This document discusses various vascular access options for hemodialysis when conventional sites are not available, including complex and unconventional approaches. It presents a case report of a patient who experienced asystole during guidewire insertion for hemodialysis catheter placement due to underlying heart block. The patient had pre-existing left bundle branch block and went into asystole when the guidewire was advanced over 35 cm, requiring resuscitation. The document then reviews risks, complications, and recommendations for vascular access procedures in difficult cases.
Endovascular treatments are minimally invasive procedures that are done inside the blood vessels and can be used to treat peripheral arterial disease. Treatments like Anti Platelets, Anti-Diabetics, Statins, Promote Collaterals, etc.
This document discusses complications that can occur during percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). It provides information on recognizing, preventing, and managing various complications including perforations, dissections, radiation exposure, contrast-induced nephropathy, and trapped equipment. Specific techniques are outlined for dealing with complications involving the septal channels, donor arteries, and aortic root. The importance of being prepared with the proper equipment and reversing anticoagulation at the right time is emphasized.
New technology new technique radiofrequency results 5 yearsuvcd
Radiofrequency ablation (RFA) has proven to be a highly effective treatment for varicose veins over 5 years, with occlusion rates similar to carotid endarterectomy. RFA results in minimal complications and excellent improvement in quality of life outcomes based on randomized controlled trials. Technological advances like segmental ablation catheters and consistent energy delivery have simplified the technique and led to more reliable results compared to earlier radiofrequency and other endovenous ablation methods.
Current role of tever in acute and chronic dissection results in chinauvcd
Current Role of TEVER in Acute and Chronic Dissection: Results in China discusses the increasing rates of acute and chronic type B aortic dissection in China, with over 15,000 new cases annually. While there are no standardized treatment guidelines in China, TEVAR is commonly used to treat over 70% of cases, especially those with complications. The use of TEVAR has grown significantly in China since the first case in 1999, with over 12,000 cases treated in 2012. The summary discusses developments in TEVAR techniques and management strategies used in China for various aortic dissection cases and complications.
This document summarizes the surgical technique and complications of central venous catheters for hemodialysis. It discusses the basic concepts, pre-operative evaluation including imaging of central veins, catheter insertion technique, and perioperative and long-term care and complications. The best site for catheter placement is the right internal jugular vein to minimize risks of kinking and central vein stenosis. Ultrasound and fluoroscopy guidance are recommended for accurate placement and tunneling of cuffed catheters. Major perioperative risks include pneumothorax, hemothorax, and nerve injury, while long-term complications consist of infection, thrombosis, stenosis, and catheter malfunction.
Endovascular treatments are minimally invasive procedures that are done inside the blood vessels and can be used to treat peripheral arterial disease. Treatments like Anti Platelets, Anti-Diabetics, Statins, Promote Collaterals, etc.
This document discusses complications that can occur during percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). It provides information on recognizing, preventing, and managing various complications including perforations, dissections, radiation exposure, contrast-induced nephropathy, and trapped equipment. Specific techniques are outlined for dealing with complications involving the septal channels, donor arteries, and aortic root. The importance of being prepared with the proper equipment and reversing anticoagulation at the right time is emphasized.
New technology new technique radiofrequency results 5 yearsuvcd
Radiofrequency ablation (RFA) has proven to be a highly effective treatment for varicose veins over 5 years, with occlusion rates similar to carotid endarterectomy. RFA results in minimal complications and excellent improvement in quality of life outcomes based on randomized controlled trials. Technological advances like segmental ablation catheters and consistent energy delivery have simplified the technique and led to more reliable results compared to earlier radiofrequency and other endovenous ablation methods.
Current role of tever in acute and chronic dissection results in chinauvcd
Current Role of TEVER in Acute and Chronic Dissection: Results in China discusses the increasing rates of acute and chronic type B aortic dissection in China, with over 15,000 new cases annually. While there are no standardized treatment guidelines in China, TEVAR is commonly used to treat over 70% of cases, especially those with complications. The use of TEVAR has grown significantly in China since the first case in 1999, with over 12,000 cases treated in 2012. The summary discusses developments in TEVAR techniques and management strategies used in China for various aortic dissection cases and complications.
This document summarizes the surgical technique and complications of central venous catheters for hemodialysis. It discusses the basic concepts, pre-operative evaluation including imaging of central veins, catheter insertion technique, and perioperative and long-term care and complications. The best site for catheter placement is the right internal jugular vein to minimize risks of kinking and central vein stenosis. Ultrasound and fluoroscopy guidance are recommended for accurate placement and tunneling of cuffed catheters. Major perioperative risks include pneumothorax, hemothorax, and nerve injury, while long-term complications consist of infection, thrombosis, stenosis, and catheter malfunction.
Combined carotid and coronary disease the strategy should beuvcd
1. Combined carotid and coronary artery disease presents challenges in determining the optimal treatment strategy. Performing carotid endarterectomy and coronary artery bypass grafting simultaneously or in stages both carry risks.
2. Factors such as the severity of stenosis in the carotid and coronary arteries, and a patient's surgical risk profile must be considered. High grade stenosis in both territories typically warrants staged procedures to avoid complications.
3. Preventing embolic sources, maintaining adequate cerebral perfusion and temperature, and using monitoring techniques can help reduce risks of central nervous system injuries during combined or staged carotid and cardiac surgeries. Close evaluation of individual patient characteristics is important for surgical planning.
This document discusses the insertion and management of tunneled dialysis catheters. It begins with an overview of venous anatomy and various sites for catheter insertion. Details are provided on equipment, catheter length selection, and the procedure for right internal jugular insertion. Potential acute complications during insertion like arterial puncture, pneumothorax, and air embolism are reviewed along with preventative measures. Subacute issues such as malposition, clotting, and fibrin sheath formation that can cause reduced flow are described. Management of tunnel tract infections is also covered. The document emphasizes safety throughout catheter procedures.
