Rehman, Zia Ur

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eCommons@AKU Department of Surgery Department of Surgery 3-2020 Cephalic vein transposition: An effective surgical option for dealing with the cephalic vein stenosis Zia Ur Rehman Aga Khan University, ziaur.rehman@aku.edu Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg  Part of the Cardiology Commons, and the Surgery Commons Recommended Citation Rehman, Z. (2020). Cephalic vein transposition: An effective surgical option for dealing with the cephalic vein stenosis. JPMA. The Journal of the Pakistan Medical Association, 70(3), 560-560. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/803 J Pak Med Assoc560Madam, Cephalic arch stenosis is a long term complicationof brachiocephalic arteriovenous fistula (AVF). It may bepresent in 19% to 77% of the patients with malfunctioningbrachiocephalic AVF.1 It is suspected by physicalexamination when a patient has an aneurysmal dilationproximal to cephalic arch and complains of prolongedhaemostasis and high venous pressure during dialysis.Percutaneous venoplasty is the treatment but is associatedwith poor primary patency rates.2 Repeated balloonangioplasty is the norm. Surgical option as cephalic archtransposition can be considered for dealing this entity in'selected' patients.We report a 29 years old lady with chronic renal failure onhaemodialysis who had left brachiocephalic AVF created1.5 years back. She developed cephalic arch stenosis. Shehad two sessions of venoplasties for the stenotic segment.This provided partial relieve for few months in betweenbut the symptoms recurred. She presented this time withbleeding from the fistula site, needing manualcompression to arrest it. Her recent venogram showedrecurrent cephalic arch stenosis and patent central veins(Figure). The narrowed segment was measuringapproximately 34 mm and causing 60-70% stenosis. Asshe was young and a good surgical candidate, cephalicarch transposition was planned. The risks and benefits ofthe procedure were explained to her. The procedure wasperformed in general anaesthesia. After standardpreparation and draping, incision was placed over thecephalic vein at the shoulder joint which was dissectedfor enough length. Axillary vein was also dissected througha separate incision. Cranial end of the dissected cephalicvein was ligated while distal end of the cephalic vein wasbrought through subcutaneous tunnel to the axillary vein.An end-to-side anastomosis was created between cephalicand axillary veins using Prolene 6/0. Both wounds wereclosed in layers. Flow character of the fistula changedfrom pulsatile to soft thrill and tense fistulous aneurysmalvein segments also relaxed. Patient had dialysis soon afterthe procedure from the same access site. She had a patentfistula on the follow up visit, 18 months after the indexprocedure with no complications.Cephalic arch stenosis is effectively treated by surgicalinterventions. Venoplasty of the stenotic segments isalthough minimal invasive but has a shorter patency.3This is partially explained by the fact that angioplasty itselfcauses intimal damage and accelerates neo-intimalhyperplasia. If the patient is a surgical candidate withgood long term expectancy, cephalic vein transpositionis an excellent option.4Disclaimer: None to declare.Conflict of interest: None to declare.Funding disclosure: None to declare.References1. Jang J, Jung H, Cho J, Kim J, Kim HK, Huh S. Central Transpositionof the Cephalic Vein in Patients with Brachiocephalic ArteriovenousFistula and Cephalic Arch Stenosis. Vasc Specialist Int 2014;30:62-7.2. Sivananthan G, Menashe L, Halin NJ. Cephalic arch stenosis indialysis patients: review of clinical relevance, anatomy, currenttheories on etiology and management. J Vasc Access 2014;15:157-62.3. Bountouris I, Kritikou G, Degermetzoglou N, Avgerinos KI. A Reviewof Percutaneous Transluminal Angioplasty in Hemodialysis Fistula.Int J Vasc Med 2018;2018:e1420136.4. Henry JC, Sachdev U, Hager E, Dillavou E, Yuo T, Makaroun M, et al.Cephalic vein transposition is a durable approach to managingcephalic arch stenosis. J Vasc Access 2017.Cephalic Vein Transposition: an effective surgical Option for dealing with thecephalic vein stenosisZia Ur Rehmanhttps://doi.org/10.5455/JPMA.50245Department of Surgery, Aga Khan University Hospital, Karachi Pakistan.Correspondence: Zia Ur Rehman. e-mail: drzia7179@gmail.comFigure: Showing stenosis at cephalic arch.

Cephalic vein transposition: An effective surgical option for dealing with the cephalic vein stenosis

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Cephalic vein transposition: An effective surgical option for dealing with the cephalic vein stenosis

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