Steal Syndrome Research Articles

Upper Arm Arteriovenous Grafts are Superior over Forearm Arteriovenous Grafts in Upper Extremity Dialysis Access

In this study, we compared the outcomes of forearm arteriovenous grafts (AVGs) and upper arm AVGs in a large, prospectively collected data set, which represents real-world experience with upper extremity prosthetic dialysis access, to determine if there are clinically significant differences in the upper arm and forearm positions. We identified 2,063 patients who received upper extremity AVGs within the Vascular Quality Initiative data set (2010-2018). Axillary to axillary upper arm AVGs were excluded (n=394) from the analysis. The main outcome measures were primary and secondary patency rates at 12months. Other outcomes were 6-month wound infection, steal syndrome, and arm swelling. The log-rank test was used to evaluate patency loss using a Kaplan-Meier analysis. Cox proportional hazards models were used to examine adjusted association between locations (forearm and upper arm) and outcomes. There were 1,160 forearm AVGs and 509 upper arm brachial artery AVGs in the study cohort. Patients with forearm AVGs were more likely to have a body mass index>30 (45% vs. 38%, P=0.013), no history of previous access (73% vs. 63%, P<0.001), and underwent local-regional anesthesia (56% vs. 43%, P<0.001). The 12-month primary patency (51.5% vs. 62.9%, P<0.001) and secondary patency (76.4% vs. 89.1%, P<0.001) were significantly lower for forearm AVGs. Wound infection, steal syndrome, and arm swelling were similar between forearm AVGs and upper arm AVGs at the 6-month follow-up. In multivariable analysis, the primary patency loss (adjusted hazard ratio (aHR) 1.66, 95% confidence interval (CI) 1.33-2.01, P<0.001) and 12-month secondary patency loss (aHR 2.71, 95% CI 1.84-3.98, P<0.001) were significantly higher for forearm AVGs at 12months. From this observational study of the Vascular Quality Initiative data set, the primary and secondary patency rates were superior for upper arm brachial artery AVGs compared with forearm AVGs.

Percutaneously created sutureless anastomosis.

