Evaluating and treating venous outflow stenoses is necessary for the successful open surgical treatment of arteriovenous fistula aneurysms.

BACKGROUND: Arteriovenous fistula (AVF) aneurysms (AVFAs) can lead to skin erosion, bleeding, difficult access while on hemodialysis, and poor cosmetic appearance. We reviewed our experience in treating patients with aneurysmal dilatation of their AVF. METHODS: We reviewed clinical data of 48 patients (37 men; overall mean age, 55 years; range, 28-85 years) with an AVFA who underwent treatment during a 30-month period. Relevant clinical variables and treatment outcomes were analyzed. RESULTS: All patients underwent a fistulogram, and 90% required percutaneous angioplasty to improve outflow. Fifty-six percent of patients had one stenotic outflow lesion, and 44% had at least two tandem outflow stenoses that required treatment. Open repair with aneurysmorrhaphy was performed in one stage in 64% of patients and in two stages in 36%. A tunneled hemodialysis catheter was required in 11 patients (23%) until the surgically repaired AVF was ready for use again, comprising 10 patients treated with single-stage surgery and only one patient in the staged group. All AVFAs were effectively treated, and patients were able to maintain functional use of their access when healed. CONCLUSIONS: There is a high association of venous outflow stenoses and AVFA. Comprehensive therapy should encompass treatment of any venous outflow stenoses before open AVFA repair. A two-stage repair may decrease tunneled hemodialysis catheter use in patients with multiple aneurysms.

Implementation of a transition of care pathway for low-risk patients presenting to the emergency department with venous thromboembolism.

Inpatient management of low-risk patients with venous thromboembolism (VTE) places a large resource burden on the healthcare system. Adult patients diagnosed with deep vein thrombosis (DVT) or pulmonary embolism (PE) in the emergency department (ED) have historically been hospitalized and treated with therapeutic anticoagulation. However, over the last two decades, outpatient treatment of patients with acute DVT and low risk PE has become increasingly accepted as an effective and safe option for patients given the low risk of short-term clinical deterioration. The purpose of this project was to establish a transition of care (TCM) program for patients with acute VTE presenting to the ED. The primary goals for the project included better quality patient follow-up in the Vascular Medicine Nurse Practitioner (NP) within one week and medication adherence. The second goal was increasing appropriate ED discharges for patients with low-risk VTE. Outcome metrics include the rate of early discharge of low-risk patients with VTE, follow-up in the Vascular Medicine NP clinic, and anticoagulant adherence.

Ankle-Brachial Index for the Assessment of Peripheral Arterial Disease in the Emergency Department.

Peripheral arterial disease, both acute and chronic ischemia, is a clinical diagnosis encountered in the emergency department setting. The emergency nurse practitioner should be able to recognize the clinical presentation, understand the diagnostic tools available to make an appropriate clinical diagnosis, and know how to coordinate the appropriate treatment plan with a vascular surgeon. Timely and appropriate diagnosis of limb-threatening arterial disease is imperative to restore arterial perfusion and prevent the loss of the lower extremity.

Successful Heart Transplantation in Two Infants With Dextrocardia-Heterotaxy Syndrome.

Infants with dextrocardia-heterotaxy syndrome pose significant surgical challenges to a successful orthotopic heart transplant. Herein we report on 2 infants with dextrocardia-heterotaxy syndrome who underwent complex heart transplantation. A combination of preoperative 3-dimensional chest computed tomography to predict optimal donor size and unique surgical technique resulted in successful outcomes.

Stent Grafts Can Convert Unusable Upper Arm Arteriovenous Fistulas into a Functioning Hemodialysis Access: A Retrospective Case Series.

INTRODUCTION: Not all newly created arteriovenous fistulas (AVFs) successfully mature and develop into a functioning access for hemodialysis. Percutaneous transluminal angioplasty (PTA) and balloon-assisted maturation (BAM) have been utilized to either treat flow-limiting stenoses or to promote and accelerate maturation. We hypothesized that unusable upper arm AVFs can be rescued by conversion to a functional access using the percutaneous placement of a stent graft (SG). METHODS: Clinical data on 12 patients with an early non-usable upper arm AVF underwent percutaneous revision using SGs. There were six brachial-cephalic, three brachial-basilic, and three brachial-brachial vein transposition AVFs. RESULTS: All patients had either at least two or more stenoses (>2 cm) within the fistula conduit, or a long segment stenosis (>4 cm) in combination with shorter segment stenoses. Nine patients had failed PTA. Three patients had failed BAM at outside access centers. All patients were referred for failure to achieve access cannulation and concomitant hemodialysis through the AVF. SGs were placed retrograde toward the arterial anastomoses and ranged in diameter (6, 7, and 8 mm in four, seven, and one patients, respectively). The average length of the SG was 10 cm (range 5-15 cm). All SGs were post-balloon dilated at the time of placement. All AVFs were salvaged, and patients were able to maintain functional use of their access with cannulation occurring through the SG. The primary patency rate at 6 and 12 months was 91% [95% confidence interval (CI), 56-98%] and 65% (95% CI, 32-87%), respectively (n = 11 and 5 at risk, respectively). The secondary patency rate at 6 and 12 months was 100 and 72% (95% CI, 46-93%), respectively (n = 11 and 7 at risk, respectively). CONCLUSION: This report outlines a successful initial experience using SGs to rescue, preserve, and convert an unusable upper arm AVF into a functioning hemodialysis access.

Elevated heparin-induced antibodies are more common in diabetic patients with vascular disease.

Background. Hypercoagulable disorders can lead to deep vein thrombosis (DVT), arterial thrombosis or embolization, and early or recurrent bypass graft failure. The purpose of this study was to identify whether diabetes increased the likelihood of heparin-induced platelet factor 4 antibodies in at risk vascular patients. Methods. We reviewed clinical data on 300 consecutive patients. A hypercoagulable workup was performed if patients presented with (1) early bypass/graft thrombosis (<30 days), (2) multiple bypass/graft thrombosis, and (3) a history of DVT, pulmonary embolus (PE), or native vessel thrombosis. Relevant clinical variables were analyzed and compared between patients with diabetes (DM) and without diabetes (nDM). Results. 85 patients (47 women; age 53 ± 16 years, range 16-82 years) had one of the defined conditions and underwent a hypercoagulable evaluation. Screening was done in 4.7% of patients with early bypass graft thrombosis, 60% of patients were screened because of multiple bypass or graft thrombosis, and 35.3% had a previous history of DVT, PE, or native vessel thrombosis. Of the 43 patients with DM and 42 nDM evaluated, 59 patients (69%) had an abnormal hypercoagulable profile. An elevated heparin antibody level was present in 30% of DM and 12% of nDM patients (chi-squared test P < 0.04). Additionally, DM was associated with a higher likelihood of arterial complications while nDM was associated with a higher rate of venous adverse events (chi-squared test P < 0.003). Conclusions. Diabetes is associated with a higher likelihood of developing heparin-induced antibodies and an increased combined incidence of arterial complications that include early or multiple bypass/graft thrombosis. This finding may influence the choice of anticoagulation in diabetic patients at risk with vascular disease.

What the primary care provider needs to know for limb salvage.

Primary care providers are often the first providers to evaluate a patient for peripheral arterial disease (PAD). Understanding the various presentations of PAD symptoms can prevent the disease from progressing to critical limb ischemia and eventual limb loss. This article provided the primary care provider with information needed to prevent limb loss and promote limb salvage, including risk factor management, clinical presentation, physical exam findings, and treatment options.