Distal Fistula Research Articles

Chronic Ischemic Monomelic Neuropathy after Arteriovenous Fistula Creation: A Unique Presentation of Vascular Steal

We discuss a case of a 58 year old male who presented for left upper extremity steal syndrome including ischemic monomelic neuropathy (IMN) 1.5 months after arteriovenous fistula creation. He presented after three surgical attempts to salvage his fistula with rest pain, complete loss of function with contracture of the 4th and 5th digits, and loss of sensation in the ulnar distribution for more than three weeks. At our institution, he underwent surgical ligation of the distal fistula and creation of a new fistula proximally, resulting in complete resolution of his vascular steal symptoms almost immediately despite the chronicity prior to surgical presentation. Our patient provides a unique perspective regarding dialysis access salvage versus patient quality of life. The patients’ functional status and pain levels should take precedence over salvage of an arteriovenous access site, and early ligation of the access should be completed prior to chronic IMN development. However, if a patient presents late along the IMN course, we recommend strong consideration of access ligation in order to attempt to regain the full neurovascular function of the extremity as we experienced in our patient.

P1346PLANNING VASCULAR ACCESS CREATION FOR HEMODIALYSIS: IS THERE A ROLE FOR THE NEPHROLOGIST? A SINGLE-CENTER EXPERIENCE

Abstract Background and Aims Vascular access planning is a crucial step in the path to dialysis treatment. Although the vascular surgeon role is of undeniable importance on vascular access creation, the nephrologist’s view may be an added advantage on vascular access planning. Method A retrospective observational study of the vascular access appointments carried out at the Centro Hospitalar de Tondela-Viseu’s nephrology department between 1/1/2017 and 13/12/2019 was performed. Of the 173 consultations reviewed, 71 patients were referred to preoperative vascular mapping, which were selected. In those selected, 38 had a vascular access built. A descriptive and statistical analysis of the population and proposed vs constructed access was performed. Results Of those patients referred to the vascular access appointment for vessel mapping, the median age was 70 years, the majority were men (59.2%), most of them had Chronic Kidney Disease (CKD) stage 5 (57.7%) and most frequently had Diabetic Nephropathy (38.6%) or Chronic Glomerulonephritis (14.9%) as the cause of kidney disease. The majority were Diabetic (62%), Hypertensive (91.5%), Obese (63.4%) and had a history of stroke, coronary or peripheral arterial disease (63.4%). The vascular mapping was performed for creation of first access in 64.8% of the patients and the nephrologist most commonly proposed a radio-cephalic fistula (63.6%) as first line access creation, followed by brachio-cephalic (30.3%) and brachio-basilic (6%) fistulas. An arteriovenous graft was suggested in only 1 case and 4 patients were not referred to the vascular surgeon as they had no vascular patrimony to autologous vascular access creation. Regarding those patients who had already a vascular access at the time of this study (n=36), 58.33% coincided with the first line access suggested by the nephrologist. We found that the nephrologist most frequently proposed a brachio-basilic fistula in older patients (median age 77.5), while younger patients had proposed other fistulas (median age 77.5 years, p=0.031). Those patients without history of stroke, coronary or peripheral arterial disease had 4.57 times more odds of being proposed to a radio-cephalic fistula (p=0.007) and those with history of atherosclerotic events had 4.36 times more odds of being proposed for a brachio-cephalic fistula (p=0.003). Patients with more vascular calcification on the vessel mapping appointment had 7 times more odds of not being proposed for a distal fistula (p=0.000) and had instead 5.56 times more odds of being proposed to a brachio-cephalic fistula (p=0.003). Gender, etiology of CKD, smoking, diabetes, hypertension, heart failure and obesity were not significantly associated with vascular access proposed by the nephrologist. Conclusion In light of the results of this study, we conclude that there is an important place for ultrasound preoperative mapping by the nephrologist on planning the vascular access for haemodialysis.

Repair of oesophageal atresia by consultants and supervised trainees results in similar outcomes.

