Technique of percutaneous closure of an endovascular arteriovenous fistula created for dialysis access.

Endovascular arteriovenous fistulas (eAVFs) are a new and less invasive type of creation for dialysis access. The anastomosis for eAVFs often occurs between the ipsilateral proximal radial artery and vein or proximal ulnar artery and vein. As eAVF creations are in locations that are not traditionally used for surgical AVF creations, the question of how to approach reversal of these fistulas arises. Here we present a case of closure of an ulnar artery to ulnar vein eAVF.

Hemodialysis Arteriovenous Access Cosmesis Scale (AVACS): A new measure for vascular access.

RATIONALE AND OBJECTIVE: This study aimed to develop a cosmesis scale to evaluate the cosmetic appearance of hemodialysis (HD) arteriovenous (AV) accesses from the perspective of the patient and clinician, which could be incorporated into clinical trials. STUDY DESIGN: Using a modified Delphi process, two AV access cosmesis scale (AVACS) components were developed in a four-round Delphi panel consisting of two surveys and two consensus meetings with two rounds of patient consultation. SETTING AND PARTICIPANTS: The Delphi panel consisted of 15 voting members including five interventional or general nephrologists, five vascular surgeons, three interventional radiologists, and two vascular access nurse coordinators. Four patients experienced with vascular access were involved in patient question development. ANALYTICAL APPROACH: For a component to be included in the AVACS, it had to meet the prespecified panel consensus agreement of ⩾70%. RESULTS: The clinician component of the AVACS includes nine questions on the following AV access features: scarring, skin discoloration, aneurysm/pseudoaneurysms and megafistula appearance. The patient component includes six questions about future vascular access decisions, interference with work or leisure activities, clothing choices, self-consciousness or attractiveness, emotional impact, and overall appearance. LIMITATIONS: Delphi panel methods are subjective by design, but with expert clinical opinion are used to develop classification systems and outcome measures. The developed scale requires further validation testing but is available for clinical trial use. CONCLUSIONS: While safety and efficacy are the primary concerns when evaluating AV access for HD, cosmesis is an important component of the ESKD patient experience. The AVACS has been designed to assess this important domain; it can be used to facilitate patient care and education about vascular access choice and maintenance. AVACS can also be used to inform future research on developing new techniques for AV access creation and maintenance, particularly as relates to AV access cosmesis.

Effectiveness of exclusion of a persistent sciatic artery aneurysm with an Amplatzer™ plug.

Persistent sciatic artery is a rare developmental anomaly. In its complete form, it provides the major arterial supply to the lower leg since the femoral system is hypoplastic. These unique arteries are prone to aneurysm formation and most commonly present with complications related to aneurysm formation, which can lead to limb loss. We encountered a 68-year-old man presenting with bilateral lower-extremity ischemia who was found to have bilateral persistent sciatic artery aneurysms. One aneurysm had already thrombosed, but the other was still patent. We treated this patient with a hybrid open and endovascular repair on the patent side. The aneurysm was excluded with an Amplatzer™ plug (St. Jude Medical, Inc., St. Paul, MN) followed by a femoropopliteal bypass with saphenous vein in situ to revascularize the lower leg. To our knowledge, this is only the second report of a persistent sciatic artery aneurysm successfully treated with Amplatzer plug occlusion.

Thermoregulatory catheter-associated inferior vena cava thrombus.

The use of thermoregulatory catheters (TRCs) in critically ill patients has become increasingly popular. TRCs have been shown to be effective in regulating patient body temperature with improved outcomes. Critically ill patients, especially multitrauma patients and those with femoral catheters, are at high risk for deep vein thrombosis (DVT). Among patients for whom chemical DVT prophylaxis is not an option, inferior vena cava (IVC) filters are often placed prophylactically. The development of intravascular ultrasound (IVUS) has allowed placement of IVC filters at the bedside for patients who are too ill for transport to the operating room or cardiac catheterization lab. After encountering several patients with occult DVT of the IVC during bedside IVC filter placement, we performed a retrospective review to determine the incidence of DVT or pulmonary embolus (PE) in patients who had been treated with a TRC at Baylor University Medical Center at Dallas. Since 2008, IVC filters have been deployed at the bedside with the use of IVUS at Baylor University Medical Center. During that same time period, 83 patients had a TRC placed for either intravascular warming or cooling during their resuscitation. Forty-seven out of 83 patients who had a TRC placed survived their injuries. Ten of 47 patients (21%) were diagnosed with DVT or PE, and 6 of these 10 (60%) were found to have caval thrombus. We present this case series as evidence that undiagnosed IVC thrombus associated with TRCs may be higher than previously suspected, given that 5 out of 10 patients who had IVUS of their IVC for prophylactic IVC filter placement, as well as one patient diagnosed with PE, were found to have caval thrombus.