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Pulmonary Hypertension and Hemodialysis Access
Journal of Vascular Surgery
Abstracts
851
Volume 64, Number 3 from vibration and is a significant health hazard to workers in any occupation that relies on the use of vibrating tools. HAVS presents similarly to both hypothenar hammer syndrome and thenar hammer syndrome, which include symptoms such as numbness, tingling, pain, and digital ischemia. Unlike HAVS, these syndromes have different mechanisms of injury and, as a result, different management strategies. The aim of this case report is to demonstrate how HAVS can be distinguished from hypothenar hammer syndrome and thenar hammer syndrome on the basis of history, physical examination, and vascular imaging and its treatment options. Case Report: Our patient was a previously healthy plumber who presented to the clinic in December 2015 after experiencing 5 months of numbness, tingling, and pain in his right hand. He sustained multiple small injuries to the tips of his right thumb and third finger that had not healed after several months. His occupational history included significant use of vibrating power tools, including jackhammers, drills, sanders, and power saws, on a daily basis. Computed tomography angiography and noninvasive vascular studies demonstrated patent ulnar and radial arteries to the level of the wrist. Right upper extremity arteriography revealed occlusions of his ulnar, radial, superficial palmar, deep palmar, and multiple digital arteries with formation of collaterals. Based on his history of prolonged exposure to vibratory tools and the pattern of disease in his imaging studies, we concluded that he had HAVS and advised limited vibration exposure, topical vasodilators, and systemic vasodilators. After several weeks of topical therapy and abstention from use of vibratory tools, the wounds on his right hand healed. Conclusions: This case illustrates the clinical manifestations of HAVS, a debilitating condition affecting people who work with vibratory tools. Vascular damage from HAVS is usually irreversible, and thus a high clinical suspicion and rapid diagnosis are critical. Early diagnosis can be achieved with a good history, physical examination, basic noninvasive studies, and confirmatory endovascular imaging of the affected extremity. Treatments include cessation of vibration exposure, topical vasodilators, and physical therapy.
with pHTN were younger (P ¼ .01) and were less likely to have congestive heart failure (P ¼ .032), peripheral vascular disease (P ¼ .044), or history of a percutaneous coronary intervention (P ¼ .018). Patients with pHTN were more likely to have obstructive sleep apnea (P ¼ .023). Survival was not affected by pHTN status (P ¼ .16). The overall fistula maturation rate (defined as successful two-needle cannulation for 4 weeks) was 78.9%. An upper arm arteriovenous fistula (P ¼ .46), an infraclavicular nonautologous graft of any diameter (P ¼ .38), a two-stage surgery (P ¼ .14), the history of a prior dialysis catheter (P ¼ .56), and pharmacomechanical thrombectomy (P ¼ .98) were not associated with the development pHTN. Patients who underwent cleaner thrombectomy (P ¼ .048) or a subsequent 4- to 7-mm chest wall graft (P ¼ .031) after the index fistula failed were more likely to have pHTN. Only one patient had the fistula ligated for worsening heart failure. Patients who experienced the onset of pHTN after DVA (DVA-pHTN; n ¼ 34 [48.6%]) were compared with patients who had pHTN before DVA (pHTN-DVA; n ¼ 36 [51.4%]). pHTN-DVA patients were less likely to have a history of a myocardial infarction (P ¼ .029). There is no difference in the mean change in right ventricular systolic function after arteriovenous fistula creation in comparing patients with pHTN with patients without pHTN (P ¼ .067) and comparing DVApHTN with pHTN-DVA (P ¼ .77). Conclusions: DVA surgery does lead to pHTN, and patients should be monitored for the development of clinically significant symptoms that merit intervention. In general, it is safe to create DVA and to perform the necessary maintenance interventions regardless of the presence or severity of pHTN. Direct central venous outflow may pose a higher risk for severe pHTN warranting DVA ligation. Author Disclosures: R. Miler: None; J. Bena: None; L. Kirksey: None.
Treatment and 5-Year Follow-Up of a 3-Year-Old Boy With Transection of Femoral Artery and Vein Patrick Bonasso, MD, Alexandre d’Audiffret, MD, Richard Vaughan, MD, and Lakshmikumar Pillai, MD. West Virginia University, Morgantown, WV Objective: The purpose of this study was to present the treatment of a 3-year-old boy with transection of his right femoral artery and vein due to dog bite.
Fig. Right upper extremity arteriogram demonstrating patency of two small areas of the superficial and palmar arches with absence of blood supply to the thumb and diminished blood supply to 2nd-5th digits. Author Disclosures: R. Campbell: None; R. I. Hacker: None.
Pulmonary Hypertension and Hemodialysis Access Roy Miler, MD, James Bena, and Lee Kirksey, MD, MBA. Cleveland Clinic, Cleveland, Ohio Objective: The purpose of this project was to identify the patient’s features and the technical factors related to an increased risk of heart failure with the creation of dialysis vascular access (DVA). Methods: The study included 269 patients with chronic kidney disease who had a baseline and postoperative echocardiogram within 6 months of fistula creation at a single institution between January 2000 and March 2015. There were 37 patients with a1-antitrypsin disease, pulmonary fibrosis or sarcoidosis, and a heart or lung transplant who were excluded, leaving 232 patients in the final cohort. Results: Patients with pulmonary hypertension (pHTN; n ¼ 70 [30.2%]) were compared with patients without pHTN (n ¼ 162 [69.8%]). Patients
Fig 1. Complete avulsion of the right common femoral artery and vein without active bleeding and obvious abdominal wall evisceration.
