Objective The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere/CryoLife Inc, Eden Prairie, Minn) has provided an innovative means to obtain hemodialysis access for patients with severe central venous occlusive disease. The outcomes of this novel treatment modality in a difficult population have yet to be clearly established. Methods A retrospective review of HeRO graft placement from June 2010 to January 2012 was performed. Patient hemodialysis access history, clinical complexity, complications, and outcomes were analyzed. Categoric data were described with counts and proportions, and continuous data with means, ranges and, when appropriate, standard deviations. Patency rates were analyzed using life-table analysis, and patency rate comparisons were made with a two-group proportion comparison calculator. Results HeRO graft placement was attempted 21 times in 19 patients (52% women), with 18 of 21 (86%) placed successfully. All but one was placed in the upper extremity. Mean follow-up after successful placement has been 7 months (range, 0–23 months). The primary indication for all HeRO graft placements except one was central vein occlusion(s) and need for arteriovenous access. Patients averaged 2.0 previous (failed) accesses and multiple catheters. Four HeRO grafts (24%), all in women, required ligation and removal for severe steal symptoms in the immediate postoperative period (P < .01 vs men). Three HeROs were placed above fistulas for rescue. All thrombosed <4 months, although the fistulas remained open. An infection rate of 0.5 bacteremic events per 1000 HeRO-days was observed. At a mean follow-up of 7 months, primary patency was 28% and secondary patency was 44%. The observed 12-month primary and secondary patency rates were 11% and 32%, respectively. Secondary patency was maintained in four patients for a mean duration of 10 months (range, 6–18 months), with an average of 4.0 ± 2.2 thrombectomies per catheter. Conclusions HeRO graft placement, when used as a last-resort measure, has been able to provide upper extremity access in patients who otherwise would not have this option. There is a high complication rate, however, including a very high incidence of steal in women. HeRO grafts should continue to be used as a last resort.

Spontaneous venous aneurysms of the upper extremities and neck are rare and typically asymptomatic. We present the first reported case of a symptomatic, primary upper extremity venous aneurysm in a patient who initially presented with pulmonary emboli. A 22-year-old patient was admitted with chest pain, dyspnea, and a right axillary mass. Computed tomography revealed diffuse, bilateral pulmonary emboli in addition to a thrombosed axillary vein. Venography confirmed the diagnosis, and also revealed a subclavian vein stenosis at the crossing of the first rib. Pharmacomechanical thrombolysis, catheter-directed thrombolysis, and venoplasty were performed with adequate flow restoration, also revealing the presence of a previously thrombosed proximal brachial/distal axillary venous aneurysm. Hematologic testing showed a positive and persistent lupus anticoagulant. The patient declined surgical reconstruction and opted for long-term anticoagulation. At 24 months, the patient continued to remain symptom-free.

Objective Outcomes of endovascular lower extremity interventions (eLEIs) have been recently linked to provider specialty; however, the indication for intervention was not examined. We sought to compare outcomes between specialties performing eLEI for different indications, in a recent statewide inpatient discharge dataset. Methods The Florida hospital discharge data from 2005 to 2009 were reviewed for patients with LEI during hospitalization. We assigned provider specialty as interventional radiology (IR), interventional cardiology (IC), or vascular surgery (VS) based on provider-associated procedures. Clinical indication was claudication or critical limb ischemia (CLI). We limited our analysis to patients without concomitant open surgery during hospitalization. We compared mortality, length of stay (LOS), major use of intensive care unit (ICU), discharge disposition, and total charges between specialties with regression models, both unadjusted and adjusted for demographic and clinical characteristics. Results A total of 15,398 patients (47% with CLI) had an eLEI. Clinical indication was significantly associated with provider type (P < .001) and outcomes. VS and IR were more likely than IC to treat CLI patients (VS 59%, IR 65%, IC 26%; P < .001). IC performed the majority of procedures on claudicants (VS 30%, IC 57%, IR 13%; P < .001), while VS performed the majority of procedures on CLI patients (VS 50%, IC 23%, IR 27%; P < .001). Adjusted analyses demonstrated no difference in mortality rates between the three specialties (odds ratio [OR] VS: reference, IR: 1.24, IC: 0.79; P = NS for both). However, compared with VS, IR-treated patients were less likely to be discharged home (OR, 0.74; P < .001), LOS was longer (β, 1.16 days; P < .001), major ICU use was more common (OR, 1.49; P < .001), and total charges were higher (β, $341; P = .001). CLI predicted poorer results for all outcomes: death (OR, 4.19; P < .001), discharge home (OR, 0.50; P < .001), increased LOS (β, 3.26 days; P < .001), major ICU use (OR, 1.95; P < .001), and total charges (β, $18,730; P < .001). Conclusions The majority of eLEI done by VS are for CLI, whereas the majority of patients treated by IC are claudicants. Although provider specialty does correlate with several clinical results, the clinical indication for eLEI is a stronger predictor of adverse outcomes. Future analyses of eLEI should adjust for clinical indication.

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Objective Aortic sources of peripheral and visceral embolization remain challenging to treat. The safety of stent graft coverage continues to be debated. This study reports the outcomes of stent coverage of these complex lesions. Methods Hospital records were retrospectively reviewed for patients undergoing aortic stenting between 2006 and 2013 for visceral and peripheral embolic disease. Renal function, method of coverage, and mortality after stent grafting were reviewed. Results Twenty-five cases of embolizing aortic lesions treated with an endovascular approach were identified. The mean age was 65 ± 13 years (range, 45–87 years), and 64% were female. Sixteen (64%) patients presented with peripheral embolic events, six with concomitant renal embolization. Five patients presented with abdominal or flank pain, and two were discovered incidentally. Three patients had undergone an endovascular procedure for other indications within the preceding 6 months of presentation. Nineteen patients had existing chronic kidney disease (stage II or higher), but only three had stage IV disease. Of the eight patients tested, four had a diagnosed hypercoagulable state. Eight of the patients had lesions identified in multiple aortic segments, and aortic aneurysm disease was present in 24%. Coverage of both abdominal and thoracic sources occurred in eight patients, whereas 17 had only one segment covered. Minimal intraluminal catheter and wire manipulation was paired with the use of intravascular ultrasound in an effort to reduce embolization and contrast use. Intravascular ultrasound was used in the majority of cases and transesophageal echo in 28% of patients. Two patients with stage IV kidney disease became dialysis-dependent within 3 months of the procedure. No other patients had an increase in their postoperative or predischarge serum creatinine levels. No embolic events were precipitated during the procedure, nor were there any recurrent embolic events detected on follow-up. The 1-year mortality rate was 25%. Conclusions Endovascular coverage of atheroembolic sources in the aorta is feasible and is safe and effective in properly selected patients. It does not appear to worsen renal function when performed with the use of specific technical strategies.