Catheter-based therapy for traumatic pseudoaneurysm of the anterior tibial artery.

Tibial artery pseudoaneurysms often result from penetrating or blunt trauma to the lower extremities, or after orthopedic and endovascular interventions. Clinically, these lesions manifest as an expanding pulsatile mass of the affected area accompanied with pain and erythema. Despite the rare occurrence, traumatic tibial pseudoaneurysms can be associated with significant morbidity including local discomfort, rupture, and lower limb ischemia. Duplex ultrasound is considered the gold standard for diagnosis. Treatment options include surgical repair, ultrasound-guided compression or thrombin injection, and endovascular repair. In this report, we describe a 42-year-old male who presented to our center with pulsatile swelling over the mid-lateral aspect of the left leg. The diagnosis of a large anterior tibial artery pseudoaneurysm was made on clinical basis and was confirmed with computed tomography angiography. The lesion was treated endovascularly with a covered stent graft. In conclusion, this case highlights the role of endovascular therapy as a surgery-sparing and minimally invasive approach in managing traumatic peripheral arterial pseudoaneurysms with excellent clinical outcomes.

Fatal superior vena cava rupture complicating dialysis catheter exchange.

Central vein stenosis (CVS) is a common and challenging complication in hemodialysis patients with chronic central venous catheters (CVCs). CVS often remains asymptomatic and is discovered incidentally during follow-up imaging. CVS symptoms include arm swelling, venous hypertension, impaired dialysis flow rates, and development of collateral veins. However, these symptoms can be nonspecific and overlap with other conditions, making the diagnosis challenging. Timely recognition and appropriate intervention are crucial to prevent complications and optimize patient outcomes. Diagnostic tools commonly used include duplex ultrasonography and venography to assess the degree and location of stenosis. Management strategies for CVS encompass a multidisciplinary approach involving nephrologists, interventional radiologists, and vascular surgeons. Initial conservative measures may include anticoagulation therapy, along with pharmacological interventions such as antiplatelet agents and thrombolytics. The endovascular approach is the first line for managing CVS by using balloon angioplasty either alone or in combination with stent placement, but CVS typically recurs frequently, requiring repeated interventions with an increased risk of complications. Additionally, alternative vascular access options such as arteriovenous fistulas or grafts may be considered. In this report, we describe a case of a 25-year-old woman who presented with an extensive history of multiple dialysis access failure for left internal jugular vein central venous tunneled catheter exchange. The procedure was complicated by a fatal superior vena cava rupture likely related to the dislodgment of the guidewire causing perforation into the pericardium space with subsequent cardiopulmonary collapse. The post-mortem autopsy showed severe organized stenosis of SVC and transmural defect above the SVC/atrial junction.

Pickering syndrome in a patient with a single kidney: role of renal artery stenting.

Renal artery stenosis (RAS) is associated with hypertension and high mortality rates. With its prevalence and associated risk of death, it is important to screen for patients displaying symptoms of RAS. RAS has a wide spectrum of clinical manifestations and is usually resistant to medical therapy. Of these clinical manifestations is Pickering syndrome which is characterized by bilateral renal arterial occlusion inflow lesions, flash pulmonary edema, acute kidney injury, and hypertensive emergencies in the setting of a preserved left ventricle function. Stenting techniques have been used extensively to treat symptomatic renal artery stenosis with excellent primary patency rate, however have failed to demonstrate a long-term benefit over the optimal medical management alone in randomized trials. However, accumulating evidence suggests that stenting is justified in specific patient subgroups that have severe occlusive renal artery stenoses with significant clinical sequelae, including flash pulmonary edema, acute ischemic kidney injury, and uncontrolled hypertension. In this report we discuss the case of a 32-year-old male who presented to our center with recurrent flash pulmonary edema and hypertensive emergency and was found to have RAS, which responded well to renal artery stenting. In conclusion, correcting the renal arterial inflow stenosis is beneficial and warranted in selective clinical scenarios.

PICC line management among patients with chronic kidney disease.

