Early cannulation of the Hemodialysis Reliable Outflow graft.

OBJECTIVE: In complex dialysis patients, central venous stenosis may preclude additional upper extremity access options. The Hemodialysis Reliable Outflow graft (Merit Medical Systems, Inc.) can bypass this stenosis providing patients with an additional upper extremity long-term access option. We report our experience with early-cannulation Hemodialysis Reliable Outflow grafts and compare them to traditional Hemodialysis Reliable Outflow grafts. METHODS: We retrospectively reviewed all patients undergoing Hemodialysis Reliable Outflow graft placement from 1 January 2013 through 15 August 2017 at our institution and compared those undergoing placement of traditional Hemodialysis Reliable Outflow grafts and simultaneous tunneled dialysis catheter insertion to those undergoing Hemodialysis Reliable Outflow graft placement using an early-cannulation Hemodialysis Reliable Outflow graft without a tunneled dialysis catheter. RESULTS: A total of 88 patients had 98 Hemodialysis Reliable Outflow grafts inserted throughout this time period. Of these, 61 (62%) were early-cannulation Hemodialysis Reliable Outflow grafts, while 37 (38%) were traditional Hemodialysis Reliable Outflow grafts. Primary, primary-assisted, and secondary patency rates at 1 year were higher for the traditional Hemodialysis Reliable Outflow graft cohort (53.1% vs 25.2%, p < 0.01; 70.1% vs 30.5%, p < 0.01; and 80.4% vs 55.4%, p = 0.07, respectively). There was no difference in the rate of postoperative hematoma, seroma, pseudoaneurysm formation, steal syndrome, or overall graft thrombosis between the two cohorts. Early-cannulation Hemodialysis Reliable Outflow grafts required earlier reintervention for thrombosis and earlier reintervention for any cause when compared to traditional Hemodialysis Reliable Outflow grafts (146 ± 184 days vs 417 ± 272 days, p < 0.01, and 123 ± 169 days vs 401 ± 311 days, p < 0.01, respectively). CONCLUSION: In complex dialysis patients, early-cannulation Hemodialysis Reliable Outflow grafts have significantly lower 1-year primary and primary-assisted patency rates and require earlier reintervention to maintain this patency compared to traditional Hemodialysis Reliable Outflow grafts.

Clinical Experience with the Gore Hybrid Vascular Graft in Complex Revascularizations Demonstrates Safety and Efficacy.

BACKGROUND: Arterial revascularizations can present significant challenges when vessels are disadvantaged and advances in technology present the surgeon with innovative opportunities. A number of studies have used the GORE® Hybrid Vascular Graft (GHVG), and we have been using this device in arterial revascularizations since it came to market. The aim of this study is therefore to present a large single-center experience using the GHVG. This series presents patients with complex revascularizations in multiple vascular beds. METHODS: We retrospectively analyzed a single-center series of 43 patients who received a total of 56 GHVGs in complex revascularization procedures at Houston Methodist Hospital from March 2012 to April 2017. We excluded 5 patients (7 grafts in total) because of loss of follow-up. An additional 8 patients were excluded from the analysis (11 grafts in total) secondary to mortalities unrelated to their grafts (7 patients died during index hospitalization and 1 patient died shortly after discharge). RESULTS: Our results demonstrated an 18-month primary patency, assisted primary patency, and secondary patency of 82, 86, and 96%, respectively. These complex revascularizations included a total of 56 devices placed. GHVGs were placed in the external iliac artery (27/56), renal artery (12/56), common femoral artery (6/56), superficial femoral artery (4/56), common iliac artery (3/56), grafts (3/56), profunda femoris artery (1/56), and the superior mesenteric artery (1/56). Early mortality in patients (7/8) was because of the nature of their disease and not related to the surgical intervention. CONCLUSIONS: The GHVG has the ability to create a sutureless anastomosis in a disadvantaged vessel or to promote a potentially better outcome by either avoiding prolonged ischemia to visceral branches or avoiding extensive abdominal or retroperitoneal exposure in an iliofemoral bypass. These results demonstrate the value of the GHVG in complex revascularizations not amenable to traditional open surgical bypass. LEVEL OF EVIDENCE: IV.

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.

Left axillary to right atrium anterior chest wall graft using bovine carotid artery conduit.

INTRODUCTION: Central venous occlusive (CVO) disease involving the superior vena cava (SVC) and inferior vena cava (IVC) can occur frequently in patients with end-stage renal disease (ESRD) on chronic dialysis. Dialysis access is essential for the survival of these patients. CASE DESCRIPTION: We report a case of a chest wall graft creation using bovine carotid artery conduit in a patient who was experiencing life-threatening loss of dialysis access secondary to her SVC and IVC occlusion along with a hypercoagulable state. We did a subcutaneous anterior chest wall graft from the left axillary artery to the right atrium (RA) using a mini thoracotomy incision. CONCLUSIONS: ESRD patients with CVO pose a unique challenge. We believe our approach can provide an excellent option for dialysis access in patients with exhausted conventional access options.

