Fistula cannulation with a Novel fistula cannula - A single centre experience

Venkatesh Rajkumar

Stent Graft for recurrent cephalic arch stenosis - A series of three cases

Venkatesh Rajkumar

Arterio-venous fistula by Nephrologist in COVID era

Nikita Pawar

Rescue therapy of an irrtrievable tunneled cuffed hemodialysis central venous catheter

Dr. Sandeep Sunildatt Singhal

9940281538

venkydr_82@yahoo.com

Venkatesh Rajkumar manan doshi

Fistula cannulation with a Novel fistula cannula - A single centre experience

Vascular Access

Introduction : Arterio venous fistulas (AVF) are traditionally cannulated with metallic needles throughout the globe. Using a novel fistula cannula in place of metal needles can offer significant advantages with reduced complications.

Methods & Results : We report 75 consecutive sessions of dialysis done with a novel AVF cannula ((Argyle®, Medtronic, 16G,30mm) which has an anti-reflux valve and a safety mechanism against needle stick injuries. Only AVFs were cannulated. Both upper arm and forearm AVFs were included. Technical success is 100%. There were no major/minor complications. There were no patient complaints which could be attributed to the cannula. Long term follow up is awaited

Conclusion and Discussion :

The Novel AVF cannula could be successfully placed by dialysis technicians after a mandatory demonstration in five cases.. It could be placed easily in forearm and upper arm AVFs including the tortuous ones as the cannula is flexible. Required blood flow could be obtained in all patients. There were no side effects/complications attributable to the cannulas as were needle stick injuries.Fixing the cannula needed extra training as it does'nt have the wings present in a conventional needle. The cost is significantly higher than a conventional needle . AVF cannulas offer a number of advantages over metallic needles for AVF cannulation and their long term effectiveness needs to be seen.

Reference :

Fistula Cannulation with a Novel Fistula Cannula: A Review of Cannulation Devices and Procedures Federico Nalesso a, b Francesco Garzotto a, b Eva Muraro b Alessandra Brendolan a, b Claudio Ronco a, b ,

9940281538

venkydr_82@yahoo.com

Venkatesh Rajkumar senguttuvan

Stent Graft for recurrent cephalic arch stenosis - A series of three cases

Interventional Nephrology

Introduction : Cephalic arch(CA)stenosis is a common problem faced in Arterio-venous fistulas(AVF) particularly in upper arm brachio-cephalic (BC) AVFs. It could be refractory to conventional percutaneous balloon angioplasty(PTA)and could be recurrent and problematic. Stent graft(SG) could be an attractive treatment option in such cases

Methods & Results : we present a prospective analysis of 3 patients with BC AVF with recurrent CA stenosis . After opening the lesion with a high pressure PTA(Boston,Mustang),a SG(Bard fluency plus) was inserted in each patient successfully. The patients were followed up at monthly intervals .A mandatory check venogram was done at 6 and 12 months. All three stent grafts remained patent at 12 months with little/no instent stenosis.

Conclusion and Discussion :

A stent graft is typically used in three situations in dialysis access and cephalic arch stenosis is one such. The other two being graft vein anastamotic stenosis in an AV graft and an in-stent stenosis. CA stenosis can be difficult to manage particularly if its recurrent or refractory to conventional PTA. SG is an attractive option in recurrent cases. It could be done with good technical and clinical success. It is clearly shown to be superior to conventional PTA alone in this situation. We report a prospective analysis of three such cases where we had used an SG. The long term patency is good (100%) at 6 and 12 (66.6%) months.

Reference :

7016222748

nikitapawar159@gmail.com

Nikita Pawar Vinant Bhargava Priti Meena A K Bhalla Ashwini Gupta Manish Malik Anurag Gupta Vaibhav Tiwari D S Rana

Arterio-venous fistula by Nephrologist in COVID era

Vascular Access

Introduction : An outbreak of the novel coronavirus (COVID-19) is challenging the healthcare system globally. There have been concerns regarding performing vascular access procedures for chronic kidney disease patients worldwide. We hereby share our experience of performing arterio-venous fistula surgery during this pandemic.

Acknowledgement : Sir Ganga Ram Hospital, Nephrology Department.

Methods & Results : A single centre observational study was conducted at Sir Ganga Ram Hospital, New Delhi, India. We enrolled 25 chronic kidney disease patients who underwent radio-cephalic arterio-venous fistula (rc-AVF) in our department over a period of 3 months. They were followed up at day 7 and at 1 month post procedure for outcomes. Primary outcome was access survival at the end of 1 month. Secondary outcome was access loss due to infection, thrombosis or aneurysm.

