Audible Bleeding

CORE RESOURCES: Rutherford's Vascular and Endovascular Therapy 10th Edition, Chapters 88, 89, 91, and 94 Atlas of Vascular Surgery and Endovascular Therapy 2nd Edition, Chapter 9 ADDITIONAL RESOURCES: Audible Bleeding Episodes Holding Pressure - Carotid Endarterectomy: https://www.audiblebleeding.com/2024/02/27/holding-pressure-carotid-endarterectomy/ Holding Pressure Case Prep - Endovascular Basics: https://www.audiblebleeding.com/2023/04/23/holding-pressure-case-prep-endovascular-basics/ Videos TCAR Technical Video: https://jnis.bmj.com/content/14/8/842 Articles Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease: https://www.jvascsurg.org/article/S0741-5214%2821%2900893-4/fulltext Technical aspects of transcarotid artery revascularization using the ENROUTE transcarotid neuroprotection and stent system: https://www.jvascsurg.org/action/showPdf?pii=S0741-5214%2816%2931862-6 Referenced Studies ROADSTER-1 https://pubmed.ncbi.nlm.nih.gov/30611582/ ROADSTER-2 https://pubmed.ncbi.nlm.nih.gov/32811386/ https://pubmed.ncbi.nlm.nih.gov/35381327/ TCAR Surveillance Project https://jamanetwork.com/journals/jama/fullarticle/2757579?utm_source=openevidence&utm_medium=referral https://pubmed.ncbi.nlm.nih.gov/36172943/ OUTLINE: CAROTID ARTERY DISEASE 1. Pathophysiology/etiology Carotid artery disease is primarily driven by atherosclerotic plaque deposition. Risk factors: hypertension, hyperlipidemia, diabetes, smoking, and advanced age. Nonatherosclerotic etiologies: fibromuscular dysplasia, carotid dissection, vasculitic disease, carotid webs, and trauma. When the endothelium is damaged, monocytes migrate to the site and differentiate into macrophages that take up oxidized LDL particles to become foam cells. Meanwhile, an inflammatory response occurs where activated platelets release thromboxane A2, platelet derived growth factor, and inflammatory cytokines that promote further platelet aggregation and vascular inflammation. Smooth muscle cells migrate and proliferate, forming the structural framework of the atheroma. Within the lesion, necrotic debris and lipid accumulate, creating a vulnerable plaque. Plaque rupture exposes this material to the bloodstream, serving as a nidus for thrombus formation which can lead to ischemic events. Carotid bifurcation is particularly prone to plaque formation due to turbulent blood flow. Embolization of plaque from this area can result in TIA or ischemic stroke. 2. Presentation Patients are often asymptomatic and stenosis is incidentally found on imaging. Symptomatic patients present with neurologic symptoms including unilateral motor and sensory loss, aphasia (difficulty finding words), dysarthria (difficulty speaking), amaurosis fugax (temporary monocular vision loss due to embolus to the ophthalmic artery), transient ischemic attacks Physical exam findings may be notable for auscultation of a carotid bruit. Patients may also have evidence of retinal artery embolization on fundoscopic examination (Hollenhorst plaque) or asymptomatic cerebral infarction. 3. Diagnosis USPTF recommends against screening for asymptomatic carotid artery stenosis. In patients with no risk factors, SVS recommends against screening for asymptomatic carotid artery stenosis. However, they do recommend screening for asymptomatic clinically significant carotid bifurcation in certain groups of patients with multiple risk factors. These risk factors include patients with clinically significant peripheral vascular disease, patients 65 and older with history of CAD, smoking, hypercholesterolemia, and patients prior to coronary artery bypass. Relevant findings on physical exam or imaging findings may warrant screening, but screening is not recommended for the presence of neck bruit alone without other risk factors, as this finding has a low sensitivity and specificity for detecting clinically significant carotid artery stenosis. Carotid duplex ultrasound: first-line imaging modality for both screening and initial evaluation of stenosis, noninvasive, low-cost CTA: rapid, high-resolution, three-dimensional imaging of vascular anatomy, risk of contrast and radiation exposure MRA: high-quality, three-dimensional imaging without radiation or contrast, expensive with longer acquisition time, can overestimate stenosis in severe disease DSA/angiography: gold standard, expensive, invasive, not generally recommended for routine diagnostic evaluation or screening 4. Classification Carotid artery stenosis is classified by degree of luminal narrowing. NASCET method: standard in current practice. Compares the minimal residual lumen at the point of greatest stenosis to the diameter of the normal distal internal carotid artery. Classification of stenosis: Mild: Moderate: 50-69% narrowing Severe: ≥70% narrowing TRANSCAROTID ARTERY REVASCULARIZATION (TCAR) 5. Relevant Trials ROADSTER-1 trial: prospective, multicenter, single-arm study evaluating TCAR with dynamic flow reversal in patients at high risk for carotid endarterectomy (CEA), including both symptomatic (≥50% stenosis) and asymptomatic (≥80% stenosis) patients. 