Management of aaa clinical practice guidelines of the esvsuvcd
This document provides guidelines for the management of abdominal aortic aneurysms (AAA). It includes 130 recommendations across 7 chapters covering topics such as screening, decision-making for repair, pre- and post-operative imaging, management of ruptured and non-ruptured AAAs, and follow-up after repair. The guidelines are based on a systematic review of the literature and aim to standardize care and improve outcomes for AAA patients across Europe.
1. There are three main types of vascular access for hemodialysis in children: tunneled catheters, arteriovenous fistulas, and arteriovenous grafts.
2. It is important to educate children with declining kidney function about their vascular access options and the importance of vein preservation for potential future access.
3. The choice of vascular access depends on multiple patient-specific factors and a dedicated vascular access clinic can help increase use of arteriovenous fistulas and decrease use of catheters.
A brief review of complications and tips and tricksEuro CTO Club
This document discusses complications that can occur during percutaneous coronary intervention (PCI) and provides tips for managing them. It begins by classifying PCI complications into coronary (vessel closes or leaks, equipment in wrong place), heart (myocardial infarction, arrhythmia, tamponade), and other (access, thromboembolic, contrast, radiation). Specific tips are then provided for managing perforations including using a covered stent or coils. The document emphasizes being prepared for complications and having a plan, as well as communicating with the medical team to resolve issues promptly.
The document discusses ultrasound guidance for hemodialysis catheter insertion. It notes that all hemodialysis catheters should be placed under ultrasound guidance, while fluoroscopy is needed for cuffed tunneled catheters. It provides statistics on variations in the positioning of the right and left internal jugular veins and cites a reference studying ultrasound guidance for the right internal jugular vein. It also outlines the process for inserting non-cuffed versus cuffed tunneled hemodialysis catheters.
The document discusses the best vascular access options for pediatric chronic kidney disease patients requiring hemodialysis. It notes that central venous catheters are currently the most common primary access for pediatric patients, despite evidence that arteriovenous fistulas have better outcomes when possible. The document recommends early referral to nephrologists and surgeons to allow time for vascular mapping, access planning and maturation. It provides guidance on patient evaluation and criteria for selecting between fistulas, grafts and catheters based on vessel size and other clinical factors. The goal is to minimize catheter use and improve pediatric vascular access outcomes.
Although large efforts are spent for creating fistula as the primary access, use of Hemodialysis Vascular catheters are still the major access on the first Hemodialysis session and after 4 month whether we would like it or not.
"USRDS 2013"
Saturday 1203 – escaned coronary perforationsEuro CTO Club
This document discusses the treatment of coronary perforations during percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). It notes that while coronary perforations are common in CTO PCI, most do not have serious consequences. It then discusses risk factors, classification systems, and specific approaches to treating different types of perforations including main vessel, distal artery, and collateral vessel perforations. Two clinical cases are presented involving perforations during CTO PCI and the management in each case, including the use of covered stents, coils, pericardiocentesis, and in one case emergency surgery. General measures for managing perforations are also outlined.
Post Myocardial infarction vsd repair by infarct exclusion techniqueJyotindra Singh
This case study examines outcomes of 26 patients who underwent surgical repair of a post-myocardial infarction ventricular septal defect (PMIVSD) over a 15-year period. 20 patients underwent defect closure with concomitant coronary artery bypass grafting (CABG), while 6 had defect closure alone. In-hospital mortality was 30.9%, with higher mortality seen in those with cardiogenic shock, posterior defects, and surgery over 3 weeks after infarction. 15 of the 20 patients who had CABG survived, compared to 3 of the 6 who had defect closure alone. Residual shunts occurred in 5 patients but did not require reoperation. Predictors of poor prognosis included cardiogenic shock, timing of surgery, and total
Global Hospitals’ Advanced Heart, Lung & Vascular Institute provides all kinds of endovascular procedures including coronary intervention and peripheral intervention, heart surgery, heart bypass surgery as well as heart transplantation surgery in Hyderabad, Chennai, and Bangalore
This study evaluated outcomes of 26 patients who underwent surgical repair of post-myocardial infarction ventricular septal defect (VSD) at Nizams Institute of Medical Sciences between 1997-2012. 20 patients underwent VSD repair with concomitant coronary artery bypass grafting, while 6 had VSD closure alone. The mean time between MI and VSD appearance was 7.2 days, and between VSD appearance and surgery was 27.2 days. Overall in-hospital mortality was 30.9% and 30-day mortality was 33%. Patients who underwent emergency surgery within 3 days of MI had 100% mortality, while those operated on after 3 weeks had 100% survival. Concomitant CABG during VSD repair was associated with lower
This document provides guidelines for vascular access in children requiring hemodialysis. It recommends that an arteriovenous fistula (AVF) be the preferred initial access when appropriate based on vessel size and surgical expertise. An AVF is created by surgically connecting an artery to a vein, allowing high blood flow that enlarges the vein over time to be used for hemodialysis. The document outlines recommendations for planning, placement, maturation assessment, cannulation, surveillance and thrombosis prevention of AVFs in children.
Endovenous ablation new methods where do we go from hereuvcd
New endovenous ablation methods fall into two categories: thermal tumescent (TT) and non-thermal non-tumescent (NTNT). TT methods like laser, radiofrequency, and steam ablation require tumescent anesthesia while NTNT methods like cyanoacrylate glue, mechanochemical ablation, polidocanol microfoam, and V Block ligation do not. Clinical trials show high occlusion rates of 90-95% at one year for various NTNT techniques with benefits of reduced pain, faster recovery, and ability to treat veins all the way to the ankle without tumescence. NTNT techniques are positioned to become the future standard for treating saphenous vein insufficiency.