Conclusion and Discussion :

In this study majority of patients were diabetics (56%), 9 (36%) patients had chronic glomerulonephritis and 2 (8%) had chronic interstitial nephritis. Other comorbidities were hypertension (22/25), coronary artery disease (7/25), chronic liver disease (1/25). The cases were all COVID negative preoperatively. 21 (84%) were male and 4 (16%) were female with median age of 50 years. The mean systolic blood pressure was 146+ 10 mm of Hg and diastolic blood pressure was 92+12 mm of Hg. AVF failure rate was 12% (3 /25). Of these 3, 2 had poor thrill post procedure which was followed by thrombosis of AVF. The primary cause of access failure was thrombosis (8%). AVF-procedure has been deferred in many centers in India due to limited staff, fear of COVID related dissemination of infection to staff and patient. Priorities were given to thrombosed/ non-functional/ infected dialysis access while new AVF or Graft replacement were deferred as guidelines given by American College of Surgeons (1). We report an 88% success rate at 1 month of follow up. We encourage other units to perform this surgery while maintaining standard universal COVID precautions.

Reference :

Al-Jabir A, Kerwan A, Nicola M, Alsafi Z, Khan M, Sohrabi C, O'Neill N, Iosifidis C, Griffin M, Mathew G, Agha R. Impact of the coronavirus (COVID-19) pandemic on surgical practice-Part 2, Internation ,

09588468573

sndp2412@gmail.com

Dr. Sandeep Sunildatt Singhal Dr Sanjeeth Peter Dr Hardik Patel Dr Sishir Gang

Rescue therapy of an irrtrievable tunneled cuffed hemodialysis central venous catheter

Vascular Access

Introduction : Tunneled cuffed hemodialysis catheters (TCC) have provided effective longterm alternatives in patients who have exhausted or failed other vascular access options(1,2). Long term catheter use can lead to serious sequelae of infection, thrombosis , central vein stenosis and mechanical dysfunction. Rarely, catheters can become firmly adhered to a vessel wall.

Acknowledgement : We acknowledge Dr. Sanjeeth Peter and his team to do such complicated surgery.

Methods & Results : We present a case of 33 year old female patient with ESRD with a 5- year dialysis vintage. She had a complicated vascular access history. She was admitted with fever and no flow from arterial port of TCC which has remained in place for 2 years. TCC removal procedure revealed catheter stuck to a vessel wall and resistant to manipulation which required surgical removal by sternovenotomy along with reconstruction of SVC using autologous pericardial patch.

Conclusion and Discussion :

Tunneled central venous catheters are commonly used in hemodialysis patients. Usually TCCs can be removed by dragging after releasing catheter cuff under local anaesthesia. However, in the event of the catheter getting stuck, then removing it becomes difficult or even impossible sometimes. Stuck catheter is a rare complication but its frequency will very likely increase in the future. The pathogenesis of TCCs incarceration are complicated, including the cumulative indwelling time as the most important risk factor, vessel calcification, repeated catheter-related infections, vascular curvature of cannulation site, fibrin sheath of TCCs , repeated catheterizations in same vessel , female gender and ipsilateral AVF (3-5). The catheter adherence to the vessel wall should be recognized as a serious complication and managed appropriately. Attempting to simply pull out the catheter can potentially result in severe haemorrhage due to tearing of the vessel wall. In cases of indwelling catheters for extended periods appropriate preparation should be made in anticipating this complication during removal - this may include forewarning the anesthesiologist regarding a potentially longer procedure, ensuring necessary endovascular and imaging equipment is available, and the access to a cardiothoracic surgery.

Reference :

Rayner, H. C. & Pisoni, R. L. The increasing use of hemodialysis catheters: evidence from the DOPPS on its significance and ways to reverse it. Semin Dial. 23, 6–10 (2010). , Aitken, E. L. et al. The use of tunneled central venous catheters: inevitable or system failure? J Vasc Access. 15, 344–350 (2014).Little MA, O’Riordan A, Lucey B, et al. A prospective study of complications associated with cuffed, tunneled haemodialysis catheters. Nephrol Dial Transplant. 2001; 11:2194–2200. , Miller LM, MacRae JM, Kiaii M, et al. Hemodialysis tunneled catheter noninfectious complications. Can J Kidney Health Dis. 2016; 3:2054358116669130. , Forneris G, Savio D, Quaretti P, Fiorina I, Cecere P, Pozzato M, Trogolo M, Roccatello D: Dealing with stuck hemodialysis catheter: state of the art and tips for the nephrologist. J Nephrol 2014; ,