Basilic Vein Research Articles

Minimally invasive basilic vein transposition in the arm or forearm for autogenous haemodialysis access: A less morbid alternative to the conventional technique

ObjectiveTo devise a minimally invasive, less morbid yet effective alternative technique for basilic vein transposition (BVT) in the arm/forearm and to compare perioperative outcomes with the conventional technique. Patients and methodsPatients undergoing BVT in the last two years (June 2013 to June 2015) were included in the study and the results were analysed. All patients were preoperatively evaluated using colour Doppler ultrasonography performed by the operating surgeon himself. For minimally invasive BVT, two or three small 1–2cm incisions were made to completely mobilise the basilic vein, transposed in an anterolateral arm/forearm tunnel, and then anastomosed to the brachial or radial artery in the forearm and arm, respectively. The incision in the conventional technique was along the full length of the basilic vein, with the rest of the procedure remaining the same. Complications, pain, analgesic use, maturation and primary patency rates were compared between the techniques. ResultsIn all, 30 patients underwent minimally invasive BVT and 34 patients underwent conventional BVT, with mean age of 52 and 55years, respectively. The complications of wound haematoma (one vs four) and wound infection/dehiscence (two vs six) were less common in the minimally invasive BVT group compared to the conventional group. The analgesic requirement and visual analogue scale pain score was significantly less in the minimally invasive BVT group. All other variables assessed, such as maturation and primary patency rate at 1year, were not significantly different between the groups. ConclusionMinimally invasive dissection of the basilic vein for vascular access transposition is a safe, reliable procedure with patency and functional outcomes comparable with those of conventional BVT.

The high-risk factors and nursing of venous thrombosis caused by PICC catheter-related on patients with acute pancreatitis

Objective To explore the high-risk factors of upper extremity venous thrombosis caused by PICC catheter on patients with acute pancreatitis, and sum up the nursing countermeasures. Methods A total of 368 cases of patients with acute pancreatitis gastroenterology indwelling PICC catheter from February 2015 to January 2016 in our hospital were selected.13 cases of patients with PICC-related venous thrombosis were studied retrospectively to analyze the age, gender, intravenous catheter, catheter body, disease severity, D-dimer (D-D), prothrombin time (PT), fibrinogen (FIB) value, and the relationship between APTT and the formation of thromboplastin venous thrombosis and the time for the formation of thrombosis. Results 13 patients were diagnosed as venous thrombosis, the differences of gender and age were not statistically significant(P>0.05). There was statistical significance in terms of the difference of thrombosis of mild and relatively severe pancreatitis patients(P<0.01). The highest rate of the formation of vein thrombosis was right cephalic (37.5%). The incidence of vein thrombosis caused by the left and right upper extremity median cubital was 12.0% and 4.7% respectively.The incidence of vein thrombosis caused by left right basilic vein thrombosis rates was 1.3% and 0.6% respectively.The PT of the patients with vein thrombosis was higher than that of the patients without vein thrombosis, and the difference was statistically significant(P<0.05). APTT, FIB , D-D of patients with thrombosis was significantly higher than that of the patients without vein thrombosis, and the difference was significant(P<0.01). The average time of the formation of thrombosis after indwelling PICC catheter was(12.6±7.8) days, thrombosis can occur as early as 3 to 4 days after the first catheter. Conclusions The formation of the venous thrombosis is directly affected by the blood coagulation and the changes of the fibrinolysis system of the patients with severe acute pancreatitis.Nurses should strengthen the awareness of prevention for PICC catheter-related venous thrombosis.The patients' coagulation indicator is strictly assessed of before the catheter.The appropriate intravenous catheter is selected during the catheter.The comprehensive nursing intervention is conducted after the catheter to reduce the incidence of PICC catheter-related venous thrombosis and prolong the catheterization time. Key words: Acute pancreatitis; PICC catheter; Venous thrombosis; Nursing Strategy

3D-microdevice for the in vivo capture of cancer-associated circulating cells.

