line. In addition, the patient underwent kidney transplantation followed by graft explantation, because of rejection. We did not exactly know, how was the condition of the renal vessels. There was a possibility that venous stenosis would be present in the postoperative area. We decided to use the PICC 'off label', to insert from the left femoral vein, the one and only possible vein to insert a line in this patient. Result(s): We used ultrasound to guide the cannulation. Through the left femoral vein, we successfully inserted a 4Fr one-lumen tunnelled PICC line without complications. We checked the distal end of the PICC also by X-ray, to ensure the right tip position. Discussion and conclusion: We managed to cannulate this complicated patient to ensure safe CVA, despite all obstacles. We conclude, that there is no non-cannulate patient. The physician must select the correct procedure and the most suitable vein to insert the catheter.

MALIGNANT GLOMUS TUMOR WITH UNSTABLE HEMORRHAGE

SESSION TITLE: Critical Complications of Cancer Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Glomus tumors are rare, benign neoplasms made up of cells resembling modified smooth muscle cells of glomus bodies. Glomus bodies are a type of arteriovenous anastomosis located primarily in dermal soft tissue and responsible for thermoregulation (1). Glomus tumors are suspected when presenting with a classic triad of severe pain, pinpoint tenderness, and hypersensitivity to cold (2). A vast majority of glomus tumors are benign with less than 1% demonstrating malignant pathology. Extradigital glomus tumors can occur, but often lack the typical presentation, making them difficult to diagnose. Treatment is surgical excision. CASE PRESENTATION: We report a case of a 35 year old female with past medical history of diabetes mellitus and morbid obesity who presented with a large 4cmX5cm fungating mass of the left posterior thigh (Figure 1 and 2). The patient was admitted to the ICU for concurrent acute hypoxemic respiratory failure secondary to COVID-19 pneumonia. The patient never received full dose anticoagulation. Due to the patient's instability, surgical evaluation was initially deferred until the patient began experiencing significant hemorrhage from the fungating mass (Figure 3), which correlated with a precipitous drop in hemoglobin requiring multiple transfusions. The mass was surgically excised (Figure 4), but continued bleeding, necessitating blood transfusions. Further evaluation of the mass by pathology established the mass as "Malignant glomus tumor showing chiefly spindle cell morphology, arising from a pre existing benign glomus tumor… showing some stromal oncocytic change as well as degenerative-appearing nuclear atypia and calcification.” The patient remained under ICU care through the remainder of her hospital stay for COVID-19 and sequela. Despite treatment, her clinical status worsened, the patient decompensated secondary to COVID-19, and the decision was made by the family to proceed with comfort measures. DISCUSSION: This patient presented with an abnormal fungating mass without symptoms typically consistent with glomus tumor. The mass displayed a malignant transformation, making it particularly unique. The case was further distinguished by hemorrhage and hemorrhagic shock directly related to the mass. Although this patient experienced a complicated course due to the hemorrhage requiring multiple postoperative transfusions, the patient was eventually stabilized and hemostasis was obtained. While it remains unclear if her malignant glomus tumor conferred increased risk of mortality from COVID-19, it is the author's belief that more research should be done to identify if a relationship between all type cancer and COVID-19 mortality exists. CONCLUSIONS: This case represents a unique case of malignant glomus tumor with previously undescribed presenting symptoms. Reference #1: 1. Gombos, Z., & Zhang, P. J. (2008). Glomus tumor. Archives of Pathology & Laboratory Medicine, 132(9), 1448–1452. https://doi.org/10.5858/2008-132-1448-gt Reference #2: 2. Sbai, M. A., Benzarti, S., Gharbi, W., Khoffi, W., & Maalla, R. (2018). Glomus tumor of the leg: A case report. Pan African Medical Journal, 31. https://doi.org/10.11604/pamj.2018.31.186.9706 Reference #3: 3. Aiba, M., Hirayama, A., & Kuramochi, S. (1988). Glomangiosarcoma in a glomus tumor. An immunohistochemical and ultrastructural study. Cancer, 61(7), 1467–1471. https://doi.org/10.1002/1097-0142(19880401)61:7<1467::aid-cncr2820610733>3.0.co;2-3 DISCLOSURES: No relevant relationships by Syed Akbarullah No relevant relationships by Devin Bradshaw No relevant relationships by LLOYD Del Mundo No relevant relationships by Gerard DiChiara No relevant relationships by Dushawn Harley No relevant relationships by Jerome Hruska No relevant relationships by Ian Ogurek No relevant relationships by Xenia Schneider No relevant relationships by Paul Stewart No relevant relationships by Joseph Telliard No elevant relationships by Ilya Yegudkin

Effect of primary balloon angioplasty on draining vein diameter and volume flow in patients with arteriovenous fistula: A cohort study.

