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Fereydooni A, Sgroi MD. Management of thoracic outlet syndrome in patients with hemodialysis access. Semin Vasc Surg 2024; 37:50-56. [PMID: 38704184 DOI: 10.1053/j.semvascsurg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 05/06/2024]
Abstract
Patients with threatened arteriovenous access are often found to have central venous stenoses at the ipsilateral costoclavicular junction, which may be resistant to endovascular intervention. Stenoses in this location may not resolve unless surgical decompression of thoracic outlet is performed to relieve the extrinsic compression on the subclavian vein. The authors reviewed the management of dialysis patients with central venous lesions at the thoracic outlet, as well as the role of surgical decompression with first-rib resection or claviculectomy for salvage of threatened, ipsilateral dialysis access.
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Affiliation(s)
- Arash Fereydooni
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, Suite CJ350, MC5639, Palo Alto, CA, 94304
| | - Michael David Sgroi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, Suite CJ350, MC5639, Palo Alto, CA, 94304.
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2
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Li X, Mantell MD, Trerotola SO. Surgical Referral for Hemodialysis Access Maintenance. Cardiovasc Intervent Radiol 2023; 46:1192-1202. [PMID: 36849837 DOI: 10.1007/s00270-023-03380-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 01/27/2023] [Indexed: 03/01/2023]
Abstract
Hemodialysis access is the lifeline for end-stage renal disease patients. However, dialysis access is associated with a host of complications, including thrombosis, recurrent stenosis, infection, aneurysmal changes and bleeding. Although endovascular therapy remains the first-line treatment owing to its less invasive nature, there are certain situations where surgical referral is recommended or even necessary. Regardless, management of dialysis access complications requires a multidisciplinary approach. Interventional radiologists should be familiar with the appropriate timing for surgical referral to better serve the complex patient population.
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Affiliation(s)
- Xin Li
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street 1 Silverstein, Philadelphia, PA, 19104, USA
| | - Mark D Mantell
- Division of Vascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Scott O Trerotola
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street 1 Silverstein, Philadelphia, PA, 19104, USA.
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Davies MG, Hart JP. Venous thoracic outlet syndrome and hemodialysis. Front Surg 2023; 10:1149644. [PMID: 37035557 PMCID: PMC10073697 DOI: 10.3389/fsurg.2023.1149644] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
Central venous stenotic disease is reported in 7%-40% of patients needing a central venous catheter for dialysis and in 19%-41% of hemodialysis patients who have had a prior central venous catheter. Half of these patients will be asymptomatic. Venous Thoracic Outlet syndrome in hemodialysis (hdTOS) is part of this spectrum of disease. The extrinsic mechanical compression of the subclavian vein at the costoclavicular triangle between the clavicle and 1st rib results in an area of external compression with a predisposition to intrinsic mural disease in the vein. The enhanced flow induced by the presence of a distal arteriovenous access in all patients exacerbates the subclavian vein's response to ongoing extrinsic and intrinsic injury. Repeated endovascular interventions during the maintenance of vascular access accelerates chronic untreatable occlusion of the subclavian vein in the long term. Similar to patients with central venous stenosis, patients with hdTOS can present immediately after access formation with ipsilateral edema or longitudinally with episodes of access dysfunction. hdTOS can be treated in an escalating manner with arteriovenous access flow reduction to <1,500 ml/min, endovascular management, surgical decompression by first rib resection in healthy patients and medial clavicle resection in less healthy patients followed by secondary venous interventions, or finally, a venous bypass. hdTOS represents a complex and evolving therapeutic conundrum for the dialysis community, and additional clinical investigations to establish robust algorithms are required.