Dr. Iyad Feteih presents information on the history and development of inferior vena cava (IVC) filters. The document discusses early surgical methods of IVC interruption and their complications. It then summarizes the development of endoluminal IVC filters beginning with the Mobin-Uddin umbrella in 1967 and the iconic Greenfield filter in 1973. The document provides details on various commercially available IVC filters from companies such as Bard, Cook Medical, Cordis, and Crux Biomedical including specifications, clinical trial results, and complications.
This document provides an overview and introduction to an atlas about dialysis vascular access. It discusses how dialysis depends on vascular access but it is often overlooked. The atlas aims to improve understanding of access anatomy and problems through images. It is intended for physicians, nurses and technicians involved in dialysis access care. The author thanks the groups and individuals who assisted with the project and hopes it leads to improved access care quality.
A speech given in Yodak Hospital, the 6th International Symposium of Cardiac Thorascopic Surgery, 10/25/2014; a report of endoscopic cardiac surgery in Taiwan
Intra-arterial therapy is an effective treatment for acute ischemic stroke when performed within 6 hours of symptom onset. It involves delivering thrombolytics directly into the blocked artery or using mechanical devices to remove the clot. Several studies found intra-arterial therapy improved recanalization rates and led to better functional outcomes and reduced disability compared to intravenous thrombolysis alone. The guidelines recommend intra-arterial therapy as an option for large vessel occlusions when performed at comprehensive stroke centers with experienced staff.
Current status of endovenous ablation for the treatment of venous insufficiencyuvcd
Endovenous ablation procedures such as laser and radiofrequency ablation are becoming more commonly used to treat varicose veins compared to traditional surgery. A randomized clinical trial found that endovenous laser ablation (EVLA) had a lower recurrence rate of varicose veins at 1 year compared to surgery. Another study found similar occlusion rates of veins between radiofrequency ablation and EVLA, but that radiofrequency ablation resulted in less bruising, pain, and faster recovery times. Guidelines now recommend endovenous thermal ablation over high ligation and stripping for treating the great saphenous vein, and recognize endovenous techniques as effective minimally invasive options for varicose vein treatment.
Perforation management of collaterals
Kambis Mashayekhi, Bad Krotzingen, Germany
11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany
This document provides an overview of catheter access options for hemodialysis and their risks and management. The preferred options are an arteriovenous fistula, followed by a graft or tunneled catheter. Complications of catheters include pneumothorax, malposition, arrhythmias, infection, and thrombosis. Infection risks can be reduced through strict sterile technique, antibiotic locks, and catheter removal when unnecessary. Overall, the document discusses vascular access types, placement techniques, complications, and infection prevention for hemodialysis catheters.
This document discusses endovascular interventions for infrapopliteal peripheral vascular disease. Infrapopliteal disease is rising due to an aging population and increased rates of diabetes and kidney disease. Surgical and early endovascular interventions historically had high failure rates in this region. Endovascular procedures now provide an alternative to bypass surgery for treating critical limb ischemia in the infrapopliteal arteries, with the goal of establishing straight line blood flow to the foot. Success depends on factors like number of vessels opened, inflow status, and addressing more proximal disease first when needed. Complications can include access issues, vessel spasm or perforation, embolism, and contrast nephropathy.
Combined carotid and coronary disease the strategy should beuvcd
1. Combined carotid and coronary artery disease presents challenges in determining the optimal treatment strategy. Performing carotid endarterectomy and coronary artery bypass grafting simultaneously or in stages both carry risks.
2. Factors such as the severity of stenosis in the carotid and coronary arteries, and a patient's surgical risk profile must be considered. High grade stenosis in both territories typically warrants staged procedures to avoid complications.
3. Preventing embolic sources, maintaining adequate cerebral perfusion and temperature, and using monitoring techniques can help reduce risks of central nervous system injuries during combined or staged carotid and cardiac surgeries. Close evaluation of individual patient characteristics is important for surgical planning.
This document discusses the insertion and management of tunneled dialysis catheters. It begins with an overview of venous anatomy and various sites for catheter insertion. Details are provided on equipment, catheter length selection, and the procedure for right internal jugular insertion. Potential acute complications during insertion like arterial puncture, pneumothorax, and air embolism are reviewed along with preventative measures. Subacute issues such as malposition, clotting, and fibrin sheath formation that can cause reduced flow are described. Management of tunnel tract infections is also covered. The document emphasizes safety throughout catheter procedures.
Management of aaa clinical practice guidelines of the esvsuvcd
This document provides guidelines for the management of abdominal aortic aneurysms (AAA). It includes 130 recommendations across 7 chapters covering topics such as screening, decision-making for repair, pre- and post-operative imaging, management of ruptured and non-ruptured AAAs, and follow-up after repair. The guidelines are based on a systematic review of the literature and aim to standardize care and improve outcomes for AAA patients across Europe.
1. There are three main types of vascular access for hemodialysis in children: tunneled catheters, arteriovenous fistulas, and arteriovenous grafts.
2. It is important to educate children with declining kidney function about their vascular access options and the importance of vein preservation for potential future access.
3. The choice of vascular access depends on multiple patient-specific factors and a dedicated vascular access clinic can help increase use of arteriovenous fistulas and decrease use of catheters.
A brief review of complications and tips and tricksEuro CTO Club
This document discusses complications that can occur during percutaneous coronary intervention (PCI) and provides tips for managing them. It begins by classifying PCI complications into coronary (vessel closes or leaks, equipment in wrong place), heart (myocardial infarction, arrhythmia, tamponade), and other (access, thromboembolic, contrast, radiation). Specific tips are then provided for managing perforations including using a covered stent or coils. The document emphasizes being prepared for complications and having a plan, as well as communicating with the medical team to resolve issues promptly.
