Management of Arteriovenous Fistula After Successful Kidney Transplantation in Long-Term Follow-Up.

Arteriovenous fistula (AVF) is the best method of vascular access for hemodialysis. This approach can lead to several complications, such as hyperkinetic heart failure due to a hyperfunctional AVF or dilatation of the feeding artery. These are late complications, especially in patients after a successful kidney transplantation. An observational study was performed focusing on patients more than 12 months after kidney transplantation. The AVF was evaluated by ultrasound and, if the outflow exceeded 1.5 L/min, an echocardiogram was performed. Surgical management was indicated if the cardiac index was higher than 3.9 L/min/m2 or upon finding a brachial artery aneurysm. A total of 208 post- kidney transplantation patients were examined over a 3-year period, of which 46 subjects (22.11%) had hyperfunctional AVF and 34 cases (16.34%) of feeding artery dilatation were determined. In total, 40 AVF flow reduction and 6 AVF ligation procedures were performed. The median AVF flow before and after the reduction was 2955 mL/min and 1060 mL/min, respectively. Primary patency after flow reduction was 88.3% at 12 months. Late AVF complications in patients following kidney transplantation are quite common. It is necessary to create a screening program to monitor AVFs in these patients.

Robotic assisted living donor nephrectomy - the first in the Czech Republic.

INTRODUCTION: A kidney transplant is the best method for treating terminal kidney failure. Long-term results of kidney transplants from living donors are significantly better than transplants from dead donors. Living kidney donors are healthy people who undergo a major operation in order to improve the health of another person. Therefore, major emphasis is on safety, low level of invasiveness and a desirable cosmetic effect of the donor nephrectomy. Since 2012, the Department of Urology at the University Hospital in Olomouc has performed 12 kidney harvestings from living donors. The kidney harvesting was conducted using various techniques. CASE REPORT: The first robotic assisted kidney harvesting in the Czech Republic was performed in June 2022. The donor was a 57-year-old man who donated his kidney to his 32-year-old daughter. The left kidney was evaluated as suitable for kidney harvesting. The operation took 174 min. The kidney's warm ischemia was 145 s. Based on the Clavien Dindo classification, no 2nd degree or high post-operative complications were recorded. The donor's pre-operative glomerular filtration was 1.63 mL/s. Six months post-operation, it went down to 1.19 mL/s. This represents a 27% decrease. The kidney recipient did not require early dialysis. Six months post-operation, the recipient's glomerular filtration was 2.03 mL/s. CONCLUSION: In the hands of experienced professionals and transplantation centres, robotic assisted donor nephrectomy is a feasible and safe option for this operation. It not only provides all the advantages of a laparoscopic operation but it also adds other technical improvements and minimizes intraoperative stress on the surgeon. Currently, the global trend is moving towards increasing the ratio of robotic assisted donor nephrectomies.

Brachial artery aneurysm as a late complication of arteriovenous fistula.

INTRODUCTION: Brachial artery aneurysm (BAA) is a rare late complication of arteriovenous fistula (AVF). It brings the risk of peripheral embolism and hand ischemia and is defined by brachial artery diameter above 10 mm or by regional dilatation by >50%. BAA is described in the literature in closed radiocephalic arteriovenous fistulas after kidney transplantation. The aim of the study was to analyze the prevalence of BAA and of their more dangerous forms. METHOD: A observational one center study performed on patients after kidney transplantation with AVF or arteriovenous graft (AVG). We invited all patients followed up for kidney transplantation in our center. Arterial diameter greater than 10 mm was considered as a brachial artery aneurysm to simplify the detection and evaluation of aneurysms. RESULTS: About 162 patients with AVF after kidney transplantation were examined between 4/2018 and 4/2020. Brachial artery aneurysm was detected in 34 patients (21%) with AVF or AVG, of them 7 had confirmed wall thrombi. AVF flow volume of more than 1500 ml/min increased the risk of BAA development by 4.54x. Eight aneurysms were treated surgically. After this surgery, the primary patency was 87.5% in 12 months. CONCLUSION: Brachial artery aneurysm was relatively frequent in our study compare to the literature. Aneurysm or dilatation of the brachial artery is more frequent in functional AVFs. Surgical correction is necessary in cases of complicated aneurysms to prevent distal embolization.

