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White NA, Xiao Z, De Winter EP, Li M, De Vries MR, Van Der Bogt KE, Rotmans JI. Hemodynamic considerations in arteriovenous vascular access modalities for hemodialysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2025; 66:3-16. [PMID: 39612189 DOI: 10.23736/s0021-9509.24.13205-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2024]
Abstract
Arteriovenous fistulas and arteriovenous grafts are the most commonly used vascular access for hemodialysis in patients with end-stage chronic kidney disease. However, both methods face significant challenges due to the hemodynamic disturbances induced by the arteriovenous anastomosis. This causes changes in vascular structure and blood flow velocity near the anastomosis site after the fistula/graft surgery, and introduces abnormal wall shear stress and cyclic stretch. This leads to endothelial cell dysfunction, vascular smooth muscle cell proliferation, and adverse remodeling. The resulting effects include low patency rates due to vascular stenosis caused by intimal hyperplasia and insufficient outward remodeling. Additionally, the high flow conduit has been linked to adverse cardiac remodeling. To address this, various strategies have been explored to correct these localized hemodynamic abnormalities, aiming to improve long-term patency rates. In this review, an overview is provided of the current surgical techniques, anastomosis types, anastomosis angles, external scaffolds, modified fistula designs, and types of grafts. It evaluates the impact of these approaches on local hemodynamics in the access conduit and their potential effects on patient outcomes.
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Affiliation(s)
- Nicholas A White
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands -
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands -
| | - Zhuotao Xiao
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Department of Nephrology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Eduard P De Winter
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Mohan Li
- Division of Endocrinology, Department of Medicine, Einthoven Laboratory of Experimental Vascular Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Margreet R De Vries
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Koen E Van Der Bogt
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
- University Vascular Center West, The Hague, the Netherlands
- Haaglanden Medical Center, The Hague, the Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
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Moughal S, Elmetwally A, Bashir M, Al-Khaffaf H. Ischaemic monomelic neuropathy of the lower limb. J Vasc Access 2024; 25:1345-1346. [PMID: 37354031 DOI: 10.1177/11297298231160577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023] Open
Abstract
Background: Ischaemic mononeuropathy (IMN) is a rarely reported type of peripheral neuropathy secondary to an ischaemic injury, due to a complication of haemodialysis access. Although underreported, this phenomenon typically occurs in diabetic patients and may reflect the predisposition to neuropathic injury on a background of chronic deleterious changes in the microvasculature in diabetes. It is characterised by mononeuropathic features such as paraesthesia, pain and motor weakness and usually is reported as a rare complication of brachiocephalic fistula. We report a case of IMN which occurred in a patient with end-stage diabetic nephropathy following polytetrafluoroethylene (PTFE) graft placement in the groin as vascular access for haemodialysis.
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Affiliation(s)
- Saad Moughal
- Vascular & Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Ahmed Elmetwally
- Vascular & Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Haytham Al-Khaffaf
- Vascular & Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, UK
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3
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Alsaadi MJ. Arterial diameter ratio as a reliable predictor for upper limb steal syndrome in patients with arteriovenous fistula for hemodialysis. Vascular 2024; 32:195-203. [PMID: 36113127 DOI: 10.1177/17085381221127741] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
OBJECTIVES The aim of this study is to assess the association between the anastomosis diameter enlargement and steal syndrome incidence in patients with upper limb arteriovenous fistula using ratios as reliable predictors. MATERIAL AND METHODS An analytical cross-sectional prospective study was conducted. A total of 49 patients with AVF hemodialysis access were recruited. Twenty-four participants with positive steal syndrome and 25 control were enrolled in the study. Anastomosis diameter, anastomosis diameter ratio, and volume flow ratio were measured ultrasonographically by two expert vascular sonographers. These clinical parameters were recorded and analyzed to assess the difference and association. Patient risk factors and steal syndrome association were emphasized. RESULTS The study analysis indicates a strong association in the anastomosis diameter and anastomosis diameter ratio between steal and non-steal patients with a p-value ≤0.05. Additionally, there was a significant increase in the volume flow ratio in the patients with steal syndrome compared to the control group (p-value ≤0.05). There was a strong relationship between steal syndrome and the presence of peripheral arterial disease (73.9%, p = 0.001). The ICC index of absolute agreement between the two observers was ICC= 0.99 (95% CI 0.99-0.99, n = 10), indicating excellent agreement between observers. CONCLUSION Anastomosis diameter and volume flow ratio strongly suggest that steal syndrome is associated with the increased diameter of anastomosis. Patients with a≥1.05 anastomosis diameter ratio have a greater risk of developing steal syndrome than those with an anastomosis ratio of ≤0.8. In addition, patients with a volume flow ratio ≥0.98 have an increased risk of developing steal syndrome than those with a volume flow ratio of ≤0.75.
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Affiliation(s)
- Mohammed J Alsaadi
- Radiology and Medical Imaging Department, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
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Vachharajani TJ, Tan TW. Dialysis Vascular Access and Critical Distal Ischemia. Clin J Am Soc Nephrol 2023; 18:1530-1532. [PMID: 37902770 PMCID: PMC10723912 DOI: 10.2215/cjn.0000000000000343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Affiliation(s)
- Tushar J. Vachharajani
- Department of Medicine, John D. Dingell Veterans Affairs Medical Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Tze-Woei Tan
- Division of Vascular Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
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Higgins MCSS, Diamond M, Mauro DM, Kapoor BS, Steigner ML, Fidelman N, Aghayev A, Chamarthy MRK, Dedier J, Dillavou ED, Felder M, Lew SQ, Lockhart ME, Siracuse JJ, Dill KE, Hohenwalter EJ. ACR Appropriateness Criteria® Dialysis Fistula Malfunction. J Am Coll Radiol 2023; 20:S382-S412. [PMID: 38040461 DOI: 10.1016/j.jacr.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for end stage renal disease patients. One's longevity on dialysis is directly dependent upon the quality of dialysis. This quality hinges on the integrity and reliability of the access to the patient's vascular system. All methods of dialysis access will eventually result in dialysis dysfunction and failure. Arteriovenous access dysfunction includes 3 distinct classes of events, namely thrombotic flow-related complications or dysfunction, nonthrombotic flow-related complications or dysfunction, and infectious complications. The restoration of any form of arteriovenous access dysfunction may be supported by diagnostic imaging, clinical consultation, percutaneous interventional procedures, surgical management, or a combination of these methods. This document provides a rigorous evaluation of how variants of each form of dysfunction may be appraised and approached systematically. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Matthew Diamond
- Research Author, Boston Medical Center, Boston, Massachusetts
| | - David M Mauro
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | | | - Nicholas Fidelman
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Ayaz Aghayev
- Brigham & Women's Hospital, Boston, Massachusetts
| | - Murthy R K Chamarthy
- Vascular Institute of North Texas, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | - Julien Dedier
- Boston Medical Center, Boston, Massachusetts, Primary care physician
| | - Ellen D Dillavou
- WakeMed Hospital System, Raleigh, North Carolina; Society for Vascular Surgery
| | - Mila Felder
- Advocate Christ Medical Center, Oak Lawn, Illinois; American College of Emergency Physicians
| | - Susie Q Lew
- George Washington University, Washington, District of Columbia; American Society of Nephrology
| | | | - Jeffrey J Siracuse
- Boston University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery
| | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
| | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
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Alqahtani SS, Aljaber FK, Alsuwailem BY, AlMashouq YA, AlHarbi BG, Elawad AM. Dialysis Access-Associated Steal Syndrome in High-Risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review and Meta-Analysis of Preventive Operative Techniques. Cureus 2023; 15:e49612. [PMID: 38161832 PMCID: PMC10755340 DOI: 10.7759/cureus.49612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
This systematic review and meta-analysis examine preventive operative techniques in high-risk patients undergoing surgery for hemodialysis access to mitigate the risk of Dialysis Access-Associated Steal Syndrome (DASS). Chronic kidney disease often leads to end-stage renal disease (ESRD), necessitating dialysis. Successful vascular access is crucial for efficient dialysis, but complications, such as DASS, pose significant challenges. DASS redirects arterial blood flow, affecting populations undergoing arteriovenous access surgery. This study aims to assess preventive strategies, including distal revascularization with interval ligation (DRIL) and extension techniques. A systematic search of PubMed, Cochrane Library, EMBASE, and Web of Science until 2022 identified 11 relevant studies. The inclusion criteria comprised non-pediatric hemodialysis patients reporting outcomes related to patency and complications. The data were analyzed using Review Manager 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen). Meta-analysis indicated a significant association between DASS and arteriovenous fistula (AVF) or arteriovenous graft (AVG) procedures. Radiocephalic AVF (RC-AVF) and distal endovascular AVF procedures were favored. Various interventions addressed venous narrowing, including simple plication and loop interposition. The Modified by Inserted Latex Link for Endovascular Repair (MILLER) technique, DRIL, Extension Technique, and Proximalization of Arterial Inflow (PAI) were assessed for arterial bypass graft and blood supply preservation. This study underscores the importance of individualized strategies in preventing DASS during hemodialysis access surgery. Prophylactic measures, such as the extension technique, show promise, while DRIL remains effective in treatment. Ongoing research is imperative for optimizing outcomes in this complex patient population.
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Affiliation(s)
- Saeed S Alqahtani
- Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, DEU
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
| | - Fahad K Aljaber
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
| | - Bader Y Alsuwailem
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
- Vascular Surgery, King Fahad Medical City, Riyadh, SAU
| | | | - Bander G AlHarbi
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
- Vascular Surgery, Samsung Medical Center, Seoul, KOR
| | - AlSayed M Elawad
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
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Ozen M, Arslan B, Yakupovich A, Turba UC, Ahmed O. Technical outcomes of below-the-elbow revascularization for upper extremity critical limb ischemia. Vascular 2023; 31:1035-1038. [PMID: 35499109 DOI: 10.1177/17085381221097310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
OBJECTIVES This study aims to report the technical results of below-the-elbow arterial revascularization in patients with critical hand ischemia. METHODS We retrospectively identified upper extremity critical limb ischemia patients treated with below-the-elbow arterial intervention between 2013 and 2017. Patient demographics, comorbidities, and procedural data were reviewed and technical success was evaluated. RESULTS Seven patients with 12 arteries that were affected by critical hand ischemia were treated. All patients had a history of end-stage renal disease. The technical success rate was 83.3%. There were no major or minor complications. The average follow-up duration was 9 months (2-26 months). One patient underwent a digital amputation at 8 months. CONCLUSION Arterial revascularization of the below-the-elbow arteries for critical hand ischemia is safe and technically feasible.