Background: Chronic kidney disease (CKD) and end-stage kidney disease (ESKD) cause major morbidity and mortality in 10% of the global population with CKD. The most common renal replacement therapy is hemodialysis with arteriovenous fistula (AVF) access. AVF often undergoes maturation failure due to feeding artery and draining vein inadequacy. Mechanical dilatation, such as primary balloon angioplasty (PBA), can overcome AVF maturation failure. The volume flow (VF) and diameter of the draining veins in AVF patients must be known to evaluate the effect of PBA on AVF maturation. This study aims to analyze the impact of PBA on VF and draining vein diameter in ESKD patients undergoing AVF surgery. Methods: A retrospective cohort clinical trial was conducted at our institution. A total of 75 participants had AVF with an arterial diameter >1.5 mm or vein diameter at the AVF creation site of 2-4 mm. The subjects were divided into 2 groups: the intervention group undergoing PBA (n = 36) and the control group, without PBA (n = 39). PBA was performed using a Mustang ballon (3-6 mm, Medtronic). Follow-ups were conducted at 1 week, 2 weeks, and 6 weeks after AVF creation. Results: Based on the data, the diameter and VF of the draining veins were significantly larger in the intervention group than in the control group (p < 0.001). Furthermore, we found significant differences in the mean diameter and VF of the draining veins between the control and intervention groups at all stages of examination, from preoperatively to 6 weeks postoperatively (p < 0.001). The strength of the analysis was more than 80%. Conclusion: PBA can increase the diameter and VF of the draining veins in patients with AVF.

Impact of COVID-19 pandemic on hemodialysis access thrombosis.

BACKGROUND: Delay in care of suspected stenosis or thrombosis can increase the chance of losing a functioning hemodialysis access. Access to care and resources were restricted during the COVID-19 pandemic. To evaluate the impact of the pandemic on arteriovenous fistula (AVF) and arteriovenous graft (AVG) procedures we have assessed the number and success of thrombectomies done before and during the COVID-19 pandemic. METHODS: We examined all AVF and AVG angiograms with and without interventions, including thrombectomies, performed at a single center during April 2017-March 2021 (pre-COVID-19 era) and April 2020-March 2021 (COVID-19 era). RESULTS: The proportion of procedures that were thrombectomies was higher during the COVID-19 era compared to the pre-COVID-19 era (13.3% vs 8.7%, p = 0.009). The proportion of thrombectomy procedures was higher during COVID-19 for AVF (8.2% vs 3.0%, p < 0.001) but there was no difference for AVG (26.5% vs 27%, p = 0.99). There was a trend toward a higher likelihood of unsuccessful thrombectomy during COVID-19 (33.3% vs 20.4%, p = 0.08). CONCLUSIONS: More dialysis access thromboses and unsuccessful thrombectomies were noted during the COVID-19 pandemic. This difference could be due to a delay in patients getting procedures to maintain their dialysis accesses.

COVID-19 Pandemic Impact on Dialysis Access Procedures for End Stage Renal Disease Patients