Is endovascular treatment of aorto-iliac aneurysms with simultaneous unilateral revascularization of internal iliac artery by branched iliac stentgraft sufficient?

AIMS: The coverage / occlusion of internal iliac artery (IIA) during endovascular treatment of aorto-iliac aneurysms (AIA) can be associated with risk of ischemic complications. To reduce these complications, unilateral or bilateral iliac branch device implantation (IBDI) has been reported. This study aims at evaluating the efficacy of simultaneous unilateral IBDI in the treatment of AIAs and comparing our results with literature. MATERIALS AND METHODS: From March 2010 to December 2019, 27 patients (25 men, 2 women, range 54-84 years) were treated for aorto-iliac/isolated common iliac aneurysms with simultaneous unilateral revascularization of IIA and surgical / endovascular occlusion of contralateral IIA. 27 iliac-branched devices were implanted in 27 patients. The results including ischemic complications were evaluated and compared with literature. RESULTS: The technical success was 100% with no perioperative mortality and morbidity of 3.7%. Primary internal iliac branch patency at a median follow-up of 52 months (range 1-118 months) was 96.42%. Secondary endoleak was observed in 6 patients (Type 1a [1], Type 1b [1], Type II [4]) and inflammatory complication in 1 patient. The incidence of buttock claudication one year after the procedure was 11.1%. Except for buttock claudication no other ischemic complications occurred. CONCLUSION: Unilateral flow preservation in the IIA territory using IBDI is associated with a lesser, but a certain risk of ischemic complications. Bilateral IBDI with bilateral flow preservation of IIAs increases the complexity, procedure -/ fluoroscopy times, contrast agent volume and cost, however, may further reduce these ischemic complications.

Arteriovenous Grafts' Types of Indications and Their Infection Rate.

BACKGROUND: Arteriovenous graft infection is a well-known and frequent complication. The objective of this study was to compare infection rates of primary and secondary indicated arteriovenous grafts (AVGs). SUBJECTS AND METHODS: Retrospectively, we evaluated the indications for AVGs created at our institution which became infected. One hundred forty AVGs were evaluated. Of these AVGs, 33 (23.6%) were primary and 107 (76.4%) secondary indicated. RESULTS: Infection of a primary AVG was detected in 5 patients (15.2 %). Infection of a secondary AVG was detected in 30 patients (28.0%). Primary and secondary patency were significantly lower in patients with infected AVG (P = 0.006; P = 0.0001). The effect of diabetes mellitus and age on development of infection was not confirmed. CONCLUSIONS: Indications for AVG creation clearly influence the future risk of infection. If the indication to use the AVG is to correct a complicated arteriovenous fistula, the risk of infection is 2 times higher.

Unusual Access for the Treatment of Iliac Artery Aneurysm in Association with Type II Endoleak After Endovascular Repair of an Aortoiliac Aneurysm.

Internal iliac artery aneurysms (IIAAs), although rare, are associated with a significant risk of mortality, if they rupture. Endovascular approach with exclusion of the aneurysm sac from antegrade and retrograde perfusion is proved to be a feasible treatment option. However, this option is not always technically possible with a preexisting endovascular aneurysm repair (EVAR) or surgical aortoiliac reconstruction with ligation of internal iliac artery origin. We report another safe treatment option of an enlarging IIAA associated with a type II endoleak after EVAR and a standard endovascular treatment was not possible. The access to the aneurysm sac was achieved retrograde via percutaneous access to the superior gluteal artery under fluoroscopy followed by treatment with embolization of the inflow and outflow vessels.

Surgical revision vs. stent-graft to treat venous anastomosis stenosis following surgical thrombectomy of hemodialysis grafts.