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Affiliation(s)
- Merve Ozen
- Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Bulent Arslan
- Department of Radiology, Rush University Medical Center, Chicago, IL, USA
| | - Anel Yakupovich
- Department of Radiology, Rush University Medical Center, Chicago, IL, USA
| | - Ulku Cenk Turba
- Department of Radiology, Rush University Medical Center, Chicago, IL, USA
| | - Osman Ahmed
- Department of Radiology, University of Chicago, Chicago, IL, USA
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Stoecker JB, Li X, Clark TWI, Mantell MP, Trerotola SO, Vance AZ. Dialysis Access-Associated Steal Syndrome and Management. Cardiovasc Intervent Radiol 2023; 46:1168-1181. [PMID: 37225970 DOI: 10.1007/s00270-023-03462-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/01/2023] [Indexed: 05/26/2023]
Abstract
Dialysis-associated steal syndrome (DASS) occurs in 1-8% of hemodialysis patients with arteriovenous (AV) access. Major risk factors include use of the brachial artery for access creation, female sex, diabetes, and age > 60 years. DASS carries severe patient morbidity including tissue or limb loss if not recognized and managed promptly, as well as increased mortality. Diagnosis of DASS requires a directed history and physical exam supported by non-invasive testing. Prior to definitive therapy, detailed arteriography, fistulography, and flow measurements are performed to delineate underlying etiologies and guide management. To optimize success, DASS treatment should be individualized according to access location, underlying vascular disease, flow dynamics, and provider expertise. Possible causes of DASS include extremity inflow or outflow arterial occlusive disease, high AV access flow rate, and reversal of distal extremity arterial blood flow; DASS may also exist without any of the prior features. Depending on the DASS etiology, various endovascular and/or surgical interventions should be considered. Regardless, in the majority of patients presenting with DASS, access preservation can be achieved.
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Affiliation(s)
- Jordan B Stoecker
- Division of Vascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Xin Li
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy W I Clark
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Penn Presbyterian Medical Center, 4 Wright Saunders Building, 51 N. 39th Street, Philadelphia, PA, 19104, USA
| | - Mark P Mantell
- Division of Vascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott O Trerotola
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ansar Z Vance
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- Penn Presbyterian Medical Center, 4 Wright Saunders Building, 51 N. 39th Street, Philadelphia, PA, 19104, USA.
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Adly M, Ladha MA, Mydlarski R, Petrasek P, Parsons L. Painless ulceration due to digital hypoperfusion ischaemic syndrome: case report and literature review. J Wound Care 2023; 32:S26-S30. [PMID: 37405963 DOI: 10.12968/jowc.2023.32.sup7.s26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Digital hypoperfusion ischaemic syndrome (DHIS), also known as steal syndrome, is a well recognised serious complication of haemodialysis (HD) access creation. The clinical presentation varies from cyanosis to tissue loss due to necrosis or gangrene. In this article, we present a case of painless digital ulceration due to DHIS and provide a review of the literature. A 40-year-old-female presented with multiple painless digital ulcerations of the left hand. Her medical profile included atherosclerotic disease, hypertension, hyperparathyroidism and type I diabetes causing retinopathy, peripheral neuropathy, gastroparesis and end-stage renal disease (ESRD). Her ESRD required HD with the construction of a left-arm basilic vein transposition arteriovenous fistula (AVF). A year later, she developed intermittent, painless ulcerations of the left hand. A Doppler ultrasound confirmed the diagnosis of DHIS. The patient was treated with AVF ligation surgery. At six months postoperatively, she had near complete re-epithelialisation of her ulcers. This case is unique in that the patient did not have preceding pain, likely due to her underlying diabetic neuropathy. While DHIS in haemodialysis patients with AVF is well documented in literature, digital ulceration in this context is an advanced form of this condition. Early recognition of digital ulceration as a complication of DHIS may enable early intervention and prevent permanent damage.
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Affiliation(s)
- Merna Adly
- University of Calgary, Cumming School of Medicine, University of Calgary, Canada
| | - Malika A Ladha
- Division of Dermatology, Department of Medicine, University of Calgary, Canada
| | - Régine Mydlarski
- Division of Vascular Surgery, Department of Surgery, University of Calgary, Canada
| | - Paul Petrasek
- Division of Vascular Surgery, Department of Surgery, University of Calgary, Canada
| | - Laurie Parsons
- Division of Dermatology, Department of Medicine, University of Calgary, Canada
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Franchin M, Tadiello M, Guzzetti L, Gattuso A, Mauri F, Cervarolo MC, D'Oria MGG, Tozzi M. Acute problems of hemodialysis access: Thrombosis, aneurysms, symptomatic high-flow fistulas, and complications related to central lines. Semin Vasc Surg 2023; 36:300-306. [PMID: 37330242 DOI: 10.1053/j.semvascsurg.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/06/2023] [Accepted: 04/17/2023] [Indexed: 06/19/2023]
Abstract
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.
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Affiliation(s)
- Marco Franchin
- Vascular Surgery Unit, Department of Surgery and Morphological Sciences, Circolo University Teaching Hospital, University of Insubria, ASST Settelaghi, Via Guicciardini, 9, 21100 Varese, Italy.
| | - Marco Tadiello
- Vascular Surgery Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Luca Guzzetti
- Anaesthesiology Unit, Circolo University Teaching Hospital, University of Insubria, ASST Settelaghi, Varese, Italy
| | - Andrea Gattuso
- Vascular Surgery Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Francesca Mauri
- Vascular Surgery Unit, Department of Surgery and Morphological Sciences, Circolo University Teaching Hospital, University of Insubria, ASST Settelaghi, Via Guicciardini, 9, 21100 Varese, Italy
| | - Maria Cristina Cervarolo
- Vascular Surgery Unit, Department of Surgery and Morphological Sciences, Circolo University Teaching Hospital, University of Insubria, ASST Settelaghi, Via Guicciardini, 9, 21100 Varese, Italy
| | | | - Matteo Tozzi
- Vascular Surgery Unit, Department of Surgery and Morphological Sciences, Circolo University Teaching Hospital, University of Insubria, ASST Settelaghi, Via Guicciardini, 9, 21100 Varese, Italy
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11
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Patel DM, Raina R, Jaar BG. Editorial: Management of hemodialysis patients. Front Med (Lausanne) 2022; 9:1116702. [PMID: 36606051 PMCID: PMC9808378 DOI: 10.3389/fmed.2022.1116702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Dipal M. Patel
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Rupesh Raina
- Akron General Medical Center, Akron Children's Hospital, Akron, OH, United States
| | - Bernard G. Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
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Anderson EM, Kim K, Fazzone BJ, Harland KC, Hu Q, Salyers Z, Palzkill VR, Cort TA, Kunz EM, Martin AJ, Neal D, O’Malley KA, Berceli SA, Ryan TE, Scali ST. Influences of renal insufficiency and ischemia on mitochondrial bioenergetics and limb dysfunction in a novel murine iliac arteriovenous fistula model. JVS Vasc Sci 2022; 3:345-362. [PMID: 36439698 PMCID: PMC9692039 DOI: 10.1016/j.jvssci.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022] Open
Abstract
Objective Hand disability after hemodialysis access surgery has been common yet has remained poorly understood. Arteriovenous fistula (AVF) hemodynamic perturbations have not reliably correlated with the observed measures of hand function. Chronic kidney disease (CKD) is known to precipitate myopathy; however, the interactive influences of renal insufficiency and ischemia on limb outcomes have remained unknown. We hypothesized that CKD would contribute to access-related hand dysfunction via altered mitochondrial bioenergetics. Using a novel murine AVF model, we sought to characterize the skeletal muscle outcomes in mice with and without renal insufficiency. Methods Male, 8-week-old C57BL/6J mice were fed either an adenine-supplemented diet to induce renal insufficiency (CKD) or a casein-based control chow (CON). After 2 weeks of dietary intervention, the mice were randomly assigned to undergo iliac AVF surgery (n = 12/group) or a sham operation (n = 5/group). Measurements of aortoiliac hemodynamics, hindlimb perfusion, and hindlimb motor function were collected for 2 weeks. The mice were sacrificed on postoperative day 14 to assess skeletal muscle histopathologic features and mitochondrial function. To assess the late outcome trends, 20 additional mice had undergone CKD induction and sham (n = 5) or AVF (n = 15) surgery and followed up for 6 weeks postoperatively before sacrifice. Results The adenine-fed mice had had a significantly reduced glomerular filtration rate and elevated blood urea nitrogen, confirming the presence of CKD. The sham mice had a 100% survival rate and AVF cohorts an 82.1% survival rate with an 84.4% AVF patency rate. The aorta and inferior vena cava velocity measurements and the vessel diameter had increased after AVF creation (P < .0001 vs sham). The AVF groups had had a 78.4% deficit in paw perfusion compared with the contralateral limb after surgery (P < .0001 vs sham). Mitochondrial function was influenced by the presence of CKD. The respiratory capacity of the CKD-sham mice (8443 ± 1509 pmol/s/mg at maximal energy demand) was impaired compared with that of the CON-sham mice (12,870 ± 1203 pmol/s/mg; P = .0001). However, this difference was muted after AVF creation (CKD-AVF, 4478 ± 3685 pmol/s/mg; CON-AVF, 5407 ± 3582 pmol/s/mg; P = .198). The AVF cohorts had had impairments in grip strength (vs sham; P < .0001) and gait (vs sham; P = .012). However, the presence of CKD did not significantly alter the measurements of gross muscle function. The paw perfusion deficits had persisted 6 weeks postoperatively for the AVF mice (P < .0001 vs sham); however, the myopathy had resolved (grip strength, P = .092 vs sham; mitochondrial respiration, P = .108 vs sham). Conclusions CKD and AVF-induced distal limb ischemia both impaired skeletal muscle mitochondrial function. Renal insufficiency was associated with a baseline myopathy that was exacerbated by the acute ischemic injury resulting from AVF creation. However, ischemia was the primary driver of the observed phenotype of gross motor impairment. This model reliably reproduced the local and systemic influences that contribute to access-related hand dysfunction and provides a platform for further mechanistic and therapeutic investigation.
