Primary Endovascular Intervention for Acute Mesenteric Ischemia Performed by Interventional Cardiologists - A Single Center Experience.

The current standard care for acute mesenteric ischemia (AMEI) involves urgent revascularization and resection of the necrotic bowel. Since 2012, we have used an AMEI protocol of our own design, which focused on early treatment and allowed interventional cardiologists to become involved when interventional radiologist was not available. A total of 8 patients were treated, and two interventional cardiologists performed all the stenting procedures. The procedure success rate was 100% in patients with non-calcified lesions (6/8). The 30-day survival rate was 100% in patients with angiographic success, and was 0% in patients with failed procedure. In two patients with total occlusion of the superior mesenteric artery, laparotomy was avoided when interventions were successful and completed within six hours of protocol activation. Four surviving patients were discharged after short intensive care unit stays (less than 48 hours); these patients returned to and remained at home throughout their 90-day follow-up. The overall procedure success rate and 30-day survival rate were both 75%. There was no access site or intervention-related complications. Using our protocol, we believe that primary endovascular treatment for AMEI is feasible. In geographic regions where healthcare resources are lacking, a time-efficient strategy adopted by interventional cardiologists should be considered for the purpose of saving lives and possibly even avoiding open laparotomy.

Pulmonary Hypertension in Hemodialysis Patients Following Repeated Endovascular Thrombectomy.

BACKGROUND: The prevalence of pulmonary hypertension is unusually high in Taiwanese patients with end-stage renal disease. Thrombosis of hemodialysis grafts is common and pulmonary embolism has been reported after endovascular thrombectomy. The aim of this study was to evaluate the relationship between pulmonary hypertension and endovascular thrombectomy of hemodialysis grafts. METHODS: One hundred and ten patients on hemodialysis via arteriovenous grafts were enrolled in our study. The mean pulmonary artery pressure (PAP) was measured by right heart catheterization. Clinical information was collected by review of medical records. Comorbid cardiopulmonary disease was evaluated by echocardiography and chest X-ray. The history of patient vascular access thrombosis was reviewed from database, hemodialysis records, and interviews with staff at hemodialysis centers. RESULTS: Fifty-two participants (47%) had pulmonary hypertension diagnosed by right heart catheterization. There was no difference in the number of thrombectomy procedures between patients with and without pulmonary hypertension. Based on multivariate analysis, the number of prior endovascular thrombectomy procedures did not correlate with mean PAP (F-value = 1.10, p = 0.30) nor was it associated with pulmonary hypertension (odds ratio = 0.92, p = 0.17). CONCLUSIONS: Prior endovascular arteriovenous graft thrombectomies were not associated with pulmonary hypertension or increased mean PAP in end-stage renal disease patients on maintenance hemodialysis.

Feasibility and Safety of Coronary Procedures via an Arteriovenous Graft Approach in Patients on Maintenance Hemodialysis.

BACKGROUND: Traditionally, a radial or brachial arterial approach is unadvisable in hemodialysis patients. Consequently, coronary angiography or angioplasty is usually performed via a femoral artery approach in these patients, who carry a higher risk of vascular access complications. In hemodialysis patients, arteriovenous grafts (AVG) are created for repeated punctures; however, the feasibility and safety of a trans-AVG approach for coronary angiography or angioplasty remains unclear. METHODS: In our institution, cardiac catheterizations were attempted via AV grafts in hemodialysis patients with a U-shaped forearm AVG. We retrospectively identified coronary angiography or angioplasty procedures in hemodialysis patients from a computer-based database in our hospital. The procedure details and outcomes were obtained from review of the clinical, angiographic and hemodialysis records. RESULTS: From 2008 to 2013, 167 procedures in hemodialysis patients were identified from 2866 diagnostic or interventional coronary procedures in our institution. Out of these, 24 procedures in 17 patients were performed via a trans-AVG approach. In all AVG procedures, a 6F 16-cm or 7F 10-cm sheath was placed from the AVG into the brachial artery. All diagnostic procedures were successfully performed. In 14 procedures, the patients also underwent angioplasty and all of the angioplasty procedures were successful. There was no arterial spasm, arterial dissection, puncture site hematoma, or acute thrombosis of the AVG during or after the procedures. CONCLUSIONS: A trans-AVG approach appears to be a feasible and safe route for coronary angiography or angioplasty in hemodialysis patients with a U-shaped forearm AVG. However, further studies with a larger patient number are necessary. KEY WORDS: Arteriovenous graft; Hemodialysis; Percutaneous coronary intervention.

Endovascular Declotting of Wall-Adherent Thrombi in Hemodialysis Vascular Access.