The document discusses ultrasound guidance for hemodialysis catheter insertion. It notes that all hemodialysis catheters should be placed under ultrasound guidance, while fluoroscopy is needed for cuffed tunneled catheters. It provides statistics on variations in the positioning of the right and left internal jugular veins and cites a reference studying ultrasound guidance for the right internal jugular vein. It also outlines the process for inserting non-cuffed versus cuffed tunneled hemodialysis catheters.
The document discusses the best vascular access options for pediatric chronic kidney disease patients requiring hemodialysis. It notes that central venous catheters are currently the most common primary access for pediatric patients, despite evidence that arteriovenous fistulas have better outcomes when possible. The document recommends early referral to nephrologists and surgeons to allow time for vascular mapping, access planning and maturation. It provides guidance on patient evaluation and criteria for selecting between fistulas, grafts and catheters based on vessel size and other clinical factors. The goal is to minimize catheter use and improve pediatric vascular access outcomes.
Although large efforts are spent for creating fistula as the primary access, use of Hemodialysis Vascular catheters are still the major access on the first Hemodialysis session and after 4 month whether we would like it or not.
"USRDS 2013"
Saturday 1203 – escaned coronary perforationsEuro CTO Club
This document discusses the treatment of coronary perforations during percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). It notes that while coronary perforations are common in CTO PCI, most do not have serious consequences. It then discusses risk factors, classification systems, and specific approaches to treating different types of perforations including main vessel, distal artery, and collateral vessel perforations. Two clinical cases are presented involving perforations during CTO PCI and the management in each case, including the use of covered stents, coils, pericardiocentesis, and in one case emergency surgery. General measures for managing perforations are also outlined.
Post Myocardial infarction vsd repair by infarct exclusion techniqueJyotindra Singh
This case study examines outcomes of 26 patients who underwent surgical repair of a post-myocardial infarction ventricular septal defect (PMIVSD) over a 15-year period. 20 patients underwent defect closure with concomitant coronary artery bypass grafting (CABG), while 6 had defect closure alone. In-hospital mortality was 30.9%, with higher mortality seen in those with cardiogenic shock, posterior defects, and surgery over 3 weeks after infarction. 15 of the 20 patients who had CABG survived, compared to 3 of the 6 who had defect closure alone. Residual shunts occurred in 5 patients but did not require reoperation. Predictors of poor prognosis included cardiogenic shock, timing of surgery, and total
Global Hospitals’ Advanced Heart, Lung & Vascular Institute provides all kinds of endovascular procedures including coronary intervention and peripheral intervention, heart surgery, heart bypass surgery as well as heart transplantation surgery in Hyderabad, Chennai, and Bangalore
This study evaluated outcomes of 26 patients who underwent surgical repair of post-myocardial infarction ventricular septal defect (VSD) at Nizams Institute of Medical Sciences between 1997-2012. 20 patients underwent VSD repair with concomitant coronary artery bypass grafting, while 6 had VSD closure alone. The mean time between MI and VSD appearance was 7.2 days, and between VSD appearance and surgery was 27.2 days. Overall in-hospital mortality was 30.9% and 30-day mortality was 33%. Patients who underwent emergency surgery within 3 days of MI had 100% mortality, while those operated on after 3 weeks had 100% survival. Concomitant CABG during VSD repair was associated with lower
This document provides guidelines for vascular access in children requiring hemodialysis. It recommends that an arteriovenous fistula (AVF) be the preferred initial access when appropriate based on vessel size and surgical expertise. An AVF is created by surgically connecting an artery to a vein, allowing high blood flow that enlarges the vein over time to be used for hemodialysis. The document outlines recommendations for planning, placement, maturation assessment, cannulation, surveillance and thrombosis prevention of AVFs in children.
Endovenous ablation new methods where do we go from hereuvcd
New endovenous ablation methods fall into two categories: thermal tumescent (TT) and non-thermal non-tumescent (NTNT). TT methods like laser, radiofrequency, and steam ablation require tumescent anesthesia while NTNT methods like cyanoacrylate glue, mechanochemical ablation, polidocanol microfoam, and V Block ligation do not. Clinical trials show high occlusion rates of 90-95% at one year for various NTNT techniques with benefits of reduced pain, faster recovery, and ability to treat veins all the way to the ankle without tumescence. NTNT techniques are positioned to become the future standard for treating saphenous vein insufficiency.
Dr. Iyad Feteih presents information on the history and development of inferior vena cava (IVC) filters. The document discusses early surgical methods of IVC interruption and their complications. It then summarizes the development of endoluminal IVC filters beginning with the Mobin-Uddin umbrella in 1967 and the iconic Greenfield filter in 1973. The document provides details on various commercially available IVC filters from companies such as Bard, Cook Medical, Cordis, and Crux Biomedical including specifications, clinical trial results, and complications.
This document provides an overview and introduction to an atlas about dialysis vascular access. It discusses how dialysis depends on vascular access but it is often overlooked. The atlas aims to improve understanding of access anatomy and problems through images. It is intended for physicians, nurses and technicians involved in dialysis access care. The author thanks the groups and individuals who assisted with the project and hopes it leads to improved access care quality.
A speech given in Yodak Hospital, the 6th International Symposium of Cardiac Thorascopic Surgery, 10/25/2014; a report of endoscopic cardiac surgery in Taiwan
Intra-arterial therapy is an effective treatment for acute ischemic stroke when performed within 6 hours of symptom onset. It involves delivering thrombolytics directly into the blocked artery or using mechanical devices to remove the clot. Several studies found intra-arterial therapy improved recanalization rates and led to better functional outcomes and reduced disability compared to intravenous thrombolysis alone. The guidelines recommend intra-arterial therapy as an option for large vessel occlusions when performed at comprehensive stroke centers with experienced staff.
