The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Dr Ohira, has published an original Japanese guideline, ‘Guidelines for Vascular Access Construction and Repair for Chronic Hemodialysis’. The guideline was created mainly because of the existence of numerous factors characteristic of Japanese hemodialysis therapy, which are described in this report, and because we recognized the necessity for standardization in vascular access-related surgeries. This guideline consists of 10 chapters, each of which includes guidelines, explanations or comments and references. The first chapter discusses informed consent of vascular access (VA)-related surgeries, which often resulted in trouble between dialysis staff and patients. The second chapter describes the fundamentals of VA construction and timing of the introduction of hemodialysis with emphasis on the avoidance of catheter indwelling if at all possible. In the third chapter, arteriovenous fistula (AVF) construction and management are discussed from the viewpoint of the most preferable type of VA. The fourth chapter deals with arteriovenous grafts (AVG) which has recently increased in clinical applications. The factors which improve the AVG patency rate are discussed and postoperative management methods are emphasized to avoid possible complications. The fifth chapter deals with short and long-term vascular catheters. It is emphasized that these methods are definitely effective but, at the same time, are apt to be associated with several serious complications and might result in vascular damage. In the sixth chapter, superficialization of an artery is explained. This was originally for emergency use or backup but has been used permanently in 2–3% of Japanese hemodialysis patients. In the seventh chapter, methods for the use of VA are described and the buttonhole method is referred to as one of the options for patients who complain of intense pain at every cannulation. In the eighth chapter, the importance of continuous monitoring is stressed for maintaining appropriate function of VA. As a rule, the internal shunt type VA (AVF, AVG) places a burden on cardiac function. Thus, in the ninth chapter, it is stressed that VA construction, maintenance and repair should always be carried out with consideration of cardiac function which is not constant but variable. The 10th chapter forms one of the cores of this guideline and deals with repair and timing of VA. It is shown how to select a surgical or interventional repair method. In the final 11th chapter, VA types and resultant morbidity and mortality of hemodialysis patients are reviewed.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/1744-9987.12296

2011 update Japanese Society for Dialysis Therapy Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis

Subclavian 'steal' phenomenon is a function of the proximal subclavian artery (SA) steno-occlusive disease, with subsequent retrograde blood flow in the ipsilateral vertebral artery (VA). The symptoms from the compromised vertebrobasilar and brachial blood flows constitute the subclavian steal syndrome (SSS), and include paroxysmal vertigo, drop attacks and/or arm claudication. Once thought to be rare, the emergence of new imaging techniques has drastically improved its diagnosis and prevalence. The syndrome, however, remains characteristically asymptomatic and solely poses no serious danger to the brain. Recent studies have shown a linear correlation between increasing arm blood pressure difference with the occurrence of symptoms. Atherosclerosis of the SA remains the most common cause. Doppler ultrasound is a useful screening tool, but the diagnosis must be confirmed by CT or MR angiography. Conservative treatment is the initial best therapy for this syndrome, with surgery reserved for refractory symptomatic cases. Percutaneous angioplasty and stenting, rather than bypass grafts of the subclavian artery, is the widely favored surgical approach. Nevertheless, large, prospective, randomized, controlled trials are needed to compare the long-term patency rates between the endovascular and open surgical techniques.

/pdf/a-review-of-subclavian-steal-syndrome-with-clinical-3ndu9mzcge.pdf

A review of subclavian steal syndrome with clinical correlation.

The eustachian valve is an embryologic remnant of the valve of the inferior vena cava. It may be prominent in some individuals, but the echocardiographic appearance of a divided right atrium, as the consequence of a large eustachian valve, is extremely rare. Herein we describe an unusual giant eustachian valve with an echocardiographic appearance of a septal structure dividing the right atrium into 2 separate chambers. This abnormality should be differentiated from cor triatriatum dexter, a very rare cardiac malformation for which it could be mistaken.

Giant Eustachian Valve: with Echocardiographic Appearance of Divided Right Atrium

A 28-year-old man with patent foramen ovale and a prominent Eustachian valve with a history of transient ischemic attack underwent transcatheter closure using Amplatzer patent foramen ovale occluder. During deployment, some of the prominent valve tissue was entrapped on the delivery cable and a piece of the valve was extracted unintentionally. Anatomico-clinical and technical implications are discussed.

Persistent redundant Eustachian valve interfering with Amplatzer PFO occluder placement: Anatomico-clinical and technical implications

Nonatheromatous Popliteal Artery Disease

A child presented at birth with severe cyanosis. Echocardiography showed hypoplasia of the right heart with a right-to-left shunt at atrial level. A conservative approach was adopted initially, and the situation improved over a few months, with reversal of the atrial shunt. Surgery was successfully performed at 4 years of age after further echocardiography revealed a congenitally large Eustachian valve and an atrial septal defect.

/pdf/divided-right-atrium-diagnosis-by-echocardiography-and-22fmtisdzj.pdf

Divided right atrium. Diagnosis by echocardiography, and considerations on the functional role of the Eustachian valve.

Introduction Subclavian steal phenomenon due to proximal subclavian artery stenosis or occlusion is not un-common but often remains asymptomatic. Case report We describe the case of a 66-year-old man with end-stage renal disease hemodialysed through a brachio-brachial loop graft of the left forearm. Echo-Doppler precerebral examination showed a high reversed flow of 570 ml/min in the ipsilateral vertebral artery. After successful endovascular recanalization of the subclavian artery, access blood flow increased and vertebral flow decreased to 30 ml/min. Complete neurological examination was normal both before and after endovascular treatment. Discussion This case demonstrates how high a subclavian steal can be without causing symptoms and how well precerbral and cerebral circulation can adapt to hemodynamic changes.

Asymptomatic high flow subclavian steal in a patient with hemodialysis access.

Introduction Popliteal artery entrapment syndrome, although uncommon, usually affects young men under 50 years old. Report We describe the case of a 56 years old woman with acute right limb ischemia due to popliteal and distal arteries thrombosis. She had no history of leg pain and no cardio-vascular risk factor. Diagnosis of popliteal artery entrapment syndrome was made after successful thrombolysis. Treatment was completed surgically. Discussion Regarding age, sex and clinical manifestation, our patient put together three uncommon features of popliteal artery entrapment syndrome. This diagnosis should be considered even in patients over 50 without any cardiovascular risk factor presenting with subacute or acute limb ischemia.

Popliteal Artery Entrapment Syndrome: 3 Unusual Features in the Same Patient

Introduction Subclavian steal phenomenon due to proximal subclavian artery stenosis or occlusion is not uncommon but often remains asymptomatic. Case Report We describe the case of a 66-year-old man with end-stage renal disease hemodialysed through a brachio-brachial loop graft of the left forearm. Echo-Doppler precerebral examination showed a high reversed flow of 570 ml/min in the ipsilateral vertebral artery. After successful endovascular recanalization of the subclavian artery, access blood flow increased and vertebral flow decreased to 30 ml/min. Complete neurological examination was normal both before and after endovascular treatment. Discussion This case demonstrates how high a subclavian steal can be without causing symptoms and how well precerebral and cerebral circulation can adapt to hemodynamic changes.

Asymptomatic high flow subclavian steal in a patient with hemodialysis access

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Papers

Divided right atrium. Diagnosis by echocardiography, and considerations on the functional role of the Eustachian valve.

Asymptomatic high flow subclavian steal in a patient with hemodialysis access.

Popliteal Artery Entrapment Syndrome: 3 Unusual Features in the Same Patient

Asymptomatic high flow subclavian steal in a patient with hemodialysis access