A rare case of spontaneous carotid sheath abscess presenting as a painful neck mass.

Infections of the carotid arteries and sheath without any underlying etiology are extremely uncommon. In this article, we report the successful open repair of a right carotid sheath abscess in a 71-year-old woman with multiple comorbidities. The repair consisted of excision of the affected carotid segment and reconstruction by interposition of a reversed great saphenous vein graft. Postoperative Doppler ultrasound examination showed patent right carotid artery, and the patient demonstrated no recurrence postoperatively. This case suggests that, although rare, spontaneous carotid sheath remains a possible cause of neck mass, warranting high suspicion index for optimal treatment in a timely manner to avoid further complications.

Successful mechanical thrombectomy of an intermediate-high risk acute pulmonary embolism using the Alpha Vac aspiration catheter.

Large-bore aspiration thrombectomy is emerging as a promising alternative for thrombus removal in acute pulmonary embolism (PE). In this article, we report a successful case with the newly approved AlphaVac F1885 device in a 76-year-old patient presenting with an intermediate- to high-risk acute PE. Preoperative imaging demonstrated bilateral PE with a modified miller index of 30 and an right ventricle-to-left ventricle ratio of 2.1. Mechanical thrombectomy was performed under local anesthesia with mild sedation. The pulmonary artery pressures decreased from 85/27 to 46/13 immediately after thrombectomy. The postoperative course was notable for marked symptom improvement and repeat imaging showed a 63% decrease in clot burden with a decrease in right ventricle-to-left ventricle ratio to 1.3.

Open thrombectomy, patch angioplasty, and retrograde stenting for isolated superior mesenteric artery dissection.

Isolated superior mesenteric artery dissection without aortic involvement is an exceptionally rare event. Nonoperative management remains the first-line therapy. However, surgical interventions can be indicated in the event of bowel ischemia. In the present report, we describe a case of complicated isolated superior mesenteric artery dissection treated with a hybrid approach.

Midterm outcomes of arteriovenous fistula aneurysm repair with simultaneous inflow revision or outflow tract revascularization.

OBJECTIVE: The aim of this study was to investigate the 2-year outcomes of extensive revisions aimed at simultaneously addressing arteriovenous fistula (AVF) aneurysms, outflow stenosis, and/or high flow volumes. METHODS: This was a retrospective cohort study in a tertiary referral center. The study population comprised hemodialysis patients with aneurysmal AVFs requiring revision. Subjects were eligible if they were ≥18 years of age and had aneurysm repair associated with inflow revision or treatment of outflow lesions. Patients were followed-up for a minimum of 2 years, and the primary outcome measure was cumulative patency. RESULTS: Our cohort comprised 93 patients with a mean age of 56 ± 12 years. The most frequent access type was brachiocephalic fistula (61%), and the median access age at the time of revision was 66 months (interquartile range, 46-93 months). The median access flow volume was 2300 ml/min (interquartile range, 1281-2900), and 31 subjects (33%) presented aneurysms associated with both high flow and venous obstruction. Aneurysm repair consisted of aneurysmorraphy in the overwhelming majority (95%). Inflow revision was performed in a total of 49 cases (53%), and outflow tract obstruction was treated in 71 patients (72%), with 27 patients (29%) receiving a simultaneous 3-component revision. At 2 years, the primary, primary assisted, and cumulative patencies were 60% ± 1%, 91% ± 3%, and 94% ± 3%, respectively. The most frequent indication for first-time reinterventions was outflow tract stenosis (24%). Aneurysm recurrence was observed in 13 subjects (14%) during the entire follow-up and was responsible for reinterventions in seven of them (8%), with a 2-year freedom from aneurysm-related reintervention rate of 95% ± 3%. CONCLUSIONS: Extensive AVF revision with simultaneous aneurysm repair, inflow revision, and outflow tract revascularization is feasible, safe, and associated with favorable 2-year patency rates.

