Treatment Options for Hemodialysis-related Central Vein Occlusive Disease: Case Series and Review of Literature.

Central venous occlusive disease is commonly seen in patients undergoing hemodialysis and can threaten the viability of the arteriovenous access. Majority of cases are related to central venous catheter placement. This paper reports on three patients on chronic hemodialysis who presented with signs and symptoms of upper extremity venous hypertension and underwent three different therapeutic modalities, all with successful relief of symptoms. A review of the existing literature on past and current treatment options is done.

New Imaging Markers in Multiple Sclerosis and Related Disorders: Smoldering Inflammation and the Central Vein Sign.

Concepts of multiple sclerosis (MS) biology continue to evolve, with observations such as "progression independent of disease activity" challenging traditional phenotypic categorization. Iron-sensitive, susceptibility-based imaging techniques are emerging as highly translatable MR imaging sequences that allow for visualization of at least 2 clinically useful biomarkers: the central vein sign and the paramagnetic rim lesion (PRL). Both biomarkers demonstrate high specificity in the discrimination of MS from other mimics and can be seen at 1.5 T and 3 T field strengths. Additionally, PRLs represent a subset of chronic active lesions engaged in "smoldering" compartmentalized inflammation behind an intact blood-brain barrier.

Multiple Sclerosis: Clinical Update and Clinically-Oriented Radiologic Reporting.

Multiple sclerosis (MS) is a chronic inflammatory disease of the nervous system. MR imaging findings play an integral part in establishing diagnostic hallmarks of the disease during initial diagnosis and evaluating disease status. Multiple iterations of diagnostic criteria and consensus guidelines are put forth by various expert groups incorporating imaging of the brain and spine, and efforts have been made to standardize imaging protocols for MS. Emerging ancillary imaging findings have also attracted increasing interests and should be sought for on radiologic examination. In this paper, the authors review the clinical guidelines and approach to imaging of MS and related disorders, focusing on clinically impactful image interpretation and MR imaging reporting.

Unveiling the Therapeutic Potential of Vitamin-E in Preventing Inflammation and Stromal Congestion in Alcoholic Liver Injury.

OBJECTIVES: The objective of the research was to investigate and assess how effective Vitamin E is in preventing or reducing liver inflammation and stromal congestion associated with alcoholic liver injury. STUDY DESIGN: This is a laboratory-based experimental study. METHODOLOGY: A total of 18 domestic rabbits were divided into groups A, B, and C. Group A was the control group and treated with normal saline as a placebo. Groups B and C were given 30% ethanol in a daily dose of 30 ml/kg/day. Additionally, group C was treated with vitamin E at 50 mg/kg/day. All three groups were sub-divided into two sub-groups I and II on the basis of experimental duration of eight weeks and four weeks respectively. The subgroups with eight weeks of experimental time duration were categorized as "category E8" and subgroups with an experimental duration of four weeks were categorized as "category E4". Liver tissue samples from each animal were subjected to staining using hematoxylin and eosin (H&E) stain for histological staining in order to assess portal inflammation and to measure the sizes of hepatic sinusoids and central veins to evaluate hepatic congestion. RESULTS: A statistically significant variance was observed in the size of central veins, hepatic sinusoids, and invasion of inflammatory cells in portal areas across and between the groups within categories E4 and E8. Animals treated with vitamin E exhibited lower invasion of inflammatory cells and larger central veins and sinusoids compared to those not treated with vitamin E. CONCLUSION: Vitamin E may have a significant role in reducing or limiting the infiltration of inflammatory cells and could help prevent hepatic congestion in cases of alcoholic liver injury.

Incidence and Predictors of Acute Coronary Syndrome in Patients on Maintenance Hemodialysis: A Prospective Cohort Study.

