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Background: We report a case of a patient who suffered thrombosis of a radial artery-cephalic vein fistula accompanied by aneurysm and a single outflow path of the elbow perforating vein. We performed open surgery combined with Fogarty balloon catheter embolectomy, anastomotic reconstruction and forearm median vein transposition., Case Presentation: The patient presented with an arteriovenous fistula (AVF) after haemodialysis 5 years ago. In the process of dialysis, the fistula vein was punctured, resulting in aneurysm, high pressure and difficult haemostasis after needle extraction. AVF occlusion was observed on April 12, 2022. We performed a combined open surgery. First, a Fogarty balloon catheter was used to remove the thrombus, and the anastomosis was then reconstructed to restore AVF fistula patency. Finally, forearm median vein transposition was used to establish dual outflow. Postoperative haemodialysis was possible. There are various methods for removing the thrombus in AVF. Here, we report a case in which we performed open surgery combined with Fogarty balloon catheter embolectomy, anastomotic reconstruction and forearm median vein transposition to ensure fistula patency., Conclusion: We removed a complete reverse 'Z'-shaped thrombus of the elbow perforating vein in a haemodialysis fistula. This report provides an effective strategy to manage a high-pressure fistula with single outflow of the elbow perforating vein., (© 2022. The Author(s).)

Purpose: The objective of the investigation was to determine the concomitant effects of upper arm blood flow restriction (BFR) and inversion on elbow flexors neuromuscular responses., Methods: Randomly allocated, 13 volunteers performed four conditions in a within-subject design: rest (control, 1-min upright position without BFR), control (1-min upright with BFR), 1-min inverted (without BFR), and 1-min inverted with BFR. Evoked and voluntary contractile properties, before, during and after a 30-s maximum voluntary contraction (MVC) exercise intervention were examined as well as pain scale., Results: Inversion induced significant pre-exercise intervention decreases in elbow flexors MVC (21.1%, [Formula: see text] = 0.48, p = 0.02) and resting evoked twitch forces (29.4%, [Formula: see text] = 0.34, p = 0.03). The 30-s MVC induced significantly greater pre- to post-test decreases in potentiated twitch force ([Formula: see text] = 0.61, p = 0.0009) during inversion (↓75%) than upright (↓65.3%) conditions. Overall, BFR decreased MVC force 4.8% ([Formula: see text] = 0.37, p = 0.05). For upright position, BFR induced 21.0% reductions in M-wave amplitude ([Formula: see text] = 0.44, p = 0.04). There were no significant differences for electromyographic activity or voluntary activation as measured with the interpolated twitch technique. For all conditions, there was a significant increase in pain scale between the 40-60 s intervals and post-30-s MVC (upright

With the advance of radial access and ulnar access there has been an increased interest in performing right heart catheterization (RHC) and right-heart based procedures via antecubital venous access. Our purpose is to describe the venous anatomy of the upper extremities, technique, equipment, and cost for employing this approach. Reported also is the international experience based on publications assessing procedural success, complications, fluoroscopy time and radiation dose, access-site compression time, and time to ambulation. We conclude that antecubital-venous-access based RHC carries satisfactory success rates, requires a short learning curve, and is exceptionally safe even when performed with full anticoagulation. It is our hope that industry will provide us with even better tools to extend the practice of antecubital-venous-access based procedures and interventions.

