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Qusai Aljarrah,1 Mohammed Allouh,2 Amer H Hallak,3 Shamikh E Alghezawi,3 Mamoon Al-Omari,4 Mwaffaq Elheis,4 Mooath Al-Jarrah,4 Sohail Bakkar,5 Abdelwahab J Aleshawi,6 Hussam Al-Jarrah,1 Khalid S Ibrahim,7 Jan Mohammed Al Shishani,8 Aws Almukhtar9 1Department of General & Vascular Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 2Department of Anatomy, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 17666, United Arab Emirates; 3Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 4Department of Diagnostic and Interventional Radiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 5Department of Surgery, Faculty of Medicine, The Hashemite University, Zarqa 13133, Jordan; 6Department of Ophthalmology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 7Department of General & Cardiovascular Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 8Department of Vascular Surgery, King Hussein Medical Center, Amman 11733, Jordan; 9Department of Surgery and Cancer, Imperial College London, London SW7 2BU, UKCorrespondence: Qusai AljarrahDepartment of General & Vascular Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, JordanTel +962 775593131Email qmaljarrah@just.edu.joMohammed AllouhDepartment of Anatomy, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab EmiratesTel +971 37 137 551Email m_allouh@uaeu.ac.aePurpose: Central venous lesions (CVLs) can adversely affect hemodialysis access maturation and maintenance, which in turn worsen patient morbidity and access circuit patency. In this study, we assessed several clinical variables, patient characteristics, and clinical consequences of symptomatic central vein stenosis and obstruction in patients who underwent renal replacement therapy in the form of hemodialysis.Patients and Methods: The medical records of all hemodialysis patients with clinically symptomatic CVLs who underwent digital subtraction angiography treatment at King Abdullah University Hospital between January 2017 and December 2019 were retrieved. Patient characteristics and the clinical and anatomical features of CVLs were analyzed retrospectively. Pearson’s chi-square tests of association were used to identify and assess relationships between patient characteristics and CVLs.Results: The study cohort comprised 66 patients with end-stage renal disease who developed symptomatic central vein stenosis. Of the 66 patients, 56.1% were men, and their mean age was approximately 52 years. Most (62.1%) of the patients were determined to have a history of central catheter insertion into the jugular vein. Hypertension was the most common comorbidity (78.8%, p< 0.001), followed by type 2 diabetes mellitus (47.0 %, p< 0.01). The incidence of stenosis was found to be significantly higher in the brachiocephalic vein than in other central veins (43.9%, p< 0.001). A repeated central catheter insertion in a patient was predictive of central venous occlusion (p< 0.05). Stenotic lesions were found to be associated with a significantly higher success rate than occlusive lesions (91.2%, p< 0.01).Conclusion: Multiple central venous catheters (CVCs) are found to be associated with occlusive CVLs and unfavorable recanalization outcomes. Multiple CVC should be avoided by creating a permanent vascular access in a timely fashion for patients with chronic kidney disease and by avoiding the ipsilateral insertion of CVC and AVF.Keywords: central venous lesions, brachiocephalic vein, central line catheterization, percutaneous transluminal angioplasty, fistula, hemodialysis

Qusai Aljarrah,1 Sohail Bakkar,2 Abdelwahab Aleshawi,3 Omar Al-Gharaibeh,3 Mooath Al-Jarrah,3 Radi Ebwayne,1 Mohammed Allouh,4 Ahmad K Abou-Foul5 1Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 2Department of Surgery, Faculty of Medicine, The Hashemite University, Zarqa 13133, Jordan; 3School of Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 4Department of Anatomy, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain 17666, United Arab Emirates; 5Department of Otolaryngology, Head and Neck Surgery, Imperial College Healthcare NHS Trust, St Mary’s Hospital, London W2 1NY, UKCorrespondence: Qusai AljarrahDepartment of Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, JordanTel +962775593131Fax +96227200627Email qmaljarrah@just.edu.joPurpose: Non-traumatic major lower extremity amputation (NMLEA) is a commonly performed procedure that presents a substantial cost burden. Patients who undergo NMLEA are usually considered as a high-risk group with significant comorbidities, which translates into a protracted peri-operative course and increased health-care costs. The primary aim of this study was therefore to perform a contemporary peri-operative cost analysis of NMLEA performed in our center. We are a major tertiary referral hospital that provides vascular surgery services to the entire northern counties in Jordan. We also aimed to assess the various factors that influence the cost of NMLEA in less economically developed countries.Methods: Records of all patients who underwent NMLEA at King Abdullah University Hospital between January 2012 and December 2017 were retrieved. Total inpatient cost was calculated and analyzed against different patients’ variables.Results: A total of 140 patients underwent NMLEA between 2012 and 2017 in our facility. Below-knee amputations accounted for 110 cases, while above-knee amputations included 30 patients. Approximately two-thirds of the cases (61.4%) were males, with average age of the patients being approximately 62.9 years. The commonest comorbidities were diabetes mellitus and hypertension, which were recorded in 89.3% and 80.3% of the patients, respectively. The average operative time was 133.0 ± 10.8 mins, and the average length of stay (LOS) was 6.7±0.4 days. The mean cost for amputations was 4904.7± 429.3 United States dollars. Multiple linear regression analysis demonstrated that LOS and admission-to-operation time were the independent predictors of cost.Conclusion: Delayed amputations and prolonged LOS remain the most important determinants for the peri-operative cost of NMLEA. When amputation is deemed inevitable, an expedited multidisciplinary approach may possibly reduce undue delays and result in cost-effective delivery of this age-old remedy.Keywords: health care cost, amputation, ischemia, diabetic foot syndrome, length of stay