Thrombectomy and temporary arterio-venous fistula for ilio-femoral venous thrombosis

Sixty patients operated for ilio-femoral venous thrombosis with thrombectomy and temporary arterio-venous fistula (AVF) were evaluated. Fifty-one thromboses occurred in women and 48 were left-sided. A triggering mechanism was found in most patients. Fifty per cent of the women were pregnant or in the immediate postpartum period, one third of all patients had a recent operation or trauma and in one third a hereditary disorder could be traced. Blood coagulation studies postoperatively revealed disorders in the coagulation or fibrinolytic systems in 34 of 47 investigated patients. At operation it was possible to open the iliac vein in 50 patients and 42 received a functioning AVF. The AVF was closed after 3 months. Forty-six patients have been followed from 6 months to 5 years with one or several of the following investigations: venous plethysmography, radionuclide venography or routine venography. At follow-up the iliac vein was judged to be patent in 29 patients, in 17 it was occluded and in 8 patients it was probably occluded. All patients over 50 years of age were among those with occluded veins as were 6 of 9 men. The best results were achieved in women operated during pregnancy or in the puerperium. Venous thrombectomy with temporary AVF is effective treatment for ilio-femoral venous thrombosis, particularly in younger females with an obvious precipitating cause e.g. pregnancy or delivery.     

Preoperative Ultrasonographic Mapping of Blood Vessels Before Arteriovenous Fistula Construction in Elderly Patients With End‐stage Renal Disease

The aim of our retrospective study was to evaluate the ultrasonographic mapping of both arm and forearm vessels before primary arteriovenous fistula (AVF) construction in elderly patients with end‐stage renal disease. There were 129 patients aged 75 ± 6 (65–93) years, 58% men, 37% diabetics, who participated in the study. The inner diameter of veins (under compression) and arteries, and the arterial peak systolic velocity (PSV) were measured. The presence of arterial calcifications was noted. The positions for possible native AVF construction (radiocephalic and brachiocephalic) were suggested and an AVF was constructed by a trained nephrologist. An adequate cephalic vein was present in 76 (59%) patients (diameter 4.9 ± 1.1 mm) in the right arm, and in 83 (64%) patients (4.7 ± 1.2 mm) in the left arm. Suitable veins in the forearm were recorded in 73 (57%) patients on the right (3.7 ± 0.7 mm) and in 76 (59%) patients on the left (3.5 ± 1.0 mm) side. The inner arterial diameter was: brachial—right 4.6 ± 0.6 mm (calcifications in 26%), left 4.6 ± 0.7 mm (calcifications in 20%); radial—right 2.3 ± 0.4 mm (calcifications in 36%), left 2.3 ± 0.5 mm (calcifications in 29%). In 32% of patients, one native AVF was possible, in 17% two, in 23% three and in 18% four, while in 10% no AVF was possible. In 84% of patients an AVF was constructed, with no significant difference in non‐diabetic vs. diabetic patients (88% vs. 80%) or females vs. males (87% vs. 83%). Native AVF can be constructed in the majority of elderly patients, often in multiple positions, with no significant differences in terms of sex or diabetic status.     

