Arteriovenous Fistula Formation Research Articles

Impact of arteriovenous fistula formation on trajectory of kidney function decline: a target trial emulation

Abstract Background Prior nonrandomised studies have suggested nephroprotective effects of arteriovenous fistula (AVF) formation, but these are plausibly susceptible to immortal time and selection biases. Methods We studied patients attending nephrology clinics in the West of Scotland during 2010-2022 with an eGFR ≤15mL/min/1.73m2 and no prior AVF. Using target trial emulation and a sequential trial design, we simulated a hypothetical trial that would randomise patients to either undergo AVF formation immediately or not to undergo AVF formation. The primary outcome was the difference in eGFR slope for the first six months of follow-up, estimated using a mixed-effects model. The secondary outcomes were 5-year absolute risks of dialysis and death, estimated using the Aalen-Johansen and Kaplan-Meier estimators respectively. Results 1,364 unique patients (mean age 51.1, 55.7% male) contributed 3,125 person-trials, with 561 in the AVF and 2,564 in the no AVF group. Mean eGFR was 12.6mL/min/1.73m2 and the median number of eGFR measurements per person-trial was 7 (IQR 4 – 12). Slope of eGFR decline did not differ significantly between the AVF and no AVF groups (between group difference -0.67mL/min/1.73m2/year, 95%CI -1.43, 0.10). The 5-year absolute risk of dialysis was 87% (95%CI 84, 91) in the AVF group and 75% (95%CI 73, 77) in the no AVF group and the 5-year survival probability was 77% (95%CI 70, 83) in the AVF group and 67% (95%CI 64, 69) in the no AVF group. Conclusions In this study of patients with advanced CKD, there was no evidence of a nephroprotective effect of AVF formation.

A variant deep femoral artery passing anterior to femoral vein: an anatomical observation with implication in femoral vein cannulation.

The common femoral artery (CFA) typically gives rise to its superficial and deep branches, with the deep femoral artery (DFA) being the largest and most substantial of these branches. This case study presents a rare variation of the DFA characterized by an unusual branching pattern and its specific relationship with the femoral vein within the subinguinal region. In nutshell, the DFA and the medial femoral circumflex artery shared a common origin from the medial aspect of the CFA. The DFA assumed an unusual course, initially passing anterior to the femoral vein above the saphenofemoral junction, followed by a spiraling trajectory around the medial aspect of the femoral vein before running posteriorly. The embryological origins and clinical implications of this anatomical variation are thoroughly examined. This unusual vascular relationship in the subinguinal region may potentially result in arterial injury during femoral vein cannulation or formation of arteriovenous fistula after the procedure.

Is there an association between arteriovenous fistulas and axillary artery aneurysms? A report of two cases

IntroductionAxillary artery aneurysms are rare vascular conditions that can present with various clinical manifestations, including neurological deficits and vascular compromise. While the underlying pathophysiology remains complex and multifactorial, potential associations with trauma, arteriovenous fistula formation, and atherosclerosis have been reported.Presentation Of Case.Two male patients, aged 33 and 38, with a history of kidney transplantation and previous arteriovenous fistula (AVF) presented with symptoms of upper limb ischemia and neurological compromise. Imaging revealed large axillary artery aneurysms. Open surgical repair was performed for both cases. Two weeks after discharge, one patient showed good pronation and supination with mildly limited extension. The other patient's wrist drop gradually improved with physiotherapy. DiscussionMultifactorial pathophysiology encompassed altered blood flow dynamics, inflammation, and the underlying vascular pathology. Chief complaints and prior vascular interventions contributed. Open surgical repair was preferred to endovascular approaches, achieving favorable outcomes. ConclusionAxillary artery aneurysms in patients with a history of AVF are rare but potentially serious complications. The cases highlight the complexity of axillary artery aneurysms and the need for careful evaluation and surgical intervention This strategy is crucial to prevent potential complications and optimize patient outcomes. Further research is needed to elucidate the precise pathophysiology and the potential association between AVF and the subsequent development of axillary artery aneurysms. Increasing awareness among surgeons could enable earlier detection of aneurysms, thereby reducing the risk of complications.

Is endovascular arteriovenous fistula a feasible alternative for hemodialysis patients?

