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Article ; Online: Fatal superior vena cava rupture complicating dialysis catheter exchange.

Ali, Ahmed E / Al-Balas, Alian / Benson, Paul V / Almehmi, Ammar

2024 , Page(s) 11297298231219288

Abstract: Central vein stenosis (CVS) is a common and challenging complication in hemodialysis patients with chronic central venous catheters (CVCs). CVS often remains asymptomatic and is discovered incidentally during follow-up imaging. CVS symptoms include arm ... ...

Abstract	Central vein stenosis (CVS) is a common and challenging complication in hemodialysis patients with chronic central venous catheters (CVCs). CVS often remains asymptomatic and is discovered incidentally during follow-up imaging. CVS symptoms include arm swelling, venous hypertension, impaired dialysis flow rates, and development of collateral veins. However, these symptoms can be nonspecific and overlap with other conditions, making the diagnosis challenging. Timely recognition and appropriate intervention are crucial to prevent complications and optimize patient outcomes. Diagnostic tools commonly used include duplex ultrasonography and venography to assess the degree and location of stenosis. Management strategies for CVS encompass a multidisciplinary approach involving nephrologists, interventional radiologists, and vascular surgeons. Initial conservative measures may include anticoagulation therapy, along with pharmacological interventions such as antiplatelet agents and thrombolytics. The endovascular approach is the first line for managing CVS by using balloon angioplasty either alone or in combination with stent placement, but CVS typically recurs frequently, requiring repeated interventions with an increased risk of complications. Additionally, alternative vascular access options such as arteriovenous fistulas or grafts may be considered. In this report, we describe a case of a 25-year-old woman who presented with an extensive history of multiple dialysis access failure for left internal jugular vein central venous tunneled catheter exchange. The procedure was complicated by a fatal superior vena cava rupture likely related to the dislodgment of the guidewire causing perforation into the pericardium space with subsequent cardiopulmonary collapse. The post-mortem autopsy showed severe organized stenosis of SVC and transmural defect above the SVC/atrial junction.
Language	English
Publishing date	2024-01-02
Publishing country	United States
Document type	Journal Article
ZDB-ID	2252820-9
ISSN	1724-6032 ; 1129-7298
ISSN (online)	1724-6032
ISSN	1129-7298
DOI	10.1177/11297298231219288
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Article: Pickering syndrome in a patient with a single kidney: role of renal artery stenting.

Malas, Amer / Ali, Ahmed E / Al-Balas, Alian / Almehmi, Ammar

Radiology case reports

2023 Volume 18, Issue 8, Page(s) 2618–2620

Abstract: Renal artery stenosis (RAS) is associated with hypertension and high mortality rates. With its prevalence and associated risk of death, it is important to screen for patients displaying symptoms of RAS. RAS has a wide spectrum of clinical manifestations ... ...

Abstract	Renal artery stenosis (RAS) is associated with hypertension and high mortality rates. With its prevalence and associated risk of death, it is important to screen for patients displaying symptoms of RAS. RAS has a wide spectrum of clinical manifestations and is usually resistant to medical therapy. Of these clinical manifestations is Pickering syndrome which is characterized by bilateral renal arterial occlusion inflow lesions, flash pulmonary edema, acute kidney injury, and hypertensive emergencies in the setting of a preserved left ventricle function. Stenting techniques have been used extensively to treat symptomatic renal artery stenosis with excellent primary patency rate, however have failed to demonstrate a long-term benefit over the optimal medical management alone in randomized trials. However, accumulating evidence suggests that stenting is justified in specific patient subgroups that have severe occlusive renal artery stenoses with significant clinical sequelae, including flash pulmonary edema, acute ischemic kidney injury, and uncontrolled hypertension. In this report we discuss the case of a 32-year-old male who presented to our center with recurrent flash pulmonary edema and hypertensive emergency and was found to have RAS, which responded well to renal artery stenting. In conclusion, correcting the renal arterial inflow stenosis is beneficial and warranted in selective clinical scenarios.
Language	English
Publishing date	2023-05-26
Publishing country	Netherlands
Document type	Case Reports
ZDB-ID	2406300-9
ISSN	1930-0433
ISSN	1930-0433
DOI	10.1016/j.radcr.2023.04.063
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Article ; Online: Dialysis access-associated steal syndrome with percutaneous endovascular arteriovenous fistula creation.