e579 Background: Circulating tumor cells (CTCs) are cancer cells that have detached from a tumor and have entered into the blood circulation at a very low concentration (D. Shook, Mech. Dev., Nov 2003). CTCs have a strong prognostic value, as their number has been correlated to overall survival in different metastatic cancers (J. S. de Bono, Clin. Cancer Res., Oct 2008). Considering the rareness of CTCs in blood, capturing them in vitro is very challenging. CTCs being mainly larger and less deformable than most of blood cells, ISET was the first system exploiting their physical traits using a filtration membrane to enrich 10mL blood samples (G. Vona, Am. J. Pathol., Jan 2000). However, placing the trapping system directly within the bloodstream would increase the amount of blood screened and ensure no sampling bias. To our knowledge, the only system developed for in vivo capture of CTCs relies on an immunologic detection targeting CTCs with specific epithelial-cell adhesion molecules (N. Saucedo-Zeni, Int. J. Oncol., Oct 2012). The major drawback of this technique is the selection bias induced, given the strong heterogeneity of antigen expression profiles in CTC population as confirmed by several studies. Methods: Our device combines the advantages of in vivo capture and physical trapping of CTCs. A polymeric 3D net-like microdevice is fabricated using a Direct Laser Writing technique (Nanoscribe) and integrated onto a Nitinol guidewire to be introduced into the basilic vein through a routine 20G catheter. To optimize the design, we conducted simulation studies and in vitro assays using a fluidic platform reproducing in vivo conditions. Results: We succeeded in capturing PC3 human prostate cancer cells from 20 mL healthy donor blood spiked with 1,000 PC3 cells in 2 minutes, demonstrating the capability to capture CTCs in conditions close to those found in vivo, in terms of pressure and flow rate and without any additional treatment or dilution of the blood. Conclusions: This device could facilitate treatment personalization and follow-up. Its versatility should render it transposable to the capture of single or clustered CTCs, derived from all types of cancer and, by extension, to other circulating cellular and molecular biomarkers.

A comparison of Broviac® and peripherally inserted central catheters in children with intestinal failure

PurposeCentral venous catheters (CVCs) are a source of morbidity for children with intestinal failure (IF). Complications include infection, breakage, occlusion, and venous thrombosis. Broviacs® have traditionally been preferred, but peripherally inserted central catheters (PICCs) are gaining popularity. This study compares complications between Broviacs® and PICCs in children with IF. MethodsAfter IRB approval, children with IF receiving parenteral nutrition (2012–2016) were reviewed. Complications were compared between Broviacs® and PICCs using the generalized estimation equation population-averaged Poisson regression model. P values <0.05 were considered significant. Results36 children (0.1–16years) with IF were reviewed, accounting for 27,331 catheter days, 108 Broviacs® (3F–9F), and 54 PICCs (2-11F). Broviacs® had a significantly higher infection rate (4.2 vs. 2.6/1000 catheter days, p=0.011), but PICCs were more likely to break (1.56 vs. 0.26/1000 catheter days, p=0.002). When comparing same size catheters (3F), there were no significant differences in infection, breakage, or occlusion. Twelve children (33%) had central venous thrombosis, all after Broviac® placement. Three children (8%) had basilic vein thrombosis after PICC placement. ConclusionAlthough Broviacs® and PICCs had similar complication rates, there were fewer central venous thromboses associated with PICCs. This should be considered when choosing catheters for children with IF. Level of evidence11b (Prognosis Study).

Basilic vein transposition: A viable alternative for multiple failed arteriovenous fistulas - A single center experience.

Primary use of the autogenous arteriovenous access is recommended by the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines. In spite of troublesome comorbidities associated with basilic vein transposition (BVT), it is still the most preferred technique when autologous veins are not suitable to construct radio-cephalic fistula (RCF) and brachiocephalic fistula (BCF), arteriovenous fistula (AVF). The present study highlights our experience with BVT, with small incision technique, over a period of two years with excellent outcome. This retrospective study included all the patients who underwent BVT at our tertiary care center between March 2013 and March 2015. It was performed in patients with failed previous RCF or BCF or who had small caliber or thrombosed cephalic veins. The patients with minimum 3 mm basilic vein diameter on Doppler were only included in the study. A 3-cm horizontal incision was made in antecubital fossa to expose brachial artery and basilic vein. Multiple longitudinal separate second skin incisions (2-3 cm) were made to explore proximal part of basilic vein. Side branches of the vein were isolated and ligated. The divided basilic vein in antecubital fossa was brought over fascia through newly created subcutaneous tunnel followed by end-to-side anastomosis. A total of 18 (12 males and 6 females) underwent BVT in the two years period. The mean fistula maturation time was 42 ± 10 days. Maturation rate was 100%, and the postoperative flow rate was 290 ± 22 (mL/min). No bleeding, thrombosis, failure, pseudo aneurysm, or rupture occurred in our patients. Arm edema occurred in ix (33%) patients, infection in three (17%), and lymphorrhea in five (28%). The mean follow-up was six months. BVT is an alternative method with excellent initial maturation and functional patency rates requiring less extensive skin incision and surgical dissection. It is the most durable hemodialysis access procedure for those patients having multiple forearm AVF surgeries.

