Palpable Thrill Research Articles

A novel technique for snuffbox fistula creation.

In this pilot study, we describe a novel technique for creating a snuffbox fistula (SBF) and present the preliminary outcomes after 4-6 weeks of follow-up. The study included eight male patients with a mean age of 50 years (range 36-66 years). All patients received an SBF using the modified no-touch technique (MNTT) and piggyback straight-line on-lay technique (pSLOT). Immediate patency was obtained for all patients. In one case, a thrombosis developed at the juxta anastomosis. The remaining seven SBFs met the clinical arteriovenous fistula maturity criteria at the physical examination performed 4-6 weeks after surgery, showing an easily palpable vein, a straight superficial segment >10 cm in length and a sufficient diameter, and good palpable thrill. In addition, an ultrasound examination showed that the diameter of the drainage vein was 4-6 mm, and the brachial blood flow was ⩾500 mL/min. The combination of MNTT and pSLOT was used to successfully establish SBFs, and the success rate of surgery and access maturity were high.

8409 Thyroid Nodules A to V: A Discussion on Thyroid Nodules and a Case Report of a Rare Thyroid Arteriovenous Malformation

Abstract Disclosure: M. Townsend: None. M. Brennan: None. C. Kazmierczak: None. P. Czako: None. Introduction: Thyroid nodules are an increasingly common finding on imaging, and the differential is broad. Arteriovenous malformations (AVMs) are a very rare cause of thyroid lesions, with only 6 reported cases to date. Given their scarcity, there is a lack of information regarding these lesions and how they are diagnosed and managed. Our case aims to address these gaps in information. Case: A 58-yo female with a history of hypertension was found by her PCP to have an enlarged left thyroid lobe with a new left sided bruit and palpable thrill. She had undergone prior thyroid ultrasonography for the enlarged left thyroid lobe which noted dilated and tortuous vascular structures at the posterior aspect of the left thyroid consistent with varices. These were being monitored clinically. Thyroid function tests were all normal. Due to concern for atherosclerotic disease, carotid ultrasound was obtained and showed patent carotid arteries with a large left sided thyroid mass. CTA of the neck revealed the mass to be a large (6.0 x 3.0 x 2.4 cm) AVM centered at the left thyroid gland. She underwent diagnostic angiography that confirmed the size of the mass and showed predominant arterial supply from the left superior thyroidal artery as well as bilateral inferior thyroidal arteries. Since the patient was asymptomatic with no reported neck pain, dysphagia or dyspnea, non-operative management with angioembolization was pursued given the risk of significant blood loss with surgical intervention. Following angioembolization, the results and adequacy of treatment are to be followed with repeat imaging given the high risk of reoccurrence. Discussion: AVMs of the thyroid are a very rare but clinically significant cause of thyroid lesions. Left untreated, they can grow in size and lead to compression of the esophagus or trachea, serious bleeding and high output heart failure. Their presentation is often non-specific and on routine thyroid imaging they can be difficult to differentiate from malignant tumors or varices, as in the case of our patient. Management prioritizes embolization, either alone or in conjunction with surgery, depending on the clinical scenario. Regardless of the treatment modality, reoccurrence rates remain high. Conclusion: Our case aims to add to the available information about thyroid AVMs and discuss the clinical presentation, challenges in diagnosis, imaging findings and treatment modalities available to manage these lesions. Presentation: 6/2/2024

Early Prediction of Native Arteriovenous Fistula for Maturation by Doppler Ultrasound Study