Background: The superficial vein of the resting limb constricts sympathetically during exercise. Central command is the one of the neural mechanisms that controls the cardiovascular response to exercise. However, it is not clear whether central command contributes to venous vessel response during exercise. Tendon vibration during static elbow flexion causes primary muscle spindle afferents, such that a lower central command is required to achieve a given force without altering muscle force. The purpose of this study was therefore to investigate whether a reduction in central command during static exercise with tendon vibration influences the superficial venous vessel response in the resting limb., Methods: Eleven subjects performed static elbow flexion at 35% of maximal voluntary contraction with (EX + VIB) and without (EX) vibration of the biceps brachii tendon. The heart rate, mean arterial pressure, and rating of perceived exertion (RPE) in overall and exercising muscle were measured. The cross-sectional area (CSAvein) and blood velocity of the basilic vein in the resting upper arm were assessed by ultrasound, and blood flow (BFvein) was calculated using both variables., Results: Muscle tension during exercise was similar between EX and EX + VIB. However, RPEs at EX + VIB were lower than those at EX (P <0.05). Increases in heart rate and mean arterial pressure during exercise at EX + VIB were also lower than those at EX (P <0.05). CSAvein in the resting limb at EX decreased during exercise from baseline (P <0.05), but CSAvein at EX + VIB did not change during exercise. CSAvein during exercise at EX was smaller than that at EX + VIB (P <0.05). However, BFvein did not change during the protocol under either condition. The decreases in circulatory response and RPEs during EX + VIB, despite identical muscle tension, showed that activation of central command was less during EX + VIB than during EX. Abolishment of the decrease in CSAvein during exercise at EX + VIB may thus have been caused by a lower level of central command at EX + VIB rather than EX., Conclusion: Diminished central command induced by tendon vibration may attenuate the superficial venous vessel response of the resting limb during sustained static arm exercise.

This study investigated the adjustments in muscle activation and oxygenation in biceps and triceps brachii during two tasks sustained to failure at 20 and 60% of the maximal voluntary contraction (MVC) force. The tasks required participants either to push against a rigid restraint (force task) or to support an inertial load (position task) with the elbow flexor muscles. The surface EMG was recorded for biceps brachii, brachioradialis, triceps brachii and trapezius superior muscles. Muscle oxygenation of biceps and triceps brachii was measured by near-infrared spectroscopy. The position task was briefer (404 ± 159 s) than the force task (533 ± 194 s) when performed at 20% MVC (P = 0.011), but endurance time did not differ at 60% MVC (54 ± 19 versus 64 ± 16 s, respectively; P = 0.13). Biceps brachii oxygenation decreased slightly (by ~7%) during tasks performed at 20% MVC, whereas it dropped (-40%) for tasks sustained at 60% MVC. However, the decrease in muscle oxygenation was not a significant predictor of time to failure at the two target forces, although its contribution to muscle fatigue cannot be completely ruled out at 60% MVC. In contrast, time to failure was predicted by the increase in EMG of biceps brachii for both tasks at 20% MVC, and EMG of brachioradialis and trapezius for both tasks at 60% MVC. These results suggest that neural adjustments rather than muscle oxygenation limited the time to failure for the force and position tasks at low and high target forces.

To assess the effect of regional anesthesia on the outcome of elbow arteriovenous fistula (AVF), prospectively studied consecutive patients with end-stage renal disease referred for permanent vascular access to the Vascular Unit of King Fahd University Hospital between September 2004 and September 2007. The patients were divided into 2 groups: Group 1: patients who underwent the construction of the AVF under regional anesthesia and Group 2: patients who were operated under general anesthesia, indicated by their preferences or failure of regional anesthesia. Data including patient characteristics and type of AVF were recorded. The internal diameter of the vein and the artery and intra-operative blood flow were measured. The complications of both types of anesthesia were recorded. The patients were followed up for three months. Eighty four cases were recruited in this study. Complete brachial plexus block was achieved in 57 (68%) patients. Seven patients were converted to general anesthesia and 20 patients had AVF under general anesthesia from the start. There were no significant differences between the 2 groups with regard to basic characteristics or operative data. There were no instances of systemic toxicity, hematomas, or nerve injury from the regional block. No major complications were reported from the general anesthesia. There was no significant difference between both groups regarding early failure of AVF (Group 1, 14% vs. Group2; 11%. P= 0.80). No significant advantage of regional over general anesthesia in terms of early outcome of AVF was seen in this study.

