Objective To evaluate the application of percutaneous right atrial puncture and tunneled cuffed catheter insertion and the establishment of peripheral arteriovenous(AV)access in hemodialysis patients with superior vena cava occlusion(SVCO),and to provide evidence-based support for the re-establishment of vascular access in patients with limited vascular resources.Methods Patients with SVCO were enrolled.Then,either right neck percutaneous puncture catheterization or peripheral AV access construction was performed on the patients according to their personal preference.The patients were divided into the catheter group and the AV access group accordingly.Under the guidance of double C-arm digital subtraction angiography,a puncture was made in the right brachiocephalic vein or the stump of superior vena cava.Portal venous shunt instrument RUPS100 was then inserted through the guide wire,and the hard end of the guide wire was used to puncture the right atrium to achieve sharp recanalization of the occlusive superior vena cava.Afterwards,balloon expansion of the obstructive superior vena cava lesion and the subsequent implantation of the tunneled-cuffed catheter were performed.In AV access group,after evaluating the collateral veins by venougraphy and the peripheral vessel by ultrasound,autologous AV fistula or graft was established according to the vascular conditions of the patient and their personal preferences.The demographic information and clinical outcomes,such primary and primary assisted patency of access,were documented and the incidence of complications was monitored.With the duration of patent access defined as the survival time,Kaplan-Meier survival analysis was performed to compare the patency rates of the two groups.Results A total of 45 SVCO patients were enrolled and underwent re-establishment of vascular access.Among them,21 cases were in the catheter group and 24 cases were in the AV access group.All patients had their vascular access successfully constructed and received hemodialysis,and no relevant complications or deaths occurred during the procedure.Over the mean follow-up period of(471.22±125.94)days,the primary patency rates in the catheter group 95.2％and 85.7％at 6 and 12 months,respectively,and the primary assisted patency rates were 100％and 95.2％,respectively.The primary patency rates of the AV access group were 79.2％and 62.5％at 6 and 12 months,and the primary assisted patency rates were 95.8％and 87.5％,respectively.No significant difference was observed between the two groups.Kaplan-Meier survival analysis showed that the median survival time(defined as the duration of patent access)was 670.00(468.99,871.01)days in the catheter group and 450.00(339.24,560.76)days in the AV access group,with the catheter group outperforming the AV access group.The primary patency rate of the catheter group was better than that of the AV access group(P=0.049).On the other hand,no significant difference was observed in the primary assisted patency rates of the two groups.Conclusions Long-term vascular access can be established for SVCO patients by either percutaneous catheterization through the right atrium of superior vena cava stump or the establishment of peripheral AV access.The comprehensive plan,which includes the establishment of AV access first and the subsequent catheterization,is expected to improve the total duration of long-term vascular access and prolong the overall survival of dialysis patients,which provides new ideas for re-establishing dialysis access in patients with exhausted central venous resources.

Objective Tunneled-cuffed catheters(TCCs)are frequently used for establishing hemodialysis access for maintenance hemodialysis in older patients with exhausted resources of peripheral vessels.Fibrin sheath formation around the catheter is one of the most common complications of long-term use of indwelling catheter,which may cause the malfunction of the catheter.In this study,we intend to compare the prognosis of two catheter replacement methods,in situ replacement and replacement through a fibrin sheath crevice,with both being assisted by balloon dilation,and to explore the optimal catheter replacement process.Methods A retrospective study was conducted with 52 patients who underwent a replacement of their TCCs.Among them,27 cases had their TCC replaced by the modified method of replacement through a fibrin sheath crevice and were referred to as the sheath crevice group,while 25 cases underwent in situ catheter replacement and were referred to as the in situ group.The primary outcome indicators included maximum blood flow in hemodialysis catheter and the urea clearance rate calculated by Kt/V values at the 1,3,and 6-month follow-ups.The secondary outcomes included dialyzer alarms being set off and catheter-related infections during follow-up.Results There was no significant difference between the general data of the two groups.There was no massive blood loss during the replacement procedure.Neither were there cardiac tamponade,catheter-associated infections,or other complications.Follow-ups were made 1,3,and 6 months after the replacement procedure.The sheath crevice group had higher catheter blood flow and Kt/V values at the 6-month follow-up than the in situ group did([241.85±9.62]mL/min vs.[234.40±11.21]mL/min,P=0.014 and 1.31±0.55 vs.1.27±0.49,P=0.005,respectively).During the follow-up process,access alarms were reported in 5 patients(three in the in situ group and two in the sheath crevice group)during dialysis.No catheter-associated infection occurred in either group.Conclusion The catheter replacement method of balloon dilation-assisted catheter insertion through a fibrin sheath crevice is safe and effective,resulting in better long-term catheter blood flow compared with that of in situ catheter replacement.