Introduction: There are significant chances of maturation failure in arteriovenous fistulas (AVFs) made for vascular access for hemodialysis. AVFs are usually assessed for maturation 6 weeks after the operation. Significant time is lost for performing a salvage radiological procedure or making an alternative AVF, in case the AVF fails to mature. Materials and Methods: This prospective observational study was conducted to predict the chances of maturation of AVF by Doppler ultrasound (USG) study. One hundred and thirty-seven patients in whom native AVF was made as a vascular access procedure for hemodialysis were included in the study. In five patients, palpable thrill was absent after 48 h of operation and were excluded from the study. The velocity of the blood, diameter of the vessel, and depth of the vessel from the skin were assessed by USG Doppler 3 weeks after the operation and were correlated with AVF maturation. Results: Successful maturation occurred in 114 (86.3%) AVF. The flow rate of the blood and depth of the vein were statistically different in successful and unsuccessful AVF maturation for both the groups of radial artery (RA) and brachial artery (BA) based AVF. For RA AVF, successful maturation was predicted by the flow rate of 539 mL/min (sensitivity 95% and specificity 83%) and 4.2 mm diameter of the vein (sensitivity 93% and specificity 100%). For BA AVF, successful maturation was predicted by the flow rate of 456 mL/min (sensitivity 93% and specificity 100%) and 5.7 mm diameter of the vein (sensitivity 77% and specificity 100%). The measurement of flow and depth at 3 weeks after AVF may predict the maturation of AVF. Conclusion: It will be beneficial to do a USG Doppler study 3 weeks after making AVF, as the measurement of flow may predict the maturation of AVF.

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.

A case of cirsoid aneurysm: Case report

Scalp cirsoid aneurysm is an arteriovenous fistula of the scalp that is usually unconnected by intracranial or cerebral vessels. Variceal dilatation of draining veins can produce cosmetic concerns, masses, local pain, palpable thrills, audible bruits, headache, tinnitus, and torrential hemorrhage. Its etiopathogenesis is not well understood. Treatment includes surgery (fistula repair by simple surgical ligation until gross total resection), embolization (whether percutaneous or endovascular), or a combination of the two. Here is a case report of a 40-year-old male patient who had right superficial temporal artery cirsoid aneurysm who underwent surgical ligation with complete excision of the lesion.

A Palpable Thrill at the Base of the Neck After Inadvertent Arterial Puncture: Successful Management of a Carotid-Jugular Fistula.

A Palpable Thrill at the Base of the Neck After Inadvertent Arterial Puncture: Successful Management of a Carotid-Jugular Fistula.

Abstract 15479: High Output Cardiac Failure Associated With Arteriovenous Fistula

Introduction: High output heart failure (HOHF) secondary to arteriovenous fistula (AVF) is known. However, having a high index of suspicion for the latter when encountering diuretic resistance in patients with a remote history of hemodialysis is key. Case A 68-year-old female with a history of kidney transplant in 2012 with no recent dialysis, hypertension, hyperlipidemia, pulmonary hypertension, heart failure with reduced ejection fraction, and atrial fibrillation presented with decompensated heart failure and acute kidney injury (AKI). Physical exam was remarkable for anasarca, and no apparent fistulas were noted. She was started on milrinone and furosemide drips. Clinical decision making Initial transthoracic echocardiogram (TTE) revealed an ejection fraction (EF) of 20%, which declined from 35%, along with new mitral and tricuspid regurgitation. Her hospitalization was complicated by altered mental status, worsening AKI requiring hemodialysis, atrial fibrillation with rapid ventricular response, and resistance to multiple diuretics and after-load reduction combinations. Diuretics and inotropic support were discontinued due to worsening clinical status. Given concerns for valvular disease, a transesophageal echocardiogram was obtained, confirming moderate to severe mitral and tricuspid valve regurgitation, bi-atrial enlargement, and reduced biventricular function. However, the patient was not clinically optimized for Mitra-clip. Further hemodynamics and volume status assessment with RHC revealed a mean PAP 44, PCWP 26, and CO 11 L/min. RHC results raised suspicion for HOHF. Interestingly, the patient was noted to have a right inguinal surgical scar with a palpable thrill, and an arteriovenous graft duplex revealed high volume flow. The patient underwent ligation of the right inguinal fistula. Repeat TTE two weeks post AVF ligation showed EF of 40% and improved functional mitral and tricuspid valve regurgitation. The patient ultimately was taken off hemodialysis and had clinically improved heart failure. GDMT was optimized, and outpatient evaluation for mitral valve intervention was scheduled. Conclusion Longstanding AVF can cause HOHF. Early index of suspicion is warranted for AVF ligation as it results in rapid EF recovery.

