Secondary interventions after iliac vein stenting for chronic proximal venous outflow obstruction.

OBJECTIVE: Iliac vein stent placement is an increasingly common procedure in the treatment of chronic proximal venous outflow obstruction (PVOO), but secondary interventions after vein stent placement remain poorly characterized. Our goal was to identify the incidence, indications, operative findings, and outcomes of secondary interventions after the primary iliac vein stent procedure at a single institution. METHODS: We retrospectively reviewed the clinical history of 490 patients (57.6% female, 42.4% male; mean age, 60.77 years [range, 18-92 years]; 93.28% follow-up, with a mean follow-up of 308.59 days) who underwent iliac vein stent placement for PVOO between October 2013 and January 2016. We evaluated the clinical presentation, intraoperative findings, and outcomes of those patients requiring a secondary intervention after an initial iliac vein stent procedure. RESULTS: Secondary interventions after an initial stent placement were identified in 50 of 490 patients (10.2%; mean age, 61.54 years [range, 19-92 years]; 58% female [n = 29]). At the time of each individual intervention, 1, 18, 17, 1, and 13 patients had Clinical, Etiology, Anatomy, and Pathophysiology class 2, 3, 4, 5, and 6 disease, respectively. Of these 50 patients, 58% (n = 29) of secondary interventions were due to recurrence of symptoms after the initial stent surgery, 18% (n = 9) were due to the development of new symptoms, and 24% (n = 12) were due to persistence of symptoms. The primary cause of PVOO in the patient cohort was 52% (n = 26) extrinsic iliac vein compression, 28% post-thrombotic, and 20% mixed. Intraoperative findings during the secondary intervention included malposition or angulation of the stent (6% [n = 3]); acute deep venous thrombosis/thrombosis (14% [n = 7]); an additional lesion, that is, stenosis in a native iliac vein proximal or distal to the original lesion (68% [n = 34]); stenosis within the stent, that is, stent stenosis without finding of thrombus or isolated, focal intrastent thrombosis (38% [n = 19]); and impairment of flow of the contralateral vessel from the previously placed stent (6% [n = 3]). The types of secondary interventions included placement of a new stent (86% [n = 43]), isolated balloon angioplasty alone (10% [n = 5]), and catheter pharmacomechanical thrombectomy (14% [n = 7]). Symptomatic improvement was observed after the secondary intervention in 90% of patients (n = 45), whereas only 2% (n = 1) of patients experienced only a transient improvement, and 8% of patients (n = 4) reported no improvement in their symptoms after the secondary interventions. CONCLUSIONS: This study establishes a secondary intervention rate of 10.2% after iliac vein stent placement for chronic PVOO and identifies discrete and definable intraoperative findings as targets for quality improvement. The very good results strongly suggest that an aggressive approach to treatment of these complications is warranted.

Hemodialysis Vascular Access: Rising Costs as a Surrogate Marker for Patency and Function of Arteriovenous Fistulas.

BACKGROUND: Establishment and maintenance of vascular access for hemodialysis is life-sustaining for patients needing renal-replacement therapy. Arteriovenous fistulas (AVFs) are the preferred type of access, but the costs associated with creation and maintenance are poorly characterized, especially with respect to patient characteristics. METHODS: A prospectively maintained registry has been established at The Mount Sinai Hospital for patients undergoing access procedures since 2007. We studied 163 patients undergoing successfully placed and cannulated AVFs as their first permanent ipsilateral access and for whom 3-year follow-up was available, including 18 patients with failed contralateral AVFs. Records were analyzed for institutional inpatient and outpatient procedures related to access maturation, imaging, catheter-related procedures, and revisions. We determined hospital costs for 3 AVF locations, assessing the contribution of various factors to variation in costs and patency. RESULTS: The median first-year cost of patent AVFs was $8,662, with $4,754 attributable to initial creation. For fistulas remaining patent for at least 3 years, median cumulative 36-month costs were $11,639, with $1,343 attributable to imaging and $10,478 to creation and interventions. Fistulas with patent lifetimes of 19-30 months (3.7%) had median cumulative costs of $26,035. Those with patent lifetimes of 6 months or shorter (6.7%) had median cumulative costs of $17,526. Right-sided fistulas were associated with 41% higher 1-year costs and 38% higher 3-year costs when compared with left-sided fistulas. Human Immunodeficiency Virus (HIV) status and prior history of complex contralateral access were also associated with higher 1-year and 3-year costs. CONCLUSIONS: Hemodialysis access maintenance contributes significantly to the healthcare burden of renal disease. Our data suggest that particular patient characteristics factor into patency and costs. Short-term mounting costs associated with AVF maintenance may portend poor long-term patency. Rising healthcare costs cannot be easily controlled without understanding the clinical factors driving them.