Variation of the cephalic and basilic veins: A case report

Cephalic and basilic veins begin their path from around the wrist and continue towards the area above the forearm. The basilic vein becomes deep around the mid-arm, while the cephalic vein becomes deep around the upper forearm, in deltopectoral groove. The superficial veins are most commonly used for vein puncture, transfusion, bypass graft, and cardiac catheterization. In renal patients, the basilic vein use as an arteriovenous graft or fistula for haemodialysis access. During a routine dissection in the department of anatomy in Isfahan, we observed a variation in the left arm of an infant boy (six months old). The cephalic and basilic veins directly joined together in the middle of the cubital fossa. The brachial vein began from this point and, unlike the normal anatomy location, there was no paired brachial vein; rather, it was one unpaired brachial vein.

Comprehensive Analysis of Chicken Vessels as Microvascular Anastomosis Training Model

BackgroundNonliving chickens are commonly used as a microvascular anastomosis training model. However, previous studies have investigated only a few types of vessel, and no study has compared the characteristics of the various vessels. The present study evaluated the anatomic characteristics of various chicken vessels as a training model.MethodsEight vessels—the brachial artery, basilic vein, radial artery, ulnar artery, ischiatic artery and vein, cranial tibial artery, and common dorsal metatarsal artery—were evaluated in 26 fresh chickens and 30 chicken feet for external diameter (ED) and thicknesses of the tunica adventitia and media. The dissection time from skin incision to application of vessel clamps was also measured.ResultsThe EDs of the vessels varied. The ischiatic vein had the largest ED of 2.69±0.33 mm, followed by the basilic vein (1.88±0.36 mm), ischiatic artery (1.68±0.24 mm), common dorsal metatarsal artery (1.23±0.23 mm), cranial tibial artery (1.18±0.19 mm), brachial artery (1.08±0.15 mm), ulnar artery (0.82±0.13 mm), and radial artery (0.56±0.12 mm), and the order of size was consistent across all subjects. Thicknesses of the tunica adventitia and media were also diverse, ranging from 74.09±19.91 µm to 158.66±40.25 µm (adventitia) and from 31.2±7.13 µm to 154.15±46.48 µm (media), respectively. Mean dissection time was <3 minutes for all vessels.ConclusionsOur results suggest that nonliving chickens can provide various vessels with different anatomic characteristics, which can allow trainees the choice of an appropriate microvascular anastomosis training model depending on their purpose and skillfulness.

Subpopulations of natural killer-T-like cells before and after surgical treatment of laryngeal cancer.

IntroductionTumours connected with head and neck comprise about 5% of all tumours. The most frequent histological type of laryngeal carcinoma is squamous cell carcinoma. Different research projects suggest that the role of T lymphocytes might be significant in tumour development. iNKT cells are a new subpopulation of T cells and show cytotoxic activity against tumours. iNKT cells participate in modulating the function of other cells which have anti-tumour properties and secrete cytokines, which have pro-inflammatory and anti-inflammatory effects. In animal models the significance of iNKT cells in various diseases including cancer was shown.Aim of the studyThe aim of this study was to determine the percentages of iNKT cells, CD161+ cells, CD161– cells, iNKT CD4+ cells, and iNKT CD8+ cells, NK cells, NKT-like cells, and T cells subsets present in peripheral blood of patients with laryngeal cancer before and two months after the tumour resection, in comparison to healthy volunteers.Materials and methodsThis study included material from laryngeal patients who were treated at the Department of Otolaryngology and Laryngological Oncology (Medical University of Lublin) between 2012 and 2013. A total of 50 patients (40 men and 10 women) aged between 45 and 77 years (median age: 60 years) were enrolled. Based on the TNM classification, the patients were classified as having stage I-IV laryngeal cancer. The control group was composed of 15 healthy volunteers (12 men and three women) aged between 43 and 82 years (median age: 61 years). The protocol of the study was approved by the Local Bioethical Committee at the Medical University of Lublin.Peripheral blood samples (15 ml) from the basilic vein were collected by venipuncture using sterile, sodium heparin-treated tubes (20 units per ml of blood) and used for cytometric analyses.ResultsiNKT cells were analysed among T CD3+ cells. The percentage of CD3+ and CD3+CD4+ T cells before tumour resection was higher than in the control group, but the increase of CD3+ T cells was not significant. The T CD3+CD4+ / T CD3+CD8+ cell ratio was significantly higher than in healthy donors. After tumour resection a decreased percentage of CD3+CD4+ T cells but an increased percentage of CD8+CD3+T cells was noted. The T CD3+CD4+ / T CD3+CD8+ cell ratio was significantly higher in patients before and after the surgery than in the control group. The amount of NKT-like cells increased after resection and was significantly higher than in the control group.ConclusionsOur study exhibited the change in percentage of iNKT, NK, NKT-like cells, and T lymphocytes after tumour resection in patients with laryngeal cancer. The research explains the contribution of those cells in immunological response against tumour.