Ventricular septal defect associated with aortic regurgitation and ascending aortic aneurysm: a case report

IntroductionVentricular septal defect (VSD) is one of the most common congenital cardiac anomalies. Patients with perimembranous VSD may have aortic regurgitation (AR) secondary to prolapse of the aortic cusp.Case presentationWe present a case of 23-year-old White man with VSD, AR and ascending aortic aneurysm. The patient presented to outpatient clinic with weakness and gradual worsening shortness of breath for the past 5 years. Clinical examination revealed regular heart rhythm and loud continuous systolic-diastolic murmur (Lewin’s grade 6/6), heard all over the precordium, associated with a palpable thrill. The ECG showed right axis deviation, fractionated QRS in V1 and signs of biventricular hypertrophy. The chest X-ray showed cardiomegaly. Transthoracic and transesophageal echocardiograms showed a perimembranous VSD with moderate restrictive shunt (Qp/Qs = 1.6), aortic regurgitation (AR), and ascending aortic aneurysm. Other clinical and laboratory findings were within normal limits.ConclusionsPerimembranous VSD, may be associated with aortic regurgitation and ascending aortic aneurysm as secondary phenomenon if it is not early diagnosed and successfully treated.

Abstract 520: Stethoscope Still Saving Lives: Catching A Ruptured Sinus Of Valsalva Aneurysm

Introduction: Sinus of Valsalva aneurysm (SVA) is a rare cardiac abnormality that can occur congenitally or as a result of acquired conditions. It is characterized by a weakness in the elastic lamina at the junction of the aortic media and annulus fibrosis, leading to the formation of an SVA. We present an interesting case of a 54-year-old man, initially diagnosed with infective endocarditis and later on found to have a severe acute rupture of an SVA. Case Presentation: A 54-year-old man with a past medical history of raynaud's disease and rheumatoid arthritis presented with shortness of breath and low-grade fever for two weeks. On further evaluations, a diligent finding of a continuous cardiac murmur and a palpable thrill across the precordium led to a transthoracic echocardiogram (TTE). The TTE revealed a 1.3 x 1.3 cm, nonmobile, ball of material near the base of the septal leaflet of the tricuspid valve, raising concerns about infective endocarditis and thus initiation of broad-spectrum intravenous antibiotics. Subsequent transesophageal echocardiogram, however, revealed an outpouching from the right coronary sinus suggestive of the right sinus of Valsalva which was ruptured with jet hitting the tricuspid valve continuously during diastole and systole, mimicking falsely as vegetation on TTE. Emergency interventions including CT angiogram, catheterization, and surgical repair resulted in a favorable outcome for the patient. Discussion: SVA has a higher prevalence among males and individuals of Asian ethnicity. Its presentation is variable and can include chest discomfort, shortness of breath, pulmonary edema, or even rupture. It can also be an incidental finding on an echocardiogram. The preferred initial diagnostic approach is echocardiography, and surgical repair is often required for patients, especially if the aneurysm has ruptured. Upon diagnosis, prompt evaluation by a cardiothoracic surgeon is crucial as delay in treatment may lead to fatal consequences. Conclusion: The prognosis for ruptured SVAs is poor, which further emphasizes the significance of early diagnosis and prompt treatment. A diligent physical examination is very crucial and can be lifesaving, especially in such circumstances.

Radial Arteriovenous Fistula After Coronary Catheterizations

A 57-year-old man with a history of 2 percutaneous coronary interventions through the right radial artery (6 months and 5 months prior) reported a right radial bruit with a palpable thrill. Doppler ultrasound imaging revealed a radial arteriovenous fistula (AVF). Transbrachial angiogram showed blood flow between the radial artery and venous system (Fig. 1). The patient's condition was managed conservatively because it was a case of AVF without pain or heart failure symptoms. Two years later, the patient presented with progressive development of the bruit and new wrist pain. Physical examination revealed local swelling of the right distal forearm (Fig. 2). A worsened AVF with dilated superficial veins was confirmed on Doppler ultrasound imaging (Fig. 3). Consequently, the patient underwent surgical ligation under local anesthesia (Fig. 4). The swelling, thrill, and pain resolved. The patient underwent follow-ups every 3 months for 2 years, and no vascular events occurred during that time.Arteriovenous fistula as a complication of catheterization generally occurs at brachial and femoral arteries/veins. Radial AVF is extremely rare, with an incidence of approximately 0.05% in the transradial approach, according to the SPIRIT of ARTEMIS study.1 Other complications of the transradial approach include radial artery occlusion, perforation, and pseudoaneurysm.1 Radial AVF, which can be generally described as a delayed-onset vascular complication, can cause wrist pain and heart failure symptoms because of left-to-right shunt. The management of radial AVF, which can include surgery, percutaneous intervention, or conservative management, varies according to individual cases, as reported previously.2–4 Conservative management occasionally fails, as noted in this case. Percutaneous intervention is less invasive, but there is a possibility of stent restenosis and stent fracture resulting from excessive wrist and forearm movement. Surgical ligation would enable a repeat transradial approach in coronary reinterventions. In this era of radial access catheterizations, cardiac interventionists should be knowledgeable about appropriate evaluation and management of radial AVF.The authors thank Dr Kazuhiro Yoneda and Dr Masako Okada for helping with the patient's treatment.

