Letter to the Editor
Embolism as a cause of early thrombosis of arteriovenous fistula of hemodialysis patients
Embolismo paradójico como causa de trombosis precoz de fístula arteriovenosa para hemodiálisis
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He is an 80-year-old man; after 7 years in PD is switched to because of poor dose of dialysis. A left humerus-perforan vein AVF was made that quickly thrombosed at 24<span class="elsevierStyleHsp" style=""></span>h. During Re-intervention it was observed permeable vessels and a thrombus are detected in the middle third of the humeral artery suggesting an arterial embolism. Thromboembolectomy was successful and anticoagulation was prescribed. The ECG presented sinus rhythm and the echocardiography showed no abnormalities. Transesophageal echocardiography (TEE) is performed, showing PFO with early bubbles after the injection of agitated saline solution. In the descending thoracic aorta, a giant fibrocalcified atherosclerosis plaque with irregularities and thrombotic content occupying 40% of the light was observed.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Thereafter he presented transient cerebrovascular event with loss of intellectual abilities with lower limb chronic small vessel ischemia and injuries suggestive of cholesterol crystals atheroembolism which caused with severe pain, livedo reticularis, cyanotic punctate lesions and cyanosis of the first toe of the left foot with preserved pulses. Then, Sintrom® was discontinued and it was changed to subcutaneous LMWH 60<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h, aspirin and clopidogrel were added and statins dose was increased to 80<span class="elsevierStyleHsp" style=""></span>mg daily as recommended by vascular surgery. The patients lost 15<span class="elsevierStyleHsp" style=""></span>kg in 8 months, albumin 2.1<span class="elsevierStyleHsp" style=""></span>g/L and CRP was 57<span class="elsevierStyleHsp" style=""></span>mg/L with severe anemia despite increased EPO. The patient decided to voluntarily stop HD</p><p id="par0020" class="elsevierStylePara elsevierViewall">Paradoxical embolism as the cause of AV thrombosis has not previously been described in the literature. Arterial embolism is a rare cause of fistula thrombosis,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> and even less frequent is paradoxical embolism,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> which is the passage of a venous thrombus located in the right cardiac cavities to the arterial circulation through a cardiac defect. The most frequent is PFO, with a prevalence of 25% by autopsy and 35% by TEE.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The definitive diagnosis is made if a thrombus going through a septum defect is observed by ultrasound, but a diagnosis also made by: (a) systemic arterial embolism, in the absence of atrial fibrillation, from source located in the left heart cavities or proximal arteries; (b) right-to-left short circuit at any level, and (c) venous thrombosis and/or pulmonary embolism or (d) if PFO is detected, as in the present case.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Echocardiogram is one of the most useful tools for the diagnosis of emboligial heart disease. With the Valsalva maneuver and the introduction of intravenous contrast a PFO can be identified (sensitivity: 60% and specificity: 78%).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The diagnostic possibilities improve with TEE.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The treatment of PFO is anticoagulation and, in selected cases, surgical closure or percutaneous closure, with a morbidity of 10%, may be considered.</p><p id="par0040" class="elsevierStylePara elsevierViewall">One important finding in this patient was the presence of a large fibrocalcified atherosclerotic plaque in the descending aorta containing a thrombus. This type of plaques is associated with a high risk of stroke and peripheral embolization.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> In renal patients abdominal aorta calcification is observed in 81% of patients and it is severe in 51% of cases.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Vascular calcification is an independent risk factor for cardiovascular mortality. These plaques are the cause of 2 types of emboli: thromboembolism and atheroemboli (emboli by cholesterol crystals). The latter are characterized by the release of small emboli either spontaneously (25%) or provoked by interventions such as cardiac catheterization, arteriography, peripheral interventions, or cardiac surgery.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> In this case, the fistula intervention may have been a precipitating factor.