Dual Use of an Arterio-Venous Fistula for Total Parentral Nutrition and Haemodialysis: Potential and Pitfalls

Introduction: We present the dual use of an arteriovenous fistula (AVF) for contemporaneous administration of home parenteral nutrition (PN), and hemodialysis (HD). Case Report: A 52 year old female patient required PN due to short bowel syndrome, following extensive resection for ischemic bowel. After she was rendered dialysis dependent secondary to multifactorial renal failure, a left forearm basilica vein transposition onto the radial artery was undertaken. Venous access for PN was problematic. We commenced home PN via the AVF, using a ‘buttonhole’ technique to cannulate the fistula for both HD and PN. The peripheral administration of PN necessitated reduction in the osmolality, with larger volumes and longer administration times. This required adjustment of the HD regime to compensate.The patient received simultaneous PN and HD at home through the AVF successfully for seven weeks. Unfortunately after this time she suffered a staphylococcal fistula infection with septicemia. Discussion: We have shown that dual use of AVF for HD and PN is feasible, although not without risk. Reduction of osmolality and staggering of PN and HD sessions is required, with administration of PN over longer times. It has been shown that the buttonhole cannulation technique has a higher rate of infection than alternatives, and we propose this may have contributed to our patient’s complication. We believe this report would be helpful if dual use of AVF for PN and HD is contemplated.

Basilic elevation transposition may improve the clinical outcomes for superficialization of basilic arteriovenous fistula veins

ObjectiveBasilic vein arteriovenous fistulas are an important and common option for hemodialysis access and require superficialization before use. Various superficialization techniques have been employed, such as basilic tunnel transposition (BTT), basilic elevation, and basilic elevation transposition (BET). Each technique may have advantages and disadvantages, and there have been few reports directly comparing the outcomes of these techniques. This report compares the clinical outcomes of BET vs BTT performed by a single operator and discusses some technical considerations derived from this study and the literature. MethodsThe demographic and outcome data of patients who underwent second-stage basilic vein transposition at an ambulatory surgery center from February 2009 to January 2016 were collected and analyzed. ResultsOf the 99 patients identified, 53% were male and 64% were diabetic; the mean age was 61 ± 16 years; 27 had BTT and 72 had BET; the mean follow-up was 26.2 ± 20.5 (range, 1-83) months. The primary patency, assisted primary patency, and secondary patency rates of the whole fistula conduit were 26%, 91%, and 100% for the BTT group and 46%, 98%, 100% for the BET group at 1 year and 21%, 80%, 94% for the BTT group and 38%, 98%, 98% for the BET group at 2 years. The primary patency rate of the basilic vein (segment of the fistula conduit superficialized by transposition) at 1 year was significantly lower for the BTT group vs the BET group (26% vs 61%; P = .004). The average number of percutaneous interventions required for the basilic vein was significantly more for the BTT group vs the BET group (1.5 ± 1.3 vs 0.6 ± 1.0/access-year; P = .007). Based on a Cox regression analysis, the surgical techniques were the only clinical factor that significantly affected the basilic vein primary patency (hazard ratio of 2.28 in favor of BET over BTT; 95% confidence interval, 1.25-4.14; P = .007). ConclusionsBET is a reliable approach that yields a high cumulative fistula survival rate. Compared with BTT, BET is associated with improved basilic vein primary patency and reduced need for endovascular interventions.

Thermal Resistance Anastomosis Device for the Percutaneous Creation of Arteriovenous Fistulae for Hemodialysis

PurposeTo evaluate the safety and efficacy of arteriovenous fistula (AVF) creation with a thermal resistance anastomosis device (TRAD). Materials and MethodsFrom January 2014 to March 2015, 26 patients underwent ultrasound (US)-guided percutaneous creation of proximal radial artery–to–perforating vein AVFs with a TRAD that uses heat and pressure to create a fused anastomosis. Primary endpoints were fistula creation, patent fistula by Doppler US, two-needle dialysis at the prescribed rate, and device-related complications. ResultsTechnical success rate of fistula creation was 88% (23 of 26). Procedure time averaged 18.4 minutes (range, 5–34 min), and 96% of anastomoses (22 of 23) were fused. At 6 weeks, 87% of AVFs (20 of 23) were patent, 61% (14 of 23) had 400-mL/min brachial artery flow, 1 patient was receiving dialysis, 2 fistulae had thrombosed, and 1 patient had died unrelated to the procedure. Eighty percent (16 of 20), 70% (14 of 20), and 60% (12 of 20) of patients were receiving dialysis at 3, 6, and 12 months; 4 patients died, 3 fistulae failed, and one patient was lost to follow-up. Overall, 87% of AVFs (20 of 23) had an additional procedure at a mean of 56 days (range, 0–239 d), including balloon dilation in 43% (n = 10), brachial vein embolization in 26% (n = 6), basilic vein ligation in 17% (n = 4), venous transposition in 30% (n = 7), and valvulotomy in 4% (n = 1). There were no major complications related to the device. ConclusionsPercutaneous AVFs created with a TRAD met the safety endpoints of this study. Midterm follow-up demonstrated intact anastomoses and fistulae suitable for dialysis.