Is Systemic Heparinization Beneficial in Arteriovenous Fistula Surgery? - Our Experience

Background: Arteriovenous fistula (AVF) is the most preferred means to achieve vascular access for hemodialysis in chronic kidney disease patients. Systemic heparinization during surgery is a well-established practice to prevent thrombosis and maintain graft patency. Patients and Methods: All patients who underwent AVF surgery between November 2015 and October 2021 were evaluated. Systemic heparinization was deliberately avoided. They were followed up at 1 week and 4 weeks post-procedure. Results: Two hundred and fifty-six patients were reviewed. One hundred and fifty-one (58.98%) radiocephalic AVF were created while 105 (41.02%) had brachial-antecubital AVF. The mean duration of surgery was 54.5 ± 7.2 minutes while that of clamp time of artery was 16.3 ± 9.7 minutes. Two hundred and forty-seven (96.5%) had palpable thrill or bruit could be auscultated immediately after surgery. It remained the same after 1 week. Graft thrombosis was 3.5%. Eight (3.12%) did not have any thrill or bruit, and were concluded to have graft thrombosis when assessed at 4 weeks. Four patients (1.56%) needed repeat procedures, while seven (2.7%) had hematoma and two (0.7%) had infection. Statistical analysis showed all observed values to be significant (P &lt; 0.05). Conclusion: This analysis revealed, systemic heparinization did not have any additional benefit on maintaining graft patency and preventing thrombosis. Their incidence was, in fact, much lower than that proven in standard literature and previous studies. Preventing adverse effects like hemorrhage is beneficial too. Larger studies are required to establish whether systemic heparin use is at all necessary in AVF surgery.

Iatrogenic left common carotid artery to right internal jugular vein arteriovenous fistula.

A 47-year-old female patient presented with a palpable right-sided neck thrill, dyspnea, and dysphagia 14 days after discharge from a 102-day hospitalization for COVID-19 pneumonia. Computed tomography angiography (CTA) of the neck demonstrated an unusual left common carotid artery to right internal jugular vein (IJV) arteriovenous fistula (AVF) with aneurysmal dilatation of the fistulous tract of up to 2.8 cm, causing mass effect on the proximal trachea and esophagus, which led to her experience of dysphagia and palpable thrill.

Radial arteriovenous fistula complicated with ischemic steal syndrome after transradial cardiac catheterization: a case report and literature review

BackgroundThe radial arteriovenous fistula (AVF) is a rare complication occurring after transradial cardiac catheterization. Patients with AVF typically present with signs of venous dilation, such as swelling or palpable thrills. However, neurological complications secondary to radial AVFs are rare. This paper reported a rare case of ischemic steal syndrome that occurred 11 months after the transradial cardiac catheterization, most likely as a consequence of radial arteriovenous fistula.Case presentationThis paper described a case of a 73-year-old female, who complained of right forearm swelling and radial 1–3 fingers numbness for several months after the catheterized stent surgery through radial approach. Upon Clinical examination, this patient presented with a slight bump and palpable thrill at the distal third of right forearm, and the sensory of radial 1–3 fingers and pinch force was compromised. The Ultrasonography and computed tomography angiography (CTA) of the upper extremity revealed AVF between the right radial artery and the adjacent vein. Microsurgery was performed successfully to ligate the fistula and reconstruct the radial artery. The numbness has gradually improved about 1 week after the surgery, with no recurred swelling. The two-point pinch force and digital sensitivity recovered at the 20-month follow-up. What’s more, due to the scarcity of cases, the optimal therapy for iatrogenic radial AVF is controversial. Accordingly, we provided a literature review of previous reports of catheter-related radial AVFs and proposed an algorithm to manage them.ConclusionsWe believe that once an AVF is diagnosed, early treatment options such as compression or surgery are necessary to relieve symptoms and prevent further complications. Otherwise, serious complications can occur, including the ischemic steal syndrome.

