Veno-Venous Surgical Bypass for Central Vein Occlusion in a Child: The First in the Literature.

Introduction: During the past two decades, the incidence of chronic kidney disease (CKD) in children worldwide has steadily increased and, even in children, native arteriovenous fistula (AVF) remains the access of choice. Nevertheless, maintaining a well functioning fistula is limited by central venous occlusion due to the widespread use of central venous access devices before AVF creation. Report: A 10 year old girl with end stage renal failure dialysing through a left brachiocephalic fistula presented with left upper limb and facial swelling. She had previously exhausted the option of ambulatory peritoneal dialysis for recurrent peritonitis. A central venogram showed occlusion at the left subclavian vein, which was not amenable for angioplasty through either an upper limb or femoral approach. Given the precious fistula with concomitant worsening venous hypertension, an ipsilateral axillary vein to external iliac vein bypass was performed. Subsequently, her venous hypertension was significantly resolved. This report is the first in English literature on this surgical bypass in a child with central venous occlusion. Discussion: Central venous stenosis or occlusion rates are rising due to extensive central venous catheter use in the paediatric population with end stage renal failure. In this report, an ipsilateral axillary vein to external iliac vein bypass was used successfully as a safe temporary option to maintain AVF. Ensuring a high flow fistula pre-operatively and continued antiplatelet post-operatively will allow longer patency of the graft.

Single-stage inferior vena caval intravenous leiomyomatosis excision.

Intravascular tumour extension can occur in many different types of cancer. Those with the highest tendency include renal cell carcinoma, adrenal cortical carcinoma and hepatocellular carcinoma. Inferior vena cava (IVC) tumour thrombus in gynaecological malignancy is rarely reported. We present a report on a female patient with extensive IVC tumour thrombus (intravenous leiomyomatosis) with concurrent intrauterine leiomyomatosis. She underwent a single-stage procedure, involving laparotomy and a sternotomy to remove her pelvic tumour, as well as the intracaval and intracardiac thrombus. The clinical presentation and management of this rare tumour will be detailed in this case report.

Malaysian clinical practice guidelines for management of diabetic foot: A synopsis for the primary care physician.

Diabetic foot requires careful attention and coordinated management by a dedicated team. Screening, prevention, adequate assessment, and appropriate referral are crucial to prevent complications. Multimodal treatment and rehabilitation are recommended to ensure a better quality of life and reduction of amputation rate in people with diabetic foot.

Transposed Basilic Vein Fistula: A Credible Option.

Objective: Native fistula creation for hemodialysis in patients who have exhausted all their superficial veins presents a challenge to vascular practice. We review our experience in transposed basilic vein fistula (BVT) creation and its usage for hemodialysis. Materials and Methods: We analyzed the hospital operative registry from January 2009 till June 2012 to identify the total number of BVT created in our center. Medical records of all patients were traced, and patients were interviewed using a standard proforma. In our center, BVT is performed as a two-stage procedure. All patients were routinely assessed with duplex scan preoperatively and postoperatively. Results: Two hundred thirty-nine patients were recruited in the study. Of these patients, 50.6% were male and 49.4% were female. Mean age was 53.4 years. Of these patients, 81.2% had history of other previous fistula creation. Risk factors profile includes diabetes mellitus in 59.8%, hypertension in 86.2%, and smoking in 13.0%. Of these patients, 84.5% had no operative complication. Commonest complication was wound infection, 6.3%, followed by hemorrhage or hemotoma required surgical intervention, 5.9%, and pseudoaneurysm, 1.3%. Primary and secondary patencies were at 84.2% and 86.1% at 1 year and 67.7% and 70.5% at 3 years, respectively. Conclusion: BVT is a credible option for challenging patients with absence of superficial veins for native fistula creation with good patency and low operative complication rate. Preoperative ultrasound assessment improves patient selection and outcome of BVT.

The effect of sequential intermittent pneumatic compression of foot and calf on popliteal artery mean systolic blood flow in patients with intermittent claudication.

OBJECTIVE: To determine the effect of intermittent pneumatic foot and calf compression on popliteal artery mean systolic blood flow in patients with intermittent claudication. The secondary objective was to determine the change in blood flow with posture. METHODS: This was a cross sectional study carried out on claudication patients at the Vascular Laboratory, Department of General Surgery, Kuala Lumpur Hospital, from January 2009 to August 2009. The effect of posture (supine to sitting to standing) and the effect of intermittent pneumatic compression (IPC) of the foot and calf on popliteal artery flow immediately and 10 minutes post compression were studied. RESULTS: Fifteen patients were studied. There was a consistent drop in flow from supine to sitting and to standing in all patients. Immediately after IPC application there was an increase in flow ranging from 29-335% (p<0.05). Increase in flow was reduced but still sustained after 10 minutes with a flow range of 17-113mL/minute with a median of 63mL/minute (p<0.05). CONCLUSION: There is a significant reduction in popliteal artery mean systolic flow from supine to sitting and to the standing position, and popliteal artery flow is significantly increased after application of IPC and even persists after 10 minutes.