Background: Cardiovascular diseases are the leading cause of death among patients on hemodialysis, with approximately 40% of the cardiovascular deaths linked to acute coronary syndrome. We aimed to investigate the incidence and risk factors of acute coronary syndrome in patients undergoing hemodialysis. Methods: Patients undergoing hemodialysis were prospectively enrolled from January 2018. Data regarding hospitalization due to acute coronary syndrome were collected at 3-month intervals through December 31, 2021. Cox regression model was used to estimate the association between baseline factors and incident acute coronary syndrome during follow-up. Results: Patients' mean age was 66 years, 48% were men, and 16% had a history of coronary artery disease at enrolment. Over a median follow-up of 1,187 days, 85 patients were hospitalized due to acute coronary syndrome. Left main or triple vessel disease was identified in 67 patients. Risk factors associated with incident acute coronary syndrome included aging, male sex, smoking, low diastolic blood pressure, and baseline comorbidities, in addition to dialysis factors including low urea clearance, central venous catheter use, and history of dialysis access dysfunction. After multivariate analysis, age, diabetes, hyperlipidemia, smoking, and frequent interventions for vascular access remained significant risk factors. Conclusions: A high acute coronary syndrome incidence was observed in our cohort, with traditional risk factors playing a consistent role with that in the general population. A history of frequent dialysis access dysfunction was also associated with incident acute coronary syndrome.

Successful management of fatal cardiac tamponade resulting from intravascular intervention for central vein occlusion in hemodialysis patients: A case report.

This case report highlights the successful management of fatal cardiac tamponade caused by intravascular intervention for central vein occlusion in hemodialysis patients. Prompt diagnosis and treatment are essential for patient prognosis in such cases. We present a case involving a challenging surgical procedure to address multiple complications, emphasizing the importance of early detection and appropriate interventions. The patient, who had a history of long-term central venous catheter use for hemodialysis, was diagnosed with central vein stenosis in addition to superior vena cava occlusion, hemodialysis catheter rupture, hypertension, and end-stage renal disease. Urgent ultrasound examination during surgery revealed pericardial effusion, prompting immediate pericardial drainage for stabilization. To overcome the complex challenges, we successfully performed an innominate vein-right atrial appendage bypass to restore vascular access and salvage the patient's life. The timely use of echocardiography for diagnosis and pericardial drainage contributed to stabilizing the patient's vital signs, providing an opportunity for subsequent surgical intervention. The innominate vein-right atrial appendage bypass procedure successfully relieved central vein stenosis and saved the patient's life. Although this surgical technique is not widely documented in hemodialysis patients with central venous involvement, it show cases the potential benefits for clinicians managing vascular access in this patient population. This case report underscores the need for awareness among clinicians regarding the risk of cardiac tamponade associated with intravascular intervention for central vein stenosis in hemodialysis patients. Minimizing central venous catheterization and prioritizing autogenous arteriovenous fistulas are crucial principles in preparing vascular access for hemodialysis patients. Early detection, timely interventions, and consideration of alternative surgical techniques can improve outcomes and prevent life-threatening complications.

Susceptibility-weighted image features in AQP4-negative-NMOSD versus MS.