Pulmonary hypertension in patients with chronic renal failure

BACKGROUND: Many etiologies causing pulmonary hypertension (PH) have been reported, and one of the background disease seen with patients with PH is chronic renal failure (CRF); however, the pathogenesis of PH in this group of patients is not explained satisfactorily. OBJECTIVES: The aims of this study were to evaluate the incidence of unexplained PH among patients with CRF and to suggest possible etiologic factors. METHODS: Two hundred and eleven patients with CRF were evaluated and the ones who have comorbid conditions that cause PH were excluded. Pulmonary arterial pressure (PAP) and cardiac functions were evaluated by Doppler echocardiography. Arteriovenous fistula (AVF) flow was measured by Doppler sonography. The patients were followed for at least 6 months. RESULTS: Forty-eight CRF patients (20 males, 28 females) were included: 23 were predialysis patients, and 25 patients received hemodialysis via AVF. Patients were followed for 7.5 +/- 1.01 months. Systolic PAP >35 mm Hg was found in 56% (14/25) of patients receiving hemodialysis (36.8 +/- 10.7 mm Hg) and in 39.1% (9/23) of predialysis patients (29.5 +/- 9.5 mm Hg). The parathyroid hormone level, cardiac output values and CRF duration were found to be increased in patients with elevated systolic PAP (p < 0.05). AVF flow and AVF duration were positively correlated with systolic PAP in patients receiving hemodialysis (p < 0.05). There was a negative correlation between systolic PAP and residual urine volume (p < 0.05). AVF compression in hemodialysis patients decreased systolic PAP from 36.8 +/- 10.7 to 32.8 +/- 10.5 mm Hg. Systolic PAP values were increased at the end of the study in the predialysis group, whereas they were decreased at the end of the follow-up in the hemodialysis group (36.9 +/- 10.5 and 32.04 +/- 10.5 mm Hg, respectively). CONCLUSIONS: This study demonstrates a high incidence of PH among patients with CRF. CRF duration, AVF flow, parathyroid hormone level and cardiac output may be involved in the pathogenesis of PH. The effective hemodialysis and dry weight reduction decreased systolic PAP values.     

Self‐Care Behavior of Hemodialysis Patients With Arteriovenous Fistula in China: A Multicenter,Cross‐Sectional Study

Improving the level of arteriovenous fistula (AVF) self‐care behavior by people receiving hemodialysis is an effective way to reduce the occurrence of complications and mortality. The aim of this study was to assess the self‐care behavior of Chinese patients undergoing hemodialysis with arteriovenous fistula. The assessment of self‐care behaviors with arteriovenous fistula in hemodialysis (ASBHD‐AVF, Portuguese version) was translated into Chinese using Brislin's translation model. The content validity was evaluated by six experts. Then we involved 301 hemodialysis patients with AVF to explore the construct validity of the Chinese version of ASBHD‐AVF. Ultimately 216 patients from eight dialysis centers of general hospitals in China were recruited to evaluate the patients’ self‐care behavior about AVF. Measures included demographic questionnaire, and the Chinese ASBHD‐AVF. The Chinese ASBHD‐AVF that included 12 items has a good internal consistency (α = 0.865) and content validity (CVI = 0.979). Principal component analysis generated two factors which explained 53.525% of the total variance. About 69.9% of hemodialysis patients’ AVF self‐care behavior were at a low or moderate level. The level of self‐care behavior and knowledge need to be improved. Nurses should give specific guidance according to the patients’ own characteristics and different influence factors, in order to improve the recipients’ self‐care behavior.     

Long-term safety and feasibility of arteriovenous fistulae as vascular accesses in children with haemophilia: a prospective study

Infectious and thrombotic complications limit the long-term use of subcutaneous ports as venous accesses for children with haemophilia. This study has evaluated for the first time the safety and feasibility of internal arteriovenous fistulae (AVF) as alternative accesses. During the 3-year study period, 27 severe haemophiliacs, 14 with factor VIII inhibitors (52%), underwent the creation of 31 proximal AVF in the forearm. Mild forearm haematomas were observed after five procedures (16%) in five patients who had or developed inhibitors after surgery. Inadequate AVF maturation was observed after five of 31 procedures (16%) in four children. AVF were first accessed after a median of 42 d and regularly used at home by 26 patients (96%) for a median follow-up period of 29 months. Thrombosis of a venous branch occurred in one AVF (3%) after 9 months of uncomplicated use in a child with inhibitor who spontaneously recovered from the symptoms and still used AVF for nine additional months. Mild symptoms, referable to distal ischaemia, were transiently reported by two children (7%) who needed no remedial intervention. This study demonstrates that the use of AVF in haemophiliacs enabled long-term treatment at home in all patients but one.     

Detection of deep vein thrombosis: combined flow and blood pool radionuclide venography vs contrast venography.