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Affiliation(s)
- Mark G. Davies
- Center for Quality, Effectiveness and Outcomes in Cardiovascular Diseases, Division of Vascular and Endovascular Surgery, University of Texas Health at San Antonio, San Antonio, TX, United States
- Correspondence: Mark G. Davies
| | - Joseph P. Hart
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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Cui L, Gao D, Lu X, Gao Z, Yuan H, Hu F. A retrospective cohort study comparing high and low balloon inflation pressure on technical success and patency for treating central venous lesions in patients on chronic hemodialysis. Ren Fail 2021; 43:1281-1287. [PMID: 34503376 PMCID: PMC8439207 DOI: 10.1080/0886022x.2021.1975741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background We aimed to analyze the success rates and the access patency rates at 12 months between patients on chronic hemodialysis with symptomatic central venous stenosis (CVS) or occlusion (CVO), receiving high or low balloon inflation pressure for treatment. Methods We performed a retrospective study in which angioplasty balloons were inflated using a low-pressure or a high-pressure for the management of hemodialysis patients with CVS/CVO. The outcomes of this study were the success rate and the access patency rates at 12 months after balloon angioplasty, and the differences between groups were compared. Results We included a total of 74 patients on hemodialysis and assigned them to the low-pressure or the high-pressure groups. Success rates in patients of the high-pressure group (94.12%) were higher than those in patients of the low-pressure group (67.50%) (p = 0.005). With a total of 59 patients with technical success, at 6 and 12 months after angioplasty, the rates of access patency in the low-pressure group were 68 and 48%, respectively; on the other hand, the primary patency rates in the high-pressure group were 86.67% (6-months) and 76.67% (12-months). The 6 and 12 months post-interventional patency rates were higher in patients of the high-pressure group than those in patients of the low-pressure group (p = 0.10 at 6 months and p = 0.03 at 12 months). Conclusions Compared to balloon angioplasty using a low inflation pressure, hemodialysis patients with CVS/CVO receiving angioplasty using a high inflation pressure have significantly higher technical success and 12-month patency rates.
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Affiliation(s)
- Long Cui
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Dan Gao
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Xiaohan Lu
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Zhao Gao
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Hai Yuan
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Fengqi Hu
- Department of Nephrology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
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Uceda PV, Feldtman RW, Ahn SS. Long-term results and patient survival after first rib resection and endovascular treatment in hemodialysis patients with subclavian vein stenosis at the thoracic outlet. J Vasc Surg Venous Lymphat Disord 2021; 10:118-124. [PMID: 34020110 DOI: 10.1016/j.jvsv.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/05/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Hemodialysis patients with upper extremity vascular access and subclavian vein stenosis at the thoracic outlet can present with significant arm edema and threatened dialysis access that is frequently refractory to endovascular therapy without bone decompression. We have presented our long-term results of first rib resection, followed by endovascular therapy. METHODS We performed a retrospective review of 15 consecutive hemodialysis patients with subclavian vein stenosis treated with first rib resection and endovascular therapy from 2013 to January 2021. The diagnosis was confirmed by ultrasound and venography. Bone decompression was performed with transaxillary or infraclavicular rib resection. RESULTS During the study period, we treated 1440 unique dialysis patients. Of these 1440 patients, 346 had undergone subclavian vein angioplasty. Of the 346 patients, 15 had undergone first rib resection and were the subject of the present report. Of the 15 patients, 10 were women and 5 were men. Their mean age was 56.4 years (range, 30-82 years). The most commonly associated medical conditions were hypertension and diabetes. The mean previous hemodialysis duration was 5.4 years (range, 1-13 years). Fourteen patients had preexisting functioning access and severe arm edema. Nine patients (60%) with subclavian vein occlusion had undergone vein recanalization before the bone decompression procedure. Of the 15 patients, 5 had undergone transaxillary and 10 had undergone infraclavicular first rib resection. In addition, nine patients had undergone simultaneous vein stenting, six had undergone vein stenting within 4 weeks, and one had undergone stenting at 13 months. A stent-graft was used in eight patients and a bare metal stent was used in seven. All preexisting dialysis access sites were used the day after the procedure. The average postoperative stay was 2.6 days (range, 1-8 days). No complications developed. The average follow-up was 35.13 months (range, 4-86 months). The freedom from any subsequent intervention was 50% at 10.5 months. The average number of endovascular procedures per patient during follow-up was 4.6. Ten patients had required access surgery during follow-up. Secondary patency was 100%. The median patient survival was 69.3 months. CONCLUSIONS Symptomatic hemodialysis patients with threatened vascular access caused by subclavian vein stenosis at the thoracic outlet were safely and successfully treated with first rib resection, followed by endovascular techniques. The procedure resulted in no morbidity and preserved dialysis access function in all patients during follow-up. Our experience has confirmed that excellent secondary patency and long-term clinical success can be obtained with regular follow-up, although with multiple secondary interventions. The median survival of 69 months after the procedure suggests it is worthwhile to expend this effort to maintain the hemodialysis access function of these patients.