An 80-year-old male diabetic patient with end-stage renal disease was evaluated for decreasing access flow and difficult cannulation of his established percutaneous arteriovenous fistula (pAVF), created 6 months ago with the Ellipsys vascular access system (Avenu Medical, San Juan Capistrano, Calif).1Mallios A. Jennings W.C. Boura B. Costanzo A. Bourquelot P. Combes M. Early results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System.J Vasc Surg. 2018; 68: 1150-1156Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 2Mallios A. Fonkoua H. Allouache M. Boura B. Percutaneous arteriovenous dialysis fistula.J Vasc Surg. 2020; 71: 1395Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 3Mallios A. Bourquelot P. Franco G. Fonkoua H. Allouache M. Boura B. et al.Mid-term results of percutaneous arteriovenous fistula creation with the Ellipsys vascular access system, technical recommendations and an algorithm for maintenance.J Vasc Surg. 2020 Apr 7; ([Online ahead of print])Abstract Full Text Full Text PDF Scopus (26) Google Scholar The patient's ipsilateral hand was cool without distal pulses. Percutaneous transluminal angioplasty of the pAVF anastomosis had only modestly improved access flow because of significant diffuse arterial calcifications. Bilateral distal arterial occlusions were present and the pAVF remained dysfunctional. Further and more aggressive attempts with percutaneous transluminal angioplasty were thought likely to result in severe hand ischemia (steal syndrome); therefore, arterial inflow proximalization was established using a 4- to 7-mm graft (W. L. Gore & Associates, Flagstaff, Ariz) with a lateral axillary artery anastomosis and an end-to-end outflow anastomosis to the mature cephalic vein, ligating the distal pAVF inflow site. An excellent thrill was recovered immediately over the entire length of the cephalic vein in the arm. Distal circulation improved substantially. A/Cover, B, and Video 1 show a perioperative view of the percutaneously created Ellipsys anastomosis between the proximal radial artery and perforating vein of the elbow. To our knowledge, this is the first direct visualization of an Ellipsys pAVF anastomosis in a human. The anatomic configuration and natural course of the pAVF are apparent along with the absence of suture or fibrosis, yielding a shape similar to surgical proximal radial artery AVFs described by Jennings et al.4Jennings W. Mallios A. Mushtaq Proximal radial artery arteriovenous fistula for hemodialysis vascular access.J Vasc Surg. 2018; 67: 244-253Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar C (medial view), D (anterior view), and Video 2 show the ligated pAVF anastomosis. Need for ligation of a pAVF has been a concern of some critics because of the multiple venous branches. This report demonstrates that in the rare case in which ligation is necessary, an Ellipsys pAVF may be easily ligated without consequence or technical challenges. The patient's informed consent was obtained before submission of this manuscript. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkM2YxZjljYzQzMTczOTJhZDVmYzdiMjVmYjJmMDc3YSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjU5NjgwMTEyfQ.P2iwekbqoGENyxeFwVBltgYalZQe974yt_1Pylg0oqw2wFHO3H5CWSPevIxJUo12W3mIV07CWaNMIpXXz890jVkEezWvpGPFAxKusFybJG_J-dUhtw2jZOOPABJPZG57mLmCApG-jTPEMAHW9pySwjjAkCUSrKAtXkkDyhYRg9KC4hAUWNilnBi-_azL08GN--bXaVldB4WfATLWRNN0AD8X_3mTXzlx_QakMBjMTbIc_JlN1rqNjO2zj3X2xxIyscs4nu7HNDe4Yl8ALcJg4rbz3dXNZm9xYBzLti2FU-yetHtrydtcxMLAVp3Fyk5IF4QMtPBmJ6GImX4mAYjwgg Download .mp4 (0.98 MB) Help with .mp4 files Video 1Perioperative view of the percutaneously created Ellipsys anastomosis between the proximal radial artery and perforating vein of the elbow.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4Yjk0MWI1ZWQwOTI1YzFjNmE0ZTAyMTJkN2YyODFjNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjU5NjgwMTEyfQ.HCPbtwp0lEn6tVnP5ipUjgo9Onu8BqDai6EaTcoSnwhdy1nK0swZeXM-bhdYhkOHKJoygNoK2-KvvS0ogyTxmhdk4F4pH_uKLQ0aBVKS1U7mXOouNT7J4OYjQRKkWFFxHaJWdePogqOgipV0cU_g0q4Mvzdqrwz-NM5QJTjg-rCAciba72xGohrwgvkUD24fZ21KOdzuGHnQD3HJlUmu5pbDBMCl6oLq5Uq970eaiRxZt66Y9ky_xXvbywthSc5h81x5QAqsGyLpDWA7oyrVn61ol7zdANzYpKlKsL9YKEgXAoBS8SNAMubTKpBlYIGCQrUtMDl602MclcggLFcrRA Download .mp4 (0.63 MB) Help with .mp4 files Video 2Ligated percutaneous arteriovenous fistula anastomosis.

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.

A Single-Center Experience in Portal Flow Augmentation in Liver Transplantation With Prior Large Spontaneous Splenorenal Shunt

Large portosystemic shunts may cause portal steal syndrome in liver transplantation (LT). Because of the possible devastating consequences of the syndrome, the authors recommend perioperative management of these large shunts. Fourteen adult recipients who underwent portal flow augmentation, including left renal vein ligation (LRVL), renoportal anastomosis (RPA), shunt ligation (SL), and splenic vein ligation (SVL) for large spontaneous splenorenal shunt (SSRS), are included in this study, and the results were analyzed. A total of 13 patients had a large SSRS, and in 1 patient, the large shunt was placed between the superior mesenteric vein and the right renal vein. LDLT was performed in 13 patients. LRVL (n = 5), SVL (n = 6), RPA (n = 2), SL (n = 1) were performed to the patients as graft inflow augmentation. The graft-recipient weight ratios (GRWR) were less than 0.8% in 5 patients (35.7%): 2 had LRVL, and 3 had SVL. Small-for-size syndrome (SFSS) occurred only in these 2 patients with LRVL (GRWR ≤0.8%) and, splenic artery ligation was performed for graft inflow modulation. No mortality or serious complications were reported during follow-up. We consider that in patients with large SSRS and small-for-size grafts, SVL can be performed safely and with satisfactory outcomes.

