Assessment of Proximal Radio-median Cubital/Radio-Cephalic Arterio-venous Fistula

The present study aims to conducted the Assessment of Proximal radio-median cubital/radio-cephalic Arterio-venous Fistula. Arterio-venous Fistula is life line for long-term hemodialysis for end stage renal disease patients. The order of preference as per National Kidney Foundation/ Kidney Disease Out Come Quality Initiative (KDOQI) is distal Radio Cephalic fistula is considered as gold standard followed by elbow Brachio Cephalic Fistula, transposed Brachio-Basilic Fistula, forearm arterio-venous graft. This is a cross sectional-prospective interventional study, 05/2017 to 04/2019, JNMC, Wardha, MH, with sample size of 66 cases. Out of 66 cases 25 % patients had diabetes mellitus, 48% cases were suffering from chronic glomerulonephritis, 15 % cases were suffering hypertension, 6 % cases had COPD and another 6 % cases had some cardiovascular disease. About 54 % cases had previous access failure. In our study the mean flow volume for AV fistula in proximal forearm was 485± 291 ml/minon postoperative day1, 695 ± 298 on postoperative day 7 and 755± 347 ml/min. Overall postoperative complications in 12% cases was reported in our case study though Yilmiz et al reported postoperative complications in 15% cases.

Prevalence and Risk Factors of Arterio-Venous Fistula Obstruction on Patient with Chronic Kidney Disease

Prevalence and Risk Factors of Arterio-Venous Fistula Obstruction on Patient with Chronic Kidney Disease Ismail MT1, Hariawan H1, Wardhani Y2, Puspitasari M2, Artayasa IPA1, Ramadhan G1, Tarigan T1, Triatmaja R1 1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, 55284, Indonesia 2Department of Internal Medicine Faculty of Medicine Universitas Gadjah Mada-RSUP Dr. Sardjito Yogyakarta Indonesia ABSTRACT Aim: AV fistula obstruction has become one of the main vascular access complications in patients undergoing haemodialysis. This complications have significant impacts on the morbidity and mortality of dialysis patients while also leading to higher medical costs. Clinical monitoring has been routinely used for early detection of AV fistula stenosis and obstruction, however screening with Doppler ultrasound is still not a routine recommendation. This study aims to know prevalence and risk factors of AV Fistula obstruction detected by Duplex ultrasound examination. Methods: This study was a hospital-based descriptive analytic study with cross sectional design conducted at the haemodialysis center of National General Hospital Dr. Sardjito, Yogyakarta, Indonesia. Patient demographic and clinical risk factor were recorded using direct interview. AV fistula obstruction were assessed using Duplex ultrasound by professional sonographer. Results: Seventy four (74) patients are using AV fistula as entry access for hemodialysis in RSUP dr. Sardjito. It is consist of 39 male (53%) and 35 Female (47%). The mean age of patients is 50 years old. Surveillance using Doppler ultrasound found 20 patients (27%) have stenotic AV Fistula. Smoking habits (OR 5.37, 95% CI, 1.760 - 16.431, p=0.002) and diabetes mellitus (OR 5.00, 95% CI, 1.631 – 15.503, p=0.004) increase risk for having stenotic AV fistula. Only 4 patient (20 %) of all 20 patient with stenotic AV fistula were symptomatic, and needed for further vascular intervention Conclusion: Prevalence of AV fistula obstruction detected by Doppler ultrasound was 27% of all AV fistula patient with only 5% had symptomatic AV fistula failure. Smoking habits and diabetes mellitus are important risk factor for AV fistula obstruction. Asymptomatic AV fistula obstruction often goes undetected by clinical monitoring that can increase of risk of symptomatic AV fistula obstruction in the future. The further study is needed to determine level recommendation of routine AV fistula surveillance with Doppler Ultrasound. Key words: AV Fistula obstruction, CKD, Doppler ultrasound surveillance, Risk factors, Prevalence