Introduction: The COVID-19 pandemic has affected the health services globally. The impact on the provision of vascular access services for patients with chronic kidney disease is not known. One can speculate that reduced hospital bed capacity, limited elective theatre lists, and the shielding requirement for vulnerable patients in this particular group will have an adverse effect. This study was conducted to evaluate the effect of the COVID-19 pandemic on dialysis access procedures performed at a tertiary care centre. Methods: This was a single centre, retrospective, observational study of all dialysis access procedures performed between January 2019 and December 2020. Patient data were collected from electronic patient records, operation theatre databases, and clinical case records. Vascular access procedures were categorised according to the site and type of dialysis access (autogenous/non-autogenous fistulas) and secondary access procedures. Secondary access procedures were those that dealt with complications of vascular access. Peritoneal access procedures were also included in the data. Placement of acute and long term dialysis catheter lines were excluded. Pre-COVID data from 2019 were compared with the 2020 data. Statistical methods for data analysis were performed using SPSS version 23.0 by applying Pearson’s chi square test for variables to measure the significance of outcome. Results: A total of 271 dialysis access related procedures were performed in 2019 versus 212 in 2020. There was a significant drop of 21.7% in the total number of dialysis access procedures during the COVID-19 pandemic in the year 2020 (p <.05). In the pre-COVID era, 162 (59.8%) procedures were the formation of autogenous arteriovenous fistulas. The case mix consisted of 69 (25.5%) radiocephalic fistulas, 70 (25.8%) brachiocephalic fistulas, 13 (4.8%) first stage basilic vein transpositions, and 10 (3.7%) second stage basilic vein transpositions. In comparison, during the year 2020, 118 (55.7%) procedures were autogenous arteriovenous fistulas. The case mix included 54 (25.5%) radiocephalic fistulas and a similar proportion of brachiocephalic fistulas (n = 54 [25.5%]), six (2.8%) first stage basilic vein transpositions, and four (1.9%) second stage basilic vein transpositions. There were 14 (5.2%) non-autogenous arteriovenous graft formations in 2019 versus 21 (9.9%) in 2020 (p <.05). There were 53 (19.5%) secondary vascular access procedures in 2019 versus 30 (14.1%) in 2020 (p <.05). The proportion of peritoneal dialysis catheter placements, repositioning, and catheter exchanges increased slightly. Forty-two (15.5%) procedures were done in 2019 versus 43 (20.3%) in 2020. The proportion of new peritoneal catheters was significantly higher in the year 2020 (p <.05). There were 35 (12.9%) new peritoneal dialysis catheter placements (nine laparoscopic/26 open insertions) in 2019, whereas in 2020 there were 38 (17.9%) n (one laparoscopic, 31 open and five percutaneous). There were no laparoscopic peritoneal dialysis catheter placements after the start of the pandemic. Conclusion: During the COVID-19 pandemic, there was a significant reduction in the total number of vascular access procedures performed and also secondary surgical interventions, but an increase in the use of arteriovenous grafts. The number of new peritoneal dialysis access increased despite overall reduction in the total number of procedures. Percutaneous peritoneal tube insertion technique was introduced during the pandemic to reduce hospital admissions while laparoscopic techniques were abandoned.

Iatrogenic left common carotid artery to right internal jugular vein arteriovenous fistula closure.

We report a minimally invasive approach to the repair of a 2.8-cm × 6.0-cm left proximal common carotid to right internal jugular vein arteriovenous fistula. A 47-year-old woman with coronavirus disease 2019 pneumonia had received extracorporeal membranous oxygenation and developed a rare, presumably cannulation-related, vascular injury. We used a plug designed and typically used for the endovascular management of a patent ductus arteriosus.

Point of Care Ultrasound Examination for Preop Evaluation of Arteriovenous Access Patients

INTRODUCTION: Ultrasound examination is an essential component in the preoperative evaluation of patients needing creation of an arteriovenous access. This test is not usually incorporate as part of the initial outpatient visit. Point of care ultrasound examination as part of the initial physician visit decrease cost, generate a surgical planning, as a one-time stop before scheduling. We the experience of incorporation POCUS examination of the upper extremities, in the initial consultation visit of patients needing creation of an arteriovenous access. METHODS: A retrospective review of a prospectively maintain database of dialysis access patients;from which data was collected from patients which have point of care ultrasound as planning imaging during their initial visit, and then underwent a surgical access creation. Data was extracted from periprocedural and clinical follow-up records. RESULTS: Nineteen patients underwent point of care ultrasound examination at vascular surgery visit and underwent creation of an arteriovenous access. The mean age of patients 50.5 years (24-70 years). Twelve patients were male (63%), and seven patients were female (37%). An arteriovenous fistula was successfully created on 18 patients (95%). Thirteen patients are using their access for hemodialysis (68%). CONCLUSION: This preliminary study demonstrates that performance of POCUS examination by operating surgeon in office, is a suitable technique which allows for a successful rate for arteriovenous access creation, allowing savings in healthcare costs of the patient, allowing the visit as a one-stop evaluation and surgical planning. This study was performed during the COVID-19 pandemic.