Arteriovenous access ischemic steal (AVAIS) in haemodialysis: a consensus from the Charing Cross Vascular Access Masterclass 2016.

Arteriovenous access ischaemic steal (AVAIS) is a serious and not infrequent complication of vascular access. Pathophysiology is key to diagnosis, investigation and management. Ischaemia distal to an AV access is due to multiple factors. Clinical steal is not simply blood diversion but pressure changes within the adapted vasculature with distal hypoperfusion and resultant poor perfusion pressures in the distal extremity. Reversal of flow within the artery distal to the AV access may be seen but this is not associated with ischaemia in most cases.Terminology is varied and it is suggested that arteriovenous access ischemic steal (AVAIS) is the preferred term. In all cases AVAIS should be carefully classified on clinical symptoms as these determine management options and allow standardisation for studies.Diabetes and peripheral arterial occlusive disease are risk factors but a 'high risk patient' profile is not clear and definitive vascular access should not be automatically avoided in these patient groups.Multiple treatment modalities have been described and their use should be directed by appropriate assessment, investigation and treatment of the underlying pathophysiology. Comparison of treatment options is difficult as published studies are heavily biased. Whilst no single technique is suitable for all cases of AVAIS there are some that suit particular scenarios and mild AVAIS may benefit from observation whilst more severe steal mandates surgical intervention.

Outcomes of dialysis catheters placed by the Y-TEC peritoneoscopic technique: a single-center surgical experience.

BACKGROUND: In the last few years, peritoneal dialysis (PD) catheter placement techniques and outcomes have become important because of the growing population of PD patients. Although there are a growing number of catheters placed by the minimally invasive Y-TEC peritoneoscopic technique, there are still limited data on outcomes for these catheters, especially those placed by a surgeon. We aimed to conduct a retrospective study of our experience with PD catheters placed by the Y-TEC peritoneoscopic technique in our institution. METHODS: We reviewed patients with peritoneoscopic PD catheter insertion over the last decade and described their complications and outcomes. In a secondary analysis, we compared the outcomes and complications of these catheters with those with open placement placed by the same surgeon. RESULTS: We had complete data on 62 patients with peritoneoscopic catheter placement during the study period. The mean age was 55 years, 48.4% were females and the most common cause of end-stage renal disease was diabetes mellitus (33%). Surgical complications were seen in only 6/62 (9.6%) and peritonitis in 16/62 (26%) of peritoneoscopic catheters. Most catheters were used after 2 months of placement, while 12.3% were used within 2 months. When compared with 93 patients with open placement of catheters as a secondary analysis, peritoneoscopic catheters were found to have a higher 2-year survival. CONCLUSION: Our large series of peritoneoscopically placed catheters by a surgeon demonstrate low surgical complications and peritonitis rates as well as superior 2-year survival compared with open placement of catheters.

Prospective multicenter study with a 1-year analysis of a new vascular graft used for early cannulation in patients undergoing hemodialysis.