Сardiorenal Syndrome in Patients on Renal Replacement Therapy

In this chapter authors discusses cardiorenal relationships in patients with renal replacement therapy (RRT) which are considered as a separate type of cardiorenal syndrome (CRS). Frequency and severity of CRS in patients on dialysis are correlated with quantity of years of the dialysis treatment; depend on quality of dialysis regimen and level of residual renal function. RRT-associated cardiac pathology are including left ventricular hypertrophy, ischemic cardiomyopathy, congestive heart failure, coronary atherosclerosis and calcinosis, severe arrhythmias. The article analyzes role of malnutrition and dialysis-induced cachexia, bio-incompatibility of dialysis membranes, oxidative stress and inflammation, arterio-venous fistula, decrease of residual renal function in the development of dialysis-induced CRS. The review examines the mechanisms of progressive myocardial ischemia induced by dialysis: myocardial stunning, hemodialysis-induced hypotension, uremic small vessel disease. Prevention of dialysis-induced CRS includes a choice of the optimal RRT method (peritoneal dialysis or hemodialysis), соntrol of dialysis regimen, residual renal function, biocompatibility of membrane, inflammatory markers, body mass index, serum level albumin, phosphate, calcium, parathyroid hormone, fibroblast growth factor-23. Electrocardiogram, ultrasonic monitoring and coronarography reveals indications for соnservative cardioprotective therapy and angioplasty interventions, including coronary artery bypass surgery and cardiac pacemaker implantation, in patients with dialysis-induced CRS.

Abstract 1122‐000013: Spinal Dural Arterio‐Venous Fistula: A Masquerade as a Longitudinal Myelitis

Introduction : SDAVF are rare and frequently misdiagnosed due to their nonspecific symptomatology and delay of presentation on imaging. Spinal digital subtraction angiogram is the gold standard diagnostic test. Delayed diagnosis and treatment of SDAVF can lead to irreversible neurologic damage. Methods : None Results : Two female patients, 69 and 74 years old, each developed recurrent episodes of subacute worsening myelopathy and urinary retention. The subacute onset of symptoms and longitudinal appearance on cord imaging raised concern for inflammatory myelitis. Despite a negative CSF analysis, and the absence of serum inflammatory, metabolic and infectious markers, the working diagnosis was seronegative neuromyelitis optica spectrum disorder. In accordance, both patients were treated with plasma exchange and IV rituximab, initially displaying stabilization on imaging. However, further worsening and extension of the myelopathy alongside the presence of flow voids in one patient’s repeat MRI nine months post‐presentation raised the question of an alternate etiology. A spinal angiogram was ordered for the patient, revealing SDAVF. Subsequently, the patient underwent complete Onyx embolization of the right L2 feeder and surgical clipping of the right L1 feeder. This resulted in stabilization and improvement of symptoms. Although the second patient did not display flow voids in their MRI, they were ordered a spinal angiogram due to their similar clinical course, indeed confirming SDAVF. The patient underwent successful complete embolization of the L3 segmental artery on the right resulting in improvement of symptoms. Conclusions : Clinicians should have a high index of suspicion for SDAVF when a patient presents with a longitudinally extensive transverse myelitis negative for inflammatory markers and is unresponsive to treatment. While the appearance of flow voids on imaging is a helpful diagnostic feature, these may not be present in patients.

Spontaneous Intracranial Hypotension Without CSF Leakage—Concept of a Pathological Cranial to Spinal Fluid Shift

Objective: Spontaneous intracranial hypotension (SIH) is typically caused by CSF leakage from a spinal dural tear, a meningeal diverticulum, or a CSF venous fistula. However, some patients present with classic orthostatic symptoms and typical intracranial imaging findings without evidence of CSF leakage despite repeated diagnostic work-up. This article aims to elaborate a hypothesis that would explain a pathologically increased orthostatic shift of CSF from the cranial to the spinal compartment in the absence of a CSF leak.Medical Hypothesis: The symptoms of SIH are caused by a decrease in intracranial CSF volume, intracranial hypotension, and downward displacement of intracranial structures. A combination of pathologically increased spinal compliance, decreased intracranial CSF volume, low CSF outflow resistance, and decreased venous pressure might result in a pathological orthostatic cranial-to-spinal CSF shift. Thus, in rare cases, intracranial hypotension may occur in the absence of CSF leakage from the dural sac.Conclusion: We propose a pathophysiological concept for the subgroup of SIH patients with typical cranial imaging findings and no evidence of CSF leakage. In these patients, reducing the compliance or the volume of the spinal compartment seems to be the appropriate therapeutic strategy.

Transvenous embolization of a cerebrospinal fluid–venous fistula for the treatment of spontaneous intracranial hypotension

Cerebrospinal fluid–venous fistula is an increasingly recognized cause of spontaneous intracranial hypotension.1 The site of the leak is between the dural sleeve around a spinal nerve root and the surrounding foraminal veins. In appropriately investigated patients, transvenous embolization of the draining foraminal and paraspinal veins has been shown to be an effective way of treating the disease, with low periprocedural morbidity, improvement in symptoms and radiological appearances.2 Video 1 shows the technique employed in a typical case using Onyx (Medtronic, Minnesota, USA) to embolize a CSF–venous fistula at the right T10 neural foramen.Video 1