When Hearing Hoofbeats Is Actually Zebras: A Common Presentation of Uncommon Pathology

Since the beginning of the SARS CoV-2 pandemic two years ago respiratory complaints have been one of the most common presenting symptoms to the emergency departments across the United States. At this time, over 45 million Americans have tested positive for the SARS CoV-2 virus and the vast majority of the patients who present to the hospital with this infection are due to the consequences of systemic inflammation, most significantly in the lungs. We would like to share a case of a 79 year old female with known cystic lung disease (suspected Pulmonary Langerhans Cell Histiocytosis) on 4L oxygen via nasal cannula (NC) at baseline who presented to a community hospital from her nursing facility for hypoxia. Upon presentation to the hospital she was found to test positive for the SARS CoV-2 virus. In the course of her work up she received a CTA of the chest which did show mild ground glass changes consistent with a mild viral pneumonia, more significantly, the scan revealed numerous pulmonary arterio-venous malformations (AVMs) in bilateral lower lobes that were not present on previous imaging of the chest. A detailed work up of the patient was unable to be performed due to the patient declining invasive testing and wishing to pursue hospice. The patient was found to have an estimated shunt fraction >30% with a cardiac echo that confirmed an intrapulmonary shunt and an acute drop in the patient's left ventricular ejection fraction (LVEF) due to an NSTEMI 3 months prior to admission. We believe that this patient had underlying hereditary hemorrhagic telangiectasia resulting in pulmonary AVMs that were minimally symptomatic until the patient's acute drop in her LVEF which led to a drastic increase in her intrapulmonary shunt fraction.

Baby Blues: A Rare Case of Transient Pulmonary Arteriovenous Malformation During Pregnancy

Unexplained hypoxia in a pregnant patient is an alarming finding for patient and provider. The differential for hypoxia is broad, and many imaging techniques and procedures are contraindicated in pregnancy. Transient pulmonary arteriovenous malformations (AVMs) are a rare and relatively poorly studied cause of hypoxia in pregnancy. Our patient is a 27-year-old G1P0 female with a remote history of asthma who presented to clinic with slowly progressive exertional dyspnea, exertional tachycardia, and paroxysmal nocturnal dyspnea. She reported use of a home oximeter which read in the high 80s% during exertion. Prior to presentation, the patient was evaluated in the Emergency Department and noted to have an oxygen saturation of 86% on room air. A transthoracic echocardiogram, computed tomography angiography of chest, and basic laboratories including B-type natriuretic peptide, troponin, COVID-19, and hemoglobin were unremarkable. Her clinical timeline is presented in Figure 1. Further testing was obtained, including pulmonary function testing, bubble echocardiogram, nocturnal oximetry, and shunt study. Work-up revealed a 15-20% shunt, depending on calculation, and insignificant desaturations during nocturnal oximetry. Her symptoms progressed, and repeat nocturnal oximetry showed marked overnight desaturations requiring supplemental oxygen for the remainder of her pregnancy. She delivered a healthy baby girl via cesarean section without serious complication. Repeat testing in the post-partum period showed resolution of nocturnal desaturations and decreased shunt, and her exertional dyspnea and desaturations resolved spontaneously. This case illustrates the challenging diagnosis of transient pulmonary AVM in pregnancy. Case reports of this phenomenon have been published, but as in our case, no definitive diagnosis was made secondary to testing limitations in pregnancy and quick resolution of symptoms in the post-partum period. Some reports describe pre-existing pulmonary AVM becoming worse during pregnancy causing hemothorax, fetal demise and even death. While the mechanism is not known, theories include the vasodilatory effects of progesterone on vascular smooth muscle as well as other physiologic changes in pregnancy such as increased plasma volume. These AVM are thought to be like those seen in hepatopulmonary syndrome. Similar to our case, increasing positional hypoxia has been reported as the pregnancy progresses. Further research dedicated to early and accurate detection of pulmonary AVMs in pregnancy is necessary. (Figure Presented).