OBJECTIVE: To characterize the susceptibility-weighted image (SWI) features including paramagnetic rim and nodular lesions with signal intensity changes and central vein sign (CVS) associated with aquaporin 4 (AQP4)-immunoglobulin G (IgG)-negative neuromyelitis optica spectrum disorder (NMOSD), and explore whether they can be used as potential imaging biomarkers for differentiating multiple sclerosis (MS) from this disorder. METHODS: We prospectively recruited NMOSD with AQP4-IgG-negative (AQP4- NMOSD) and IgG-positive (AQP4+ NMOSD), and MS subjects from the Clinical and Imaging Patterns of Neuroinflammation Diseases in China (CLUE) project (NCT0410683) between 2019 and 2021. The SWI features including paramagnetic rim and nodular lesions with signal intensity changes and CVS were analyzed and compared among groups, and the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined for distinguishing MS from AQP4- NMOSD. RESULTS: We enrolled a total of 160 consecutive patients (22 AQP4- NMOSD, 65 AQP4+ NMOSD, and 73 MS). We observed paramagnetic rim lesion (0/120 lesions, 0 %) and nodular (1/120, 1 %) lesions with hypointense signals on SWI in the AQP4- NMOSD group. These characteristics were similar to those recorded from AQP4+ NMOSD patients (rim: 0/369 lesions, 0 %, P = 1.000; nodular: 10/369 lesions, 2.7 %, P = 1.000), but differed significantly from those observed in the MS group (rim: 162/1665 lesions, 9.7 %, P<0.001; nodular: 392/1665 lesions, 23.5 %, P < 0.001). AQP4- NMOSD patients had fewer average CVS+ rate (12 %) than MS patients (46 %, p<0.001), similar to AQP4+ NMOSD (13 %, p = 1.000). The SWI imaging features denoting lesions with paramagnetic rim or nodular hypointense SWI signals showed 90.4 % sensitivity, 95.5 % specificity, 98.5 % PPV, and 75 % NPV, and the criteria with≥3 CVS lesions showed sensitivity of 91.8 %, specificity of 90.9 %%, PPV of 97.1 %, and NPV of 76.9 % in distinguishing MS from AQP4- NMOSD. DISCUSSION: The SWI imaging features including lesions with paramagnetic rim or nodular hypointense SWI signals and 3 CVS lesions carries useful information in distinguishing MS from AQP4- NMOSD.

Central intra-lesional iron deposits as a possible novel imaging marker at 7 Tesla MRI in Susac Syndrome - an exploratory study.

BACKGROUND: Susac syndrome (SuS) is a rare autoimmune disease that leads to hearing impairment, visual field deficits, and encephalopathy due to an occlusion of precapillary arterioles in the brain, retina, and inner ear. Given the potentially disastrous outcome and difficulties in distinguishing SuS from its differential diagnoses, such as multiple sclerosis (MS), our exploratory study aimed at identifying potential new SuS-specific neuroimaging markers. METHODS: Seven patients with a definite diagnosis of SuS underwent magnetic resonance imaging (MRI) at 7 Tesla (7T), including T2* weighted and quantitative susceptibility mapping (QSM) sequences. T2 weighted hyperintense lesions were analyzed with regard to number, volume, localization, central vein sign, T1 hypointensity, and focal iron deposits in the center of SuS lesions ("iron dots"). Seven T MRI datasets from the same institute, comprising 75 patients with, among others, MS, served as controls. RESULTS: The "iron dot" sign was present in 71.4% (5/7) of the SuS patients, compared to 0% in our control cohort. Thus, sensitivity was 71.4% and specificity 100%. A central vein sign was only incidentally detected. CONCLUSION: We are the first to demonstrate this type of "iron dot" lesions on highly resolving 7T T2*w and QSM images in vivo as a promising neuroimaging marker of SuS, corroborating previous histopathological ex vivo findings.

A multicenter pilot study evaluating simplified central vein assessment for the diagnosis of multiple sclerosis.

BACKGROUND: The central vein sign (CVS) is a proposed magnetic resonance imaging (MRI) biomarker for multiple sclerosis (MS); the optimal method for abbreviated CVS scoring is not yet established. OBJECTIVE: The aim of this study was to evaluate the performance of a simplified approach to CVS assessment in a multicenter study of patients being evaluated for suspected MS. METHODS: Adults referred for possible MS to 10 sites were recruited. A post-Gd 3D T2*-weighted MRI sequence (FLAIR*) was obtained in each subject. Trained raters at each site identified up to six CVS-positive lesions per FLAIR* scan. Diagnostic performance of CVS was evaluated for a diagnosis of MS which had been confirmed using the 2017 McDonald criteria at thresholds including three positive lesions (Select-3*) and six positive lesions (Select-6*). Inter-rater reliability assessments were performed. RESULTS: Overall, 78 participants were analyzed; 37 (47%) were diagnosed with MS, and 41 (53%) were not. The mean age of participants was 45 (range: 19-64) years, and most were female (n = 55, 71%). The area under the receiver operating characteristic curve (AUROC) for the simplified counting method was 0.83 (95% CI: 0.73-0.93). Select-3* and Select-6* had sensitivity of 81% and 65% and specificity of 68% and 98%, respectively. Inter-rater agreement was 78% for Select-3* and 83% for Select-6*. CONCLUSION: A simplified method for CVS assessment in patients referred for suspected MS demonstrated good diagnostic performance and inter-rater agreement.