This study was performed to validate the combined study of flow radionuclide venography (FRV) with subsequent 99mTc-red blood cell(RBC) blood pool radionuclide venography(BRV) for the detection of deep vein thrombosis (DVT). Findings in 32 patients with suspected DVT of lower extremities (n = 52) were compared with those of corresponding contrast venograms (CV) serving as a reference method. FRV was performed by using three separate doses of a large 99mTc04-bolus (10-12 cc) injection. The findings were as follows: concerning the detection of DVT in calf veins, agreement between FRV and CV, FRV+BRV and CV, and BRV and CV were 67%, 73% and 60%, respectively. For femoral veins, agreement between FRV and CV was 96%, while it was 87% between BRV and CV. When FRV and BRV of femoral veins were evaluated in combination, 100% agreement between radionuclide and radiologic method was observed. For iliac veins there was no disagreement in comparison of the methods either singly or in combination. In 7.6% of the extremities, collaterals not demonstrated by CV and BRV were visualized only by FRV. Although the radioactive agent was injected in a relatively large volume, all of the calf veins could not be filled even when they were completely patent. It was concluded that a combined study of FRV with BRV improved the diagnostic value of radionuclide venography for the detection of DVT in calf and femoral veins.     

Arteriovenous fistula creation for hypoxia after single ventricle palliation: A single‐institution experience and literature review

Background: Hypoxia is a common and sometimes severe morbidity of single ven‐ tricle congenital heart disease (CHD). Creation of an arteriovenous fistula (AVF) is occasionally performed for patients after superior or total cavopulmonary connec‐ tion (SCPC or TCPC) in an attempt to improve oxygen saturations. Despite previ‐ ous reports, AVF creation is a rare palliation with inadequately defined benefits and risks. We sought to determine changes in peripheral oxygen saturation (SpO₂) and risk of adverse event after AVF creation in children with single ventricle CHD at our institution.
Methods: We conducted a retrospective chart review of patients with a history of single ventricle palliation and history of surgical AVF creation who were seen at our tertiary care center from 1996 to 2017.
Results: A total of seven patients were included in our study. SpO₂ for the overall co‐ hort did not significantly increase after AVF creation (pre‐AVF 79.1 ± 6.9%, post‐AVF 82.7 ± 6.0% [P = .23]). SpO₂ trended up for large shunts (>5 mm) (pre‐AVF 75.0 ± 7.6%, post‐AVF 84.0 ± 5.3% [P = .25]). SpO₂ did not improve for small shunts (≤5 mm) (pre‐ AVF 82.3 ± 6.5%, post‐AVF 81.0 ± 8.5% [P = .50]). The 12‐month overall and transplant‐ free survival were 85.7% and 71.4%, respectively. Freedom from AVF‐related compli‐ cation (cephalic edema, thrombotic occlusion) was 51.4% at 12 months.
Conclusion: Palliative AVF creation for patients with single ventricle CHD and hy‐ poxia does not universally improve SpO₂ and is prone to early complications. Despite a lack of durable benefit and known risks, AVF creation remains a reasonable pallia‐ tion for a subset of patients after SCPC who are not candidates for TCPC, or poten‐ tially as a bridge to heart transplantation.     

Simple pressure measurement is not reliable in detection of access stenosis in native AV fistulas

