Management of depth to achieve timely arteriovenous fistula utilization.

OBJECTIVE: Failure to achieve timely arteriovenous fistulae (AVFs) utilization due to excessive depth (>6 mm) remains an ongoing concern for dialysis access. This study evaluates the outcomes of radiocephalic (RCF) and brachiocephalic (BCF) fistula elevation required for access utilization. METHODS: A retrospective review of all patients undergoing first-time autologous access over 10 years was undertaken. RCF and BCF were analyzed, and cases of initial access failure due to depth alone were selected for study. Primary and staged brachio-basilic AVF were excluded. Outcomes of early thrombosis, line placement, maturation (successful progression to hemodialysis [HD), reintervention, and functional dialysis (continuous HD for 3 consecutive months) were examined. RESULTS: From January 2012 to December 2022, 1733 patients (67% female; mean age, 61 ± 14 years) underwent autologous AVF placement. Of these, 298 patients (17%) had depth-related AVF access issues (BCF, 71% and RCF, 29%). Nineteen percent of these AVFs underwent a primary balloon-assisted maturation (BAM), and 2% had side branch coil embolization before consideration for elevation. The average time to intervention for depth was 11 ± 4 weeks after primary creation. During elevation, side branch ligation occurred in 38% of cases, and 15% underwent intraoperative BAM, The pre-elevation depth was 8.2 ± 3.1 mm, and the mean post-elevation depth was 4.7 ± 2.9 mm (P = .002). Early thrombosis (<18 days) occurred in 4% of cases. There was no mortality, and the 30-day major adverse cardiac event rate was 2%, with a 30-day morbidity of 5%, which was driven by wound issues. Six percent of the AVFs underwent follow-up BAM within 3 months. Mean maturation of the AVFs was 74% ± 3% vs 72% ± 3% (P = .58) for the elevation vs no-elevation groups at 24 weeks, respectively. However, there was an increase in tunneled central line placement in pre-emptive fistula patients due to the delay in maturation (elevation, 17% vs no-elevation, 8%; P = .008). There was a mean successful access time of 6 ± 3 weeks after elevation (16 ± 4 weeks after access creation). There was a median of 2.4 secondary interventions per year after elevation compared with a median of 2.7 secondary interventions per year without elevation. Mean access functionality was 68% ± 8% vs 75% ± 8% at 3 years for the elevation vs no-elevation groups, respectively (P = .25). CONCLUSIONS: Elevation of deep BCF and RCF occurs late after placement but can be successfully achieved with low morbidity and satisfactory long-term functionality. It results in an increase in tunneled central line placement in pre-emptive fistula patients. Elevation is a valuable adjunct to AVF maturation and enhances an autologous access policy.

Resection and a rare type of reconstruction of the superior vena cava with the left brachiocephalic vein.

Resection and reconstruction of the superior vena cava (SVC) are required in a selected group of patients with anterior mediastinal tumors and lung neoplasms. We present the case of a 63-year-old woman who underwent invasive type B2 thymoma resection and a rare type of reconstruction of the superior vena cava using a patch of the left brachiocephalic vein (LBV). The various types of reconstruction of the superior vena cava are discussed.

Complex aortic-arch pseudoaneurysm with aorto-innominate vein fistula in a case of traumatic chest injury.

A patient in his late 30s presented with issues of retrosternal chest pain and palpitations. He had sustained a splinter injury to the left hemithorax a year ago for which he had been managed with a tube thoracostomy. During subsequent evaluations, he was found to have atrial fibrillations and a CT angiography revealed an arch of the aorta pseudoaneurysm with a fistulous communication with the innominate vein, which being a rare condition has no established treatment protocols. Endovascular salvage of the condition required an aortic Ishimaru zone 2 deployment of the thoracic endovascular aortic repair stent graft to provide an adequate landing zone. The elective left subclavian artery revascularisation was obtained by a left carotid artery to left subclavian artery bypass. Post procedure there was complete exclusion of the pseudoaneurysm sac, and the fistulous aorto-venous communication inflow tract. The patient recuperated well and has returned to full active duties.

Successful resection of a primary angiosarcoma of the azygos vein: A case report.