Current status of endovenous ablation for the treatment of venous insufficiencyuvcd
Endovenous ablation procedures such as laser and radiofrequency ablation are becoming more commonly used to treat varicose veins compared to traditional surgery. A randomized clinical trial found that endovenous laser ablation (EVLA) had a lower recurrence rate of varicose veins at 1 year compared to surgery. Another study found similar occlusion rates of veins between radiofrequency ablation and EVLA, but that radiofrequency ablation resulted in less bruising, pain, and faster recovery times. Guidelines now recommend endovenous thermal ablation over high ligation and stripping for treating the great saphenous vein, and recognize endovenous techniques as effective minimally invasive options for varicose vein treatment.
Perforation management of collaterals
Kambis Mashayekhi, Bad Krotzingen, Germany
11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany
This document provides an overview of catheter access options for hemodialysis and their risks and management. The preferred options are an arteriovenous fistula, followed by a graft or tunneled catheter. Complications of catheters include pneumothorax, malposition, arrhythmias, infection, and thrombosis. Infection risks can be reduced through strict sterile technique, antibiotic locks, and catheter removal when unnecessary. Overall, the document discusses vascular access types, placement techniques, complications, and infection prevention for hemodialysis catheters.
This document discusses endovascular interventions for infrapopliteal peripheral vascular disease. Infrapopliteal disease is rising due to an aging population and increased rates of diabetes and kidney disease. Surgical and early endovascular interventions historically had high failure rates in this region. Endovascular procedures now provide an alternative to bypass surgery for treating critical limb ischemia in the infrapopliteal arteries, with the goal of establishing straight line blood flow to the foot. Success depends on factors like number of vessels opened, inflow status, and addressing more proximal disease first when needed. Complications can include access issues, vessel spasm or perforation, embolism, and contrast nephropathy.
Trans-radial access (TRad) is commonly used for coronary interventions due to lower complication rates compared to femoral access. This study evaluated the safety and feasibility of TRad for non-coronary and peripheral vascular interventions in 24 cases over 3 years. TRad was successful in all cases with no access complications. Indications included absent femoral pulses, morbid obesity, femoral bypass, and groin infections. Procedures included diagnostic angiograms and interventions like iliac angioplasty/stenting and femoral anastomosis angioplasty. 31% had asymptomatic radial artery occlusion. Larger sheath sizes were associated with higher occlusion rates. TRad is a safe alternative to femoral access for select peripheral cases
Hemodialysis procedure dr. mohamed kamalFarragBahbah
This document discusses various types of vascular access for hemodialysis patients, including central lines, arteriovenous fistulas, and grafts. It notes that without adequate vascular access, hemodialysis efficiency is reduced and morbidity and mortality increase. Short-term catheters should only be used short-term, while long-term catheters require a plan for permanent access. Fistulas are the preferred permanent access but have high failure rates, especially in older patients and those with comorbidities. Early identification of failing fistulas allows for interventions like angioplasty and stent placement to salvage the access. Overall access-related problems account for half of hospitalizations in hemodialysis patients, emphasizing
A 79-year-old woman presented with severe leg pain and acute renal failure. Examination showed absent leg pulses. Imaging showed aortoiliac occlusions. The next step was a CT angiogram, which confirmed aortoiliac occlusions. Percutaneous revascularization was then performed by obtaining femoral access and crossing the occlusion with guidewires. Angioplasty and stenting of the aortoiliac bifurcation and infrarenal aorta were performed, resulting in excellent blood flow.
The document discusses recent surgical updates for pancreatic resections. It introduces novel techniques for pancreatic resections like the Cattell Braasch maneuver, triangle operation, and modified Appleby procedure. It summarizes outcomes from using these techniques on 45 patients, finding no mortality and comparable morbidity. The document also discusses techniques like vein resection without reconstruction that can increase resectability in select cases.
A 44-year old male presented with chest pain and was found to have acute prosthetic aortic valve failure due to abnormal pannus proliferation trapping the valve orifice. He underwent emergency aortic valve replacement. Pannus formation leading to valve obstruction is a known complication of prosthetic heart valves. Both mechanical and bioprosthetic valves carry risks of structural deterioration or valve obstruction. Transesophageal echocardiography is the gold standard for diagnosing prosthetic valve thrombosis, while treatment options include thrombolysis or surgery depending on the patient's clinical status and risks.
This document discusses bile duct injuries during cholecystectomy and their management. It covers:
- Bile duct injuries are a dreaded complication that may require biliary-enteric reconstruction.
- Injuries are often not recognized immediately and can damage the doctor-patient relationship.
- Surgical techniques for repair include hepaticojejunostomy or hepaticoduodenostomy using magnification and fine sutures for a tension-free anastomosis. Postoperative stents and imaging are used to ensure patency.
- With proper preoperative imaging and surgical expertise, biliary reconstruction can successfully treat bile duct injuries with good long-term outcomes. However, more research is still needed to improve quality
This document discusses complications of diagnostic and therapeutic cerebral angiography procedures and their management. Some key points:
- Neurological complications like ischemic stroke are most common, caused by thrombosis, embolization, or vessel disruption. Transient global amnesia and cortical blindness can also occur.
- Risk factors for complications include age over 70, referral for stroke/TIA, extensive vessel disease, long/complex procedures, multiple catheters, hypertension, renal impairment, or recent surgery.
- Treatment depends on the complication but may include thrombolysis, hyperbaric oxygen, induced hypertension, lidocaine/nicardipine for vasospasm. Recognition and use of available treatments is important for air e
Transposition of great arteries with lvoto managementIndia CTVS
Transposition of the great arteries (TGA) with left ventricular outflow tract obstruction (LVOTO) can be managed through various surgical options depending on the severity and type of LVOTO. The Rastelli procedure and Lecompte procedure are two common definitive corrective surgeries that involve tunneling the left ventricle to the aorta while connecting the right ventricle to the pulmonary artery with or without a conduit. The Nikaidoh procedure, or aortic translocation, is an alternative used when anatomy is unsuitable for Rastelli or Lecompte, involving translocating the aortic root posteriorly to relieve LVOTO. Long-term outcomes of these procedures can include reintervention needs but provide
GIT Kurdistan Board GEH J Club SEMS for AVB.Shaikhani.