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Mortality in patients with extensive atherosclerotic plaques in the thoracic aorta is 20% at 3 years, cerebrovascular events are observed in 20% of patients, other types of embolic events are seen in 7% and 1% may have cholesterol crystals embolism.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In patients with atherosclerotic aortic plaques, a high incidence of atheroembolism has been attributed to anticoagulants treatment; however recent randomized clinical trials do not seem to confirm this.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The treatment includes antithrombotic therapy and statins. Presently is recommended either with aspirin 50–325<span class="elsevierStyleHsp" style=""></span>mg daily or clopidogrel 75<span class="elsevierStyleHsp" style=""></span>mg daily versus the combined treatment<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> or warfarin administration.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> There are no data on the use of non-vitamin K dependent oral anticoagulants and therefore they are not recommended.</p><p id="par0060" class="elsevierStylePara elsevierViewall">This case illustrates an exceptional complication of AVF, but given the high frequency of atherosclerosis in HD patients it should be considered.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Arenas MD, Pérez R, Rodriguez JA. Embolismo paradójico como causa de trombosis precoz de fístula arteriovenosa para hemodiálisis. Nefrologia. 2017;37:556–557.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Embolismo arterial de fístula arteriovenosa en paciente en hemodiálisis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Bordils" 1 => "R. García" 2 => "J.A. Fonseca" 3 => "R. Mcclean" 4 => "C. Campos" 5 => "N. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 20 | 6 | 26 |
| 2024 October | 62 | 27 | 89 |
| 2024 September | 68 | 29 | 97 |
| 2024 August | 95 | 54 | 149 |
| 2024 July | 72 | 20 | 92 |
| 2024 June | 86 | 44 | 130 |
| 2024 May | 79 | 29 | 108 |
| 2024 April | 74 | 39 | 113 |
| 2024 March | 50 | 33 | 83 |
| 2024 February | 48 | 34 | 82 |
| 2024 January | 52 | 26 | 78 |
| 2023 December | 44 | 26 | 70 |
| 2023 November | 68 | 39 | 107 |
| 2023 October | 82 | 38 | 120 |
| 2023 September | 53 | 28 | 81 |
| 2023 August | 38 | 25 | 63 |
| 2023 July | 45 | 24 | 69 |
| 2023 June | 65 | 18 | 83 |
| 2023 May | 52 | 27 | 79 |
| 2023 April | 40 | 15 | 55 |
| 2023 March | 64 | 23 | 87 |
| 2023 February | 39 | 20 | 59 |
| 2023 January | 52 | 21 | 73 |
| 2022 December | 79 | 26 | 105 |
| 2022 November | 59 | 30 | 89 |
| 2022 October | 66 | 38 | 104 |
| 2022 September | 34 | 33 | 67 |
| 2022 August | 58 | 53 | 111 |
| 2022 July | 41 | 52 | 93 |
| 2022 June | 52 | 30 | 82 |
| 2022 May | 82 | 35 | 117 |
| 2022 April | 60 | 43 | 103 |
| 2022 March | 74 | 47 | 121 |
| 2022 February | 88 | 36 | 124 |
| 2022 January | 100 | 39 | 139 |
| 2021 December | 102 | 36 | 138 |
| 2021 November | 92 | 48 | 140 |
| 2021 October | 95 | 54 | 149 |
| 2021 September | 68 | 36 | 104 |
| 2021 August | 62 | 46 | 108 |
| 2021 July | 100 | 60 | 160 |
| 2021 June | 62 | 24 | 86 |
| 2021 May | 64 | 42 | 106 |
| 2021 April | 116 | 67 | 183 |
| 2021 March | 70 | 31 | 101 |
| 2021 February | 66 | 28 | 94 |
| 2021 January | 53 | 14 | 67 |
| 2020 December | 45 | 18 | 63 |
| 2020 November | 62 | 17 | 79 |
| 2020 October | 55 | 18 | 73 |
| 2020 September | 51 | 18 | 69 |
| 2020 August | 52 | 14 | 66 |
| 2020 July | 49 | 17 | 66 |
| 2020 June | 50 | 23 | 73 |
| 2020 May | 63 | 14 | 77 |
| 2020 April | 61 | 13 | 74 |
| 2020 March | 45 | 28 | 73 |
| 2020 February | 44 | 25 | 69 |
| 2020 January | 59 | 23 | 82 |
| 2019 December | 62 | 34 | 96 |
| 2019 November | 71 | 23 | 94 |
| 2019 October | 56 | 12 | 68 |
| 2019 September | 68 | 14 | 82 |
| 2019 August | 70 | 16 | 86 |
| 2019 July | 67 | 22 | 89 |
| 2019 June | 48 | 20 | 68 |
| 2019 May | 81 | 31 | 112 |
| 2019 April | 110 | 41 | 151 |
| 2019 March | 97 | 33 | 130 |
| 2019 February | 50 | 27 | 77 |
| 2019 January | 54 | 22 | 76 |
| 2018 December | 151 | 45 | 196 |
| 2018 November | 244 | 22 | 266 |
| 2018 October | 203 | 26 | 229 |
| 2018 September | 106 | 29 | 135 |
| 2018 August | 72 | 18 | 90 |
| 2018 July | 60 | 14 | 74 |
| 2018 June | 90 | 13 | 103 |
| 2018 May | 112 | 16 | 128 |
| 2018 April | 79 | 8 | 87 |
| 2018 March | 118 | 10 | 128 |
| 2018 February | 115 | 6 | 121 |
| 2018 January | 100 | 8 | 108 |
| 2017 December | 80 | 13 | 93 |
| 2017 November | 36 | 11 | 47 |
| 2017 October | 63 | 17 | 80 |
| 2017 September | 2 | 0 | 2 |
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