Varma, Rakesh / Betancourt-Torres, Manuel / Bready, Eric / Al-Balas, Alian

CVIR endovascular

2022 Volume 5, Issue 1, Page(s) 13

Abstract: Background: Dialysis access-associated steal syndrome (DASS) is an infrequent complication after hemodialysis access creation. Clinical symptoms depend on the degree of steal. Percutaneous arteriovenous fistula creation offers a minimally invasive ... ...

Abstract	Background: Dialysis access-associated steal syndrome (DASS) is an infrequent complication after hemodialysis access creation. Clinical symptoms depend on the degree of steal. Percutaneous arteriovenous fistula creation offers a minimally invasive alternative to surgical creation, though complications have been reported. The following presents the first described case of DASS after percutaneous endovascular arteriovenous fistula creation, and discusses risk factors and management. Case presentation: Our case is that of a 27-year-old male with end stage renal disease due to congenital renal dysplasia, who underwent left percutaneous arteriovenous fistula creation for initiation of dialysis. Two months after the procedure the patient complained of coldness, pain, tingling, and numbness in the left arm during dialysis, concerning for steal syndrome. The patient subsequently underwent brachial artery angiogram, which showed minimal antegrade flow through the ulnar and interosseous arteries towards the hand, and a focal, severe stenosis in the distal ulnar artery. Angioplasty of the stenosis was performed, though steal symptoms continued. Conclusions: DASS, though rare, can be seen with percutaneous arteriovenous fistula creation. Identification of the risk factors prior to creation can help avoid this complication. Management is largely guided by clinical presentation. As long as there is adequate collateral supply to the extremity, single vessel occlusion is not a contraindication to percutaneous arteriovenous fistula creation with the use of WavelinQ technology. Careful patient selection with pre-creation angiogram may reduce the risk of symptomatic steal.
Language	English
Publishing date	2022-02-26
Publishing country	Switzerland
Document type	Journal Article
ISSN	2520-8934
ISSN (online)	2520-8934
DOI	10.1186/s42155-022-00289-z
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Article ; Online: Predialysis Vascular Access Placement and Catheter Use at Hemodialysis Initiation.

Allon, Michael / Al-Balas, Alian / Young, Carlton J / Cutter, Gary R / Lee, Timmy

Clinical journal of the American Society of Nephrology : CJASN

2023

Abstract: Background: Current guidelines encourage placement of an arteriovenous (AV) fistula in patients with advanced CKD to avoid initiation of hemodialysis with a central venous catheter. However, the relative merits of predialysis placement of an AV fistula ... ...