Cardiovascular collapse during mechanical thrombectomy for acute pulmonary embolism and the role of extracorporeal membrane oxygenation in patient rescue.

BACKGROUND: Driven by the ability to avoid thrombolytics and provide a one stop procedure with immediate hemodynamic improvement, there has been a dramatic increase in the use of mechanical thrombectomy (MT) devices for the treatment of intermediate-to-high risk pulmonary embolism (PE). This study investigated the incidence and outcomes of cardiovascular collapse during MT procedures and demonstrates the role of extracorporeal membrane oxygenation (ECMO) in salvaging patients. METHODS: This single-center retrospective review included patients with PE undergoing MT with the FlowTriever device between 2017 and 2022. Patients presenting periprocedural cardiac arrest were identified and their perioperative characteristics and postoperative outcomes were evaluated. RESULTS: A total of 151 patients with a mean age of 64 ± 14 years who presented with intermediate-to-high risk PE received LBAT procedures during the study period. The simplified PE severity score was ≥1 in 83% of cases and the average RV/LV ratio was 1.6 ± 0.5, with and elevated troponin in 84%. Technical success was achieved in 98.7% and a significant decrease in pulmonary artery systolic pressure (PASP) was observed (37 mm Hg vs 56 mm Hg; P < .0001). Intraoperative cardiac arrest occurred in nine patients (6%). These patients were more likely to present PASP of ≥70 mm Hg (84% vs 14%; P < .001), were more hypotensive upon admission (systolic of 94 ± 14 mm Hg vs 119 ± 23 mm Hg; P = .004), presented lower oxygen saturation levels (87 ± 6% vs 92 ± 6%; P = .023) and were more likely to present with a history of recent surgery (67% vs 18%; P = .004). Four patients were rescued successfully with ECMO and their residual PE was subsequently removed before discharge by surgical embolectomy in two of the four cases and repeat MT in the other two. All five patients (3%) who did not receive ECMO support expired intraoperatively. The overall 30-day mortality was 8% with no death occurring in patients who were salvaged with ECMO. CONCLUSIONS: Large-bore aspiration thrombectomy for acute PE is associated with favorable technical outcomes, but the concern for acute cardiac decompensation is non-negligible in patients presenting with high-risk features and a PASP of ≥70 mm Hg. ECMO can help to salvage some of these patients and should be considered in the treatment algorithms of patients deemed at high risk.

Surgical creation of upper extremity arteriovenous fistula and grafts: a narrative review.

Background and Objective: Surgical creation of arteriovenous fistulas (AVF) and grafts (AVG) continues to be the mainstay access for hemodialysis (HD). Avoidance of dependence on dialysis catheters continues to be a worldwide mission in dialysis access. Importantly, there is no one-size-fits-all approach to hemodialysis access and each patient should undergo access creation that is patient-centered. The aim of this paper is to review the literature, current guidelines, and discuss the common types of upper extremity hemodialysis access and their reported outcomes. We will also share our institutional experience regarding the surgical creation of upper extremity hemodialysis access. Methods: The literature review incorporates twenty-seven relevant articles from 1997 to present and one case report series from 1966. Sources were gathered from electronic databases including PubMed, EMBASE, Medline, and Google Scholar. Only articles written in the English language were considered and study designs varied from current clinical guidelines, systematic and meta-analyses, randomized controlled trials, observational studies, and two main vascular surgery textbooks. Key Content and Findings: This review exclusively focuses on the surgical creation of upper extremity hemodialysis accesses. Creating a graft versus fistula ultimately is decided by the existing anatomy, and is centered around the need of the patient. Preoperatively, the patient should undergo a thorough history and physical exam, with special attention to any previous central venous access, as well as, delineating the vascular anatomy with ultrasound imaging. The major tenets of access creation are choosing the most distal site of the non-dominant upper extremity whenever possible; and ideally creation of an autogenous access is preferred over a prosthetic graft. Described in this review are multiple surgical approaches for upper extremity hemodialysis access creation and associated institutional practices performed by the surgeon author. In the postoperative period, follow up care and surveillance are imperative to preserve a functioning access. Conclusions: The most recent guidelines regarding hemodialysis access still favor arteriovenous fistula as the primary goal for patients with suitable anatomy. Preoperative evaluation including patient education, intraoperative ultrasound assessment, meticulous technique, and careful postoperative management are all paramount for successful access surgery. Dialysis access remains quite challenging, but with diligence the great majority of patients can be dialyzed without catheter dependence.