Humans ; Vena Cava, Inferior ; Catheterization, Central Venous ; Renal Dialysis ; Catheters ; Catheters, Indwelling

Objective:To explore the risk factors of hypotension in patients with hemodialysis-related superior vena cava diseases.Methods:This was a retrospective cohort study. The maintenance hemodialysis patients diagnosed as superior vena cava stenosis ≥50% or occlusion in West China Hospital of Sichuan University from January 1, 2019 to March 31, 2022 were selected. The patients were divided into hypotensive group and non-hypotensive group according to the occurrence of hypotension during non-dialysis period. The differences of general clinical data, cardiac ultrasound parameters and blood biochemical indexes between the two groups were compared. Multivariate logistic regression model was used to analyze the risk factors of hypotension in patients with hemodialysis-related superior vena cava lesions.Results:A total of 202 patients with hemodialysis-related superior vena cava lesions were included, of whom 84 patients (41.6%) developed hypotension during non-dialysis. Compared with the non-hypotensive group, patients in the hypotensive group had longer dialysis age ( Z=2.093, P=0.036), shorter left atrial diameter ( t=2.316, P=0.022), lower aortic valve orifice flow rate ( t=3.702, P=0.001) and serum calcium ( t=2.320, P=0.021), thicker left ventricular posterior wall ( t=3.042, P=0.003), lower proportions of hypertension history ( χ2=9.125, P=0.003), and higher proportion of residual superior vena cava ≤30% or occlusion ( χ2=8.940, P=0.003) and azygous vein opening ( χ2=11.067, P=0.001). Multivariate logistic regression analysis results showed that no history of hypertension ( OR=0.383, 95% CI 0.156-0.943, P=0.037), slow aortic valve orifice flow ( OR=0.207, 95% CI 0.062-0.695, P=0.011) and low blood calcium ( OR=0.236, 95% CI 0.066-0.841, P=0.026) were the independent influencing factors of hypotension in patients with hemodialysis-related superior vena cava diseases. Conclusions:Hemodialysis patients with severe stenosis or occlusion of the superior vena cava during non-dialysis have a higher risk of hypotension. No history of hypertension, slow aortic valve orifice flow, and low blood calcium are the independent risk factors of hypotension in patients with hemodialysis-related superior vena cava diseases.