30-day stroke rate of 1.4% and a combined stroke/death/MI rate of 3.5%, with technical success in 99% of cases At 1 year, the ipsilateral stroke rate was 0.6%, indicating excellent durability in a high-risk population Limitations: highly controlled environment with a select group of experienced operators, which raised concerns about the generalizability, especially among physicians new to TCAR. Additionally, ROADSTER-1 was a single-arm study without a comparison group. ROADSTER-2: prospective, multicenter, post-approval registry format. Addressed limitations of ROADSTER-1 by enrolling a larger and more diverse group of operators, the majority of whom were TCAR-naïve. The per-protocol population had a 30-day stroke rate of 0.6% and a combined stroke/death rate of 0.6%, with technical success in 99.7% of cases. These results confirmed the low perioperative stroke and death rates seen in ROADSTER-1, even with less experienced operators. TCAR Surveillance Project: ongoing study that provides real-world, comparative data using the VQI registry. In propensity-matched analyses, TCAR had similar in-hospital stroke/death rates to CEA (1.6% vs 1.6%) and significantly lower rates than transfemoral carotid artery stenting (TF-CAS, 2.9%). TCAR was also associated with significantly lower cranial nerve injury and myocardial infarction rates compared to CEA (0.7 vs 2.4%, and 0.5 vs 0.9%, respectively). At 1 year, stroke/death rates remained similar between TCAR and CEA (5.1-6.4% vs 5.2-6.6%, respectively), but TCAR outperformed TF-CAS (5.1-6.4% vs 9.6-9.7%). 6. Indications for Surgery All patients with carotid artery stenosis benefit from best medical therapy (BMT): antiplatelet, high-intensity statin, aggressive risk factor control, and lifestyle modification. Asymptomatic patients: ≥70% stenosis, provided the anticipated perioperative risk for stroke, MI, or death is Symptomatic patients: >50% stenosis, benefit of revascularization increases with higher degrees of stenosis. Carotid intervention for symptomatic patients should be performed 2-14 days after stroke. TCAR anatomic criteria: Internal carotid artery diameter 4-9mm Clavicle-carotid bifurcation distance ≥ 5cm Common carotid artery (CCA) diameter ≥ 6mm No or mild puncture site plaque TCAR may be more favorable than CEA in patients who have a high lesion at or above C2 vertebral level, high carotid bifurcation, "hostile neck" (restenosis post-CEA, cervical spine immobility, history of neck irradiation or radical neck dissection) Contraindications: 100% occlusion, or patients with severe comorbidities or life expectancy 3, unsuitable anatomy or an inability to tolerate flow reversal 7. Surgery Preop DAPT at least 3 days and statin for 5 days to reduce periprocedural risk of stroke and mortality. Anesthesia: general anesthesia or MAC Positioning: supine position with the head extended and turned to the contralateral side. The neck and contralateral groin are prepped and draped in sterile fashion. Steps to the procedure and relevant anatomy Common carotid artery exposure Identify the triangle created by the sternal and clavicular heads of the sternocleidomastoid muscle (SCM) and the superior edge of the clavicle. Create a 2- to 4-cm longitudinal or transverse incision between the two heads. Electrocautery is used to divide through the subcutaneous tissue and platysma. The SCM is retracted laterally to access the carotid sheath. The carotid sheath contains three critical structures. From medial to lateral we have the common carotid artery, vagus nerve, and internal jugular vein. The internal jugular vein is dissected and retracted. A branch off of the internal jugular vein that we commonly encounter is the facial vein. This can be safely ligated when encountered. In most patients, the vagus nerve lies lateral and posterior to the common carotid artery and care should be taken to avoid injury to it, especially in the later steps when we get to clamping the artery. Other critical structures: Hypoglossal nerve: crosses the carotid artery transversely approximately 2-3 cm above the carotid bifurcation Ansa cervicalis: encountered in the carotid sheath as it branches from the hypoglossal nerve as it crosses the internal carotid artery Carotid body: at the base of the carotid bifurcation Marginal mandibular branch of the facial nerve: encountered at higher incisions, though this is not as common as with carotid endarterectomies Once the