More than 1 million peripherally inserted central catheters (PICC) are placed annually in the US and are used to provide convenient vascular access for a variety of reasons including long term antibiotic treatment, chemotherapy, parenteral nutrition, and blood draws. Although they are relatively easy to place and inexpensive, PICC line use is associated with many complications such as phlebitis/thrombophlebitis, venous thrombosis, catheter-related infection, wound infection, and central vein stenosis. These complications are far more deleterious for patients with chronic kidney disease (CKD) whose lives depend on a functioning hemodialysis access once they reach end stage kidney disease (ESKD). Despite recent guidelines to avoid PICC lines in CKD and ESKD patients, clinical use remains high. There is an ongoing urgency to educate and inform health care providers and the CKD patients themselves in preserving their venous real estate. In this article, we review AV access and PICC line background, complications associated with PICC lines in the CKD population, and recommendations for alternatives to placing a PICC line in this vulnerable patient population.

The role of stents in hemodialysis vascular access.

Vascular access is the Achilles' heel of dialysis therapy among patient with end stage kidney disease. The development of neointimal hyperplasia and subsequent stenosis is common in vascular access and is associated with significant morbidity. Percutaneous transluminal angioplasty using balloon inflation was the standard therapy of these lesions. However, the balloon-based approaches were associated with poor vascular access patency rate necessitating new inventions. It is within this context that different types of stents were developed in order to improve the overall dialysis vascular access functionality. In this article, we review the available literature regarding the use of stents in treating dialysis vascular access stenotic lesions. Further, we review the major clinical trials of stent use in different anatomic locations and in different clinical scenarios.

Loop arteriovenous graft of the chest wall as a viable option for dialysis.

The search for a reliable, complication-free vascular access is crucial among dialysis patients. The creation of a long-term access site for hemodialysis is dependent on several factors that mandate forming a life-plan for dialysis access, with upper extremity vascular access being the preferred route. However, complications including poor maturation, venous anastomosis lesions, and thrombosis are all associated with poor survival of these accesses. As a result, numerous patients within the dialysis population have exhausted access sites in the upper and lower extremities, requiring the search for other access options including chest wall arteriovenous graft (AVG). However, limited data is available about the outcomes of these chest wall grafts. Here, we describe two 62-year-old female dialysis patients who exhausted other dialysis access sites and subsequently underwent arteriovenous loop graft of the chest wall that connected the axillary artery with the ipsilateral axillary vein. These AVGs remained functional during the follow up period. This report highlights the viability of chest wall AVG access in the unique subset of hemodialysis patients who exhausted all other access sites.

Feasibility of Creation of an Endovascular Arteriovenous Fistula in Patients Undergoing Preoperative Vascular Mapping.

Background: The first endovascular arteriovenous fistula (endoAVF) device (WavelinQ), a novel percutaneous technique of AVF creation, was approved by the Food and Drug Administration in 2018 and has been placed in a small number of United States patients on hemodialysis. It is unknown how often patients with advanced CKD have vascular anatomy suitable for WavelinQ creation. The goal of this study was to determine the proportion of patients with vascular anatomy suitable for WavelinQ creation and to assess patient characteristics associated with such suitability. Methods: All patients referred for vascular access placement at a large academic medical center underwent standardized preoperative sonographic vascular mapping to assess suitability for an AVF. During a 2-year period (March 2019 to March 2021), we assessed the suitability of the vessels for creation of WavelinQ. We then compared the demographic characteristics, comorbidities, and vascular mapping measurements between patients who were or were not suitable for WavelinQ. Results: During the study period, 437 patients underwent vessel mapping. Of these, 51% of patients were eligible for a surgical AVF, and 32% were eligible for a WavelinQ AVF; 63% of those suitable for a surgical AVF were also suitable for a WavelinQ AVF. Patients with a vascular anatomy suitable for WavelinQ were younger (age 55±15 versus 60±14 years, P=0.01) but similar in sex, race, diabetes, hypertension, coronary artery disease, and peripheral artery disease. Conclusions: Among patients with CKD with vascular anatomy suitable for a surgical AVF, 63% are also suitable for a WavelinQ endoAVF. Older patients are less frequently suitable for WavelinQ.