Risk Factors and Management of Steal Syndrome After Hemodialysis Access Creation

Steal syndrome is an uncommon but significant complication after hemodialysis access creation that may require intervention. This study examined the risk factors for steal syndrome requiring intervention and compared the outcomes of the different treatment modalities.

Comparison between bovine carotid artery graft and polytetrafluoroethylene graft for haemodialysis vascular access: A systematic review and meta-analysis.

There is a renewed interest in using bovine carotid artery grafts for haemodialysis vascular access after recent advances in conduit manufacturing and endovascular management of access-related complications. Our aim was to summarize the results of the recent studies comparing bovine carotid artery grafts with polytetrafluoroethylene grafts as vascular access for haemodialysis. A systematic review was conducted for original articles comparing bovine carotid artery with polytetrafluoroethylene grafts for haemodialysis vascular access published between January 2000 and December 2019 searching the databases of Medline, Scopus, Google Scholar, ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials. Four studies were included (one prospective randomized controlled trial and three retrospective studies) with 676 patients in total (bovine carotid artery: 395, polytetrafluoroethylene: 281). There was lower graft infection rate per patient-year in bovine carotid artery grafts (mean difference: -0.03, p < 0.0001). Bovine carotid artery grafts required fewer interventions per patient-year to maintain or restore patency (mean difference: -0.81, p = 0.002). No significant difference was detected regarding pseudoaneurysm formation (p = 0.24), steal syndrome (p = 0.11) or patency rates (primary: 1 year: p = 0.15, 2 years: p = 0.69; primary assisted: 1 year: p = 0.18, 2 years: p = 0.54; secondary: 1 year: p = 0.22, 2 years: p = 0.17). Bovine carotid artery and polytetrafluoroethylene grafts have similar short-term and long-term outcomes, with a possible advantage of bovine carotid artery grafts concerning graft infections and number of required interventions. Thus, bovine carotid artery grafts can be a useful alternative modality for haemodialysis vascular access.

P134410 YEARS EXPERIENCE WITH HEMODIALYSIS TUNNELED CATHETERS

Abstract Background and Aims A well functioning vascular access ( VA) is vital for hemodialysis (HD) patients. To date a native arteriovenous fistula ( NAVF) remains the gold standard but patients vascular characteristics are often not optimal for vascular surgery. A tunneled central venous catheter (tCVC) are becoming increasingly used as permanent dialysis access and are also competitive to NAVF for the easy and safe insertion tecnique. Our retrospective study observe, during a 10 years period, infection rate of tCVC, bacteriologic analysis and cause of removal. Method From January 2010 to December 2019, 176 tCVC were placed in 158 patients ( mean age 74 +/- 18) . All tCVC were inserted by nephrologist in internal giugular vein (IGV), subclavian vein (SV) and femoral vein (FV) using ultasonographic guide. Standards protocols, according to European Renal Best Practice (2010) detailing all aspects of preventive care were used. Each tCVC was followed until it was removed or until the end of the study. 62110 days was the follow up period. 143 tCVC wew placed in IGV ( 81,5%), 22 in FV ( 11,5 %) and 11 in SV (7%). The diagnosis of infection was based on clinical evidence and positive blood culture or positive exit site swab, with no sign of other infection site. We considered a tCVC disfunction in case of blood flow less than 250 ml/m'. Event rates were calculated per 1000 catheters days. Results Mean tCVC duration was 353 days. We observed a progressive increment in CVC prevalence during the observational period ( from 15% in 2010 to 39% in 2019). Catheter replacement recurred in 19 patients and the main cause of replacement was loss of patency ( 0,3 per 1000 catheter days). We observed 63 catheter related bloodstream infection (CRBI) and 71 exit site/tunnel infection (ESI/TI). Incidence for CRBI was 1 per 1000 catheter days and ESI/TI was 1,14 per 1000 catheter days. In CRBI the most common organism isolated were MRSA (40%) and MSSA (26%) . In ESI/TI the most common organism isolated was Staphilococcus epidermidis (39.5%) . We used systemic antibiotics, local therapy and lock therapy with a 93% resolution without removal. 12 tCVC were removed for recurrent CRBI ( 0,19 per 1000 catheter days). At the end of the observation 25 tCVC were still in use. Conclusion Our data showed an high survival rate of tCVC in hemodialysis patients. We observed CRBI and ESI/TI rates at the lower limits of the data reported in the literature. Infections were successfully treated conservately in most cases. Careful nursing protocol may reduced the frequency of infection and an early diagnosis can facilitate the rescue of the tCVC with systemic/lock therapy or local therapy. We consider in an elderly population with many comorbidities the use on tCVC recommended especially in patients with poor native peripheral vessels, in patients with steal syndrome high risk and also with a low life expectancy.