For hemodialysis (HD) patients, the selection of vascular access (VA) is a crucial factor that significantly affects morbidity and mortality. Historically, native Arteriovenous Fistulas (AVFs) have been established using surgical techniques. However, devices facilitating percutaneous endovascular arteriovenous fistula formation have recently been introduced in clinical practice, showing promising initial evidence. The primary objectives were technical success, efficacy, and cannulation rates. The secondary objectives included primary and cumulative patency, safety, and the number of procedures required to maintain fistula patency. A prospective, single-center, single-arm study that included all patients who underwent endovascular arteriovenous fistulas (endoAVF) creation using the WavelinQ™ EndoAVF System at a University Hospital between December 2021 and August 2023. A total of 20 patients who underwent an endoAVF were included. Technical success was 100%. 75% (15) of the endoAVFs met the criteria for physiological suitability. The cannulation rate was 66% (10/15) for endoAVFs that reached physiological suitability. At 6 months of follow-up, the primary and cumulative patency rates were 65% and 75%, respectively; at 12 months, these were 50% and 70%, respectively. Serious adverse events were not observed. The reintervention rate was 0.33 procedures/patient-year. Based on our experience, creating AVFs using the WavelinQ 4-F EndoAVF system is safe and effective, with high technical success rates and acceptable patency and reintervention rates.

Combined treatment of wounded with traumatic aneurysm of posterior communicating artery complicated by intraventricular hemorrhage

Cerebral blood vessel trauma (CBVT) is a serious condition of craniocerebral injury. According to literature data, different varieties of CBVT in penetrating gunshot craniocerebral injuries are found in 30–45 % of cases. Traumatic pseudoaneurysms are the most common finding in late evaluation and can lead to life-threatening episodes of intracranial hemorrhage.In addition, CBVT includestraumatic occlusion, dissection of vessels, rupture of cerebral arteries, formation of arteriovenous fistulas (carotid-cavernous anastomoses), venous stasis, etc. Injured persons with traumatic dissection and injury of vertebrobasilar pool have the highest risks of lethal outcome. There are no largerandomised trials and national recommendations for the treatment of CBVT, individual observations and small series of clinical cases have been published. In this connection, there is a need for a detailed analysis of all clinical cases, the development of tactics for early diagnosis and an algorithm for the treatment of wounded with CBVT.The article presents a review of the literature data that characterizes the current understanding of CBVT, and a clinical case of traumatic occlusion of the middle cerebral artery and pseudoaneurysm of the posterior communicating artery in a wounded man with a gunshot penetrating cranioorbital wound, who was treated at the neurosurgical center of the N.N. Burdenko Main Military Clinical Hospital.In the early period after the injury, the patient underwent endovasal occlusion of a traumatic aneurysm of the posterior connective artery by microspirals followed by local thrombolysis of intraventricular hematomas through a ventricular catheter. The catamnesis was 150 days, the score on the modified Rankin scale was 3, the Glasgow outcome scale extended was 5.

Anatomical Feasibility of Percutaneous Arteriovenous Fistula Formation in Korea.

Currently, there are two types of percutaneous arteriovenous fistula (pAVF) formation systems approved by the FDA: Ellipsys and WavelinQ. Although these systems are already in use in Europe or the United States, they have not been approved for use in Korea yet. For this reason, this study aimed to check anatomical feasibility of these systems for Korean population prior to their actual use. Consecutive patients who received ultrasound vein mapping for arteriovenous fistula formation from June 2021 to June 2022 were included. The anatomical feasibility of each system was confirmed according to the manufacturer's instructions for use (IFU). Upper extremity ultrasonography was performed for a total of 83 patients to determine their feasibility for pAVF formation. Of these patients, 65.1% were feasible for pAVF formation with appropriate deep communicating vein (DCV) and outflow. Among them, 57.8% were feasible for the Ellipsys system and 54.2% were feasible for the WavelinQ system. Most patients who were infeasible for pAVF formation had a DCV of small size. Ulnar vessels were more suitable than radial vessel for WavelinQ (54.2% vs 33.7%, P-value = .012). The most common reason for not meeting the criteria was a small vein size at the access site. More than half of all patients were feasible for pAVF formation in this study. Ellipsys had a higher feasibility than WavelinQ, although they showed no significant difference in the feasibility. If these devices are imported into Korea, it will be a good opportunity for many patients to reduce the surgical burden and create AVFs more easily through these procedures.

