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Usman S, Cheema MAI, Mustafa S, Iftikhar A. Fatal Hemoptysis With Pleural Effusions Secondary to Superior Vena Cava Obstruction as a Complication of Central Venous Catheterization. Cureus 2024; 16:e59690. [PMID: 38840990 PMCID: PMC11150072 DOI: 10.7759/cureus.59690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 06/07/2024] Open
Abstract
This report outlines a rare case of superior vena cava (SVC) syndrome presenting with hemoptysis in a 33-year-old female Jehovah's Witness patient with a complex medical history, including systemic lupus erythematosus (SLE) and chronic hemodialysis dependency due to end-stage renal disease and a failed renal transplant. The SVC syndrome was attributed to occlusion from a right subclavian dialysis catheter. The management of this case was particularly challenging due to the patient's severe anemia and the development of a tension hemothorax following thoracentesis, compounded by her refusal of blood transfusions in adherence to her religious beliefs. A multidisciplinary approach, incorporating bloodless medical techniques such as erythropoietin and iron infusions alongside surgical interventions without blood transfusion, was successfully employed. This case sheds light on the evolving etiology of SVC syndrome and highlights the uncommon but potentially fatal occurrence of hemoptysis as a complication. It also emphasizes the importance of respecting patient values in complex medical decisions.
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Affiliation(s)
| | | | - Saleem Mustafa
- Internal Medicine, Northwell Health, Port Jefferson, USA
| | - Asma Iftikhar
- Pulmonary and Critical Care Medicine, Northwell Health, Port Jefferson, USA
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2
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Jiang Z, Liu M, Zhou L, Chen W, Lou L, Xu L. Effect of early cannulation with metal needles on arteriovenous fistula patency in patients undergoing hemodialysis. J Vasc Access 2024:11297298241245742. [PMID: 38600613 DOI: 10.1177/11297298241245742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Autogenous arteriovenous fistula (AVF) is the preferred vascular access mode. However, the earliest possible time for AVF puncture and whether premature puncture affects the AVF patency rate remain unclear. METHODS In this multicenter retrospective cohort study, adult uremic patients who underwent AVF surgery for the first time at Taizhou Hospital or Enze Hospital of Zhejiang Province between September 1, 2018 and August 31, 2021 were enrolled. All patients were followed up for 1 year after puncture, and the status of fistula establishment and puncture, subsequent patency, loss to follow-up, renal transplantation, conversion to peritoneal dialysis, abandonment of the fistula, and death, were recorded. RESULTS A total of 465 patients with AVFs were included in this study, including 59 (12.7%) patients with fistulas that were cannulated within 30 days. In the early puncture group, the levels of serum creatinine and urea nitrogen were higher, while the levels of hemoglobin and albumin were lower, suggesting that these patients needed urgent dialysis. Furthermore, the rate of non-cuffed catheter use was higher, while the rate of cuffed catheter use was lower, and femoral vein puncture was preferred over internal jugular vein puncture. The mean duration of catheter indwelling was shorter in the early puncture group (19 vs 70 days, p < 0.001). The estimated AVF primary and cumulative functional patency at 12 months was 81.1% versus 82.3% and 98.3% versus 98.7% in the early puncture and control groups, respectively. Kaplan-Meier analysis revealed no significant difference in AVF primary and cumulative functional patency between the two groups. CONCLUSIONS In patients with an established fistula in urgent need of hemodialysis, to avoid new catheterization, a puncture can be performed within 30 days in those with well-developed blood vessels after adequate ultrasound and clinical evaluation without affecting the patency of the fistula.