BACKGROUND: There is no unanimous strategy for treating stenosis of the venous anastomosis (VA) of an occluded arteriovenous graft (AVG) following surgical thrombectomy. In this study, we compared classical surgical treatment and endovascular treatment procedures with the use of stent- graft in a single center study. The aim was to evaluate whether, the VA stenosis of thrombosed AVG treated endovascularly by stent-graft implantation, have as good results as surgical VA treatment, so that it may be considered the method of choice. METHODS: The study included patients who underwent surgical AVG thrombectomy with subsequent angiographically confirmed VA stenosis between 1/2009 and 12/2014. Surgical angioplasty was then performed in 15 patients and 17 patients underwent primary stent-graft implantation. RESULTS: In the surgically treated patients, the postintervention primary patency, primary assisted patency and secondary patency after 12 months were 50.7%, 56.3%, 62.4%, respectively. In the group of patients with occluded AVG who underwent stent-graft implantation, the postintervention primary patency, primary assisted patency and secondary patency after 12 months were 32.8%, 44.1% a 55.6%, respectively. No statistically significant difference in primary patency (P=0.391), primary assisted patency (P=0.605), and secondary patency (P=0.702) was observed between the groups. CONCLUSIONS: Stent-graft implantation into stenotic VA of an occluded AVG showed to be effective and maintained good long-term patency. It is the preferred method due to its minimal invasiveness. The superiority of this method must be confirmed on a larger set of patients.

Arteriovenous graft for hemodialysis, graft venous anastomosis closure - current state of knowledge. Minireview.

UNLABELLED: Backround. The use of artificial vascular grafts (arteriovenous graft, AVG) is indicated in patients in hemodialysis programs if the subcutaneous venous bed is exhausted or unsuitable for arteriovenous fistula (AVF) creation. The native fistula should be the hemodialysis access of first choice: AVF has better results in terms of function and potential complications. However, the use of AVG is necessary in some patients. In these patients, extensive clinical examination, color duplex sonography and angiography should be performed prior to indication. The technique of graft implantation requires respect for geometric relations for the graft anastomoses to minimize the formation of intimal hyperplasia mainly on the venous anastomosis. The main complications of AVG are stenosis on the venous anastomosis (VAG), causing closure of graft and graft infection. The cumulative function of AVG is 59-90% in the first year and 50-82% in the second year. Arteriovenous graft stenosis leading to thrombosis is a major cause of complications in patients undergoing hemodialysis. The purpose of this review is to summarise current knowledge of the diagnostics and treatment of graft thrombosis and discuss the issue in combination with relevant publications via Pubmed database. CONCLUSION: The most frequent cause of failure of AVG for hemodialysis is stenosis and closure by VAG. AVG closure can be addressed surgically, endovascularly (amenable to thrombectomy by radiological or surgical means) and by hybrid performance.

Current treatment methods for long occlusions of the femoropopliteal segment in patients with intermittent claudication: Minireview.

UNLABELLED: Backround. Intermittent claudication is a classic symptom of peripheral arterial disease. It is mainly treated conservatively but if this fails, a form of revascularization is indicated. The revascularization in chronic occlusion of femoropopliteal region is currently performed by two basic methods: the standard method of surgical bypass and the newer miniinvasive alternative represented by the endovascular method. The treatment of patients with solely claudication and long occlusion of femoropopliteal region remains controversial. The aim of this minireview was to determine whether surgical bypass is still the best method of choice in a time of endovascular techniques. METHODS: A MEDLINE search for original and review articles using key terms, intermittent claudication and long femoropopliteal oclusion. RESULTS AND CONCLUSION: No ideal treatment for long occlusions of the femoropopliteal segment has been established to date. It is clear that the role of endovascular techniques in the treatment of SFA occlusions is increasing. It remains that, lower risk patients with claudication should be examined to assess the quality of veins suitable for revascularization and bypass should be selected as the first method of choice.

Infected prosthetic dialysis arteriovenous grafts: a single dialysis center study.