BACKGROUND: To investigate the efficacy, safety, and patency following treatment of wall-adherent thrombus in hemodialysis vascular access with a wall-contact device, the Arrow-Trerotola percutaneous thrombolytic device (PTD). METHODS: We retrospectively reviewed an existing database of procedures fulfilling the following criteria: thrombosed hemodialysis access, wall-adherent thrombus, and use of PTD for mechanical thrombectomy. Data on immediate success, complications, and patency were collected from medical records, dialysis records, and angiographic reports. RESULTS: Ninety-three patients with 108 episodes of vascular access thrombosis were included in the study. Fifty-three of the procedures were performed on native fistulas, and 55 were on synthetic grafts. Anatomical and clinical success was achieved in 97% and 96% of the procedures, respectively. The average procedure time was 52 ± 23 minutes. Complications occurred in three of the procedures (2.7%), but none of these complications were device-related. The primary patency rates in the native fistula group were 57% and 42% at three and six months, respectively. The primary patency rates in the synthetic graft group were 40% at three months, and 27% at six months. The secondary patency rates at six months were 91% in the native fistula group, and 93% in the synthetic graft group. CONCLUSIONS: Our results show that a wall-contact mechanical device, PTD, is effective and safe for endovascular removal of wall-adherent thrombi in hemodialysis vascular access in both native fistulas and synthetic grafts. KEY WORDS: Adherent; Angioplasty; Endovascular; Hemodialysis; Thrombectomy; Vascular access.

Radial artery approach to salvage nonmaturing radiocephalic arteriovenous fistulas.

PURPOSE: To evaluate the usefulness of an approach through the radial artery distal to the arteriovenous anastomosis for salvaging nonmaturing radiocephalic arteriovenous fistulas. METHODS: Procedures that fulfilled the following criteria were retrospectively reviewed: (1) autogenous radiocephalic fistulas, (2) fistulas less than 3 months old, (3) distal radial artery approach for salvage. From 2005 to 2011, a total of 51 patients fulfilling the above criteria were enrolled. Outcome variables were obtained from angiographic, clinical and hemodialysis records, including the success, complication, and primary and secondary patency rates. RESULTS: The overall anatomical and clinical success rates for the distal radial artery approach were 96 and 94%, respectively. The average procedure time was 36 ± 19 min. Six patients (12%) experienced minor complications as a result of extravasations. No arterial complication or puncture site complication was noted. The postinterventional 6-month primary patency rate was 51%, and the 6-month secondary patency rate was 90%. When the patients were divided into a stenosed group (20 patients) and an occluded group (31 patients), there were no differences in the success rate, complication rate, or primary and secondary patency rates. CONCLUSION: An approach through the radial artery distal to the arteriovenous anastomosis is an effective and safe alternative for the salvage of nonmaturing radiocephalic arteriovenous fistulas, even for occluded fistulas.

Impending cardiac tamponade caused by salt supplement in a hyponatremic patient with chronic kidney disease.

We documented a hyponatremic patient who developed imminent cardiac tamponade upon oral salt supplement. A 72-year-old diabetic woman had hemorrhagic stroke; pericardial effusion; and chronic kidney disease, stage IV. She developed hyponatremia (serum sodium level, 125 mmol/L), compatible with the syndrome of inappropriate antidiuretic hormone, and received oral salt supplement 9 g/d for 4 days. Shortness of breathing and increasing heart rate ensued, and the echocardiography found accumulation of pericardial effusion with signs of impending cardiac tamponade. Pig-tail drainage through pericardiocentesis was done, and the vital signs were stabilized. We found the production of pericardial effusion increased from 100 to 220 mL/d after oral salt supplement at 3 g/d was reassumed. We discuss the relationship between serum sodium levels, the dose of salt supplement and the accumulation of pericardial effusion.

Acute paresthesia in a patient with migraine.

Ergot-containing medications are widely used to treat migraine patients in some countries but nowadays intoxication is only reported rarely. We report a 35-year-old woman who presented with acute paresthesia of the extremities. An angiogram revealed diffuse vasospasm of the femoral arteries bilaterally and the right brachial artery. History taking disclosed a possible interaction between ergotamine and macrolide antibiotics. The patient's symptoms improved rapidly after discontinuation of the offending medication and administration of vasodilators. This report aims to remind physicians that catastrophic adverse effects can develop through unrecognized drug interactions, even with widely prescribed medications given in safe dosages. The importance of a detailed drug history and knowledge of drug interactions cannot be overemphasized in the diagnosis of ergotism.

Baseline plasma glycemic profiles but not inflammatory biomarkers predict symptomatic restenosis after angioplasty of arteriovenous fistulas in patients with hemodialysis.

OBJECTIVE: The aim of the study was to evaluate the role of atherosclerosis risk factors and baseline inflammatory status in the development of restenosis after successful percutaneous transluminal angioplasty (PTA) of hemodialysis arteriovenous (AV) fistulas. RESEARCH DESIGN AND METHODS: We obtained baseline plasma biochemistry and inflammatory markers in 140 patients with dysfunctional AV fistulas before the PTA procedures. Patients were followed clinically for 6 months. RESULTS: There was no significant difference in the baseline inflammatory markers between the restenosis and patency group. The Kaplan-Meier analysis showed that non-diabetic patients had higher patency rate than diabetic patients (69% vs. 48%, p=0.02) and diabetic patients with optimal glycemic control had higher patency rate than patients with suboptimal glycemic control (61% vs. 30%, p=0.01). CONCLUSIONS: The presence of diabetes mellitus predicted restenosis of AV fistulas after PTA and optimal blood glucose control might be critical to the patency after PTA.