Dynamic arterial and venous pressures (PA, PV) are used as the simplest tools to assess vascular access quality (VAQ). An increased PV over three consecutive dialyses is believed to indicate a stenosis, a rule devised for synthetic grafts (AVG) but not adequately validated for AV fistulas (AVF). In this study dynamic PV and static intra-access pressure (calculated by means of the simplified formula PIA=(PA+PV)/2) changes were evaluated in 46 accesses in which balloon angioplasty had to eventually be performed. The whole group consisted of 30 forearm AVF, 5 upper arm AVF and 11 AVG. Pressures were compared in each patient at a time of satisfactory access flow (QVA) and immediately before the angioplasty and pressure difference over that period (deltaPV, deltaPIA) evaluated. Despite a significant drop in QVA over the follow-up interval in both AVF and AVG, the mean deltaPV and deltaPIA in AVF were only several mm Hg and the chosen threshold limit of 20 mmHg was exceeded in approximately 10% of patients only. The results in the AVG group were, however, very different: The mean deltaPV and deltaPIA were close to 20 mmHg and almost 60% of patients in the AVG group exceeded this limit. Evaluation of PIA did not improve stenosis detection in either group. It is concluded that PV and/or PIA monitoring may be useful to detect a stenosis in AVG but not in AVF.     

Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: implications for risk stratification and treatment

OBJECTIVES: We sought to determine the incidence of arteriovenous fistulas (AVF), identify risk factors for AVF, and follow up the clinical outcome of femoral AVF. BACKGROUND: Arteriovenous fistulas are a potential harmful complication of cardiac catheterization. Incidence and clinical outcome of iatrogenic AVF are unknown so far, although important for risk stratification and treatment. METHODS: A total of 10,271 consecutive patients undergoing cardiac catheterization were followed up prospectively over a period of three years. Diagnosis of AVF was performed by duplex sonography. RESULTS: The incidence of AVF was 0.86% (n = 88). The following significant and independent risk factors for AVF were identified: high heparin dosage (odds ratio [OR]) = 2.88), coumadin therapy (OR = 2.34), puncture of the left groin (OR = 2.21), arterial hypertension (OR = 1.86), and female gender (OR = 1.84). Within 12 months 38% of all AVF closed spontaneously. No signs of cardiac volume overload or limb damage were observed in patients with persisting AVF. None of the risk factors for AVF influenced the incidence or the rate of AVF closure. Only intensified anticoagulation showed a tendency to extend AVF persistence. CONCLUSIONS: Almost 1% of patients undergoing cardiac catheterization acquire femoral AVF, for which patient- and procedure-related risk factors could be identified. One-third of iatrogenic AVF close spontaneously within one year. Cardiac volume overload and limb damage are highly unlikely with AVF persistence. Thus, a conservative management for at least one year seems to be justified.     

Brachial Artery–Brachial Vein Fistula for Hemodialysis: One- or Two-Stage Procedure—A Review

Purpose The purpose of the study was to investigate the patency rate of the brachial vein transposition–arteriovenous fistula [BVT–AVF] and to review the available literature regarding the comparison of the one-stage with the two-stage procedure. Methods A multiple electronic health database search was performed, aiming to identify studies on brachial vein superficialization. Case reports and series with five or less patients were excluded from the study. End points of the study were the patency rates at 12, 24, and 36 months of follow-up. The patency of the one- or two-stage BVT–AVF procedure was investigated. Results Overall, 380 BVT–AVFs were analyzed. The primary patency rate at 12 months ranged between 24 and 77%. Rate of early fistula malfunction or failure of maturation of the fistula resulting in loss of functionality ranged from 0 to 53%. Forearm edema, hematomas, wound infection, and early thrombosis were among the most common complications. Limited data were available for the comparison of patency rates between the one- and the two-stage procedure because of the absence of sufficient comparative studies. However, series with one-stage procedure presented a lower patency rate at 12 months compared to series with two stages. Conclusion Patency rates after BVT–AVF, although not excellent, has encouraging results taking into account that patients undergoing these procedures do not have an accessible superficial vein network; failure of maturation and the increased rate of early postoperative complications remain a concern. The BVT–AVF is a valuable option for creating an autologous vascular access in patients lacking adequate superficial veins.     