Hemodialysis Patients with Higher Serum Levels of Soluble Receptor for Advanced Glycation End Products Have an Increased Risk for Arteriovenous Fistula Failure

Background: Arteriovenous fistula (AVF) failure due to thrombosis is a major cause of morbidity in patients undergoing regular hemodialysis (HD). Advanced glycation end products (AGEs) and their receptor (RAGE) might contribute to inflammation, neointimal hyperplasia, and thrombosis. RAGE has a C-truncated secretory receptor form, called soluble RAGE (sRAGE). In this study, we aimed to evaluate the association of serum sRAGE with AVF failure due to thrombosis in HD patients. Methods: Eighty-eight prevalent HD patients with functional AVF were included in the study. The presence of stenosis, clinical and laboratory data, and serum sRAGE was evaluated at inclusion. sRAGE concentration was measured by a competitive enzyme-linked immunosorbent assay, and stenosis was detected by ultrasound. Patients were prospectively followed up for 36 months. During this period, AVF failure (defined as the absence of blast or palpable thrill and impossible cannulation with 2 needles because of complete thrombosis) was noted and thrombosis was certified by ultrasound examination. Results: During follow-up, 16 (18.18%) patients lost their vascular access due to thrombosis. In multivariate Cox regression analysis, sRAGE was a significant predictor of vascular access thrombosis (hazard ratio = 1.15, 95% confidence interval: 1.03–1.25, p = 0.012). Kaplan-Meier analysis showed a significantly lower AVF patency time in patients with sRAGE >16.78 ng/mL than those with sRAGE <16.78 ng/mL (p = 0.02). In the subgroup of patients with stenosis at baseline, sRAGE, serum albumin, obesity, and ischemic heart disease were associated with thrombosis. Conclusion: In our study, baseline, systemic sRAGE is associated with the occurrence of thrombosis of AVF, and this marker has a significant impact on AVF survival.

Alternant Approach to Manage Patent AVF With Untreatable Venous Hypertension from Central Stenosis

<h3>Introduction and Objective</h3> Arteriovenous fistula (AVF) associated venous hypertension from central venous obstruction is commonly seen to cause dysfunctional dialysis access and severe swelling. It is traditionally managed by a variety of surgical, interventional approaches, but when the central stenosis/occlusion cannot be corrected, focus shifts only to relieve the edema. The most common approach is sacrificing the vein with ligation and starting anew despite risks of non-maturity and/or using a non-autologous conduit. We report a novel approach by translocating a patient's native and "mature" vein to create a new AVF and treat both problems. This minimizes time-to-maturity, quickly establish long-term, autologous vascular access for hemodialysis and simultaneously treat the swollen extremity. <h3>Case Report</h3> 80-year-old female with a functional brachiocephalic AVF had severe and painful venous hypertension due to presumed central vein obstruction. The AVF was created in 2017 and unused until November 2019. It worked for 7 months until developing left upper extremity swelling and pain. She underwent five balloon angioplasty procedures at an outside facility without lasting resolution. In January 2021 her left upper extremity was tense, edematous and significant erythema. The left arm had evolving elephantiasis with Peux D'Orange skin changes, warmth, tenderness, with a distant, but palpable thrill. We attempted resolution via femoral venous access which revealed a >70% stenosis of her subclavian vein close to the innominate junction and near her first rib and clavicle interface. Balloon angioplasty with a 12 × 40mm Conquest balloon at 20 ATM had immediate reversal of her venous hypertension and symptomatic relief. At one month she reported recurrence of swelling and pain. We discussed first rib resection, AVF ligation and/or catheter-only dialysis or starting again. She refused a rib resection. We harvested and excised her large and mature left cephalic vein and translocated it to her right forearm to create a new radial artery to Brachial vein AVF (with a tunneled catheter for acute access). Due to size mismatch, we everted the left cephalic vein to do valvulotomy, and the anastomosis was done in a non-reversed fashion with two end-to-side anastomosis. This simultaneously corrected her venous hypertension and gave her an autologous AVF using her contralateral cephalic vein. At one month, her left upper extremity had complete resolution and the AVF was cleared for access. <h3>Discussion</h3> Venous hypertension and central venous obstruction with a functional AVF can compromise efficient dialysis and be very debilitating leading to AVF ligation and abandonment when it cannot be resolved. This approach offers an accessible technique for salvage of a relatively common AVF complication with high success for cannulation.

