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[en] The purpose of this paper is to describe a unique 'eighth note' deformity of the autogenous radiocephalic fistula for hemodialysis and to retrospectively evaluate the efficacy and safety of its endovascular treatment. Over 3 years, a total of 808 patients and 558 autogenous radiocephalic fistulas were treated for vascular access dysfunction or thrombosis. These included 14 fistulas in 14 patients (9 men, 5 women; mean age, 58.2 ± 2.8 years; range 27-79 years) whose fistulograms before treatment resembled a musical note, the eighth note. Endovascular treatment sought to remodel the deformed vascular access to a classic radiocephalic fistula and increase the number of cannulation sites available for hemodialysis. The technical and clinical success rates were each 92.8% (13/14). Fistula remodeling was successful in 13 patients. The postintervention primary patency was 100% at 90 days, 91.7 ± 0.8% at 120 days, 78.6 ± 13.9% at 180 days, 62.9 ± 17.9% at 360 days, 31.4 ± 24.0% at 540 days, and 0% at 720 days. The postintervention secondary patency was 100% at 90 days, 100% at 120 days, 100% at 180 days, 85.7 ± 13.2% at 360 days, and 85.7 ± 13.2% at 720 days. No major complications were noted. Minor complications were found in 71.4% of patients, all of which resolved spontaneously. In conclusion, endovascular treatment of fistulas with the eighth note deformity can effectively increase the number of available cannulation sites, facilitate fistula maturation, and facilitate thromboaspiration after fistula thrombosis.
[en] We describe percutaneous, translumbar placement of a 14-Fr dialysis catheter into an ascending lumbar vein to achieve tip position in an enlarged azygos vein. The patient had thrombosis of all traditional vascular sites, as well as the inferior vena cava. This catheter functioned well for 7 months before fatal catheter-related infection developed.
[en] Tunneled hemodialysis catheters become essential in dialysis access when there is no possibility of using a functioning arteriovenous fistula. Collateral or occluded veins visible on ultrasound are used for puncture and passage of catheters into the central venous system. Chronically occluded veins are crossed with guidewires to allow dilatation and subsequent passage of hemodialysis catheters. We performed a retrospective analysis of patient demographics, comorbidities, procedural complications, functional survival, performance, and history of previous vascular access. The study group was compared with two control groups in which dialysis catheters were inserted either by radiologists in the interventional suite or by clinicians on the wards. Nineteen patients from the study group were compared with same number of patients in both control groups. The mean age of the study group was higher compared with the control groups. There was no significant difference in mean functional survival, infection rates, dialysis pump speeds in the first 2 weeks, and procedural complications between the study group and the controls. The study group had a significantly higher number of previous vascular access interventions, longer dialysis careers, and more comorbidities. Tunneled dialysis catheter placement by way of collateral or occluded veins appears safe and effective. These techniques give the operator further options when faced with patients possessing challenging vascular access. Indeed, there may be a case for preferential use of these veins to keep patent central veins in reserve.
[en] The purpose of the present study was to evaluate the clinical outcome of peripheral stent placement after failed balloon angioplasty in patients with grafts who are on hemodialysis. We examined 30 Wallstents that were placed in 26 patients because balloon angioplasty failed or early restenosis (<3 months) occurred within 3 months. We retrospectively reviewed 267 consecutive balloon angioplasties performed in 71 patients with graft access between August 2000 and March 2007. Stent placements accounted for 30 (11.2%) of the 267 balloon angioplasties. The clinical success rate of stent placement was 93.3% (28 of 30 stent placements). The 3-, 6-, and 12-month primary patency rates were 73.3%, 39.3%, and 17.7%, respectively. The 1-, 2-, and 3-year secondary patency rates were 90.2%, 83.8%, and 83.8%, respectively. Primary patency was significantly prolonged by stent placement after early restenosis compared with previous balloon angioplasty alone (P = 0.0059). Primary patency after stent placement was significantly lower than after successful balloon angioplasty without indications for stent placement (P = 0.0279). Secondary patency rates did not significantly differ between stent placement and balloon angioplasty alone. The mean number of reinterventions required to maintain secondary patency after stent placement was significantly larger than that after balloon angioplasty alone (Mann-Whitney U test, P = 0.0419). We concluded that peripheral stent placement for graft access is effective for salvaging vascular access after failed balloon angioplasty and for prolonging patency in early restenosis after balloon angioplasty. However, reinterventions are required to maintain secondary patency after stent placement. Furthermore, peripheral stent placement for graft access cannot achieve the same primary patency as balloon angioplasty alone.
