Staged brachioradial artery to brachioradial vein arteriovenous fistula creation for hemodialysis access in three patients with a high origin of the radial artery.

When patients lack suitable superficial veins in the upper extremity to create an arteriovenous fistula, surgeons are faced with a decision between a synthetic graft or autologous fistula using deep veins, such as a brachial artery to brachial vein arteriovenous fistula. In patients with a high radial artery origin (or brachioradial artery) and inadequate superficial veins, arteriovenous fistula creation will be even more challenging. In the present report, we describe a technique used in three such patients who underwent successful staged brachioradial artery to brachioradial vein arteriovenous fistula creation.

Aneurysm of the anterior tibial artery as a complication of infectious endocarditis.

OBJECTIVE: Mycotic aneurysms of the infrapopliteal vessels are rare, with few cases reported in the literature. Management strategies are diverse and should be tailored to the patient's presentation. METHODS: We describe the case of a 40-year-old male who presented with a painful left leg mass in the setting of bacteremia and infective endocarditis. Imaging revealed an aneurysm of the anterior tibial artery. RESULTS: The patient was treated with antibiotics and open surgical repair with excision of the aneurysmal sac, ligation of the anterior tibial artery, and primary repair of the popliteal artery and tibioperoneal trunk. CONCLUSION: The epidemiology, pathophysiology, and clinical management of infrapopliteal aneurysms are briefly reviewed in this case study.

Four patients with a clinically significant radial artery anomaly.

The superficial radial artery is an anatomic variant in which the radial artery passes superficial to the tendons of the anatomic snuffbox. Cadaver studies have shown its incidence to be 0.5% to 1%. Four patients with this anatomic variation were encountered in our practice, and their clinical courses and anatomy are described. One patient presented with digital ischemia after catheter placement in the anomalous radial artery. Three patients with end-stage renal disease were found to have a superficial radial artery incidentally, and this was used for inflow in the creation of hemodialysis fistulas.

Placement of Upper Extremity Arteriovenous Access in Patients with Central Venous Occlusions: A Novel Technique.

BACKGROUND: Central venous occlusion is a common occurrence in patients with end-stage renal disease. Placement of upper extremity arteriovenous access in patients with occlusion of the brachiocephalic veins is often not an option. Avoidance of lower extremity vascular access can decrease morbidity and infection. METHODS: The central venous lesions were crossed centrally via femoral access. The wire was retrieved in the neck extravascularly. A Hemodialysis Reliable Outflow catheter was then placed in the right atrium and completed with an arterial anastomosis. RESULTS: We describe a novel technique for placing upper extremity arteriovenous access in patients with occlusion of the brachiocephalic veins. This technique was utilized in 3 patients. The technical success was 100%. CONCLUSIONS: The placement of upper extremity arteriovenous access in patients with central venous occlusions is technically feasible.

Distal Radial Artery Embolization: An Alternative Approach towards Access Preservation and Limb Salvage in Radiocephalic Arteriovenous Fistulae Complicated by Steal Syndrome.

The incidence of radiocephalic arteriovenous fistulae complicated by ischemic steal syndrome is low; however, its sequelae can be quite devastating. Traditional management includes open ligation of the distal radial artery. This series details 4 cases of successful embolization of the distal radial artery for flow interruption to treat ischemic steal syndrome and salvage functional dialysis access. For radiocephalic arteriovenous fistulae complicated by steal syndrome, distal radial artery endovascular coil embolization is a valuable treatment strategy.

Comparison of Nonpenetrating Titanium Clips versus Continuous Polypropylene Suture in Dialysis Access Creation.

BACKGROUND: Nonpenetrating titanium surgical clips (clips) offer a theoretical advantage of inducing less intimal hyperplasia at an anastomosis because of less endothelial injury. Whether this translates into improved outcomes when used in the creation of arteriovenous fistulas (AVFs) remains unclear. We sought to compare the maturation, patency, and failure rates of anastomoses created using traditional continuous polypropylene suture and clips. METHODS: All primary AVF created at a single Veterans Administration Medical Center were reviewed over a 6-year period. Anastomoses were created with either clips or suture based on surgeon preference. Patient characteristics and surgical outcomes were collected. Comparisons were made between the 2 groups. RESULTS: Over a 6-year period, 334 fistulas were created (29% suture and 71% clips) in 326 patients. The mean age was 64.8 ± 11 years with 98% males. Comorbidities included diabetes (70%), hypertension (96.1%), and tobacco use (52.9% previous or current). Approximately half the patients were predialysis. Comparison of patient characteristics showed no differences between the suture and clip groups. There was no significant difference in maturation rate (suture 79% versus clips 72%, P = 0.25), median time to maturation (suture 62 ± 35 versus clips 71 ± 13 days, P = 0.07), 1 year primary patency rate (suture 37.4% versus clips 39.6, P = 0.72), 1 year assisted primary patency rate (suture 82.4% versus clips 76.3%, P = 0.31), or overall failure rates (suture 62% versus clips 58%, P = 0.56). Median time to initial failure or reintervention was not significantly different in the clip group (suture 615 [range, 239-991] versus clips 812 [range, 635-989] days, P = 0.72). CONCLUSIONS: Compared to traditional polypropylene suture creation of upper extremity AVFs, nonpenetrating clips had equivalent maturation, 1-year patency, and overall failure rates. Neither clips nor suture offers any clear advantage in the creation of AVF.