A 63-year-old woman was admitted to our department for the investigation of superior vena cava (SVC) syndrome. Computed tomography revealed an azygos tumor extending into the SVC. Video-assisted thoracic surgery (VATS) was performed to remove the distal end of the azygos vein in the left lateral position, followed by complete resection of the entire tumor under median sternotomy in the supine position. The histological diagnosis was a primary angiosarcoma of the azygos vein. The patient was discharged without any complications and is now alive and tumor-free 24 months after surgery. In addition, contrast-enhanced computed tomography revealed no graft occlusion in the two reconstructed brachiocephalic veins. Thoracoscopic surgery in the lateral position is useful for safe and reliable complete resection of a tumor arising from the azygos vein.

Comparison of supraclavicular brachiocephalic and femoral vein approaches for tunneled dialysis catheter placement in patients with thrombosed internal jugular veins.

INTRODUCTION: There is still debate on the best access route in case of bilateral internal jugular vein thrombosis. We aimed to compare the safety, effectiveness, and outcomes of tunneled dialysis catheter placement via supraclavicular brachiocephalic and femoral vein approaches in patients with bilateral internal jugular vein thrombosis. METHODS: Between January 2018 and December 2021, data of the patients in whom tunneled dialysis catheters were placed via the supraclavicular brachiocephalic vein (n = 42) and femoral vein (n = 57) approaches were extracted. Patient demographics, technical and clinical success rates, complications, and outcomes were noted. The Likert scale was used to assess patient satisfaction. FINDINGS: Forty two (42.4%) patients were men, and the mean age was 61.9 (range, 12-93) years. The technical and clinical success rate was 100% for both groups. No major complication was encountered. The mean follow-up period was 497.5 (range, 32-1698) catheter days. Thirty-day patency was similar for the brachiocephalic vein and femoral vein group (40 [95.2%] vs. 55 [96.5%], p = 0.754). Also, primary and cumulative patency rates were comparable (p = 0.158; p = 0.660). The infection rate was 2.6 and 4.1 per 1000 catheter days for the brachiocephalic vein and femoral vein group. The infection-free survival was significantly higher in the brachiocephalic vein group (71.9% vs. 35.3% at 12 months, p < 0.001). Patient satisfaction was higher in the brachiocephalic vein group (median satisfaction, 5 vs. 4, p < 0.001). DISCUSSION: Both supraclavicular brachiocephalic vein and femoral vein approaches have high technical and clinical success with comparable patency rates. However, low infection rate and high patient satisfaction make the supraclavicular brachiocephalic vein approach a reasonable alternative before proceeding to the femoral vein access.

Tetralogy of Fallot with an Anomalous Course of the Brachiocephalic Vein.

CLINICAL DATA: Infant, 11-month-old, male, diagnosis of Tetralogy of Fallot with retrotracheoesophageal course of the brachiocephalic vein. Usual findings of Tetralogy of Fallot on physical examination. Technical description: Chest radiography showed slightly reduced pulmonary vascular markings and no cardiomegaly. Normal preoperative electrocardiogram with postoperative right bundle branch block. Usual findings of Tetralogy of Fallot on echocardiogram. Postoperative computed tomography angiography confirmed left brachiocephalic vein with anomalous retrotracheoesophageal course, configuring a U-shaped garland vein, in addition to postoperative findings of total correction of Tetralogy of Fallot. OPERATION: Complete surgical repair was performed with pulmonary valve commissurotomy and placement of bovine pericardial patch to solve right ventricular outflow tract obstruction, pulmonary trunk enlargement, and ventricular septal defect closure. COMMENTS: Systemic venous drainage may show variations in patients with Tetralogy of Fallot. These abnormalities are usually of little clinical relevance, as they are asymptomatic. We presented a rare case of retrotracheoesophageal course of an anomalous left brachiocephalic vein with intraoperative diagnosis, confirmed by imaging during postoperative follow-up, without compromising clinical management or surgical approach.

Most complex brachiocephalic vein occlusion in hemodialysis patients can be treated with simple endovascular techniques in an office-based angiosuite.

