Primary forearm arteriovenous fistula for hemodialysis access--an integrated approach to improve outcomes.

PURPOSE: Maximizing the ratio of primary arteriovenous fistula (PAVF) over bridge graft fistula (BGF) for hemodialysis access is a primary recommendation of the National Kidney Foundation published as Dialysis Outcomes Quality Initiative (DOQI). Imaging, anesthetic and surgical techniques were taken into account to achieve this and other goals, including extensive use of forearm vessels to lower immediate and early failure rates and prolong the useful life of PAVFs. DESIGN: Prospective non-randomized study. METHODS: High-resolution duplex ultrasonography (DUS) was added to careful clinical assessment in planning and follow-up of the dialysis access. Brachial plexus block, which allowed the use of an arterial tourniquet and gave a postoperative sympathectomy type effect, was used for anesthesia, and together with meticulous surgical technique, prevented spasm. Access puncture, post-operative follow-up and surgical revisions were planned in close cooperation with the nephrology team. FINDINGS: Ninety (57.3%) of the 157 fistulas constructed for new hemodialysis access between August 1998 and March 2000 were PAVFs. Seventy-three (81.1%) of these were confined to the forearm and comprise the study population, with a mean follow-up of 8.4+/-4.4 months. There were no immediate failures in the study group. The early failure rate (1 month) was 6.8% and revisions based on DUS were easily accomplished in all cases. The one year assisted primary patency rate was 81.8% and the secondary patency rate at 18 months was 98.6%. CONCLUSIONS: DUS for planning and follow-up of PAVF along with careful surgical technique under a brachial plexus blockade can achieve a PAVF/BGF ratio well above 50% with a low early failure rate and a high secondary patency rate. Algorithms are presented to achieve these goals.

Dialysis access induced limb ischemia corrected using quantitative duplex ultrasound.

Dialysis access induced limb ischemia (DAILI) is a rare complication after the creation of an arteriovenous fistula in infancy but can cause irreversible ischemic limb damage in severe cases. The incidence of DAILI is higher in bridge graft fistulas than in native fistulas. DAILI patients may be managed by surgically reducing the volume flow in the fistula. However, in the pediatric age group, such a reduction of volume flow may result in thrombosis or an inadequate flow for effective dialysis. Several methods have been described to achieve the delicate balance between essential flow in the fistula and adequate limb perfusion pressure. We have developed a new method employing preoperative duplex ultrasonography to predict quantitatively the reduction in volume flow in the fistula that will allow effective dialysis while providing adequate limb perfusion. The preoperative assessment was reproduced on the operating table using intraoperative duplex. A 3-year-old girl thus treated has had resolution of her ischemic symptoms and maintains long-term patency of her dialysis access.

Management of dialysis access-associated steal syndrome: use of intraoperative duplex ultrasound scanning for optimal flow reduction.

Dialysis access-associated steal syndrome (DASS) is an uncommon complication after the creation of an arteriovenous fistula and can cause irreversible ischemic damage in severe cases. Dialysis access-associated steal syndrome has been managed with the surgical reduction of the volume flow in the fistula, but this is associated with a certain incidence of access loss. Several methods are described to achieve the delicate balance between essential flow in the fistula and an adequate limb perfusion pressure. We have developed a new method with duplex ultrasound scanning to quantitate the reduction in volume flow, which will allow effective dialysis and provide adequate limb perfusion. The preoperative assessment was reproduced on the operating table with intraoperative duplex scanning. A 65-year-old woman who underwent this treatment has had resolution of her ischemic symptoms and maintains long-term patency of her dialysis access.

Primary blast injury after a bomb explosion in a civilian bus.