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Affiliation(s)
- Erik M. Anderson
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Kyoungrae Kim
- Department of Applied Physiology and Kinesiology, Center for Exercise Science, University of Florida, Gainesville, FL
| | - Brian J. Fazzone
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Kenneth C. Harland
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Qiongyao Hu
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Zach Salyers
- Department of Applied Physiology and Kinesiology, Center for Exercise Science, University of Florida, Gainesville, FL
| | - Victoria R. Palzkill
- Department of Applied Physiology and Kinesiology, Center for Exercise Science, University of Florida, Gainesville, FL
| | - Tomas A. Cort
- Department of Applied Physiology and Kinesiology, Center for Exercise Science, University of Florida, Gainesville, FL
| | - Eric M. Kunz
- Department of Applied Physiology and Kinesiology, Center for Exercise Science, University of Florida, Gainesville, FL
| | - Andrew J. Martin
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Kerri A. O’Malley
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Scott A. Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Terence E. Ryan
- Department of Applied Physiology and Kinesiology, Center for Exercise Science, University of Florida, Gainesville, FL
| | - Salvatore T. Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
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Dukkipati R, Richler A, Shah A, de Virgilio C. Median Nerve and Ulnar Nerve Entrapment with Cubital Tunnel Syndrome in a Hemodialysis Patient Following Creation of an Arteriovenous Fistula. Case Rep Nephrol Dial 2021; 11:275-280. [PMID: 34703827 PMCID: PMC8460880 DOI: 10.1159/000518001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/19/2021] [Indexed: 11/19/2022] Open
Abstract
Neurological and vascular complications associated with creation of arteriovenous access need to be recognized promptly to deliver appropriate interventions for relief of symptoms and avoid loss of function of the involved extremity. We present here a 55-year-old female with end-stage renal disease on hemodialysis secondary to diabetic nephropathy who had a surgical creation of first stage of the brachial artery-basilic vein fistula in the left arm. She subsequently developed pain and weakness of the left arm which was diagnosed as median and ulnar nerve entrapment. She was treated with surgical nerve release and neurolysis and her symptoms improved.
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Affiliation(s)
- Ramanath Dukkipati
- Harbor-UCLA Medical Center, Torrance, California, USA.,Lundquist Research Institute, Torrance, California, USA.,UCLA School of Medicine, Westwood, California, USA
| | - Aaron Richler
- Harbor-UCLA Medical Center, Torrance, California, USA.,UCLA School of Medicine, Westwood, California, USA
| | - Anuja Shah
- Harbor-UCLA Medical Center, Torrance, California, USA.,Lundquist Research Institute, Torrance, California, USA.,UCLA School of Medicine, Westwood, California, USA
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14
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Dung NH, Loc ND, Quyen DBQ, Tuan NM, Tuan PNH, Quyet D, Thang LV. Association between low serum prealbumin levels and carpal tunnel syndrome in maintenance hemodialysis patients. Ren Fail 2021; 42:944-949. [PMID: 32912012 PMCID: PMC7946053 DOI: 10.1080/0886022x.2020.1811118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Aims Carpal tunnel syndrome (CTS) and low serum prealbumin concentration are common in maintenance hemodialysis patients. In this study, we focused on the association between low serum prealbumin levels and carpal tunnel syndrome in maintenance hemodialysis (MHD) patients using low-flux dialysis reuse. Materials and methods Serum prealbumin levels were assessed to determine the association between low serum prealbumin levels and CTS in 373 prevalent MHD patients (the mean age was 45 years old, hemodialysis duration was 46 months). The patients were divided into 2 groups: the CTS group with 44 patients and the non-CTS group with 329 patients. Results The prevalence of CTS was 11.8%. Serum prealbumin showed a good prognostic value to predict CTS in MHD patients using low-flux dialysis reuse (the Area Under the Curve = 0.841, p < .001; cutoff value: 26.5 mg/dL with sensitivity = 72.7% and specificity = 79.9%). Conclusions Serum prealbumin was a good prognostic biomarker of CTS in MHD patients using low-flux dialysis reuse.
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Affiliation(s)
| | | | | | | | | | - Do Quyet
- Viet Nam Military Medical University, Hanoi, Vietnam
| | - Le Viet Thang
- Viet Nam Military Medical University, Hanoi, Vietnam.,Military Hospital 103, Hanoi, Vietnam
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15
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Assessment of blood distribution in response to post-surgical steal syndrome: A novel technique based on Thermo-Anatomical Segmentation. J Biomech 2021; 119:110304. [PMID: 33631660 DOI: 10.1016/j.jbiomech.2021.110304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/03/2021] [Indexed: 11/20/2022]
Abstract
The distal ischemic steal syndrome (ISS) is a complication following the construction of an arteriovenous (A-V) access for hemodialysis. The ability to non-invasively monitor changes in skin microcirculation improves both the diagnosis and treatment of vascular diseases. In this study, we propose a novel technique for evaluating the palms' blood distribution following arteriovenous access, based on thermal imaging. Furthermore, we utilize the thermal images to identify typical recovery patterns of patients that underwent this surgery and show that thermal images taken post-surgery reflect the patient's follow-up status. Thermal photographs were taken by a portable thermal camera from both hands before and after the A-V access surgery, and one month following the surgery, from ten dialysis patients. A novel term "Thermo-Anatomical Segmentation", which enables a functional assessment of palm blood distribution was defined. Based on this segmentation it was shown that the greatest change after surgery was in the most distal region, the fingertips (p < 0.05). In addition, the changes in palm blood distribution in both hands were synchronized, which indicates a bilateral effect. An unsupervised machine learning model revealed two variables that determine the recovery pattern following the surgery: the palms' temperature difference pre- and post-surgery and the post-surgery difference between the treated and untreated hand. Our proposed framework provides a new technique for quantitative assessment of the palm's blood distribution. This technique may improve the clinical treatment of patients with vascular disease, particularly the patient-specific follow-up, in clinics as well as in homecare.
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16
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Beathard GA, Jennings WC, Wasse H, Shenoy S, Hentschel DM, Abreo K, Urbanes A, Nassar G, Dolmatch B, Davidson I, Asif A. ASDIN white paper: Assessment and management of hemodialysis access-induced distal ischemia by interventional nephrologists. J Vasc Access 2020; 21:543-553. [PMID: 31884872 DOI: 10.1177/1129729819894774] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Although not common, hemodialysis access-induced distal ischemia is a serious condition resulting in significant hemodialysis patient morbidity. Patients with signs and symptoms suggestive of hand ischemia frequently present to the general and interventional nephrologist for evaluation. In order to care for these cases, it is necessary to understand this syndrome and its management. Most cases can be managed conservatively without intervention. Some cases requiring intervention may be treated using techniques within the scope of practice of the interventional nephrologists while other cases require vascular surgery. In order for the interventional nephrologists to evaluate and manage these cases in a timely and appropriate manner, practice guidelines are presented.
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Affiliation(s)
| | - William C Jennings
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | | | - Surendra Shenoy
- Barnes-Jewish Hospital, Washington University, St. Louis, MO, USA
| | | | - Kenneth Abreo
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
| | - Aris Urbanes
- Internal Medicine, Wayne State University, Detroit, MI, USA
| | - George Nassar
- Weill Cornell Medicine, New York, NY, USA
- Houston Methodist Hospital, Houston, TX, USA
| | | | - Ingemar Davidson
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Arif Asif
- Hackensack Meridian School of Medicine at Seton Hall University, Nutley, NJ, USA
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17
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Keita AI, Bah AB, Balde MC, Spataru L, Cadene A, Rostaing L. Success of rheopheresis to treat digital hypoperfusion ischemic syndrome. Ther Apher Dial 2020; 25:362-364. [PMID: 32681699 DOI: 10.1111/1744-9987.13563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/11/2020] [Accepted: 07/15/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Alex I Keita
- Department of Nephrology and Dialysis, Centre Hospitalier du Val d'Ariège, Foix, France
| | - Alpha B Bah
- Department of Nephrology and Dialysis, Centre Hospitalier du Val d'Ariège, Foix, France
| | - Mamadou C Balde
- Department of Nephrology and Dialysis, Centre Hospitalier du Val d'Ariège, Foix, France
| | - Luciana Spataru
- Department of Nephrology and Dialysis, Centre Hospitalier du Val d'Ariège, Foix, France
| | - Agnes Cadene
- Department of Vascular Medicine, Centre Hospitalier du Val d'Ariège, Foix, France
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France.,Grenoble University, Grenoble, France
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18
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Salman L, Asif A. New Horizons in Dialysis Access: Approach to Hand Ischemia. Adv Chronic Kidney Dis 2020; 27:208-213. [PMID: 32891304 DOI: 10.1053/j.ackd.2020.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 11/11/2022]
Abstract
Hand ischemia is a relatively common complication of hemodialysis arteriovenous (AV) access. Clinical manifestations frequently start with pale and cold ipsilateral hand. Symptoms can progress to pain during dialysis and can eventually lead to tissue necrosis and gangrene if not addressed in a timely fashion. Comprehensive physical examination of the hand, AV access, and comparing it with the contralateral hand will assist in differentiating hand ischemia from carpal tunnel syndrome, osteoarthritis of the hand, and others. There are several treatment options for hand ischemia based on the severity of symptoms. Conservative management with careful monitoring can be applied in early stages. However, if symptoms persist or worsen, a full arteriogram of the ipsilateral extremity should be performed to evaluate for the presence of arterial stenosis. Angioplasty of the arterial stenosis, if present, will frequently lead to the resolution of symptoms. There are several percutaneous and surgical treatment options for hand ischemia, if no arterial stenosis was found or angioplasty does not relieve symptoms. We discuss in this article these treatment options in detail. Treatment goal is to improve hand ischemia symptoms while maintaining hemodialysis AV access and preserving patient's hand. Access ligation remains a treatment of last resort.