Paramagnetic rim lesions and the central vein sign: Characterizing multiple sclerosis imaging markers.

BACKGROUND AND PURPOSE: Paramagnetic rims and the central vein sign (CVS) are proposed imaging markers of multiple sclerosis (MS) lesions. Using 7 tesla magnetic resonance imaging, we aimed to: (1) characterize the appearance of paramagnetic rim lesions (PRLs); (2) assess whether PRLs and the CVS are associated with higher levels of MS pathology; and (3) compare the characteristics between subjects with and without PRLs in early MS. METHODS: Prospective study of 32 treatment-naïve subjects around the time of diagnosis who were assessed for the presence of PRLs and the CVS. Comparisons of lesion volume and macromolecular pool size ratio (PSR) index, a proxy of myelin integrity, between PRLs and non-PRLs, and CVS-positive and CVS-negative lesions were carried out. Differences in clinical/demographic characteristics between patients with PRLs and those without were tested. RESULTS: Fifteen subjects had ≥1 PRL for a total of 36 PRLs, of which two-thirds had a full rim. PRLs predicted a larger lesion size and decreased PSR signal. Lesion volume and presence of cervical spine lesions were significantly different between subjects with PRLs and those without, although neither remained significant after adjusting for multiple comparisons. One hundred and eighty-one lesions with CVS were identified with no differences between CVS-positive and CVS-negative lesions in volume (p = .27) and PSR values (p = .62). CONCLUSIONS: PRLs, but not CVS-positive lesions, are larger and have lower myelin integrity. Our findings indicate that PRLs are associated with higher levels of lesion-specific pathology prior to the start of disease-modifying therapy.

Treatment options for hemodialysis-related central vein occlusive disease: Case series and review of literature

@#Central venous occlusive disease is commonly seen in patients undergoing hemodialysis and can threaten the viability of the arteriovenous access. Majority of cases are related to central venous catheter placement. This paper reports on three patients on chronic hemodialysis who presented with signs and symptoms of upper extremity venous hypertension and underwent three different therapeutic modalities, all with successful relief of symptoms. A review of the existing literature on past and current treatment options is done.

Cervical spinal cord susceptibility-weighted MRI at 7T: Application to multiple sclerosis.

BACKGROUND: Susceptibility-weighted imaging (SWI) has been extensively studied in the brain and in diseases of the central nervous system such as multiple sclerosis (MS) providing unique opportunities to visualize cerebral vasculature and disease-related pathology, including the central vein sign (CVS) and paramagnetic rim lesions (PRLs). However, similar studies evaluating SWI in the spinal cord of patients with MS remain severely limited. PURPOSE: Based on our previous findings of enlarged spinal vessels in MS compared to healthy controls (HCs), we developed high-field SWI acquisition and processing methods for the cervical spinal cord with application in people with MS (pwMS) and HCs. Here, we demonstrate the vascular variability between the two cohorts and unique MS lesion features in the cervical cord. METHODS: In this retrospective, exploratory pilot study conducted between March 2021 and March 2022, we scanned 12 HCs and 9 pwMS using an optimized non-contrast 2D T2*-weighted gradient echo sequence at 7 tesla. The overall appearance of the white and gray matter as well as tissue vasculature were compared between the two cohorts and areas of MS pathology in the patient group were assessed using both the magnitude and processed SWI images. RESULTS: We show improved visibility of vessels and more pronounced gray and white matter contrast in the MS group compared to HCs, hypointensities surrounding the cord in the MS cohort, and identify signal changes indicative of the CVS and paramagnetic rims in 66 % of pwMS with cervical spinal lesions. CONCLUSION: In this first study of SWI at 7T in the human spinal cord, SWI holds promise in advancing our understanding of disease processes in the cervical cord in MS.

