Alexandros Mallios

A New Therapeutic Approach to Congenital Pelvic Arteriovenous Malformations

BACKGROUND Internal iliac arteriovenous malformations (AVM) are difficult to treat. Arterial embolization is chosen in most cases but the angio-architecture of these arteriovenous shunts can provide an explanation for the several reported failures. We report the long-term results of peroperative intravenous embolization. METHODS Between the years 1980 and 2008, seven patients were treated for complex and symptomatic internal AVM. These patients underwent a surgery which involved massive embolization of the venous hypogastric compartment, followed by the ligation of the hypogastric vein at its origin. RESULTS There were no deaths reported in this group. The mean follow-up was 7 years (range: 10 months-12 years), with no cases of recurrences found. Computed tomographic scans of controls with reconstruction did not show any residual arteriovenous shunts. CONCLUSION Intravenous embolization of the internal iliac AVM is a therapeutic strategy which is well adapted to the special angio-architecture of the arteriovenous shunts. Clinical and anatomic results have confirmed the validity of this strategy.

Proximal radial artery arteriovenous fistula for hemodialysis vascular access

Objective This study reviewed our experience with proximal radial artery‐based arteriovenous fistulas (PRA‐AVFs) for hemodialysis vascular access, evaluating characteristics of the patients, functional patency, risk of steal syndrome, survival of the patient, and technical considerations. Methods We retrospectively analyzed our database of consecutive patients, identifying those individuals with a PRA‐AVF created during a 12‐year period. In addition to physical examination, all patients underwent ultrasound vessel mapping by the operating surgeon, identifying the PRA‐AVF configuration and outflow target most likely to succeed. Results PRA‐AVFs were created in 1396 individuals during the 12‐year study period. The mean age was 59 years (standard deviation, ±15.9 years); 717 (51%) patients were women, 819 (59%) were diabetic, and 394 (28%) were obese. A transposition procedure was required in 400 patients, and 189 (47%) of these were completed in two‐staged operations. Preoperative characteristics with a negative impact on PRA‐AVF cumulative patency included female gender (hazard ratio, 1.90; 95% confidence interval, 1.37‐2.65), obesity (hazard ratio, 1.92; 95% confidence interval, 1.40‐2.65), and younger age. Dialysis‐associated steal syndrome (DASS) requiring an intervention occurred in 39 (2.8%) patients, and 85% of these were diabetic. The most common procedures required to restore hand perfusion while preserving the AVF were banding and outflow branch ligation or coil occlusion to decrease access flow. DASS emerged spontaneously in 15 (1.1%) of the patients, and 24 (1.7%) individuals developed hand ischemia requiring intervention after fistulography with balloon angioplasty of the PRA‐AVF anastomosis during the first years of the study period. Limiting angioplasty balloon size for such patients avoided these uncommon angioplasty‐induced DASS events in later years. Primary, primary assisted, and cumulative (secondary) patency rates were 60%, 90%, and 93% at 12 months and 47%, 86%, and 91% at 24 months, respectively. Follow‐up was 0.7 to 127 months (median, 25 months). Conclusions PRA‐AVFs offer excellent functional patency with low risk of dialysis access‐related steal syndrome. The antecubital site has a wide range of venous outflow options for both direct PRA‐AVFs and transposition procedures.

When Arteriovenous Fistulas Are Too Deep: Options in Obese Individuals

BACKGROUND Obesity in the hemodialysis population is roughly twice that of the general population. An arteriovenous fistula (AVF) remains the recommended vascular access; however, obesity results in fewer autogenous accesses, more complexity, and higher AVF failure rates. We reviewed our vascular access experience in obese individuals in whom the depth of an AVF prevented reliable cannulation. STUDY DESIGN We reviewed our database of consecutive vascular access patients, identifying individuals in whom the planned venous outflow cannulation segments were too deep and required additional surgical procedures to establish a functional hemodialysis access. These additional procedures included lipectomy, outflow elevation, cephalic transposition, liposuction, or an implantable cannulation guide. RESULTS During the study period, 1,874 consecutive new patients had an autogenous vascular access constructed. We identified 120 patients in whom an additional procedure was required due to the depth of the cannulation sites; these comprised this study group. Ninety-nine (83%) were female, 85 (71%) were diabetic, and 53 (45%) had previous access operations. Body mass index was 25.4 to 62.8 kg/m(2) (mean 40.8 kg/m(2)), age range was 27 to 81 years (mean 54 years), and follow-up was 1 to 101 months (mean 25 months). Primary and cumulative patency rates for all patients were 63% and 93% at 1 year and 46% and 91% after 2 years, respectively. The most common additional procedure performed was a lipectomy (n = 78), with 1-year primary and cumulative patency rates of 78% and 97% and 2-year rates of 69% and 91%, respectively. CONCLUSIONS A variety of surgical options were found to be successful in establishing a functional autogenous vascular access for individuals in whom cannulation sites were simply too deep. Cumulative patency rates for all patients were 93% at 1 year and 91% after 2 years.

Long-Term Preservation of Native Arteriovenous Dialysis Fistulas

Preservation of native arteriovenous fistulas (AVFs) in the long term can be technically challenging. Various anatomic or functional problems can occur and multiple open and/or endovascular interventions may be required for extended preservation of native accesses. In this report, we review vascular access maintenance in a 72-year-old woman during a 5-year period. Multiple complications of her native radiocephalic AVF included recurrent occlusions, a central venous stent fracture and symptomatic venous outflow stenosis. We present this case to illustrate the various techniques and combination of approaches used in the long-term preservation of a native AVF.