common carotid artery is dissected and exposed, a vessel loop or umbilical tape is placed to facilitate manipulation of the vessel during carotid artery access. A purse string or U-stitch 5-0 polyproline suture is placed on the common carotid for the closure of the arterial puncture site at the end of the procedure. Femoral vein access Femoral triangle anatomy: Borders Superior: inguinal ligament Lateral: medial border of the sartorius muscle Medial: lateral border of the adductor longus muscle Contents Lateral to medial: femoral nerve, femoral artery, femoral vein, empty space/femoral canal, and lymphatics Mnemonic - NAVEL: nerve, artery, vein, empty space, lymphatics Using ultrasound guidance, the femoral vein contralateral to the common carotid artery we just exposed is visualized. The common femoral vein is typically accessed 1-2 cm below the inguinal ligament and is around 2-4 cm deep to the skin in most adults. We access the vein with a micropuncture system via Seldinger technique. The TCAR venous return sheath is advanced over a 0.035-inch guidewire. Blood is aspirated from the flow line and the sheath is flushed with heparinized saline to ensure proper access. Secure the venous return sheath with suture. The contralateral femoral vein is accessed to facilitate optimal circuit setup and minimize interference with arterial access and other steps. Common carotid artery access and sheath placement Heparin should be given prior to obtaining arterial access. An activated clotting time, also known as ACT, between 250-300 should be achieved. Obtain micropuncture access of the common carotid at the site where we previously placed the suture. A 21-gauge micropuncture needle is slowly advanced into the anterior wall of the common carotid artery and a 0.018-inch micropuncture wire is advanced 3 cm into the common carotid artery. A micropuncture sheath and dilator are advanced 2-3 cm into the common carotid. After removal of the dilator and micropuncture wire, brisk and pulsatile backbleeding confirms correct positioning. Angiogram is obtained to delineate the carotid bifurcation and where the lesion is located. A 0.035-inch ENROUTE J wire is positioned in the CCA, the micropuncture sheath is removed, and the arterial sheath and dilator are inserted (stop short technique). The arterial access sheath is advanced to the 2.5-cm marker, predetermined by the sheath stopper. The sheath position should be checked using angiography in two projections after removal of the dilator to ensure the sheath tip is placed coaxially within the common carotid. Secure the sheath to the patient at 3 points using 2-0 silk stitches. The side ports are burped and a control run confirms no evidence of dissection or vessel injury. Initiation of dynamic flow reversal The flow controller is connected to the arterial access sheath. The column should be held upward and arterial blood should fill the column. Once it fills to the line on the controller, connect the system to the venous return sheath. You have now established an extracorporeal AV shunt. The integrity of the circuit is verified by flushing the venous sheath with hep saline and confirming rapid blood flow through the circuit. Perform a TCAR time out, confirming systolic blood pressure 140–160 mmHg, heart rate >70 bpm, and ACT >250 seconds to optimize cerebral perfusion and minimize thrombotic risk. Clamp the carotid artery just proximal to the arterial sheath to establish active flow reversal. Flow controller settings: Low setting High setting Flow-stop button: allows for temporary cessation of flow (used when we inject contrast). Confirm flow reversal via two different ways: The first way is to stop flow to the venous return sheath with the stopcock, clearing the line with hep saline injection, and then opening the stopcock and seeing the blood returning to the controller in a reverse fashion. The second way is to perform an angiogram with a small amount of contrast injection while holding the flow-stop button. Using the angio we want to make sure that contrast is flowing retrograde in the cervical ICA thereby confirming flow reversal. Carotid artery stenting, balloon angioplasty, and completion angiogram At this point, a standard carotid angioplasty and stenting procedure is performed. ENROUTE transcarotid Neuroprotection System device: inner diameter of 8F and an outer diameter of 10F Has its own carotid artery stent system but is also compatible with all FDA-approved carotid stents. Final angiogram is performed to confirm stent position, vessel patency, and absence of complications including vasospasm at the distal end of the stent and filling defects from protrusion of atheromatous material through the stent Cessation of flow reversal and sheath removal Allow the