[en] A method for hemodialysis catheter placement in patients with central thoracic venous stenosis or occlusion is described and initial results are analyzed. Twelve patients, with a mean age of 63.2 years (42-80 years), with central venous stenosis or occlusion, and who required a hemodialysis catheter were reviewed. All lesions were confirmed by helical CT or phlebography. Five patients had stenosis while seven patients were diagnosed with an occlusion of thoracic central veins. All patients were asymptomatic, without sign of superior vena cava syndrome. After percutaneous transstenotic catheterization or guidewire-based recannalization in occlusions, a balloon dilatation was performed and a stent was placed, when necessary, prior to catheter placement. Technical success was 92%. Three patients had angioplasty alone and nine patients had angioplasty with stent placement. Dialysis catheters were successfully inserted through all recannalized accesses. No immediate complication occurred, nor did any patient develop superior vena cava syndrome after the procedure. The mean follow-up was 21.8 months (range, 8-48 months). Three patients developed a catheter dysfunction with fibrin sheath formation (at 7, 11, and 12 months after catheter placement, respectively). Two were successfully managed by percutaneous endovascular approach and one catheter was removed. In conclusion, for patients with central venous stenosis or occlusion and those who need a hemodialysis catheter, catheter insertion can be reliably achieved immediately after endovascular recannalization with acceptable technical and long-term success rates. This technique should be considered as an alternative procedure for placing a new hemodialysis catheter through a patent vein.
[en] Purpose: Central venous catheters (CVC) may fail for many reasons, though 'fibrin sheaths' blocking catheter ports are usually implicated. We examined the sheaths removed from dialysis catheters to determine their histopathology.Methods: Ten catheter strippings were performed and the removed material was studied grossly and microscopically.Results: The histologic specimens showed thrombus both with and without a proteinaceous sheath.Conclusion: Dialysis catheters fail because of thrombus formation. This can occur in either the absence or presence of a protein coating on the catheter, the so-called 'fibrin sheath.'
[en] We describe a useful technique for the removal of an irretrievable/stuck long-term intravenous catheter. The alternative would have meant removing it surgically or snaring it in a case of extremely difficult venous access. The process we used was effective in this particular case.
[en] Central venous catheters that have been in place for a long time can become fixed to the vein wall, making them impossible to pull out. Leaving them in situ is undesirable because of the risk that they could act as a nidus for thrombosis. Moreover, inserting new catheters alongside the old ones might compromise flow in the superior vena cava, further predisposing to thrombosis. Surgical removal is likewise undesirable, as this would necessitate thoracotomy with the attendant risks. We describe a novel technique, which we were able to use to remove retained long-term hemodialysis catheters in a patient who needed new catheters and who would have been a high-risk candidate for surgery. The right internal jugular vein was punctured adjacent to the site of insertion and a guide wire was used to form a snare, which was passed around the catheters and used to saw through the fibrous attachments to the vein wall. The midsection of one catheter could not be freed but the snare was used to cut off the proximal and distal ends, which could then be removed, the latter via the femoral vein. New catheters were then inserted via the left internal jugular vein. This technique enabled successful catheter extraction and replacement in a patient who would have been a poor candidate for cardiothoracic surgery