We hypothesized that interrupting the connection between superficial and deep veins of the upper extremity at the elbow for creation of hemodialysis arteriovenous fistulas (AVFs), in addition to adequate dilation of the elbow veins, will reduce the risk of steal syndrome and venous hypertension. In this prospective study over a period of one year, patients who were candidates for creation of elbow AVFs based on Doppler ultrasound findings and physical examination, were enrolled into the study. For creation of AVFs, based on the anatomy of the vessels, side-to-side or end-to-side anastomosis between the brachial artery and either cephalic or median antecubital or basilic veins was performed. In some cases, Gracz AVF was created. For interrupting the connection between superficial and deep veins, the perforating vein was either ligated or used for anastomosis. The patients were then followed-up regarding patency rate of the AVF and complications. AVFs were created in 50 patients and the duration of follow-up varied from one to eight months. About 56% (n = 28) of the patients had history of failed AVF or arteriovenous graft and 48% (n = 24) of them had history of insertion of a dual-lumen catheter for hemodialysis. Neuromuscular problem (n=1) and infection (n=1) were the observed complications. None of the patients developed steal syndrome or venous hypertension. At the end of the study, 47 AVFs (94%) were patent and adequate. Our study suggests that interrupting the connection between the superficial and deep venous systems of the upper extremity can reduce the risk of development of steal syndrome and venous hypertension despite side-to-side anastomosis. These techniques provided acceptable patency rate for elbow AVFs.

Objective: We postulated that ligation of a consistent perforating venous branch at the elbow would improve distention and flow in the superficial veins about the elbow. This would also lesson the likelihood of arterial steal enabling a favorable outcome following a brachial artery medial antecubital or cephalic vein arterio-venous fistula (AVF)., Methods: Pressure measurements were made from the radial artery after side-to-side brachial artery antecubital or cephalic vein AVF in 20 patients. Clamping of the perforating vein increased radial artery pressure significantly indicating that a considerable amount of flow from the side-to-side AVF was diverted into the deep system and away from the accessible superficial veins. Encouraged by this finding, we studied the outcome of brachial cephalic or brachial antecubital AVF with ligation of the deep branch in 134 patients who were not candidates for radio-cephalic AVF. The end point of the study was successful hemodialysis using the fistula., Results: Of the 134 patients treated, 24 died, and 11 were lost to follow-up and were censored from analysis of fistula performance at that time point. The primary fistula success rate was 89.7% +/- 2.66% and 83.7% +/- 3.5% at 1 and 2 years by life table analysis. No patient developed significant arterial steal or venous hypertension., Conclusion: We recommend this simple one-stage procedure for patients requiring hemodialysis whose cephalic vein at the wrist is unsuitable.

This describes the indivisible anastomosis of the main stem of median nerve with ulnar nerve through cubital tunnel followed by the anomaly of ulnar artery that appears as superficial ulnar artery. Both anomalies are found during the anatomical dissection of a grown-up male cadaver, on his right arm. Such case is very rare as, in the literature available to us, it has not been described.

Objectives: The aim of this study was to analyse the results of brachiocephalic fistulas for haemodialysis and to determine possible predictors of failure., Patients and Methods: Between April 1999 and September 2004, a consecutive series of 100 autologous brachiocephalic fistulas were created in 96 patients. There were 57 men and 39 women with a mean (SD) age of 59.2 (15.6) years. Data were prospectively gathered., Results: The mean (SD) follow-up was 20.1 (16.4) months. The primary, primary assisted, and secondary patency rates after 6 months were 73.4, 83.2 and 86.4%, respectively. After 1 year, these figures were 54.7, 72.3 and 79.2%, and after 2 years 40.4, 59.2 and 67.5%, respectively. Predictors of failure with regard to primary patency, determined with Cox regression multivariate analysis, included diabetes mellitus (HR 2.81, p < 0.001) and a history of contralateral PTFE loop graft (HR 7.79, p = 0.007)., Conclusion: Primary patency of brachiocephalic fistulas is comparable to that of radiocephalic fistulas. Primary assisted and secondary patency rates can, however, be brought to a much higher level, especially in patients without diabetes and a large-diameter venous outflow tract.