Dynamic Computed Tomography Angiography is More Accurate in Diagnosing Endoleaks than Standard Triphasic Computed Tomography Angiography and Enables Targeted Embolization.

BACKGROUND: The primary objective was to compare the accuracy of dynamic computed tomography (CT) angiography (d-CTA) with standardized triphasic contrast enhanced CT angiography (t-CTA) in diagnosing endoleak type after endovascular aortic repair (EVAR) using digital subtraction angiography (DSA) as reference standard. The secondary objective was to study the impact of d-CTA on image fusion-guided endoleak embolization. METHODS: A retrospective review of patients who underwent d-CTA imaging after EVAR between March 2019 and July 2021 was performed. Deidentified images were independently reviewed by two-two blinded readers to document endoleak type and target vessels. An impact of d-CTA-guided embolization was evaluated by a number of planning angiograms, radiation exposure, and accuracy of target vessel overlay. RESULTS: During the study period, 52 patients underwent d-CTA and 19 had all 3 modalities available for analysis. DSA imaging confirmed 4 (21.0%) type-I, 14 (73.7%) type-II, and 1 (5.3%) type-III endoleak. Findings from d-CTA matched with DSA in 19/19 cases (100%), whereas t-CTA matched in 14/19 cases (73.7%). In type-II endoleaks, the number of target vessels identified by d-CTA, t-CTA, and DSA were 23, 17, and 16, respectively. Mean dose-length product from d-CTA and t-CTA was 1,445 ± 551 and 1,612 ± 530 mGy × cm (P = 0.26). Nine patients underwent d-CTA-guided type-II endoleak embolization, using a median of 1 (range: 1-4) planning angiogram before embolization using 21.6 (± 8.7)% of total procedural radiation dose. Target vessel overlay was accurate in 9/9 (100%) cases. CONCLUSIONS: Dynamic, time-resolved CTA is more accurate compared to standardized triphasic contrast enhanced CTA in diagnosing endoleak type after EVAR. In type-II endoleak, d-CTA better identified target vessels and enabled safe, targeted embolization.

Advanced intraoperative imaging guidance for inside-out central venous recanalization using a novel catheter access system.

BACKGROUND: The novel Surfacer Inside-Out recanalization technique facilitates right-sided central venous access in occluded vessels but carries a risk of arterial and pleural injuries. This article demonstrates how an advanced intraoperative imaging protocol can help to avoid these potential complications. METHODS: This retrospective review included patients undergoing the Surfacer Inside-Out central venous recanalization procedure between December 2017 and October 2021. The study sample comprised patients included in the SAVE-US trial at our site as well as patients treated after US Food and Drug Administration approval of the device. All procedures were performed using intraoperative cone-beam computed tomography (CBCT) angiography to map out the trajectory of the device through the mediastinum and supraclavicular space with fusion imaging for guidance. Procedures were aborted if CBCT findings predicted injury to arterial or respiratory structures. The intraoperative coronal and sagittal orientation of the device was compared to preoperatively predicted trajectory. RESULTS: A total of 17 procedures were performed in 16 patients with end-stage renal disease and a mean age of 61 ± 11 years. Most patients presented a type 3 central venous occlusion (9/15). Successful recanalization was achieved in 14 of the 17 cases (82.4%) with no intraoperative complications. The procedure had to be aborted in 3 of the 17 cases based on intraoperative CBCT findings, which projected the device to perforate the right pleural space in one patient, the trachea and right subclavian artery in another, and the innominate artery in the third patient. The total radiation dose per procedure was 753 ± 346 mGy and the mean procedural time was 101.6 ± 29.7 minutes. A median of 2 (range, 1-5) intraoperative CBCT scans were performed per patient and accounted for 70% of the total radiation dose. Statistical analysis showed intraoperative CBCT findings to differ significantly from preoperative predicted values. CONCLUSIONS: The nonsteerable and penetrating nature of the Surfacer device may lead to serious complications when performed under fluoroscopic guidance alone. Intraoperative CBCT with fusion overlay enhances the safety and effective use of this device and inside out crossing technique.