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Affiliation(s)
- Pablo V Uceda
- DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex
| | - Robert W Feldtman
- DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex; Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, Tex
| | - Samuel S Ahn
- DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex; Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, Tex.
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Lim S, Alarhayem AQ, Rowse JW, Caputo FJ, Smolock CJ, Lyden SP, Kirksey L, Hardy DM. Thoracic outlet decompression for subclavian venous stenosis after ipsilateral hemodialysis access creation. J Vasc Surg Venous Lymphat Disord 2021; 9:1473-1478. [PMID: 33676044 DOI: 10.1016/j.jvsv.2021.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/12/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Central venous stenosis is one of the most challenging complications in patients requiring hemodialysis. Venous thoracic outlet syndrome is an underappreciated cause of central venous stenosis in patients requiring dialysis that can result in failed percutaneous intervention and loss of a functioning dialysis access. Limited data exist about the safety and outcomes of first rib resection in patients requiring hemodialysis, and the results have been confounded by the various surgical approaches used. The purpose of the present study was to evaluate the safety, operative outcomes, and patency of the existing dialysis access after transaxillary thoracic outlet decompression. METHODS A retrospective medical record review was performed from January 2008 to December 2019 of patients who had undergone thoracic outlet decompression for subclavian vein stenosis with ipsilateral upper extremity hemodialysis access. The baseline characteristics and comorbidities were reviewed. The operative and postoperative course were evaluated. The survival and patency rates were analyzed using the life-table method and Kaplan-Meier curve. RESULTS A total of 18 extremities in 18 patients were identified. Their mean age was 59 ± 11 years, and 89% were men. A total of 13 fistulas and 5 grafts were included. All patients had undergone repair via a transaxillary approach. First rib resection, anterior scalenectomy, and circumferential venolysis were performed in all 18 patients. The mean operative time was 99 ± 19 minutes, with an estimated blood loss of 78 ± 66 mL. The median length of stay was 2 days. No patient had died at 30 days. The survival rate at 1 year was 83%. The primary, primary-assisted, and secondary patency at 1 year were 42%, 69%, and 93%, respectively. CONCLUSION Thoracic outlet decompression via the transaxillary approach is a technically feasible and safe operation in patients with ipsilateral upper extremity hemodialysis access. Patients with threatened dialysis access due to subclavian vein stenosis should be carefully evaluated for possible extrinsic compression at the costoclavicular junction. These patients might benefit from transaxillary first rib resection, scalenectomy, and venolysis.
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Affiliation(s)
- Sungho Lim
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Abdul Q Alarhayem
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jarrad W Rowse
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Francis J Caputo
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christopher J Smolock
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sean P Lyden
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lee Kirksey
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David M Hardy
- Department of Vascular Surgery, Sydell and Arnold Miller Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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Eguchi D, Honma K. Results of Stenting for Central Venous Occlusions and Stenoses in the Hemodialysis Patients. Ann Vasc Dis 2020; 13:235-239. [PMID: 33384724 PMCID: PMC7751087 DOI: 10.3400/avd.oa.20-00114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objectives: We aim to investigate the results of stenting for central venous occlusions and stenoses in the hemodialysis patients. Methods: Twenty-nine cases treated with endovascular recanalization with deployment of bare metal stent (BMS) for central venous occlusions (24 cases) and recurrent stenoses (5 cases) between 2014 and 2018 were retrospectively analyzed. Results of these procedures including success rate, operative time, estimated blood loss, morbidity, primary patency, assisted primary patency and freedom from target-lesion revascularization (TLR) were evaluated. Results: Nine lesions were in brachiocephalic vein (Occlusion/Stenosis: 8/1) and 20 lesions were in subclavian vein (Occlusion/Stenosis: 16/4). Procedural success was 94% (29/31 cases) and operation time/estimated blood loss was 68±39 min/28±54 g. Symptom were relieved or disappeared in all successful cases. Morbidity (extravasation of contrast medium) was 3% (1/29). During the period of observation, 1 stent fracture with occlusion and 1 stent migration to periphery were recognized. 1-year primary patency, freedom from TLR, and assisted primary patency were 40% (median patent time: 256 days), 67% (median patent time: 524 days), and 77%, respectively. Conclusion: Stenting for central venous occlusions and stenoses in the hemodialysis patients is safe and durable treatment option. However, considering its off-label use and potential hazard including vessel rupture, stent migration, and stent fracture, the indication for BMS deployment should be conservative, and interventionist should be well acquainted with prevention and measures to these complications. (This is a translation of Jpn J Vasc Surg 2019; 28: 193–198.)