Background: In the hypothesis that the increased collagen metabolism in the intestinal wall of patients affected by inflammatory bowel disease (IBD) is reflected in the systemic circulation, we aimed the study to evaluate serum level of procollagen III peptide (PIIIP) in peripheral and splanchnic circulation by a commercial radioimmunoassay of patients with different histories of disease., Methods: Twenty-seven patients, 17 with Crohn and 10 with ulcerative colitis submitted to surgery were studied. Blood samples were obtained before surgery from a peripheral vein and during surgery from the mesenteric vein draining the affected intestinal segment. Fifteen healthy age and sex matched subjects were studied to determine normal range for peripheral PIIIP., Results: In IBD patients peripheral PIIIP level was significantly higher if compared with controls (5.0 +/- 1.9 vs 2.7 +/- 0.7 microg/l; p = 0.0001); splanchnic PIIIP level was 5.5 +/- 2.6 microg/l showing a positive gradient between splanchnic and peripheral concentrations of PIIIP. No significant differences between groups nor correlations with patients' age and duration of disease were found., Conclusions: We provide evidence that the increased local collagen metabolism in active IBD is reflected also in the systemic circulation irrespective of the history of the disease, suggesting that PIIIP should be considered more appropiately as a marker of the activity phases of IBD.

Background: Modeling of pharmacokinetic parameters and pharmacodynamic actions requires knowledge of the arterial blood concentration. In most cases, experimental measurements are only available for a peripheral vein (usually antecubital) whose concentration may differ significantly from both arterial and central vein concentration., Methods: A physiologically based pharmacokinetic (PBPK) model for the tissues drained by the antecubital vein (referred to as "arm") is developed. It is assumed that the "arm" is composed of tissues with identical properties (partition coefficient, blood flow/gm) as the whole body tissues plus a new "tissue" representing skin arteriovenous shunts. The antecubital vein concentration depends on the following parameters: the fraction of "arm" blood flow contributed by muscle, skin, adipose, connective tissue and arteriovenous shunts, and the flow per gram of the arteriovenous shunt. The value of these parameters was investigated using simultaneous experimental measurements of arterial and antecubital concentrations for eight solutes: ethanol, thiopental, 99Tcm-diethylene triamine pentaacetate (DTPA), ketamine, D2O, acetone, methylene chloride and toluene. A new procedure is described that can be used to determine the arterial concentration for an arbitrary solute by deconvolution of the antecubital concentration. These procedures are implemented in PKQuest, a general PBPK program that is freely distributed http://www.pkquest.com., Results: One set of "standard arm" parameters provides an adequate description of the arterial/antecubital vein concentration for ethanol, DTPA, thiopental and ketamine. A significantly different set of "arm" parameters was required to describe the data for D2O, acetone, methylene chloride and toluene - probably because the "arm" is in a different physiological state., Conclusions: Using the set of "standard arm" parameters, the antecubital vein concentration can be used to determine the whole body PBPK model parameters for an arbitrary solute without any additional adjustable parameters. Also, the antecubital vein concentration can be used to estimate the arterial concentration for an arbitrary input for solutes for which no arterial concentration data is available.

The frequent use of veins in surgery, especially in the replacement of clogged arteries in the lower extremities, persuaded the authors to conduct research concerning the morphology of superficial veins in the human upper extremity. In a post-mortem study a group of 40 male subjects of 22-92 years of age was examined. The preparation of the region of the elbow fossa was performed in order to establish the architecture of superficial veins in the extremity. Many detailed anthropometrical measurements were also carried out, enabling a typological evaluation to be made of the deceased under study. Two characteristic pictures of venous anastomosis were tested, one with symmetrical tributaries to the vena basilica et cephalica and the second characterised by a rich set of tributaries to the vena basilica. The characteristics, calibre and structure of both these suggest a fruitful application of them in vessel surgery. The vena cephalica in particular, taken with efficient valves, may successfully play the role of vessel implant.

Objectives: diabetes mellitus is an increasingly common cause of end stage renal failure (ESRF) and the establishment of adequate permanent vascular access for dialysis is a major cause of morbidity and mortality in these patients. The aim of this study was to compare the availability of suitable vein, maturation rates, patency and complication rates of autogeneous elbow fistulas in diabetics and non-diabetics at a single centre where an autogeneous vein only policy is employed., Design: retrospective series., Patients and Methods: two hundred and ninety-three elbow fistulas were attempted in 232 patients over a seven year period, [median age 60 years (range 14-94 years)], of which 210 were in non-diabetic and 83 were in diabetic patients. The diabetic group had a significantly higher proportion of male patients (p < 0.05), peripheral vascular disease and established ESRF., Results: there was a trend towards a higher technical success rate in the non-diabetic group (98% versus 93% p = 0.057). There was no significant difference between the primary failure rate, fistula maturation rate, revision rate or incidence of complications between the two groups. Diabetes had no effect on cumulative secondary fistula patency even when stratified for Type 1/Type 2 diabetes, female sex, old age or primary versus subsequent procedures., Conclusion: diabetes mellitus has no significant detrimental effect on outcome following formation of autogeneous elbow fistulas for haemodialysis., (Copyright 2002 Elsevier Science Ltd.)