Arterio‐venous fistula for automated red blood cells exchange in patients with sickle cell disease: Complications and outcomes

Erythrocytapheresis (ER) can improve outcome in patients with sickle cell disease (SCD). A good vascular access is required but frequently it can be difficult to obtain for sickle cell patients. Arterio‐venous fistulas (AVFs) have been suggested for ER in SCD supported by limited evidence. We report the largest cohort of ER performed with AVFs from three French SCD reference centers. Data of SCD patients undergoing ER with AVFs in the French SCD reference center were retrospectively collected. The inclusion criteria were: SS or Sβ‐Thalassemia and AVF surgery for ER. SCD‐related complications, transfusion history, details about AVF surgical procedure, echocardiographic data before and after AVF, AVF‐related surgical and hemodynamical complications were collected. Twenty‐six patients (mean age 20.5 years, mean follow‐up 68 months [11–279]) were included. Twenty‐three patients (88.5%) required central vascular access before AVF. Fifteen AVFs (58%) were created on the forearm and 11 (42%) on the arm. Nineteen patients (73%) had stenotic, thrombotic or infectious AVF complications. A total of 0.36 stenosis per 1,000 AVF days, 0.37 thrombosis per 1,000 AVF days and 0.078 infections per 1.000 AVF days were observed. The mean AVF lifespan was 51 months [13–218]. One patient with severe pulmonary hypertension worsened after AVF creation and died. We report the first series of SCD patients with AVF for ER, demonstrating that AVFs could be considered as a potential vascular access for ER. Patients with increased risk for hemodynamic intolerance of AVFs must be carefully identified, so that alternative vascular accesses can be considered. Am. J. Hematol. 92:136–140, 2017. © 2016 Wiley Periodicals, Inc.     

Characteristics of Exercise‐Induced Intrapulmonary Arteriovenous Fistula in Patients with Unexplained Exertional Dyspnea

Dynamic appearance of intrapulmonary arteriovenous fistula (AVF) during exercise may be associated with unexplained exertional dyspnea (UED) and can be diagnosed with an agitated saline contrast study during exercise echocardiography. However, the occurrence of AVF during exercise in patients with UED has not been well described. Thus, the frequency of exercise‐induced intrapulmonary AVF in the outpatients with UED was retrospectively analyzed. Thirty‐nine outpatients (age: 53 ± 12, 33 female) with UED underwent symptom‐limited supine bicycle exercise echocardiography. Ten patients (26%) developed exercise‐induced intrapulmonary AVF. Patients with and without AVF showed the similar peak exercise heart rate, systolic blood pressure, and rate‐pressure product. The patients with AVF demonstrated a small but significant decrease in arterial oxygen saturation with exercise as compare to baseline (95.6 ± 2.8% at peak, vs. 97.5 ± 2.5% at baseline, P < 0.05 with a paired Student t‐test). Our study suggests that exercise‐induced intrapulmonary AVF is relatively common in the outpatients with UED and associated with mild exercise desaturation; however, the mechanism of desaturation could not be determined by this study. Further investigation to characterize and determine the clinical significance of AVF is warranted. (Echocardiography 2010;27:908‐913)     

Microsurgery in children for creation of arteriovenous fistulas in renal and non-renal diseases

Microsurgery for angioaccess in children includes the use of a surgical microscope, microsurgical instruments, prophylactic tourniquet-induced hemostasis and no-touch surgery. In the recent publications concerning angioaccess in children, the percentages of grafts versus arteriovenous fistulas (AVF) varied from 54 to 76% without microsurgery, and from 0 to 14% with microsurgery. Similarly, the percentages of AVF which failed to mature varied from 30 to 33% without microsurgery, and from 5 to 10% with microsurgery. In a personal series of 380 children receiving hemodialysis, 434 microsurgical angioaccesses were created, 78% being distal autologous AVF. Eighty-five percent of the distal radial-cephalic AVF were patent after 2 years and 60% after 4 years. These results of microsurgically created AVF are probably responsible, at least in part, for the high percentage of end-stage renal disease (ESRD) children treated by hemodialysis on 1 February 2003 in Paris using an autologous fistula (70% of 33 children), while only 24% were hemodialyzed via a central venous catheter and 6% were on peritoneal dialysis. This compares favorably with the annual publication of the North American Pediatric Renal Transplant Cooperative Study in 1996 reporting that two-thirds of the dialysis population were maintained on peritoneal dialysis and that the majority of hemodialysis accesses were external percutaneous catheters. Microsurgical AVF are also created successfully in non-ESRD children requiring frequent blood access for various chronic diseases. It has been possible to create a distal AVF in 68% of cases and the long-term patency rate was just below 60% after 10 years. Microsurgery is mandatory for creation of arteriovenous fistulas, the best form of angioaccess for children treated by hemodialysis or requiring repeated access to blood in various non-renal diseases.     