OBJECTIVE: More than 85% of patients with end-stage renal disease start dialysis through a tunneled dialysis catheter (TDC) for long periods while their arteriovenous fistula or vascular access graft (arteriovenous graft [AVG]) matures. Because TDCs are associated with a high risk of complications, including death and infection, use of an AVG that can be cannulated safely immediately after implantation may reduce morbidity in these patients by allowing earlier TDC removal. We report a prospective multicenter study of a new early-cannulation AVG (Gore ACUSEAL Vascular Graft; W. L. Gore & Associates, Flagstaff, Ariz). METHODS: Patients requiring creation of a prosthetic vascular access for hemodialysis were enrolled between July 2010 and February 2012 and observed for 12 months. Data were collected on the patients' baseline characteristics; location, position, loss of patency, and revisions of prior AVGs; dialysis sessions using the AVG; and major adverse events related to graft implantation or cannulation. Cumulative and primary unassisted graft patency rates were calculated. A subgroup analysis compared outcomes in patients in whom the AVG was first cannulated within 72 hours after implantation with outcomes in patients in whom the initial cannulation was performed >21 days postoperatively. RESULTS: The population of this study was formed by 138 patients who received an ACUSEAL graft. During follow-up, 17 patients died and the AVG was abandoned in 27. The median value for follow-up was 360 days for all patients (variance 15,387). The overall mean time to initial cannulation was 15 days, with 54 grafts (40%) first cannulated within 72 hours after graft implantation and 33 grafts first cannulated >21 days afterward. The reason for late cannulation in some patients was dependent on the implanting surgeon's decision and the surgeon's personal experience with early cannulating grafts. The 1-year overall cumulative patency rate was 79% (95% confidence interval, 71%-85%); the primary unassisted patency rate was 35% (95% confidence interval, 27%-44%). Adverse events included 6 hematomas (two of which were related to cannulation and occurred 107 and 169 days, respectively, after AVG implantation), 15 graft infections, and 15 cases of steal syndrome requiring intervention. Patients in the early- and later-cannulation groups had similar characteristics and no significant differences in rates of cumulative or primary unassisted patency or adverse events. CONCLUSIONS: This study demonstrated that the new, early-cannulation AVG graft can be cannulated soon after implantation without a significant difference in patency and complication rates compared with rates associated with standard cannulation of expanded polytetrafluoroethylene grafts in the literature. This new AVG may allow early removal or avoidance of TDC use in patients undergoing hemodialysis, potentially reducing or eliminating the number of days of catheter-dependent dialysis, but further studies will be needed to demonstrate this potential.

Inflow stenosis as a contributing factor in the etiology of AV access-induced ischemic steal.

OBJECTIVE: To determine how frequent inflow stenosis is a contributing factor in the etiology of arteriovenous access-induced steal (AVAIS). METHODS: A retrospective review of hemodialysis patients who underwent interventions from October 1998 to December 2011 for AVAIS was conducted at Mount Sinai Hospital. Patients with grade 3 AVAIS and complete arch and upper extremity vascular imaging were included. Demographics, access history, time to AVAIS, preoperative angiographic imaging and interventions performed were analyzed. RESULTS: A total of 52 patients were diagnosed with grade 3 (severe) AVAIS requiring intervention over the study period. Forty-seven percent of the patients were male, average age was 62 years, 47% were of African American race and 88% were diabetic. Seventeen consecutive patients, with imaging, were included in this study. The average time to presentation of steal symptoms was 147±228 days. All of the accesses were proximal, and 65.7% were autogenous. Imaging studies consisted of angiography (14) and computed tomography angiography (3). Five patients had imaging evidence of >50% luminal inflow stenosis (29.4%). The location of stenosis was the subclavian (3 cases) and brachial (2 cases) arteries. Patients underwent distal revascularization and interval ligation (3), ligation (1) and angioplasty/stenting (1). CONCLUSION: In our population, nearly one-third of the patients with severe AVAIS had a significant subclavian or brachial artery stenosis. The implications of this finding suggest the importance of complete preoperative imaging. The treatment of the inflow stenosis by itself may not be curative, but the correction may serve as an adjunct and contribute to the success of other therapeutic procedures.

Primary leiomyosarcoma of saphenous vein presenting as deep venous thrombosis.