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Affiliation(s)
- Zuanhong Jiang
- Department of Nephrology, Taizhou Hospital, Zhejiang University, Linhai, Zhejiang, China
| | - Manman Liu
- Department of Nephrology, Taizhou Hospital, Zhejiang University, Linhai, Zhejiang, China
| | - Lingling Zhou
- Department of Nephrology, Taizhou Hospital, Zhejiang University, Linhai, Zhejiang, China
| | - Weizhen Chen
- Department of Nephrology, Taizhou Hospital, Zhejiang University, Linhai, Zhejiang, China
| | - Lili Lou
- Department of Nephrology, Taizhou Hospital, Zhejiang University, Linhai, Zhejiang, China
| | - Liyun Xu
- Department of Nephrology, Taizhou Hospital, Zhejiang University, Linhai, Zhejiang, China
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D'Amico R, Nicoli A, Zdoroveac A, Gürke L, Isaak A. Vascular access challenges in hemodialysis patients with superior vena cava syndrome. J Vasc Access 2024:11297298241227549. [PMID: 38316621 DOI: 10.1177/11297298241227549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Superior vena cava syndrome in hemodialysis patients resulting from previous or current use of a tunneled central vein catheter is a rare but potentially severe condition. Two aspects have to be addressed during management and treatment: the restoration of central venous flow and the creation of an alternative vascular access to guarantee hemodialysis. RESEARCH DESIGN Conforming to the current guidelines and literature, we present a stepwise approach and discuss therapeutic options. The removal of the tunneled central vein catheter should be attempted and a native vascular access created whenever feasible. RESULTS First, an upper extremity AVF should be preserved or, as in our case, made functional. Endovascular treatment of CVSO should primarily consist of balloon dilatation. Placement of a stent or stent graft should be considered as a secondary option. HeRO graft placement may be considered in recurrent CVSO and recanalization with a Surfacer. LL-AVF or AVG need to be discussed and may be an alternative for certain HD patients when the risk of lower limb ischemia and infection is considered. CONCLUSION Several therapeutic options are available and the basic principles are well established in the literature, although the level of evidence is not high. Therefore, we propose a stepwise and interdisciplinary approach to guide the challenging decision-making process in SVC.
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Affiliation(s)
- Rosalinda D'Amico
- Vascular and Endovascular Surgery, Cantonal Hospital Aarau, Aarau, Aargau, Switzerland
| | - Andrew Nicoli
- Vascular and Endovascular Surgery, Cantonal Hospital Aarau, Aarau, Aargau, Switzerland
| | - Andrei Zdoroveac
- Vascular and Endovascular Surgery, Cantonal Hospital Aarau, Aarau, Aargau, Switzerland
| | - Lorenz Gürke
- Vascular and Endovascular Surgery, Cantonal Hospital Aarau, Aarau, Aargau, Switzerland
- Vascular and Endovascular Surgery, University Hospital Basel, Basel, Basel-Stadt, Switzerland
| | - Andrej Isaak
- Vascular and Endovascular Surgery, Cantonal Hospital Aarau, Aarau, Aargau, Switzerland
- Vascular and Endovascular Surgery, University Hospital Basel, Basel, Basel-Stadt, Switzerland
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4
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Ali AE, Al-Balas A, Benson PV, Almehmi A. Fatal superior vena cava rupture complicating dialysis catheter exchange. J Vasc Access 2024:11297298231219288. [PMID: 38166439 DOI: 10.1177/11297298231219288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024] Open
Abstract
Central vein stenosis (CVS) is a common and challenging complication in hemodialysis patients with chronic central venous catheters (CVCs). CVS often remains asymptomatic and is discovered incidentally during follow-up imaging. CVS symptoms include arm swelling, venous hypertension, impaired dialysis flow rates, and development of collateral veins. However, these symptoms can be nonspecific and overlap with other conditions, making the diagnosis challenging. Timely recognition and appropriate intervention are crucial to prevent complications and optimize patient outcomes. Diagnostic tools commonly used include duplex ultrasonography and venography to assess the degree and location of stenosis. Management strategies for CVS encompass a multidisciplinary approach involving nephrologists, interventional radiologists, and vascular surgeons. Initial conservative measures may include anticoagulation therapy, along with pharmacological interventions such as antiplatelet agents and thrombolytics. The endovascular approach is the first line for managing CVS by using balloon angioplasty either alone or in combination with stent placement, but CVS typically recurs frequently, requiring repeated interventions with an increased risk of complications. Additionally, alternative vascular access options such as arteriovenous fistulas or grafts may be considered. In this report, we describe a case of a 25-year-old woman who presented with an extensive history of multiple dialysis access failure for left internal jugular vein central venous tunneled catheter exchange. The procedure was complicated by a fatal superior vena cava rupture likely related to the dislodgment of the guidewire causing perforation into the pericardium space with subsequent cardiopulmonary collapse. The post-mortem autopsy showed severe organized stenosis of SVC and transmural defect above the SVC/atrial junction.