Abstract	Background: Current guidelines encourage placement of an arteriovenous (AV) fistula in patients with advanced CKD to avoid initiation of hemodialysis with a central venous catheter. However, the relative merits of predialysis placement of an AV fistula or graft have been poorly studied. Methods: This study included 380 patients (mean age 59±14 years, 73% Black patients, 51% male) from a large academic medical center who underwent predialysis placement of an AV fistula (286) or AV graft (94). The study quantified three end points: time from access placement to initiation of dialysis, likelihood of starting hemodialysis without a catheter, and number of vascular access procedures before dialysis initiation. Results: The eGFR at access surgery was <10, 10-14, and ≥15 ml/min per 1.73 m 2 in 87 (23%), 179 (47%), and 114 (30%) patients, respectively. The median time from access surgery to hemodialysis initiation was 69, 156, and 429 days in patients with an eGFR of <10, 10-14, and ≥15 ml/min per 1.73 m 2 , respectively ( P < 0.001). Hemodialysis was initiated within 2 years of access surgery in 298 (78%) of the patients. Catheter-free hemodialysis initiation was higher in patients with an AV graft versus an AV fistula when the eGFR was <10 ml/min per 1.73 m 2 (88% versus 43%; odds ratio [OR], 9.10 [95% confidence interval, 2.74 to 26.4]) and when the eGFR was 10-14 ml/min per 1.73 m 2 (88% versus 54%; OR, 6.05 [2.35 to 15.0]) but similar when the eGFR was ≥15 ml/min per 1.73 m 2 (90% versus 75%; OR, 3.00 [0.48 to 34.9]). Patients undergoing an AV fistula were more likely to undergo an angioplasty (11% versus 0%, P < 0.001), surgical access revision (26% versus 8%, P < 0.001), a second access placement (16% versus 6%, P = 0.02), and a catheter insertion (32% versus 11%, P < 0.001). Conclusions: Among patients with CKD undergoing vascular access surgery when their eGFR was <15 ml/min per 1.73 m 2 , catheter use at dialysis initiation was much less likely when an AV graft, rather than an AV fistula, was placed.
Language	English
Publishing date	2023-10-16
Publishing country	United States
Document type	Journal Article
ZDB-ID	2226665-3
ISSN	1555-905X ; 1555-9041
ISSN (online)	1555-905X
ISSN	1555-9041
DOI	10.2215/CJN.0000000000000317
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Zs.A 6584: Show issues

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Article ; Online: Effects of a More Selective Arteriovenous Fistula Strategy on Vascular Access Outcomes.

Allon, Michael / Al-Balas, Alian / Young, Carlton J / Cutter, Gary R / Lee, Timmy

Journal of the American Society of Nephrology : JASN

2023 Volume 34, Issue 9, Page(s) 1589–1600

Abstract: Significance statement: The optimal choice of vascular access for patients undergoing hemodialysis-arteriovenous fistula (AVF) or arteriovenous graft (AVG)-remains controversial. In a pragmatic observational study of 692 patients, the authors found that ...

Abstract	Significance statement: The optimal choice of vascular access for patients undergoing hemodialysis-arteriovenous fistula (AVF) or arteriovenous graft (AVG)-remains controversial. In a pragmatic observational study of 692 patients, the authors found that among patients who initiated hemodialysis with a central vein catheter (CVC), a strategy that maximized AVF placement resulted in a higher frequency of access procedures and greater access management costs for patients who initially received an AVF than an AVG. A more selective policy that avoided AVF placement if an AVF was predicted to be at high risk of failure resulted in a lower frequency of access procedures and access costs in patients receiving an AVF versus an AVG. These findings suggest that clinicians should be more selective in placing AVFs because this approach improves vascular access outcomes. Background: The optimal choice of initial vascular access-arteriovenous fistula (AVF) or graft (AVG)-remains controversial, particularly in patients initiating hemodialysis with a central venous catheter (CVC). Methods: In a pragmatic observational study of patients who initiated hemodialysis with a CVC and subsequently received an AVF or AVG, we compared a less selective vascular access strategy of maximizing AVF creation (period 1; 408 patients in 2004 through 2012) with a more selective policy of avoiding AVF creation if failure was likely (period 2; 284 patients in 2013 through 2019). Prespecified end points included frequency of vascular access procedures, access management costs, and duration of catheter dependence. We also compared access outcomes in all patients with an initial AVF or AVG in the two periods. Results: An initial AVG placement was significantly more common in period 2 (41%) versus period 1 (28%). Frequency of all access procedures per 100 patient-years was significantly higher in patients with an initial AVF than an AVG in period 1 and lower in period 2. Median annual access management costs were significantly higher among patients with AVF ($10,642) versus patients with AVG ($6810) in period 1 but significantly lower in period 2 ($5481 versus $8253, respectively). Years of catheter dependence per 100 patient-years was three-fold higher in patients with AVF versus patients with AVG in period 1 (23.3 versus 8.1, respectively), but only 30% higher in period 2 (20.8 versus 16.0, respectively). When all patients were aggregated, the median annual access management cost was significantly lower in period 2 ($6757) than in period 1 ($9781). Conclusions: A more selective approach to AVF placement reduces frequency of vascular access procedures and cost of access management.
MeSH term(s)	Humans ; Kidney Failure, Chronic/therapy ; Arteriovenous Shunt, Surgical/methods ; Retrospective Studies ; Renal Dialysis/methods ; Arteriovenous Fistula ; Treatment Outcome
Language	English
Publishing date	2023-07-04
Publishing country	United States
Document type	Observational Study ; Journal Article ; Research Support, N.I.H., Extramural
ZDB-ID	1085942-1
ISSN	1533-3450 ; 1046-6673
ISSN (online)	1533-3450
ISSN	1046-6673
DOI	10.1681/ASN.0000000000000174
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Article: Percutaneous Creation of Dialysis Arteriovenous Fistula: Patient Selection and Ultrasound Mapping.

