P1359PATTERNS OF CENTRAL VENOUS OBSTRUCTION AND OUTCOMES OF ENDOVASCULAR INTERVENTIONS IN CKD PATIENTS ON HAEMODIALYSIS

Background and Aims Central Venous Obstruction (CVO) is one of the major causes of morbidity in Chronic Kidney Disease (CKD) patients on maintenance Hemodialysis (HD). The aim of the study was to assess the patterns of CVO and the role of Endovascular interventions to restore the patency of vascular access in patients on HD with CVO. Method We report 15 cases of CVO in HD patients between April 2015 to April 2018. Data regarding patients’ basic information, primary disease, dialysis duration, access at initiation, number and sites of central venous catheterizations, vascular segments stenosed or thrombosed, type of endovascular interventions done and outcomes were collected from electronic record system. Results Out of 15 cases of CVO, 11 had the first dialysis with a temporary catheter either to Internal Jugular vein or femoral vein. The average time of presentation to our hospital from initiation of dialysis was 14.8 months. 8 patients presented with symptomatic SVC obstruction. The most common site of CVO was left Brachio-cephalic vein followed by right brachio-cephalic, right subclavian and left subclavian vein. 12 patients underwent Percutaneous Transluminal Angioplasty (PTA) and 3 required bare metal stenting (BMS) along with PTA. One patient required repeat PTA after 4 months. 11 patients did not require further procedure in the mean follow up period of 110 days. PTA was found to be successful in 11 out of 12 cases. Post PTA 9 patients underwent tunneled HD catheter insertion. Conclusion Patients of CKD who present late to the nephrologists require HD to be initiated through temporary catheters to central veins. Repeated central venous catheterization is associated with CVO. Endovascular intervention is an effective modality for maintaining HD access patency in such cases.

Natural courses and long-term results of type A acute aortic intramural haematoma and retrograde thrombosed type A acute aortic dissection: a single-centre experience

OBJECTIVES Few reports on the outcomes of patients treated for Stanford type A acute aortic intramural haematoma (TAAIMH) and retrograde thrombosed type A acute aortic dissection exist. This study aimed to evaluate their long-term results and predictors of adverse outcomes. METHODS We retrospectively analysed 40 patients with TAAIMH and retrograde thrombosed type A acute aortic dissection. All patients underwent urgent surgery on presentation of life-threatening complications. Before discharge, 18 patients underwent open aortic surgery, and 22 were treated with medical therapy alone. Clinical features of these patients and image appearances were reviewed, and the relationship with overall survival, aortic events, and aortic death was investigated. RESULTS The in-hospital mortality rate was 4.5% (1 patient) with medical therapy alone and 11.1% (2 patients) with surgical intervention. No patient with initial medical therapy required urgent surgery for life-threatening complications beyond 3 days of admission. The overall survival and aortic death-free survival rates at 1, 5 and 10 years were 85.0%, 72.5% and 59.8% and 90.0%, 81.6% and 77.1%, respectively. TAAIMH associated with penetrating aortic ulcer (PAU) was a risk factor of aortic events (P = 0.020) and significantly influenced aortic death-free survival (P = 0.003). CONCLUSIONS Urgent surgery for complicated TAAIMH and retrograde thrombosed type A acute aortic dissection patients and initial medical therapy for uncomplicated patients show favourable long-term survival rates. TAAIMH is frequently associated with PAU; PAU enlargement is common. Although PAU can remain stable for years, it is a strong predictor of poor prognosis. For optimal long-term results, surgical repair is recommended for TAAIMH associated with PAU.

Type A Intramural Hematoma Often Turns Out To Be a Type A Dissection

<p><b>Background:</b> The management of type A intramural hematoma (IMH) is controversial. Although most Western countries still recommend immediate surgical repair, some centers in Asia have shown good results recently with medical treatment alone. Here, we present a case of type A IMH which was discovered during the operation to be a thrombosed type A dissection.</p><p><b>Case Report:</b> An 83-year-old female patient presented with acute chest pain. After diagnostic exclusion of myocardial infarction, computed tomography was performed, which showed an IMH from the ascending to the descending aorta. No intimal flap could be detected. The ascending aorta was replaced surgically with a prosthesis. During the operation, we found a ruptured intimal plaque, which had caused dissection of the aorta with thrombosis of the false lumen. The true diagnosis�thrombosed type A dissection and not IMH�was revealed neither by computed tomography nor by transesophageal echocardiography.</p><p><b>Conclusion:</b> Type A IMH should still be treated with immediate surgical repair because in many cases it turns out to be thrombosed type A dissection.</p>