Only a small number of venous leiomyosarcomas have been previously reported. Of these tumors, those of saphenous origin comprise a minority of cases. A 59-year-old man presented with symptoms of deep vein thrombosis and was eventually diagnosed with primary leiomyosarcoma of great saphenous vein origin. The tumor was treated with primary resection and femoral vein reconstruction with autologous patch. Although extremely rare, saphenous leiomyosarcoma can present as deep vein thrombosis. Vascular tumors should be included in the differential diagnosis of atypical extremity swelling refractory to conventional deep vein thrombosis management.

Experience of HeRO dialysis graft placement in a challenging population.

OBJECTIVE: To assess the outcomes of the hemodialysis reliable outflow (HeRO) device in a subset of hemodialysis access-challenged patients with central venous obstruction. METHODS: Retrospective analysis of a series of patients in 2 centers who underwent placement of the HeRO device between September 2009 and November 2010. Patients' demographics, access history, HeRO patency, and number of reinterventions were analyzed. RESULTS: Eleven patients underwent 12 HeRO implantations. The average duration of dialysis prior to HeRO placement was 5.55 ± 3.64 years. Primary and secondary patencies at 6 months and 1 year were 36.4% and 54.5% and 9.1% and 45.5%, respectively. CONCLUSIONS: In the end-stage renal disease population with central venous occlusive disease, the HeRO device offers the best long-term dialysis option when an arteriovenous fistula or graft is not possible. Close follow-up and subsequent aggressive interventions can prolong the use of the HeRO and avoid the last resort of dialysis catheters.

Duplex ultrasound evaluation of hemodialysis access: a detailed protocol.

A detailed protocol for the performance and interpretation of duplex ultrasound evaluation of hemodialysis access is described.

Endovenous ablation plus microphlebectomy/sclerotherapy for the treatment of varicose veins: single or two-stage procedure?

OBJECTIVE: The purpose of this study was to establish how often after the performance of endovenous ablation (EA), a second stage is required. METHODS: Eighty-six consecutive lower extremities in 76 patients treated with laser EA were the cohort of this study. The clinical result after EA at 1 month was classified as excellent (no varicosities), good (major reduction in size), and poor (no change). Need for further intervention (sclerotherapy or microphlebectomy) was determined at the 1-month follow-up. RESULTS: Complete resolution of varicosities after EA was found in 36 extremities (41.8%), reduction in size in 48 extremities (55.8%), and no change in 2 extremities (2.3%). Of the 86 extremities studied, 36 (41.8%) were considered in need of a second stage procedure. CONCLUSION: After EA, 58.2% of extremities did not require further treatment. These results add further justification to the performance of EA alone as a first stage.

Brachial artery ligation with total graft excision is a safe and effective approach to prosthetic arteriovenous graft infections.

OBJECTIVE: While autogenous arteriovenous access is preferred, prosthetic arteriovenous grafts (AVG) are still required in a large number of patients. Infection of AVGs occurs frequently and may cause life-threatening bleeding or sepsis. Multiple treatment strategies have been advocated (ranging from graft preservation to excision with complex concomitant reconstructions), indicating a lack of consensus on appropriate management of infected AVGs. We undertook this study to evaluate if, in the setting of anastomotic involvement, brachial artery ligation distal to the origin of the deep brachial artery accompanied by total graft excision (BAL) is safe and effective. METHODS: All prosthetic arteriovenous graft infections managed by a single surgeon between 1995 and 2006 were reviewed retrospectively. Patients were identified from a computerized vascular registry, and data were obtained via patient charts and the electronic medical record. RESULTS: We identified 45 AVG infections in 43 patients. Twenty-one patients (49%) demonstrated arterial anastomotic involvement and were treated with BAL; these form the cohort for this analysis. Mean patient age was 53.2 (SD 9.5) years. The primary etiologies for end stage renal disease (ESRD) were hypertension (29%), HIV (24%), and diabetes (19%). An upper arm AVG was present in 95% of patients; one (5%) had a forearm AVG. The majority of grafts were polytetrafluoroethylene (PTFE) (90%). Follow-up was 100% at 1 month, 86% at 3 months, and 67% at 6 months. No ischemic or septic complications occurred in the 21 patients who underwent BAL. CONCLUSION: BAL is an effective and expeditious method to deal with an infected arm AVG in frequently critically ill patients with densely scarred wounds. In the short term, BAL appears to be well tolerated without resulting ischemic complications. Further study with longer duration of follow-up is necessary to ascertain whether BAL results in definitive cure, or whether patients may ultimately manifest ischemic changes and require additional intervention.