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19
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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 1238] [Impact Index Per Article: 247.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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20
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Arm and hand function in hemodialysis patients. A cross sectional analytical study. SCIENTIA MEDICA 2020. [DOI: 10.15448/1980-6108.2020.1.35301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Aims: To investigate the arm and hand function in hemodialysis patients.Methods: Upper limb function using validated questionnaires such as Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), Cochin and Boston were applied to 57 chronic renal failure patients on hemodialysis and 60 healthy controls. Epidemiological data, data on pain and paresthesia in the upper limb and handgrip strength were obtained.Results: The three questionnaires showed worse performance of upper limb function in chronic renal failure patients than controls: DASH questionnaire with P = 0.05; Cochin questionnaire with P = 0.0004 and Boston questionnaire with P = 0.03. The questionnaire scores were affected by presence of pain (P = 0.05 for DASH and < 0.0001 for Boston questionnaires) and paresthesia (DASH with P = 0.003; Cochin with P = 0.01 and Boston questionnaire with P < 0.0001). Handgripstrength was lower in hemodialysis patients when compared with controls (P = 0.02) but did not affect the performance of any of the studied questionnaires.Conclusions: Upper limb function is impaired in hemodialysis patients and the main associations found were with pain and paresthesia.
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21
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Nassar GM, Beathard G, Nguyen DT, Graviss EA. The effect of angioplasty of single arteriovenous fistula-associated stenosis on arteriovenous fistula blood flow rate. J Vasc Access 2020; 21:705-714. [PMID: 31992122 DOI: 10.1177/1129729819901223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Percutaneous balloon angioplasty of arteriovenous fistula-associated stenosis is performed for a variety of indications. Successful percutaneous transluminal angioplasty (PTA) is expected to increase in arteriovenous fistula blood flow rate (Qa). A validated approach to predicting changes in Qa based upon stenosis characteristics is not available. METHODS Three baseline parameters were determined in a group of patients with a single arteriovenous fistula-associated stenosis undergoing PTA. These were percent estimated stenosis, stenosis minimum luminal diameter, and baseline Qa. The relationship between these parameters and changes in Qa following PTA was analyzed using Spearman's rank correlation and linear regression. RESULTS 113 patients (total group) were studied. Of these,106 had peripheral stenosis (total peripheral subgroup) and 7 had central stenosis. For the total group and total peripheral subgroup, a highly significant inverse correlation was seen between changes in Qa and baseline Qa. A weaker correlation was seen between changes in Qa and minimum luminal diameter, but no correlation was seen with percent estimated stenosis. A minimum luminal diameter ⩽2.0 mm was predictive of ⩾300-mL/min increases in Qa, whereas a minimum luminal diameter >4.5 mm was associated with <300-mL/min increases in Qa. PTA of Central vein stenosis was not associated with significant changes in Qa. CONCLUSION Baseline Qa is the best predictor for change in Qa following PTA. Stenosis minimum luminal diameter cutoffs of ⩽2.0 and >4.5 mm are useful in predicting the magnitude of changes in Qa. Percent estimated stenosis is not predictive of change in Qa. PTA of central veins does not seem to change Qa.
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Affiliation(s)
- George M Nassar
- North Shepherd Dialysis Access Management Center, Nephrology Dialysis and Transplantation Associates, Institute of Academic Medicine, Houston Methodist Hospital & Weill Cornell Medicine & The Kidney Institute, Houston, TX, USA
| | | | - Duc T Nguyen
- Department of Pathology & Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research, Houston Methodist Research Institute, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology & Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research, Houston Methodist Research Institute, Houston, TX, USA
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22
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Kordzadeh A, Parsa AD. A systematic review of distal revascularization and interval ligation for the treatment of vascular access-induced ischemia. J Vasc Surg 2019; 70:1364-1373. [PMID: 31153703 DOI: 10.1016/j.jvs.2019.02.060] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 02/05/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Vascular access-induced ischemia remains a rare but significant complication of arteriovenous fistulas. Distal revascularization and interval ligation (DRIL) is one form of treatment. However, its collated efficacy through a systematic review is yet to be established. METHODS An electronic and systematic search of the literature in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and Cochrane Library from 1966 to 2017 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Quality assessment of the articles was performed using the Oxford Critical Appraisal Skills Programme, and the recommendation for practice was examined through the National Institute for Health and Care Excellence. Data of treated cases, success, time to ischemia, follow-up, age, sex, diabetes mellitus, fistula type, conduit type, and grade of ischemia were extracted and subjected to a pooled variance-weighted random-effects model. RESULTS Twenty-two studies (n = 459 individuals) were subjected to DRIL. Time to ischemia was 196 days (interquartile range, 30-600 days). Ischemia grade 3/4 (52%) was the most common presentation. The overall success (grades 1-4) was 81% (95% confidence interval, 80.9%-82.5%) during a mean and median follow-up of 22.2 months (interquartile range, 1-60 months) and 18 months, respectively. The conduit of choice was the great saphenous vein (n = 300/459 [65%]), and bypass thrombosis was highest in the polytetrafluoroethylene group (n = 19/44 [43%]). CONCLUSIONS DRIL with adequate long-term outcomes is an effective technique for the treatment of vascular access-induced ischemia.
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Affiliation(s)
- Ali Kordzadeh
- Department of Vascular, Endovascular and Renal Access, Broomfield Hospital, Mid Essex Hospital Service NHS Trust, Essex, United Kingdom; Faculty of Medical Sciences, Anglia Ruskin University, Cambridge, United Kingdom.
| | - Ali Davod Parsa
- Faculty of Medical Sciences, Anglia Ruskin University, Cambridge, United Kingdom
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23
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Datta S, Mahal S, Govindarajan R. Ischemic Monomelic Neuropathy after Arteriovenous Fistula Surgery: Clinical Features, Electrodiagnostic Findings, and Treatment. Cureus 2019; 11:e5191. [PMID: 31565598 PMCID: PMC6758992 DOI: 10.7759/cureus.5191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Ischemic monomelic neuropathy (IMN) is a rare complication of vascular access in the hemodialysis patients, characterized by multiple mononeuropathies in the absence of clinical ischemia. Most commonly seen in the female gender, diabetes mellitus, and it must be differentiated from vascular steal syndrome, where we see clinical ischemia as the main pathognomonic feature. Early recognition of the symptoms and prompt intervention was shown to be beneficial. A delay in the treatment can lead to irreversible damage to the nerves and muscles. This article is depicting a case of an elderly male patient who presented with signs and symptoms of IMN which developed after arteriovenous (AV) fistula graft surgery.
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Affiliation(s)
- Sorabh Datta
- Neurology, University of Missouri, Columbia, USA
| | - Shanan Mahal
- Internal Medicine, Baptist Health-University of Arkansas for Medical Sciences, North Little Rock, USA
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24
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Oprea A, Molnar A, Scridon T, Mircea PA. Digital pressure in haemodialysis patients with brachial arteriovenous fistula. Indian J Med Res 2019; 149:376-383. [PMID: 31249203 PMCID: PMC6607816 DOI: 10.4103/ijmr.ijmr_415_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background & objectives : The pathophysiological mechanisms involved in distal pressure changes following arteriovenous fistula (AVF) creation in patients with end-stage renal disease (ESRD) are not completely understood. This study was aimed to assess digital pressure changes post-AVF creation and to identify the factors that might influence these changes in ESRD patients. Methods : In this prospective study, 41 patients with ESRD underwent AVF creation. Basal digital pressure (BDP), digital brachial index (DBI), calcium, phosphorus and blood urea levels were assessed preoperatively. BDP, DBI, vein and artery diameters, and AVF blood flow were also evaluated at one and two month(s) post-AVF creation. Results : Mean BDP significantly decreased from 131.64±25.86 mmHg (baseline) to 93.15±32.14 and 94.53±32.90 mmHg at one and two months post-AVF creation, respectively (P <0.001). Mean DBI significantly decreased one month post-AVF creation versus baseline (0.70±0.18 vs. 0.89±0.17 mm, P <0.001) and remained similar at two versus one month(s) postoperatively (0.70±0.23 vs. 0.70±0.18 mm). At both postoperative timepoints, no correlation between DBI decrease and increased artery and vein diameters or fistula blood flow was observed. Mean DBI difference between patients with previous ipsilateral access versus those without was not significant from pre to one month postoperatively. No correlation was observed between baseline phosphorus, calcium and blood urea nitrogen and DBI changes. Interpretation & conclusions : Our findings suggest that decrease in distal pressure following AVF creation may not be influenced by the arterial remodelling degree, vein diameter or fistula flow. In uraemic patients, those with low calcium and/or increased phosphorus, no association between these parameters and DBI changes could be observed.