Sharbidre, Kedar G / Alexander, Lauren F / Al-Balas, Alian / Robbin, Michelle L

Seminars in interventional radiology

2023 Volume 40, Issue 1, Page(s) 87–99

Language	English
Publishing date	2023-05-04
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	848341-3
ISSN	1098-8963 ; 0739-9529
ISSN (online)	1098-8963
ISSN	0739-9529
DOI	10.1055/s-0043-1764430
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Article ; Online: Value of Immediate Post-Kidney Biopsy Ultrasound in Excluding Late Hemorrhagic Complications.

Al-Balas, Alian / Almehmi, Ammar / Allon, Michael

Kidney360

2020 Volume 1, Issue 8, Page(s) 797–800

Abstract: Background: Hemorrhage is the most serious potential complication of percutaneous kidney biopsy. Patients are typically observed for at least 6-8 hours after a kidney biopsy, with serial measurements of vital signs and hemoglobin to monitor for major ... ...

Abstract	Background: Hemorrhage is the most serious potential complication of percutaneous kidney biopsy. Patients are typically observed for at least 6-8 hours after a kidney biopsy, with serial measurements of vital signs and hemoglobin to monitor for major hemorrhage. This study assessed whether an immediate postbiopsy ultrasound can reliably exclude delayed major hemorrhage. Methods: We retrospectively evaluated the clinical outcomes in 147 patients undergoing an outpatient native kidney biopsy with an 18-gauge needle at a large medical center during a 2.5-year period (January 2017 to June 2019). All patients underwent a standardized postbiopsy ultrasound to assess for active extravasation of blood. We extracted from the medical records vital signs and hemoglobin values obtained before the biopsy and at 2, 4, and 6 hours after the procedure. We ascertained whether any patients with a negative postbiopsy ultrasound developed a delayed major hemorrhage. Results: Each patient underwent two or three biopsy passes. The mean patient age was 48±17 years, 49% were female, 37% were black, 53% had hypertension, and 16% had diabetes. Of the 142 patients without evidence of active extravasation on ultrasound, the BP, heart rate, and hemoglobin remained stable during 6 hours of observation. All were discharged after 6 hours, and none had a late bleeding complication. Conclusions: If the immediate postkidney biopsy ultrasound does not show active bleeding, the patient is extremely unlikely to develop a late major hemorrhagic complication (negative predictive value, 100%). Such patients can be discharged home safely after a 2-hour observation, thereby simplifying their management.
MeSH term(s)	Adult ; Aged ; Biopsy/adverse effects ; Female ; Hemorrhage/etiology ; Humans ; Kidney/diagnostic imaging ; Middle Aged ; Retrospective Studies ; Ultrasonography/adverse effects
Language	English
Publishing date	2020-06-23
Publishing country	United States
Document type	Journal Article
ISSN	2641-7650
ISSN (online)	2641-7650
DOI	10.34067/KID.0002212020
Database	MEDical Literature Analysis and Retrieval System OnLINE

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Article ; Conference proceedings: Outcomes of Stent Grafts for Treating Thrombosed Thigh Arteriovenous Grafts

