Internal jugular to internal jugular vein bypass of symptomatic central vein obstruction

Introduction: Central venous obstruction (CVO) often arises among hemodialysis patients with upper extremity access due to a varying number of risk factors. While the true incidence of CVO in hemodialysis patients is unknown, it been reported in the range of 20%–40% in dialysis patients undergoing venograms. In the non-hemodialysis population, chronic central vein obstruction has a compensatory mechanism comprised of numerous collaterals along the chest wall, neck, and mediastinum. However, the presence of an AVF or AVG ipsilateral to a central venous stenosis or occlusion can overwhelm the collateral network due to the significantly elevated blood flow. This may result in severe and debilitating upper extremity and fascial swelling. While ligation results in almost instantaneous symptomatic relief, it does not address the patient’s underlying pathologic process and necessitates an additional access. As these patients continue to live longer, our strategies to manage these failing accesses are becoming increasingly complex. The goal of preserving existing access while correcting any symptoms is paramount. Previous case reports have documented various surgical options for preserving an existing access. Case presentation: Our patient is a 49-year-old female with hypertension and end-stage renal disease, on hemodialysis through a right arm arteriovenous (AV) fistula. She had a history of multiple AV fistulae creations in the past, all of which previously thrombosed. Several years after the creation of her most recent fistula, she developed severe throbbing headaches, right arm and facial swelling, right eye lacrimation, and blurry vision. AV fistula angiogram demonstrated right brachiocephalic vein chronic occlusion and endovascular revascularization through both trans-AVF and transfemoral approaches were attempted, but unsuccessful. Discussion: This case illustrates the success of the creation of an internal jugular-jugular vein bypass to maintain a right arm arteriovenous fistula, while at the same time, correcting the symptoms of a right brachiocephalic vein occlusion.

Dural arteriovenous fistula presenting as reversible dementia

DAVF is an abnormal connection between arteries and veins, where supply is mainly through branches arising from the external carotid artery. A 30 years old male had multiple episodes of seizures and progressive behavioral and cognitive decline, inattention and disorientation to time, place and person, along with ptosis and ophthalmoplegia in the right eye. DSA provided a definitive diagnosis of hypervascular Dural AV fistula at the right transverse sigmoid junction with significant cortical venous hypertension. Through femoral access, both underwent transarterial embolization through the Middle Meningeal branch of the right external carotid artery using onyx, resulting in complete occlusion of fistula and resolution of venous hypertension. Post embolisation, cognitive function assessment revealed increased attention span and improved orientation with time, place and person. Thus, DAVF can be one of the rare but reversible causes of dementia. Early diagnosis and treatment may help to dramatically improve patients’ clinical condition and minimize long-term disability.

Flow volume measured by duplex ultrasound in native arteriovenous fistula for hemodialysis: a case report

Background : Native arteriovenous fistula (AVF) is the vascular access of choice for hemodialysis patients. AVF lasts longer than artificial grafts or central venous catheters. In addition, AVF has fewer complications than other vascular accesses. The use of Doppler ultrasound is used to facilitate fistula construction (vascular mapping) including AVF maturation to see if AVF can be used. Doppler ultrasound monitoring for maturation of AV fistulas should be monitored sonographically until the fistula is ready for use, especially when maturation is slow and in patients whose veins cannot easily be assessed by physical examination alone (eg because of obesity). The AVF DUS flow volume measurement may be the only imaging tool that can be used to monitor a fistula even during its maturation. Even so, DUS should always be done before AVF is used for the first time. This examination provides baseline data on vascular access, which can be useful in subsequent tests performed to evaluate functional problems. Case report : A man, 52 years old who has done AV Fitula two weeks ago. Currently patients are using a double lumen catheter (CDL) for routine hemodialysis. One day the patient had his CDL removed. Even though the patient feels thrill in the AV fistula, the nephrorologist still doubts whether the AV fistula is ripe and can be used. For this reason, a Duplex Ultrasound is performed to assess the diameter, velocity flow, PSV and TAMV .By positioning the sample volume in the presumed stenosis site, the Doppler velocity test detects a systolic peak velocity. Conclusion: Color flow Doppler imaging should be used as a tool to screen for areas of high velocity and to aid in the optimal placement of the pulsed Doppler sample volume. The pulsed Doppler sample volume should be set at the smallest size possible to detect discrete changes in blood flow meanwhile doppler ultrasound should be use in monitoring for maturation of AV fistulas

Assessment of Proximal Radio-median Cubital/Radio-Cephalic Arterio-venous Fistula

The present study aims to conducted the Assessment of Proximal radio-median cubital/radio-cephalic Arterio-venous Fistula. Arterio-venous Fistula is life line for long-term hemodialysis for end stage renal disease patients. The order of preference as per National Kidney Foundation/ Kidney Disease Out Come Quality Initiative (KDOQI) is distal Radio Cephalic fistula is considered as gold standard followed by elbow Brachio Cephalic Fistula, transposed Brachio-Basilic Fistula, forearm arterio-venous graft. This is a cross sectional-prospective interventional study, 05/2017 to 04/2019, JNMC, Wardha, MH, with sample size of 66 cases. Out of 66 cases 25 % patients had diabetes mellitus, 48% cases were suffering from chronic glomerulonephritis, 15 % cases were suffering hypertension, 6 % cases had COPD and another 6 % cases had some cardiovascular disease. About 54 % cases had previous access failure. In our study the mean flow volume for AV fistula in proximal forearm was 485± 291 ml/minon postoperative day1, 695 ± 298 on postoperative day 7 and 755± 347 ml/min. Overall postoperative complications in 12% cases was reported in our case study though Yilmiz et al reported postoperative complications in 15% cases.