Use of digital pressure measurements for the diagnosis of AV access-induced hand ischemia.

Diagnosis of hand ischemia secondary to an arteriovenous (AV) hemodialysis access is predominantly based on clinical findings. Occasionally, this diagnosis is unclear and more objective diagnostic testing is needed. No validated method of objective testing currently exists. The purpose of this study is to evaluate digital pressure measurements in the diagnosis of AV access-induced hand ischemia. A case-control study of 40 patients with an upper extremity AV access consisted of 15 patients (38%) with clinical AV access-induced hand ischemia and 25 patients (62%) without clinical evidence of ischemia. Arterial pressure in the third finger ipsilateral to the AV access was measured by digital photoplethysmography. Basal digital pressure (BDP), digital to contralateral brachial index (DBI), and change in digital pressure with access compression (CDP) were determined. Logistic regression modeling with gains tables and ROC calculations were used to determine optimal test thresholds and to test model discrimination for predicting AV access-induced hand ischemia. The mean BDP (30 vs 102 mmHg; p < 0.001) and mean DBI (0.3 vs 0.8; p < 0.001) were significantly lower in patients with AV access-induced hand ischemia than in those without. The accuracy for determining hand ischemia using a threshold-adjusted BDP of 60 mmHg was 92% (sensitivity 100%, specificity 87%) and using DBI of 0.4 was 94% (sensitivity 92%, specificity 96%). While the mean CDP was significantly higher in patients with hand ischemia (85 vs 40; p < 0.001), the accuracy for predicting ischemia was marginal (78%). In conclusion, a BDP less than 60 mmHg or a DBI less than 0.4 in a patient with an AV access were highly associated with hand ischemia. CDP's marginal discrimination ability likely stems from the presence of asymptomatic physiologic steal in the group without clinical steal. Nonetheless, CDP may be useful in identifying patients with ischemia who will not benefit from an intervention that specifically targets the AV access.

Transposition of the brachial vein: a new source for autologous arteriovenous fistulas.

Increasing the prevalence of arteriovenous fistula over arteriovenous synthetic graft is critical for decreasing the morbidity and costs of dialysis patients. This is highlighted in the guidelines set forth by The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI), which encourage the increased use of autogenous vein in fistula creation. In addition to the basilic and cephalic veins, another source of autogenous vein is the brachial vein, a deep vein of the upper arm. Here we describe 2 patients with absence of adequate superficial veins, in whom a transposed brachial vein was used for the creation of an arteriovenous fistula.

Management of steal syndrome resulting from dialysis access.

Ischemic steal secondary to a hemodialysis arteriovenous (AV) access occurs in approximately 10% of cases. The pathophysiological basis of this condition is a marked decrease or reversal of flow in the arterial segment distal to the AV fistula or AV graft, induced by the low resistance of the fistula outflow. Clinically it can manifest with either mild symptoms (coolness, paresthesia, and absence of distal pulses), or severe symptoms (rest pain, severe paresthesia, paralysis, cyanosis, and gangrene) immediately after construction of the AV access or later after its inception. Diagnosis is based on clinical manifestations, aided by the vascular laboratory and angiography. Mild cases can be observed closely, most of them will reverse in a few weeks. In order to prevent permanent sequela, severe cases require immediate intervention. Several surgical treatments have been used: access ligation, banding, elongation, distal arterial ligation, and distal revascularization-interval ligation. Best results, with maintenance of access function and reversal of symptoms, have been obtained with the distal revascularization-interval ligation procedure.