The effects of chronic endoscopic variceal sclerotherapy on portal pressure in cirrhotics

The effect of obliterating esophageal varices by endoscopic sclerotherapy on portal pressure was prospectively studied in 11 cirrhotic patients with variceal hemorrhage. Portal venous pressure gradient, determined as the difference between transhepatic portal and hepatic vein pressure, increased by a mean of 31.1% +/- 14.5% in 8 (73%) and decreased by a mean of 30.1% +/- 11.7% in 3 (27%) patients, with no statistically significant change overall (P = 0.1). These changes in portal venous pressure gradient occurred despite an improvement in the laboratory and clinical parameters of hepatic function. Deep abdominal sonography with color flow imaging at variceal obliteration showed patent paraumbilical veins in 6 (55%) patients, 3 of whom had decreases in portal venous pressure gradient (29%, 19%, 42.5%) at variceal obliteration. In 5 (45%) patients without patent paraumbilical veins, a statistically significant increase in portal venous pressure gradient between initial endoscopic variceal sclerotherapy and variceal obliteration was noted (P = 0.008). Rebleeding (single episode in all 4 patients, before obliteration in 3 patients) occurred in those with an increase in portal venous pressure gradient; all patients with portal venous pressure gradient decreases were nonbleeders. No correlation between changes in portal venous pressure gradient and time to variceal obliteration, number of sclerotherapy treatments, or rebleeding episodes was observed. Thus, an increase in portal venous pressure gradient was noted in the majority of patients at variceal obliteration. Although the portal venous pressure gradient decrease may be explained by a patent paraumbilical vein, the mechanism of portal venous pressure gradient increase is not clear. It is speculated that this portal venous pressure gradient increase may be caused by an increase in collateral resistance or flow or a combination of both, resulting from obliteration of esophageal varices by endoscopic sclerotherapy.     

Heparin, heparin plus ASA and dipyridamole, and arteriovenous fistula as adjuvant methods to prevent rethrombosis after venous thrombectomy. Experimental study in rabbits

Venous rethrombosis following thrombectomy is a common event. The aim of the present study was to verify the action of heparin, heparin plus acetyl salicylic acid (ASA) and dipyridamole, and of an arteriovenous fistula (AVF) in the prevention of this complication. Thrombosis was induced in 48 male rabbits by the injection of thrombin in a segment of the left jugular vein, in which the blood flow was arrested for 10 minutes. After 48 hours, the animals were randomly allocated into one of 4 groups of treatment: (1) control, (2) subcutaneous heparin (600 S.I. Units/kg--8/8 hours), (3) heparin, in the same dose, plus ASA (10 mg/kg/once a day), and dipyridamole (0.5 mg/kg thrice a day), (4) an AVF was surgically constructed between the left carotid artery and the left maxillar vein. After 30 minutes, thrombectomy was performed. The venous blood flow, the hematocrit, activated partial thromboplastin time and thrombin time tests were performed before, right after the thrombectomy and 48 hours after thrombectomy. Venography was performed after thrombectomy and at the end of the experiment. The animals were killed 48 hours after thrombectomy and the veins were examined macroscopically. Venous rethrombosis was significantly prevented only in the AVF group (9/12), when compared to control group (0/12), heparin group (1/12) and heparin plus antiaggregating agents group (2/12). These results validate further clinical and experimental investigations with the use of AVF to prevent rethrombosis after venous thrombectomy, when a reduction of venous flow is present.     