Central vein stenosis in hemodialysis vascular access: clinical manifestations and contemporary management strategies.

Central venous stenosis is a significant and frequently encountered problem in managing hemodialysis (HD) patients. Venous hypertension, often accompanied by severe symptoms, undermines the integrity of the hemodialysis access circuit. In central venous stenosis, dialysis through an arteriovenous fistula is usually inefficient, with high recirculation rates and prolonged bleeding after dialysis. Central vein stenosis is a known complication of indwelling intravascular and cardiac devices, such as peripherally inserted central catheters, long-term cuffed hemodialysis catheters, and pacemaker wires. Hence, preventing this challenging condition requires minimization of central venous catheter use. Endovascular interventions are the primary approach for treating central vein stenosis. Percutaneous angioplasty and stent placement may reestablish vascular function in cases of elastic and recurrent lesions. Currently, there is no consensus on the optimal treatment, as existing management approaches have a wide range of patency rates.

Assessment of dysfunctional tunneled hemodialysis catheters and outcome of endovascular salvage techniques: a simple solution to a complex problem.

Objective: The aim of this study was to evaluate the causes of the dysfunctional tunneled cuffed catheters (TCCs) using multi-spiral computed tomography venography (MSCTV), and to analyze the outcomes of endovascular salvage techniques. Material and methods: This retrospective review data from 27 patients who experienced TCC dysfunction between July 1, 2016 and January 31, 2021 was conducted. Patients' demographic data, clinical signs and symptoms, and imaging data were collected from interventional radiology database. Results: MSCTV showed a range of abnormalities in the hemodialysis (HD) patients, including central venous occlusion (n = 4), fibrin sheath formation (n = 3), malposition of the catheter tips (n = 4), central venous perforation (n = 1), thrombus formation (n = 12), regular catheter exchange without determined lesions (n = 3). Interventional catheter salvage procedures were performed, such as catheter exchange, balloon disruption of a fibrin sheath, angioplasty for central vein stenosis, and stent deployment. The technical success rate for catheter insertions was 100%, and no procedure-related severe complications were observed. The 30-day catheter patency for all assessable catheters was 85.2%. Conclusion: The use of MSCTV showed abnormal findings in almost 88.9% of cases concerning dysfunctional TCC. In this study, the examined appropriate endovascular techniques were found to be safe and technically successful, with a low incidence of procedure-related complications.

Management with right atrium to jugular and brachiocephalic vein bypass for dialysis catheter-related superior vena cava syndrome.

Superior vena cava (SVC) syndrome is a spectrum of potentially life-threatening clinical manifestations resulting from either partial or complete obstruction of central venous blood flow. Approximately 70% of cases are caused by malignancy. The primary treatment end point for SVC syndrome is the achievement of long-term patency of the SVC. Malignant SVC syndrome is managed by either radiation therapy, open surgical intervention, or endovascular therapy with angioplasty and stenting. The current report describes an uncommon case of nonmalignant SVC syndrome resulting from complications of hemodialysis catheters that was managed with open revascularization between the right internal jugular and brachiocephalic veins and the right atrium.

A Case of End-Stage Renal Disease With Hemifacial Swelling.