De Novo Central Vein Stenosis in Hemodialysis Patients Following Initial Tunneled Central Vein Catheter Placement.

Background: Central vein stenosis (CVS) is a common complication in hemodialysis patients following tunneled central venous catheter (CVC) insertion. Little is known about its incidence, association with patient characteristics, or relationship with duration of CVC placement. We systematically evaluated central vein stenosis in hemodialysis patients receiving their first CVC exchange at a large medical center. Methods: All new hemodialysis patients underwent an ultrasound before their internal jugular tunneled CVC placement, to exclude venous stenosis or thrombosis. After the initial CVC insertion, if the patients were referred for CVC exchange due to dysfunction, a catheterogram/venogram was performed to assess for hemodynamically significant (≥50%) central vein stenosis. During a 5-year period (January 2016 to January 2021), we quantified the incidence of CVS in patients undergoing CVC exchange. We also evaluated the association of central vein stenosis with patient demographics, comorbidities, and duration of CVC dependence before exchange. Results: During the study period, 273 patients underwent exchange of a tunneled internal jugular vein CVC preceded by a catheterogram/venogram. Hemodynamically significant CVS was observed in 36 patients (13%). CVS was not associated with patient age, sex, race, diabetes, hypertension, coronary artery disease, peripheral artery disease, or CVC laterality. However, the frequency of CVS was associated with the duration of CVC dependence (26% versus 11% for CVC duration ≥6 versus <6 months: odds ratio (95% CI), 3.17 (1.45 to 6.97), P=0.003). Conclusions: Among incident hemodialysis patients receiving their first tunneled internal jugular CVC exchange, the overall incidence of de novo hemodynamically significant central vein stenosis was 13%. The likelihood of CVS was substantially greater in patients with at least 6 months of CVC dependence.

Chest wall arteriovenous graft for dialysis: A case report.

Upper extremity access sites are the preferred access sites for hemodialysis. With the improvement of the survival in dialysis population, most patients outlive the dialysis access lifespan. As such, some patients exhaust the vascular access options of the upper extremities, which necessitates the search for new access sites. While lower extremity grafts and hemodialysis reliable outflow devices are potential alternatives, these access sites are plagued with recurrent lesions at the venous anastomosis and subsequent thrombosis leading to poor access survival. Within this framework, the axillary-based dialysis access was developed to address these challenges. In this report, we describe a 70-year-old woman who exhausted her upper extremity access sites and eventually underwent a chest wall arteriovenous graft (AVG) that connected the right axillary artery to the right axillary vein. This chest wall AVG remained functional without any intervention for more than 3 years. In conclusion, chest wall AVG access can be a viable option for hemodialysis patients who have exhausted the access sites of the upper extremities, while potentially minimizing complications seen in other methods of vascular access.

Endovascular Management of Thrombosed Dialysis Vascular Circuits.

A functional hemodialysis vascular access is the lifeline for patients with end-stage kidney disease and is considered a major determinant of survival and quality of life in this patient population. Hemodialysis therapy can be performed via arteriovenous fistulas, arteriovenous grafts, and central venous catheters (CVCs). Following dialysis vascular access creation, the interplay between several pathologic mechanisms can lead to vascular luminal obstruction due to neointimal hyperplasia with subsequent stenosis, stasis, and eventually access thrombosis. Restoration of the blood flow in the vascular access circuit via thrombectomy is crucial to avoid the use of CVCs and to prolong the life span of the vascular access conduits. The fundamental principles of thrombectomy center around removing the thrombus from the thrombosed access and treating the underlying culprit vascular stenosis. Several endovascular devices have been utilized to perform mechanical thrombectomy and have shown comparable outcomes. Standard angioplasty balloons remain the cornerstone for the treatment of stenotic vascular lesions. The utility of drug-coated balloons in dialysis vascular access remains unsettled due to conflicting results from randomized clinical trials. Stent grafts are used to treat resistant and recurrent stenotic lesions and to control extravasation from a ruptured vessel that is not controlled by conservative measures. Overall, endovascular thrombectomy is the preferred modality of treatment for the thrombosed dialysis vascular conduits.