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Affiliation(s)
- Ahmed E Ali
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alian Al-Balas
- Department of Radiology and Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paul V Benson
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ammar Almehmi
- Department of Radiology and Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Xiong J, Wenbo Y, Gao J, Li M, Yu D. Radiofrequency ablation-induced superior vena cava stenosis in a 5-year-old boy with congenital left atrial appendage deformity: a case report and literature review. Front Surg 2023; 10:1199335. [PMID: 37492621 PMCID: PMC10365907 DOI: 10.3389/fsurg.2023.1199335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 07/27/2023] Open
Abstract
Superior vena cava (SVC) stenosis is rarely caused by iatrogenic trauma. Herein, the case of a 5-year-old boy who underwent radiofrequency ablation for paroxysmal supraventricular tachycardia but developed SVC stenosis and related syndromes is reported. Notably, the child exhibited an enlarged left atrial appendage that had partially breached the pericardium. Subsequent interventions involved successful removal of the stenosis, artificial vascular reconstruction, and comprehensive radiofrequency ablation of the entire right atrium, along with ligation of the left atrial appendage under direct vision. As a result, the child experienced relief from symptoms.
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Affiliation(s)
- Jianxian Xiong
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yu Wenbo
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Jianfeng Gao
- The First Clinical Medical College, Gannan Medical University, Ganzhou, China
| | - Meifang Li
- Department of Breast Disease Comprehensive Center, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Dongmin Yu
- Department of Breast Disease Comprehensive Center, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
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Borgquist O, Naddi L, Božović G, Hellberg M, Annborn M, Sjövall F, Adrian M, Hettinger E, Sjöberg P, Kander T. Central venous stenosis after subclavian versus internal jugular dialysis catheter insertion (CITES) in adults in need of a temporary central dialysis catheter: study protocol for a two-arm, parallel-group, non-inferiority randomised controlled trial. Trials 2023; 24:327. [PMID: 37173715 PMCID: PMC10176902 DOI: 10.1186/s13063-023-07350-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The right internal jugular vein is currently recommended for temporary central dialysis catheters (tCDC) based on results from previous studies showing a lower incidence of central vein stenosis compared to the subclavian vein. Data is however conflicting, and there are several advantages when the subclavian route is used for tCDCs. This prospective, controlled, randomised, non-inferiority study aims to compare the incidence of post-catheterisation central vein stenosis between the right subclavian and the right internal jugular routes. METHODS Adult patients needing a tCDC will be included from several hospitals and randomised to either subclavian or internal jugular vein catheterisation with a silicone tCDC. Inclusion continues until 50 patients in each group have undergone a follow-up CT venography. The primary outcome is the incidence of post-catheterisation central vein stenosis detected by a CT venography performed 1.5 to 3 months after removal of the tCDC. Secondary outcomes include between-group comparisons of (I) the patients' experience of discomfort and pain, (II) any dysfunction of the tCDC during use, (III) catheterisation success rate and (IV) the number of mechanical complications. Furthermore, the ability to detect central vein stenosis by a focused ultrasound examination will be evaluated using the CT venography as golden standard. DISCUSSION The use of the subclavian route for tCDC placement has largely been abandoned due to older studies with various methodological issues. However, the subclavian route offers several advantages for the patient. This trial is designed to provide robust data on the incidence of central vein stenosis after silicone tCDC insertion in the era of ultrasound-guided catheterisations. TRIAL REGISTRATION Clinicaltrials.gov; NCT04871568. Prospectively registered on May 4, 2021.
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Affiliation(s)
- Ola Borgquist
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
- Department of Cardiothoracic Surgery, Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden.
| | - Leila Naddi
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
| | - Gracijela Božović
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Matthias Hellberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Nephrology, Skåne University Hospital, Lund, Sweden
| | - Martin Annborn
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Fredrik Sjövall
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Maria Adrian
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Eva Hettinger
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Pia Sjöberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Clinical Physiology, Skåne University Hospital, Lund, Sweden
| | - Thomas Kander
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
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Shriki J, Dave SB. Minor Procedures in Trauma. Emerg Med Clin North Am 2023; 41:143-159. [DOI: 10.1016/j.emc.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Al Saadi W, Al Khalili H, Al Hajriy M. Superior vena cava syndrome-induced hemoptysis. Am J Med Sci 2023; 365:205-211. [PMID: 36152811 DOI: 10.1016/j.amjms.2022.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 04/26/2022] [Accepted: 07/28/2022] [Indexed: 01/11/2023]
Abstract
Superior vena cava (SVC) syndrome resulting from obstruction of the blood flow to the superior vena cava is rarely reported to present with life-threatening hemoptysis. The pathogenesis and the underlying mechanism are still not well described in the literature. We report a unique case of a 27-year-old man known to have end-stage kidney disease (ESKD) on hemodialysis that presented with shortness of breath and life-threatening hemoptysis that developed during the dialysis session. Computerized tomography with contrast (CTPA) confirmed the presence of a large, calcified thrombus within the SVC along with the formation of multiple collaterals which was diagnostic for SVC syndrome. Attempts for revascularization and stenting failed, and the patient had a prolonged and stormy course while admitted, including difficult alternative dialysis access that unfortunately resulted in death eventually. Here we are highlighting the importance of recognition of hemoptysis as a presentation of SVC syndrome by explaining the underlying pathogenesis and possible management options.