Consultants and trainees require exposure to complex cases for maintaining and gaining operative experience. Oesophageal atresia (OA) repair is a neonatal surgical procedure with indicative numbers for completion of training. A conflict of interest may exist between adequate training, maintaining consultant experience and achieving good outcomes. We aimed to review outcomes of procedures performed primarily by trainees and those performed by consultants. We carried out a retrospective case note review of all consecutive infants who underwent surgical repair of OA with distal tracheooesophageal fistula (TOF) between January 1994 and December 2014 at our institution. Only cases that underwent primary oesophageal anastomosis were included. Surgical outcomes were compared between cases that had a trainee and those that had a consultant listed as the primary operator. One hundred and twenty-two cases were included. A total of 52 procedures were performed by trainees, and 68 by consultants. Two cases were undeterminable and excluded. Infant demographics, clinical characteristics and duration of follow-up were similar between groups. All infants survived to discharge. Procedures performed by trainees and those performed by consultants as primary operators had a similar incidence of postoperative pneumothorax (trainees 4, consultants 3; p=0.46), anastomotic leak (trainees 5, consultants 3; p=0.29) and recurrent TOF (trainees 0, consultants 2; p=0.5). Overall 52% of cases had an anastomotic dilatation during follow-up, with no difference between the trainee and consultant groups (50% vs 53%; p=0.85). Surgical outcomes for repair of OA/TOF are not adversely affected by trainee operating. Trainees with appropriate skills should perform supervised OA/TOF repair. These data are important for understanding the interrelationship between provision of training and surgical outcomes.

Clinical efficacy of low-temperature radiofrequency ablaion assisted by endoscopy for the treatment of congenital pyriform sinus fistula in infants

Objective:To discuss the clinical efficacy of low-temperature radiofrequency ablaion assisted by endoscopy for the treatment of congenital pyriform sinus fistula in infants. Method:Clinical data of 15 patients with CPSF received the low-temperature radiofrequency ablaion assisted by endoscopy under laryngoscope were reviewed. After the operation, patients were followed up closely at different stages. All patients underwent neck color doppler ultrasound and electronic laryngoscopy, and the results were analyzed. Result:The operation of 15 children was successfully completed without pharyngeal fistula, dysphagia, perifistula and distal fistula infection. Followup survey ranged from 3 months to 3 years and no one recurred. Conclusion:Low-temperature radiofrequency ablaion assisted by endoscopy is a promising method for the CPSF with less trauma, less haemorrhage and good vision. It is safe and effective for the treatment of CPSF in infants and children, and is worthy of clinical promotion.

Does ligation of the dorsal branch of the cephalic vein affect the patency of a distal forearm arteriovenous fistula? A randomised study

BackgroundWhether ligation of the dorsal branch of the cephalic vein during the surgical establishment of the radiocephalic arteriovenous fistula (RCAVF) favorably or adversely affects the patency rate of the RCAVF remains controversial. We performed a randomized controlled trial to evaluate the effect of dorsal branch ligation on the patency rate of RCAVF.MethodsA total of 115 patients who underwent surgical establishment were randomized to two groups treated with or without ligation of the dorsal branch of the cephalic vein during the surgical process. The primary patency rates of the RCAVF at 90, 270, and 360 days after the surgery and the secondary patency rates during a follow-up up to 1 year were compared.ResultsThe patency rate did not differ significantly between the two groups at 3, 9, or 12 months after the procedure (P > 0.05). The combined primary patency rates of the RCAVF in patients from both groups at 3, 9 and 12 months after the procedure were 87.6, 82, and 74.5% respectively, while the combined secondary patency rate was 92.2% at the 1-year follow-up. The Log-rank test indicated that the initial patency rate and secondary patency rate did not differ significantly between the two groups (P = 0.674 and 0.759, respectively).ConclusionThis clinical study indicated that ligation of the dorsal branch of the cephalic vein does not significantly affect the patency of the arteriovenous fistula with a 1-year follow-up.Trial registrationISRCTN ISRCTN12288675, Registered 25 September 2019 in the ISRCTN registry. retrospectively registered.