Evaluation of a Novel System for RFID Intraoperative Cardiovascular Analytics.

Objective: To evaluate a novel technology for real time tracking of RF-Identified (RFID) surgical tools (Biotic System), providing intraoperative data analytics during simulated cardiovascular procedures. Ineffective asset management in the Operating Room (OR) leads to inefficient utilization of resources and contributes to prolonged operative times and increased costs. Analysis of captured data can assist in quantifying instrument utilization, procedure flow, performance and prevention of retained instruments. Methods & Results: Five surgeons performed thirteen simulated surgical cases on three human cadavers. Procedures included (i) two abdominal aortic aneurysm (AAA) repairs, (ii) three carotid endarterectomies (CE), (iii) two femoropopliteal (fem-pop) bypasses, (iv) thoracic aortic aneurysm repair, (v) coronary artery bypass graft, (vi) aortic valve replacement, (vii) ascending aortic aneurysm repair, (viii) heart transplants, and (ix) mitral valve replacement. For each case an average of 139 surgical instruments were RFID-tagged and tracked intraoperatively. Data was captured and analyzed retrospectively. Of the 139 instruments tracked across each of the 13 cases, 55 instruments (39.5%) were actually used, demonstrating a high level of redundancy. For repeat cases (i.e. CE/AAA/fem-pop): (i) average instrument usage was 41 ± 3.6 (8.8% variation) for CE (n=3); (ii) average instrument usage was 69 ± 4.0 (5.8% variation) for AAA (n=2); and (iii) average instrument usage was 48 ± 2.5 (5.3% variation) for fem- pop (n=2). Results also showed a reduction in end-of-procedure instrument counting times of 58-87%. Conclusions: We report on a method for collecting intraoperative data analytics regarding instrument usage via RFID technology. This system will help refine instrument selection, quantitate instrument utilization and prevent inadvertent retention in a patient. This should help increase efficiency in packaging and sterilization and let surgeons make objective decisions in the composition of surgical trays. Clinical and Translational Impact Statement-Intraoperative analytics of surgical tools and associated equipment may ultimately lead to safer more efficient surgeries that increase patient outcomes while decreasing the cost of care.

Vasculink iPhone Application and Risk Prediction Model for Groin Complication in Vascular Surgery.

BACKGROUND: Postoperative groin complication is a common cause of morbidity in vascular surgery. Prophylactic wound adjuncts addressing this issue have been shown to reduce complications in high-risk patients, but their widespread implementation is limited by their high cost. This study introduces a risk prediction model for patients at a high risk for groin complication which can be accessed through the iPhone application, Vasculink. METHODS: A literature search identified risk prediction models for groin complication in vascular surgery. Odds ratios of risk factors that were present in at least 2 published models were calculated with a pooled effect size. The weighted risk for each factor was used to create our model and a cutoff point defining high risk patients was chosen. The initial model was assessed and validated using a split-sample methodology on a cohort identified via a retrospective chart review of all patients undergoing open vascular surgery at our institution between 2017 and 2020. Model performance was assessed using the C-statistic. RESULTS: Risk factors included in our model were female gender, body mass index ≥28 kg/m2, ever-smoker, reoperation, use of prosthetic, emergency, and end-stage renal disease. Of 216 patients, 131 were at a high risk. The overall groin complication rate was 43%, and specific complication rates were 27% infection, 14.8% seroma, and 6.9% hematoma. Our model's sensitivity and specificity were 92.47% and 60.98%, respectively. The C-statistic is 0.768. CONCLUSIONS: By using risk factors identified in the literature we have been able to establish a highly sensitive risk prediction model for groin complication following open vascular surgery. By incorporating our model into an iPhone application, Vasculink, we hope to facilitate preoperative decision making regarding the use of prophylactic wound adjuncts.