A Pilot Study in Cancer Patients with Central Venous Catheter Associated Deep Vein Thrombosis in Upper Extremity Treated with Rivaroxaban (Catheter 2)

▪IntroductionUpper extremity deep vein thrombosis (UEDVT) represents up to 10% of cases of venous thromboembolism (VTE) and is frequently associated with central venous catheter (CVC) placement in patients receiving chemotherapy for cancer. UEDVT may be treated with low molecular weight heparin (LMWH) either as monotherapy or subsequently transitioned to warfarin as we have previously shown (Kovacs 2007). Whereas for non-cancer VTE rivaroxaban is at least as efficacious and safe as warfarin, the latter is problematic in cancer patients and direct oral anticoagulants (DOACs) such as rivaroxaban have not been studied to date in this setting. In this study weevaluated thesafety and efficacy of rivaroxaban in the treatment of UEDVT secondary to CVC in patients with cancer.MethodsWe conducted a multicentre prospective cohort study at 3 centres in Canada between December 2012 and January 2016. We enrolled patients ≥18 years of age with active malignancy and symptomatic proximal UEDVT (axillary or more proximal) with or without pulmonary embolism (PE), associated with a CVC. Exclusion criteria included dialysis catheters, active bleeding, platelet count <75 x 109/L, creatinine clearance <30 mL/min, other anticoagulants, PE with hemodynamic instability, inability to infuse through the catheter after a trial of intraluminal thrombolytic therapy (tissue plasminogen activator,tPa), patients with acute leukemia, patients with multiple myeloma awaiting bone marrow transplant within 3 months, thrombosis involving the brachial,basilic or cephalic veins only, treatment for >7 days with other anticoagulant, need for dual antiplatelet therapy (recent stent), or concomitant use of P-glycoprotein and CYP3A4 inhibitors. Primary objective was an estimate of the proportion of catheter survival at 3 months, defined as infusion failure that does not respond to 2 mg oftPa. Secondary objectives included recurrence of DVT, PE, major bleeding, clinically relevant non-major bleeding (CRNMB) and death. All events were independently adjudicated. Patients were treated with rivaroxaban at a dose of 15 mgpo bid for 3 weeks, followed by 20 mgpo daily for 9 more weeks (minimum 12 weeks).tPa (oralteplase) for management of blocked lines was allowed. Patients were followed clinically for 12 weeks to assess for clinical events including recurrent DVT and/or PE, major bleeding and CRNMB, and by phone at 6 months.ResultsWe included 70 patients (47[67%] women) with a mean age of 54.1 years. DVTs were diagnosed by ultrasound in 68 (97%) patients, and most commonly involved the subclavian (n=55, 79%) and axillary (n=49, 70%) veins, followed by the internal jugular, brachial, brachiocephalic and external jugular veins. Peripherally inserted central catheters (PICC) were most common (n=54, 77%), followed by port-a-cathlines (n=16, 23%). Types of active malignancy included breast (n=29, 41%), colon (n=8, 11%), colorectal (n=5, 7%), rectal (n=3, 4%), prostate (n=1, 1%), and other (n=24, 34%).Catheter survival was 58.6% (95% CI 46.9 to 69.4) at 12 weeks and no catheters were removed due to thrombosis. Patients had their CVCs removed prior to the end of the study due to end of therapeutic need (n=20), infection (n=2), bleeding (n=2), kinking (n=2), patient preference (n=2), and death (n=1). The 3-month incidence rate of recurrent VTE was 1.43% (95% CI 0.25 to 7.66). There was 1 episode of recurrent VTE presenting as a fatal PE at 6 weeks. It was not known if the patient had a concurrent leg DVT at the time of the PE. There were no other deaths from any cause during the study. There were 11 bleeding events in 9 patients (12.85%, 95%CI 6.9 to 22.7), 6 major and 5 CRNMB (Figure 1). All bleeding events happened during the first 39 days of treatment. 7 patients discontinued anticoagulation during the study due to death (n=1), patient or clinician preference (n=5) and dermatological adverse reaction (n=1).DiscussionIn this study rivaroxaban showed promise in treating CVC-associated UEDVT in cancer patients, resulting in preserved CVC function. However, the bleeding rates and the occurrence of 1 death due to pulmonary embolism is concerning since we cannot exclude a causative role for the known UEDVT. Further studies are still required prior to recommending rivaroxaban in this setting. [Display omitted] DisclosuresLazo-Langner:Daiichi Sankyo: Research Funding; Bayer: Honoraria; Pfizer: Honoraria. Tagalakis:Bayer: Honoraria. Louzada:Celgene: Consultancy, Honoraria; Bayer: Honoraria; Pfizer: Honoraria; Janssen: Consultancy, Honoraria. Kovacs:Bayer: Honoraria, Research Funding; Daiichi Sankyo Pharma: Research Funding; LEO Pharma: Honoraria; Pfizer: Honoraria, Research Funding.