Gastric pull-up by the retrosternal route for esophageal replacement: Feasibility in a limited-resource scenario

ObjectivesThe authors herein report the results of esophageal replacement by gastric pull-up technique through the retrosternal route as an option for esophageal replacement in a resource-constrained setup. MethodProspectively collected data upon twenty-two consecutive patients (male:female = 17:5) with mean age 24.9 months (7 months–12 years) and mean weight 7.9 kg (4.2–32 kg) who underwent retrosternal gastric pull-up for esophageal atresia (n = 18; 16 atresia with distal fistula & 2 pure atresia) and corrosive injuries to the esophagus (n = 4) over the past 8 years are presented.The management protocol and surgical technique have been described.Observations parameters included indication for esophageal replacement, age at surgery, sex of the child and other demographic details, clinical and operative findings, post-operative outcomes and follow-up details. ResultsRetrosternal gastric pull-up could be performed in all cases with no mortality or graft loss. Of 22, 20 cases were extubated on-table and 2 cases were extubated within 48 hours of surgery.Mean operative duration was 265 min (range: 175 min to 310 min) and blood loss was 115.3 ml (range: 80–400 ml). Dense vascular adhesions in the region of the esophageal hiatus were encountered in patients with abdominal esophagostomy (n = 4) which were probably related to the local dissection at the time of previous surgery.Minor anastomotic leak was observed in 8 of 22 patients which settled spontaneously over 21 days mean period (range: 18 to 31 days). Antegrade dilatation was required in 3 of 8 cases with minor leak. None of them required revision of anastomosis.Mean follow-up duration is 63 months (range: 11 months – 94 months). Weight gain after surgery was close to or beyond the 25th centile. Symptoms of dumping syndrome or GER were not observed in our cohort. ConclusionOur data have demonstrated the safety and feasibility of esophageal replacement by gastric transposition through the retrosternal route in a resource-limited setup. No significant difference has been observed from the results and complications reported in literature for the same procedure. Type of studyProspective observational study / treatment study. Level of evidenceLevel III.

Factors Contributing to Major Neurological Complications From Vein of Galen Malformation Embolization

Major neurological complications from the embolization of vein of Galen malformations (VOGMs) are poorly understood. We provide a detailed analysis of contributors to periprocedural neurological complications and lessons learned. To assess the rate of major periprocedural neurological complications following VOGM embolization with major procedural and strategic contributors. This retrospective cohort study was conducted at a quarternary referral pediatric hospital (Hospital for Sick Children; Toronto, Ontario, Canada) from January 1999 to December 2018 with a mean clinical follow-up of 44.7 months; all children with VOGM diagnosed and/or treated were eligible (n = 48). Thirty-three patients who underwent endovascular treatment were included. Endovascular staged transarterial embolization performed in 33 patients over 91 sessions. The primary outcome was the rate of periprocedural neurological complications (occurring within 1 week of embolization). The secondary outcomes were mortality, long-term neurological outcomes, and contributing anatomical and management factors to neurological complications. Of 33 patients who underwent embolization (31 boys [64.6%]; 17 girls [35.4%]; median age at first embolization, 4 months [range, 0-29 months]), 10 patients (30.3%) developed major periprocedural neurological complications. Five of these patients died. Univariate logistic regression analyses identified internal cerebral vein drainage to the main venous sac of the VOGM and use of a microcatheter with a distal outer diameter of more than 2.0F as significant predictors of poor neurological outcomes. Lessons learned from our experience include the need to assess the internal cerebral vein drainage pattern on preprocedural magnetic resonance venography, avoidance of excessive embolization into the venous sac, treatment of more distal fistulae before proximal fistulae to avoid a sump effect, and preferably use of smaller (<2.0F outer diameter) microcatheters in neonatal embolization procedures. In this cohort, 10 patients with VOGM treated with embolization (30.3%) experienced major periprocedural neurological complications, half of whom died. While these outcomes are superior to historic conservative and surgical treatment results, ongoing improvements in treatment and pretreatment diagnostic approaches are needed. Awareness of the lessons learned from our experience can help to avoid similar complications in the future for this vulnerable population.

