RESUMO
ABSTRACT Background: A well-functioning vascular access is vital to patients on regular hemodialysis. Banding the access is indicated in high-flow-associated steal syndrome. It allows for the reduction of access flow while maintaining distal limb perfusion. Nonetheless, this procedure has some limitations as it can cause hemorrhage, infection, aneurysm formation, thrombosis of access in cases of overbanding, or otherwise insufficient reduction of vascular flow. Other surgical techniques to achieve the same benefit would be useful. Methods: We performed a modified banding technique without endovascular placement of the angioplasty balloon, which is a viable alternative to other techniques. This surgery was performed in patients on chronic dialysis with steal syndrome. Pre- and post-operative access flows were measured and resolution of symptoms was recorded. Primary patency rate was defined as the intervention-free access survival from the operative time. Results: We verified that this technique allowed for access flow reduction in all our six patients, with total resolution of symptoms in all patients. Primary patency rate at 12 months was 100%. No major complications were noted during our follow-up. Conclusions: This technique allows for correction of high-flow arteriovenous fistulas in an efficient and safe way, and can be a viable alternative to other banding procedures.
RESUMO Introdução: Um acesso vascular em bom funcionamento é vital para pacientes em hemodiálise regular. A bandagem do acesso é indicada na síndrome de roubo associada a alto fluxo. Permite a redução do fluxo de acesso enquanto mantém a perfusão distal do membro. No entanto, este procedimento tem algumas limitações, pois pode causar hemorragia, infecção, formação de aneurisma, trombose de acesso em casos de excesso de bandagem (overbanding) ou, de outra forma, redução insuficiente do fluxo vascular. Outras técnicas cirúrgicas para obter o mesmo benefício seriam úteis. Métodos: Foi realizada uma técnica de bandagem modificada sem colocação endovascular do balão de angioplastia, que é uma alternativa viável às outras técnicas. Esta cirurgia foi realizada em pacientes em diálise crônica com síndrome de roubo. Os fluxos de acesso pré e pós-operatório foram medidos e a resolução dos sintomas foi registrada. A taxa de permeabilidade primária foi definida como a sobrevivência do acesso livre de intervenção desde o tempo operatório. Resultados: Verificamos que essa técnica permitiu redução do fluxo de acesso em todos os nossos seis pacientes, com resolução total dos sintomas em todos os pacientes. A taxa de patência primária em 12 meses foi de 100%. Nenhuma complicação maior foi observada durante nosso acompanhamento. Conclusões: Esta técnica permite a correção de fístulas arteriovenosas de alto fluxo de forma eficiente e segura, podendo ser uma alternativa viável a outros procedimentos de bandagem.
Assuntos
Humanos , Derivação Arteriovenosa Cirúrgica , Reoperação , Grau de Desobstrução Vascular , Estudos Retrospectivos , Diálise Renal , Resultado do TratamentoRESUMO
BACKGROUND: A well-functioning vascular access is vital to patients on regular hemodialysis. Banding the access is indicated in high-flow-associated steal syndrome. It allows for the reduction of access flow while maintaining distal limb perfusion. Nonetheless, this procedure has some limitations as it can cause hemorrhage, infection, aneurysm formation, thrombosis of access in cases of overbanding, or otherwise insufficient reduction of vascular flow. Other surgical techniques to achieve the same benefit would be useful. METHODS: We performed a modified banding technique without endovascular placement of the angioplasty balloon, which is a viable alternative to other techniques. This surgery was performed in patients on chronic dialysis with steal syndrome. Pre- and post-operative access flows were measured and resolution of symptoms was recorded. Primary patency rate was defined as the intervention-free access survival from the operative time. RESULTS: We verified that this technique allowed for access flow reduction in all our six patients, with total resolution of symptoms in all patients. Primary patency rate at 12 months was 100%. No major complications were noted during our follow-up. CONCLUSIONS: This technique allows for correction of high-flow arteriovenous fistulas in an efficient and safe way, and can be a viable alternative to other banding procedures.
Assuntos
Derivação Arteriovenosa Cirúrgica , Humanos , Diálise Renal , Reoperação , Estudos Retrospectivos , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
Abstract The occurrence of ascites after Renal Transplant (RT) is infrequent, and may be a consequence of surgical or medical complications. Case report: 61 year-old, male, history of arterial hypertension, tongue carcinoma and alcoholic habits 12-20g/day. He had chronic kidney disease secondary to autosomal dominant polycystic kidney disease, without hepatic polycystic disease. He underwent cadaver donor RT in September 2017. He had delayed graft function by surgically corrected renal artery stenosis. He was admitted in January 2018 for ascites de novo, with no response to diuretics. HE had visible abdominal collateral circulation. Graft dysfunction, adequate tacrolinemia, Innocent urinary sediment, mild anemia, without thrombocytopenia. Serum albumin 4.0g / dL. Normal hepatic biochemistry. Peritoneal fluid with transudate characteristics and serum albumin gradient > 1.1. Ultrasound showed hepatomegaly, permeable vascular axes, without splenomegaly. Mycophenolate mofetil was suspended, with reduced remaining immunosuppression. He maintained refractory ascites: excluded infectious, metabolic, autoimmune and neoplastic etiologies. No nephrotic proteinuria and no heart failure. MRI: micronodules compatible with bile cysts. Upper Digestive Tract Endoscopy did not show gastroesophageal varicose veins. Normal abdominal lymphoscintigraphy. He underwent exploratory laparoscopy with liver biopsy: incomplete septal cirrhosis of probable vascular etiology some dilated bile ducts. He maintained progressive RT dysfunction and restarted hemodialysis. The proposed direct measurement of portal pressure was delayed by ascites resolution. There was further recovery of the graft function. Discussion: Incomplete septal cirrhosis is an uncommon cause of non-cirrhotic portal hypertension. Its definition is not well known, morphological and pathophysiological. We have not found published cases of post-RT ascites secondary to this pathology, described as possibly associated with drugs, immune alterations, infections, hypercoagulability and genetic predisposition.