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Affiliation(s)
- Waleed Al Saadi
- Internal Medicine Department, Oman Medical Specialty Board, Muscat, Oman.
| | - Huda Al Khalili
- Internal Medicine Department, Oman Medical Specialty Board, Muscat, Oman; Anaesthesia and Critical Care Department, The Royal Hospital, Muscat, Oman
| | - Mahmood Al Hajriy
- Interventional Radiology, Radiology Department, The Royal Hospital, Muscat, Oman
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Abstract
Pediatric hemodialysis access is a demanding field. Procedures are infrequent, technically challenging, and associated with high complication and failure rates. Each procedure affects subsequent access and transplants sites. The choice is made easier and outcomes improved when access decisions are made by a multidisciplinary, pediatric, hemodialysis access team. This manuscript reviews the current literature and offers technical suggestions to improve outcomes.
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Molina-Gil J, Calleja-Puerta S, Rico M. Infarto cerebral por embolismo paradójico secundario a síndrome de vena cava superior por malposición de un catéter de derivación ventriculoauricular. Neurologia 2021; 36:325-327. [DOI: 10.1016/j.nrl.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/25/2020] [Accepted: 05/31/2020] [Indexed: 11/17/2022] Open
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Molina-Gil J, Calleja-Puerta S, Rico M. Ischaemic stroke secondary to paradoxical embolism as a consequence of superior vena cava syndrome by a displacement of a ventriculoatrial shunt. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2020.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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12
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Jadoul M, Labriola L. The great help of a virus in the fight against bacteria! J Nephrol 2021; 34:965-966. [PMID: 33683673 PMCID: PMC7938263 DOI: 10.1007/s40620-021-01013-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Michel Jadoul
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Laura Labriola
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
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Uceda PV, Feldtman RW, Ahn SS. Long Term Results of Bypass Graft to the Right Atrium in the Management of Superior Vena Cava Syndrome in Dialysis Patients. Ann Vasc Surg 2021; 74:321-329. [PMID: 33689760 DOI: 10.1016/j.avsg.2021.01.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/02/2021] [Accepted: 01/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Superior vena cava (SVC) occlusion in dialysis patients is a serious complication that can cause SVC syndrome and vascular access dysfunction. While endovascular therapy has advanced to become the first line of treatment, open surgical treatment may still be needed occasionally. However, no long term outcome data has been previously reported. METHODS We performed a retrospective review of 5 dialysis patients treated with bypass graft to the right atrium from 2012 to 2014. Four patients had severe dysfunction of their upper arm dialysis access as well as superior vena cava syndrome, and one patient with a femoral tunneled dialysis catheter (TDC) had SVC occlusion. None of the patients were candidates for lower extremity access creation or peritoneal dialysis (PD). Three patients underwent a left brachiocephalic-right atrial bypass and 2 underwent a bypass from the cephalic fistula to the right atrium. RESULTS All procedures were technically successful and maintained function of the arteriovenous fistulas or allowed creation of a new upper extremity dialysis graft. One-year secondary patency rate of the bypass was 100%. Longer follow up revealed that one patient died of leg sepsis and another one of a stroke within 14 months after the procedure. Another patient did well for 16 months when recurrent graft thrombosis occurred; and ultimately the graft failed after 31 months despite multiple interventions. Two patients maintained bypass graft patency during a follow up of 78 months; however, they underwent multiple endovascular interventions (23) and open vascular access procedures (4) to maintain hemodialysis function. CONCLUSION Bypass grafts to the right atrium in dialysis patients with SVC occlusion are successful in maintaining function of already existing vascular access or new ones. Long term secondary patency can be achieved but requires strict follow up and a proactive endovascular strategy to treat lesions in the access and or the bypass graft.