BACKGROUND: The prosthetic arteriovenous grafts (AVG) being used increasingly to create hemodialysis access are prone to infections that pose potentially life-threatening infectious and bleeding complications, as well as loss of dialysis access. In this study, we identified the bacteriologic agents of infected AVGs by site swab, blood culture, and prosthesis cultures, and to evaluate the role of microbiological findings in the management of the infection. METHODS: We focused on 51 patients with 53 AVGs operated on in our clinic from January 2006 to December 2009. An infected AVG was identified by clinical, ultrasound, and microbiological findings. Sensitivity to antibiotics was determined for all bacterial strains. Isolates were identified by pulsed-field gel electrophoresis (PFGE) of bacterial DNA. In a few cases, positron emission tomography-computed tomography (PET-CT) examination was performed. RESULTS: Strains of Staphylococcus spp., especially S. aureus, were the most frequent cause of infected AVG. All S. aureus strains were sensitive to methicillin. With the exception of a single case, isolates obtained simultaneously from the skin site and the vascular prosthesis were identical genetically. CONCLUSIONS: Our results suggest that bacterial infectious agents detected in site swab, blood, or graft culture confirm a suspicion of AVG infection. A PET-CT examination can provide confirmation. The combination of microbiologic and radionuclide findings can improve the management of the AVG infection, but surgery remains essential.

Surgical remodelling of haemodialysis fistula aneurysms.

INTRODUCTION: One complication of autogenous arteriovenous fistula (AVF) for haemodialysis is the formation of a venous aneurysm. CLINICAL PICTURE: The clinical picture is typically an expanding aneurysm leading to skin atrophy and ulceration with the risk of rupture and infection. Aneurysm also reduces the potential cannulation area. TREATMENT: The cases described here used a surgical 'remodelling' technique involving complete skeletonisation of the venous aneurysm, reduction of lumen diameter and retention of vein wall using a Hegar dilatator to remodel a new fistula. OUTCOME: Six patients were treated using this method and the arterior venous shunt (AVS) was used for haemodialysis the following day. No recurrent aneurysm developed. CONCLUSION: Remodelling of aneurysmal AVF is an effective and low-risk option for managing this kind of complication, allowing direct access for haemodialysis.

Ultrasonographic and perioperative macroscopic findings in acute carotid artery occlusion.

BACKGROUND AND PURPOSE: acute ischemic stroke (AIS) may occur both in the acute and chronic internal carotid artery occlusion (ICAo). Thus, it is important to assess the ICAo character when considering the recanalization method. The aim was to assess the agreement between the ultrasonographic (US) and perioperative macroscopic (PM) finding in AIS patients with acute ICAo, undergoing an emergent carotid endarterectomy. METHODS: in a retrospective, hospital-based study, the set consisted of 47 patients (36 males; age 49-79, mean 63.7 ± 8.5 years). ICAo character was classified as an acute thromboembolus either isolated or in combination with atherosclerotic plaque using the US (B-mode) and the PM evaluation. Cohen's Kappa and AC(1) coefficient were applied to assess the methods agreement. RESULTS: an acute ICAo character diagnosed by US was confirmed by the PM evaluation in all cases. US and PM findings were consistent in 41 cases. The agreement between both methods in the classification of acute ICAo was 87.2% [95% confidence interval (CI): 77.7-96.8%], κ= .589 (95% CI: .293-.885) (P < .0001), AC(1) = .815. CONCLUSIONS: US is a reliable method in the diagnostics of the acute character of ICAo and it has a good agreement with PM finding regarding a differentiation of atherosclerotic plaque and fresh thromboembolus.

Cystic adventitial disease of the popliteal artery: report on three cases and review of the literature.

