Effect of contrast administration on the renal function of predialysis patients undergoing fistuloplasty.

OBJECTIVE: The aim of this study was to investigate if administration of iodinated contrast during endovascular interventions in arteriovenous fistula (AVF) in patients not requiring dialysis (predialysis patients) (1) negatively affects their renal function and (2) if oral hydration has a protective effect. METHODS: All pre-dialysis patients who underwent endovascular interventions in AVF between August 2010 and April 2019 were included in the study. During the procedures, 35 to 50 mL of Iodixanol were administered. A pre-hydration protocol was introduced in March 2015. Data were grouped before and after this date. The difference between pre- and post-contrast estimated glomerular filtration rate (eGFR) and the difference between the eGFR of hydrated and non-hydrated groups were calculated. RESULTS: Eighty-four patients who underwent 151 procedures were included in the study. In 60.3% of procedures, a mean decrease of 1.35 mL/min/1.73 m2 in eGFR was noted (95% confidence interval [CI], 1.02-1.69 mL/min/1.73 m2), whereas in 35.1% of procedures, there was a mean increase of 1.06 mL/min/1.73 m2 (95% CI, 0.84-1.28 mL/min/1.73 m2). The mean difference between pre- and post-procedure eGFR was -0.44 mL/min/1.73 m2 (95% CI, -0.72 to -0.16 mL/min/1.73 m2; P = .002). Oral hydration was associated with a smaller mean change in eGFR of -0.32 mL/min/1.73 m2 (95% CI, -0.62 to -0.03 mL/min/1.73 m2) compared with the non-hydrated group, with mean change of -0.47 mL/min/1.73 m2 (95% CI, -0.91 to -0.03 mL/min/1.73 m2), but this was not statistically significant (P = .586). CONCLUSIONS: This study demonstrates that administration of up to 50 mL of iodinated contrast for endovascular interventions in AVF in predialysis patients has minimal adverse effect on the eGFR with questionable clinical significance. In addition, oral hydration before and after the procedure has only a mild protective effect against a decrease in eGFR.

Arteriovenous Fistula Surveillance Using Tomographic 3D Ultrasound.

OBJECTIVE: A well functioning arteriovenous fistula (AVF) is essential for haemodialysis. Despite regular duplex ultrasound (DUS) a significant number of AVFs fail. Tomographic 3D ultrasound (tUS) creates a 3D image of the AVF that can be interpreted by the clinician. DUS, tUS, and fistulograms were compared for the identification and measurement of flow limiting stenosis. METHODS: Patients with AVF dysfunction on routine Transonic surveillance, defined as (1) > 15% reduction in flow on two consecutive occasions, (2) > 30% reduction in flow on one occasion, (3) flow of < 600 mL/sec, (4) presence of recirculation, underwent DUS. AVF tUS imaging was performed prior to fistulography. All fistulograms were reported by the same consultant radiologist and tUS images by the same vascular scientist blinded to the fistulogram results. Maximum diameter reduction in all stenoses were measured using all three imaging techniques. RESULTS: In 97 patients with 101 stenoses, the mean (± standard deviation [SD]) severity of stenosis was 63.0 ± 13.9%, 65.0 ± 11.6%, and 64.8 ± 11.7% for the fistulograms, DUS, and tUS respectively. The mean (± SD) time between ultrasound and fistulography imaging was 15.0 ± 14.5 days. Assuming the fistulogram as the "gold standard", Bland-Altman agreement for DUS was -1.9 ± 15.5% (limit of agreement [LOA] -32.2 - 28.4) compared with -1.7 ± 15.4% (LOA -31.9 - 28.4) for tUS. Median (± interquartile range) time to complete the investigation was 09:00 ± 03:19 minutes for DUS and 03:13 ± 01:56 minutes for tUS (p < .001). CONCLUSION: DUS and tUS were equally accurate at detecting AVF complications but tUS investigation requires less skill and was significantly quicker than DUS.

General Anesthesia Versus Local Anesthesia in Carotid Endarterectomy: A Systematic Review and Meta-Analysis.