Calcium channel antagonists reduce restenosis after percutaneous transluminal angioplasty of an arteriovenous fistula in hemodialysis patients

Percutaneous transluminal angioplasty (PTA) for stenosis of hemodialysis fistulas is associated with a high incidence of restenosis, and improvement of the patency rate after PTA is greatly needed. In addition, angiotensin II receptor blockers (ARB), calcium channel antagonists (CCA) and antiplatelet agents (APA) are commonly administered to most hemodialysis patients. This study retrospectively examined the effect of these medications on the incidence of restenosis after angioplasty for hemodialysis fistulae. The subjects were 92 patients--54 with anastomotic stenosis of an arteriovenous fistula (AVF) and 38 with stenosis of the draining veins of an arteriovenous graft (AVG)--who underwent angioplasty between January 2001 and December 2003. The patency period was defined as the interval from the first to the second angioplasty or surgical reconstruction. We excluded patients who received angioplasty two or more times. The effect of each drug on the patency of the AVF or AVG was assessed by the Kaplan-Meier method with the log-rank test and multiple logistic regression analysis. The group receiving CCA therapy showed a higher patency rate for both an AVF and an AVG. Although multiple logistic regression analysis also showed that a CCA reduces restenosis independently in an AVF, there was no significant correlation between a CCA and patency in an AVG. Treatment with an ARB and an APA was not associated with significantly higher patency rates for either an AVF or AVG. A CCA may reduce the incidence of restenosis after percutaneous intervention for stenosis of an AVF.     

青年女性脑梗死患者常见危险因素及其对发病年龄的影响

目的探讨青年女性脑梗死患者常见的危险因素及其对发病年龄的影响。方法回顾性分析2000年11月1日—2010年10月31日,在首都医科大学宣武医院住院的260例青年女性新发脑梗死患者的临床资料,观察青年女性脑梗死的常见危险因素,采用Logrank时序检验分析各危险因素对发病年龄的影响。结果①260例患者中,36～45岁患者最多（65.8%）,18～25岁患者最少（11.5%）。最常见的危险因素是高血压（39.2%）、糖尿病（14.6%）、高脂血症（8.1%）;其次是卵圆孔未闭（4.2%）、烟雾病（3.8%）、高同型半胱氨酸血症（3.5%）、血管炎（3.5%）及心房颤动（3.5%）等;高血压的发生率随着年龄的增长而上升（χ2=17.573,P〈0.01）,卵圆孔未闭的发生率随着年龄增长而降低（χ2=12.666,P〈0.01）。②TOAST分型：原因不明性型占31.2%（81/260）;大动脉粥样硬化型占26.9%（70/260）;小动脉闭塞型和其他病因明确型,分别占16.5%（43/260）、15.0%（39/260）;心源性栓塞型占10.4%（27/260）。③Logrank时序检验分析,并未发现有高血压、糖尿病、高脂血症及心房颤动患者的卒中发病年龄低于平均年龄;而患有房间隔缺损、卵圆孔未闭、血管炎的患者,发生脑梗死时的年龄[中位数年龄（95%CI）],分别为26（13～39）、29（19～39）、35（33～37）岁,低于该组的平均年龄[39（38～40）岁],均P〈0.05。结论青年女性脑梗死患者最常见的危险因素是高血压病、糖尿病、高脂血症,烟雾病、卵圆孔未闭,同型半胱氨酸血症及血管炎亦占有较高的比例;其中患有房间隔缺损、卵圆孔未闭、血管炎者,发生脑梗死的年龄较小。     

Role of superficial femoral artery puncture in the development of pseudoaneurysm and arteriovenous fistula complicating percutaneous transfemoral cardiac catheterization