P1354POSTOPERATIVE MATURATION AND CHANGES IN CARDIAC FUNCTION DIFFER BETWEEN TYPES OF VASCULAR ACCESS

Abstract Background and Aims The blood flow of vascular access can be increased about tens of times after access creation. If the flow of vascular access is too low, vascular access does not provide sufficient circulation for hemodialysis and sometimes gets thrombosed. However, if the flow of vascular access is too high, it can result in high cardiac output and trigger heart failure. Although patients receiving hemodialysis require vascular access with necessary and sufficient flow, the actual change in flow after access creation is not well known. We investigated the relationships among preoperative factors, types of vascular access, clinical courses of access maturation, and changes in cardiac function. Method This single-center retrospective observational study included patients who underwent vascular access-related surgery, except thrombectomy, in 2016. Diameters and flow volumes of the brachial artery were examined using Doppler ultrasound before surgery and 1 week, 12 months, and 24 months after surgery. Cardiac functions were assessed using sonography at the same timepoints. Patients’ background information and data related to surgery, such as anastomosis size, were extracted from medical records. The obtained data were statistically analyzed. Results Fifty-eight patients [37 arteriovenous fistula (AVF), 10 arteriovenous graft (AVG), and 11 partial replacement using grafts (PR)] participated in this study. Diameters of the brachial artery increased from 4.7 mm to 5.4 mm at 1 week after access surgery. Blood flows of the brachial artery also increased from 106 mL/min to 699 mL/min. Blood flow through AVG at 1week was significantly higher than that through AVF (940 ml/min vs. 589 ml/min). Although blood flow through AVF at 12 and 24 months after access creation was significantly increased than that at 1 week after access creation, blood flow through AVG at 12 and 24 months after access creation did not show significant changes, and blood flow through PR at 12 and 24 months after access creation was significantly decreased. AVG and PR required more catheter intervention for vascular access than AVF during this observational period. Preoperative blood flow of the brachial artery and cardiac outputs were positively correlated to postoperative blood flow through AVF. However, this relationship was not observed in AVG and PR cases. The amount of cardiac output increased from 4.2 L/min before surgery to 4.4 L/min and 4.6 L/min at 12 and 24 months, respectively, although not significantly. Cardiac output at 24 months after surgery significantly increased only in AVF cases. Conclusion The clinical maturation course after vascular access creation surgery differs between AVF and AVG cases. Because blood flow through AVF is likely to increase gradually after access creation, surgeons should consider cardiac stresses related to vascular access, especially in cases with high-flow brachial artery or high cardiac output before surgery. Blood flow through AVG is not likely to increase in the long course. However, because blood flow through AVG just after access creation is high, regardless of the brachial artery size, surgeons should consider the risk of arteriovenous access-related ischemic steal syndrome after surgery especially in cases with severe arteriosclerosis. PR is not likely to affect blood flow volume of accesses and cardiac function.