Computational Analysis of Turbulent Hemodynamics in Radiocephalic Arteriovenous Fistulas to Determine the Best Anastomotic Angles

Hemodynamics has been known to play a major role in the development of intimal hyperplasia leading to arteriovenous fistula failure. The goal of our study is to investigate the influence of different angles of side-to-end radiocephalic anastomosis on the hemodynamic parameters that promote intimal dysfunction and therefore intimal hyperplasia. Realistic three-dimensional meshes were reconstructed using ultrasound measurements from distal side-to-end radiocephalic fistulas. The velocity at the proximal and distal radial inflows and at specific locations along the anastomosis and cephalic vein was measured through duplex ultrasound performed by a single examiner. A computational parametric study, virtually changing the inner angle of anastomosis, was performed. For this purpose, we used advanced computational models that include suitable tools to capture the pulsatile and turbulent nature of the blood flow found in arteriovenous fistulas. The results were analyzed in terms of velocity fields, wall shear stress distribution, and oscillatory shear index. Results show that the regions with high oscillatory shear index, which are more prone to the development of hyperplasia, are greater and progressively shift toward the anastomosis area and the proximal vein segment with the decrease of the inner angle of anastomosis. These results are specific to distal radiocephalic fistulas because they are subject to proximal and distal radial inflow. The results of this study show that inner anastomosis angles approaching 60-70° seem to yield the best hemodynamic conditions for maturation and long-term patency of distal radiocephalic fistulas. Inner angles greater than 90°, representing the smooth loop technique, did not show a clear hemodynamic advantage.

Midterm results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System, technical recommendations, and an algorithm for maintenance

ObjectiveThe aim of this study was to report our midterm results of percutaneous arteriovenous fistula (pAVF) creation using the Ellipsys (Avenu Medical, San Juan Capistrano, Calif) device and to present technical recommendations and our algorithm of pAVF maintenance. MethodsA single-center comprehensive database of all consecutive predialysis and end-stage renal disease patients who had a pAVF creation with the Ellipsys device was reviewed retrospectively. Study end points included technical success, maturation, functional patency, and required interventions. ResultsBetween May 2017 and July 2019, there were 234 patients (mean age, 64 years; 148 male [63%]) who had a pAVF created. Technical success was achieved in 232 individuals (99%), and average duration of the procedure was 15 minutes (7-35 minutes). Average follow-up was 252 days (range, 83-696 days). The 1-year primary, primary assisted, and secondary patency rates were 54%, 85%, and 96%, respectively. Average pAVF flow was 923 mL/min (range, 425-1440 mL/min). There were no significant adverse events related to the procedure. Only three patients (1%) required a later conversion of the pAVF anastomosis to a surgical fistula. Twenty-four (10%) patients required superficialization of deep outflow veins because of difficult cannulation. Average maturation time was 4 weeks (range, 1-12 weeks). Fourteen patients (6%) had early (<2 weeks after creation) cannulation of the pAVF. ConclusionsThe Ellipsys pAVF device allows the rapid and safe creation of a reliable autogenous access. Rates of technical success, patency, and maturation were excellent. For patients unsuited for a distal radiocephalic arteriovenous fistula, it should be considered the next preferred access option.

Should the search for ganglia in the distal rectal fistula in patients with anorectal malformation be abandoned?

PurposeOccurrence of Hirschsprung’s disease in anorectal malformation (ARM) patients is rare, but many surgeons still ask to pathologists to search for ganglia in the terminal rectum/fistula; the histological procedure is time and money consuming and the results confounding. A consecutive series of ARM patients, in which the presence of ganglia in terminal rectum was revised, is herein presented. Materials and methodsRectal specimens of ARM patients who underwent corrective surgery in the last 6 years were retrieved. The histological protocol included H&E staining and calretinin immunohistochemistry. Each specimen is processed until all material is examined if no ganglia are retrieved after the first twelve sections. ResultsForty cases were examined. Eight patients were younger than 1 month of age at operation. The mean length of the specimen was 1.5cm (range: 1–3 cm). Upon clinical request, ganglia were searched in 15/40 cases (37.5%) and resulted absent in 10/15 (66.5%). All patients have been followed and none developed signs or symptoms suggestive for Hirschsprung. ConclusionsThe practice to search for ganglia in the terminal rectum/fistula in ARM patients should be abandoned, as incidence of associated colorectal diseases is rare. Moreover, the procedure is expensive both in terms of laboratory’s reagents and working time of expert pathologists and technicians. Level of EvidenceLevel IV (Case Series with no Comparison Group)