Inhibition of endothelial to mesenchymal transition in a large animal preclinical arterio-venous fistula model leads to improved remodeling and reduced stenosis.

Vein grafts are used for many indications, including bypass graft surgery and arterio-venous fistula (AVF) formation. However, patency following vein grafting or AVF formation is suboptimal for various reasons, including thrombosis, neointimal hyperplasia and adverse remodeling. Recently, endothelial to mesenchymal transition (EndMT) was found to contribute to neointimal hyperplasia in mouse vein grafts. We aimed to evaluate the clinical potential of inhibiting EndMT, and developed the first dedicated preclinical model to study the efficacy of local EndMT inhibition immediately prior to AVF creation. We first undertook pilot studies to optimize the creation of a femoral AVF in pigs and verify that EndMT contributes to neointimal formation. We then developed a method to achieve local in vivo SMAD3 knockdown by dwelling a lentiviral construct containing SMAD3 shRNA in the femoral vein prior to AVF creation. Next, in Phase 1, 6 pigs were randomized to SMAD3 knockdown or control lentivirus to evaluate the effectiveness of SMAD3 knockdown and EndMT inhibition 8 days after AVF creation. In Phase 2, 16 pigs were randomized to SMAD3 knockdown or control lentivirus and were evaluated to assess longer-term effects on AVF diameter, patency and related measures at 30 days after AVF creation.In Phase 1, compared to controls, SMAD3 knockdown achieved a 75% reduction in the proportion of CD31+ endothelial cells co-expressing SMAD3 (p<0.001), and also a significant reduction in the extent of EndMT (p<0.05). In Phase 2, compared to controls, SMAD3 knockdown was associated with an increase in the minimum diameter of the venous limb of the AVF (1.56±1.66 versus 4.26±1.71mm, p<0.01) and a reduced degree of stenosis (p<0.01). Consistent with this, neointimal thickness was reduced in the SMAD3 knockdown group (0.88±0.51 versus 0.45±0.19mm, p<0.05). Furthermore, endothelial integrity (the proportion of luminal cells expressing endothelial markers) was improved in the SMAD3 knockdown group (p<0.05). EndMT inhibition in a preclinical AVF model by local SMAD3 knockdown using gene therapy led to reduced neointimal hyperplasia, increased endothelialization and a reduction in the degree of AVF stenosis. This provides important proof-of-concept to pursue this approach as a clinical strategy to improve the patency of AVFs and other vein grafts.

#281 AVF formation is a common complication of percutaneous ultrasound-guided renal biopsy: a single-center analysis of risk factors and clinical outcome

