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.

Safety and effectiveness of high flow extracranial to intracranial saphenous vein bypass grafting in the treatment of complex intracranial aneurysms: a single-centre long-term retrospective study

Background To summarize the safety and effectiveness of high flow extracranial to intracranial saphenous vein bypass grafting in the treatment of complex intracranial aneurysms. Methods The data of complex intracranial aneurysms patients for high flow extracranial to intracranial saphenous vein bypass grafting from January 2008 to January 2020 were retrospectively collected and analyzed. Eighty-two patients (31 men and 51 women) with 89 aneurysms underwent 82 saphenous vein bypass grafts followed by immediate parent vessel occlusion. The aneurysm was located at the internal carotid artery, middle cerebral artery, and basilar artery in 75, 11, and 3 cases, respectively. Results The patency rate of bypass grafting was 100, 100, 96.3 and 92.4% on intraoperation, on the first postoperative day, at discharge and 6 months follow-up, respectively. At discharge and 6 months follow-up, 3 and 6 patients had graft occlusions. The main postoperative complications were transient hemiparesis and hemianopsia. 3 patients died due to bypass complications and poor physical condition. Conclusions High flow extracranial to intracranial saphenous vein bypass grafting is safe and effective in the treatment of complex intracranial aneurysms and the saphenous vein can meet the requirements of brain blood supply. A high rate of graft patency and adequate cerebral blood flow can be achieved. Highlights A single-centre long-term retrospective study was conducted to assess the safety and effectiveness of high flow EC-IC saphenous vein bypass grafting in the treatment of complex intracranial aneurysms. The data of 82 patients from January 2008 to January 2020 were retrospectively collected and analysed. We found the patency rate of bypass grafting was 100, 100, 96.3 and 92.4% on intraoperation, on the first postoperative day, at discharge and 6 months follow-up, respectively. At discharge and 6 months follow-up, 3 and 6 patients had graft occlusions. Finally, we conclude that high flow extracranial to intracranial saphenous vein bypass grafting is safe and effective in the treatment of complex intracranial aneurysms and the selected blood supply vessels can meet the requirements of blood supply. As far as we know, this study is one of the maximum number of cases in the treatment of complex intracranial aneurysms with saphenous vein bypass.

Percutaneous glue embolization of arteriovenous fistula of in situ saphenous vein bypass graft: Case report and literature review

Objectives Arteriovenous fistulas (AVFs) of an in situ saphenous vein bypass can be managed surgically or through endovascular coil embolization. The complications associated with the surgical wounds required for side branch ligature can be minimized through selective vein ligature and interrupted small incisions, but endovascular methods are time-consuming and limited by vein size. In this case report, we describe percutaneous ultrasound (US)-guided balloon-assisted direct glue injection as an alternative treatment strategy for AVF closure. Methods We treated a patient with a delayed AVF in a femoral-popliteal in situ saphenous vein bypass. The patient came to our attention for the recurrence of chronic limb-threatening ischemia (CTLI) 4 years after the initial bypass creation. Ultrasound and computed tomography angiography (CTA) showed a double tandem graft in significant stenosis below an AVF connected with the deep venous system. Treatment included percutaneous angioplasty of the bypass stenosis and contemporary AVF closure via ultrasound-guided glue injection. Results We successfully performed endovascular angioplasty with a drug-eluting balloon of the bypass stenosis and ultrasound-guided fistula embolization with cyanoacrylate Glubran 2. Angiography after the procedure showed bypass graft patency, no residual stenosis, and complete closure of the AVF. Results were confirmed with US. Conclusions Percutaneous embolization using glue could be a useful technique for AVF closure. It is a minimally invasive method that reduces the need for skin incisions during in situ saphenous grafting or endovascular revascularization.

Renal autotransplantation – reappraisal of an old technique

Objective Transplantation of the patient’s own kidney into the iliac fossa has been described already more than 50 years ago, predominately for the treatment of renal trauma or peripheral renal artery aneurysms. The technique is however rarely used. We describe our experience with renal autotransplantation. Methods Retrospective analysis of consecutive patients. Results We performed renal autotransplantation in 3 patients from 2017-2019. The first patient was a 72y old male who had previously multiple stents placed in both renal arteries for renal artery stenosis and presented with a high grade in-stent stenosis of the right renal artery, complete occlusion of the left renal artery and left renal atrophy. The second patient was a 56y old male who presented with a 29mm aneurysm in the bifurcation of the left renal artery. The third patient was a 29y female with Takayasu disease, who had undergone endarterectomy of the abdominal aorta and vein bypass to the left renal artery as a child and stenting of the abdominal aorta for restenosis. She presented with aneurysmatic dilatation and high-grade restenosis of the vein bypass to the left renal artery. In the first two patients, laparoscopic nephrectomy via a retroperitoneal approach was performed as for living donor nephrectomy. The patient with the renal artery aneurysm had back table resection of the aneurysm and reconstruction by forming a common ostium of the two branch arteries. In the third patient, we explanted the kidney via laparotomy. In all patients, the kidney was perfused with cooled organ preservation solution after a brief period of warm ischemia and transplanted in the iliac fossa in standard fashion. After a median follow-up of 20 months (range 9-31) all autotransplanted kidneys showed good perfusion with no signs of renal artery stenosis. Median creatinine clearance was 97ml/min/1.7m2 (range 59-118). Conclusion Renal autotransplantation is a safe and durable procedure worth remembering when evaluating the treatment options of complex renal artery pathologies. Its use can also be envisaged for the treatment of complex renal trauma or complex ureter lesions.