Arteriovenous Fistula Is Protective in Stab Wounds Involving Major Vessels

<h3>Introduction and Objective</h3> Stab wounds to the neck resulting in major vascular injuries occur in 40% of patients. These are usually associated with significant blood loss and frequently fatal. We describe a patient with multiple stab wounds to neck resulting in almost complete transection of the right common carotid artery (CCA) with a large pseudoaneurysm and an associated internal jugular (IJ) injury, resulting in a "protective" arterio-venous (AV) fistula. Protective AV fistulae are uncommonly described in the literature. We believe this to be a novel description of a CCA transection with associated "protective" AV fistula. <h3>Case Report</h3> A middle-aged male presented to our Level I trauma center after suffering three 1 cm stab wounds to the right side of his neck. The patient arrived via ambulance. The emergency medical services crew provided basic field care including applying supplemental oxygen and covering wounds with dry gauze. Upon arrival, the patient was verbal with a Glasgow Coma Scale score of 15. Heart rate was 122 and blood pressure was 139/91. On initial examination, a large, pulsatile hematoma with a palpable thrill was noted underlying a laceration to the lateral aspect of zone two. A second and third laceration were noted without associated swelling in zone one and zone three, respectively. Minimal external bleeding was noted from all stab wounds. Computed tomography angiography was obtained en-route to the operating room and demonstrated a right CCA injury with a large pseudoaneurysm and AV fistula decompressing into the right internal jugular (IJV) vein. On operative exploration, the right CCA was found to be greater than 90% transected with the proximal and distal ends connected by small amount of bridging adventitia. The right IJV was found to have an approximately 70% wall transection and the vagus nerve was totally transected. The CCA and IJV were repaired in a primary end-to-end fashion. The vagus nerve was also repaired. The patient had an uneventful postoperative course and was discharged home on hospital day three. On follow-up visit after 6 weeks patient was doing well with no neurovascular deficit. <h3>Discussion</h3> Penetrating injuries of the neck involving major vessels are associated with high morbidity and mortality. A traumatic AV fistula can provide a protective effect by decompressing the injured arterial structure and prevent massive blood loss and airway compression. Protective AV fistulae have been uncommonly described, and to our knowledge, this is the first case involving a >90% carotid transection with associated "protective" AV fistula ultimately allowing life-saving operative repair.