Abstract Background and Aims Percutaneous renal biopsy is a key procedure for the work-up of renal diseases. Among the possible complications of such procedure, prevalence, risk factors and clinical outcome of arterio-venous fistula (AVF) formation is unclear. We present here a single-center experience on renal biopsy-related complications with a focus on risk factors for AVFs formation and their management. Method We retrospectively analyzed all the kidney biopsies performed in our center between January 2012 and December 2022. All biopsies were conducted under real-time ultrasound (US) guidance by trained nephrologists. Kidney US and doppler mapping were performed routinely 6 and 24 hours post-procedure. In accordance with the description provided in the US report, AVFs were categorized into small, moderate, and high-flow rates. Patients’ comorbidities, histologic sample characteristics, blood tests results and the clinical course were recorded. Logistic regression was employed to investigate potential risk factors for complications. Results 1016 adult native renal biopsies were performed. The average age of patients was 55 ± 17 years, and 677/1016 (66.6%) were males. The histological sample was unsuitable in 29/1016 (2.9%) of the cases; moreover, prevalence of renal medulla and presence of large-caliber arteriole were observed in 88/1016 (8.7%) and 38/1016 (3.7%) of the samples, respectively. The most common complication was hematoma, detected by US in 175/1016 (17.2%), which was considered “complicated” in 21/1016 (2.1%) due to the association with macroscopic hematuria (n = 10), blood transfusion requirement (n = 8), or signs of active bleeding (n = 8), requiring embolization in 6/1016 patients (0.6%). AVFs were identified in 119/1016 (11.7%) biopsies; of these 20/119 (16.8%) required embolization after a median time of 16 days (IQR 5-65). Spontaneous resolution was documented in 65/119 (55%) of cases and occurred after a median of 27 days (IQR 15-49), with 50/55 (90.9%) of cases spontaneously resolving within the first month and the remaining cases no later than the fourth month (Fig. 1). High-flow AVFs more frequently necessitated angiographic intervention compared to moderate and small AVFs (75% vs 25% vs 7%), with a prolonged spontaneous resolution time (median 78 days; IQR 51-106) (Table 1). In the cases requiring embolization, the median creatinine level before and 6 months after procedure was respectively 1.7 mg/dL and 1.9 mg/dL (paired Wilcoxon signed-rank test: p = 0.908). In three cases post-embolization, a loss of renal vascularization at angiography higher than 30% was reported; however, even in these cases no differences in terms of renal function were observed at 6 months compared to the baseline. At multivariate logistic regression, hypertension (OR = 2,2; p = 0.003; 95% CI [1.3-3.7]), renal medulla prevalence (OR = 2,8; p = 0,001; 95% CI [1.6-4.8]), and large-caliber arteriole presence (OR = 2,9; p = 0,008; 95% CI [1.3-6.3]) were associated with a higher risk of AVFs, while obesity emerged as a protective factor (OR = 0,27; p = 0,013; 95% CI [0.1-0.8]). Conclusion AVF is a common complication following renal biopsy but therapeutic intervention is rarely required, as spontaneous resolution is typically observed within one month. In case of symptomatic or persistent AVFs, embolization may be required without an apparent impact on the renal function, at least in the short term. Hypertension and surrogate factors associated with a deeper penetration of the needle into the renal parenchyma are associated with an increased risk of AVF. Conversely, obesity was protective toward the risk of AVF development.

Outcomes of Surgical and Endovascular Treatment for Cephalic Arch Stenosis in Proximal Arteriovenous Fistula.

The cephalic arch is a significant site of stenosis in proximal arteriovenous fistulas (AVFs) that contributes to access dysfunction and thrombosis. This study aimed to evaluate the outcomes of surgical treatment (ST) and endovascular treatment (ET) for cephalic arch stenosis (CAS). A total of 62 patients with proximal AVF who underwent CAS revision using either ST or ET were enrolled between January 2018 and March 2023. In the ET group, only the initial ET following AVF formation was considered, to mitigate bias. In the ST group, central transposition of the native AVF (transposition group) or interposition of the prosthetic graft into the proximal basilic or axillary vein (interposition group) was performed. We evaluated primary and functional patency based on these groups and calculated the number of patency loss events after CAS treatment. Of the 62 patients, 38 (61%) were male, with a mean age of 66.4 years. ST was performed in 26 (42%) patients, including transposition in 16 and interposition in 10, whereas ET was administered to 36 patients during the study period. Among the ST recipients, 42% had a history of ET for CAS. The incidence of AVF thrombosis was marginally higher in the ST group than in the ET group (39% vs. 19%, P=0.098). The primary patency rates at 6 months, 1 year, and 3 years were 87%, 87%, and 66% in the transposition group; 45%, 23%, and 11% in the interposition group; and 66%, 49%, and 17% in the ET group, respectively. Notably, the primary patency of the transposition group was significantly higher than that of the interposition (P=0.001) and ET groups (P=0.016). The frequency of patency loss events per person-year after the initial revision was 0.40, 0.52, and 1.42 in the transposition, interposition, and ET groups, respectively. Transposition exhibited the most favorable primary patency rate and the lowest number of subsequent patency loss events during follow-up despite the higher rates of AVF thrombosis and previous ET at presentation. Consequently, transposition should be actively considered in eligible patients with CAS.