OBJECTIVE: Brachiocephalic vein (BCV) obstruction can cause dialysis access dysfunction and failure. Central vein stenosis involving the BCV may require advanced endovascular procedures. We report that most BCV occlusions can be treated using simple endovascular techniques on an outpatient basis. METHODS: From January 2009 to January 2022, 115 hemodialysis patients underwent BCV endovascular revascularization. Seventy-three of the initial procedures were performed in an office-based angiosuite. Indications for the procedure were BCV occlusion endangering the performance of a previous arm access or making the creation of a new arm access unadvisable. We recorded and analyzed risk factors and procedural results, patency rates, complications, and mortality. RESULTS: The median age was 62 years (range, 23-91 years); 56% were female. Most prevalent associated conditions were diabetes mellitus (61%) and hypertension (68%). Fifty-six patients (48.7%) presented with severe upper extremity edema ipsilateral to the side of pre-existing functioning access. Obstruction recanalization was effective using standard catheter and wire in 106 cases (92.1%) and transseptal needle in nine cases (7.8%), that included seven using inside-out procedure. Initial management of the BCV stenosis was percutaneous transluminal balloon angioplasty alone in 74 patients (64.3%), stenting in 33 (28.7%), and HeRO conduit in eight cases (7%). Treatment of other central venous lesions included 49 cases (42.6%). The procedure was successful in 99.1% of patients. No intraoperative complications occurred. All 92 patients with previous arm access maintained adequate performance (100%). In 22 of 23 patients (95.6%), new upper extremity access creation was effectively performed after the venous intervention. Overall clinical success rate was 92%. The mean postoperative monitoring was 23 months, the median was 12 months, and the range was 1 to 84 months. During this monitoring period, 266 endovascular procedures, 91% in the office and 9% in the hospital, were required to preserve access performance. Eventually, 49 patients (42.6%) were stented. Eleven patients (9.56%) had infections, and six required complete access removal. Other causes of access failure included two patients with central vein thrombosis and one with massive pulmonary embolus. At the end, nine patients (7.8%) had access failure. Thirty-two patients (27.8%) died of unrelated causes during the follow-up period. Seventy-six patients (66%) have maintained functional access. Kaplan-Meier curves determined median primary patency of 9.6 months, median primary assisted patency of 56.2 months, and secondary patency of 75% at 80 months. CONCLUSIONS: Successful endovascular revascularization of BCV obstruction can be treated safely, with simple endovascular techniques in an office-based context with minor complication rates and durable results.

Subaortic left brachiocephalic vein and real-time ultrasound-guided puncture.

We describe a subaortic left brachiocephalic vein, a congenital anomaly that can be suspected during the rapid central vein assessment before central venous catheterization. Since the vein descends vertically/obliquely rapidly from its origin, we suggest that the puncture should be made at a greater angle (50°-60°) than what is usually used to puncture this vein (20°-30°). Failure to identify this anomaly may cause a failed puncture or complications from the puncture of adjacent blood vessels.

Ultrasound guided percutaneous catheterization of the brachiocephalic vein by small caliber catheter: An alternative to epicutaneo-caval catheter in newborn and premature infants.

BACKGROUND: Umbilical Venous Catheter (UVC) and Epicutaneo-Caval Catheters (ECC) are reference catheters in the neonatal period. However, many factors such as the corpulence of neonates, poor venous capital, and anatomical variants can complicate ECC insertion or make it impossible. In newborns with failed ECC insertion, we developed an hybrid technique that combines the insertion of a long-lasting silicone or polyurethane small caliber catheter, usually used as a ECC in newborns, with the ease and speed of ultrasound guided puncture of the brachiocephalic vein (BCV). METHODS: Three years retrospective single center experience of ultrasound guided BCV insertion of silicon or polyurethane small caliber central catheter in a tertiary neonatal intensive care in case of insertion fail of ECC. RESULTS: Twenty-one echo guided BCV-ECC insertions were performed in 20 newborns. Median age was 16 days (range: 0-110 days), median weight was 1700 g (range: 605-4960 g) at insertion. In most cases, insertion was on the left side (17/21). No failures were noted. Only one attempt was necessary in all cases. Insertion time, when noted, was always of <45 min. The median duration of use of these catheters was 11 days (range 3-35 days). No complication was noted during insertion or catheter use, including catheter-related infections and thrombosis. CONCLUSION: Echo guided percutaneous catheterization of the brachiocephalic vein with a long lasting silicone or polyurethane small caliber catheter is a safe alternative to the ECC if insertion has failed. However, it requires a mastery of ultrasound-guided insertion technique in term and premature neonates.