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Affiliation(s)
- Alexandru Oprea
- Department of Cardiovascular Surgery, "Niculae Stancioiu" Heart Institute, Cluj-Napoca, Romania
| | - Adrian Molnar
- Department of Cardiovascular Surgery, "Niculae Stancioiu" Heart Institute, Cluj-Napoca, Romania
| | - Traian Scridon
- Department of Cardiovascular Surgery, "Niculae Stancioiu" Heart Institute, Cluj-Napoca, Romania
| | - Petru Adrian Mircea
- Department of Gastroenterology, Emergency Clinical County Hospital, University of Medicine & Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
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Agarwal AK, Haddad NJ, Vachharajani TJ, Asif A. Innovations in vascular access for hemodialysis. Kidney Int 2019; 95:1053-1063. [DOI: 10.1016/j.kint.2018.11.046] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/23/2018] [Accepted: 11/01/2018] [Indexed: 02/07/2023]
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Regus S, Klingler F, Lang W, Meyer A, Almási-Sperling V, May M, Wüst W, Rother U. Pilot study using intraoperative fluorescence angiography during arteriovenous hemodialysis access surgery. J Vasc Access 2018; 20:175-183. [PMID: 30200839 DOI: 10.1177/1129729818791989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION: In this pilot study, we used indocyanine green fluorescence angiography during hemodialysis access surgery. The aim was to evaluate its relevance as a diagnostic tool to visualize changes in hand microperfusion. PATIENTS AND METHODS: In this prospective single-center study, 47 adult patients (33 male, 14 female) with renal disease (24 preemptive, 23 endstage) were enrolled. Surgical creation of an arteriovenous fistula was performed (22 forearm, 25 upper arm). Microperfusion of the ipsilateral hand and fingers was evaluated intraoperatively using indocyanine green fluorescence angiography. We compared the cumulated microperfusion parameters ingress (In) and ingress rate (InR) before and after opening of the anastomosis. To compare the dimension of microcirculatory decline, we calculated the ratios of the parameters (RatioIn and RatioInR) after to those before anastomosis opening. RESULTS: The cumulated microperfusion parameters In and InR showed a significant decrease after completion of anastomosis and declamping. This effect has been seen in all patients for the hand and for each finger consecutively. During follow-up (mean 4.6, range 3-11 months), 5 patients (10.6%) complained about hemodialysis access-induced distal ischemia. The ratio of intraoperative microperfusion in those five hemodialysis access-induced ischemia patients was significantly lower compared to asymptomatic patients (RatioIn 0.23 vs 0.58, p = 0.001, and RatioInR 0.25 vs 0.62, p = 0.003). CONCLUSION: Intraoperative fluorescence angiography could visualize the deterioration of ipsilateral hand microperfusion after surgical creation of an arteriovenous fistula. It seems to be a promising tool to detect patients at risk for hemodialysis access-induced distal ischemia early in the peri- or even intraoperative stage.
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Affiliation(s)
- Susanne Regus
- 1 Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Felix Klingler
- 1 Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Werner Lang
- 1 Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Alexander Meyer
- 1 Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | | | - Matthias May
- 2 Institute of Radiology, University Hospital Erlangen, Erlangen, Germany
| | - Wolfgang Wüst
- 2 Institute of Radiology, University Hospital Erlangen, Erlangen, Germany
| | - Ulrich Rother
- 1 Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
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Spanish Clinical Guidelines on Vascular Access for Haemodialysis. Nefrologia 2018; 37 Suppl 1:1-191. [PMID: 29248052 DOI: 10.1016/j.nefro.2017.11.004] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/21/2017] [Indexed: 12/26/2022] Open
Abstract
Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.
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28
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Woodside KJ, Bell S, Mukhopadhyay P, Repeck KJ, Robinson IT, Eckard AR, Dasmunshi S, Plattner BW, Pearson J, Schaubel DE, Pisoni RL, Saran R. Arteriovenous Fistula Maturation in Prevalent Hemodialysis Patients in the United States: A National Study. Am J Kidney Dis 2018; 71:793-801. [PMID: 29429750 PMCID: PMC6551206 DOI: 10.1053/j.ajkd.2017.11.020] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/22/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Arteriovenous fistulas (AVFs) are the preferred form of hemodialysis vascular access, but maturation failures occur frequently, often resulting in prolonged catheter use. We sought to characterize AVF maturation in a national sample of prevalent hemodialysis patients in the United States. STUDY DESIGN Nonconcurrent observational cohort study. SETTING & PARTICIPANTS Prevalent hemodialysis patients having had at least 1 new AVF placed during 2013, as identified using Medicare claims data in the US Renal Data System. PREDICTORS Demographics, geographic location, dialysis vintage, comorbid conditions. OUTCOMES Successful maturation following placement defined by subsequent use identified using monthly CROWNWeb data. MEASUREMENTS AVF maturation rates were compared across strata of predictors. Patients were followed up until the earliest evidence of death, AVF maturation, or the end of 2014. RESULTS In the study period, 45,087 new AVFs were placed in 39,820 prevalent hemodialysis patients. No evidence of use was identified for 36.2% of AVFs. Only 54.7% of AVFs were used within 4 months of placement, with maturation rates varying considerably across end-stage renal disease (ESRD) networks. Older age was associated with lower AVF maturation rates. Female sex, black race, some comorbid conditions (cardiovascular disease, peripheral artery disease, diabetes, needing assistance, or institutionalized status), dialysis vintage longer than 1 year, and catheter or arteriovenous graft use at ESRD incidence were also associated with lower rates of successful AVF maturation. In contrast, hypertension and prior AVF placement at ESRD incidence were associated with higher rates of successful AVF maturation. LIMITATIONS This study relies on administrative data, with monthly recording of access use. CONCLUSIONS We identified numerous associations between AVF maturation and patient-level factors in a recent national sample of US hemodialysis patients. After accounting for these patient factors, we observed substantial differences in AVF maturation across some ESRD networks, indicating a need for additional study of the provider, practice, and regional factors that explain AVF maturation.
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Affiliation(s)
- Kenneth J Woodside
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Sarah Bell
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Purna Mukhopadhyay
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Kaitlyn J Repeck
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Ian T Robinson
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Ashley R Eckard
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Sudipta Dasmunshi
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Brett W Plattner
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Jeffrey Pearson
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Douglas E Schaubel
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Ronald L Pisoni
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI.
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Sheaffer WW, Hangge PT, Chau AH, Alzubaidi SJ, Knuttinen MG, Naidu SG, Ganguli S, Oklu R, Davila VJ. Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER): A Review of the Available Literature and Brief Overview of Alternate Therapies in Dialysis Associated Steal Syndrome. J Clin Med 2018; 7:E128. [PMID: 29843483 PMCID: PMC6025613 DOI: 10.3390/jcm7060128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/25/2018] [Accepted: 05/28/2018] [Indexed: 11/16/2022] Open
Abstract
Dialysis associated steal syndrome (DASS) is a relatively rare but debilitating complication of arteriovenous fistulas. While mild symptoms can be observed, if severe symptoms are left untreated, DASS can result in ulcerations and limb threatening ischemia. High-flow with resultant heart failure is another documented complication following dialysis access procedures. Historically, open surgical procedures have been the mainstay of therapy for both DASS as well as high-flow. These procedures included ligation, open surgical banding, distal revascularization-interval ligation, revascularization using distal inflow, and proximal invasion of arterial inflow. While effective, open surgical procedures and general anesthesia are preferably avoided in this high-risk population. Minimally invasive limited ligation endoluminal-assisted revision (MILLER) offers both a precise as well as a minimally invasive approach to treating both dialysis associated steal syndrome as well as high-flow with resultant heart failure. MILLER is not ideal for all DASS patients, particularly those with low-flow fistulas. We aim to briefly describe the open surgical therapies as well as review both the technical aspects of the MILLER procedure and the available literature.
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Affiliation(s)
- William W Sheaffer
- Department of General Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.
| | - Patrick T Hangge
- Department of General Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.
- Division of Vascular Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Anthony H Chau
- Division of Vascular Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.
| | - Sadeer J Alzubaidi
- Division of Vascular Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - M-Grace Knuttinen
- Division of Vascular Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Sailendra G Naidu
- Division of Vascular Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Suvranu Ganguli
- Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | - Rahmi Oklu
- Division of Vascular Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Victor J Davila
- Division of Vascular Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA.
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Roata EC, Morosanu C, Makkai-Popa ST, Morarasu S, Lunca S, Dimofte G. Stenotic ligature: a simple technique for managing distal hypoperfusion ischemic syndrome following arteriovenous fistulas. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2018. [DOI: 10.25083/2559.5555/31.1419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction. Distal Hypoperfusion Ischemic Syndrome (DHIS) is a multifactorial debilitating condition causing peripheral ischemia and potentially tissue necrosis. In an effort to further refine its surgical treatment we aim to describe a modified, simple and reliable technique for managing DHIS in patients with arteriovenous fistulas. Materials and Methods. Twenty-nine consecutive patients with DHIS operated by a single surgical team over a period of 7 years were included in the study. All patients underwent the same surgical technique: stenotic ligature. Outcomes were analyzed clinically and the effectiveness of the procedure was proven using McNemar test. Clinical variables were statistically analyzed in SPSS 17.0 for Windows. Results. The technique we used consists in performing a stenosing ligature on the vein, using a 0-silk suture, and adjusting the suture in order to achieve either a radial pulse or capillary pulse, while maintaining a good thrill at palpation of the vein. The procedure was successful in 83% of patients proved by immediate symptomatic relief. Paired data analysis showed significant decrease of all symptoms: cold extremity (p=0,021), paraesthesia (p less 0,001), pain (p less 0,001). History of coronary artery disease, arteriopathy or the absence of radial pulse is statistically correlated with an increased risk of developing DHIS. Conclusions. Stenotic ligature is a simple, cheap and reliable technique for managing DHIS with lower septic risks which can be easily performed under local anesthesia.
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Abreo K, Amin BM, Abreo AP. Physical examination of the hemodialysis arteriovenous fistula to detect early dysfunction. J Vasc Access 2018; 20:7-11. [PMID: 29627998 DOI: 10.1177/1129729818768183] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The maintenance of vascular access patency for end-stage renal disease patients on hemodialysis is necessary for survival. Many nephrologists, nurse practitioners, and nurses have limited experience with the physical examination of the arteriovenous fistula. In this review, we define key terms used in the assessment of an arteriovenous fistula. We discuss the arteriovenous fistula physical exam, including details of inspection, palpation, and auscultation. Using these concepts, we review the abnormal findings that can assist practitioners in determining the location of a stenosis. We review the existing literature that validates physical exam findings with gold standard tests such as ultrasound and angiography. Finally, we review data supporting the value of training physicians and nurses in arteriovenous fistula physical examination.