Resumo A ocorrência de ascite no pós-Transplante Renal (TR) é infrequente, podendo ser consequência de complicações cirúrgicas ou médicas. Caso clínico: 61 anos, masculino, antecedentes de hipertensão arterial, carcinoma da língua e hábitos alcoólicos 12-20g/dia. Doença renal crônica secundária à doença renal poliquística autossômica dominante, sem poliquistose hepática. Submetido a TR de doador cadáver em setembro de 2017. Atraso na função de enxerto por estenose da artéria renal, corrigida cirurgicamente. Internado em janeiro de 2018 por ascite de novo, sem resposta a diuréticos. Circulação colateral abdominal visível. Disfunção do enxerto, tacrolinemia adequada. Sedimento urinário inocente. Anemia ligeira, sem trombocitopenia. Albumina sérica 4,0g/dL. Bioquímica hepática normal. Líquido peritoneal com características de transudado e gradiente sero-ascítico de albumina > 1,1. Ecografia com hepatomegalia, eixos vasculares permeáveis, sem esplenomegalia. Suspendeu micofenolato mofetil, reduziu restante imunossupressão. Manteve ascite refratária: excluídas etiologias infecciosas, metabólicas, autoimunes e neoplásicas. Sem proteinúria nefrótica e sem insuficiência cardíaca. RM: micronódulos compatíveis com quistos biliares. EDA sem varizes gastroesofágicas. Linfocintigrafia abdominal normal. Submetido a laparoscopia exploradora com biópsia hepática: cirrose septal incompleta de provável etiologia vascular, alguns ductos biliares dilatados. Manteve disfunção progressiva do TR, reiniciou hemodiálise. Proposta medição direta da pressão portal, protelada por resolução da ascite. Recuperação posterior da função de enxerto. Discussão: A cirrose septal incompleta é uma causa incomum de hipertensão portal não cirrótica. A sua definição é morfológica e a fisiopatologia, pouco conhecida. Não encontramos publicados casos de ascite pós-TR secundária a esta patologia, descrita como possivelmente associada a fármacos, alterações imunitárias, infecções, hipercoagulabilidade e predisposição genética.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Ascite/etiologia , Transplante de Rim/efeitos adversos , Insuficiência Renal Crônica/cirurgia , Cirrose Hepática/patologia , Ascite/diagnóstico , Diálise Renal/normas , Rim Policístico Autossômico Dominante/complicações , Função Retardada do Enxerto/complicações , Hipertensão Portal/etiologia , Cirrose Hepática/complicaçõesRESUMO
The occurrence of ascites after Renal Transplant (RT) is infrequent, and may be a consequence of surgical or medical complications. Case report: 61 year-old, male, history of arterial hypertension, tongue carcinoma and alcoholic habits 12-20g/day. He had chronic kidney disease secondary to autosomal dominant polycystic kidney disease, without hepatic polycystic disease. He underwent cadaver donor RT in September 2017. He had delayed graft function by surgically corrected renal artery stenosis. He was admitted in January 2018 for ascites de novo, with no response to diuretics. HE had visible abdominal collateral circulation. Graft dysfunction, adequate tacrolinemia, Innocent urinary sediment, mild anemia, without thrombocytopenia. Serum albumin 4.0g / dL. Normal hepatic biochemistry. Peritoneal fluid with transudate characteristics and serum albumin gradient > 1.1. Ultrasound showed hepatomegaly, permeable vascular axes, without splenomegaly. Mycophenolate mofetil was suspended, with reduced remaining immunosuppression. He maintained refractory ascites: excluded infectious, metabolic, autoimmune and neoplastic etiologies. No nephrotic proteinuria and no heart failure. MRI: micronodules compatible with bile cysts. Upper Digestive Tract Endoscopy did not show gastroesophageal varicose veins. Normal abdominal lymphoscintigraphy. He underwent exploratory laparoscopy with liver biopsy: incomplete septal cirrhosis of probable vascular etiology some dilated bile ducts. He maintained progressive RT dysfunction and restarted hemodialysis. The proposed direct measurement of portal pressure was delayed by ascites resolution. There was further recovery of the graft function. Discussion: Incomplete septal cirrhosis is an uncommon cause of non-cirrhotic portal hypertension. Its definition is not well known, morphological and pathophysiological. We have not found published cases of post-RT ascites secondary to this pathology, described as possibly associated with drugs, immune alterations, infections, hypercoagulability and genetic predisposition.