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Affiliation(s)
- Pablo V Uceda
- DFW Vascular Group, Dallas, TX; Department of Surgery, Methodist Dallas Medical Center, Dallas, TX
| | - Robert W Feldtman
- DFW Vascular Group, Dallas, TX; Department of Surgery, Methodist Dallas Medical Center, Dallas, TX; Division of Cardiothoracic Surgery, Methodist Dallas Medical Center, Dallas, TX; TCU School of Medicine, Fort Worth, TX
| | - Sam S Ahn
- DFW Vascular Group, Dallas, TX; Department of Surgery, Methodist Dallas Medical Center, Dallas, TX; TCU School of Medicine, Fort Worth, TX.
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Uceda PV, Peralta Rodriguez J, Vela H, Lozano Miranda A, Vega Salvatierra L, Feldtman R, Ahn SS. Management of Superior Vena Cava Occlusion Causing Bleeding "Downhill" Esophageal Varices. J Endovasc Ther 2021; 28:469-473. [PMID: 33480291 DOI: 10.1177/1526602821989330] [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] [Indexed: 11/15/2022]
Abstract
The health care system in Peru treats 15,000 dialysis patients annually. Approximately 45% of patients receive therapy using catheters. The incidence of catheter-induced superior vena cava (SVC) occlusion is increasing along with its associated significant morbidity and vascular access dysfunction. One of the unusual manifestations of this complication is bleeding "downhill" esophageal varices caused by reversal of blood flow through esophageal veins around the obstruction to the right atrium. Herein is presented the case of an 18-year-old woman on hemodialysis complicated by SVC occlusion and bleeding esophageal varices who underwent successful endovascular recanalization of the SVC. Bleeding from "downhill" esophageal varices should be considered in the differential diagnosis of dialysis patients exposed to central venous catheters. Aggressive endovascular treatment of SVC occlusion is recommended to preserve upper extremity access function and prevent bleeding from this complication.
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Affiliation(s)
| | | | - Hernán Vela
- Thoracic and Cardiovascular Surgery, Hospital Nacional Dos de Mayo, Lima, Peru
| | | | | | - Robert Feldtman
- DFW Vascular Group, Dallas, TX, USA.,TCU School of Medicine, Fort Worth, TX, USA
| | - Sam S Ahn
- DFW Vascular Group, Dallas, TX, USA.,TCU School of Medicine, Fort Worth, TX, USA
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15
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Uceda PV, Feldtman RW, Peralta J, Ahn SS. Endovascular treatment of type 3 and 4 thoracic central vein obstruction in hemodialysis patients. J Vasc Surg Venous Lymphat Disord 2020; 9:643-651.e3. [PMID: 33096274 DOI: 10.1016/j.jvsv.2020.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Thoracic central vein (TCV) obstruction (TCVO) in the presence of upper extremity (UE) hemodialysis access can present as superior vena cava syndrome (SVCS) and cause vascular access dysfunction and failure. We report the techniques and results of endorevascularization of TCVO in hemodialysis patients, which allowed for long-term functioning vascular access in the UE. METHODS From June 2009 to February 2020, 45 hemodialysis patients underwent TCV endorevascularization. The indications for surgery were TCVO or SVCS that threatened the function of a preexisting upper arm access or contraindicated placement of a new upper arm access. Conventional endovascular techniques were used when feasible. Patients with unfavorable anatomy were treated using a transseptal needle to cross difficult intrathoracic stenosis and occlusions or to facilitate an inside-out central venous access technique. The reestablishment of venous outflow was accomplished with angioplasty, stenting, and/or placement of HeRO conduits. Successful revascularization was followed by hemodialysis access revision or a new UE access placement. We recorded the risk factors and procedural outcomes, patency rates, complications, and mortality. RESULTS The mean age was 53 ± 16.3 years, and 51% were women. The most common risk factors were diabetes mellitus (64.2%) and hypertension (56%). Twenty-five patients (55.5%) had symptoms of SVCS. These symptoms resolved after the TCV procedure in all cases. Crossing of the TCV lesion was successful using a conventional catheter and wire in 26 cases (57.8%) and transseptal needle in 17 cases (37.8%), including 12 using an inside-out central venous access technique. Treatment of the TCV lesion included a HeRO conduit in 20 cases (44.4%), stenting in 17 (37.7%), and transluminal balloon angioplasty alone in 7 (15.5%). Other veins were treated in 33 cases (73.3%). The overall technical success rate was 95.5%. Two intraoperative complications occurred, including one case of severe hypotension and one of fatal cardiac tamponade. Of the 16 patients with preexisting UE access, its function was preserved in all 16 (100%). In 24 of 27 patients (85.7%), new arm access was successfully created after the TCV procedure. The overall clinical success rate was 88.9%. The average follow-up was 663.4 days (median, 507 days; range, 0-2679 days). During follow-up, 26 patients had undergone 90 procedures to maintain access function, 21 had undergone repeat endovascular interventions, and 17 had undergone open procedures. Eight patients (17.8%) had developed infection, five involving HeRO conduits that required excision with loss of access. During the follow-up period, 14 patients (31%) had died of unrelated causes, and 34 patients (75.5%) maintained functional access. CONCLUSIONS The results of the present study have shown that endorevascularization of TCVO reconstruction is effective in maintaining function or allowing the creation of UE hemodialysis access, with acceptable complication rates.