Evaluation of the Safety and Efficacy of Coronary Intervention through the Brachial Artery Compared to the Radial Artery in Elderly Patients with Different Extubation Times

Introduction: Percutaneous coronary intervention (PCI) is an important treatment for acute coronary syndrome. The main puncture paths of PCI include radial artery, brachial artery, and femoral artery. The aim of this study was to investigate the safety and efficacy of transbrachial intervention in elderly patients. Methods: According to intraoperative and postoperative nursing records, a retrospective analysis was performed for 70 elderly patients who underwent coronary intervention were divided into brachial artery A group (33 cases) and brachial artery B group (37 cases) according to immediate postoperative extubation compression dressing and 6 hours postoperative extubation compression dressing, and matched elderly patients who had successful transradial artery puncture in the same period as radial artery group (35 cases). The success rate of puncture and catheterization, arterial puncture time, total operation time, length of hospital stay, patient comfort score, incidence of arterial spasm and occlusion, subcutaneous ecchymosis and hematoma, epidermal blister occurrence, vagal reflex, pseudoaneurysm development, arteriovenous fistula formation, nerve damage risk assessment and osteofascial compartment syndrome were compared. Results: Compared with the radial artery group, the brachial artery group (group A and group B) had a higher success rate of puncture and catheterization (97.0% vs. 97.3% vs. 80.0%, p = 0.013), shorter arterial puncture time (2.45 ± 0.38 vs. 2.40 ± 0.35 vs. 3.40 ± 0.37, p = 0.000), and lower incidence of arterial spasm (0.0% vs. 0.0% vs. 34.3%, p = 0.000), arterial occlusion (0.0% vs. 0.0% vs. 14.3%, p = 0.005) and puncture site bleeding (12.1% vs. 5.6% vs. 40.0%, p = 0.001). The incidence of epidermal blister was higher in brachial artery A group than in brachial artery B group (24.2% vs. 2.7%, p = 0.003) or radial artery group (24.2% vs. 0%, p = 0.001), and the incidence of epidermal blister in brachial artery B group and radial artery group was not much different. There was no difference between the three groups in total operation time, length of hospital stay, comfort score, subcutaneous ecchymosis and hematoma, vagal reflex, pseudoaneurysm, arteriovenous fistula, nerve damage and osteofascial compartment syndrome. Conclusion: In elderly patients, coronary intervention through brachial artery is not inferior to radial artery.

Accuracy of physical examination versus Doppler ultrasonography for determining maturity in postoperative arteriovenous fistula formation

Differentiating between arteriovenous fistula (AVF) maturation and failure can help determine which AVF will undergo successful canulation and which ones will require immediate rescue. A prospective observational study was conducted at Vajira Hospital in Bangkok, Thailand, between October 2020-November 2022. A single vascular surgeon performed a physical examination on patients with chronic kidney disease undergoing AVF placement, and a radiologist conducted Doppler ultrasonography during the second and sixth postoperative weeks. Dialysis nurses determined AVF maturity by performing cannulation. The study compared the accuracy of physical examination and Doppler ultrasonography. A model was developed to predict the success of AVF use. Out Of the 125 recruited patients, 81% demonstrate unassisted maturation of their AVF. The male sex and brachiocephalic type are associated with AVF maturation. The physical examination findings of palpable thrill and the absence of a strong pulse at the 6th week show an area under the receiver operating curve (AUC) value of 0.79. Similarly, arterial end-diastolic velocity on ultrasonography at the 6th week also demonstrates a comparable predictive value with an AUC of 0.82 (p=0.697). Meanwhile, the model that combined end-diastolic velocity and venous volume flow yields the best results for predicting AVF maturation, with an AUC of 0.92. These models provide more accurate predictions compared to physical examination alone (AUC: 0.92 vs. 0.79; p<0.01). Although a prudent physician predicts AVF maturation through a thorough physical examination, Doppler ultrasonography is preferred in anticipating the success of postoperative AVF placement.

Results of Primary Arteriovenous Fistulas Formation with Different Types of Anastomoses in the Early Postoperative Period in Patients on Programmed Hemodialysis