Incidence and Risk factors for primary AV fistula failure

Introduction: National Kidney foundation KDOQI Vascular access guidelines rank AVF as the best available access for hemodialysis. However a significant number of AVF (28 – 53%) fail to mature adequately to support dialysis therapy.This paper analyses the incidence and risk factors associated with primary fistula failure (PF). Material and Methods: From Jan 2000 to October 2007, patients who had an A V fistula for hemodialysis were included in the study. Baseline demographic data included age,gender,co morbidities, cause of renal failure and previous catheter use.Access characteristics recorded included access type,anatomic location,dates of creation and failure to mature.Univariate analysis was done to detect the risk factors associated with PF. Results: 116 AVF were created in 100 patients (M:F = 1.85:1; Mean age = 45.24 ± 20yrs).Co morbidities included Diabetes Mellitus (DM) in 72%, Hypertension in 84%, Coronary Artery Disease (CAD) in 27%, Cerebro Vascular Disease (CVD) in 03%, and Peripheral Vascular Disease (PVD) in 20%. Diabetic nephropathy was the most common cause of CRF(60%). Left side (84%) was most commonly used and Radiocephalic fistulae done in 55% patients.Primary fistula failure was seen in 44 (37%) patients.Risk factors included Distal Fistulae (81% vs 38%), Females (59% vs 19%) and DM (90% vs 61%), CAD (50% vs 13%) and PVD (36% vs 11%). Conclusions:Primary fistula failure was seen in 38% and Female sex, Radio cephalic fistulas and Diabetes mellitus,CAD and PVD are significant risk factors for PF.

Snodgrass vs Snodgraft operation to repair the distal hypospadias in the narrow urethral plate

Using the Snodgraft technique in patients with urethral plate less than 8mm to repair distal hypospadias is still debatable. Some authors assume that augmentation may be beneficial. We aimed to compare the outcomes of the Snodgrass vs Snodgraft procedure in patients with a narrow urethral plate less than 8mm. This prospective randomized study included 60 children who had been treated by the Snodgrass or Snodgraft procedure for repair of distal penile hypospadias with narrow urethral plate from March 2017 to September 2018. They were randomized into two subgroups. Group 1 (30 patients) underwent tubularized incised plate urethroplasty, whereas the second group (30 patients) underwent the Snodgraft procedure by using the inner prepuce. Operative details, postoperative period, and complications were reported and statistically analyzed using IBM SPSS software package version 20.0. The operative time was longer for patients who underwent the Snodgraft procedure: 78 (55-95) and 110 (80-140) minutes in groups 1 and 2, respectively. In group 1, there was one case of meatal stenosis which was resolved by urethral dilation using the local anesthetic cream in the outpatient clinic. In addition, there was another case of distal penile fistula. In group 2, there was a case of complete wound disruption and another of distal penile fistula. There was no significant difference in the complication rate in any group. The operative time was longer in group 2 than in group 1 but with comparable outcomes. The Snodgraft procedure is not superior to the Snodgrass operation in the narrow healthy urethral plate.

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.

Histology of the terminal end of the distal rectal pouch and fistula region in varying the severity of anorectal malformations: Is it useful?

Aims: To Study the histology of the terminal end of distal rectal pouch and fistula region in cases of anorectal malformations (ARMs) and to get an insight on the usefulness of excising or preserving this region during its reconstruction. Materials and Methods: This was a prospective observational study of 20 consecutive cases of ARMs that underwent posterior sagittal anorectoplasty (PSARP) in our hospital over 6 months' period. The histopathological evaluation of the terminal end of the distal rectal pouch and fistula region in all cases with ARM was done. Complicated and redo cases were excluded from this study. Tissue specimen of about 0.5–1.0 cm from the most distal part of the rectal pouch and close to the fistula region was taken. Biopsy specimens were obtained from all patients undergoing a PSARP performed after a defunctioning colostomy or as a primary procedure without colostomy, and histopathological evaluation was done in all cases. Further, the internal sphincter and its morphology, hypoganglionosis or aganglionosis, anal glands and crypts, thickened nerve trunks, and other miscellaneous histopathological aberrations were studied. Based on these histological findings, conclusions were derived whether to preserve or excise this region during ARM reconstruction. Results: Out of the 20 ARM patients included, 12 patients (60%) were male and 8 (40%) were female. An internal sphincter was identified in all the patients. However, the smooth muscle bundles were disorganized in all the 20 patients (100%). While ganglion cells were absent in 90% cases, hypertrophic nerve bundles were a common histological finding (90% of patients). The abnormal mucosal finding was also noted in majority of the patients (75%). Conclusions: An atrophic or disorganized internal sphincter, absent ganglion cells, and abnormal anal mucosal findings in majority of these patients on histology would justify its excision during PSARP. However, further follow-up of these ARM patients in whom the terminal end of the distal rectal pouch and the fistula region is excised or retained is recommended.