Almehmi, Ammar / Shihab, Yazen / El Khudari, Husameddin / Broce, Mike / Al-Balas, Alian

The Arab Journal of Interventional Radiology

2023 Volume 07, Issue S 01

Event/congress	PAIRS 2023 Annual Congress, Grand Hyatt Hotel, Dubai, UAE, 2023-02-11
Language	English
Publishing date	2023-02-01
Publisher	Thieme Medical and Scientific Publishers Pvt. Ltd.
Publishing place	Stuttgart ; New York
Document type	Article ; Conference proceedings
ISSN	2542-7083 ; 2542-7075
ISSN (online)	2542-7083
ISSN	2542-7075
DOI	10.1055/s-0043-1763394
Database	Thieme publisher's database

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Article: Percutaneous Creation of Dialysis Arteriovenous Fistula: Patient Selection and Ultrasound Mapping

Sharbidre, Kedar G. / Alexander, Lauren F. / Al-Balas, Alian / Robbin, Michelle L.

Seminars in Interventional Radiology

(Seminars in IR Portal Hypertension)

2023 Volume 40, Issue 01, Page(s) 87–99

Series title	Seminars in IR Portal Hypertension
Language	English
Publishing date	2023-02-01
Publisher	Thieme Medical Publishers, Inc.
Publishing place	Stuttgart ; New York
Document type	Article
ZDB-ID	848341-3
ISSN	1098-8963 ; 0739-9529
ISSN (online)	1098-8963
ISSN	0739-9529
DOI	10.1055/s-0043-1764430
Database	Thieme publisher's database

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Article ; Online: De Novo

Al-Balas, Alian / Almehmi, Ammar / Varma, Rakesh / Al-Balas, Hassan / Allon, Michael

Kidney360

2021 Volume 3, Issue 1, Page(s) 99–102

Abstract: Background: Central vein stenosis (CVS) is a common complication in hemodialysis patients following tunneled central venous catheter (CVC) insertion. Little is known about its incidence, association with patient characteristics, or relationship with ... ...

Abstract	Background: Central vein stenosis (CVS) is a common complication in hemodialysis patients following tunneled central venous catheter (CVC) insertion. Little is known about its incidence, association with patient characteristics, or relationship with duration of CVC placement. We systematically evaluated central vein stenosis in hemodialysis patients receiving their first CVC exchange at a large medical center. Methods: All new hemodialysis patients underwent an ultrasound before their internal jugular tunneled CVC placement, to exclude venous stenosis or thrombosis. After the initial CVC insertion, if the patients were referred for CVC exchange due to dysfunction, a catheterogram/venogram was performed to assess for hemodynamically significant (≥50%) central vein stenosis. During a 5-year period (January 2016 to January 2021), we quantified the incidence of CVS in patients undergoing CVC exchange. We also evaluated the association of central vein stenosis with patient demographics, comorbidities, and duration of CVC dependence before exchange. Results: During the study period, 273 patients underwent exchange of a tunneled internal jugular vein CVC preceded by a catheterogram/venogram. Hemodynamically significant CVS was observed in 36 patients (13%). CVS was not associated with patient age, sex, race, diabetes, hypertension, coronary artery disease, peripheral artery disease, or CVC laterality. However, the frequency of CVS was associated with the duration of CVC dependence (26% versus 11% for CVC duration ≥6 versus <6 months: odds ratio (95% CI), 3.17 (1.45 to 6.97), Conclusions: Among incident hemodialysis patients receiving their first tunneled internal jugular CVC exchange, the overall incidence of
MeSH term(s)	Catheterization, Central Venous/adverse effects ; Central Venous Catheters/adverse effects ; Constriction, Pathologic/epidemiology ; Humans ; Jugular Veins/diagnostic imaging ; Renal Dialysis/adverse effects
Language	English
Publishing date	2021-10-21
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural
ISSN	2641-7650
ISSN (online)	2641-7650
DOI	10.34067/KID.0005202021
Database	MEDical Literature Analysis and Retrieval System OnLINE

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