IT'S NOT THE HEART

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: HOHF is suspected when patients present with clinical symptoms of CHF but have an elevated CI typically above 4L/min/m2 [1]. These patients can exhibit signs and symptoms of CHF and have PH as a result of elevated blood flows through the pulmonary vasculature. CASE PRESENTATION: A 56 year-old male kidney transplant recipient (KTR) presented with shortness of breath, lower extremity edema 3-months after cadaveric renal transplantation. He had a history of chronic mild systolic cardiac dysfunction (EF 50%), pulmonary hypertension (WSPH group II), and diabetes mellitus type 2 prior to kidney transplantation. Physical exam was significant for +3 pitting edema of bilateral lower extremities, crackles at lung bases and a right brachiocephalic AVF with palpable thrill. Serum creatinine was 3.5mg/dL (baseline 2.0mg/dL) and Chest X ray showed pulmonary edema. Diuresis improved the edema and shortness of breath, but worsened renal function. Renal biopsy was negative for rejection. Echocardiography (TTE) revealed an elevated right ventricular systolic pressure (RVSP) and severely dilated right atrium (RA) and ventricle (RV). Right heart catheterization demonstrated elevated right and left sided filling pressures with moderate pulmonary hypertension (PH) and an elevated cardiac output/index (CO/CI). An AVF occlusion in the cath lab resulted in a significant reduction in CO 7.75 L/min and CI 3.10 L/min/m2 by thermodilution. Findings were consistent with PH secondary to high output heart failure (HOHF), likely related to AV fistula. He underwent an AVF revision with improvement of symptoms and renal function. DISCUSSION: PH is common in patients with ESRD undergoing HD via an AVF [2] and HOHF could be an easily addressable cause of PH in ESRD. HOHF can be difficult to diagnose based on echocardiography alone. RHC typically shows an elevated CO (> 8L/min, CI>4L/min/m2), AVF/G flow > 1.5L/min, and a cardiopulmonary recirculation ratio (CPR) > 0.3 [3]. Furthermore, PH prior to transplantation appears to have an adverse impact on allograft function in kidney transplant recipients (KTR) [4]. In a retrospective analysis of KTRs in a single institution, 29/113 (26%) of patients required closure of their AVF due to symptomatic CHF. The mean AVF flow rate was significantly elevated in patients requiring AVF closure compared to those managed conservatively (2197 ml/min vs. 851 ml/min) [5]. High flow rates due to increased arterial blood shunted from left to right circulation increased the preload and stroke volume and resulted in ventricular hypertrophy leading to subsequent heart failure [6]. CONCLUSIONS: In our patient, HOHF and PH secondary to an aneurysmal AVF resulted in acute cardio-renal syndrome type 1(CRS - 1) in the transplanted kidney. The improvement in both cardiac and renal function following the revision of AVF confirmed the diagnosis of cardiorenal injury due to an aneurysmal AVF. REFERENCE #1: Reddy YN, Obokata M, Dean PG, Melenovsky V, Nath KA, Borlaug BA. Long-term cardiovascular changes following creation of arteriovenous fistula in patients with end stage renal disease. Eur Heart J. 2017 Mar 6. REFERENCE #2: Schoenberg NC, Argula RG, Klings ES, Wilson KC, Farber HW. Prevalence and Mortality of Pulmonary Hypertension in ESRD: A Systematic Review and Meta-analysis. Lung. 2020 Jun;198(3):535-45. REFERENCE #3: Wijnen E, Keuter XH, Planken NR, van der Sande FM, Tordoir JH, Leunissen KM, et al. The relation between vascular access flow and different types of vascular access with systemic hemodynamics in hemodialysis patients. Artif Organs. 2005 Dec;29(12):960-4. DISCLOSURES: Advisory Committee Member relationship with Janssen pharmaceutical Please note: 4/2020 - 4/2021 Added 04/27/2021 by Rahul Argula, source=Web Response, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: 2019-2021 Added 04/27/2021 by Rahul Argula, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Breathe Technologies Please note: 2019 Added 04/27/2021 by Rahul Argula, source=Web Response, value=Consulting feeeducational grant relationship with Reata pharmaceuticals Please note: 2018-2019 Added 04/27/2021 by Rahul Argula, source=Web Response, value=Grant/Research Consultant relationship with Accordant health / CVS Please note: 2020 - 2021 Added 04/27/2021 by Rahul Argula, source=Web Response, value=Consulting fee no disclosure on file for mona haj; No relevant relationships by Elena Vlachos, source=Web Response

Balloon angioplasty: A promising adjunct to arteriovenous fistula creation compared with hydrostatic dilatation in small-caliber cephalic veins.