A 6-kg explosive charge detonated under a seat in the center of a crowded city bus in Jerusalem, killing three passengers immediately. Of the 55 survivors, all of whom were transferred to two major medical centers, 29 were hospitalized. Among those admitted, a high rate of primary blast injuries was found, including perforated ear drums (76%), blast lung (38%), and abdominal blast injuries (14%). Two of the latter patients suffered bowel perforations, which were diagnosed with considerable delay. Eight patients (31%) had sustained life-threatening trauma, consisting of a combination of primary, secondary, and tertiary blast injuries. The overall mortality rate was 10.3%. The large number of primary blast injuries, including the unexpected finding of bowel perforations, is explained by the high amplitude of the air pressure wave (3.8-5.2 atm) and its relatively long duration (2-3 msec) resulting from the detonation of the high-energy explosive charge in the small, enclosed space of the bus. Besides the usual wounds sustained by victims of an explosion that occurs in a confined space, the possibility of primary blast injury to the abdomen and to the lungs should be taken into account by the treating surgeon.

Spontaneous rupture of the stomach: a rare complication of Nissen's fundoplication.

Spontaneous rupture of the stomach may occur in cases of abnormal distension and reduced emptying capacity, either by normal peristalsis or by vomiting, of the stomach. We present a case of spontaneous rupture of the stomach in which the dilatation was due to apple fermentation and gas formation in the stomach. Peristalsis was inadequate for stomach emptying due to impaction of apple skins in the duodenum. The inability to vomit was due to a Nissen fundoplication performed 18 months earlier.

Rectal temperature in the diagnosis of acute lower abdominal pain.

The accurate diagnosis of acute lower abdominal pain continues to be a problem. In Israel, a diagnostic sign often sought as indicating pelvic peritonitis is a rectal temperature of greater than 1.0 C higher than the simultaneous oral temperature. We established that in each of the 20 emergency rooms surveyed both oral and rectal temperatures are measured as part of the admission procedure for patients with acute lower abdominal pain. The charts of three groups of 100 patients with acute lower abdominal pain were studied retrospectively. A rectal temperature of greater than 1.0 C higher than the oral was found in about 10% of each group. Both oral and rectal temperatures were raised in 56, 69 and 37% of each group, respectively. The rectal temperature alone was elevated in 8.5% of patients with appendicitis or pelvic inflammatory disease (PID), as well as in 6% of patients with undiagnosed abdominal pain. Oral temperatures alone were elevated in 4.5% of patients with acute appendicitis or PID and also in 13% of patients with undiagnosed abdominal pain. These differences were not significant. We conclude that the common Israeli practice of measuring both rectal and oral temperatures in patients with acute lower abdominal pain gives no more information than the measurement of either one.

The use of photoplethysmography in the assessment of venous insufficiency: a comparison to venous pressure measurements.

In an attempt to develop a noninvasive test to assess objectively the magnitude of venous valvular dysfunction in pathologic states, photoplethysmography (PPG) was compared to venous pressure in the saphenous vein at the ankle. Simultaneous venous pressure and PPG recordings were taken before, during, and after exercise with subjects in the sitting position. In a total of 338 paired measurements in 24 normal, 25 postphlebitic, and 14 varicose limbs, PPG and venous pressure tracings appeared to be identical; data points had a correlation coefficient of great significance (r = 0.898). Postexercise recovery times clearly separated the normal from the postphlebitic limbs. Varicose limbs were assessed accurately regarding results of proposed surgery using an above-knee tourniquet. It appears that the PPG evaluation provides information comparable to venous pressure studies and does so more quickly and noninvasively. The test holds promise in measuring results of direct venous reconstructive surgery as well as in venectomy procedures.

Hypopharyngeal injury as a result of attempted endotracheal intubation.

Perforation of the hypopharynx due to traumatic attempted endotracheal intubation usually occurs during resuscitation efforts under poor conditions, but may occur even under optimal conditions due to improper technique. The implication of the appearance of subcutaneous emphysema in the neck, cyanosis, or pneumothorax during or following attempts at endotracheal intubation should be known. Direct laryngoscopy may be helpful in establishing the injury but early radiological examination is necessary for diagnosis of the site and extent of the perforation. The radiological contribution appears to be decisive in the choice of treatment. The radiological findings and the considerable morbidity observed in 6 cases of hypopharyngeal injury are described.