Brain dural arteriovenous fistulas in the COVID-19 Era: A warning and rationale for association.

OBJECTIVES: Brain dural arteriovenous fistulas(bDAVFs) are anomalous connections between dural arteries and cerebral veins or sinuses. Cerebral venous thrombosis(CVT) often precedes or coincides with bDAVFs and is considered a risk factor for these vascular malformations. Recently, vaccine-induced thrombotic thrombocytopenia causing CVTs has been associated with COVID-19 vaccines. Concurrently with the start of massive vaccination in our region, we have observed a fivefold increase in the average incidence of bDAVFs. Our objective is to raise awareness of the potential involvement of COVID-19 vaccines in the pathogenesis of bDAVF. METHODS: A retrospective review of demographic, clinical, radiological, COVID-19 infection and vaccination data of patients diagnosed with bDAVFs between 2011 and 2021 was conducted. Patients were divided into two cohorts according to their belonging to pre- or post-COVID-19 vaccination times. Cohorts were compared for bDAVFs incidences and demographic and clinical features. RESULTS: Twenty-one bDAVFs were diagnosed between 2011 and 2021, 7 of which in 2021. The mean age was 57.7 years, and 62 % were males. All cases except one were treated; of them, 85 % exclusively managed with surgery. All treated cases were successfully occluded. The incidence in 2021 was significantly higher than that in the prevaccination period (1.72 vs 0.35/100,000/year;p = 0.036; 95 %Confidence Interval=0.09-2.66). Cohorts were not different in age, sex, hemorrhagic presentation, dural sinus thrombosis or presence of prothrombotic or cardiovascular risk factors. CONCLUSION: The significant increase in the incidence of bDAVF following general vaccination policies against COVID-19 observed in our region suggests a potential correlation between these two facts. Our findings need confirmation from larger cohorts and further pathogenic research.

HEALTH RELATED QUALITY OF LIFE IN PATIENTS WITH END-STAGE RENAL DISEASE BEFORE AND AFTER STARTING DIALYSIS DURING PANDEMIC COVID-19

BACKGROUND AND AIMS: Patients with end-stage renal disease (ESRD) have complex functional and social changes that affect their quality of life (QoL), leading to an increased cardiovascular risk, mortality and overall morbidity. Several studies showed that general QoL worsened after dialysis initiation but improved by 12 weeks. The influence of coronavirus (COVID-19) among pre-dialysis CKD patients starting dialysis during pandemic COVID-19 is challenging and still largely unexplored. To evaluate the quality of life in patients with ESRD before and after initiating dialysis during pandemic COVID-19, in Constanta County, a south-eastern Romanian region. METHOD: We assessed 59 patients (mean age = 61.65year ± 11.36, Male : Female = 3:1, 13.79% employee) with ESRD before and after dialysis started (T1-12 weeks and T2-24 weeks), using KDQOL-36TM, in the interval of time of 1 year (May 2020-May 2021). RESULTS: QoL was severely affected in patients with diabetes and hypertension, especially because of diet restrictions (58.6%, P < 0.01), fatigue (67.5%, P < 0.01), concerns about the kidney disease (72.4%, P < 0.05) and permanent need for medical services (48.6%, P = NS). Most of the patients required acute initiation of haemodialysis on CVC (66.1%) due to uraemic manifestations and late referral, 34.4% started planned haemodialysis on AV fistula and 8.47% started planned peritoneal dialysis. An overall improvement of QoL was seen both in patients with urgent and planned dialysis initiation, in women group less than in males (P < 0.05). Among dialysis patients at T2, we have found significantly lower levels for mean Mental Component Summary (MCS), calculated as 45.9 ± 14.1, about 3.1 points less than the majority of other studies. The following mental health-related symptoms were claimed during the COVID-19 pandemic 'second and third waves': feeling sad, worrying, feeling nervous and trouble falling asleep, even though dialysis patients seemed less impacted by social distancing measures. CONCLUSION: The initiation of dialysis was an important factor in improving the QoL in our ESRD patients and the type of dialysis and planned initiation contribute substantially to the patient's perception of the disease and influence the main psychosocial parameters of QoL. COVID-19 pandemic affected the QoL of patients that started dialysis in the established interval of time, especially the mean MCS score, probably associated with the high morbidity and mortality of Romanian ESRD and dialysis patients.