The study includes the analysis of the results of using the different types of arteriovenous anastomoses in the formation of arteriovenous fistulas and their impact on fistula maturation in the early postoperative period. One of the main aspects of the work is to determine the optimal type of anastomosis to ensure the proper functioning of arteriovenous fistula that is an important element of vascular access in patients on renal replacement therapy. It is important to consider such factors as the diameter of formed arteriovenous fistula, the blood flow velocity through it, the incidence of complications and the duration of its functioning. The study also takes into account the impact of patients’ characteristics, such as age, condition of arteries and veins, as well as general health indicators on the results of surgery. Taking these factors into account allows to identify the groups of patients who can benefit most from a particular type of anastomosis.&#x0D; During the sample period, 384 patients with terminal stage of renal failure aged 20 to 84 years undergoing programmed hemodialysis, the native arteriovenous fistula was formed. It was found that 94.01 % of arteriovenous fistulas were successful in the early postoperative period. The average age of these patients was 44.2 years, while unsuccessful cases developed in people with an average age of 66.8 years. It was also found that within an hour after surgery for the formation of an arteriovenous fistula with the type end-to-side anastomosis, its diameter increases from 2.08±0.42 mm to 2.96±1.68 mm, and the blood flow velocity increases from 21.4±7.6 ml/min to 212.4±74.6 ml/min. The risk factor for effective fistula formation, in addition to age, is the diameter of vessels, anatomical features of the venous system, the presence of concomitant pathology (primarily diabetes mellitus).&#x0D; The obtained results can serve as a basis for the developing of recommendations for the optimal choice of anastomosis type for certain categories of patients who will undergo renal replacement therapy. The study is aimed at improving the results of surgical treatment and increasing the quality of life of patients with chronic renal failure.

De novo formation of remote dural arteriovenous fistula following treated cavernous sinus dural arteriovenous fistula

BackgroundThe development of new dural arteriovenous fistulas (DAVFs) at another location following endovascular treatment of cavernous sinus DAVFs (CSDAVFs) are extremely rare. Our aim is to review cases of de Novo DAVFs that occurred after treatment of CSDAVFs at our institution and those reported in the literature. MethodsWe reviewed all cases of CSDAVFs evaluated by 2 experienced neuroradiologists. A literature search was performed using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines focusing on De Novo DAVFs following the endovascular treatment of cerebrovascular malformations. Addition articles were searched through the reference lists of the included articles. ResultsFrom June 2004 and September 2019., we identified 3 (2.5%) cases of De Novo DAVFs occurred after endovascular treatment or spontaneous obliteration of CSDAVFs from 119 treated CSDAVFs at our institute. Our review yielded 9 articles involving 12 patients with 15 de novo DAVFs, including our 3 patients. The mean age was 55.08 ± 12.9 years (range 43–69), 83.3% were females (n = 10). The new remote DAVFs occurred after endovascular treatment of CSDAVFs in 10 (83.3%) patients. The de novo DAVFs occurred following spontaneous complete regression in 2 (16.7%) patients. All de novo DAVFs developed after complete obliteration of treated CSDAVFs. ConclusionSinus thrombosis and elevated venous pressure may play an important role in the pathogenesis of a de novo DAVF formation. In addition, thrombophilic abnormalities and the use of contraceptives may contribute to sinus thrombosis, leading to the development of the second remote DAVF after treatment of CSDAVFs.

AUDIT OF COVID-19 WARD PERFORMANCE AND PRACTICE IN THE COVID-19 PANDEMIC: FUTURE DIRECTIONS FOR UNDERSTANDING: A RETROSPECTIVE STUDY

A retrospective study was conducted to assess the trend of the COVID-19 pandemic in the COVID Ward emergency and COVID Ward treatment departments of the Department of COVID Ward at POF Hospital Wah Cantt from January 2021 to January 2022. Data on every patient admitted to the COVID Ward department over a year was gathered retroactively. The following demographic factors were recorded: diagnosis, COVID-19 work-up, admission specialization, and COVID-19 ward vs. conservative therapy. In total, there were 156 patients, with 108 being primarily men (70.4%). Of these patients, 90 (72%) were admitted via the clinic, and 124 (46%) were admitted in May. One hundred five patients (62.8%) had a COVID-19 PCR, 135 had a chest x-ray (90.2%), and 56 patients (31.4%) had a chest HRCT. The orthopedic COVID Ward was the most common department for operational interventions, with 88.4% of patients undergoing operative care, despite the general COVID Ward being the busiest service line with 89 total patient admissions (43.1%). The study found that the existing local protocols for patient flow and COVID-19 crisis management are effective and practical. Hospitals should be prepared to redirect their resources to high-volume specialties like orthopaedics and general COVID Wards after the later COVID-19 waves. Arteriovenous fistula formation is a simple yet crucial technique that should only be discontinued in the event of a labor shortage.