flow reversal to run for a few minutes after the final balloon angioplasty to clear any debris. Antegrade flow is restored by releasing the carotid clamp and closing the stopcocks on the neuroprotection system. The patient is auto-transfused the blood from the flow line back to the venous system. As the arterial access system is removed and the puncture site is closed with the U-stitch. IV protamine is administered to reverse the heparin. Standard closure is performed at the incision site. Meanwhile, hemostasis is achieved after removal of the femoral vein sheath with brief manual compression. Postop care/complications Postop care All patients after a TCAR should be monitored in the ICU setting for 24 hours, as an embolic stroke, hypotension with or without bradycardia, or hypertension can occur. Should a TIA or stroke be observed, a carotid duplex scan and CT angiogram should be immediately obtained to assess the stent site and the presence of an embolic or thrombotic filling defect, dissection, or occlusion. Dual antiplatelet therapy: continue for 45 days to 12 months Aspirin and statin therapy: continued indefinitely Surveillance duplex imaging: 4 weeks, 6 months, and 12 months, and annually thereafter. Postop complications Hematoma Stroke Myocardial infarction Cerebral hyperperfusion syndrome Sudden and excessive increase in cerebral blood flow to previously hypoperfused brain tissue is met with vasculature that cannot constrict appropriately from chronic vasodilation Leads to breakthrough hyperperfusion. This results in cerebral edema, intracerebral hemorrhage, and neurological symptoms. Cranial nerve injury Hypoglossal nerve (CN XII) injury: ipsilateral tongue deviation. It is the most commonly injured cranial nerve. Vagus nerve (CN X) injury: hoarseness and possible vocal cord paralysis. Glossopharyngeal nerve (CN IX) injury: soft palate dysfunction. Recurrent laryngeal nerve injury: voice hoarseness and inability to cough as it innervates all of the voice box muscles except for the cricothyroid muscle Marginal mandibular nerve injury: ipsilateral lip droop, injury is rare in TCAR. Stent restenosis Pseudoaneurysm Access site infection

Audible Bleeding editors Falen Demsas, an integrated vascular surgery resident at Massachusetts General Hospital, and Sasank Kalipatnapu (@ksasank), a fifth-year general surgery resident at UMass Chan Medical School, are joined by Megan Tracci (@MeganTracci), James Black (@JamesHBlackMD), and Lauren West-Livingston (LWestLivingston) for a discussion following the inaugural SVS Leadership and Advocacy Summit. In this episode, the group reflects on the importance of surgeon advocacy, highlights key takeaways from the Summit, and discusses how vascular surgeons throughout training and practice can engage in policy, leadership, and organized medicine at local and national levels. The conversation explores the evolving role of advocacy within the Society for Vascular Surgery, including the work of the SVS Advocacy Council and its collaboration across Government Relations, Coding, VA advocacy, and quality and policy initiatives. Dr. Tracci shares insights from her leadership roles within SVS advocacy efforts and her work as ACS Medical Director for Surgeon Engagement. Dr. Black discusses his longstanding advocacy work on behalf of patients and physicians, including numerous trips to Capitol Hill over the course of his career. Dr. West-Livingston reflects on her experience attending the recent Advocacy & Leadership Conference as a trainee and the importance of resident involvement in advocacy work. Show Guests Megan Tracci Leader within the SVS Advocacy Council, which includes Government Relations, Coding, VA advocacy, and quality and policy collaboration efforts. She also serves as the ACS Medical Director for Surgeon Engagement. James Black Chief of Vascular Surgery and Endovascular Therapy at Johns Hopkins University and longtime advocate who has made countless trips to Capitol Hill to advocate for patients and physicians. Lauren West-Livingston Integrated vascular surgery resident at Duke University and member of the SVS Government Relations Committee who attended the recent Advocacy & Leadership Conference. Notable Mentions The inaugural SVS Leadership and Advocacy Summit Advocacy efforts within the Society for Vascular Surgery, including Government Relations, Coding, VA advocacy, and quality and policy collaboration. Learn more here SVS Advocacy Council Opportunities for vascular surgeons to engage in advocacy throughout all stages of training and practice. Sign up for updates Follow us @audiblebleeding Learn more about us at Audible Bleeding and provide us with your feedback through our listener survey. Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.