Perioperative ultrasound: a critical element in diagnosis and salvage of complex vascular access dysfunction:

Background Perioperative ultrasound performed by the operative surgeon can improve outcomes of vascular access surgery. We present the case of a patient referred for dysfunctional vascular access with two separate and patent right arm arteriovenous fistulas (AVF). Pre-operative ultrasound vessel mapping defined the complex anatomy and intraoperative ultrasound allowed the optimal surgical approach for access salvage while avoiding the need for catheter placement. Case report A 45-year-old male patient of African descent presented with a malfunctioning right forearm AVF and aneurysm formation in the arm. Clinical examination revealed a soft, low-flow forearm fistula merging into a high-flow and pulsatile AVF outflow aneurysm in the arm. Multiple well healed surgical incisions were present. Ultrasound examination revealed two separate AVFs. One was a low-flow radiocephalic AVF at the wrist that was used routinely for cannulation in the forearm, although with some difficulty due to low inflow pressure. The second AVF, a brachiocephalic anastomosis, was pulsatile, aneurysmal, and not in use. Blood flow in the proximal brachial artery was 3.0 L/min. Surgeon-performed ultrasound (SP-US) was used perioperatively to plan the surgical approach and incision, closing the existing brachial anastomosis and creating a veno-venous anastomosis between both outflow veins, establishing a mature and undisturbed cannulation conduit from the wrist through the arm. The revised AVF was immediately usable for hemodialysis with restored normal AVF flow in the forearm and appropriately reduced flow in the arm. Importantly, dialysis catheter placement was avoided.

A new technique for reconstruction of the aortic bifurcation with saphenous vein panel graft

A 60-year-old male patient presented with a false aneurysm of the common iliac artery and methicillin-resistant Staphylococcus aureus septicemia complicating previously placed kissing covered stents of the aortic bifurcation. We removed the prosthetic material and repaired the aortic bifurcation with a composite saphenous vein panel graft. To our knowledge, this technique is presented for the first time in the literature.

Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms With the Endurant Device

BACKGROUND Endovascular treatment of ruptured aortic aneurysms is performed in many centers around the world. New endovascular stent-grafts may prove to improve results. We report our experience with the Endurant device. METHODS From June 2010 to November 2010, we treated five male patients (mean age: 75.8 years) suffering from ruptured abdominal aortic aneurysm with the Endurant device. The mean aneurysm diameter was 90.2 mm; the mean neck length was 13 mm; the mean proximal neck diameter was 27 mm; and the mean proximal angulation was 64°. RESULTS Technical success rate was 100%. In one patient, a proximal leak was diagnosed intraoperatively, and a proximal extension was successfully deployed. No secondary procedures were necessary and no open conversions required during the first admission. One patient required a proximal extension at 3 months for a type I endoleak. The 30-day mortality was 20%, and no further deaths occurred during the follow-up (mean duration: 15 months). CONCLUSION New stent-grafts may ameliorate the prognosis of ruptured abdominal aortic aneurysms. Our experience with the Endurant device has shown promising results. To our knowledge, this is the first report of endovascular treatment of ruptured aortic aneurysms with this stent-graft.

Proximal ulnar artery arteriovenous fistula inflow is an uncommon but useful vascular access option

Introduction A proximal ulnar artery arteriovenous fistula (PUA-AVF) is a logical vascular access option when the distal ulnar artery is occluded or inadequate in addition to other specific vascular anatomic variants. This study reviews a series of patients where the proximal ulnar artery was used for AVF inflow in establishing a reliable autogenous access for these uncommon patients. Materials and methods All new patients referred for vascular access with a PUA-AVF created during an eight-year period were evaluated. In addition to physical and ultrasound examinations, all patients had an Allens test performed augmented with Doppler evaluation of the palmer arch. Analysis placed these patients into three anatomic groups: 1) A dominant radial artery with distal ulnar artery occlusive disease; 2) No cephalic or basilic vein option with an isolated and intact brachial vein originating from the ulnar vein for later staged transposition; 3) A proximal radial artery ≤2 mm in diameter and a normal Doppler augmented Allens test. Results PUA-AVFs were created in 32 new patients during an eight-year period. Primary and cumulative patency rates were 80% and 94% at 12 months and 55% and 81% at 36 months. Follow-up was 2-62 months (mean 14 months). No patients developed steal syndrome during the study period. Conclusions A PUA-AVF is a safe and reliable autogenous access. It is particularly important when the radial artery is the only or dominant arterial supply to the hand, in patients with small but patent radial arteries, and in selected individuals requiring a brachial vein transposition.

De Novo Periaortic Fibrosis after Endovascular Aortic Repair

We report a case of a 63-year-old man presenting with abdominal pain and hydronephrosis secondary to periaortic fibrosis (PAF) 8 months after an endovascular aortic repair (EVAR) using a woven polyester bifurcated graft. De novo delayed PAF after open repair is rare and even more infrequent after EVAR. All 3 previously reported cases occurred after woven polyester grafts and no reported cases after polytetrafluorethylene grafts. Management included steroidal anti-inflammatory treatment and bilateral double J tube placement. Satisfactory results were obtained.

Hybrid Repair of a Hepatic Artery Aneurysm

Visceral arterial aneurysm is a rare pathology. Currently, there are no sufficient data to support the superiority of surgical or endovascular treatment. The choice depends mainly on patient characteristics and the anatomy of the aneurysm. We present a case of a 12-cm fusiform aneurysm of the common hepatic artery. A combined approach including endovascular exclusion of the celiac trunk and surgical closure of the aneurysm was chosen. The postoperative course was uneventful. To our knowledge, this is the first case in the literature describing this combined approach.