Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option.
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PURPOSE: Central venous obstruction is a common problem in patients with chronic renal failure who undergo maintenance hemodialysis. We studied the use of right atrial bypass grafting in nine cases of central venous obstruction associated with upper extremity venous hypertension. To better understand the options for managing this condition, we discuss the roles of surgery and percutaneous transluminal angioplasty with stent placement. METHODS: All patients had previously undergone placement of bilateral temporary subclavian vein dialysis catheters. Severe arm swelling, graft thrombosis, or graft malfunction developed because of central venous stenosis or obstruction in the absence of alternative access sites. A large-diameter (10 to 16 mm) externally reinforced polytetrafluoroethylene (GoreTex) graft was used to bypass the obstructed vein and was anastomosed to the right atrial appendage. This technique was used to bypass six lesions in the subclavian vein, two lesions at the innominate vein/superior vena caval junction, and one lesion in the distal axillary vein. RESULTS: All patients except one had significant resolution of symptoms without operative mortality. Bypass grafts remained patent, allowing the arteriovenous grafts to provide functional access for 1.5 to 52 months (mean, 15.4 months) after surgery. CONCLUSION: Because no mortality directly resulted from the procedure and the morbidity rate was acceptable, this bypass grafting technique was adequate in maintaining the dialysis access needed by these patients. Because of the magnitude of the procedure, we recommend it only for the occasional patient in whom all other access sites are exhausted and in whom percutaneous dilation and/or stenting has failed. (+info)
Totally implantable central venous access ports for high-dose chemotherapy administration and autologous stem cell transplantation: analysis of overall and septic complications in 68 cases using a single type of device.
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Sixty-eight patients suffering from breast cancer, ovarian cancer, lymphoma or multiple myeloma were treated with high-dose chemotherapy and autologous stem cell transplantation. They underwent placement of a central venous port via the subclavian vein for delivery of chemotherapy and reinfusion of stem cells. All patients were followed prospectively for device-related and overall complications, comprising a total of 18,213 days in situ (median: 267 days, range: 90-480). One patient experienced a pneumothorax (1.4%) spontaneously resolved, as an acute toxicity. Two patients (2.8%, 0.1 episodes/1000 days of use) were forced to have the port removed due to infection, caused by Streptococcus mitis in one case, while the causative agent was not identified by laboratory tests in the second. The other 66 patients completed the therapeutic programme, including peripheral stem cell reinfusions and supportive care, such as i.v. antibiotics, antiemetics or fluid administration and blood sample collection, without additional complications. In conclusion, the use of totally implantable central venous access ports has resulted in good long-term access to central veins, in spite of the severe neutropenia and increased septic risk of this category of oncology patients. (+info)
Central venous injuries of the subclavian-jugular and innominate-caval confluences.
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Injuries to the central venous system can result from penetrating trauma or iatrogenic causes. Injuries to major venous confluences can be particularly problematic, because the clavicle and sternum seriously limit exposure of the injury site. We report our institution's experience with central venous injuries of the subclavian-jugular and innominate-caval venous confluences. Significant injuries of the subclavian-jugular venous confluence frequently result from penetrating trauma, while injuries to the innominate-caval confluence are usually catheter-related. Median sternotomy provides adequate exposure of the innominate-caval confluence, while exposure of the subclavian-jugular venous confluence requires extension of the median sternotomy incision into the neck and resection of the clavicle. The literature is reviewed. (+info)
Management of penetrating cervicomediastinal venous trauma.
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OBJECTIVES: to evaluate the results of management of penetrating cervicomediastinal venous trauma. DESIGN: retrospective study. Materials forty-nine consecutive patients with cervical and thoracic venous injuries treated at a tertiary hospital between 1991 and 1997. Method patients identified from a computerised database and data extracted from case records. RESULTS: forty-five patients were male and the mean age was 25.3 years. Forty injuries were due to stabs and 9 to gunshots. 22 patients were shocked, 25 actively bleeding and 31 were anaemic. Veins injured were internal jugular in 25, subclavian in 15, brachiocephalic in 6, and superior vena cava in 3. Injured veins were ligated in 25 cases and repaired by lateral suture in 22. No complex repairs were performed. There were 8 perioperative deaths and 5 cases of transient postoperative oedema. Venous ligation was not associated with increased risk of postoperative oedema. CONCLUSIONS: ligation is an acceptable form of treatment of cervicomediastinal venous injuries in the presence of haemodynamic instability, or where complex methods of repair would otherwise be necessary. (+info)
Exchange of pacing or defibrillator leads following laser sheath extraction of non-functional leads in patients with ipsilateral obstructed venous access.
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Occlusion of the subclavian or brachiocephalic vein in pacemaker or defibrillator patients prohibits ipsilateral implantation of new leads with standard techniques in the event of lead malfunction. Three patients are presented in whom laser sheath extraction of a non-functional lead was performed in order to recanalise the occluded vein and to secure a route for implantation of new leads. This technique avoids abandoning a useful subpectoral site for pacing or defibrillator therapy. The laser sheath does not affect normally functioning leads at the same site. (+info)
Surgical intervention is not required for all patients with subclavian vein thrombosis.