BACKGROUND: During the past nine years three cases of cystic adventitial disease of the popliteal artery have been diagnosed and treated in our medical institution. Different approaches were used in the treatment in all these cases. The purpose of this report is to summarise the current knowledge of the etiology, presentation, diagnostics and treatment of this condition, with the addition of new cases. METHODS: Information about three new cases is presented and discussed together with that from the relevant publications obtained from the Pubmed database. Results. In the first case resection with synthetic graft interposition was used. Nine years after the surgery the patient is without any signs of recurrence, but he experienced local thrombolysis of the occluded graft and repeated PTA of hemodynamically significant anastomotic stenoses. The second case treated with US-guided aspiration has demanded repeated reinterventions due to recurrence; nevertheless, the result is satisfactory. In the last instance, the cyst was evacuated and excised. Six months after the surgery the patient is symptom-free and without signs of recurrence. CONCLUSIONS: CAD of the popliteal artery is a rare vascular condition. However, it must be considered in the differential diagnosis, especially in middle-aged male patients without evidence of atherosclerotic disease in whom intermittent claudication has developed suddenly with a rapid progression or with fluctuation in severity. Duplex ultrasound and MRA are the the best diagnostic methods. Based on the existing knowledge, the treatment of choice is surgery (either evacuation with the removal of the cystic wall or resection and grafting).

Infectious complications of arteriovenous ePTFE grafts for hemodialysis.

BACKGROUND: Insufficient venous vasculature disallows autologous arteriovenous fistula creation. In this case an arteriovenous conduit of expanded polytetrafluoroethylene (ePTFE) interponed between artery and vein is used for hemodialysis. Although arteriovenous graft infection is an infrequent complication, infected grafts cannot be used for hemodialysis and can cause infection, sepsis and bleeding. Treatment options remain limited but the general approach is to maintain functional angioaccess and to eradicate infection. AIM: To summarize current knowledge of the prevention and treatment of arteriovenous graft infection. METHODS: Literature review. CONCLUSIONS: ePTFE graft present an unreplaceable material used for angioaccess in patients with an insufficient venous vasculature. A number of risk factors causing graft infection is known. Since hemodialysis patients are a high-risk group, an effective strategies for graft infection prevention and early diagnosis should be determined. Among the most important risk factors belong surgical procedure, recurrent venipuncture and other infection disease. The prostheses should be removed when infected, especially in the presence of sepsis. In case of "localized infection", the prostheses can be removed partially only under the condition of careful patient selection and subsequent follow-up.

Subintimal angioplasty in femoropopliteal region-Mid-term results.

PURPOSE: Subintimal angioplasty is becoming more frequently used treatment option for patients with long arterial occlusions or diffuse atherosclerotic changes as an alternative to surgical treatment in claudicants especially in patients with critical limb ischemia. The aim of our article is to retrospectively assess mid-term outcomes of subintimal angioplasty of chronic arterial occlusions in femoropopliteal region followed clinically and by Doppler ultrasonography. MATERIALS AND METHODS: From May 2002 to December 2007, 133 femoropopliteal artery occlusions in 123 patients were indicated for subintimal recanalisation. The indications for treatment were intermittent claudications in 84 patients (63.15%) and critical limb ischemia in 49 patients (36.85%). The median length of lesions was 11.4 cm, range 2-30 cm. Except doppler ultrasonographic examination done 24h after the procedure and clinical examination before discharge, both clinical and ultrasonographic examinations were performed 6 and 12 months after the procedure and yearly thereafter. Statistical analysis of our cohort was performed by Kaplan-Meier analysis, log-rank test and Cox regression. RESULTS: Technical success was achieved in 86.46%. Primary patency rate was 83.1% (SE: 3.9%), 67.5% (SE: 5%), 58% (SE: 5.9%) a 48.4% (SE: 7.1%) at 6, 12, 24 and 36 months respectively. No statistically significant difference of primary patency was found between the group of claudicants and the group of patient with critical limb ischemia. Statistically significant prediction factors for primary patency were only the quality of the run off and the length of the occlusion. Limb salvage rate in our group of patients with critical limb ischemia was 80.8% at 12 months. CONCLUSION: : Subintimal recanalisation is a simple and safe procedure for treatment of chronic peripheral arterial occlusions with high primary technical success rate, acceptable primary patency rate, low percentage of complications and mortality is as low as nil. Subintimal angioplasty is definitely advantageous and fast method in patients with critical limb ischemia with high possibility of limb salvage. Surgical treatment can be replaced by subintimal angioplasty in claudicants with high risk of operative treatment, without suitable autologous vein graft or where distal femoropopliteal or femorocrural bypass is needed.