Incidence and Outcomes of Catheter Related Thrombosis in Acute Leukemia: Single Centre Experience

▪IntroductionCatheter related thrombosis (CRT) is a common complication of central venous catheters (CVCs) in patients with hematological and solid organ cancers. However, little is known about the incidence of CRT in acute leukemia patients and the optimal approach to anticoagulant therapy especially in the presence of concurrent and often prolonged thrombocytopenia. Some of these patients might receive sub-therapeutic anticoagulation with a potentially higher risk of recurrent CRT, device failure and thromboembolic events.MethodWe conducted a retrospective chart review of adult patients with newly diagnosed acute leukemia at Vancouver General Hospital (VGH), Canada from January 2014 to December 2014. The study aimed to determine the incidence of CRT and review the current practice of CRT management. The outcomes were symptomatic thrombotic and bleeding events, catheter complications (e.g. infection), and blood product use. Only objectively confirmed CRT cases were included. The follow up period was from CRT diagnosis to last known date of follow-up.ResultsA total of 151 patients were identified, of whom 116 received CVC insertion. Eleven patients (78.5%) received more than one CVC (median 2, range 1-4). Fourteen patients (12%) were diagnosed with symptomatic CRT (table). All CRT events occurred within 30 days (range 4-30 days) after CVC insertion and 85.7% within the first 6 months (range 0.26-6 months) after their diagnosis of acute leukemia. Median follow up of these 14 patients was 447 patient-days (range 13-759). Two patients were lost to follow-up at 13 and 23 days due to transfer of care to other hospitals. Three out of 14 patients died during follow up (at 72, 86 and 372 days, respectively) due to leukemia.Eleven patients (78.5%) were treated with therapeutic anticoagulation using low molecular weight heparin (LMWH). Three untreated patients had CRT confined to basilic vein. Nine out of 11 patients required LMWH dose reduction due to thrombocytopenia according to our local protocol (1). Full dose weight-based LMWH was administered if platelet count could be maintained above 50 × 109/L (with or without platelet transfusion in acute phase, i.e. within 1 month of CRT diagnosis). For platelet counts between 20 and 50 × 109/L, half-dose LMWH was administered with close monitoring. LMWH was withheld if platelet count was lower than 20 x 109/L in subacute phase, i.e. after 1 month. No patient had recurrent CRT or pulmonary embolism during anticoagulation and follow up.Bleeding events occurred in 3 (27%) patients during anticoagulation. There was one major bleeding (spontaneous retroperitoneal hematoma), one clinically relevant non-major bleeding (adenovirus induced cystitis and hematuria requiring hospital admission) and one minor bleeding (bruise) event. Catheter-related infection was documented in 4 (36%) patients. No deaths occurred due to CRT or its treatment.Patients were treated for a minimum of 3 months or longer if the implicated catheter was still in situ. Median treatment time was 3 months (range 2 weeks-7 months). Three patients stopped anticoagulation prior to 3 months (palliation and lost follow-up). None of the CVC was removed as a result of CRT, but 4 were removed for infection, 3 for the completion of chemotherapy, 2 non tunnelled catheters were replaced with long term CVCs, 1 was accidentally dislodged and 1 was removed for logistic reason. The median CVC dwell time was 30 days (range 4-173).Among the 11 treated patients, 8 patients received platelet transfusions during treatment with LMWH. Eighty seven doses of pooled platelets (or its equivalent) and 64 packed red cells were transfused. Sixteen doses (18%) of platelet transfusions were given to keep platelet count above 20-50 for anticoagulation during the first month of CRT; the remainder were given for clinical indications. Only 4 units (6%) of packed red cells were transfused for major bleeding in one patient while 60 units were used for routine support when hemoglobin was <80 g/L.ConclusionTwelve percent of newly diagnosed acute leukemia patients developed CRT. Anticoagulation with LMWH using a dose reduction approach for thrombocytopenia appeared safe and effective with no recurrent VTE events and few bleeding events.1) Lee AY, Peterson EA. Treatment of cancer-associated thrombosis. Blood. 2013 Oct 3; 122:2310-7 [Display omitted] DisclosuresLee:LEO: Consultancy, Honoraria; Bristol Myers-Squibb: Consultancy, Honoraria, Research Funding; Bayer: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria.