Giant Left Atrial Aneurysm In A Three Year Old

Background: The PA to the LA fistula is a rare cause of central cyanosis. Embryologically, incomplete degeneration of septum between the arterial and venous plexus of the pulmonary vascular bed or defective capillary loop leads to formation of thin-walled sacs resulting in formation of pulmonary arteriovenous fistula. The more restrictive the fistula is, the more subtle is the extent of cyanosis and the less evident is the clinical presentation Case Description We describe the case of three years-old patient, who presented with unresolving pneumonia, that necessitated CT imaging. CT imaging revealed a mass in the posterior mediastinum that was communicating with the left atrium. Originally it was thought that this is an aneurysmal dilation of one of the pulmonary veins, that could have resulted from mitral regurge. Echocardiography showed an aneurysmal dilation of the left atrium, with an abnormal retrograde flow across the roof of the left atrium, pulmonary hypertension and mitral regurge were excluded. 3D CT angiographic reconstruction revealed the presence of a fistulous communication between the RPA and left atrium, this explains the low normal oxygen saturations of this patient due to mixing (90-92%) and the high hemoglobin concentration (160) due to chronic subclinical hypoxia. Conclusion and learning points Aneurysmal dilation of left atrium is commonly encountered with severe mitral regurge, rare causes such as PA to LA fistulae should be thought of especially if clinical or subclinical hypoxia or polycythemia is present.

Effect of Different Methods of Anesthesia on Surgically Created Arteriovenous Fistula

Aim of the study was to determine the advantages of peripheral nerve blocks (PNB) versus local infiltration anesthesia (LIA) in the formation of arteriovenous fistula (AVF) surgically created for hemodialysis treatmentType of study: prospective non-randomized study. Approved by the ethics committee of JLF UK in Martin.Type of workplace: clinical workplace of a university hospital.Material and method. The cohort of patients (N=40) who required arteriovenous fistula (AVF) creation was divided into 2 groups, 20 patients each: patients operated under peripheral nerve blockade and patients operated under local infiltration anesthesia. The preserved function of the fistula was monitored 24 hours, 6 weeks and one year after the operation, without revision. Patient inclusion criteria included: age 19–75 years, ASA 3–4, weight 40–120 kg, BMI up to 40. Statistical treatment of data included Mann-Whitney exact test, Fisher's test, t-test, Shapiro–Wilk normality test.Results. After 24 hours, all fistulas created with peripheral nerve blockade were functional whereas only 90% developed under local infiltration anesthesia remained functional (P&gt;0.05 between groups). However, after 6 weeks, 80% of fistulas created under peripheral nerve block were functional, compared to 50% of functional fistulas created in patients under local infiltration anesthesia (P=0.048). One year after surgery, the difference remained as a trend since 55% of fistulas created under peripheral nerve block remained functional while only 35% of fistulas created in patients receiving local infiltration anesthesia were functional without complications (P=0.097).Conclusion. In our study, the peripheral nerve block anestesia seem superior in term of improved survival of created fistula compared to local infiltration anesthesia.

A rare case report: compartment syndrome after brachiocephalic arteriovenous fistula formation in a hemodialysis patient

Introduction: Acute compartment syndrome is a condition in which increased pressure in the tight fascia space reduces capillary perfusion below the level required for tissue viability. Very few cases of acute compartment syndrome associated with dialysis have been reported. It can lead to severe damage to the tissues of the arm. Case Illustration: A 47-year-old woman with end-stage renal failure presented to the emergency room with swelling and pain in the right upper extremity and has lasted for a day. Three days before admission, the patient underwent right brachiocephalic arteriovenous (AV) fistula surgery. Physical Examination showed a blackish bruise at the fossa cubiti, radial and ulnar artery were not palpable, but there is trill at AV fistula. Decreased motoric strength, reduced hand sensation and decreased capillary return in fingers. Oxygen blood saturation of the right fingers could not be read. Diagnosis of acute compartment syndrome was made. The patient was immediately taken to the operating room for decompression surgery. Emergency compartment fasciotomy was performed. After fasciotomy, necrotomy was performed. Furthermore, brachiocephalic AV fistula was ligated. Postoperative evaluation obtained good radial and ulnar artery. Six months after the surgery, the wound was fully healed and no sign of neuromuscular or vascular deficit. Conclusion: Compartment syndrome is a possible complication after AV fistula formation that can have disastrous consequences. However, it can be effectively treated if detected and treated early. Prognosis of compartment syndrome after fasciotomy depends on how quickly the condition is diagnosed and treated.