Endotension after endovascular treatment of abdominal aortic aneurysm: percutaneous treatment.

Endotension is one of the possible specific late complications of endovascular treatment of abdominal aortic aneurysm (AAA). We describe the treatment of endotension in a small group of 3 patients (all men, aged 58, 70, and 70-years-old) by translumbar puncture of the aneurysm sac and aspiration of its content. It was transudate and its culture was negative. Sac size reduced after aspiration in all patients and no subsequent enlargement was seen. Percutaneous translumbar puncture of the aneurysm sac with aspiration of sac content could be an easy and effective method of treatment in endotension. But a larger group of patients and long-term follow-up are needed.

Endovascular treatment of abdominal aortic paraanastomotic pseudoaneurysms after surgical reconstruction.

PURPOSE: To evaluate the efficacy of endovascular treatment of paraaortic postoperative abdominal aortic pseudoaneurysms. MATERIALS AND METHODS: From April 1996 to November 2007 five men with paraaortic postoperative abdominal aortic pseudoaneurysm underwent endovascular treatment. Average age was 64.2 years (range 54-73). The average time interval between the primary surgery and endovascular treatment was 12.4 years (4 months-23 years). Three patients were treated by aortouniiliacal stentgrafts and two patients by tube stentgrafts. RESULTS: Technical success rate was 100%. Pseudoaneurysms were primarily excluded from circulation without perioperative complications in all patients. At follow-up (mean 38.5 months) there were no deaths and no endoleaks. In one patient thrombosis of stentgraft was found and it was successfully treated by thrombectomy. All pseudoaneurysms still continued to be excluded from circulation in the last follow-up. CONCLUSION: Endovascular treatment is minimally invasive, effective and safe option of surgery for paraaortic postoperative pseudoaneurysms.

Lesser saphenous vein aneurysm and popliteal vein aneurysm: report of two cases and review of the literature.

BACKGROUND: During the last ten years we diagnosed two cases of venous aneurysm. The purpose of this report was to point out a certain risk of the thrombembolism of superficial venous aneurysms and to review our experience in the management of superficial and deep venous aneurysms. METHODS: The presentation and management of these lesions were reviewed and discussed together with other cases from available literature. RESULTS: In the first case an aneurysm of lesser saphenous vein with a possible threat of thrombembolism was revealed and surgically solved with saphena resection. Ten years after the surgery she is still symptom free. In the second case a small fusiforme popliteal vein aneurysm without any evidence of mural thrombus was diagnosed. The patient was treated conservatively with regular venous duplex imaging follow up. Two years later the disease has been stable. CONCLUSIONS: Superficial venous aneurysms can have a certain risk of the thrombembolism. Since surgical therapy is very simple, it can be recommended in all cases. Nevertheless, trombembolism is more common in deep venous aneurysms, especially popliteal ones, in which surgical repair can be based on their pathological features and presentation or can be indicated in all cases.

Operating management of central venous hypertension complicating upper extremity dialysis access.

AIM: To evaluate the importance of surgical bypass between the terminal part of functional arteriovenous shunt (av) for hemodialysis on upper extremity and inner jugular vein in axillosubclavian venous segment obstruction associated with central venous hypertension. METHOD: Retrospective assessment of surgical bypass between central segments of av fistula and ipsilateral/contralateral inner jugular vein using ePTFE graft in 17 patients over a 20 year period (1987-2006). RESULTS: The surgical procedure was not associated with intra- or post-operative complications. Primary cumulative bypass and av fistula function persisted for 26 months on average. CONCLUSION: An accurate bypass to salvage the functional dialysis access associated with central venous hypertension requires careful decision based on clinical and radiological examination. The bypass procedure is beneficial where endovascular treatment is not indicated. Clinical and radiological bypass monitoring is crucial.