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Affiliation(s)
- Kenneth Abreo
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
| | - Bakhtiar M Amin
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
| | - Adrian P Abreo
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
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Miller G, Khariton K, Kardos S, Koh E, Goel N, Khariton A. Flow Interruption of the Distal Radial Artery: Treatment for Finger Ischemia in a Matured Radiocephalic AVF. J Vasc Access 2018. [DOI: 10.1177/112972980800900110] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose To establish an effective approach for diagnosis and treatment of hand ischemia in matured radiocephalic arteriovenous fistulae (AVF). Methods One hundred and fifty end-stage renal disease patients (4% of our practice) presented to our outpatient vascular access facility complaining of a range of symptoms including coldness, numbness and pain in the fingers indicative of ischemia due to steal syndrome. In 15 patients the symptoms of steal syndrome were limited to the fingers, sparing the hand. Physical examination was indicative of steal syndrome caused by shunting of blood from the ulnar artery via the palmar arch, away from the fingers and into the fistula. To confirm the diagnosis, angiography was performed which demonstrated retrograde flow in the distal radial artery (DRA), a hypertrophied palmar arch, and a patent hypertrophied ulnar artery. Ischemia was treated with DRA flow interruption. Transcatheter coil embolization of the DRA (10 patients) was preferred because it proved to be a quick, safe and effective technique. Whenever embolization was not possible ligation of the DRA was performed in accordance with accepted surgical literature (five patients). Results DRA flow interruption was effectively accomplished by either ligation or coil embolization in all cases. All patients had symptomatic improvement. Complete symptom resolution was experienced by 100% (10/10) of patients who received DRA embolization and by 3/5 patients who required ligation. The average follow-up period was 9 months. There were no complications during the procedure or during the follow-up period. Conclusion Diagnosis using physical examination, angiography and treatment with embolization or ligation of the DRA can be performed with great success in an outpatient setting.
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Affiliation(s)
- G.A. Miller
- American Access Care of Brooklyn, New York - USA
| | - K. Khariton
- American Access Care of Brooklyn, New York - USA
| | - S.V. Kardos
- American Access Care of Brooklyn, New York - USA
| | - E. Koh
- American Access Care of New Jersey, New York - USA
| | - N. Goel
- American Access Care of Florida, Plantation FL - USA
| | - A. Khariton
- American Access Care of Brooklyn, New York - USA
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Malik J, Tuka V, Kasalova Z, Chytilova E, Slavikova M, Clagett P, Davidson I, Dolmatch B, Nichols D, Gallieni M. Understanding the Dialysis access Steal Syndrome. A Review of the Etiologies, Diagnosis, Prevention and Treatment Strategies. J Vasc Access 2018. [DOI: 10.1177/112972980800900301] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Distal hypoperfusion ischemic syndrome (DHIS), commonly referred to as hand ischemia or “steal” after dialysis access placement, occurs in 5–10% of cases when the brachial artery is used, or 10 times that of wrist arteriovenous fistulas (AVFs) using the radial artery. It is typically seen in elderly women with diabetes, and may carry severe morbidity including tissue or limb loss if not recognized and treated. Three distinct etiologies include (1) blood flow restriction to the hand from arterial occlusive disease either proximal or distal to the AV access anastomosis, (2) excess blood flow through the AV fistula conduit (true steal), and (3) lack of vascular (arterial) adaptation or collateral flow reserve (ie atherosclerosis) to the increased flow demand from the AV conduit. These three causes of steal may occur alone or in concert. The diagnosis of steal is based on an accurate history and physical examination and confirmed with tests including an arteriogram, duplex Doppler ultrasound (DDU) evaluation with finger pressures and waveform analysis. Treatment of steal includes observation of developing symptoms in mild cases. Balloon angioplasty is the appropriate intervention for an arterial stenosis. At least three distinct surgical corrective procedures exist to counteract the pathophysiology of steal. The ultimate treatment strategy depends on severity of symptoms, the extent of patient co-morbidity, and the local dialysis access technical team support and skills available.
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Affiliation(s)
- J. Malik
- Third Department of Internal Medicine, General University Hospital and 1st School of Medicine, Charles University, Prague - Czech Republic
| | - V. Tuka
- Third Department of Internal Medicine, General University Hospital and 1st School of Medicine, Charles University, Prague - Czech Republic
| | - Z. Kasalova
- Third Department of Internal Medicine, General University Hospital and 1st School of Medicine, Charles University, Prague - Czech Republic
| | - E. Chytilova
- Third Department of Internal Medicine, General University Hospital and 1st School of Medicine, Charles University, Prague - Czech Republic
| | - M. Slavikova
- Department of Cardiovascular Surgery, General University Hospital and 1st School of Medicine, Charles University, Prague - Czech Republic
| | - P. Clagett
- Division of Transplant, Department of Surgery, Parkland Memorial Hospital University of Texas Southwestern Medical Center, Dallas - USA
| | - I. Davidson
- Division of Transplant, Department of Surgery, Parkland Memorial Hospital University of Texas Southwestern Medical Center, Dallas - USA
| | - B. Dolmatch
- Division of Interventional Radiology, Parkland Memorial Hospital University of Texas Southwestern Medical Center, Dallas - USA
| | - D. Nichols
- Division of Transplant, Department of Surgery, Parkland Memorial Hospital University of Texas Southwestern Medical Center, Dallas - USA
| | - M. Gallieni
- Renal Unit, San Paolo Hospital, University of Milan, Milan - Italy
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Du YC, Shih JB, Wu MJ, Chiou CY. Development of an AVF Stenosis Assessment Tool for Hemodialysis Patients Using Robotic Ultrasound System. MICROMACHINES 2018; 9:E51. [PMID: 30393327 PMCID: PMC6187484 DOI: 10.3390/mi9020051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/24/2018] [Accepted: 01/25/2018] [Indexed: 11/17/2022]
Abstract
With the aging population and lifestyle changes, the number of hemodialysis (HD) patients increases year by year. The arteriovenous fistula (AVF) is the gold standard vascular access used to access the blood for HD treatment. Since the status of stenosis affects HD efficiency, current clinical practices usually use a Doppler ultrasound imaging system to assess the parameters of the stenosis, such as the degree of stenosis (DOS). Unfortunately, this is a very time-consuming task. Furthermore, it is difficult to stably maintain the ultrasound probe for a prolonged period to give doctors clearer or reproducible images. In this study, a robotic ultrasound system (RUS) with ultrasound sequential imaging analysis was designed to evaluate the DOS of the AVF. The sequential imaging analysis was capable of image smoothing and vessel boundary detection. It enabled clinicians to mark the thickness of the plaque for further processing. Finally, the system was used to reconstruct 3D models of fistulas and calculated the DOS for clinical assessment. We also designed a pressure sensing module attached to the ultrasound probe to prevent the probe from coming loose, vibrating, and exerting abnormal pressure on the skin. In the phantom test, the results showed that the error of the DOS that was calculated by RUS was less than 3%. The results of clinical trials obtained from ten patients show that the error between the RUS and clinicians' measurement was about 10% and had a highly linear correlation (R Square > 0.95). In addition, the reproducibility error was about 3% and could effectively save about 46% of the time during clinical examinations.
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Affiliation(s)
- Yi-Chun Du
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, No. 1, Nan-Tai Street, Yungkang Dist., Tainan 71005, Taiwan.
| | - Jheng-Bang Shih
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, No. 1, Nan-Tai Street, Yungkang Dist., Tainan 71005, Taiwan.
| | - Ming-Jui Wu
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, No. 1, Nan-Tai Street, Yungkang Dist., Tainan 71005, Taiwan.
- Department of Internal Medicine, Kaohsiung Veterans General Hospital Tainan Branch, Tainan 71051, Taiwan.
| | - Chung-Yi Chiou
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, No. 1, Nan-Tai Street, Yungkang Dist., Tainan 71005, Taiwan.
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Van Canneyt K, Pourchez T, Eloot S, Guillame C, Bonnet A, Segers P, Verdonck P. Hemodynamic Impact of Anastomosis Size and Angle in Side-to-End Arteriovenous Fistulae: A Computer Analysis. J Vasc Access 2018; 11:52-8. [DOI: 10.1177/112972981001100111] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose An arteriovenous fistula (AVF) is the first choice vascular access for hemodialysis. The AVF pathway can be seen as consisting of seven segments: proximal artery, distal artery, arterial collaterals, proximal vein, distal vein, venous collaterals, and the anastomosis. While most studies describe access complications without considering the impact of the anastomosis (7th segment), the present mathematical study investigated the hemodynamic impact of anastomosis size and angle on pressure drop and flow distribution. Methods A side-to-end AVF model was developed, consisting of an anastomosis with a given cross-sectional area (substudy 1) and angle (substudy 2). Starting from two reference cases (one for each substudy) with fixed flow distribution, pressure drop over the anastomosis was calculated for an arterial inflow in the range 600 to 1200 ml/min. The same reference cases, subsequently with fixed pressure boundary conditions, were further used to assess flow distribution over the proximal vein and distal artery. Results Pressure drop decreased with a larger anastomosis cross-sectional area and an angle wider than 43°, while it was almost stable for smaller angles. Although proximal arterial inflow increased for larger anastomosis areas, the overall flow distribution shifted almost totally to the proximal vein. When the anastomosis angle exceeded 58°, the proximal arterial inflow was not sufficient to deliver enough flow, leading to distal arterial flow reversal. Conclusion Despite the underestimation of the hemodynamic impact of the anastomosis size and angle in the literature, this study showed major influences on the pressure drop over the anastomosis and, with it, on flow distribution towards the arterial and venous outflow.