Acute variceal bleeding (AVB) is a life-threatening complication of liver cirrhosis that results from bleeding esophageal or gastric varices. Management of AVB involves hemodynamic resuscitation, treatment of complications, and achieving hemorrhage control. Endoscopic therapies are the primary treatment but balloon tamponade, transjugular intrahepatic portosystemic shunt (TIPS), and surgery are rescue options for uncontrolled bleeding. A new potential treatment is self-expandable metal stents (SEMS) deployed endoscopically, which may offer advantages over balloon tamponade in controlling refractory AVB, but further large studies are still needed.
1. Aortoenteric fistula (AEF) is a communication between the aorta and gastrointestinal tract that can be primary, between the native aorta and GI tract, or secondary, between a reconstructed aorta and GI tract.
2. Infection is the main cause of both primary and secondary AEF, leading to local compression, ischemia and erosion of the aortic wall.
3. Clinical presentation of AEF includes gastrointestinal bleeding, abdominal pain, and a pulsatile abdominal mass. Diagnosis is made using CT scan, endoscopy or angiography.
4. Treatment requires urgent surgery to control hemorrhage and resection of infected material. Reconstruction options depend on the extent of infection
This slide will provide illustrative information regarding coronary angioplasty . It also focus on practical area knowledge of cardiac catheterization which one should focus while caring patient with coronary angioplasty.
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes.
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes. Quite useful for general surgery residents and medical students and also general physicians.
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes
1. Most common cardiac conduction abnormalities during CVC insertion are right bundle branch blocks and new left anterior and posterior fascicular blocks which result from overzealous advancement of the guide wire.
2. The most common site of catheter-related deep vein thrombosis is the internal jugular vein. Risk factors include history of DVT, subclavian insertion site, and improper catheter tip positioning.
3. Symptoms of venous air embolism during CVC insertion include chest pain, dyspnea, headache, EKG changes, and decreased cardiac output. Treatment involves stopping air entry, placing the patient in Trendelenburg and left lateral position, and
This study evaluated 188 patients who underwent coronary endarterectomy (CE) for a diffusely diseased left anterior descending artery (LAD) over a 10-year period. CE was performed using an open technique with a long arteriotomy to allow for complete plaque removal. Early and follow-up angiography showed high patency rates of over 90% for the internal thoracic artery graft and reconstructed LAD. CE provided satisfactory long-term outcomes for revascularizing a diffusely diseased LAD when conventional grafting was difficult.
This document describes a case of Budd-Chiari syndrome treated with percutaneous hepatic vein stenting. A 50-year-old female presented with right upper quadrant pain and loss of appetite. Imaging showed hepatic vein occlusion and ascites. Percutaneous access was obtained and a self-expanding stent was placed across the occlusion, restoring antegrade flow. The patient's symptoms improved and ascites resolved post-procedure. Percutaneous stenting is an effective alternative to surgery for selected Budd-Chiari syndrome patients that can help preserve liver function by relieving congestion.
This document provides an overview of cardiac resynchronization therapy (CRT). It discusses how conduction delays can lead to electromechanical dyssynchrony and impair the heart's function. CRT aims to improve this synchrony and thereby improve systolic and diastolic function. The document outlines different types of dyssynchrony and methods to assess it, including echocardiography. Current guidelines recommend CRT for symptomatic heart failure patients with low ejection fraction and wide QRS duration. The implantation procedure involves placing right atrial/ventricular leads and a left ventricular lead via the coronary sinus.
The document discusses hypertension and its effects on the kidney. It begins by defining normal blood pressure regulation and the role of the kidney in long-term blood pressure control. It then discusses the epidemiology of hypertension globally and in various countries. The document also covers the epidemiology of chronic kidney disease, how hypertension affects the kidney and can lead to hypertensive nephropathy, and how chronic kidney disease in turn affects blood pressure. It concludes by outlining blood pressure targets and treatment strategies for patients with hypertension and chronic kidney disease.
Septic shock, updated presentation, including latest guidelines from Intensive care societies and how to approach to the diagnosis with few notes about Early Goal Directed Therapy and role of steroids
TB 2013_Diagnosis and clinical presentationRamadan Arafa
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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2. Guidewire – induced asystole
A case report
Dr. Ramadan Arafa; MD, FRCPI
Physician and Nephrologist
Fujairah hospital
3. Vascular accesses for Hemodialysis are:
AV fistula, an AV graft, and a venous catheter
4. Recommendations
Renal Association 2011 guidelines
• Preferred type of vascular access
We recommend that any individual who
commences haemodialysis should do so with an
AVF as first choice, an AV graft as second choice, a
tunneled venous catheter as third choice and a non
tunneled catheter as an option of necessity. (1B)
13. • 23 patients required a single transhepatic access
procedure.
• Technical success was achieved in 22 procedures.
• Functionality success was achieved in 20 patients.
Functionality failure occurred in 3 patients.
• The trans-hepatic catheters stayed in place
between 90 and 300 days. Complications occurred
in 14 patients (3 major + 11 minor).
14. Prosthetic axillary- axillary AVG
• Prosthetic axillary-axillary arm loop AVG for
hemodialysis (Hossam El Wakeel et al; 2013):
– The primary patency rate at 1 year was 63.4% and at 2
years was 21.8%. The secondary patency rate at 1 year
was 75.6% and at 2 years was 43.5%.
• AVG with outflow in the proximal axillary vein
(Teruya et al 2009):
– Patency rates were 78%, with mean follow-up of 16
months.