Complications of Percutaneous Peritoneal Dialysis Catheter.

A functional peritoneal dialysis (PD) catheter is the cornerstone for the success of renal replacement therapy. This success is largely dependent on adhering to best practices during catheter insertion, which starts with a comprehensive preoperative evaluation that helps in determining the catheter configuration type and both entry and exit sites. Additionally, following the best practice guidelines during PD catheter insertion minimizes undesirable complications and provides a durable functional access for dialysis. However, adverse complications are still encountered despite abiding with these clinical guidelines. These complications are categorized into mechanical and infectious groups. The description and management of these adverse events are discussed in detail in this article with particular attention to the technical pitfalls that can occur during catheter insertion. Avoiding these pitfalls can minimize PD catheter complications and potentially improve clinical outcomes.

Peritoneal Dialysis Catheter Placement: Percutaneous and Peritoneoscopic Techniques.

Chronic peritoneal dialysis (PD) is an underutilized renal replacement therapy in treating end-stage renal disease that has several advantages over hemodialysis. The success of continuous ambulatory PD is largely dependent on a functional long-term access to the peritoneal cavity. Several methods have been developed to place the PD catheter using both surgical and percutaneous techniques. The purpose of this article is to describe the percutaneous techniques using fluoroscopy guidance and peritoneoscope method. While fluoroscopic method uses fluoroscopy guidance and a guidewire to place the PD catheter, the peritoneoscopic technique utilizes a needlescope to directly visualize the peritoneal space to avoid adhesions and omentum during catheter placement. These percutaneous approaches are minimally invasive procedures that can be performed on an outpatient basis without the need for general anesthesia.

Hemodialysis Catheters: Update on Types, Outcomes, Designs and Complications.

Hemodialysis catheters (HDCs) are an essential part of kidney replacement therapy. While these catheters are considered only the bridge to long-term vascular access such as arteriovenous fistulas and grafts, they are associated with significant morbidity and mortality and subsequent increased health care expenditures. However, despite these risks, a large proportion of end stage kidney disease population initiates dialysis using these catheters. The pathogenicity of HDCs stems from its invasive nature to the venous vasculature tree resulting in both mechanical and infectious complications. Therefore, the wide use these catheters in dialysis population and the associated complications necessitated continuous innovations in the catheter material, design, and placement techniques. This review provides an update on the catheter types, catheter tip designs, and the new technologies and innovations aimed to improve the catheter functionality and mitigate its related complications.

Delayed diagnosis of a retained guidewire after bedside femoral venous catheter insertion: A preventable complication.

Central venous catheter (CVC) insertion is a commonly performed procedure that is used for continuous invasive hemodynamic monitoring, fluid resuscitation, drug therapy, and hemodialysis. CVC placement can be associated with serious complications that are mostly preventable. One of these complications is the loss of the guidewire within the intravascular space, which carries a high morbidity and mortality. Here, we describe a 44-year old patient who presented with acute kidney injury and metabolic derangements that necessitated bedside right femoral dialysis catheter to initiate emergent renal replacement therapy. A day after the catheter insertion, the guidewire was noted on a routine chest X-ray extending into the base of the skull. The clinical course was complicated with cerebral infarction. Subsequently, the retained guidewire was removed a few days after the CVC insertion. In summary, the retained guidewire within the circulation is associated with potentially life-threatening and hazardous outcomes. Continuing education, vigilant supervision, and implementing certain protocols are likely to prevent such undesirable events.

Inferior epigastric artery injury after percutaneous imaging-guided peritoneal dialysis catheter placement.