Abstracts
851
Volume 64, Number 3 from vibration and is a significant health hazard to workers in any occupation that relies on the use of vibrating tools. HAVS presents similarly to both hypothenar hammer syndrome and thenar hammer syndrome, which include symptoms such as numbness, tingling, pain, and digital ischemia. Unlike HAVS, these syndromes have different mechanisms of injury and, as a result, different management strategies. The aim of this case report is to demonstrate how HAVS can be distinguished from hypothenar hammer syndrome and thenar hammer syndrome on the basis of history, physical examination, and vascular imaging and its treatment options. Case Report: Our patient was a previously healthy plumber who presented to the clinic in December 2015 after experiencing 5 months of numbness, tingling, and pain in his right hand. He sustained multiple small injuries to the tips of his right thumb and third finger that had not healed after several months. His occupational history included significant use of vibrating power tools, including jackhammers, drills, sanders, and power saws, on a daily basis. Computed tomography angiography and noninvasive vascular studies demonstrated patent ulnar and radial arteries to the level of the wrist. Right upper extremity arteriography revealed occlusions of his ulnar, radial, superficial palmar, deep palmar, and multiple digital arteries with formation of collaterals. Based on his history of prolonged exposure to vibratory tools and the pattern of disease in his imaging studies, we concluded that he had HAVS and advised limited vibration exposure, topical vasodilators, and systemic vasodilators. After several weeks of topical therapy and abstention from use of vibratory tools, the wounds on his right hand healed. Conclusions: This case illustrates the clinical manifestations of HAVS, a debilitating condition affecting people who work with vibratory tools. Vascular damage from HAVS is usually irreversible, and thus a high clinical suspicion and rapid diagnosis are critical. Early diagnosis can be achieved with a good history, physical examination, basic noninvasive studies, and confirmatory endovascular imaging of the affected extremity. Treatments include cessation of vibration exposure, topical vasodilators, and physical therapy.
with pHTN were younger (P ¼ .01) and were less likely to have congestive heart failure (P ¼ .032), peripheral vascular disease (P ¼ .044), or history of a percutaneous coronary intervention (P ¼ .018). Patients with pHTN were more likely to have obstructive sleep apnea (P ¼ .023). Survival was not affected by pHTN status (P ¼ .16). The overall fistula maturation rate (defined as successful two-needle cannulation for 4 weeks) was 78.9%. An upper arm arteriovenous fistula (P ¼ .46), an infraclavicular nonautologous graft of any diameter (P ¼ .38), a two-stage surgery (P ¼ .14), the history of a prior dialysis catheter (P ¼ .56), and pharmacomechanical thrombectomy (P ¼ .98) were not associated with the development pHTN. Patients who underwent cleaner thrombectomy (P ¼ .048) or a subsequent 4- to 7-mm chest wall graft (P ¼ .031) after the index fistula failed were more likely to have pHTN. Only one patient had the fistula ligated for worsening heart failure. Patients who experienced the onset of pHTN after DVA (DVA-pHTN; n ¼ 34 [48.6%]) were compared with patients who had pHTN before DVA (pHTN-DVA; n ¼ 36 [51.4%]). pHTN-DVA patients were less likely to have a history of a myocardial infarction (P ¼ .029). There is no difference in the mean change in right ventricular systolic function after arteriovenous fistula creation in comparing patients with pHTN with patients without pHTN (P ¼ .067) and comparing DVApHTN with pHTN-DVA (P ¼ .77). Conclusions: DVA surgery does lead to pHTN, and patients should be monitored for the development of clinically significant symptoms that merit intervention. In general, it is safe to create DVA and to perform the necessary maintenance interventions regardless of the presence or severity of pHTN. Direct central venous outflow may pose a higher risk for severe pHTN warranting DVA ligation. Author Disclosures: R. Miler: None; J. Bena: None; L. Kirksey: None.
Treatment and 5-Year Follow-Up of a 3-Year-Old Boy With Transection of Femoral Artery and Vein Patrick Bonasso, MD, Alexandre d’Audiffret, MD, Richard Vaughan, MD, and Lakshmikumar Pillai, MD. West Virginia University, Morgantown, WV Objective: The purpose of this study was to present the treatment of a 3-year-old boy with transection of his right femoral artery and vein due to dog bite.
Fig. Right upper extremity arteriogram demonstrating patency of two small areas of the superficial and palmar arches with absence of blood supply to the thumb and diminished blood supply to 2nd-5th digits. Author Disclosures: R. Campbell: None; R. I. Hacker: None.
Pulmonary Hypertension and Hemodialysis Access Roy Miler, MD, James Bena, and Lee Kirksey, MD, MBA. Cleveland Clinic, Cleveland, Ohio Objective: The purpose of this project was to identify the patient’s features and the technical factors related to an increased risk of heart failure with the creation of dialysis vascular access (DVA). Methods: The study included 269 patients with chronic kidney disease who had a baseline and postoperative echocardiogram within 6 months of fistula creation at a single institution between January 2000 and March 2015. There were 37 patients with a1-antitrypsin disease, pulmonary fibrosis or sarcoidosis, and a heart or lung transplant who were excluded, leaving 232 patients in the final cohort. Results: Patients with pulmonary hypertension (pHTN; n ¼ 70 [30.2%]) were compared with patients without pHTN (n ¼ 162 [69.8%]). Patients
Fig 1. Complete avulsion of the right common femoral artery and vein without active bleeding and obvious abdominal wall evisceration.