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Affiliation(s)
- Pablo V Uceda
- DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex; Crescent Medical Center, Lancaster, Tex
| | - Robert W Feldtman
- DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex
| | - Julio Peralta
- Departamento de Cirugia Toracica y Cardiovascular, Hospital Nacional Dos de Mayo, Lima, Peru
| | - Sam S Ahn
- DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex; Department of Surgery, Texas Christian University School of Medicine, Fort Worth, Tex.
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The Face Is the Mirror of the Soul. The Cardiovascular Physical Exam Is Not Yet Dead! Curr Probl Cardiol 2020; 46:100644. [PMID: 32600656 DOI: 10.1016/j.cpcardiol.2020.100644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/07/2020] [Indexed: 11/20/2022]
Abstract
Cardiac pathology can be congenital or acquired with underlying genetic predispositions. In this era of medicine there is a concern that the comprehensive physical examination doctors prided themselves on is becoming a lost art. Research studies have also revealed a decline in physical examination skills. The full clinical cardiovascular examination is indeed quite complex and does take significant time to master. It is critical that physicians be competent in the physical exam. Not identifying subtle clinical findings leading to missed or delayed diagnosis which can lead to significant morbidity and mortality. In this paper we intend to highlight the clinical cardiovascular findings that may be detected on patients even before initiating the physical exam. The head and neck visual examination may be quite revealing.
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Elmoheen A, Eltawagny M, Elmesery A, Bashir K. Sore throat turned to be a bronchogenic carcinoma with superior vena cava syndrome. BMJ Case Rep 2019; 12:12/12/e231738. [PMID: 31822531 PMCID: PMC6904152 DOI: 10.1136/bcr-2019-231738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Superior vena cava (SVC) syndrome is a group of symptoms caused by complete or partial obstruction of the flow of blood through the SVC. The obstruction is, in most cases, caused by the formation of thrombus or infiltration of a tumour through the vessel wall. The result is venous congestion that creates a clinical situation relating to increase in the venous pressure in the upper part of the body. Symptoms commonly associated with vena cava syndrome include cough, dyspnoea, swelling of the neck, face and the upper extremities and dilation of the chest vein collaterals. In this paper, we examine the case of a 50-year-old man who presented to the emergency department with ‘sore throat’ which can be easily misdiagnosed as a case of uncomplicated acute pharyngitis. It was a real challenge to diagnose our patient as SVC syndrome caused by bronchogenic carcinoma.
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Affiliation(s)
- Amr Elmoheen
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Ahmed Elmesery
- Radiology Department, Sultan Qaboos Hospital, Salalah, Oman
| | - Khalid Bashir
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
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Chylothorax and Chylopericardium: A Complication of Long-Term Central Venous Catheter Use. Case Rep Pulmonol 2019; 2019:4908259. [PMID: 31380138 PMCID: PMC6657625 DOI: 10.1155/2019/4908259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022] Open
Abstract
The development of chylothorax and chylopericardium is an uncommon complication of the long-term use of central venous catheters. We describe a unique case of an end stage renal disease patient on hemodialysis with a left jugular tunneled catheter who developed superior vena cava syndrome. Our patient presented with both a large pleural and pericardial effusion that despite drainage continued to reaccumulate. Further imaging with CT scan of the thorax revealed stenosis of the superior vena cava leading to recurrent chylothorax and chylopericardium.
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Sherman RA. Briefly Noted. Semin Dial 2019. [DOI: 10.1111/sdi.12776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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