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Affiliation(s)
| | - Kenichi Honma
- Department of Vascular Surgery, Fukuoka City Hospital
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Reindl-Schwaighofer R, Matoussevitch V, Winnicki W, Kalmykov E, Gilbert J, Matzek W, Sengölge G. A Novel Inside-out Access Approach for Hemodialysis Catheter Placement in Patients With Thoracic Central Venous Occlusion. Am J Kidney Dis 2020; 75:480-487. [DOI: 10.1053/j.ajkd.2019.08.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 08/30/2019] [Indexed: 11/11/2022]
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Dougherty MJ. Routine use of large-diameter stent grafts for hemodialysis-related central venous obstruction. J Vasc Surg Venous Lymphat Disord 2020; 8:205-206. [PMID: 32067726 DOI: 10.1016/j.jvsv.2019.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/07/2019] [Indexed: 11/28/2022]
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10
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Percutaneous Costoclavicular Bypass for Thoracic Outlet Syndrome and Cephalic Arch Occlusion in Hemodialysis Patients. J Vasc Interv Radiol 2019; 30:1779-1784. [DOI: 10.1016/j.jvir.2019.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/09/2019] [Accepted: 04/16/2019] [Indexed: 11/30/2022] Open
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DeGiovanni J, Son A, Salehi P. Transposition of external jugular to proximal internal jugular vein for relief of venous thoracic outlet syndrome and maintenance of arteriovenous fistula access for chronic hemodialysis: A new approach. J Vasc Access 2019; 21:98-102. [PMID: 31232170 DOI: 10.1177/1129729819851063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We are reporting a case of venous thoracic outlet syndrome with recurrent subclavian vein thrombosis in the setting of an ipsilateral brachiocephalic arteriovenous fistula for hemodialysis that was malfunctioning due to the central vein obstruction. The patient also had a concomitant external jugular vein origin stenosis. Given her body habitus and aversion to recovery after traditional first rib resection, we elected for an alternative treatment with an external jugular vein to internal jugular vein transposition with balloon angioplasty of the stenosed external jugular origin segment. The goal of this was to provide simultaneous relief of her outlet obstruction symptoms and salvage her dialysis access with a less invasive technique.