In this episode, we spotlight editorials and abstracts from the Journal of Vascular Surgery Cases, Innovations, and Techniques (JVS-CIT). Editorials and Abstracts are read by Authors as well as members of the SVS Social Media Ambassadors. Guests: Isabel Banks, MS4, SLU Selected publications regarding lower extremity chronic ischemia and the diabetic foot from the Journal of Vascular Surgery: Cases and Innovative Reports 2025, Volume 11 Best of 2025—abdominal aortic and iliac aneurysm Double anonymous peer review in JVSCIT—lessons from our pilot trial and next steps Endovascular stapling with Aortoseal as an adjunct for the hostile neck The transcaval approach may be the new route vascular surgeons need in their arsenal Intraoperative positioning system-guided antegrade in situ laser fenestration in an aortic model Single-center experience using Endologix anatomically fixated endograft device for treatment of aortoiliac occlusive disease Short-term analysis of botulinum toxin A for functional popliteal artery entrapment syndrome Comparing neurological complications between endovascular and open surgical repair of the descending thoracic aorta Hosts: John Culhane (@JohnCulhaneMD) Follow us @audiblebleeding, @JVS-CIT Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.

Audible Bleeding Editor and vascular surgery fellow Richa Kalsi (@KalsiMD) is joined by 4th year general surgery resident Joe El Badaoui (@JosephBadaouiMD), JVS editor Dr. Audra Duncan (@ADuncanVasc), and JVS-VS editor Dr. John Curci (@CurciAAA) to discuss two great articles in the JVS family of journals. The first article discusses an extensive experience using cryopreserved arterial allografts for vascular reconstruction after major oncologic surgery. The second article sheds light on nanoplastics in atherosclerotic plaques. This episode hosts Dr. Sebastian Cifuentes, Dr. Randall DeMartino (@randydemartino), Dr. Pierce Massie, and Dr. Ross Clark, the first and senior authors of these two papers. Articles: Part 1:Ten-year experience using cryopreserved arterial allografts for vascular reconstruction during major oncologic surgery (Drs. Cifuentes & DeMartino) Part 2: Micro- and nanoplastics are elevated in femoral atherosclerotic plaques compared with undiseased arteries (Drs. Clark & Massie) Show Guests Dr. Sebastian Cifuentes is a first year integrated vascular surgery resident at University of Michigan in Ann Arbor, MI Dr. Randall DeMartino is a Professor of Surgery and the chair of the Division of Vascular and Endovascular Surgery at the Mayo Clinic in Rochester, MN Dr. Pierce Massie is a general surgery resident in his research time at the University of New Mexico School of Medicine in Albuquerque, NM Dr. Ross Clark is an Assistant Professor of Vascular Surgery and Assistant Professor of Cell Biology and Physiology at the University of New Mexico School of Medicine in Albuquerque, NM Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

SAVC (Section on Ambulatory Vascular Care) formed a GPO to help SVS members in private practice access competitive pricing on medical supplies, devices, pharmaceuticals, and services. The podcast episode explores the history of the collaboration, the benefits for SVS private practice members, and how they can become involved. Guest Info Dr. Anil Hingorani is a previous President of the Eastern Vascular Society. He is currently the Chair of the Section on Ambulatory Vascular Care (SAVC) of the Society for Vascular Surgery. Dr. Naveed A. Rahman, Editor, is a Vascular Surgery Fellow at the University of Maryland. Website Links SVS launches partnership to help private practice vascular surgeons cut costs Section on Ambulatory Vascular Care in SVS. How to Join the SVS - Group Purchasing Organization

Resources: Rutherford Chapters (10th ed.): 174, 175, 177, 178 Prior Holding Pressure episode on AV access creation: https://www.audiblebleeding.com/vsite-hd-access/ The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access: https://www.jvascsurg.org/article/S0741-5214%2808%2901399-2/fulltext KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update: https://pubmed.ncbi.nlm.nih.gov/32778223/ Venous Hypertension Definition A functioning AV circuit delivers high volume arterial flow towards a stenotic venous segment, causing buildup in pressure and venous hypertension. If there are few or no branching veins between the access and stenosis, thrombosis could occur Etiology The most common etiology is venous stenosis caused by a history of vessel wall trauma by centrally-inserted venous devices such as tunneled and non-tunneled dialysis catheters, central lines, pacemakers, or defibrillator. In a study performed at a large academic medical center1, new hemodynamically significant central venous stenosis was associated with the duration of catheter