Surgical removal of a foreshortened right innominate vein Wallstent causing venous outflow obstruction.

OBJECTIVES: Stenting of central venous stenosis to preserve upper extremity hemodialysis access is well-described, though upper extremity complications secondary to these stents are less frequently discussed. METHODS: We present the case of a 43-year-old male with a right brachiocephalic fistula who developed symptoms of venous hypertension following placement of a Wallstent for central venous stenosis. Workup demonstrated venous outflow obstruction secondary to stent foreshortening into the right subclavian vein. RESULTS: The Wallstent was removed in a piecemeal fashion using an open surgical technique and a HeRO graft was placed for dedicated fistula outflow with complete relief of the patient's symptoms. CONCLUSION: In situations where a stent has migrated and endovascular removal is not possible, individual Wallstent fibers can be removed through a limited venotomy.

Surgical Resection of an Intravascular Lipoma of the Superior Vena Cava.

Intravascular lipomas (IVL) located in the superior vena cava (SVS) are rare benign primary venous tumors with less than 15 cases reported in the literature. We report a case of a 64-year-old woman with IVL of the SVC extending to the right brachiocephalic vein. She was treated successfully using a hybrid procedure which involved endovascular control of the right subclavian vein and surgical approach via median sternotomy followed by mass resection and use of pericardial patch for vein defect closure.

Treatment for cephalic arch stenosis with cephalic vein to external jugular vein bridging graft.

AIM: Percutaneous transluminal angioplasty or cephalic vein transposition to the axillary vein is mainly used for treatment of cephalic arch stenosis, a common complication of brachiocephalic fistulas. However, the results of such interventions have been disappointing. METHODS: We used a polytetrafluoroethylene prosthesis with a 6 mm diameter to bridge the cephalic vein and the ipsilateral external jugular vein, and successfully created a new drainage outlet and established immediate restoration of flow through brachiocephalic fistulas. RESULTS: This surgery allowed the cephalic venous arch and subclavian vein, which are vulnerable to stenosis, to be bypassed altogether and the puncture segment could be elongated by about 20 cm. CONCLUSION: It is a safe and effective alternative to traditional methods of treatment for cephalic arche stenosis.

Surgical correction of partial anomalous left superior pulmonary venous connection to the innominate vein.

Partial anomalous pulmonary venous connection is reported to occur in 0.4 to 0.7% of children. Only 3% of these cases involve an anomalous left-sided pulmonary venous connection to the innominate vein [1]. In this video tutorial, we present the technique of reimplantation of the partial anomalous left superior pulmonary venous connection to the left atrial appendage through a median sternotomy and with a cardioplegic heart. We debate the merits of our strategy with respect to our ultimate goal of achieving long-term patency.

Kissing Viabahn VBX stent graft reconstruction of thoracic central veins for management of superior vena cava syndrome.

