Prophylactic Ligature of AV Fistula Prevents High Output Heart Failure after Kidney Transplantation.

BACKGROUND: Arteriovenous (AV) fistulas are considered the gold standard for ensuring safe and long-term vascular access in patients with haemodialysis-dependent end-stage renal disease. However, previous studies demonstrated that high-flow AV fistulas might add additional cardiovascular burden in the post-transplant setting, leading to frequent fistula closure in this population. Currently, there is no consensus regarding management of high-flow fistulas in post-transplant patients with stable kidney function. The present randomized controlled trial examines the effect of prophylactic AV fistula closure on high-output heart failure. METHODS: Twenty-eight kidney transplant patients with stable graft function, absence of pre-existing severe cardiac failure, and brachial arterial flow rate of at least 1,500 mL/min were recruited and randomized in a 1:1 ratio to an intervention and control group, respectively. The intervention group was subject to immediate fistula ligature. Patients within the control group were referred to fistula ligature only if the main study endpoint high-output heart failure was reached. The latter was defined by the presence of at least 1 clinical sign (i.e., worsening NYHA score) and at least 2 of the following echocardiographic parameters: diameter of right atrium (major) >53 mm, right atrium (minor) >44 mm, inferior vena cava ≥21 mm, right pulmonary artery >20 mm, TAPSE <16 mm, systolic pulmonal artery pressure >40 mm Hg, and/or left ventricular eccentricity index <1. During a 24-month follow-up period, quarterly measurements of kidney function, NT-proBNP, and lactate dehydrogenase as well as a biannual echocardiographic check-up were performed. RESULTS: High-output heart failure attributable to high-flow fistula was reported in 5 of 13 control patients (38.5%), whereas no patient in the intervention group presented with clinical and echocardiographic signs of high-output heart failure during the follow-up period. Thus, prophylactic ligature of high-flow fistulas avoided high-output heart failure in our patient population (p = 0.013). Three patients in the control group, however, had to undergo fistula ligature due to aneurysm formation (n = 2) and steal phenomenon (n = 1). Median NT-proBNP levels decreased from 317 ng/L pre-ligature to 223 ng/L post-ligature (p = 0.003). Serum creatinine levels did not significantly differ before and after AV fistula ligature (1.69 vs. 1.60 mg/dL, respectively, p = 0.059). Improvement of echocardiographic findings (e.g., a decrease in systolic pulmonary arterial pressure) was found in 7 of 8 ligature patients but did not reach statistical significance. CONCLUSION: Prophylactic ligature of high-flow AV fistulas after kidney transplantation can avoid high-output heart failure, and a more liberal approach to close AV fistulas might be justified.

Iatrogenic Cardiac Tamponade During Endovascular Aortic and Mesenteric Stent Grafting: A Case Report.

The authors report a case of left ventricular perforation and cardiac tamponade in a patient undergoing endovascular aortic and mesenteric stent grafting. During the procedure, the anesthetist noticed a sudden increase in central venous pressure and a decrease in blood pressure. Cardiac tamponade was suspected and confirmed by transesophageal echocardiography. Pericardiotomy resulted only in temporary stabilization. Emergency sternotomy revealed left ventricular perforation. Both anesthetists and radiologists have to be aware of such rare but severe complications of interventional procedures.

Segmental disruption of the internal elastic lamina as a potential pathogenetic mechanism of a true posttraumatic femoral artery aneurysm, years after single blunt trauma.

We present an unusual case of a true posttraumatic aneurysm of the superficial femoral artery (SFAA) 7 years after a motorcycle accident including blunt trauma to the thigh. Surgical reconstruction was accomplished without any complications by aneurysm resection and interposition of an autologous reversed saphenous vein. Histopathological examination revealed a true aneurysm with segmental disruption and fragmentation of the internal elastic lamina (IEL) in van Gieson's stain. This is a first-time finding in context with SFAA and may represent the pathogenetic explanation for the rare formation of posttraumatic true aneurysms.

Phosphocreatine kinetics in the calf muscle of patients with bilateral symptomatic peripheral arterial disease during exhaustive incremental exercise.

PURPOSE: To investigate the relationship between the atherosclerotic lesion load determined on magnetic resonance angiography (MRA) and phosphocreatine (PCr) kinetics during incremental, exhaustive calf exercise in patients with bilateral, symptomatic peripheral arterial disease (PAD). PROCEDURES: Using a 1.5 Tesla MR scanner, 26 patients with bilateral symptomatic PAD and 24 healthy male controls underwent serial phosphorus-31 MR spectroscopy (31P MRS) during incremental exercise at 2, 3, 4, and 5 Watts. For each increment and recovery, PCr time constants, amplitudes of PCr changes and pH values were calculated from the MR spectra. In patients, the run-off resistance (ROR) was determined on MRA. RESULTS: The patients exhibited significantly (p

Peripheral ischemia caused by paradoxical embolization: an underestimated problem?

Although a patent foramen ovale (PFO) is often found in younger patients with transient ischemic attacks or stroke, paradoxical embolization through PFO is rarely considered as a cause of acute limb ischemia. We report a single-center experience of 5 consecutive patients with limb-threatening ischemia due to paradoxical embolization within a one-year period. All patients were treated by catheter thrombectomy and long-term oral anticoagulation after surgery. The fact that the 5 embolectomies made up 10% of all embolectomies performed in our center during this time interval may indicate that the role of paradoxical embolization is still underestimated in peripheral embolic disease.

Subtotal tongue necrosis in delayed diagnosed giant-cell arteritis: a case report.

Giant-cell arteritis (GCA) is a chronic systemic vasculitis of large- and medium-sized vessels, mainly affecting elderly patients. Headache, vision impairment, jaw claudication, and scalp tenderness are common symptoms. However, diagnosis can be difficult because GCA can affect almost every vascular pathway and lead to a variety of possible manifestations. We report the case of a belated diagnosed GCA, resulting in nearly complete necrosis of the mobile part of the tongue, visual impairment, and neurologic as well as intestinal ischemic symptoms. Aggressive immunosuppressive treatment resolved the symptoms, but the patient remained severely morbid because of bilateral necrosis of the mobile part of the tongue. In any case of unclear ischemic symptoms in an elderly patient, one must keep GCA in mind as the possible culprit disease.