Inferior epigastric artery (IEA) injury is a rare clinical entity that is usually associated with abdominal wall procedures and injuries though can also be spontaneous, particularly in individuals with coagulopathy. Of all described mechanisms of injury, percutaneous peritoneal dialysis (PD) catheter insertion is a rarely encountered, particularly in instances where insertion is performed under imaging guidance. While this injury is self-limited, it can be associated with hemodynamic instability and acute blood loss anemia, which can be fatal if left untreated. Computed tomographic (CT) angiography is the diagnostic method of choice. Transcatheter arterial embolization is an effective treatment modality with a high success rate. Here, we describe a 41-year-old female who underwent percutaneous PD catheter insertion that, despite intraprocedural imaging guidance, was complicated by large hemoperitoneum and clinical instability. Prompt identification of IEA injury followed by immediate intervention with coil embolization led to a successful outcome for this patient in the setting of a life-threatening uncommon complication of such procedure. The details of the diagnostic evaluation and management are outlined.

Endovascular embolization for managing a massive shoulder arteriovenous malformation.

Arteriovenous malformations (AVMs) are congenital high flow pathologic linkages between arteries and veins of different sizes that may occur in any part of the body. The clinical presentation is largely dependent on the size and location of AVMs and can range from an asymptomatic birthmark to congestive heart failure in extreme cases. In this report, we describe a 20-year-old male who presented with a large AVM of the right shoulder that resulted in significant cosmetic and physical impairment and treated with several sessions of endovascular embolization with good clinical outcomes. This case highlights the complexity of diagnosing and managing these AVMs. Most of these anomalies require a multi-disciplinary approach that integrates both trans-catheter and surgical interventions with trans-arterial lesion embolization being the cornerstone of the treatment.

Transhepatic Tunneled Catheter Using Left Hepatic Vein: The Last Resort for Dialysis.

Vascular access is the Achilles tendon of hemodialysis and is considered the lifeline for patients with end stage renal disease. Arteriovenous fistulas and grafts are the preferred traditional access for performing dialysis therapy. However, some patients exhaust the traditional routes of dialysis vascular access for different reasons. In search for alternatives, other unusual vascular routes have been explored, such as transhepatic and translumbar approaches, as the last resort to preserve life in this unfortunate population. Here, we present the unusual case of a 66-year-old female who ran out of the traditional vascular access options and became catheter dependent via the right femoral vein. However, due to recurrent femoral catheter infections, extensive skin calciphylactic lesions and her body habitus, other routes were explored and the decision was to use the transhepatic approach. Traditionally, the right and middle hepatic veins are used to insert these catheters. However, the use of the left hepatic vein was not reported in the literature. Hence, in order to avoid the skin lesions seen in our patient, the dialysis catheter was inserted using the left hepatic vein. Overall, this case highlights the challenges of securing a reliable vascular access to perform dialysis therapy and brings attention to other vascular dialysis routes in certain clinical scenarios.

Comparative Study on the Outcomes of Elective-Start versus Urgent-Start Peritoneal Dialysis Catheter Placement.

The aim of this study is to compare the outcomes of the elective-start versus urgent-start use of peritoneal dialysis (PD) catheters using percutaneous radiologic or laparoscopic techniques. Patients having their first peritoneal dialysis catheter placed and used between January 2005 and January 2018 were identified, and their medical records were retrospectively reviewed. Two groups were identified: elective-start (n = 211) and urgent-start (n = 29). Patient's demographics were similar between the two groups with the exception of age, which was higher in the elective-start group. The catheter complication rates and catheter removal rates at 3 and 12 months, mean days-to-first complication, mean days-to-catheter removal, and overall patient survival at 12 months were analyzed. Catheter complication rates at 3 and 12 months were similar between the two groups (27.8% and 48.9%, respectively, in the elective-start group versus 35.9% and 54.2%, respectively, in the urgent-start group, p=0.415). The catheter removal rates at 3 and 12 months were also similar between the two groups (p=0.088). Catheter leak was higher in the urgent-start group (13.8% versus 3.3%, respectively, p=0.011). There was no difference between the elective-start and the urgent-start groups in the mean days-to-first complication (95 vs 69, p=0.086), mean days-to-catheter removal (145 vs 127, p=0.757), and overall patient survival at 12 months (100% vs 97%, p=0.41). In conclusion, apart from catheter leak, there were similar rates of catheter complication and removal for PD catheter used for the elective-start compared to the urgent-start PD. Furthermore, the technique of placement did not affect the outcomes.