A systematic review of management of superficial venous reflux in the setting of deep venous obstruction.

BACKGROUND: Because of the fear of obliterating the collateral outflow path and thus worsening venous hypertension, many physicians believe that deep venous obstruction (DVO) is a contraindication for the treatment of superficial venous reflux (SVR). In the present review, we have described the available clinical data for this important group of patients. METHODS: A literature search was performed of PubMed, Web of Science, and Google Scholar to identify clinical research studies reported between 1991 and 2021 that had evaluated the concomitant management of SVR and DVO. Studies were excluded if they had included fewer than five patients, had not specified the interventions used to treat SVR, or had no follow-up data available. All the studies included were observational, and their quality was assessed using the Newcastle-Ottawa scale. RESULTS: Ten retrospective cohort studies were included, with a total of 2476 limbs in 2428 patients, with concurrent SVR and DVO or a known history of deep vein thrombosis treated in 944 limbs. Of the 10 studies, 8 were comparative. The level of DVO was suprainguinal, when specified, in most cases. The mean age range was 42 to 65 years, 1432 patients (59%) were women, and advanced chronic venous disease (ie, CEAP [clinical, etiologic, anatomic, pathophysiologic] class 4-6) was present in 614 limbs (70%), with two studies reporting uniquely on C6 patients. Of the 944 limbs treated for concomitant SVR and DVO, a combination of saphenous vein ablative procedures and deep venous stenting was performed in 483 limbs (51.2%), saphenous vein ablative procedures alone in 293 limbs (31%), and deep venous stenting alone in 168 (17.8%). Of the five studies comparing the different treatment strategies to treat concurrent SVR and DVO, four reported better outcomes after a combination of deep venous stenting and saphenous vein ablation compared with ablation alone. Studies comparing the outcomes of saphenous ablation for patients with reflux alone vs patients with concurrent reflux and DVO did not find any significant differences in clinical improvement and postoperative complication rates. CONCLUSIONS: The current evidence is weak owing to the limited number of studies and small sample size but suggests that ablation of SVR is safe for patients with concurrent DVO. Patients with advanced venous disease and iliac vein obstruction had better results when SVR ablation was combined with treatment of iliac vein obstruction. Additional contemporary studies are needed to confirm the safety and specifically investigate the efficacy of SVR ablation in relieving the symptoms of patients with concurrent infrainguinal obstruction.

Novel technique of stent retrieval after migration to the right heart.

Central venous obstruction in the symptomatic patient is often treated with endovascular stenting. A rare, but serious, complication of this treatment is migration of the stent from the original site of deployment. Treatment of this complication requires either open or endovascular retrieval of the displaced stent. To treat a rare, but potentially devastating, complication, we have presented an effective endovascular method for migrated stent retrieval using a combination of a large bore sheath, balloon, and snare.

Open bilateral common femoral and popliteal vein aneurysm repair.

Although venous aneurysms are rare, typically asymptomatic, and most commonly found incidentally on imaging studies, patients with this pathology can develop pulmonary emboli owing to these aneurysms acting as a nidus for thrombus formation. There is no clear consensus regarding conservative management with anticoagulation vs operative intervention as the best treatment of deep venous aneurysms. We report the clinical course and surgical treatment of a patient presenting with both bilateral common femoral vein and bilateral popliteal venous aneurysms who had a known history of prior symptomatic pulmonary emboli.

