Novel technique of percutaneous bypass in a brachiocephalic arteriovenous fistula with cephalic arch occlusion: A case report.

OBJECTIVE: Arteriovenous fistulas are a principal mainstay of long-term dialysis access for patients with end stage renal failure. However, the patency of arteriovenous fistulas is limited, often requiring percutaneous transluminal angioplasty as a salvage procedure. We report a case of percutaneous method of arteriovenous fistula salvage. METHODS: A gentleman with brachiocephalic arteriovenous fistula created in 2015 was admitted under us for dialysis access issue. His fistula history was notable for recurrent and refractory venous outflow stenosis of the cephalic vein and the cephalic arch with multiple previous interventions. Ultrasound showed cephalic arch occlusion with high venous pressures. He underwent left brachicephalic fistula percutaneous bypass. We describe the percutaneous creation of a brachial-subclavian arteriovenous fistula via a bypass graft from a worsening brachial-cephalic fistula with cephalic arch occlusion that is not amendable to angioplasty. RESULTS: Final angiogram showed smooth flow to central vein. He is 2 years post procedure, and his fistula remained patent with no interventions required. CONCLUSION: Percutaneously created jump bypass grafts can reliably produce sustained long-term patency.

Restoring Sesamoid Position in Scarf Osteotomy: A Learning Curve.

Incomplete reduction of the sesamoid is a known risk factor for recurrence of the deformity after scarf osteotomy for correction of hallux valgus. The purpose of the present study was to determine whether a learning curve exists for successfully restoring the sesamoid position in scarf osteotomy. We reviewed 71 consecutive cases (71 feet) of scarf osteotomy performed on female patients during a 2.5-year period by the same surgeon. The cases were divided into 3 groups according to the date of surgery, with the first 24 cases assigned to group 1, the next 24 to group 2, and the last 23 to group 3. We compared the median sesamoid position of the 3 groups at 6 weeks postoperatively and patient reported satisfaction at 6 months postoperatively. The sesamoid position ranged from 1 to 7, using the Hardy and Clapham classification system. The median sesamoid position for all patients had improved from 7 preoperatively to 2 postoperatively. The postoperative sesamoid position was significantly better for the second and third groups than for the first (p < .05), and 92% of the patients were satisfied with the procedure. We have concluded that a learning curve to optimally restoring the position of the sesamoid in scarf osteotomy is present and that this has a direct effect on reducing the risk of recurrence of the deformity.