Ligation Of The Left Renal Vein In Liver Transplant Recipients Diagnosed With A Spontaneous Splenorenal Shunt – Case Report

IntroductionFor patients diagnosed with hepatic cirrhosis and portal hypertension, qualified for liver transplantation, the presence of portosystemic collateral circulation constitutes a typical phenomenon. One of its types is the spontaneous splenorenal shunt. Large or multiple ones may cause the steal syndrome and graft hypoperfusion. An attempt to remove such shunts directly is technically difficult and fraught with complications. An easier and safer method would involve ligating the left renal vein. The aim of this paper is to present a case where proper perfusion of a transplanted liver is ensured by the left renal vein ligation, performed in a recipient with a splenorenal shunt, and to review the scientific reports devoted to portosystemic shunts in liver transplant recipients. Case reportA 63-year-old female with alcoholic liver disease was qualified for liver transplantation. The CT-angiography showed numerous splenorenal shunts with diameter up to 13 mm. During the anhepatic phase of the liver transplantation a very weak effusion from the portal vein was observed, which improved significantly following clamping of the left renal vein. Thus renal vein orifice was ligated in order to achieve the correct graft reperfusion. Postoperative Doppler ultrasound showed a correct portal blood flow. The early liver and renal function was good. Finally, in the 7th month, the patient underwent a re-transplantation due to biliary necrosis caused by late hepatic artery thrombosis. ConclusionLigation of the left renal vein efficiently prevents the steal syndrome in the liver transplant recipients with splenorenal shunt and ensures good graft perfusion.

Dialysis Access Steal Syndrome

The current literature indicates that patients who are dependent on dialysis are more frequent users of ED services, with patients on dialysis presenting 8.5 times more frequently than the general population.1 Patients on dialysis are at risk for a variety of medical emergencies related to the complications of chronic renal disease and dialysis treatment. It is important for emergency nurses to recognize abnormalities upon assessment to promote optimal outcomes for these patients. One serious complication, although uncommon (6% incidence), is dialysis access steal syndrome.

Combination of Basilic Vein Transposition and Proximalization of the Arterial Inflow for Management of a Patient with Limited Puncture Sites and the Dialysis Access-associated Steal Syndrome: Case Report

Combination of Basilic Vein Transposition and Proximalization of the Arterial Inflow for Management of a Patient with Limited Puncture Sites and the Dialysis Access-associated Steal Syndrome: Case Report

Double Plication of Basilic Vein of Brachial-Basilic Arteriovenous Fistula as Effective Treatment for Dialysis Related Steal Syndrome (DRESS) : A Case Report

Introduction Overall incidence of steal syndrome in AVF is 1% to 9%, but can produce devastating complication hand ischemia (1), this frequency increases depending on the type of AVF (2, 3), and were predominantly (83%) brachial based (4). There were several different term for hand ischemia re

AIUM Practice Parameter for the Performance of an Ultrasound Examination of Solid-Organ Transplants.

AIUM Practice Parameter for the Performance of an Ultrasound Examination of Solid-Organ Transplants.