Purpose: Plasma and whole blood viscosity are elevated in patients with intermittent claudication. The objectives of this study were to investigate whether critical limb ischemia influences hemorheologic variables and whether the rheologic variables in blood from the affected limb differ from the general circulation. We also intended to study whether successful infrainguinal reconstruction improved hemorheologic variables., Methods: Ten consecutive patients with critical limb ischemia (CLI) underwent arterial reconstruction, one patient with profundaplasty and nine patients with bypass procedures. Venous blood was sampled from the antecubital vein (arm) and the femoral vein (leg) of the affected limb 1 day before and 1 month after surgery. Ten control subjects (matched according to age, sex, diabetic status, and renal insufficiency) were also sampled. Whole blood viscosity, plasma viscosity, erythrocyte aggregation tendency, and erythrocyte fluidity (the latter variable describing the deformability of the erythrocytes) were measured by means of rotational viscometry. Erythrocyte volume fraction was also determined. Fibrinogen was measured in the patients with CLI., Results: Erythrocyte fluidity, blood viscosity, and erythrocyte volume fraction were lower in patients with CLI than in control subjects (P <.01, P <.01, and P <.05, respectively). No major differences between cubital and femoral vein blood were seen before or after the operation in patients with CLI or in control subjects. Successful revascularization did not influence the hemorheologic variables, except for a decrease in blood viscosity in femoral vein blood (P <.05)., Conclusion: Hemorheologic properties was impaired in patients with CLI. Because no differences were seen between the systemic and local circulation and because no major improvement occurred 1 month after arterial reconstruction, other mechanisms besides local tissue ischemia may play a role.

Eight years' experience with the brachiocephalic fistula for vascular access are reported. Eighty one fistulae were created in 77 patients. Forty one fistulae were created by an end to side anastomosis and 40 using a side to side technique. Overall patency was 70% at 1 year; 57% at 2 years; 50% at 3 years, which compares well with other secondary access procedures. Anastomotic configuration did not significantly affect fistula survival. Cardiac failure and arterial steal syndrome were significant problems with the side to side fistula. Two patients died from fistula complications; one exsanguinated at home from a cannulation site and another succumbed to high output cardiac failure. Infection was rare. The end to side brachiocephalic fistula is recommended as the secondary vascular access procedure of choice. It is a simple, reliable procedure which does not require graft implantation and preserves the saphenous vein, should tertiary access be required.

1 The effect of nifedipine on peripheral blood vessels has been studied in man. 2 Nifedipine induced dilatation of the forearm resistance vessels when given either by local intra-arterial infusion or sublingually (10 mg). 3 Local infusion of the drug did not relax hand veins preconstricted by infusion of noradrenaline and neither local infusion nor sublingual administration prevented constriction mediated by the sympathetic nervous system. Nifedipine was, however, a potent inhibitor of hand vein contractions induced by high concentrations of potassium provided that the noradrenergic component of the response was suppressed by simultaneous infusion of phentolamine. 4 Sublingual nifedipine (10 mg) did not dilate the elbow collateral arteries. 5 The effects of nifedipine on peripheral blood vessels are similar, but not identical, to those of verapamil. The pattern of action, with dilatation of resistance vessels but not capacitance, resembles that of hydralazine rather than glyceryl trinitrate and this suggest that nifedipine may prove useful in the treatment of hypertension.

Lung perfusion scintigraphy, with Tc-99m MAA injected into a left antecubital vein, revealed extensive uptake in the myocardium, kidneys, spleen, thyroid, and brain. After a right antecubital injection, a normal pulmonary perfusion pattern was found. This finding is specific for right-to-left shunting due to anomalous systemic venous drainage into the left atrium.