Axillary artery injury from a closed humeral neck fracture: A case report

Axillary artery injury from humeral neck fracture is an uncommon event. Vascular damage due to these injuries may threaten limb loss. In some cases, the signs of ischemia may not be evident just after the injury and may only appear later on. Therefore, a high index of suspicion is essential. It is important to bear this association in mind, so as to make an early diagnosis and avoid serious complications. We are describing the case of a young patient involved in a motor vehicle crash with an axillary artery trauma due to the surgical neck of humerus fracture. The patient underwent a basilic vein grafting, the postoperative course was good.

The Appropriate Use of PICC Lines in Inflammatory Bowel Disease

Our patient is a 49-year-old male with a history of Ulcerative Colitis (UC) with recurrent flares on Remicade and Prednisone who presented with acute-onset left upper extremity swelling. One day prior to his admission, he was discharged from an outside hospital after being treated for a UC flare for 9 days. During this hospitalization, a peripherally inserted central catheter (PICC) line was placed for poor vascular access and repeated blood draws. His left arm PICC line was removed on the day of discharge without complication. However, the following morning he developed progressively worsening swelling and skin discoloration of his left arm. On presentation, his vitals were stable. Examination of his left upper extremity revealed non-pitting edema in the entirety of his left arm with erythematous skin overlying his biceps and antecubital fossa with ecchymosis. His vascular and neurological exams were intact. Duplex of the left arm revealed a DVT from the left subclavian vein to the axillary vein and involving the basilic and medial brachial veins as well as the cephalic vein in the upper arm. He was promptly started on intravenous heparin. He greatly improved and was discharged on anticoagulation which he will continue for at least 3 months. The insertion of PICC lines has become commonplace in medical practice due to a myriad of reasons such as reliable venous access, ease of insertion, and cost-effectiveness. Despite these benefits, insertion of these central venous catheters (CVCs) is not without risk. Such risks include central lineassociated bloodstream infections and venous thromboembolism. A concern was raised regarding the suitable use of a PICC line in our patient with a chronic inflammatory disease for the purpose of vascular access. The literature reveals that many PICC lines are not actively used or were inserted in patients who also had peripheral intravenous catheters. A recent study showed that 1 in 5 inpatient providers did not know that their patients had CVCs, with lack of awareness being greatest for PICC lines. Guidelines on the proper use of PICCs have been proposed with insertion rated as appropriate when the proposed duration of use for frequent phlebotomy or difficult venous access was 6 or more days. Although there are several advantages of PICCs, the duration of venous access, type of infusate, and specific reason for use should be carefully evaluated prior to placement to minimize the risk to our patients.

Brachial Artery Reconstruction in Trauma Using Reversed Arm Vein from the Injured Upper Limb

Background:Brachial artery repair may be technically challenging with a paucity of guidelines. The use arm vein (AV) from the traumatized limb is herein described.Methods:Data were prospectively collected from 2002 to 2016 on brachial artery injury including age, sex, mechanism/site of injury, and repair technique. Categories included AV and non-arm vein (NAV) groups. One-year outcomes were noted.Results:All 31 cases studied were of men with an age range of 16 to 73 years (mean = 28). Injuries included 13 gunshots, 7 stabbings, 6 glass injuries, 2 dislocated elbows, 1 crush, 1 impalement, and 1 avulsion. Site of injuries included the antecubital region in 25, midbrachial in 5, and proximal brachial in 1, with 4 associated fractures. Repair was done using reversed AV from the traumatized limb in 15 cases and NAV in 16. In the AV group, the adjacent basilic vein was used in 9 cases, the adjacent cephalic vein in 3, and the distal (or wrist area) cephalic vein in 3. The limb salvage rates in the AV versus NAV groups were 100% and 94%, respectively (Fisher’s exact t test, P = 1.00), with no major technique-related complications.Conclusions:The outcomes of using reversed AV from the traumatized limb are equivalent to those of other standard techniques such as primary repair, polytetrafluoroethylene, or reversed great saphenous vein, with a 1-year limb salvage rate of 100%. Additionally, advantages include decreased wound complications, better vein graft--artery caliber match, and shorter operating times while maintaining acceptable patency rates.

Outcomes of Arteriovenous Fistula for Hemodialysis in Pediatric and Adolescent Patients.