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Affiliation(s)
| | - Andrew Son
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Payam Salehi
- Tufts University School of Medicine, Boston, MA, USA.,Department of Surgery, Tufts Medical Center, Boston, MA, USA
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Auyang PL, Chauhan Y, Loh TM, Bennett ME, Peden EK. Medial claviculectomy for the treatment of recalcitrant central venous stenosis of hemodialysis patients. J Vasc Surg Venous Lymphat Disord 2019; 7:420-427. [DOI: 10.1016/j.jvsv.2018.10.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022]
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Wooster M, Fernandez B, Summers KL, Illig KA. Surgical and endovascular central venous reconstruction combined with thoracic outlet decompression in highly symptomatic patients. J Vasc Surg Venous Lymphat Disord 2019; 7:106-112.e3. [DOI: 10.1016/j.jvsv.2018.07.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 07/31/2018] [Indexed: 10/27/2022]
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Schmidli J, Widmer MK, Basile C, de Donato G, Gallieni M, Gibbons CP, Haage P, Hamilton G, Hedin U, Kamper L, Lazarides MK, Lindsey B, Mestres G, Pegoraro M, Roy J, Setacci C, Shemesh D, Tordoir JH, van Loon M, ESVS Guidelines Committee, Kolh P, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Lindholt J, Naylor R, Vega de Ceniga M, Vermassen F, Verzini F, ESVS Guidelines Reviewers, Mohaupt M, Ricco JB, Roca-Tey R. Editor's Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:757-818. [DOI: 10.1016/j.ejvs.2018.02.001] [Citation(s) in RCA: 346] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Wooster M, Reed D, Tanious A, Illig K. Postoperative Pain Management following Thoracic Outlet Decompression. Ann Vasc Surg 2017; 44:241-244. [PMID: 28479443 DOI: 10.1016/j.avsg.2017.03.175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/04/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Thoracic outlet decompression (TOD) is associated with significant postoperative pain often leading to hospital length of stay out of proportion to the risk profile of the operation. We seek to describe the improvement in hospital length of stay and patient pain control with an improved multiagent pain management regimen. METHODS We retrospectively reviewed the hospital length of stay, medication regimen/usage, operative details, and operative indications for all patients undergoing TOD from January 2012 through June 2015. During early experience, single-agent narcotic therapy was the mainstay of postoperatively pain control. Since 2014, we have adopted a regimen consisting of narcotic patient controlled analgesia, oral narcotics, and scheduled ibuprofen and valium, which is transitioned to oral narcotics/valium upon discharge. Operative approach (supraclavicular, infraclavicular, transaxial, or paraclavicular) was determined by patient anatomy and indication for procedure (neurogenic/arterial thoracic outlet syndrome or arteriovenous access dysfunction). RESULTS Seventy-four patients were treated with TOD over the study period: 36 (49.3%) for neurogenic thoracic outlet syndrome, 23 (31.5%) for venous thoracic outlet syndrome, and 15 (19.2%) for arteriovenous access dysfunction. Prior to 2014, the mean length of stay was 4 days with a median pain score of 6. Since 2014, the mean length of stay was 2.6 (P = 0.04) with a median pain score of 4 (P = 0.005). There was no statistically significant difference in the indication for operation or operative approach between the two periods. CONCLUSIONS Since adoption of a multiagent pain management regimen to include scheduled NSAIDs and benzodiazepines, we have reduced the mean pain score experienced by our patients as well as the hospital length of stay.
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Affiliation(s)
- Mathew Wooster
- Division of Vascular and Cardiothoracic Surgery, College of Medicine, University of South Florida, Tampa, FL.
| | - Dana Reed
- Division of Vascular and Cardiothoracic Surgery, College of Medicine, University of South Florida, Tampa, FL
| | - Adam Tanious
- Division of Vascular and Cardiothoracic Surgery, College of Medicine, University of South Florida, Tampa, FL
| | - Karl Illig
- Division of Vascular and Cardiothoracic Surgery, College of Medicine, University of South Florida, Tampa, FL
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Abstract
Angiography of the dialysis access is an important procedure in dealing with dialysis arteriovenous access (AVA) dysfunction. It is an integral part and the initiating procedure for all the interventional procedures performed for the management and salvage of dialysis AVA. The performance of this procedure and normal dialysis access-related anatomy including anatomical variants are discussed. In addition, pathology commonly encountered in association with the anatomy is reviewed.
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Affiliation(s)
- Gerald A Beathard
- University of Texas Medical Branch, Lifeline Vascular Access, Houston, Texas
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17
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McHugh SM, Hussain MA, Aljabri B, Greco E, Al-Omran M. First rib removal and decompression of the thoracic outlet as an indication to facilitate hemodialysis. J Vasc Surg Cases Innov Tech 2016; 2:111-113. [PMID: 38827210 PMCID: PMC11140384 DOI: 10.1016/j.jvscit.2016.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 04/20/2016] [Indexed: 11/19/2022] Open
Abstract
We present two cases of thoracic outlet decompression performed to facilitate hemodialysis through upper limb arteriovenous fistulas. In patients undergoing arteriovenous fistula formation for dialysis access, venous hypertension is a well-known complication. We used a supraclavicular approach in our two reported cases to remove the first rib to facilitate hemodialysis. Dialysis patients presenting with central venous stenosis should be assessed for evidence of extrinsic compression by the first rib as management options differ from those with central venous stenosis due to an intravenous catheter.
