Pierfrancesco Frosini

Hybrid simultaneous treatment of thrombosed prosthetic grafts for hemodialysis

Purpose The aim of the study was to evaluate our experience in the hybrid simultaneous treatment (open and endovascular) of acute thrombosis of prosthetic grafts for hemodialysis. Methods Between January 2011 and June 2013, 23 patients with acute thrombosis of a prosthetic graft for hemodialysis were urgently treated with a hybrid simultaneous treatment in order to obtain a prompt restoration of the flow. A new puncture of the graft was scheduled after 24 hours. Results Intraoperative technical success was 100% with a completion angiography showing the restored patency of the graft. As adjunctive procedures, in 6 patients (26.1%) locoregional thrombolysis was necessary and in all cases further endovascular manoeuvres (angioplasty/stenting) were immediately performed to solve a significant stenosis of the venous anastomosis/first tract of the vein. At 24 hours when the first puncture was done, three grafts were occluded resulting in a primary patency of 87%. During the follow-up (mean duration 5.6 months) four reocclusions occurred. In-stent restenosis occurred in all patients undergone stenting. At 1 year the rates of primary patency, primary assisted patency and secondary patency were 58.7%, 78.3% and 87%, respectively. Conclusions In our series the combined simultaneous hybrid approach in urgency maximizes the use of different available techniques, which appeared to improve overall success rate to save a thrombosed graft for hemodialysis. The great difference showed between primary and primary assisted patency demonstrates the necessity of a close follow-up.

Outcomes of three types of native arteriovenous fistula in a single center

Objective To study the outcomes of three different types of native arteriovenous fistula (AVF), the distal (D: radial-cephalic), middle-arm (MA: radial-cephalic) and proximal (P: brachial-cephalic) AVF access creation for hemodialysis patients in a single center. Methods An 8-year retrospective review, from 2006 to 2014, was conducted at a single institution in which the surgical outcomes for three different types of native AVF creation were reviewed. Preoperative duplex vein mapping was obtained in all patients to choose the best vein and site for access. Results There were 317 patients identified with 41 D-AVFs, 120 MA-AVFs and 156 P-AVFs. Younger patients with a lower Charlsons Index were more frequent in the D-AVF group (p = 0.02). Mean operating room time was 15 minutes longer for the MA-AVF group than the two others (p = 0.018). Early failure (thrombosis at 30-day), one-year patency, one-year primary AVF functional patency for the D-AVF, MA-AVF, and P-AVF groups were 2.4% (n = 1), 8% (n = 1), 3.8% (n = 6), (p = 0.14); 97.6% (n = 39), 99% (n = 117), 89% (n = 129), (p<0.001); 80.5% (n = 33), 75.8% (n = 91), and 61.5% (n = 96) (p<0.001), respectively. Reintervention for fistula maturation was required in 17% (n = 7), 23% (n = 28), and 24% (n = 38) (p<0.01). The one-year venipuncture hematoma and steal syndrome occurrences were 9.7% (n = 4), 6.7% (n = 8), 3.8% (n = 6) (p = 0.06); and 0%, 0% and 3.8% (n = 6) (p = 0.04), respectively. In case of failure of either MA-AVF or D-AVF, a P-AVF was always feasible as a second native AVF hemodialysis access. Conclusions D-AVF is still the gold-standard access for hemodialysis. If D-AVF is not possible, MA-AVF should be always investigated before committing to a P-AVF.

Impact of Pedal Arch Patency on Tissue Loss and Time to Healing in Diabetic Patients with Foot Wounds Undergoing Infrainguinal Endovascular Revascularization

Objective To retrospectively evaluate the impact of pedal arch quality on tissue loss and time to healing in diabetic patients with foot wounds undergoing infrainguinal endovascular revascularization. Materials and Methods Between January 2014 and June 2015, 137 consecutive diabetic patients with foot wounds underwent infrainguinal endovascular revascularization (femoro-popliteal or below-the-knee, arteries). Postprocedural angiography of the foot was used to divide the patients into the following three groups according to the pedal arch status: complete pedal arch (CPA), incomplete pedal arch (IPA), and absent pedal arch (APA). Time to healing and estimated 1-year outcomes in terms of freedom from minor amputation, limb salvage, and survival were evaluated and compared among the three groups. Results Postprocedural angiography showed the presence of a CPA in 42 patients (30.7%), IPA in 60 patients (43.8%), and APA in 35 patients (25.5%). Healing within 3 months from the procedure was achieved in 21 patients with CPA (50%), 17 patients with IPA (28.3%), and in 7 patients with APA (20%) (p = 0.01). There was a significant difference in terms of 1-year freedom from minor amputation among the three groups (CPA 84.1% vs. IPA 82.4% vs. APA 48.9%, p = 0.001). Estimated 1-year limb salvage was significantly better in patients with CPA (CPA 100% vs. IPA 93.8% vs. APA 70.1%, p < 0.001). Estimated 1-year survival was significantly better in patients with CPA (CPA 90% vs. IPA 80.8% vs. APA 62.7%, p = 0.004). Conclusion Pedal arch status has a positive impact on time to healing, limb salvage, and survival in diabetic patients with foot wounds undergoing infrainguinal endovascular revascularization.

Massively calcified intravascular cast after removal of a tunneled central vein catheter for hemodialysis.

Vascular calcifications usually affect the arteries, while central vein calcifications are rare. A 45-year-old hemodialysis patient underwent a chest CT scan before central vein catheterization required for arteriovenous access thrombosis, in July 2011. He was on hemodialysis since 1995 and from 2005 on warfarin treatment because of repeated thrombosis and dysfunction of arteriovenous fistula and central vein catheters (CVC). A previous tunneled CVC placed in the left external jugular vein was removed in December 2010. Eight months later a chest CT scan showed a 79-mm irregular, linear, tubular radiopaque density in the superior vena cava and left brachiocephalic vein. The possibility of a retained catheter fragment was considered, but the final diagnosis was: calcified “cast” adherent to the vessel wall. This is the first report of an intravenous calcified “cast” (originating from peri-catheter calcification) retained after removal of a tunneled dialysis CVC. This finding is significant because it mimics a retained catheter fragment possibly leading to misdiagnosis and exposing patients to additional risk for unnecessary retrieving interventions. Catheter removal or over the wire substitution in the presence of a calcified cast could also be considered a risky procedure. Retained calcified cast should be included among the long-term complications of hemodialysis CVCs. At the time of publication, the patient is alive without any complication related to the pathology reported.