PDGFRA in vascular adventitial MSCs promotes neointima formation in arteriovenous fistula in chronic kidney disease.

Chronic kidney disease (CKD) induces the failure of arteriovenous fistulas (AVFs) and promotes the differentiation of vascular adventitial GLI1-positive mesenchymal stem cells (GMCs). However, the roles of GMCs in forming neointima in AVFs remain unknown. GMCs isolated from CKD mice showed increased potential capacity of differentiation into myofibroblast-like cells. Increased activation of expression of PDGFRA and hedgehog (HH) signaling were detected in adventitial cells of AVFs from patients with end-stage kidney disease and CKD mice. PDGFRA was translocated and accumulated in early endosome when sonic hedgehog was overexpressed. In endosome, PDGFRA-mediated activation of TGFB1/SMAD signaling promoted the differentiation of GMCs into myofibroblasts, extracellular matrix deposition, and vascular fibrosis. These responses resulted in neointima formation and AVF failure. KO of Pdgfra or inhibition of HH signaling in GMCs suppressed the differentiation of GMCs into myofibroblasts. In vivo, specific KO of Pdgfra inhibited GMC activation and vascular fibrosis, resulting in suppression of neointima formation and improvement of AVF patency despite CKD. Our findings could yield strategies for maintaining AVF functions.

Medial claviculectomy for the treatment of recalcitrant central venous stenosis of hemodialysis patients.

OBJECTIVE: Outflow tract stenosis is the leading cause of hemodialysis access loss. Many lesions are highly resistant to endovascular treatment, necessitating open surgical intervention. We present our experience using medial claviculectomy for treatment of recalcitrant lesions at the thoracic outlet. METHODS: We retrospectively reviewed patients who underwent medial claviculectomy for dialysis-associated venous thoracic outlet syndrome at our institution between February 2013 and February 2018. Data collection included demographics, past medical history, access history, subsequent procedures, preoperative and postoperative brachial volume flows, and access use. RESULTS: We performed 25 medial claviculectomies in 25 patients with central venous stenosis. Four patients underwent concomitant central venous bypass and were excluded from this study. Twelve accesses were created at our institution; of these, the average access age was 41.6 months (±26.7 months). All patients previously underwent multiple angioplasty attempts to treat outflow stenosis and continued to have residual symptoms and poor fistula function. Medial claviculectomy with venolysis and angioplasty were performed to treat residual outflow stenosis at the level of the subclavian vein. Twenty-one patients had residual stenosis requiring angioplasty. Six patients had subclavian rupture requiring stent graft placement. All patients reported symptom improvement and immediate use of the fistula after medial claviculectomy. Nineteen (76%) patients reported complete resolution of symptoms after the procedure. Ultimately, eight (32%) ipsilateral arteriovenous accesses were lost, and six (24%) patients died in follow-up with patent, functional fistulas. Median length of follow-up was 17 months (interquartile range, 5-28 months). The 18-month primary patency and secondary patency with regard to subclavian vein interventions were 28% (95% confidence interval, 13.8%-56.1%) and 84% (95% confidence interval, 69.7%-100%), respectively. One patient required ligation for high-output cardiac failure. One patient had contralateral brachiocephalic jailing, which was corrected with kissing brachiocephalic stents. CONCLUSIONS: Medial claviculectomy is an effective treatment of recalcitrant central venous stenosis of the thoracic outlet. Balloon angioplasty or stent or stent graft placement is often necessary after extrinsic compression is alleviated and demonstrates acceptable secondary patency rates.

Notch signaling in bone marrow-derived FSP-1 cells initiates neointima formation in arteriovenous fistulas.