Prevalence and Risk Factors of Arterio-Venous Fistula Obstruction on Patient with Chronic Kidney Disease

Prevalence and Risk Factors of Arterio-Venous Fistula Obstruction on Patient with Chronic Kidney Disease Ismail MT1, Hariawan H1, Wardhani Y2, Puspitasari M2, Artayasa IPA1, Ramadhan G1, Tarigan T1, Triatmaja R1 1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, 55284, Indonesia 2Department of Internal Medicine Faculty of Medicine Universitas Gadjah Mada-RSUP Dr. Sardjito Yogyakarta Indonesia ABSTRACT Aim: AV fistula obstruction has become one of the main vascular access complications in patients undergoing haemodialysis. This complications have significant impacts on the morbidity and mortality of dialysis patients while also leading to higher medical costs. Clinical monitoring has been routinely used for early detection of AV fistula stenosis and obstruction, however screening with Doppler ultrasound is still not a routine recommendation. This study aims to know prevalence and risk factors of AV Fistula obstruction detected by Duplex ultrasound examination. Methods: This study was a hospital-based descriptive analytic study with cross sectional design conducted at the haemodialysis center of National General Hospital Dr. Sardjito, Yogyakarta, Indonesia. Patient demographic and clinical risk factor were recorded using direct interview. AV fistula obstruction were assessed using Duplex ultrasound by professional sonographer. Results: Seventy four (74) patients are using AV fistula as entry access for hemodialysis in RSUP dr. Sardjito. It is consist of 39 male (53%) and 35 Female (47%). The mean age of patients is 50 years old. Surveillance using Doppler ultrasound found 20 patients (27%) have stenotic AV Fistula. Smoking habits (OR 5.37, 95% CI, 1.760 - 16.431, p=0.002) and diabetes mellitus (OR 5.00, 95% CI, 1.631 – 15.503, p=0.004) increase risk for having stenotic AV fistula. Only 4 patient (20 %) of all 20 patient with stenotic AV fistula were symptomatic, and needed for further vascular intervention Conclusion: Prevalence of AV fistula obstruction detected by Doppler ultrasound was 27% of all AV fistula patient with only 5% had symptomatic AV fistula failure. Smoking habits and diabetes mellitus are important risk factor for AV fistula obstruction. Asymptomatic AV fistula obstruction often goes undetected by clinical monitoring that can increase of risk of symptomatic AV fistula obstruction in the future. The further study is needed to determine level recommendation of routine AV fistula surveillance with Doppler Ultrasound. Key words: AV Fistula obstruction, CKD, Doppler ultrasound surveillance, Risk factors, Prevalence

Rupture of a de novo dural AV fistula following adult cerebral AVM resection

Acquired unruptured dural arteriovenous fistulas (DAVFs) have been described; however, ruptured de novo DAVFs remain exceedingly rare. We describe the case of a man in his 40s who presented with a recurrent intraparenchymal haemorrhage several years after angiographic cure of an intracranial arteriovenous malformation (AVM). Repeat angiography identified a new Cognard type IV DAVF anterior to the prior craniotomy. He underwent preoperative embolisation followed by craniotomy to completely obliterate the fistulous point. This case illustrates the need for close monitoring of AVM patients, even after complete obliteration, as local recrudescence of arteriovenous shunting can occur even in adulthood.

Clinical profile of hemodialysis patients attending a tertiary care hospital in Delhi, India