dependence (26% in patients with CVCs for more than 6 months, versus 11% in patients with CVCs for less than 6 months). PICC lines can directly damage cephalic and basilic veins Venous stenosis can often go undetected until AV access creation occurs Patient Presentation Symptoms of venous insufficiency will be present– most commonly regional edema, in the area of venous stenosis. If there are patent venous branches between the AV anastomosis and the stenotic area, swelling can occur throughout the arm. Pigmentation, induration, dermatosclerosis, and ulceration may also be observed. An extensive collateral network of veins may be visible throughout anterior chest, shoulder, or flank SVC obstruction can result in swelling of the head, neck and shoulders, as well as a feeling of head and neck fullness, airway compromise, and visual problems Normal palpable thrill can be replaced by a strong pulse Dialysis can be complicated by difficulty with needle access, recirculation syndrome, and arm swelling after dialysis sessions. Workup Central vein thrombosis can be hard to detect on ultrasound because clavicle and sternum can block transmission Venography is essential to determine the presence and severity of venous stenosis or occlusion. Prevention The ideal scenario is to avoid central dialysis catheters completely, and this involves evaluating CKD patients and placing AVF or AVG before the need for dialysis arises. If a patient presents placement of an AVF/AVG, it is important to perform venography if a patient has a history of a central venous catheter or clinical signs of venous hypertension. A history of SVC obstruction from any cause can preclude permanent AV access creation in both upper extremities Treatment Endovascular approaches to venous outflow stenosis can be first-line treatment options, due to their minimal risk. They can also be performed at the same time as a diagnostic venogram. Angioplasty alone or with stenting are the endovascular options. In a study by Bakken et al2 that compared primary high-pressure balloon angioplasty versus stenting, primary patency was equivalent between groups, with 30-day rates of 76% for both groups and 12-month rates of 29% for angioplasty and 21% for stenting. Assisted primary patency was also equivalent with a 30-day patency rate of 81% and 12-month rate of 73% for the angioplasty group, 84% at 30 days, and 46% at 12 months for the stenting group. This study, along with others, shows that the major downside of endovascular interventions, whether angioplasty or stenting, often require repeat intervention and have poor long-term patency. For subclavian vein stenosis, angioplasty alone is appropriate due to its anatomical location that can put a stent at risk for extrinsic compression from the first rib and clavicle. Surgical bypass can be performed Possible bypasses include axillary-axillary, axillary-jugular, axillary-right atrial, and axillary-femoral. In these bypasses, the preferred conduits are autogenous saphenous or femoral veins. In cases where the proximal subclavian vein is obstructed, a jugular vein turndown can be performed. In this procedure the distal jugular vein is transected, sewed end-to-side at the distal subclavian vein, effectively acting as a bypass route for that obstructed segment. The Hemoaccess Reliable Outflow (HeRO) Vascular Access Device can be used as a hybrid approach, combining endovascular and open surgical techniques to bypass a central venous occlusion and provide a reliable outflow for dialysis. This device has a PTFE inflow limb that is sewn end-to-side onto the brachial artery. This limb is tunneled subcutaneously and connected to a silicone-coated nitinol outflow catheter that is inserted into a central vein and tracked directly into the right atrium. This effectively bypasses central venous stenoses. In the largest study to date on HeRO access grafts placed in 167 patients,3 HeRO primary and secondary patency was 48.8% and 90.8%, respectively, at 12 months. Interventions to maintain or re-establish patency were required in 71.3% of patients resulting in an intervention rate of 1.5/year. Access-related infections were reported in 4.3% patients. The authors concluded that HeRO device had performed comparably to standard AVGs and had proven superior to tunneled dialysis catheters in terms of patency, intervention, and infection rates. If no treatment options for venous hypertension or outflow obstruction are available, an alternate AV access site can be created, either in the contralateral arm if the SVC is uninvolved, or through placement of femoral AV access or a peritoneal dialysis catheter. Bleeding Access Site Etiology and Risk Factors Bleeding can be caused by high venous pressure after dialysis, pseudoaneurysm rupture, or trauma. Patients with end stage