New predictors of complications in carotid body tumor resection.

OBJECTIVE: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. METHODS: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. RESULTS: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92). CONCLUSIONS: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

Revision using distal inflow is a safe and effective treatment for ischemic steal syndrome and pathologic high flow after access creation.

OBJECTIVE: Ischemic steal syndrome (ISS) and pathologic high flow (HF) are a complications after hemodialysis access creation. Their management is complex and varied with most requiring surgical revision for correction of symptoms. Revision using distal inflow (RUDI) has been described in small series for the treatment of ISS. We present our experience with RUDI for the treatment of ISS and pathologic HF. METHODS: We retrospectively reviewed consecutive patients who underwent RUDI for ISS from April, 2010 to March, 2014. Data collection included demographic characteristics, medical histories, subsequent procedures, volume flows, access usage, limb salvage, and patient survival. RESULTS: We performed 29 RUDI procedures in 28 patients (16 women, 12 men). Indications for surgery were pathologic HF in 13 and ISS in 19. Ten percent had previous banding for ISS or HF. Sixty-nine percent of patients had a history of diabetes. Fifty-two percent had a history of atherosclerotic disease. Mean time to intervention from creation was 40 months (range, 6-88 months). Accesses included 1 upper arm graft and 27 brachial artery-based fistulas. Outflow included 25 cephalic veins and 3 basilic veins. Distalization targets were 19 radial arteries and 10 ulnar arteries. Mean flow reduction was 1191 mL/min. Primary assisted patency at 1 year was 74%. Secondary patency at 1 year was 87%. A single access was ligated for continued heart failure after RUDI. ISS symptom resolution was reported as complete in 69% and partial in 31%. CONCLUSIONS: RUDI is an effective and durable treatment of ISS and HF comparable with reported experiences with distal revascularization-interval ligation, proximalization of the arterial inflow, and banding. Patient selection is key for optimizing relief of symptoms and maintaining use of the access.

Retrograde Pedal Access and Endovascular Revascularization: A Safe and Effective Technique for High-Risk Patients with Complex Tibial Vessel Disease.

BACKGROUND: Endovascular revascularization is an established approach for limb salvage in the setting of critical limb ischemia. However, failure rate of antegrade recanalization in complex femoropopliteal to infrapopliteal occlusions is as high as 20%. We report a series of 21 patients who underwent retrograde pedal access and recanalization of below-the-knee chronic total occlusions after failed antegrade attempts. METHODS: This is a retrospective review of prospectively maintained data for all patients who underwent ultrasound-guided percutaneous pedal access for retrograde endovascular treatment of advanced tibial vessel disease between 2011 and 2014. All patients had undergone prior unsuccessful attempts at antegrade revascularization. Pedal vessel access was followed by angioplasty with selective stenting and completion angiogram. Patients were followed up with duplex ultrasound to evaluate for patency. Time-dependent outcomes were determined by Kaplan-Meier survival analyses. Median follow-up was 9 months. RESULTS: A total of 21 patients (17 men, 4 women, mean age 68) underwent retrograde tibial recanalization. Eighty-one percent of the patients presented with Rutherford category 4, 5, or 6 critical limb ischemia. The average Prevent III amputation risk score was 7.0 ± 2.9. Eighteen patients (86%) were medium or high risk (Prevent III amputation risk score ≥ 4). Retrograde pedal access was successful in 95% of the patients (dorsalis pedis = 11, posterior tibial = 5, anterior tibial = 4). Retrograde revascularization was achieved in 14 patients (67%) using balloon angioplasty (n = 14) and additional stent placement (n = 2). Revascularization failed in 7 patients (33%). There were no pedal access site complications. Forty-eight percent of the patients experienced improvement or resolution of their symptoms. The 30-day major adverse cardiac events (MACE), major adverse limb events (MALE), and amputations were all 5%. At 1 year, limb salvage was 88 ± 8% with amputation-free survival of 61 ± 12% and freedom from MALE of 81 ± 10%. Primary assisted and secondary patencies were both 84 ± 10% at 1 year. CONCLUSIONS: Early outcomes for ultrasound-guided retrograde pedal access show that it is safe, with low 30-day mortality, and a low rate of MACE. Freedom from MALE and limb salvage are both high at 1-year follow-up. This technique expands revascularization options after failed conventional endovascular antegrade approaches.