15. Translumbar inferior vena cava catheter
• Initially used for post bone marrow
transplantation
• Later was used as a vascular access in ESRD
patients for hemodialysis with difficult access
• A complication specific to placement of IVC
hemodialysis catheters is migration of the
catheter into the subcutaneous soft tissues,
retroperitoneum, or iliac veins
Alain Guy Assounga et al; SAMJ 2008
Goupta et al; J Am Soc Nephrol. 1995
Rajan et al; Radiographics 1998
16. Transthoracic SVC catheterization
• Transthoracic permanent catheter placement
is an appropriate alternative for patients in
whom traditional venous access sites are no
longer available.
Wellons et al; Journal of Vascular Surgery 2005
17. Saphenofemoral AVF
• SFAVF is an adequate alternative for patients
without the possibility for other access in the
upper limbs, allowing efficient dialysis with
good long-term patency with a low
complication rate.
Correa et al, BMC Surgery201010:28
21. • If the patient has a coagulopathy, the femoral
or external jugular veins are the preferred
first site, and the internal jugulars are the 2nd
choice.
• Relative contraindications for subclavian
insertion include bilateral pulmonary
pathology, high-pressure mechanical
ventilation, and altered local anatomy.
22. • If one attempt at subclavian insertion has been
unsuccessful, an attempt on the opposite
subclavian is relatively contraindicated because
of the risk of bilateral pneumothorax
• If a unilateral pulmonary disease is present, SC
and IJ insertion should be done on the same
side as the affected lung.
23. •Avoid putting lines close to contaminated areas (eg
burns, infected tracheostomy site)
• Inexperienced operators are only allowed 2 passes
for the vein at a particular site before requesting
help
•Only insert lines with the number of lumens that
are required e.g patients requiring long-term
venous access for antibiotics only require a single
lumen
24. • K/DOQI Guidelines state that subclavian
vein (SCV) catheterization should be
avoided in patients with ESRD because of
the risk for central venous stenosis, with
subsequent loss of the entire ipsilateral arm
for vascular access.
25. • Both the National Institute of Clinical
Excellence in the UK and the USA KDOQI
recommend ultrasound guidance as the
preferred method for insertion of central
venous catheters into the internal jugular
vein
26. Documentation
The following must be legibly documented in
patient notes:
• Date, time
• Operator(s) and his / her assistants.
• Form of anasthesia or use of analgesia
• Line type and indication for use
• Insertion site
• Complications recognized during insertion,
including arterial puncture
• CXR result
32. • Mr. K A is a 72 year old gentleman, has HTN, DM II,
PVD and ESRD.
• He was admitted with poor oral intake, persistent
vomiting and shortness of breath with raised
serum creatinine and urea. His serum potassium
was 5.4 mmol/L and bicarbonate was 23 mmol/L.
He was planned for long-term regular hemodialysis
through a right internal jugular venous access till
creation of arteriovenous fistula.
33. • He had repeated episodes of acute pulmonary
edema associated with gradual progressive
worsening of renal function which required
hemodialysis.
• ECG showed LBBB with QRS duration of 140 ms.
• Echocardiography: severe LV dysfunction (LV EF
28%) with global hypokinesia and evidence of
dysynchrony.
35. • After threading the guidewire in the needle and
advancing it in for about 35-40 cm, the patient
suddenly collapsed and the monitor showed
asystole. The guidewire was pulled immediately
out, the procedure was terminated and
cardiopulmonary resuscitation was initiated. He
was managed with chest compression, IV
adrenaline, atropine, sodium bicarbonate, calcium
gluconate and bag breathing
36. • He had alternating episodes of asystole followed
by wide complex bradycardia with RBBB pattern
with left axis deviation (LAHB) at a rate of 36 – 48
beats/minute. Appropriate resuscitation was done
and continued for approximately 2 hours.
• Transcutaneous pacing was not effective in
capturing. Hence, a temporary trans-venous
pacemaker was inserted and he was revived.
38. • He regained his consciousness fully without
neurologic deficit.
• Three days later, the temporary pacemaker
was changed to a Dual chamber CRT
Defibrillator Device with permanent pacing.
Follow up ECG later showed paced rhythm.
41. Guidewire – induced arrhythmia
• Guidewire – related cardiac complications are
rare. The commonest arrhythmias noticed are
premature atrial and ventricular contractions, and
supraventricular tachyarrhythmia.
• The commonest cardiac conduction abnormalities
are RBBB, LAHB and very rarely asystole.
• Complete heart block (CHB) is a well-documented
complication known to occur during
catheterization of one side of the heart when
contralateral bundle branch block pre-exists
Jain et al; International journal of Case Reports and Images, vol. 2, No. 4, April 2011.
Eissa NT, Kvetan V. Anesthesiology 1990; 73: 772-4
42. • Unnikrishnan documented CHB in a patient with
pre-existing LBBB during central venous cannula
insertion. RBBB may occur in 5% of cases while
CHB may occur in 23% of cases with pre-existing
LBBB.
• In published cases of guide wire – induced CHB, it
was transient and most of patients recover
without the need for permanent pacing.
Unnikrishnan et al. British Journal of Anaesthesia, 2003, Vol. 91, No. 5 747-749
D. Morris et al; Archives of Internal Medicine ,vol.147,no.11,pp.2005–2010,1987
43. • In our case the patient has asystole which
alternates with severe bradyarrhythmia and left
anterior fascicular block pattern. He did not
respond to immediate measures of atropine,
adrenaline or transcutaneous pacing. He was
revived only with transvenous pacing.
44. • The pathophysiology of CHB in patients with pre-
existing LBBB is not clear but it may be due to
direct impingement of the catheter up on right
bundle branch. Fascicular block may be due to
longitudinal dissociation of fibres in the bundle of
His but the exact proven mechanism is still
unknown.