Purpose:This retrospective review aimed to report the outcomes of arteriovenous fistula (AVF) and to evaluate the suitability of AVF as a permanent vascular access in pediatric populations.Materials and Methods:Data were collected for all patients aged 0 to 19 years who underwent AVF creation for hemodialysis between January 2000 and June 2014.Results:Fifty-two AVFs were created in 47 patients. Mean age was 15.7±3.2 years and mean body weight was 46.7±15.4 kg. Of the 52 AVFs, 43 were radiocephalic AVFs, 7 were brachiocephalic AVFs and 2 were basilic vein transpositions. With a mean follow-up of 49.7±39.2 months, primary patency was 60.5%, 51.4%, and 47.7% at 1, 3, and 5 years, respectively and secondary patency was 82.7%, 79.2% and 79.2% at 1, 3, and 5 years, respectively. Age, body weight, AVF type, the presence of a central venous catheter, use of anticoagulation therapy, and history of vascular access failure were not significantly associated with patency rates. There were 9 cases (17.3%) of primary failure; low body weight was an independent predictor. Excluding cases of primary failure, the mean duration of maturation was 10.0±3.7 weeks. During follow-up, 20 patients (42.6%) underwent kidney transplantation, with a median interval to transplantation of 36 months.Conclusion:AVF creation in children and adolescents is associated with acceptable long-term durability, primary failure rate and maturation time. Considering the waiting time and limited kidney graft survival, placement of AVFs should be considered primarily even in patients expected to receive transplantation.

An Alternative Needling Site for Hemodialysis—Retrograde Brachiocephalic AV Fistulas: A Case Series

Establishing a patient with a functioning arteriovenous fistula (AVF) remains a challenge for vascular access surgeons. The presence of venous branches directing flow away from the main outflow vein in a brachiocephalic fistula may be one of the reasons for their failure to mature, and often these are ligated. When not ligated, “retrograde flow” may occur and develop into an “unorthodox” fistula. At the Cardiff &amp; Vale University Health Board, 331 brachiocephalic fistulas were created for hemodialysis access over a 3-year period. Five male patients were identified, with a median age of 69 years, who had, as a result of proximal cephalic vein stenosis/occlusion, developed a functioning mature fistula within a distal branch/forearm vein that eventually drains via the basilic vein. Moreover, the flow rates within these new fistula outflow veins were comparable to functioning conventional brachiocephalic fistulas. These retrograde brachiocephalic fistulas that have been inadvertently/accidentally created appear to be successful in providing stable vascular access for hemodialysis. These cases are an interesting find, as such branches often would have been ligated at the time of fistula creation. When creating an AVF between the brachial artery and the median cubital vein, consideration should be given to not ligating the below elbow cephalic vein.

AIUM Practice Parameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis Access

AIUM Practice Parameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis Access

How to Avoid Damaging the Terminal Branches of the Medial Antebrachial Cutaneous Nerve and the Medial Brachial Cutaneous Nerve During Operations Involving the Medial Elbow?

Objective: Medial elbow incision is obligatory for cubital tunnel syndrome surgical treatment. However, the terminal branches of both the medial antebrachial cutaneous nerve (MACN) and the medial brachial cutaneous nerve (MBCN) are likely to be harmed using the current incision technique. The aim of this study was to seek a new incision to avoid damaging the branches of MACN and MBCN during the operation for cubital tunnel syndrome. Methods: Ten fresh frozen cadaver upper extremities and 20 clinical cases (elbows) were analyzed. A conventional incision and a new incision were used in the cadaveric specimens and the clinical cases, respectively. The medial epicondyle was set as the reference landmark to quantify the location of the terminal branches, with the elbow at full extension. The numbers of the terminal branches and their locations were noted for MACN and MBCN, and the locations of the posterior branch of the MACN were recorded in the elbow medial incision. Results: The average numbers of MACN’s posterior terminal branches were 2.6 ± 1.6 and 4.4 ± 2.4 in the cadaveric specimens and clinical cases, respectively. The average number of MBCN’s terminal branches was 2 ± 0.87 in the cadaveric specimens. The MACN’s posterior terminal branches were located at 19 and 45 mm, respectively, measuring from the medial epicondyle. And the posterior branch of MACN was always located in between the medial epicondyle and the basilic vein, and the average distance was 10 ± 6 mm to the medial epicondyle. We could preserve all the MBCN’s terminal branches in the new incision. The MACN’s posterior terminal branches could be perfectly exposed by the use of the antegrade dissection technique, finding the MACN’s posterior branch in advance. Conclusions: The new elbow medial incision technique could reduce the risk of injuring the terminal branches from the MBCN. The medial epicondyle and the basilic vein are reliable anatomical landmarks to identify the posterior branch of the MACN. An antegrade method of dissection can effectively identify and avoid the injury to the terminal branches of the MACN in the elbow medial incision.