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Affiliation(s)
- Koen Van Canneyt
- Institute of Biomedical Technology (IBiTech), Ghent University, Ghent - Belgium
| | | | - Sunny Eloot
- Nephrology Department, Ghent University Hospital, Ghent - Belgium
| | - Caroline Guillame
- Institute of Biomedical Technology (IBiTech), Ghent University, Ghent - Belgium
| | - Alexandre Bonnet
- Institute of Biomedical Technology (IBiTech), Ghent University, Ghent - Belgium
| | - Patrick Segers
- Institute of Biomedical Technology (IBiTech), Ghent University, Ghent - Belgium
| | - Pascal Verdonck
- Institute of Biomedical Technology (IBiTech), Ghent University, Ghent - Belgium
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Preoperative management of arteriovenous fistula (AVF) for hemodialysis. J Vasc Access 2017; 18:451-463. [PMID: 29027182 DOI: 10.5301/jva.5000771] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2017] [Indexed: 11/20/2022] Open
Abstract
Native arteriovenous fistula (AVF) is the favorite access for hemodialysis (HD). The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) recommends its creation in most patients with renal failure. Unfortunately, intensive efforts to promote native AVF in patients with marginal vessels have increased the rate of primary fistula failure. A non-functioning fistula prompts the use of central venous catheter (CVC) that, unlike AVF, has been associated with an increased risk of morbidity and mortality among patients receiving HD. We believe that successful and timely AVF placement relies on the development of a multidisciplinary integrated preoperative program divided into five stages: (i) management of patients with advanced chronic kidney disease (CKD), (ii) management of preoperative risk factors for AVF failure, (iii) planning of native AVF, (iv) assessment of patient eligibility and (v) preoperative vascular mapping. Focusing specifically on native AVF, we review scientific evidence regarding preoperative management of this vascular access in order to favor construction of long-term functioning fistula minimizing development of severe complications.
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Ischemic monomelic neuropathy: a long-term follow-up of two cases. J Vasc Access 2017; 18:e89-e91. [PMID: 28665460 DOI: 10.5301/jva.5000743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2017] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Ischemic monomelic neuropathy (IMN) is the most dreaded complication of an arteriovenous access creation. While uncommon, it can lead to pain, paresthesia or/and hand weakness. Creation of an arteriovenous connection causing a sudden diversion of blood away from the nerves can lead to ischemic injury to the neural tissue and cause IMN. Immediate surgical ligation has been traditionally recommended to limit ongoing neural tissue injury. CASE DESCRIPTION We present two diabetic patients who developed IMN after the creation of a left upper extremity brachial-cephalic fistula and refused to undergo surgical ligation. The clinical examination revealed paresthesia localized to the volar aspect of the left forearm with mild weakness of the thumb, index and middle finger. Rehabilitation therapy was initiated in both and revealed a significant improvement in weakness but paresthesia persisted. Fistula maturation was achieved in both patients with an access flow of 1100-1200 cc/min. At 4 months, fistula was used successfully for dialysis in both patients. At a follow-up of 11 months, hand weakness did not progress and paresthesia disappeared. CONCLUSIONS These cases demonstrate sensory-motor improvement with time and rehabilitation therapy and challenge the traditional approach of fistula ligation. The approach presented in this paper also results in the preservation of the lifeline of a patient. Future investigations should focus on identifying candidates who could benefit from physical therapy and rehabilitation.
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Wu JX, Li CM, Chen GC, Ho YR, Lin CH. Peripheral arterial disease screening for hemodialysis patients using a fractional-order integrator and transition probability decision-making model. IET Syst Biol 2017; 11:69-76. [PMID: 28476975 DOI: 10.1049/iet-syb.2016.0046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Atherosclerosis and resultant peripheral arterial disease (PAD) are common complications in patients with type 2 diabetes mellitus or end-stage renal disease and in elderly patients. The prevalence of PAD is higher in patients receiving haemodialysis therapy. For early assessment of arterial occlusion using bilateral photoplethysmography (PPG), such as changes in pulse transit time and pulse shape, bilateral timing differences could be used to identify the risk level of PAD. Hence, the authors propose a discrete fractional-order integrator to calculate the bilateral area under the systolic peak (AUSP). These indices indicated the differences in both rise-timing and amplitudes of PPG signals. The dexter and sinister AUSP ratios were preliminarily used to separate the normal condition from low/high risk of PAD. Then, transition probability-based decision-making model was employed to evaluate the risk levels. The joint probability could be specified as a critical threshold, < 0.81, to identify the true positive for screening low or high risk level of PAD, referring to the patients' health records. In contrast to the bilateral timing differences and traditional methods, the proposed model showed better efficiency in PAD assessments and provided a promising strategy to be implemented in an embedded system.
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Affiliation(s)
- Jian-Xing Wu
- National Synchrotron Radiation Research Center, Hsinchu Science Park, Hsinchu 30076, Taiwan
| | - Chien-Ming Li
- Division of Infectious Diseases, Department of Medicine of Chi Mei Medical Center, Tainan City 710, Taiwan
| | - Guan-Chun Chen
- National Synchrotron Radiation Research Center, Hsinchu Science Park, Hsinchu 30076, Taiwan
| | - Yueh-Ren Ho
- Department of Biochemistry, Medical College of National Cheng Kung University Tainan City, Tainan 70101, Taiwan
| | - Chia-Hung Lin
- Department of Electrical Engineering, Kao-Yuan University, Kaohsiung City 82151, Taiwan.
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Korn A, Alipour H, Zane J, Gray K, Ryan T, Kaji A, De Virgilio C, Bowens N. Predictors of Steal in Hemodialysis Access. Am Surg 2017. [DOI: 10.1177/000313481708301017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pathological steal is an uncommon but devastating complication after the creation of arteriovenous access for hemodialysis. In this study, we sought to assess predictors of clinically significant steal syndrome and to further evaluate the outcome of differing surgical treatment approaches. A retrospective analysis was performed of 282 consecutive patients undergoing hemodialysis access at a single center from November 2014 to April 2016. Adequate follow-up to assess for the development of steal was obtained in 237 patients. One hundred and fifty-seven (66%) patients were male, 152 (64%) Hispanic, and 164 (69%) had diabetes. Forty-three (18%) had prior access procedures. Autologous fistula was created in 218 patients (92%). Pathologic steal occurred in 15 patients (6.7%). On univariate analysis, significant predictors of steal included female sex [P = 0.03, odds ratio (OR) = 3.3, CI [1.1–9]), no systemic heparin at operation (P = 0.02, OR = 5.0, CI [1.4–10]), use of angiotensin-converting enzyme inhibitor (P = 0.003, OR = 5.6, CI [1.7–18.6]), and increased vein size (3.1 vs 4.1 mm P = 0.01). Twelve patients had steal managed with an intervention, but only one patient received distal revascularization. Furthermore, we identify key predictors of clinically significant steal syndrome while demonstrating that distal revascularization and/or fistula ligation are rarely indicated treatment modalities.
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Affiliation(s)
- Abraham Korn
- Harbor-UCLA Medical Center, Department of Surgery, Division of Vascular Surgery, Torrance, California
| | - Hamid Alipour
- Harbor-UCLA Medical Center, Department of Surgery, Division of Vascular Surgery, Torrance, California
| | - Joshua Zane
- Harbor-UCLA Medical Center, Department of Surgery, Division of Vascular Surgery, Torrance, California
| | - Kelsey Gray
- Harbor-UCLA Medical Center, Department of Surgery, Division of Vascular Surgery, Torrance, California
| | - Timothy Ryan
- Harbor-UCLA Medical Center, Department of Surgery, Division of Vascular Surgery, Torrance, California
| | - Amy Kaji
- Harbor-UCLA Medical Center, Department of Surgery, Division of Vascular Surgery, Torrance, California
| | - Christian De Virgilio
- Harbor-UCLA Medical Center, Department of Surgery, Division of Vascular Surgery, Torrance, California
| | - Nina Bowens
- Harbor-UCLA Medical Center, Department of Surgery, Division of Vascular Surgery, Torrance, California
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Karavias D, Tsolakis I, Papadoulas S. Dialysis-associated steal syndrome with limb ischaemia. BMJ Case Rep 2017; 2017:bcr-2017-221436. [PMID: 28775113 DOI: 10.1136/bcr-2017-221436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Dimitrios Karavias
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham, UK
| | - Ioannis Tsolakis
- Department of Vascular Surgery, University of Patras School of Medicine, Patras, Greece
| | - Spyros Papadoulas
- Department of Vascular Surgery, University of Patras School of Medicine, Patras, Greece
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Pulpillo-Ruiz A. Chronic Ulceration in a Kidney Transplant Recipient. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2017.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Chronic Ulceration in a Kidney Transplant Recipient. ACTAS DERMO-SIFILIOGRAFICAS 2017; 108:589-590. [PMID: 28238408 DOI: 10.1016/j.ad.2016.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/15/2016] [Accepted: 11/27/2016] [Indexed: 11/23/2022] Open
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Koller FL, Woodside KJ. Advances in Vascular Access. TECHNOLOGICAL ADVANCES IN ORGAN TRANSPLANTATION 2017:87-115. [DOI: 10.1007/978-3-319-62142-5_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2025]
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44
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Dariushnia SR, Walker TG, Silberzweig JE, Annamalai G, Krishnamurthy V, Mitchell JW, Swan TL, Wojak JC, Nikolic B, Midia M. Quality Improvement Guidelines for Percutaneous Image-Guided Management of the Thrombosed or Dysfunctional Dialysis Circuit. J Vasc Interv Radiol 2016; 27:1518-30. [DOI: 10.1016/j.jvir.2016.07.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 07/12/2016] [Accepted: 07/14/2016] [Indexed: 01/20/2023] Open
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MacRae JM, Dipchand C, Oliver M, Moist L, Yilmaz S, Lok C, Leung K, Clark E, Hiremath S, Kappel J, Kiaii M, Luscombe R, Miller LM. Arteriovenous Access: Infection, Neuropathy, and Other Complications. Can J Kidney Health Dis 2016; 3:2054358116669127. [PMID: 28270919 PMCID: PMC5332082 DOI: 10.1177/2054358116669127] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/04/2016] [Indexed: 12/16/2022] Open
Abstract
Complications of vascular access lead to morbidity and may reduce quality of life. In this module, we review both infectious and noninfectious arteriovenous access complications including neuropathy, aneurysm, and high-output access. For the challenging patients who have developed many complications and are now nearing their last vascular access, we highlight some potentially novel approaches.
