Gracz fistula is a feasible option after two failed percutaneous arteriovenous fistulae

Two devices for the creation of an endovascular percutaneous (pAVF) endovascular (endoAVF) arteriovenous fistulae (AVF) are available: the Ellipsys and the WavelinQ-4F systems. The main difference is the location of the anastomosis, making it feasible to use both pAVFs and surgical Gracz-type AVF in an algorithm sequence. A 66-year-old male patient with end-stage kidney disease and HIV was referred for a creation of a dialysis access after failed peritoneal dialysis. A radial-radial WavelinQ-pAVF with simultaneous coil embolization of a brachial vein was created but failed within 4 weeks. Therefore, an Ellipsys-pAVF was successfully created between the proximal radial artery and perforating vein on the same arm. After 2 days, however, the Ellipsys-pAVF anastomosis occluded. The ipsilateral Gracz-AVF was created, anastomosing perforating vein with the antecubital brachial artery. Cannulations were started 28 days later. During the follow up of 807 days, the AVF remained patent with last known volume flow of 1500 ml/min and no need for secondary interventions. We report a successful creation of a Gracz-AVF after primary failed pAVFs created with both pAVF-systems in a single patient and in the same arm. Thus, based on that case we recommend creation of pAVF prior to Gracz-AVF as integral part of Vascular Access creation algorithm, based on each patient’s life plan.

Demographic examination of lymphedema seen in the lower extremities

Background: We aimed to indicate the frequency of this disease according to blood groups, other disease types, age, weight and other demographic characteristics.Methods: We examined total of 236 patients who applied to our clinic because of lower extremity edema within 5 years. All patients had a diagnosis of lymphedema. Patients with a diagnosis of congenital lymphedema or a diagnosis secondary to cancer were excluded. Obesity, presence of venous disease, diabetes mellitus and hypertension which are considered as causes of secondary lymphedema were included in the study. Also the relationship between lymphedema patients and blood groups were evaluated.Results: 81% (n:193) of patients were women. The mean age of the patients was 50.71 (±10.28). All patients had diagnosis of lymphedema. Most of patients (n:189) had bilateral lower extremity edema. Body mass index was above 25 in 149 (63.1%) patients. Deep venous insufficiency accompanied in 75 (31.8%) patients. Perforator vein incompetance was observed with lymphedema in 96 (40.7%) patients. The number of diabetic and hypertensive patients was 64 (27.1%) and 67 (28.4%), respectively. Patients with B type blood group constituted the largest patient profile with a rate of 41.9% (n:99).Conclusions: In our study, demographic characteristics were not statistically corolated to lymphedema development, however, the rate of lymphedema in patients with perforating vein insufficiency was statistically significant (p<0.05, P=0.002). The most important point to be considered here is whether lymphedema plays a role in the development of additional pathology or do additional pathologies trigger the development of lymphedema?

Outcomes of Single Anastomoses for Superficial and Deep-System Venous Drainage of Radial Forearm Free Flaps

Objective Venous insufficiency occurs in radial forearm free flaps (RFFFs) when either the deep venous system (DVS) or superficial venous system (SVS) is used as the venous outlet. We report our experience using the antecubital perforating vein (APV) in a single-vessel anastomosis to the median-cubital or cephalic vein to drain both systems. Study Design Retrospective review. Setting Single, academic, tertiary care center. Methods Data were collected from 72 patients who underwent RFFF from October 2009 to January 2017. In all cases, DVS and SVS were dissected, and an APV single-vessel anastomosis was attempted. Results Anatomical variations precluded single-vessel anastomosis in 11 (15.3%) cases. In 61 (84.7%) cases, single-vessel anastomosis produced unobstructed drainage for DVS and SVS without intrinsic venous insufficiency. Venous thrombosis and total loss occurred in 2 (3.3%) and 1 (1.6%) patients, respectively. Proximal dissection of the cephalic vein addressed a vessel-depleted neck in 3 cases. Conclusion The antecubital perforating vein is present and functional in most patients, allowing for single anastomosis techniques for RFFF. Antecubital perforators capture DVS and SVS outflow through a single, extended venous pedicle, eliminating the risk of venous insufficiency and need for vein grafts.

The absence of the great saphenous vein: aplasia or involution? A clinical case

There are different types of great saphenous vein (GSV) anatomy that have been reported in the literature. GSV hypoplasia is frequently observed anatomical type with twice higher incidence than GSV aplasia. Proximal GSV aplasia including sapheno-femoral junction (SFJ) is the rarest anatomical type that is always accompanied by anterior accessory saphenous vein (AASV) acting as the alternative drainage route in such cases. In the case of SFJ absence the AASV connects common femoral vein at the level of typical SFJ location. In this case report we present the situation of complete GSF and AASV absence with the subsartorious perforating vein as the proximal junction between superficial and deep veins. At the same time this perforating vein is the source of pathological venous reflux towards the varicose veins of the thigh and leg. There is no information about phlebectomy of GSV in this case but it is known that the accident of the knee trauma with a subsequent operation and also the operation on the GSV tributaries on the leg (puncture without avulsion according to the patient memories) took place in the past. As such events are associated with the risk of thrombotic complications the postthrombotic involution of GSV could be contemplated in this case as the reason of GSV disappearance. Foam sclerotherapy of the incompetent thigh perforator vein with miniphlebectomy on the thigh was performed. Leg varicose veins were left untreated as their reduction after reflux elimination was expected. 14 days after treatment perforating vein obliteration and leg varicose veins reduction were diagnosed.