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Affiliation(s)
- Seamus M. McHugh
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Mohamad A. Hussain
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Badr Aljabri
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
- King Saud University-Li Ka Shing Collaborative Research Program and Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Elisa Greco
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- King Saud University-Li Ka Shing Collaborative Research Program and Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
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Venous Thoracic Outlet Syndrome as a Cause of Intractable Migraines. Ann Vasc Surg 2016; 39:285.e5-285.e8. [PMID: 27531080 DOI: 10.1016/j.avsg.2016.05.109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 11/22/2022]
Abstract
Thoracic outlet syndrome (TOS) refers to the compression of the neurovascular bundle within the thoracic outlet. Cases are classified by primary etiology-arterial, neurogenic, or venous. In addition to the typical symptoms of arm swelling and paresthesias, headaches have been reported as a potential symptom of TOS. In this report, we describe a patient with debilitating migraines, which were consistently preceded by unilateral arm swelling. Resolution of symptoms occurred only after thoracic outlet decompression. Patients with migraines and concomitant swelling and/or paresthesias, especially related to provocative arm maneuvers, should be considered a possible atypical presentation of TOS and evaluated in more detail.
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Illig KA, Gabbard W, Calero A, Bailey C, Shames M, Armstrong P, Nelson PR. Aggressive Costoclavicular Junction Decompression in Patients with Threatened AV Access. Ann Vasc Surg 2015; 29:698-703. [DOI: 10.1016/j.avsg.2014.11.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/21/2014] [Accepted: 11/23/2014] [Indexed: 10/23/2022]
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Hemodialysis Reliable Outflow device impingement in the subclavian position: a case report. J Vasc Access 2015; 16:428-30. [PMID: 25791275 DOI: 10.5301/jva.5000380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2015] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The purpose of this study is to report a case of Hemodialysis Reliable Outflow (HeRO) device malfunction in the subclavian position secondary to costoclavicular impingement. METHODS AND RESULTS The electronic medical record was reviewed for the patient in question and pertinent imaging was collected and photographs were taken with the patient's consent. The patient presented with signs of outflow obstruction after a period of HeRO venous outflow component function. The outflow component was found to be crushed between the first rib and the clavicle at the costoclavicular junction. CONCLUSIONS This case suggests that costoclavicular impingement should be considered as a mode of outflow failure with the HeRO outflow component in the subclavian position. Other central venous access points should be considered first, and the central veins accessed through the lower extremities are possible alternatives if this failure mode was to arise. First rib resection would also be a viable strategy to relieve impingement at this site.
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Skupien FJ, Gomes RZ, Shimada EH, Brandao RI, Skupien SV. Transposition of cephalic vein to rescue hemodialysis access arteriovenous fistula and treat symptomatic central venous obstruction. J Vasc Bras 2014. [DOI: 10.1590/jvb.2014.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
It is known that stenosis or central venous obstruction affects 20 to 50% of patients who undergo placement of catheters in central veins. For patients who are given hemodialysis via upper limbs, this problem causes debilitating symptoms and increases the risk of loss of hemodialysis access. We report an atypical case of treatment of a dialysis patient with multiple comorbidities, severe swelling and pain in the right upper limb (RUL), few alternative sites for hemodialysis vascular access, a functioning brachiobasilic fistula in the RUL and severe venous hypertension in the same limb, secondary to central vein occlusion of the internal jugular vein and right brachiocephalic trunk. The alternative surgical treatment chosen was to transpose the RUL cephalic vein, forming a venous necklace at the anterior cervical region, bypassing the site of venous occlusion. In order to achieve this, we dissected the cephalic vein in the right arm to its junction with the axillary vein, devalved the cephalic vein and anastomosed it to the contralateral external jugular vein, providing venous drainage to the RUL, alleviating symptoms of venous hypertension and preserving function of the brachiobasilic fistula.
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Illig KA. Management of Central Vein Stenoses and Occlusions: The Critical Importance of the Costoclavicular Junction. Semin Vasc Surg 2011; 24:113-8. [DOI: 10.1053/j.semvascsurg.2011.05.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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