Aggressive Costoclavicular Junction Decompression in Patients with Threatened AV Access.

BACKGROUND: A substantial number of patients with threatened arteriovenous (AV) access are found to have stenoses at the costoclavicular junction (CCJ), which frequently are resistant to angioplasty and stenting. We believe that stenoses in this location will not resolve unless bony decompression is performed to relieve the extrinsic compression on the vein. This article describes our short- to medium-term results following such decompression in patients with failing fistulae. METHODS: We reviewed a prospectively maintained database to identify all patients with threatened AV access operated on for stenoses at the CCJ. Pre- and postoperative course along with long-term follow-up were analyzed. RESULTS: Between July 2012 and December 2013, 24 patients with threatened access were operated on for CCJ stenoses at our institution. Fifteen had highly dysfunctional AV fistulae otherwise felt to need ligation, 10 had significant arm and/or head swelling, and 3 required access but had no contralateral options. In 6 patients, the subclavian vein was occluded and 18 stenotic; 5 of these had stents in place through the CCJ. Decompression was performed via claviculectomy in 3 patients, 2 of whom underwent reconstruction (one jugular vein, one prosthetic bypass) and 1 was stented. The other 21 patients underwent first rib resection, 20 via an infraclavicular exposure and 1 via a supraclavicular rib resection. A variety of interventions were performed in the arm, including aneurysm plication, cephalic to deep bypass, one prophylactic distal revascularization interval ligation, and several primary fistulae. 30-Day mortality was minimal: there was one significant hematoma and one hemothorax in a patient who underwent on-table thrombolysis and there were no deaths or cardiac, neurologic, or other significant morbidity. Median length of stay was 2 days. At follow-up up to 20 (median 10) months, 4 patients died of unrelated causes and 1 patient undergoing central reconstruction with prosthetic bypass required excision of this for infection and ligation of his fistula. Two other fistulae failed. One-year assisted primary patency of the fistula was 85%, and of the central bypass, 89%. At last follow-up, the index arm continued to be used for access in 85% of patients, and overall survival was 68%. Virtually all patients experienced dramatic symptom relief. CONCLUSIONS: In this group of high-risk patients whose access was judged otherwise nonsalvageable, excellent symptom relief and long-term fistula and ipsilateral arm use can be achieved with aggressive decompression of the bony CCJ followed by endovascular intervention as needed.

Long-segment plication technique for arteriovenous fistulae threatened by diffuse aneurysmal degeneration: short-term results.

BACKGROUND: A substantial number of patients with autologous arteriovenous fistulas (AVFs) develop diffuse aneurysmal degeneration, which frequently interferes with successful access. These AVFs are often deemed unsalvageable. We hypothesize that long-segment plication in these patients can be performed safely with acceptable short-term AVF salvage rates. METHODS: We reviewed a prospectively maintained database to identify all patients with extensive AVF aneurysmal disease operated on for this problem. RESULTS: Thirty-five patients, 25 (71%) male and 10 (29%) female were operated on between July 2012 and January 2014. AVFs included 23 (66%) brachiocephalic, 5 (14%) radiocephalic, and 7 brachiobasilic (20%) fistulae (one first stage only but in use). The cohort had one or a combination of local pain, arm edema, cannulation issue, recurrent thrombosis, dysfunctional during dialysis, or extreme tortuousity. Time range for AVF creation to consultation ranged from 3 months to 11 years. All underwent long-segment plication over a 20-Fr Bougie with or without segmental vein resection; 3 underwent concomitant first rib resection for costoclavicular stenosis; 21 patients had tunneled catheter placement for use while healing, whereas 13 were allowed segmental use of their AVF during the perioperative period (1 patient was not yet on dialysis). Early in our experience, AVFs were left under the wound, whereas all but one repaired since early 2013 were left under a lateral flap. All patients were followed by clinical examination and duplex. In the 30-day postoperative period, 2 AVFs (5.7%) became infected requiring excision, 2 occluded (5.7%), 1 day 1 and the other at 24 days out, 1 patient developed steal and required DRIL 1 week postoperatively, and 1 patient died, unrelated to his surgery. Postoperative functional primary patency was 88% (30 of 34). Of the patients needing temporary access catheter, mean time to first fistula use was 44 days. No wound or bleeding complications have occurred in repaired AVF left under skin flaps. CONCLUSIONS: In this group of patients whose access was threatened by diffuse aneurysmal degeneration, long-segment placation allowed salvage of 88% of fistulae with relatively low morbidity. Fewer complications are associated by covering the revised fistula with intact skin.

Simultaneous double hemodialysis for the control of refractory hyperammonemia.

INTRODUCTION: In adults, hyperammonemia is generally associated with hepatic dysfunction or as a complication of urinary diversions when infected or obstructed. Hyperammonemia has also rarely been reported in association with multiple myeloma. With modest elevations, hyperammonemia often leads to encephalopathy. However, when ammonia reaches extreme levels cerebral edema and herniation may occur leading to coma, seizures, or death. CASE: We describe a 72-year-old Caucasian male with a history of end-stage renal disease (ESRD) and multiple myeloma who developed profound encephalopathy and eventual obtundation. He was found to have severe hyperammonemia that was not due to any identified hepatic impairment. His hyperammonemia proved to be refractory to medical therapy with cathartics and antibiotics, prolonged high-flux hemodialysis, and even continuous venovenous hemodialysis (CVVHD). This metabolic derangement as well as encephalopathy was eventually reversed with simultaneous CVVHD and extended daily hemodialysis (EDD). A more durable response was achieved after vincristine and dexamethasone were administered, which allowed the patient to resume his previous intermittent hemodialysis (IHD) schedule. The patient regained his full sensorium and was eventually discharged to home. CONCLUSIONS: Simultaneous double hemodialysis may be used as an important adjunct in treating refractory hyperammonemia.