Perforating veins incompetence. Clinical aspects and evaluation mode

This manuscript represents a literature review on evaluation mode of perforating vein incompetence and its clinical impact on chronic venous disease development. Perforating veins (PV) serve as a complex anatomical and functional structure which incompetence indicates possible pathological processes in superficial and deep veins. PV almost never become a reflux source and though never require to be treated to abolish its incompetence. At the same time accurate diagnostic evaluation of PV condition must be performed to distinguish PV incompetence from PV compensatory changes that correct effects of vertical venous refluxes.

TRANSFASCIAL THROMBOSIS SURGERY IN THE GREAT SAPHENOUS VEIN BASIN

The aim: To evaluate the effectiveness of surgical treatment of varicothrombophlebitis complicated by transfascial thrombosis. Materials and methods: The results of examination and treatment of 45 patients with varicothrombophlebitis of the great saphenous vein complicated by transfascial thrombosis. Results: The indications for surgical prophylaxis of pulmonary embolism in transfascial thrombosis in the basin of the great saphenous vein have been substantiated. In the postoperative period, all patients with transfascial thrombosis, regardless of the radical nature of the surgical intervention, were offered to prescribe treatment as in deep vein thrombosis. The introduction of active surgical tactics in transfascial thrombosis allows for effective prevention of pulmonary embolism. Conclusions: In varicothrombophlebitis complicated by transfascial thrombosis, thrombectomy with further prevention of recurrence of the disease and pulmonary embolism should be considered the main standard of treatment. For perforating vein thrombosis, subfascial thrombectomy followed by perforating ligation should be performed. All patients with transfascial thrombosis, regardless of the volume of surgery, should be treated as for deep vein thrombosis.

Feasibility for arteriovenous fistula creation with Ellipsys®

Objective: To investigate the feasibility of percutaneous arteriovenous fistula creation in consecutive patients screened for first access creation. Methods: Prospective study of ultrasound mapping based on the following minimal anatomic requirements: a patent proximal radial artery and adjacent elbow perforating vein with straight trajectory, each greater than or equal to 2 mm in diameter and within 1.5 mm of each other. In addition, the same population was evaluated for feasibility of a distal radiocephalic fistula established. Results: One hundred consecutive patients were examined between November 2018 and January 2019. Sixty-seven were male (67%) and mean age was 61 years. Sixty-three patients (63%) and a total of 100 limbs (50%) were found to be eligible for a percutaneous fistula creation with Ellipsys®. Thirty-seven percent of patients were ineligible because of the absence of both median cephalic and median cubital veins (15%), absence or inadequate elbow perforating vein and/or smaller than 2 mm proximal radial artery (14%), and/or distance greater than 1.5 mm (8%). We found suitable vessels for a surgical distal fistula creation in 91 extremities (45%), but this percentage dropped to 17% in patients over 70 years old. Among the 100 limbs eligible for percutaneous arteriovenous fistula, only 30 (30%) were eligible for radiocephalic arteriovenous fistula. Conclusion: More than 60% of patients were eligible for Ellipsys. The absence of veins at the elbow and a large distance between vessels were the most common limiting factors. Less than one half of the patients were candidates for surgical fistula and this percentage dropped significantly for older individuals.

Ultrasound evaluation of percutaneously created arteriovenous fistulae between radial artery and perforating vein at the elbow

Objective: To investigate the hemodynamics of percutaneous arteriovenous fistulae (pAVF) created between the proximal radial artery and the deep communicating vein of the elbow. Methods: Consecutive patients with a percutaneously created proximal radial artery to perforating vein arteriovenous fistulae were evaluated and compared with control patients with clinically well-functioning surgical wrist radiocephalic arteriovenous fistulae (sWRC-AVF). Results: Thirty-one patients with a pAVF (21 males – 68%, mean age: 62 years, range: 53–81), with mean follow-up of 254 days (range: 60–443) and 32 patients with a surgical fistula (20 males – 62%, mean age of 63 years, range: 30–84) were evaluated. Mean access flow and distribution range were similar in the two study groups, with a mean flow of 859 mL/min vs 919 mL/min, respectively. There was no significant difference in the mean radial artery diameter (4 mm vs 4.3 mm, p = 0.2). Statistically significant trends were observed for resistive index (0.57 pAVF vs 0.52 (0.07) and brachial vein cross-sectional area (13 pAVF vs 33 mm2, p = 0.06). The arteriovenous anastomosis area was significantly smaller with pAVFs (13 vs 43 mm2, p = 0.002) and the pressure difference between extremities was less for the pAVF group vs sWRC-AVF (19 vs 27 mm Hg, respectively, p = 0.03). Existence of single cephalic or basilic versus cephalic and basilic outflow did not affect vein maturation or overall flow. Conclusions: pAVF have a favourable hemodynamic profile with many similarities when compared with surgically created wrist fistulae. Cephalic and/or basilic vein matured with only minor outflow shunted to the deep venous system.