Neointima formation is a major contributor to arteriovenous fistula (AVF) failure. We have previously shown that activation of the Notch signaling pathway contributes to neointima formation by promoting the migration of vascular smooth muscle cells (VSMCs) into the venous anastomosis. In the current study we investigated the mechanisms underlying the dedifferentiation and migration of VSMCs, and in particular the role of bone marrow-derived fibroblast specific protein 1 (FSP-1)+ cells, another cell type found in models of vascular injury. Using VSMC-specific reporter mice, we found that most of the VSMCs participating in AVF neointima formation originated from dedifferentiated VSMCs. We also observed infiltration of bone marrow-derived FSP-1+ cells into the arterial anastomosis where they could interact with VSMCs. In vitro, conditioned media from FSP-1+ cells stimulated VSMC proliferation and phenotype switching. Activated Notch signaling transformed FSP-1+ cells into type I macrophages and stimulated secretion of cytokines and growth factors. Pretreatment with a Notch inhibitor or knockout of the canonical downstream factor RBP-Jκ in bone marrow-derived FSP1+ cells decreased FSP1+ cell infiltration into murine AVFs, attenuating VSMC dedifferentiation and neointima formation. Our results suggest that targeting Notch signaling could provide a new therapeutic strategy to improve AVF patency.

A randomized trial of vonapanitase (PATENCY-1) to promote radiocephalic fistula patency and use for hemodialysis.

OBJECTIVE: Arteriovenous fistulas created in patients with chronic kidney disease often lose patency and fail to become usable. This prospective trial evaluated the efficacy of vonapanitase, a recombinant human elastase, in promoting radiocephalic fistula patency and use for hemodialysis. METHODS: PATENCY-1 was a double-blind, placebo-controlled trial that enrolled 349 patients on or approaching hemodialysis and being evaluated for radiocephalic arteriovenous fistula creation. Of these, 313 were randomized and 311 treated. Patients were assigned to vonapanitase (n = 210) or placebo (n = 103). The study drug solution was applied topically to the artery and vein for 10 minutes immediately after fistula creation. The primary and secondary end points were primary patency (time to first thrombosis or corrective procedure) and secondary patency (time to abandonment). Tertiary end points included use of the fistula for hemodialysis, fistula maturation by ultrasound, and procedure rates. RESULTS: The Kaplan-Meier estimates of 12-month primary patency were 42% (95% confidence interval [CI], 35-49) and 31% (95% CI, 21-42) for vonapanitase and placebo (P = .25). The Kaplan-Meier estimates of 12-month secondary patency were 74% (95% CI, 68-80) and 61% (95% CI, 51-71) for vonapanitase and placebo (P = .048). The proportions of vonapanitase and placebo patients were 39% and 25% (P = .035) with unassisted use for hemodialysis and 64% and 44% (P = .006) with unassisted plus assisted use. CONCLUSIONS: Vonapanitase treatment did not significantly improve primary patency but was associated with increased secondary patency and use for hemodialysis. Further research is needed to evaluate these end points.

Axillary Artery to Right Atrial Graft for Dialysis Access Using an Autologous Femoropopliteal Vein.

Patients with prolonged history of central venous catheters can develop central venous occlusion. We report the creation of an axillary artery to right atrial graft using the femoropopliteal vein (FPV) for dialysis access in a patient with end-stage renal disease on hemodialysis with history of central venous occlusion. The patient had previously developed steal syndrome following a right brachial artery to right atrial polytetrafluoroethylene graft requiring revision to a left axillary artery inflow which subsequently thrombosed. This is the first report of using an autologous FPV conduit to the right atrium for dialysis.

Superior Vena Cava Reconstruction Using Femoropopliteal Vein as a Panel Graft.

There has been an increase in superior vena cava (SVC) syndrome secondary to the growing use of indwelling catheters and pacemaker wire insertions. These 2 factors can account up to 74% cases of benign SVC syndrome. Endovascular therapy is considered the first line of treatment. Surgery is an excellent option and is generally reserved for SVC syndrome not amenable to traditional endovascular procedures. We report a case of central venous reconstruction including an SVC reconstruction using the femoropopliteal vein as a panel graft in a patient with SVC syndrome due to pacemaker wires who failed multiple endovascular interventions.