A 64-year-old male, with end-stage renal disease on maintenance hemodialysis twice a week for the last two years, presented with swelling over the left half of his face, left side of the neck, and left upper limb for two months. The vascular access for hemodialysis was the left brachiocephalic arteriovenous (AV) fistula. There was no history of insertion of a dialysis catheter on the left side of the neck. Physical examination showed dilated and tortuous veins over the left side of his chest and left arm with normal-functioning AV fistula. Computed tomography (CT) venogram revealed narrowing in the left brachiocephalic vein and cephalic vein with multiple collaterals in the left upper limb and shoulder region. Ballon angioplasty was done across the stenotic segments, and a good flow was achieved with no remnant stenosis. This is a rare presentation as there was no history of cannulation of left-sided central vessels.

Recanalization of occluded central veins in hemodialysis patients using a dual lumen microcatheter.

BACKGROUND: Percutaneous transluminal angioplasty (PTA) is the standard therapy for stenosis or occlusion of the central vein in patients with chronic kidney disease undergoing routine hemodialysis. In the case of chronic total occlusion (CTO) of the central vein, crossing the lesion might be the most challenging part of the procedure. Although several techniques have been successfully used, a new, additional strategy that is safer yet equally effective would be beneficial. METHODS: We reported two cases of central vein occlusion in which the lesions could not be crossed by multiple escalating wires even with the support of a microcatheter. The wires could not penetrate the hardest part of the lesion and were always deflected to the false route. A dual lumen microcatheter was used as a support for the first wire and to facilitate the insertion of a second wire through the chronic occlusion. RESULTS: The dual lumen microcatheter successfully facilitated wire crossing of the CTO lesion in two patients. CONCLUSIONS: Dual lumen microcatheters may serve as an alternative strategy to cross central vein occlusions during PTA.

Central Vein Sign in Pediatric Multiple Sclerosis and Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease.

BACKGROUND: The central vein sign (CVS) on brain magnetic resonance imaging (MRI) is a promising diagnostic marker for distinguishing adult multiple sclerosis (MS) from other demyelinating conditions, but its prevalence is not well-established in pediatric-onset multiple sclerosis (POMS) versus myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). MOGAD can mimic MS radiologically. This study seeks to determine the utility of CVS, together with other radiological findings, in distinguishing POMS from MOGAD in children. METHODS: Children with POMS or MOGAD were identified in a pediatric demyelinating database. Two reviewers, blinded to diagnosis, fused fluid-attenuated inversion recovery sequences and susceptibility-weighted imaging from clinical imaging to identify CVS. Agreement in CVS number was reported using intraclass correlation coefficients (ICC). We performed topographic analyses as well as characterization of the clinical information and lesions on brain, spinal cord, and orbital MRI when available. RESULTS: Twenty children, 10 with POMS and 10 with MOGAD, were assessed. The median lesion percentage of CVS was higher in POMS versus MOGAD for both raters (rater 1: 80% vs 9.8%; rater 2: 22.7% vs 7.5%). Inter-rater reliability for identifying total white matter lesions was strong (ICC 0.94 [95% confidence interval [CI] 0.84, 0.97]); however, it was poor for detecting CVS lesions (ICC -0.17 [95% CI: -0.37, 0.58]). CONCLUSION: The CVS can be a useful diagnostic tool for differentiating POMS from MOGAD. However, advanced clinical imaging tools that can better detect CVS are needed to increase inter-rater reliability before clinical application.

Acute problems of hemodialysis access: Thrombosis, aneurysms, symptomatic high-flow fistulas, and complications related to central lines.

Hemodynamic complications frequently affect vascular access and are important causes of morbidity and mortality. We present a review of acute complications affecting vascular accesses, focusing on classical and new treatments. Acute complications in hemodialysis vascular access are often underestimated and undertreated, and can present a challenge for both vascular surgeons and anesthesiologists. Accordingly, we considered different anesthesiologic approaches to both hemorrhagic and nonhemorrhagic patients. A strict collaboration among nephrologists, surgeons, and anesthesiologists can potentially improve prevention and management of acute complications and quality of life.