OBJECTIVE: In the present study, we evaluated the technical and clinical outcomes of thoracic central vein reconstruction for superior vena cava (SVC) syndrome using kissing Viabahn VBX stent grafts (W.L. Gore & Associates, Flagstaff, AZ). METHODS: All adult patients with SVC syndrome who had undergone attempted bilateral brachiocephalic vein-to-SVC reconstruction using kissing VBX stent grafts at an academic hospital between August 2019 and February 2021 were reviewed. The technical results, adverse events, imaging follow-up findings, and clinical outcomes were recorded. Patency over time was assessed using Kaplan-Meier analysis. RESULTS: A total of 28 patients (16 women and 12 men; mean age, 52.0 years) constituted the study cohort. Of the 28 patients, 17 (60.7%) had had benign and 11 (39.3%) malignant etiologies. The presenting symptoms included neck swelling (n = 17; 60.7%), bilateral upper extremity swelling (n = 15; 53.6%), dyspnea (n = 7; 25%), unilateral upper extremity swelling (n = 4; 14.3%), and dysphagia (n = 1; 3.6%). SVC reconstruction with VBX stent grafts in a kissing configuration was successfully completed in 27 of the 28 patients (96.4%). Four major adverse events were noted in the benign etiology subgroup (23.5%), including intraprocedural hemopericardium (n = 3) and delayed pneumothorax (n = 1). Of the 28 patients, 27 (96.4%) had experienced resolution of their presenting symptoms. The mean clinical follow-up for the living patients was 358.8 ± 77.2 days (range, 78-645 days). The mean imaging follow-up for the living patients was 272.6 ± 91 days (range, 26-594 days). The primary, primary-assisted, and secondary patency rates at 12 months were 71.8%, 88.8%, and 100%, respectively. CONCLUSIONS: For the management of SVC syndrome, thoracic central vein reconstruction with kissing VBX stent grafts was feasible with a high rate of symptom resolution and acceptable patency. However, this technique should not be recommended for those with benign SVC syndrome owing to the high risk of cardiac tamponade.

Percutaneous superior vena cava puncture successful recanalization of a long-segment, angled central venous occlusion: a case report.

BACKGROUND: Multiple complete central venous occlusion (CVO) is rare complication among the hemodialysis population. Percutaneous transluminal angioplasty (PTA) is the recommended treatment for CVO; however, cases with long-segment occlusion remain challenging. CASE DESCRIPTION: We reported a patient who complained of a swollen right arm for 1 month. On admission, his vital signs were within normal limits. The 76-year-old man had been on hemodialysis with a right forearm arteriovenous fistula (AVF) for 4 years with a history of temporizing catheterization and left forearm AVF failure. One year ago, he gradually developed a slight swelling in his right arm and the swelling in his arm was significantly worse one month ago. Digital subtraction angiography (DSA) revealed occlusion in his right innominate vein (IV), proximal subclavian vein (SV), and external and internal jugular veins, as well as stenosis of the ipsilateral cephalic arch and axillary vein (AV). The operation was performed with a pioneered bidirectional approach via ipsilateral superior vena cava (SVC) and AV puncture. The occluded lesions were successfully recanalized, and the patient's symptoms resolved after the operation. The patency of his vascular access was well maintained at the 4-month follow-up. CONCLUSIONS: To the best of our knowledge, this is the first report regarding the application of SVC puncture in PTA for CVO. This technique could be a possible approach when performed by appropriately qualified operators in patients with limited or no other options.

Rare case of epithelioid hemangioendothelioma in the right innominate vein-An innovative diagnostic approach.

BACKGROUND AND AIMS: Epithelioid hemangioendothelioma is a rare malignant vascular tumor with limited literature. AIMS: We reported an innovative endovascular biopsy of the right innominate vein tumor. MATERIALS AND METHODS: Endovascular suction thrombectomy was performed with multipurpose catheter and constant negative pressure under fluoroscopic guidance. RESULTS: Epithelioid hemangioendothelioma was diagnosed preoperatively and a complete margin-free tumor resection with patch repair of the right innominate vein was achieved via sternotomy. DISCUSSION: Preoperatively diagnosis is usually not available due to lesions' location. Identifying malignant vascular tumors becomes valuable to guide the surgical treatment. CONCLUSIONS: In this case report, this innovative endovascular approach led to a rare preoperative diagnosis of EHE and subsequent margin-free resection.

[Hemangioendothelioma of the right innominate vein]. / Gemangioendotelioma pravoi plechegolovnoi veny.

The authors report a rare case of hemangioendothelioma of the right innominate vein complicated by superior vena cava syndrome. Considering development of enlarged venous collaterals, we performed circular resection of superior vena cava together with the right and left innominate veins without replacement. There were no postoperative complications. The use of vascular prosthesis in patients with long-standing superior vena cava compression and enlarged collaterals is associated with high risk of thrombosis and subsequent pulmonary embolism. Safe circular resection of superior vena cava without replacement is possible after intraoperative test clamping.