Objective To observe the incidence,clinical characteristics,related factors,adverse events during hospitalization and short-term prognosis of postprandial hypotension (PPH) in elderly patients with coronary heart disease.Methods One hundred and sixty-eight elderly patients with coronary heart disease hospitalized in the Department of Cardiology,Second Hospital of Hebei Medical University from January 2014 to January 2015 were selected as the research subjects.They were monitored by 24 h ambulatory blood pressure monitoring.According to the diagnostic criteria of PPH,they were divided into postprandial hypotension group (PPH group) 34 cases and non-postprandial hypotension group (NPPH group) 134 cases.The clinical characteristics,risk factors related to PPH,occurrence of adverse events and prognosis of all-cause death,cardiovascular and cerebrovascular adverse events were compared between the two groups.Results Among 168 elderly patients with coronary heart disease,thirty-four patients had PPH,and the incidence rate was 20.2％ (34/168).The average systolic blood pressure before meals in PPH group was (139.8± 18.6) mmHg (1 mmHg =0.133 kPa).The proportion of taking calcium antagonists was 50.0％ (17/34) higher than that in NPPH group (127.4± 13.2) mmHg,27.6％ (37/134).The difference between the two groups was statistically significant (t =6.463,x2=6.232,P＜ 0.05).PPH was higher in breakfast and dinner than in lunch;the higher the basal systolic blood pressure level,the higher the incidence of PPH.Logistic regression analysis showed that the basal systolic blood pressure level and age were positively correlated with the occurrence of PPH (r =0.301,r =0.208,P＜ 0.05).Follow-up for 26 months showed that the incidence of all-cause death and cerebrovascular events in PPH group was higher than that in NPPH group (x2 =5.800,11.560,P＜ 0.05).Conclusion The incidence of PPH in elderly patients with coronary heart disease during hospitalization is 20.2％.Breakfast and dinner at three meals are prone to PPH.Older age and high systolic blood pressure level will increase the incidence of PPH.PPH will increase the incidence of mid-term all-cause death and cerebrovascular events.

Objective To assess the value of cardiac magnetic resonance (CMR) imaging in left ventricular structure and function in patients with end stage renal disease (ESRD).Methods Twenty-five patients with ESRD and 10 healthy subjects underwent CMR.Left ventricular end diastolic volume(EDV),end-diastolic diameter(EDD),end-systolic volume(ESV),end-systolic diameter(ESD),stroke volume(SV),ejection fraction(EF),LVM and interventricular septum (IVS) thickness were measured and compared.The parameters from CMR and 2DTTE were compared.Results The EF in patients with ESRD was significantly lower than that in controls (P＜0.001),while ESV,ESD,IVS and LVM were respectively higher than these in controls (P＜0.05).There was no significant difference (P＞0.05) in ESV between CMR and 2DTTE,but EF of CMR was significantly higher than this of 2DTTE (P＜0.05).There was no significant difference (P =0.296) in left ventricular systolic functional category.Bland-Altman plots showed a good agreement between the two methods.Conclusion CMR is a helpful tool to assess left ventricular structure and function in patients with ESRD.

Objective To analyze the validity of Caprini venous thrombosis risk assessment model (Caprini RAM) in the tunneled cuffed dialysis catheters (TCCs) dysfunction patients with central venous thrombosis (CVT).Methods A total of 187 maintenance hemodialysis patients with TCCs dysfunction admitted to West China Hospital of Sichuan University from January 2013 to September 2016 were analyzed retrospectively.According to the chest computed tomography venography results,patients were divided into CVT group and non CVT group.Their general clinical data (age,gender,primary diseases,history of dialysis access,etc.),blood biochemical data (hemoglobin,serum albumin,blood lipid,etc.) and 40 risk factors of Caprini RAM were collected.Caprini RAM scores were computed for risk stratification of thrombosis.Two groups were compared to analyze the value of Caprini RAM in these patients by statistics.Results One hundred and twenty CVT patients and sixty-seven non CVT patients were enrolled.In CVT group the duration of dialysis,hemoglobin and hematocrit were higher than those in non CVT group (all P ＜ 0.05).There was no significant difference between the two groups in gender,age,primary diseases,duration of catheter dependence,catheter tip position,usage of urokinase (all P ＞ 0.05).The average score of Caprini RAM in CVT group and non CVT group did not show statistical difference (6.23+ 1.81 vs 6.19+ 1.95,P=0.913).All patients were stratified into higher risk level and highest risk level according to Caprini RAM.Higher risk level patients accounted for 18.18％ and highest risk level patients accounted for 81.82％.As patients with inequable Caprini RAM scores,their incidence of CVT did not differ statistically (x2=0.105,P=0.746).CVT incidence rate of higher risk level patients was 61.76％,and of highest risk level patients was 64.70％.Conclusions Caprini RAM verifies that maintenance hemodialysis patients with TCCs dysfunction have high risk of venous thrombosis,but this model fails to distinguish patients between CVT group and non CVT group.Its clinical diagnosis is relatively limited and needs to be further explored.