Expanding Indications for Flow Diverters: Distal Aneurysms, Bifurcation Aneurysms, Small Aneurysms, Previously Coiled Aneurysms and Clipped Aneurysms, and Carotid Cavernous Fistulas

Flow diverter devices have gained wide acceptance for the treatment of unruptured intracranial aneurysms. Most studies are based on the treatment of large aneurysms harboring on the carotid syphon. However, during the last years the “off-label” use of these stents has widely grown up even if not supported by randomized studies. This review examines the relevant literature concerning “off-label” indications for flow diverter devices, such as for distal aneurysms, bifurcation aneurysms, small aneurysms, recurrent aneurysms, and direct carotid cavernous fistulas.

The utility of venous bifurcation for anastomosis with small-caliber veins in distal forearm radiocephalic arteriovenous fistula: Retrospective analysis of 52 fistula cases

Context: Distal forearm radiocephalic (RC) arteriovenous fistula (AVF) is the gold standard for vascular access for hemodialysis. The use of venous bifurcation to facilitate anastomoses in small-caliber vessels is well known in microvascular surgery. Small-caliber cephalic vein (CV) is frequently encountered during AVF creation in the distal forearm. We present here the utility of this technique for the creation of distal RC AVF in small-caliber CVs. Objective: The objective was to assess the utility of venous bifurcation for distal forearm RC AVF creation in small-caliber CV. Methodology: Fifty-two cases with CV diameter

Effect of Distal Cephalic Vein Ligation on Primary Patency Rates and Proximal Flow Rates in Distal Radiocephalic Fistula.

Introduction:The Brescia-Cimino radiocephalic fistula, originally devised as a side-to-side anastomosis, is simple to perform and provides a smooth vein–artery interface but requires greater mobilization for vein–artery approximation than does the end-to-side approach. Distal cephalic vein ligation is performed to prevent venous hypertension. The study aims to assess primary patency at one month following distal side-to-side radiocephalic fistula creation with and without distal cephalic vein ligation, to assess the effect of distal cephalic vein ligation on flow rates at one month, and to document the occurrence of venous hypertension over one year follow up.Method:A total of 100 patients requiring vascular access for hemodialysis were assigned to side-to-side anastomosis with and without distal cephalic vein ligation. Follow up Doppler exam was performed at one month for assessment of patency and flow rates and after one year clinical exam to document venous hypertension and the need for revision surgery. The quantitative and qualitative variables were evaluated using student t test and chi square test, respectively.Results:The patency rates of distal ligation and no ligation groups were 86.4% and 85.4%, respectively. The proximal flow rates of distal ligation and no ligation groups were 1192+/−812 ml/min and 1217+/−796 ml/min, respectively. The difference was not statistically significant (P > 0.05). Only two cases (5%) with no ligation required revision ligation within one year of surgery.Conclusion:Distal cephalic vein ligation does not increase the proximal cephalic flow rates and primary patency rates after one month. However, venous hypertension was associated in 5% of nonligated cases at one year follow up.

Early Post-Operative Outcome and Complication of Arteriovenous Fistula Creation under Regional Anesthesia

Introduction: Arteriovenous fistula (AVF) is the commonest vascular access for patients with end stage renal disease (ESRD) undergoing hemodialysis, however there is no consensus regarding mode of anaesthesia for creation of AVF. Mode of anaesthesia may have effect on outcome and complication of AVF. Methods: This is a retrospective descriptive study conducted on the basis of data collected from patients undergoing AVF under brachial plexus block (BPB) from January 2018 to December 2018 at Manmohan Cardiothoracic Vascular and Transplant Center (MCVTC). Data regarding demographics, results and complications have been analyzed. Results: A total of 79 patients (male: female=45:34) underwent AVF under BPB during one year period at University teaching hospital with a mean age group of 56.76±11.65 years (24-86 years). In three patients, the brachial plexus block failed and was substituted with general anaesthesia while 21 patients needed some adjuncts with block to create fistula. In 38 patients (48.10%) brachiocephalic fistula was created and in 48 patients (60.76%), plan to make fistula at proximal site was changed after application of block to more distal level. All fistulas were patent at 24 hours (100%, 79 patients) and the rate was 93.67% (74 patients) at 6weeks. The complications seen post procedure were limb oedema in five patients (6.33%), thrombosis and infection in one patient each, hematoma in two patients and bleeding in three patients. Conclusion: Brachial plexus block is effective modality of anaesthesia to create AVF for hemodialysis as it increases chances of creating distal fistula and also increases the effectiveness of it.