Background: CKD (chronic kidney disease) is one of the major complications of diabetes and hypertension. With increase in prevalence of non-communicable diseases, the patients presenting with the symptoms of CKD are also rising. Most of the patients suffering from CKD eventually land up on renal replacement therapy, putting extra burden economically as well as psychologically to the self and their family. The aim of the study is to find out the socio demographic and clinical profile of the patients suffering from CKD attending a tertiary care hospital in Delhi.Methods: It was a record based descriptive analysis, conducted between January 2019 and June 2019 in one of the ESIC (Employee State Insurance Corporation) hospital of Delhi. Medical Records of the only those patients were considered whose complete data were present in the record file. Data about Socio demographic profiles , clinical data, duration of CKD, duration of haemodialysis, viral markers, number of blood transfusions, vascular access, number of failed AV fistula etc. were entered in MS Excel and analysed through SPSS 11.Results: Hospital records of 473 CKD patients undergoing hemodialysis were analyzed. It was found that 315 (67%) were males and 158 (33%) were females. Majority of the patients i.e. 245 were in the age group of 41-60 years followed by 166 who were in the age group of 21 to 40. Out of total patients, 195 (41.2%) participants were undergoing hemodialysis twice a week, 276 (58.4%) thrice a week, 2 (0.4) patients were undergoing hemodialysis session four times a week. Majority of the participants i.e. 414 (88%) were Hindu. Out of total 473 participants, 439 (93%) participants had sero negative for viral marker (i.e. HbsAg, HCV, HIV I and II) and 33 (7%) participants were sero positive for viral marker. Most common etiology of CKD was found to be hypertension in our study followed by diabetes.Conclusions: Patients suffering from chronic kidney diseases are increasing day by day with increasing prevalence of hypertension. Most of the patients of CKD patients were middle aged males. Most of the patients have to visit 3 times a week to any health care institution for hemodialysis. Many of the patients are getting infected with viral hepatitis during course of the illness.

Ensuring hemodialysis adequacy by dialysis dose monitoring with UV spectroscopy analysis of spent dialyzate

Introduction: Patients’ session-to-session variation has been shown to influence outcomes, making critical the monitoring of dialysis dose in each session. The aim of this study was to detect the intra-patient variability of blood single pool Kt/V as measured from pre-post dialysis blood urea and from the online tool Adimea®, which measures the ultraviolet absorbance of spent dialyzate. Methods: This open, one-armed, prospective non-interventional study, evaluates patients on bicarbonate hemodialysis or/and on hemodiafiltration. Dialysis was performed with B. Braun Dialog+ machines equipped with Adimea®. In the course of the prospective observation, online monitoring with Adimea® in each session was established without the target warning function being activated. A sample size of 97 patients was estimated. Results: A total of 120 patients were enrolled in six centers in China (mean age 51.5 ± 12.2 years, 86.7% males, 24.2% diabetics). All had an AV-fistula. The proportion of patients with blood Kt/V < 1.20 at baseline was 48.3%. During follow-up with Adimea®, the subgroup with Kt/V > 1.20 at baseline remains at the same adequacy level for more than 90% of the patients. Those with a Kt/V < 1.20 at baseline, showed a significant increase of Kt/V to 60% of the patients reaching the adequacy level >1.20. The coefficient of variation for spKt/V as evaluated by Adimea® was 9.6 ± 3.4%, not significantly different from the 9.6 ± 8.6% as blood Kt/V taken at the same time. Conclusion: Online monitoring of dialysis dose by Adimea® improves and maintains dialysis adequacy. Implementing online monitoring by Adimea into daily practice moves the quality of dialysis patient care a significant step forward.

Evaluation of Factors Affecting Wrist Radio-Cephalic Arteriovenous Fistula Maturation: A Single Institutional Observational Study

Background: Chronic renal failure is the most common indication for which arterio-venous (AV) fistula creation surgery is being performed. Various studies have found that native arteriovenous fistulas are the best in long-term patency with lower complications. We conducted this study to find out the role of preprocedural duplex ultrasound (DUS) in predicting outcomes of radio-cephalic fistula in the wrist in the North-Karnataka population. Methods: This prospective study was conducted from May 2019 to July 2020 on 50 patients who were hemodialysis-dependent and underwent AV fistula creation with age from 20 to 70 years. All the patients underwent preoperative DUS and were followed up post-operatively after one, two, and six weeks. Hemodialysis was initiated through the constructed fistula once it was mature, and the maximum blood flow through the fistula was measured. SPSS version 20.0 was used for statistical analysis. Results: Among 50 subjects, the overall cumulative success of AVF maturation was 86% (43), and failure to mature rate was 14% (7). Logistic regression of maturation outcome in the wrist autologous arteriovenous fistula for individual factors showed statistically significant results (P < 0.05) for the diameter of the radial artery > 1.6 mm and the distensibility of the cephalic vein > 0.4 mm. Conclusions: Vein distensibility and radial artery diameter are key factors in predicting successful AVF maturation. The use of intraoperative papaverine instillation directly on vessels can improve arteriovenous fistula outcomes.

A rare case of gastric varices and splenic artery aneurysm secondary to splenic arteriovenous fistula

A 33-year-old male with no past medical history presented with a few months of fatigue and reduced exercise tolerance and was found to have iron-deficiency anemia. An esophagogastroduodenoscopy revealed a cluster of isolated gastric fundal varices with high-risk stigmata. Serologic workup for cirrhosis was negative, and a FibroScan measured liver stiffness at 4.2 kilopascals. Computed tomography (CT) of his abdomen and pelvis showed non-cirrhotic portal hypertension, as well as the presence of a splenic arteriovenous (AV) fistula and splenic artery aneurysm (SAA). Resection of the fistula, SAA, and spleen completely resolved the gastric varices and anemia.