renal disease (ESRD) have a baseline elevated risk of bleeding due to uremia-induced platelet dysfunction and use of systemic anticoagulation within the hemodialysis circuit. Additional risk factors include dialysis through an AV graft, hypertension, longer duration of access use, and compromised integrity of the vascular access due to complications (clotting, infection) or invasive procedures. Dual antiplatelet therapy is also associated with overall bleeding events in ESRD patients. Dialysis patients could be on antiplatelet therapy for management of comorbid cardiovascular risk and/or patency of AV graft Patients with bleeding fistulas often present from their dialysis unit when standard digital pressure at the cannulation site fails to stop the bleeding. This is a very serious condition since most mature fistulas have high blood flow and the patients are at risk for hemorrhagic shock and death. Initial Management The first step of management is to obtain hemostasis. Elevate the limb above the level of the heart and apply firm and directed pressure at the site of bleeding using gauze for at least 30-40 minutes Milosevic et al4 reviewed non-operative management of bleeding fistulas and grafts and found that compared to standard dressings, the use of specialized hemostatic dressings decreased bleeding time at arterial and venous cannulation sites. These hemostatic materials included the IRIS compression bandage and cellulose-based, chitosan-based, poly-N-acetyl glucosamine-based, and thrombin-soaked dressings. There has been a "bottlecap method" described where the hollow side of a bottlecap is pressed on top of the puncture site. Maintaining pressure on the cap will cause the cap to fill with blood and clot, which tamponades the bleeding. The provider can also place a shallow figure-of-8 or purse string stitch just below the skin surface to aid in hemostasis. It is important to avoid placing the suture too deep as this can cause inadvertent fistula ligation. During this process, an assistant applies pressure just proximal and distal to the bleeding site to stop blood flow so the sutures can be placed. If these methods fail to achieve hemostasis, apply a tourniquet proximal to the fistula and tighten it until bleeding stops and the radial pulse is lost. This signifies complete occlusion of arterial inflow to the fistula. Tourniquet use should be limited to 3 hours or less, since limb ischemia beyond this timepoint is associated with permanent neuromuscular damage. Regardless of the method used for initial hemostasis, the patient is at risk for repeat hemorrhage, hematoma formation, vessel stenosis, and thrombosis. They should be evaluated by a vascular surgeon as soon as possible. Definitive Management Definitive management depends on etiology of each case, and there are a variety of interventions that can be pursued (i.e. aneurysmorrhaphy for aneurysmal bleeding) If skin erosion over the conduit is present, it should be assumed that the AV access is infected and emergency intervention should be pursued. A jump graft can be placed through with healthy tissue. A covered stent could be introduced through a separate percutaneous puncture site Finally, coagulopathy can be addressed by administering cryoprecipitate, DDAVP, erythropoietin, estrogen, tranexamic acid. Aneurysms and Pseudoaneurysms Definition and Etiology Aneurysms involve all three layers of the vessel wall and they develop due to hemodynamic changes causing remodeling of the vein wall in an AV fistula. This is necessary for vein maturation, but becomes problematic if the post-anastomotic vein continues to dilate and becomes aneurysmal. Aneurysms can also occur at anastomosis sites due to technical aspects of the surgery. Pseudoaneurysms only involve some layers of the vessel wall caused by repeated puncture for hemodialysis. Both aneurysms and pseudoaneurysms can enlarge due to venous outflow stenosis causing increased intraluminal pressures. Both true aneurysms and pseudoaneurysms can lead to overlying skin erosion and subsequent hemorrhage, pain, AV access dysfunction, and cannulation difficulties. Dialysis cannulation should be avoided at the aneurysmal sites to prevent bleeding complications. Diagnosis They can be diagnosed on ultrasound, which also provide information on flow rates, presence inflow/outflow/stenoses, and vessel diameters. Indications for Treatment Treatment is indicated for aneurysms that are rapidly expanding or ulcerating through the skin surface. These are at high risk for rupture and hemorrhage, which is life-threatening. Treatment is also indicated when the aneurysm occurs at the anastomotic site of the AV fistula, the patient has a cosmetic concern, cannulation becomes difficult, there is concern for infection, or the patient has high-output heart