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Affiliation(s)
- Jennifer M MacRae
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Matthew Oliver
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Louise Moist
- Department of Medicine, University of Western Ontario, London, Canada
| | - Serdar Yilmaz
- Department of Surgery, University of Calgary, Alberta, Canada
| | - Charmaine Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Kelvin Leung
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Edward Clark
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | - Joanne Kappel
- Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Mercedeh Kiaii
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Rick Luscombe
- Department of Nursing, Providence Health Care, Vancouver, British Columbia, Canada
| | - Lisa M Miller
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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Du YC, Stephanus A. A Novel Classification Technique of Arteriovenous Fistula Stenosis Evaluation Using Bilateral PPG Analysis. MICROMACHINES 2016; 7:mi7090147. [PMID: 30404320 PMCID: PMC6190273 DOI: 10.3390/mi7090147] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/16/2016] [Accepted: 08/18/2016] [Indexed: 11/16/2022]
Abstract
The most common treatment for end-stage renal disease (ESRD) patients is the hemodialysis (HD). For this kind of treatment, the functional vascular access that called arteriovenous fistula (AVF) is done by surgery to connect the vein and artery. Stenosis is considered the major cause of dysfunction of AVF. In this study, a noninvasive approach based on asynchronous analysis of bilateral photoplethysmography (PPG) with error correcting output coding support vector machine one versus rest (ESVM-OVR) for the degree of stenosis (DOS) evaluation is proposed. An artificial neural network (ANN) classifier is also applied to compare the performance with the proposed system. The testing data has been collected from 22 patients at the right and left thumb of the hand. The experimental results indicated that the proposed system could provide positive predictive value (PPV) reaching 91.67% and had higher noise tolerance. The system has the potential for providing diagnostic assistance in a wearable device for evaluation of AVF stenosis.
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Affiliation(s)
- Yi-Chun Du
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan City 71005, Taiwan.
| | - Alphin Stephanus
- Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan City 71005, Taiwan.
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Tomoi Y, Soga Y, Fujihara M, Iida O, Shintani Y, Zen K, Ando K. Outcomes of Endovascular Therapy for Upper Extremity Peripheral Artery Disease With Critical Hand Ischemia. J Endovasc Ther 2016; 23:717-22. [PMID: 27421289 DOI: 10.1177/1526602816659279] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To investigate the clinical outcomes of endovascular therapy (EVT) for upper extremity peripheral artery disease (PAD) with critical hand ischemia (CHI). METHODS A subanalysis was performed of multicenter registry data on 36 consecutive patients (mean age 65.7±10.3 years; 19 men) who underwent EVT from January 2003 to December 2013 for angiographically diagnosed de novo upper limb PAD with CHI in 40 limbs. Fifty percent of patients had diabetes, and two-thirds were on hemodialysis. Technical success of EVT was straight-line flow to the hand and final residual diameter stenosis ≤50% for balloon angioplasty alone and ≤30% without flow-limiting dissection for subclavian artery stenting. The primary outcome was 12-month amputation-free survival [AFS; freedom from a composite of major (above-the-wrist) amputation and death]. The 12-month secondary outcomes were overall survival, limb salvage, freedom from major adverse limb events (MALE; major amputation or any repeat revascularization of the limb), and wound healing (complete epithelialization without death or major amputation). RESULTS Initial success was achieved in 87% (35 of 40 limbs); 1 patient experienced puncture site problems, and 3 (8%) of 36 patients (4 treated limbs) died within 30 days. Hand symptoms were alleviated in 37 (92%) limbs. The mean follow-up was 26.8±27.8 months. Seven fingers (5 limbs) underwent phalanx amputations and 2 limbs had an amputation above the wrist. Complete wound healing was achieved in only 5 (19%) of 26 surviving patients at 12 months. At 1 year, the Kaplan-Meier estimates for AFS, overall survival, limb salvage, and freedom from MALE were 56.4%, 59.4%, 93.1%, and 78.5%, respectively. Univariate analysis revealed that the predictors of AFS at 1 year were diabetes (p=0.03), hemodialysis (p<0.001), PAD (p=0.003), and the presence of a wound (p<0.001). During follow-up, 20 (56%) patients died; a cardiovascular cause accounted for 40% of deaths. CONCLUSION Endovascular therapy for upper limb PAD with CHI was technically successful and alleviated symptoms in the majority of cases, but the prognosis of patients with CHI was extremely poor in real-world clinical practice.
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Affiliation(s)
- Yusuke Tomoi
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Masahiko Fujihara
- Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada, Japan
| | - Osamu Iida
- Department of Cardiology, Kansai Rosai Hospital, Amagasaki, Japan
| | | | - Kan Zen
- Department of Cardiovascular Medicine, Omihachiman Community Medical Center, Shiga, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
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Jaryal A, Vikrant S, Thakur P. Volkmann's ischemic contracture: An unusual complication of arterio-venous fistula. Hemodial Int 2016; 21:E1-E3. [PMID: 27329788 DOI: 10.1111/hdi.12444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/18/2016] [Indexed: 11/30/2022]
Abstract
Native arterio-venous fistulae (AVF) are vascular access of first choice for chronic hemodialysis. However, AVF are also associated with many adverse events like: primary or secondary failure, infection, lymphedema, stenosis, thrombosis, and ischemia of distal extremities. The most common ischemia related complications of AVF are: ischemic neuropathy and steal syndrome with its consequences like pain and peripheral necrosis. Ischemic muscle contracture is a rare complication of AVF. Herein, we are reporting a case of Volkmann's ischemic contracture developing after creation of brachiocephalic AVF.
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Affiliation(s)
- Ajay Jaryal
- Department of Nephrology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, 171001 India
| | - Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, 171001 India
| | - Preyander Thakur
- Department of Nephrology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, 171001 India
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Wu JX, Chen GC, Wu MJ, Lin CH, Chen T. Bilateral photoplethysmography for arterial steal detection in arteriovenous fistula using a fractional-order decision-making quantizer. Med Biol Eng Comput 2016; 55:257-270. [PMID: 27154237 DOI: 10.1007/s11517-016-1503-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 03/28/2016] [Indexed: 11/29/2022]
Abstract
As inflow and outflow stenoses worsen, both flow resistance and pressure increase in the stenotic vascular access. During dialysis, when blood flow decreases, it may retrograde from the peripheral artery through the palmar arch to the arterial anastomosis site. Arterial steal syndrome (ASS) causes distal hypoperfusion, resulting in hand ischemia or extremity pain and edema. Hence, this study proposes the bilateral photoplethysmography (PPG) for ASS detection in arteriovenous fistulas. The decision-making quantizer utilizes the fractional-order feature extraction method and a non-cooperative game (NCG) framework to evaluate the ASS risk level. Bilateral asynchronous PPG signals have significant differences in the rise time and amplitude in relation to the degree of stenosis. The fractional-order self-synchronization error formulation is a feature extraction method used to quantify bilateral differences in blood flow changes between the dexter and sinister PPG signals. The NCG model as a method of decision-making is then employed to evaluate the ASS risk level. Using an acoustic Doppler measurement, the resistive (Res) index is also used to evaluate the vascular access stenosis at the arterial anastomosis site. In contrast with alternative methods including the high-sensitivity C-reactive protein level or Res index, our experimental results indicate that the proposed decision-making quantizer is more efficient in preventing ASS during hemodialysis treatment.
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Affiliation(s)
- Jian-Xing Wu
- National Synchrotron Radiation Research Center, Hsinchu Science Park, Hsinchu, Taiwan
| | - Guan-Chun Chen
- National Synchrotron Radiation Research Center, Hsinchu Science Park, Hsinchu, Taiwan
| | - Ming-Jui Wu
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan City, 71051, Taiwan.
| | - Chia-Hung Lin
- Department of Electrical Engineering, Kao-Yuan University, Kaohsiung City, 82151, Taiwan.
| | - Tainsong Chen
- Department of Biomedical Engineering, National Cheng Kung University, Tainan City, 70101, Taiwan
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Dilator-assisted Banding and Beyond: Proposing an Algorithm for Managing Dialysis Access-associated Steal Syndrome. J Vasc Access 2016; 17:299-306. [DOI: 10.5301/jva.5000570] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2016] [Indexed: 11/20/2022] Open
Abstract
Purpose Dialysis access-associated steal syndrome (DASS) is a major complication of arteriovenous hemodialysis accesses. Although its underlying pathology is diverse, it is most often associated with excessive access flow. Dilator-assisted banding (DAB) is a simple flow-reduction technique that we described previously. This report is to illustrate the expansion of DAB and analyze the outcome of DAB in managing DASS. Methods From February 2011 to April 2015, 30 patients underwent DAB for DASS. Their relevant clinical data were retrospectively reviewed or prospectively collected, and further analyzed statistically. Results Of the 30 patients, 23 had an arteriogram and 3 required angioplasty ± stent placement for inflow artery stenosis. Besides intraluminal DAB (12/30), this report also included extraluminal DAB (14/30) and open fistula reduction plus DAB (4/30). After DAB, the severity scores of DASS were reduced from 2.8 ± 0.4 to 0.2 ± 0.4 for the fistula group (n = 24, p<0.001) and from 3.0 ± 0.0 to 1.2 ± 1.2 for the graft group (n = 6, p = 0.041). DAB was effective in all but two graft patients who subsequently underwent proximalization of arterial inflow (PAI) that resulted in resolution of DASS. During follow-up of 18.7 ± 14.5 months (range 1-50), all accesses remained functional. At 24-months post-DAB, the primary patency, primary-assisted patency and secondary patency rates of the fistula group were 72%, 91% and 100%, respectively. Conclusions DAB is a simple, effective and versatile approach for managing DASS. PAI may be employed for rescue or as primary choice when banding is ineffective. Based on our data and the literature, an algorithm is proposed for managing DASS.
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