Early vascular consultation in the setting of oncologic resections: benefit for patients and a continuing source of open vascular surgical training.

BACKGROUND: Oncologic surgeons have become more aggressive at tumor resections that often require complex open vascular interventions. Vascular surgeons may be consulted preoperatively to aid in these cases, or commonly called into the operating room for an urgent consult. These operations provide a challenge to the vascular surgeon and also an opportunity for open vascular surgical training of residents. We present our experience with vascular surgical interventions during oncologic resections. METHODS: A retrospective review of a prospectively maintained vascular registry was performed to identify patients undergoing vascular surgery in the setting of oncologic resections. Tumor histology, location, type of vascular intervention, vascular, and oncologic outcomes were recorded and reviewed. RESULTS: Over a 7-year period, 21 oncologic cases involving vascular surgeons were identified. Tumor types included sarcoma (9), adenocarcinoma (4), germ cell (4), paraganglioma (2), and others (2). Tumor locations included abdominal/pelvic (15), cervical (3), and extremity (3). Complete resection was achieved in 18 of the 19 patients; 2 patients underwent exploration alone for carcinomatosis. Vascular surgical procedures included bypass grafts in 7 patients, resection with primary repair in 5 patients, ligation/excision in 4 patients, and arterial mobilization in 3 patients. No major vascular complications occurred. Short-term patency rates were 100%. Survival rates following therapeutic resection were 90%, 80%, and 80% at 1, 3, and 5 years, respectively. Vascular surgeons were involved in the preoperative planning in 11 cases (52%). Patients with preoperative vascular consultation had significantly fewer vascular injuries, a nonsignificant trend toward lower blood loss, and a nonsignificant trend toward improved survival than those with urgent intraoperative vascular consultation. CONCLUSIONS: Vascular interventions can lead to favorable long-term outcomes during definitive oncologic resection of diverse tumor histologies and locations. Vascular surgeons must be prepared to participate, frequently urgently, in oncologic procedures. Standard open techniques employing all aspects of vascular exposures continue to be integral to vascular surgery training. Preoperative consultation between the oncologic and vascular surgeons may lead to improved outcomes.

Evaluation of superficial femoral artery remote endarterectomy for treatment of critical limb ischemia in patients with limited autogenous conduit.

BACKGROUND: Many patients with critical limb ischemia require infrageniculate bypass with a prosthetic graft due to the limited availability of autogenous vein. Prosthetic grafts have been shown to have inferior patency and subject the patient to increased infection rates when compared to bypass with autogenous conduit for lower extremity revascularization. In an effort to avoid the use of prosthetic material, we evaluated the use of remote superficial femoral artery endarterectomy (RSFAE) with distal autogenous revascularization in patients with critical limb ischemia and limited conduit. METHODS: This study is a retrospective review of a prospectively maintained database from January 2009 to September 2011. All patients undergoing RSFAE for critical limb ischemia were identified. Patients undergoing RSFAE with simultaneous distal revascularization constituted the study group. Outcome variables, including patency, time to healing, limb salvage, ambulatory status, and survival, were analyzed. RESULTS: Twenty-one patients underwent RSFAE at our institution. The study group was comprised of 5 patients undergoing RSFAE and adjunct distal revascularization for critical limb ischemia during the study period. Four patients (80%) presented with tissue loss, and 1 (20%) presented with ischemic rest pain. Three (60%) required simultaneous outflow sequential vein bypass and 2 (40%) required distal endovascular revascularization. The distal target vessels for bypass included the infrageniculate popliteal artery, posterior tibial artery, and peroneal artery. The mean operative time was 5.3 hours. The mean length of hospital stay was 8 days. Technical success was 100%, and there were no early reconstruction failures. There was 1 popliteal wound complication, and no groin wound complications during the study follow-up. At 6 months postoperatively, 4 of 5 reconstructions were patent. Two of 5 patients (40%) required percutaneous reintervention for restenosis at 10 and 11 months, respectively. Primary assisted patency was 80% with a mean follow-up of 12.6 months (range 8-22 months). The 4 patients with tissue loss achieved initial wound healing at a mean time of 4.8 months. The limb salvage rate was 80% and there have been no deaths. CONCLUSIONS: Remote superficial femoral artery endarterectomy with distal revascularization allows for autogenous reconstruction in patients with critical limb ischemia and compromised conduit by shortening bypass length. This procedure constitutes an appealing alternative to the use of synthetic material for lower extremity revascularization. Further study is needed to determine whether the long-term results are superior to distal composite bypass or polytetrafluoroethylene bypass alone.