Objective To evaluate clinical value of interventional radiology in difficult extraction of stuck tunnel hemodialysis catheter (TCC).Methods Maintenance hemodialysis patients who required removal of stuck TCC in our hospital from June 2015 to June 2017 were enrolled.Medical history and preoperative examinations were carefully evaluated.Patients were pulled rotationally the catheter under the fluoroscopy guidance and exchanged the TCC.The information and procedure-related complication were recorded.Balloon dilation or snare technique would be used when failed to remove the stuck catheter.Results A total of 22 patients were enrolled,with an average age of (67.2±18.5) years,a median dialysis time of 54(18,106) months,and catheter indwelling time of 37(14,82) months.All patients were successfully removed the stuck catheter,among which 18 cases (81.8％) had fibrin sheath and 13 cases with sheath calcification.TCC mainly stuck in the junction of internal jugular vein and innominate vein,middle and lower innominate vein and middle part of superior vena cava.No procedure-related major complication occurred.Sixteen cases (72.7％) complained of transient substernal extraction pain and 1 case occurred groin hematoma during operation.Conclusions Catheter incarceration problem should be alert to the hemodialysis patients with catheter indwelling time of more than 2-3 years.The minimally invasive interventional techniques including rotationally pull-out under fluoroscopy guidance and balloon angioplasty are safe and effective in removal of the stuck TCC.

Establishing a long-term vascular access in patients exhibiting vascular access exhaustion is challenging.In this study,we reported a case of a direct catheterization in the superior vena cava of a hemodialysis patient with vascular access exhaustion and original dysfunctional catheter inserted via the left internal jugular vein.The direct catheterization was performed with cuffed tunnel catheter (CUFF) and guided by digital subtraction angiography (DSA) and multidetector computedtomography venography (MDCTV).The DSA and MDCTV results revealed an occlusion in the right innominate vein and thromboses in the left innominate,right internal jugular,subclavian,and femoral veins.The distal end of the superior vena cava was localized clearly by the original CUFF under DSA.Directed at the distal end of the superior vena cava,a 0.5-cm secondary puncture was introduced below the lateral head of the sternocleidomastoid muscle via the right neck area.This study is one of the few reports regarding direct catheterization of CUFF via the superior vena cava of a patient with vascular access exhaustion and CUFF dysfunction on the left internal jugular vein.We believe that our study can provide a new alternative for inserting central venous catheter for such patient.

Objective To explore the effects of intra-jugular vein dual lumen catheter lock heparin in different concentrations on the coagulation function,hemorrhagic tendency and catheter thrombosis risk in hemodialysis patients,and to investigate the reasonable lock heparin cuncentration. Method Ninety end stage renal disease (ESRD)patients receiving regular hemodialysis were enrolled and randomly assigned into 3 groups(n=30):Group A(pure heparin lock solution,6250 U/m1),GrouP B(medium heparin lock solution,1040 U/ml)and Group C(low hepafin lock solution,625 U/ml).The coagulation indexes were determined in short term.Complications such as bleeding,thrombosis,infection and thrombocytopenia were monitored.Results Prothrombin time(PT),actiwtted partial thromboplastin time(APTT)and thrombin time (TT)were significantly prolonged in Group A(P＜0.01);only APTT was signifieanlly prolonged in Group B:however,no significant changes were observed in Group C.Hemorrhage risk was much higher in Group A than that in Group B and C (26.7%vs 10%and 0.P＜0.05).Catheter thrombosis incidence was significantly higher in Group C than that in Group A and B(23.3%vs 0and 10%,P＜0.05).Only 1 suspected catheter related infection was found in Group C,and 2cases of moderated thrombocytopenia in Group A. Concltrsion Moderate concentration of lock heparin solution has the best balance of hemorrhagic and thrombotic risk,and should be recommended to most of regular hemodialysis patients.