Of 13,203 transfemoral diagnostic and therapeutic cardiac catheterization procedures performed between January 1,1980 and December 31,1990,73 (0.55%) were complicated by pseudoaneurysm (PA) formation, and 15 (0.11%) by arteriovenous fistulas (AVF). The rate of PA increased progressively from 0.44% (1980–1987), to 0.59% (1987–1989), to 0.92% (1990), with no corresponding change in the incidence of AVF. The rising incidence of PA complicating transfemoral cardiac catheterization was associated closely with the use of larger diameter catheters and aggressive antiocoagulation during coronary interventions, but findings during surgical repair suggested that puncture of the superficial femoral (SFA), rather than the common femoral artery (CFA), was an important avoidable cause of some PA and AVF. A technique for fluoroscopic localization of the puncture site to avoid inadvertent SFA puncture and the associated increased risk of complication is proposed.     

多排螺旋CT检测肺静脉变异及肺静脉孔指数在心房颤动射频消融术前的应用

目的评价心房颤动（房颤）射频消融术前肺静脉变异类型及肺静脉孔指数。方法回顾性分析2005年6月至2006年5月房颤患者射频消融术前16排螺旋CT肺静脉造影64例,在最大密度投影重建图像上测量左上、左下、右上、右下、共干及独立肺静脉孔处肺静脉的前后径及上下径,计算肺静脉孔指数,比较左上、左下、右上、右下肺静脉孔指数差异有无统计学意义。所有统计工作由SPSS软件完成。结果在64例房颤患者中,肺静脉正常无变异11例,占17．19％;肺静脉提前分支45例,占70．31％,共69支肺静脉;左侧共干5例,占7．81％,其中1例两侧共干;右侧独立肺静脉5例,占7．81％;左侧中肺静脉1例,占1．56％。同侧、两侧上肺静脉的肺静脉孔指数差异无统计学意义,P〉0．05。左上与右下、左下与右上及两下肺静脉的肺静脉孔指数差异有统计学意义,P〈0．05。右下肺静脉孔最圆,平均指数最大,为0．88;左下肺静脉孔最接近椭圆型,平均指数最小,为0．72。结论多排螺旋CT肺静脉造影能为房颤射频消融术提供肺静脉解剖信息,如肺静脉变异及肺静脉孔指数,应列为术前常规检查。     

Reconstruction of stenotic or occluded iliofemoral veins and inferior vena cava using intravascular stents: re-establishing access for future cardiac catheterization and cardiac surgery

OBJECTIVES: The study evaluated the safety and efficacy of stent reconstruction of stenotic/occluded iliofemoral veins (IFV) and inferior vena cava (IVC). BACKGROUND: Patients with congenital heart defects and stenotic or occluded IFV/IVC may encounter femoral venous access problems during future cardiac surgeries or catheterizations. METHODS: Twenty-four patients (median age 4.9 years) underwent implantation of 85 stents in 22 IFV and 6 IVC. Fifteen vessels were severely stenotic and 13 were completely occluded. Although guide wires were easily passed across the stenotic vessels, occluded vessels required puncture through the thrombosed sites using a stiff wire or transseptal needle. Once traversed, the occluded site was dilated serially prior to stent implantation. RESULTS: Following stent placement, the mean vessel diameter increased from 0.9 +/- 1.6 to 7.4 +/- 2.6 mm (p < 0.05). Twenty-one of 28 vessels had long segment stenosis/occlusion requiring two to seven overlapping stents. Repeat catheterizations were performed in seven patients (9 stented vessels) at mean follow-up of 1.6 years. Seven vessels remained patent with mean diameter of 6.4 +/- 2.0 mm. Two vessels were occluded, but they were easily recanalized and redilated. Echocardiographic follow-up in two patients with IVC stents demonstrated wide patency. In four additional patients, a stented vessel was utilized for vascular access during subsequent cardiac surgery (n = 3) and endomyocardial biopsy (n = 1). Therefore, 13 of 15 stented vessels (87%) remained patent at follow-up thus far. CONCLUSIONS: Stenotic/obstructed IFV and IVC may be reconstructed using stents to re-establish venous access to the heart for future cardiac catheterization and/or surgeries.