To maintain the patency and longevity of arteriovenous fistula, the availability of a venous segment with adequate diameter is important. In Indian population, many chronic kidney disease patients have poor caliber veins. The study aimed to evaluate the efficacy of hydrostatic dilatation versus Primary balloon angioplasty of small caliber cephalic veins of (≤2.5 mm) preoperatively in terms of patency rate and maturation time of arteriovenous fistula. Patients (n = 80) with an end-stage renal disease requiring arteriovenous access surgery for hemodialysis with small caliber cephalic veins were randomized into two groups, i.e., hydrostatic dilatation and primary balloon angioplasty, each with 40 patients. All patients underwent a thorough clinical examination as well as duplex ultrasound vein mapping of both upper extremities. Patients were followed up for six months and primary patency, maturation time, and complications were noted. Immediate technical success with good palpable thrill was achieved in 97.5% of patients in the primary balloon angioplasty group and 87.5% in the hydrostatic dilatation group. The fistula maturation time in the primary balloon angioplasty group was 34.41 days and 46.18 days in the hydrostatic dilatation group. In the primary balloon angioplasty group, the primary patency of the fistula was 97.5% and 87.5% in the hydrostatic dilatation group, at six months. The arteriovenous fistula functioning rate was 77.5% in the hydrostatic dilatation group as compared to 92.5% in the primary balloon angioplasty group at six months. The incidence of surgical site infection was 5% in the primary balloon angioplasty group as compared to 10% in the hydrostatic dilatation group. Primary balloon angioplasty of small caliber cephalic veins (≤2.5 mm) performed prior to arteriovenous fistula creation for hemodialysis is a beneficial procedure.

Traumatic Common Carotid-jugular Fistula In A 6-year-old Child: Rare Cause Of Pulsatile Neck Mass

Background: Traumatic common carotid artery-jugular vein fistula is an uncommon clinical entity that may follow penetrating neck injury. It is rarely seen in children. It usually presents with a pulsatile neck mass following a history of trauma to the neck. It may present with pulsatile mass, thrill on palpation and murmurs on auscultation. There may be a neurologic deficit, which may vary from hemiparesis to hemiplegia. We present a case of traumatic arteriovenous fistula that presented as pulsatile anterior neck swelling in a school child. Case Presentation: A 6 year old male child, presented with a 3 days history of penetrating gunshot injury to the right side of the neck, as a result of accidental discharge from a gun during a marriage ceremony. The patient said to have bled profusely from the site of injury and had transient loss of consciousness. Examination revealed a healing wound and a slight swelling on the right side of the neck just anterior to the anterior border of the sternocleidomastoid muscle. The mass was pulsatile, with palpable thrill and bruit on auscultation. Colour doppler ultrasound demonstrated an abnormal connection with abnormal blood flow from the right common carotid artery to the right internal jugular vein. He was successfully treated surgically by neck exploration, excision of the fistula, and repair of defects in both vessels. Conclusions: Traumatic carotid-jugular fistula following gunshot injury is rarely seen in children. Guns should not be used or left unattended to in crowds so as to forestall future occurrence of accidental discharge that could lead to avoidable injuries. We recommended strict adherence to the rules and regulations guarding the use of firearms by civilians.

Management of Post-traumatic Peripheral Arterial Pseudoaneurysm in Antananarivo

Background: Pseudoaneurysm is the usual complication of arterial injury. The aim of this study is to describe the etiology and the management of post-traumatic peripheral arterial pseudoaneurysm in Antananarivo.&#x0D; Methods: This is a bicentric retrospective study for 10 years period (January 2010 to December 2019), performed in Cardiovascular Unit in Joseph Ravoahangy Andrianavalona Teaching Hospital and in Vascular Unit in Soavinandriana Hospital Center, including all patient who underwent a surgical procedure of post-traumatic peripheral arterial pseudoaneurysm.&#x0D; Results: 38 patients were recorded in 10 years period, which 26 patients recorded in JRA hospital and 12 patients in Soavinandriana Hospital. Patients were 33 males (86.84%) and 5 females (13.15%). Gunshots wounds (47.36%) and stabs wounds (34.21%) were the commonest circumstances of etiology. Pulsatile mass (84.21%), pain (60.52%) and palpable thrill (71.05%) were the usual of peripheral pseudoaneurysm. Doppler ultrasound (94.73%) and computed tomographic angiography (13.15%) performed the diagnosis of the pseudoaneurysm. Femoral artery (39.47%) and brachial artery (31.57%) were the most involved vessels. All patients underwent an open surgery. Surgical procedures were arterial repair in 26 patients (68.42%), reversed saphenous vein interposition in 5 patients (13.15%), PTFE graft in 2 patients (5.26%) and ligation excision in 5 patients (13.15%). There was no reoperation or mortality in early postoperative period.&#x0D; Conclusion: Trauma is the most common etiology of pseudoaneurysm in Antananarivo. Open surgical repair remains the procedure to treat the post-traumatic peripheral arterial pseudoaneurysm in our experience.