An Interesting Spin on Proximalisation of Arterial Inflow for Steal Syndrome

An Interesting Spin on Proximalisation of Arterial Inflow for Steal Syndrome

SAT-239 VASCULAR ACESS OUTCOME-MULTIDISCIPLINARY APPROACH IN THE VASCULAR ACESS CARE CLINIC

The vascular accesses are prone to thrombosis, infection and other complications, which can decrease the adequacy of dialysis treatment leading to under dialysis and increased hospitalizations. To ensure the patency of AV access and decrease complications, regular monitoring, and surveillance is mandatory. Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines enlist regular monitoring and surveillance of AV access. These include physical examination, blood flow and venous pressure monitoring and access recirculation. Vascular access stenosis in AV fistula being diagnosed by Doppler ultrasound and angiography showed a sensitivity of 96% and specificity of 76%. Aim is early detection of the vascular access problems and reduce the surgical interventions and maintain the patency. Vascular access care clinic ( VACC) was designed in Dubai hospital since there are no in house vascular surgeons available in hospital. So a dedicated vascular access care team comprising of nephrologist, vascular surgeon and nurses with experience in cannulation were formed. The team was assigned for the surveillance and care of all vascular accesses and present the problematic cases in the clinical meetings with documentation of access blood flow, dynamic venous pressure, hematoma, prolonged bleeding, hand swelling, steal syndrome, and dialysis adequacy. Further evaluation was done in VACC. Doppler study by vascular surgeon substantiated the need for fistulogram or surgical intervention. This prospective study was done from January 2017 to September 2019.236 patients with problematic vascular access were detected during the study Majority of patients were in the age group of 40-70yrs (68%) Of which females were 47% and males were 53%. 55% of patient had diabetic ESKD. Selected patients were seen in our VACC which was conducted 2 times per month with the vascular surgeon, and the team. Patients were evaluated in the clinic with the aid of color Doppler. The anastomotic site, velocity of the blood flow, length and depth of the fistula, presence of accessory veins etc were assessed. Out of 236 patients, 140 (59.3%) had a corrective procedure done.86 patients had fistulogram, of which 74 patients had fistuloplasty .21 patients had superficialization.96 (41%) patients were managed with non-surgical intervention like ultrasound-guided cannulation; AVF was accessed for maturation Out of 236 patients, 170 (72%) were successfully able to use the AVF of cannulation. Out of 140 patients who had intervention, 115 (82.1%) had successful procedure and AVF was used 40 patients had failure of the procedure and AVF was non salvageable so was advised creation of new AVF 16 patients refused procedure In our study 41% patients were managed with non-surgical intervention because their problems were detected early and necessary measures was taken so we were able reduce the financial burden.A dedicated team approach to monitoring the vascular access in dialysis patients can immensely help in early identification of complications and by appropriate, timely intervention, we can ensure better vascular access patency rates in patients on hemodialysis. This can minimize fistula failure and decrease morbidity in dialysis-dependent patient population. Our vascular access distribution - 74 % of patients on hemodialysis have functional AVF /AV graft

Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience

We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid–subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid–subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.

Splenic Artery Embolization for Nonocclusive Hepatic Artery Hypoperfusion

AbstractVarious minimally invasive, surgical, and laparoscopic interventions are performed for treatment and management of splenic artery steal syndrome in liver transplant and cirrhotic patients. Common approaches include splenic artery banding, ligation, stenting, and embolization to increase hepatic arterial flow. Splenic artery embolization has undergone further development to facilitate timely diagnosis, increase efficacy, decrease adverse outcomes, and improve patient selection. We review the current diagnostic modalities and technical advancements of splenic artery embolization to improve hepatic arterial perfusion in patients with splenic artery steal syndrome.

4:12 PM Abstract No. 21 Percutaneous fistula maturation for hemodialysis

To report results from the Ellipsys EndoAVF registry From October 2018 to June 2019, 123 patients were vein mapped for vascular access. 63% (60/95) had EndoAVF and 37% (35/95) surgical fistulas. At 4 weeks EndoAVF had flow directed into a target vein. Physiologic maturation was defined as target vein flow volume of 500 mL/min and 5 mm diameter, clinical maturation as two-needle cannulation (2NC) of fistula for dialysis. Technical and clinical success was 97% (60/62). The target vein was the cephalic 70% (42/60), basilic 22% (13/60), and brachial 8% (5/60). 4-week maturation increased target vein flow volume from 182 to 572 mL/min (P < 0.0005). Superficialization reduced mean target vein depth in 33% (20/60) of patients from 10.9 to 3.7 mm (P < 0.0001). Physiologic maturation was achieved at mean 36 ± 27 (0-130) days. Patients achieving 2NC had brachial artery flow of 944 ± 284 mL/min, with target vein flow, diameter and depth of 674 ± 292 mL/min, 6.1 ± 0.8 mm, and 3.6 ± 1.3 mm. In patients on hemodialysis the mean time to 2NC was 76 ± 42 (1-201) days, and 57 ± 29 (1-155) days in patients without superficialization. 2NC was achieved in 78% (47/60); 10% (6/60) are not on dialysis; 5% (3/60) fistulas were abandoned for intractable arm swelling, steal syndrome, and thrombosis; and 6.8% (4/60) patients have died. The 6-month cumulative and functional patency were both 91%. Ellipsys EndoAVF demonstrated high clinical success with rapid physiologic and clinical maturation.