failure that could be exacerbated by high flow through the fistula. Treatment is not indicated in asymptomatic aneurysms, regardless of their size. True aneurysms and pseudoaneurysms are not prone to spontaneous rupture. Treatment Options Aneurysmorrhaphy is the most common treatment. It involves the resection of the aneurysmal vein wall to restore a normal diameter and removal of excess skin. Anastomosis is performed along the lateral wall to prevent issues with cannulation along the suture line. Aneurysm resection with interposition grafting is also possible. If multiple aneurysmal segments require treatment, staging their repairs can allow for continuation of dialysis without needing to place a temporary dialysis catheter. AV access ligation is an appropriate alternative to AV access salvage in certain situations but usually requires excision of the aneurysm/pseudoaneurysm due to the potential to develop thrombophlebitis and the cosmetic appearance of the thrombosed segment. If there is concern for an infected pseudoaneurysm or aneurysm, surgery should include removal of all infected material. References 1. Al-Balas A, Almehmi A, Varma R, Al-Balas H, Allon M. De Novo Central Vein Stenosis in Hemodialysis Patients Following Initial Tunneled Central Vein Catheter Placement. Kidney360. 2022;3(1):99-102. doi:10.34067/KID.0005202021 2. Bakken AM, Protack CD, Saad WE, Lee DE, Waldman DL, Davies MG. Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients. J Vasc Surg. 2007;45(4):776-783. doi:10.1016/j.jvs.2006.12.046 3. Gage SM, Katzman HE, Ross JR, et al. Multi-center Experience of 164 Consecutive Hemodialysis Reliable Outflow [HeRO] Graft Implants for Hemodialysis Treatment. Eur J Vasc Endovasc Surg. 2012;44(1):93-99. doi:10.1016/j.ejvs.2012.04.011 4. Milosevic E, Forster A, Moist L, Rehman F, Thomson B. Non-surgical interventions to control bleeding from arteriovenous fistulas and grafts inside and outside the hemodialysis unit: a scoping review. Clin Kidney J. 2024;17(5):sfae089. doi:10.1093/ckj/sfae089

Audible Bleeding Editor and vascular surgery fellow Richa Kalsi (@KalsiMD) is joined by vascular surgery fellow Javaneh Jabbari (@JabbariMD) in hosting Dr. Gustavo Oderich (@GustavoOderich), Dr. Shahab Toursavadkohi (@Toursavadkohi ), and Dr. Mehrdad Ghoreishi (@dr_ghoreishi) to discuss the "final frontier" in the endovascular management of aortic pathology, or the Endo-Bentall Procedure. This episode highlights collaboration between vascular and cardiac surgery as we take a deep dive into physician modification of grafts to manage aortic root pathology. We will discuss the off-label use of endovascular devices and hear insights into the future of endovascular and open aortic surgery from these leaders and innovators in the field. For some background on the topic, see the resources below Articles: First-in-Human Endovascular Aortic Root Repair (Endo-Bentall) for Acute Type A Dissection Link to the Presentation on this by Dr. Ghoreishi at AATS for more procedural details Show Guests Dr. Shahab Toursavadkohi - Professor of Vascular surgery and Co-director of the Center for Aortic Disease at the University of Maryland Medical System Dr. Mehrdad Ghoreishi - Associate Professor of Cardiac Surgery and Co-director of aortic surgery and medical director of cardiac surgery research at Baptist Health Miami Cardiac & Vascular Institute Dr. Gustavo Oderich - Professor and Chief of the Division of Vascular Surgery and Endovascular Therapy at the Texas Heart Institute and director of the new Baylor Medicine Center for Aortic Surgery Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.

In this episode, we spotlight editorials and abstracts from the Journal of Vascular Surgery Cases, Innovations, and Techniques (JVS-CIT). Editorials and Abstracts are read by Authors as well as members of the SVS Social Media Ambassadors. Guests: Juliet Blakeslee-Carter, MD (@AWBeckMD) The value and structure of writing a vascular surgery case report: A student's guide Neha Gupta (@nehaha00) We don't know what we don't know, until we do Colonic ischemia and the role of inferior mesenteric artery reimplantation after abdominal aortic aneurysm repair Abdominal aortic aneurysm classification based on dynamic intraluminal thrombus analysis during cardiac cycle Quantitative intra-arterial fluorescence angiography for direct monitoring of peripheral revascularization effects Ben Li, MD (@ben_li123) An introduction to the journal review and editorial process Hosts: John Culhane (@JohnCulhaneMD) Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey. *Gore is a financial sponsor of this podcast, which has been independently developed by the presenters and does not constitute medical advice from Gore. Always consult the Instructions for Use (IFU) prior to using any medical device.