Early Post-Operative Outcome and Complication of Arteriovenous Fistula Creation under Regional Anesthesia

Introduction Arteriovenous fistula (AVF) is the commonest vascular access for patients with end stage renal disease (ESRD) undergoing hemodialysis, however there is no consensus regarding mode of anaesthesia for creation of AVF. Mode of anaesthesia may have effect on outcome and complication of AVF.&#x0D; MethodsThis is a retrospective descriptive study conducted on the basis of data collected from patients undergoing AVF under brachial plexus block (BPB) from January 2018 to December 2018 at Manmohan Cardiothoracic Vascular and Transplant Center (MCVTC). Data regarding demographics, results and complications have been analyzed.&#x0D; ResultsA total of 79 patients (male: female=45:34) underwent AVF under BPB during one year period at University teaching hospital with a mean age group of 56.76±11.65 years (24-86 years). In three patients, the brachial plexus block failed and was substituted with general anaesthesia while 21 patients needed some adjuncts with block to create fistula. In 38 patients (48.10%) brachiocephalic fistula was created and in 48 patients (60.76%), plan to make fistula at proximal site was changed after application of block to more distal level. All fistulas were patent at 24 hours (100%, 79 patients) and the rate was 93.67% (74 patients) at 6weeks. The complications seen post procedure were limb oedema in five patients (6.33%), thrombosis and infection in one patient each, hematoma in two patients and bleeding in three patients.&#x0D; ConclusionBrachial plexus block is effective modality of anaesthesia to create AVF for hemodialysis as it increases chances of creating distal fistula and also increases the effectiveness of it.

Long-term outcomes of percutaneous closure of coronary artery fistulae in the adult: A single-center experience.

We describe our 20-year experience with percutaneous closure of CAF in adult patients, focusing on long-term outcomes. From 1995 to 2015, 25 adult patients underwent 33 transcatheter interventions to close 26 CAF at our institution. Mean age was 51.4 ± 16.8 years, and 14 (56%) were female. All the patients were symptomatic with dyspnea (21/25, 84%) being the most common complaint followed by chest pain (17/25, 68%), palpitations (9/25, 36%), and heart failure (2/25, 8%). Two patients presented with acute coronary syndrome, whereas 10/25 (40%) also had inducible ischemia on stress test. These CAFs were classified as medium (12, 46.2%), large (5, 19.2%), and giant (9, 34.6%). Immediately postprocedure complete occlusion was achieved in 21 (21/26, 81%), and residual trace leak was observed in three fistulae, whereas we could not deliver coils/device in two cases. Periprocedural complications occurred in the form of coronary dissection (n = 1), myocardial infarction (n = 2), coil embolization (n = 1), transient ST elevation (n = 1); the majority of complications were observed in the early years of our experience. Patients reported marked improvement in symptoms after the intervention. During a mean follow-up of 76 ± 69 (5-214 months) (n = 22), 15 patients were investigated by either conventional (n = 6) or CT angiography (n = 8) or both (n = 1) that demonstrated thrombotic occlusion of a proximal coronary artery where a distal fistula was treated. Another patient was noted to have thrombus proximal to a vascular plug in a distal giant fistula. Three patients were lost to follow-up. None of the investigated patients had recanalization of their fistula. We did not observe remodeling of the native coronary artery that was feeding the fistula, even after successful complete closure. Percutaneous device closure of CAF is a feasible and effective therapeutic intervention in adult patients; however, patients with distal fistulas represent a significant challenge and the outcomes of these procedures are in question. All patients should have long-term angiographic follow-up.