THE LONGITUDINAL EVOLUTION OF COVID-19 OUTCOMES AMONG HEMODIALYSIS PATIENTS: A NATIONWIDE MULTICENTRE CONTROLLED STUDY

BACKGROUND AND AIMS: Haemodialysis (HD) patients are at increased risk for adverse short-term consequences of COVID-19. In this study, we investigated the characteristics of chronic HD patients in the post-COVID-19 period and compared them with the control group. METHOD: We conducted a national multicentre observational study involving adult chronic HD patients recovering from COVID-19. The control HD group was selected from patients with similar characteristics who did not have COVID-19 in the same center. SARS-CoV-2 RT-PCR negative patients and patients in the active period of COVID-19 were not included. RESULTS: A total of 1223 patients (635 COVID-19 groups, 588 control groups) were included in the study from the data collected from 47 centres between 21 April 2021 and 11 June 2021. The patients' baseline demographics, comorbidities, medications, HD characteristics and basic laboratory tests were quite similar between the groups (Table 1). 28th-day mortality and between 28th day and 90th day mortality were higher in the COVID-19 group than in the control group [19 (3.0%) patients and 0 (0%) patients;15 (2.4%) patients and 4 (0.7%) patients, respectively]. Presence of respiratory symptoms, rehospitalization, need for home oxygen therapy, lower respiratory tract infection and A-V fistula thrombosis were significantly higher in the COVID-19 group in the first 28 days of illness and between 28 and 90 days. Mortality was significantly associated with preexisting COVID-19, age, current smoking, use of tunneled HD catheter, persistence of respiratory symptoms, rehospitalization, need for home oxygen support, presence of lower respiratory tract infection within 28 days and persistence of respiratory symptoms. CONCLUSION: In the post-COVID-19 period, mortality, rehospitalization, respiratory problems and vascular access problems are higher in maintenance HD patients who have had COVID-19 compared to control HD patients. (Table Presented).

SAFETY OF SAME DAY DISCHARGE AFTER LEAD EXTRACTION PROCEDURES

Background: Lead extraction procedures historically involve overnight hospital observation to detect delayed manifestation of procedural complications. The need for routine hospitalization patients after uncomplicated lead extractions remains to be determined. A desire to limit hospitalization during the COVID 19 pandemic provided an opportunity to assess the appropriateness of same-day discharge (SDD) after lead extraction. Objective: To determine the appropriateness of SDD and identify characteristics that identify potential candidates for SDD in a selected cohort after lead extraction. Methods: We reviewed procedural outcomes in consecutive patients undergoing lead extraction between Jan 2020 and October 2021. Events identified as complications during the first 30 days after the procedure include death, the need for rescue cardiac/chest surgery, hemopericardium with or without tamponade, venous tear, septic embolism, hematoma or pneumothorax requiring intervention, and access-associated AV fistula. Results: One-hundred eighty-four patients, 53% women of mean age 65.6± 14 years, underwent lead extraction at our institution during the specified interval. We discharged seventy-three patients (40%) on the same day;we chose to observe another 111 (60%) in the hospital at least one night. Table 1 shows the baseline and procedural characteristics in both groups. The SDD cohort preferentially included older (68 ± 12 vs. 63.2 ± 16.7, p=0.02) patients, women (59% vs. 44%, p=0.02), those with fewer (1.4 vs. 1.9, p<0.001) leads requiring extraction, a shorter lead dwell time (3.5 ± 4.2 years vs.7.4 ± 12 years, p=0.01), and an indication for extraction other than infection (4% vs. 54%, p<0.0001). The SDD patients suffered fewer complications (0 vs. 6%, p<0.001). Complications observed in the non-SDD group include one femoral AV fistula requiring surgical intervention, three pocket hematoma, and three septic emboli causing hemodynamic instability. Four patients died from underlying sepsis during their hospitalization. Conclusion: SDD appears appropriate in selected patients following lead extraction. Women with relatively fewer leads, shorter lead dwell times, and indications other than infection appear reasonable candidates for SDD. Age alone does not identify better candidates for SDD. [Formula presented]