• Careful insertion of guidewire to less than 22 cm
decreases the incidence of complications by 70%.
So, it is better to consider the safe limit up to 18
cm
Jain et al; International journal of Case Reports and Images, vol. 2, No. 4, April 2011.
Eissa NT, Kvetan V. Anesthesiology 1990; 73: 772-4
Wani et al; Case Reports in Critical Care, Volume 2016, Article ID 9531210,
45. • The risk factors for guidewire – induced
arrhythmia are: height less than 170 cm, female
gender, the use of rigid guide wire and advancing
the guidewire more than 20 cm. The risk of
asystole is higher if the patient has preexisting left
bundle branch block.
• Some authors suggest using a prophylactic
temporary trans-venous pacemaker in high risk
patients because of the risk of CHB, while others
argue against it because of low incidence of this
complication and need for care during GW
insertion in patient with preexisting blocks.
Lee et al; J Clin Anesth. 1996 Aug;8(5):348-51.
50. 1. Bleeding:
Check the clotting screen on the day of insertion.
CVC insertion should be postponed (or done by
experienced clinicians) if the platelet count is <
50,000 or the INR is > 1.5.
2. Arterial puncture
Stop procedure and compress the site for 10
minutes by the clock (better to use US-guided
insertion)
3. Air embolism
Patient should be lying head down -15 to -20°
during SC or IJ insertion. Keep the needle hub and
catheter lumens as close to patient skin as possible.
51. Risks and …. continue
4. Break in sterile technique
• Re-gown if required. Replace any contaminated
equipment before continuing with the procedure
5. Pneumothorax
• If patient is at high risk of pneumothorax
because of lung hyper-expansion, the IJ site is
preferable. Check CXR post-insertion (SC or IJ)
52. Risks and …. continue
7. Malposition
• Check CXR post-insertion (SC and IJ only).
• Catheter tip should lie in the lower SVC
8. Thoracic duct damage
• Avoid the LIJ or LSC site if possible
9. Catheter-induced thrombosis
• Limit insertion attempts to 2 for inexperienced
clinicians
• Tip of SC or IJ CVC should lie in the lower SVC
• Any femoral CVC must be removed after 6 days
regardless of the clinical situation.
56. What are the interventions for CRI ?
1. Surveillance and data feed back
2. Chlorhexidine for skin antisepsis: during catheter
insertion and during dressing changes
3. Hand hygiene audits
4. Catheter care and access care observations
5. Scrub the hub
6. Patient education and engagement
7. Staff education and competency
8. Catheter reduction
9. Antimicrobial ointment or chlorhexidine sponge at
catheter exit site
57. Treatment of infection
• 7.4.1 Catheter exit-site infections, in the absence
of a tunnel infection, should be treated with
topical and/or oral antibiotics, ensuring proper
local exit-site care. In general, it should not be
necessary to remove the catheter.
• 7.4.2 If a patient with bacteremia is afebrile
within 48 hours and is clinically stable, catheter
salvage might be considered by using an
interdialytic antibiotic lock solution and 3 weeks
of parenteral antibiotics in appropriate situations.
A follow-up blood culture 1 week after
completion of the course of antibiotics should be
performed.
58. Treatment of infection … cont’d
• 7.4.3 Antibiotic lock with antibiotic to which the
organism is sensitive is indicated when follow-up
cultures indicate reinfection with the same
organism in a patient with limited catheter sites.
• 7.4.4 Short-term catheters should be removed
when infected. There is no conclusive evidence to
support a rationale for scheduled replacement
except for those in the femoral area.
KDIGO guidelines 2006
59. Points for discussion
1. Prophylactic vancomycin injection?
2. If yes; before or after the procedure?
3. If No; is it absolutely contraindicated?
4. Thrombolytic therapy for possible infected
catheter?
5. Thrombolytic therapy for AVG thrombosis: what
is your experience?
6. HIV cases: what is the preferred approach?
Vascular access remains a key component of hemodialysis. The ideal vascular access should provide safe and effective blood flow by enabling the removal and return of blood via an extracorporeal circuit. Vascular access should be easy to use, reliable and have minimal risk to the individual receiving hemodialysis.
Longitudinal follow up study of 48 patients have done SFAVF in Brazil (Sao Paulo), followed up for 5 years. 8 patients have 2 fistulae.
Vascular access implicationsFirst of all, catheter use poses a great risk to patients. The bottom line is, catheters kill, and patients with a catheter, depending on the study, have up to double the relative risk of death. So what that means is when you choose, for whatever reason, rightly, wrongly, or because there is no choice, to get a catheter in a patient, in that patient you have increased the risk of dying as part of the contract. We know that fistulas have the lowest complication rates and require the fewest procedures. When you look, this is USRDS data, what you can see is, that although catheter procedures total are lower than grafts, look at the infection, look at the sepsis, and the cost issues. Catheters are a morbidity issue, they are a mortality issue.
Now, I'm going to show you some data. Rather than go back to the series of studies from the literature I could show you, I chose to show you network data from Florida because it's stuff you haven't seen and it's not as sifted, it's not as manicured. And this looks at hospitalization in the state of Florida, Medicare hospitalization, from claims. So it's claims-based data, and what you can see is, that the folks with catheters in the first 180 days have an admission rate of 1.8 admissions, 2.9 within 365 days, 2007 and 2008. it's not very different now. You could see that the fistula patients are lower, and graft patients are in between. That's just why data is not controlled, but that's what you see, that's what you know from your hospital.
End-stage renal disease mortality by access typeAnd if you look at mortality, same story. Look at the mortality rate in patients with catheters. First 180 days, first year. Huge mortality relative to these other folks. Now, patients are different, but in studies that Michael Landt has done and numerous other groups have done, every study done shows that catheters, independent of patient characteristics, increase your mortality risk. End of story.