Radial artery approach for endovascular salvage of occluded autogenous radial-cephalic fistulae.

BACKGROUND: The endovascular salvage of occluded autogenous radial-cephalic fistulae is a more challenging procedure than that for stenotic fistulae. To obtain an access to the fistula is one of the keys to success. Both retrograde venous approach and brachial artery approach have some disadvantages. The radial artery approach has been used in the endovascular therapy of fistula dysfunction, but few data focused on their feasibility and safety for the totally occluded fistulae. METHODS: We retrospectively reviewed the patients with occluded autogenous radial-cephalic fistulae receiving endovascular salvage via the radial artery approach in our institution. From January 2004 to July 2007, 48 patients fulfilling the above criteria were enrolled. Balloon maceration was used for patients with small clots. Mechanical thrombectomy with an Arrow-Trerotola percutaneous thrombolytic device or an AngioJet rheolytic catheter was used for patients with large clot burden. Outcome variables included anatomic and clinical success, complications and primary and secondary patency. RESULTS: All the transradial punctures were successful. Anatomic and clinical success was achieved in 96% of the cases. The post-interventional primary patency rates were 92%, 77%, 55% and 44% at 1, 3, 6 and 12 months, respectively. The post-interventional secondary patency rates were 96%, 93%, 89% and 89% at 1, 3, 6 and 12 months, respectively. The 12-month primary patency of the short-segment thrombus group was better than that of the long-segment thrombus group (57% versus 19%, P = 0.005). The complication rate was 4%. No puncture-site-related complications were noted, and all the radial arteries were palpable at follow-up. CONCLUSIONS: An endovascular intervention through the radial artery approach is a safe and feasible strategy choice for restoring occluded autogenous radial-cephalic fistulae.

Plasma ADMA predicts restenosis of arteriovenous fistula.

Plasma levels of asymmetrical dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide production, correlate with endothelial dysfunction and the development of cardiovascular events in patients with uremia. It is not known whether endothelial dysfunction contributes to the dysfunction of arteriovenous fistulas (AVFs) in hemodialysis patients. Here, we studied the predictive value of baseline plasma ADMA for symptomatic restenosis of an AVF after percutaneous transluminal angioplasty in dialysis patients. We obtained baseline plasma ADMA levels before percutaneous transluminal angioplasty in 100 consecutive patients with dysfunctional AVFs. Patients were followed up clinically for up to 6 mo after angioplasty for recurrent dysfunction. During the 6 mo after angioplasty, 46 patients experienced recurrent dysfunction of their AVF; of these, follow-up fistulography showed restenosis at the same location in 41, new stenosis at different locations in two, and no significant stenosis in three patients. Up to 60% of the patients with high levels of ADMA (>0.910 microM) had target lesion restenosis compared with 25% of those with low levels (<0.910 microM; P < 0.001). In multivariate analysis, plasma ADMA independently nearly tripled the risk for recurrent symptomatic stenosis of an AVF after percutaneous transluminal angioplasty (hazard ratio 2.65; 95% confidence interval 1.33 to 5.28). These results suggest a role for ADMA in the progression of symptomatic restenoses of AVFs after percutaneous transluminal angioplasty and call for preventive strategies that target ADMA and/or endothelial dysfunction to decrease the risk for AVF restenosis.

Comparison of cutting balloon versus high-pressure balloon angioplasty for resistant venous stenoses of native hemodialysis fistulas.

PURPOSE: To compare the technical success, safety, and patency of cutting balloon angioplasty versus high-pressure balloon angioplasty in the treatment of resistant native hemodialysis fistula stenoses. MATERIALS AND METHODS: The authors retrospectively reviewed 1,220 percutaneous transluminal angioplasty procedures performed to treat dysfunctional native hemodialysis fistulas. Seventy patients with stenoses resistant to conventional balloon angioplasty (up to 24 atm) were included in this study: 35 patients underwent cutting balloon angioplasty from September 2003 through February 2005, and 35 patients underwent high-pressure balloon angioplasty from March 2005 through April 2006. Evaluation included technical success, complications, and postintervention patency rates up to 6 months. RESULTS: The technical success rates were similar between the cutting balloon (100%) and high-pressure balloon (97.1%) groups. After cutting balloon angioplasty, the primary lesion patency rates were 100% (35/35), 88.6% (31/35), and 71.4% (25/35) at 1 month, 3 months, and 6 months, respectively. After high-pressure balloon angioplasty, the primary lesion patency rates were 97.1% (34/35), 62.9% (22/35), and 42.9% (15/35) respectively. The primary lesion patency rates at 3 and 6 months were significantly better with cutting balloon angioplasty than with high-pressure balloon angioplasty (P = .018 and .009, respectively). There were no device-related complications in the cutting balloon group. Six device-related extravasations occurred in the high-pressure balloon group. CONCLUSIONS: The results of this retrospective study suggest that, for resistant stenoses in native hemodialysis fistulas, both high-pressure balloon and cutting balloon angioplasty are effective; however, cutting balloon angioplasty seems to provide more long-standing primary patency at 6-month follow-up.