OBJECTIVE: The choice of anesthetic technique in carotid endarterectomy (CEA) has been controversial. This study compared the outcomes of general anesthesia (GA) and local anesthesia (LA) in CEA. DESIGN: Systematic review and meta-analysis of comparative studies. SETTING: Hospitals. PARTICIPANTS: Adult patients undergoing CEA with either LA or GA. INTERVENTIONS: The effects of GA and LA on CEA outcomes were compared. MEASUREMENTS AND MAIN RESULTS: PubMed, OVID, Scopus, and Embase were searched to June 2018. Thirty-one studies with 152,376 patients were analyzed. A random effect model was used, and heterogeneity was assessed with the I2 and chi-square tests. LA was associated with shorter surgical time (weighted mean difference -9.15 min [-15.55 to -2.75]; p = 0.005) and less stroke (odds ratio [OR] 0.76 [0.62-0.92]; p = 0.006), cardiac complications (OR 0.59 [0.47-0.73]; p < 0.00001), and in-hospital mortality (OR 0.72 [0.59-0.90]; p = 0.003). Transient neurologic deficit rates were similar (OR 0.69 [0.46-1.04]; p = 0.07). Heterogeneity was significant for surgical time (I2 = 0.99, chi-square = 1,336.04; p < 0.00001), transient neurologic deficit (I2 = 0.41, chi-square = 28.81; p = 0.04), and cardiac complications (I2 = 0.42, chi-square = 43.32; p = 0.01) but not for stroke (I2 = 0.22, chi-square = 30.72; p = 0.16) and mortality (I2 = 0.00, chi-square = 21.69; p = 0.65). Randomized controlled trial subgroup analysis was performed, and all the aforementioned variables were not significantly different or heterogenous. CONCLUSION: The results from this study showed no inferiority of using LA to GA in patients undergoing CEA. Future investigations should be reported more systematically, preferably with randomization or propensity-matched analysis, and thus registries will facilitate investigation of this subject. Anesthetic choice in CEA should be individualized and encouraged where applicable.

Peri-cardiac arrest following blunt bicycle handlebar trauma to the iliac vessels: management of a rare case.

Iliac vessel disruption following blunt trauma is an unusual presentation, particularly in the absence of an orthopaedic injury. We present the unique case of a 14-year-old boy who sustained a blunt bicycle handlebar impalement that resulted in complete transection of the external iliac artery and laceration of the external iliac vein, without a skeletal fracture. The patient deteriorated rapidly, entering hypovolaemic shock and peri-cardiac arrest at anaesthetic induction. Once haemodynamic stability was achieved, the lacerated external iliac vein was used to form an interposition graft to repair the external iliac artery. The rare occurrence and lack of familiarity with this injury, combined with the potential for fatal exsanguination if not swiftly diagnosed makes this case crucial to highlight. Blunt bicycle handlebar injury should carry a high suspicion of severe vascular compromise. If diagnosed this should be rapidly managed with aggressive resuscitation and revascularisation.

Recalcitrant Foot Ulceration in a Patient With Type 1 Diabetes Mellitus.

We describe the case of a middle-aged woman with type 1 diabetes mellitus who presented to the emergency department with diabetic ketoacidosis. An intravenous cannula was inserted into the veins of the dorsum of the right foot due to difficulty in obtaining intravenous access in the upper limb for managing diabetic ketoacidosis. Our patient developed edema and bullae on the dorsum of the right foot and received intravenous antibiotics for bullous cellulitis. Our patient developed ulceration on the dorsum of the right foot and over the next few months was admitted to hospital on several occasions with infected foot ulceration, which required several courses of intravenous antibiotics, larval therapy and surgical debridement of the necrotic eschar and slough. With regular review in the multidisciplinary diabetic foot clinic, the foot ulceration finally healed in eight months. This case highlights the importance of avoiding trauma in any form to the feet of people with diabetes even if aseptic techniques are taken.

Granulated sugar to reduce an incarcerated prolapsed defunctioning ileostomy.

This case report discusses the successful application of granulated sugar to reduce a prolapsed ileostomy thereby eliminating the need for an emergency surgery.