Management of Traumatic Arteriovenous Fistula as a Complication of Minimally Invasive Endoscopic Maxillofacial Surgery: A Case Report

A traumatic arteriovenous fistula (AVF) is a type of acquired vascular malformation, caused by blunt or penetrating trauma. Traumatic AVFs result in a pathologic connection between arterial and venous vasculature, bypassing the corresponding capillaries. When an intra-operative insult to vasculature within a surgical site is implicated in the subsequent formation of a traumatic AVF, the suspected etiology is iatrogenic. Although the most common etiology of traumatic AVFs of the entire body is iatrogenic trauma, intraoperative vascular insults (ie, ligation and cauterization) are routinely delivered within maxillofacial surgical sites, without formation of an acquired vascular malformation. A traumatic AVF in the pre-auricular region is exceedingly rare and has infrequently been described as a complication following minimally invasive temporomandibular joint (TMJ) surgery, managed with endovascular surgery. We describe a rare case of bilateral TMJ arthroscopies complicated by the formation of a pulsatile, traumatic AVF between the right superficial temporal artery and right retromandibular vein, treated with minimally invasive endovascular embolization by the interventional radiology team. This case report highlights the diagnosis of a traumatic AVF in the pre-auricular region and multi-specialty management of an early complication of minimally invasive maxillofacial surgery.

Same day discharge after large bore vascular access in percutaneous coronary intervention of chronic total coronary occlusions

Abstract Background Same day discharge (SDD) in patients undergoing percutaneous coronary intervention (PCI) of a chronic total coronary occlusion (CTO) appears feasible, safe, and carries economic advantage. However, SDD may be hampered by the application of large bore dual arterial access, due to its association with vascular complications. Nevertheless, increasing French size augments therapeutic options and is therefore considered fundamental in complex CTO PCI. Purpose The present study investigated the feasibility of SDD in patients undergoing CTO PCI with large bore dual arterial access. Methods Between 2013 and 2018, a total of 683 patients were prospectively enrolled in a single-center CTO registry and underwent single-vessel CTO PCI. Large bore arterial access was defined as the application of 7 and/or 8 French sheaths in at least one access site. Technical success was defined as Thrombolysis in Myocardial Infarction flow grade 3 and residual stenosis &amp;lt;30%. Vascular access complications were defined as a composite of clinically significant bleeding and/or hematoma, urgent transfusion, dissection, pseudoaneurysm, arteriovenous fistula formation, and thrombosis. Results Mean age was 66 ± 11 years; 83% were male. Large bore arterial access was applied in 87%; the most common set-up was radial-femoral (68%) and bifemoral (23%) access. In 432 (62%) patients, SDD was achieved. Patients within the SDD group were younger and had lower rates of prior MI, prior CABG, renal insufficiency, and peripheral artery disease. A high Japanese CTO score (≥2) was less common in patients with versus without SDD (58% vs. 72%, p&amp;lt;0.001). In addition, technical success rate was higher in the SDD group (96% vs. 89%, p&amp;lt;0.001). Vascular access complications were found in 22 (3,2%) cases, with 17 (77,2%) occurring in the non-SDD group. Local access site bleeding was found to be the most common complication (82,4% of total vascular access complications). Finally, multivariable analysis showed that female gender (OR 2.22, 95% CI: 1.30 – 3.78) and local access site bleeding (OR 12.0, 95% CI: 4.37 – 33.21) were significantly associated with a lower probability of SDD. Conclusions Our study demonstrates the feasibility of SDD in the majority of patients undergoing CTO PCI with large bore dual arterial access, with high rates of technical CTO PCI success and acceptable vascular access complication rates. Care should be taken to avoid local access site bleeding since this hinders SDD.

Lumbo-renal arteriovenous fistula: An unusual complication of percutaneous kidney biopsy

Arteriovenous fistula formation after percutaneous kidney biopsy is not uncommon. Most of these fistulas are intrarenal and close spontaneously. Formation of a fistula between an intercostal branch of the lumbar artery and the renal vein is a very rare complication. Our case has lumbo-renal arteriovenous fistula (AVF) following a percutaneous kidney biopsy. The AVF was successfully treated with embolization. Post-biopsy observations should include Doppler surveillance in order to detect such rare but potentially catastrophic complications.