3:27 PM Abstract No. 159 Endovascular treatment of splenic artery steal in pediatric liver transplant patients

Literature regarding splenic artery embolization for splenic artery steal syndrome (SASS) in the pediatric liver transplant population is limited, possibly due to lack of recognition of this entity. The purpose of this study is to evaluate the safety and efficacy of splenic artery embolization in pediatric liver transplant patients with clinical and imaging findings concerning for SASS. A retrospective review was performed on all pediatric liver transplant patients who had undergone splenic artery embolization for suspected SASS at a tertiary pediatric institution between June 2013 and May 2018. Parameters assessed included patient age, time from transplant to splenic artery embolization, transplant type, pre-and-post procedure Doppler ultrasound (DUS) findings, procedural details, complication rate, pre-and-postprocedural laboratory parameters, and clinical efficacy. 5 patients (average age, 8 years; median, 10 years; range, 2-17 years) had proximal to mid splenic artery embolization for suspected SASS. Technical success = 100%. Average time from transplant to embolization was 61.6 days (median = 3 days; range, 2-265). All patients had parvus tardus waveform on pre-embolization DUS. Average pre and post embolization peak hepatic artery systolic velocity = 35.7 cm/s (median, 24 cm/s; range, 15.7-89) and 39.1 cm/s (median, 32 cm/s; range, 26-55), respectively. Average pre and post embolization resistive indices = 0.71 (median, 0.73; range, 0.4-1) and 0.62 (median, 0.6; range, 0.5-0.8), respectively. Average pre and post embolization total bilirubin levels = 1.5 mg/dL (median, 1.3; range, 0.4-3.7) and 1.02 mg/dL (median, 0.9; range, 0.3-2.4), respectively. Average pre and post embolization platelet levels = 72.6 thousand/microL (median, 43; range, 18-181) and 141 thousand/microL (median, 111; range, 49-183). There were no major complications. All patients had morphologically improved hepatic artery upstroke on DUS following splenic artery embolization. Splenic artery embolization for suspected SASS in pediatric liver transplant patients is potentially a safe and effective technique in improving graft function and improving thrombocytopenia.

Significance of hemodynamic assessment by pressure wire for endovascular therapy of subclavian steal syndrome

Subclavian steal syndrome results from hemodynamic impairment due to stenosis or occlusion of subclavian artery. Therefore, it is important for subclavian steal syndrome patients to assess hemodynamic status during endovascular therapy. Eleven subclavian steal syndrome patients undergoing endovascular therapy attended this study. Pressure wire was used to measure trans-stenosis pressure difference (ΔP). Digital subtraction angiography, Transcranial Doppler and Electronic sphygmomanometer were introduced to assess stenotic rate, steal grade and inter-arm systolic pressure difference, respectively. Clinical symptoms and restenosis were followed up after endovascular therapy. The associations of ΔP with stenotic rate, inter-arm pressure difference, steal degree, clinic symptoms and restenosis were analyzed in this paper. Prior to the therapy, ΔP moderately correlated with stenotic rate (r = 0.757, p = 0.007) and inter-arm pressure difference (r = 0.701, p = 0.016). ΔP was ≥6 mmHg in all patients, and 6-9 mmHg for grade 1 steal and ≥10 mmHg for grade 2 and 3 steals. After the therapy, all patients had technique success, and 10 patients had clinic success, and 1 patient appeared restenosis. ΔP was ≤3 mmHg and steal disappeared in the patients with clinical success. ΔP was 18 mmHg and grade 3 steal still existed in one patient without clinical success. One patient with 1 mmHg of ΔP after therapy appeared restenosis in the follow-up. The trans-stenosis pressure difference is closely related to steal degree and clinical symptoms. The measurement of hemodynamic status by pressure wire is very useful to guide endovascular therapy in subclavian steal syndrome patients. However, the restenosis may still occur, even though the hemodynamic impairment is improved.