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PURPOSE: The role of thoracic outlet decompression in the treatment of primary axillary-subclavian vein thrombosis remains controversial. The timing and indications for surgery are not well defined, and thoracic outlet procedures may be associated with infrequent, but significant, morbidity. We examined the outcomes of patients treated with or without surgery after the results of initial thrombolytic therapy and a short period of outpatient anticoagulation. METHODS: Patients suspected of having a primary deep venous thrombosis underwent an urgent color-flow venous duplex ultrasound scan, followed by a venogram and catheter-directed thrombolysis. They were then converted from heparin to outpatient warfarin. Patients who remained asymptomatic received anticoagulants for 3 months. Patients who, at 4 weeks, had persistent symptoms of venous hypertension and positional obstruction of the subclavian vein, venous collaterals, or both demonstrated by means of venogram underwent thoracic outlet decompression and postoperative anticoagulation for 1 month. RESULTS: Twenty-two patients were treated between June 1996 and June 1999. Of the 18 patients who received catheter-directed thrombolysis, complete patency was achieved in eight patients (44%), and partial patency was achieved in the remaining 10 patients (56%). Nine of 22 patients (41%) did not require surgery, and the remaining 13 patients underwent thoracic outlet decompression through a supraclavicular approach with scalenectomy, first-rib resection, and venolysis. Recurrent thrombosis developed in only one patient during the immediate period of anticoagulation. Eleven of 13 patients (85%) treated with surgery and eight of nine patients (89%) treated without surgery sustained durable relief of their symptoms and a return to their baseline level of physical activity. All patients who underwent surgery maintained their venous patency on follow-up duplex scanning imaging. CONCLUSION: Not all patients with primary axillary-subclavian vein thrombosis require surgical intervention. A period of observation while patients are receiving oral anticoagulation for at least 1 month allows the selection of patients who will do well with nonoperative therapy. Patients with persistent symptoms and venous obstruction should be offered thoracic outlet decompression. Chronic anticoagulation is not required in these patients. (+info)
Claviculectomy for subclavian venous repair: long-term functional results.
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OBJECTIVES: The purpose of this study was to determine the long-term functional results after medial claviculectomy and venous patch angioplasty or bypass grafting using internal jugular vein after incomplete thrombolysis of effort thrombosis of the subclavian vein. METHODS: The records of 11 patients with effort thrombosis who were treated over the past 9 years were reviewed. Patients have been followed up between 3 and 9 years at 6-month intervals with duplex imaging and contrast venography when indicated and have had an orthopedic evaluation of their shoulder function. RESULTS: All reconstructed veins are patent, and only one patient complains of any arm swelling after prolonged usage. This patient is one of three with postphlebitic changes at the site of repair and has similar findings in her basilic vein. All patients have returned to their prethrombosis vocation without limitation. Four of the 11 patients have jobs requiring heavy physical labor. No patient describes any limitations of shoulder function, but one man who works as a diesel mechanic complains of shoulder aching with overuse with repetitive pulling. Three patients describe upper extremity paresthesias when lying on the operated side. Two patients (one man and one woman) are bothered by the large scar and indentation at the site of the incision. Every patient considers the overall result completely successful from a functional standpoint. CONCLUSIONS: Early subclavian venous repair performed through a medial claviculectomy is a durable operation with excellent long-term functional results. Half of the patients noted minor but significant symptoms, but all are uniformly able to return to normal function. (+info)
Identification of microemboli during haemodialysis using Doppler ultrasound.
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BACKGROUND: Doppler ultrasound methods were used during haemodialysis sessions for the detection of microemboli and determination of their origin. METHODS: A 2-MHz ultrasound probe (Multidop X(4) DWL((TM))) was used to assess the number of microembolic signals (MES) in the subclavian vein downstream from the arteriovenous fistula before the dialysis session and over two periods of 15 min at the beginning and end of haemodialysis sessions in 25 patients without previous cardiovascular disease. A similar probe was used during in vitro studies to detect MES at different sites in the dialysis machine (before and downstream from the blood pump, and before and downstream from the air trap). RESULTS: No MES were detected during in vivo studies before haemodialysis sessions. MES were registered in all patients (100%) at the beginning and end of the haemodialysis procedure at an average of 12.7+/-9 and 16. 7+/-11.5 signals/min respectively. The average intensity of MES was 19.2+/-5.0 dB and 19.4+/-3.9 dB respectively. No MES were detected on the arterial line during in vitro studies. In contrast, 19+/-6 MES/min were detected after the blood pump, 13+/-4.2 before the air trap, and 16.5+/-5.5 thereafter. CONCLUSIONS: In all patients, MES were recorded during haemodialysis sessions in the drainage vein from arteriovenous fistulae. The results of in vitro studies indicate that MES are formed by the blood pump of the haemodialysis machine. The intensity of the MES suggests that they correspond to synthetic particles or microbubbles, which are not detected by the air trap. The final destination of these microbubbles will be assessed in further studies. (+info)