Primary Endovascular Intervention for Acute Mesenteric Ischemia Performed by Interventional Cardiologists - A Single Center Experience.

The current standard care for acute mesenteric ischemia (AMEI) involves urgent revascularization and resection of the necrotic bowel. Since 2012, we have used an AMEI protocol of our own design, which focused on early treatment and allowed interventional cardiologists to become involved when interventional radiologist was not available. A total of 8 patients were treated, and two interventional cardiologists performed all the stenting procedures. The procedure success rate was 100% in patients with non-calcified lesions (6/8). The 30-day survival rate was 100% in patients with angiographic success, and was 0% in patients with failed procedure. In two patients with total occlusion of the superior mesenteric artery, laparotomy was avoided when interventions were successful and completed within six hours of protocol activation. Four surviving patients were discharged after short intensive care unit stays (less than 48 hours); these patients returned to and remained at home throughout their 90-day follow-up. The overall procedure success rate and 30-day survival rate were both 75%. There was no access site or intervention-related complications. Using our protocol, we believe that primary endovascular treatment for AMEI is feasible. In geographic regions where healthcare resources are lacking, a time-efficient strategy adopted by interventional cardiologists should be considered for the purpose of saving lives and possibly even avoiding open laparotomy.

Deficiency of Endothelial Progenitor Cells Associates with Graft Thrombosis in Patients Undergoing Endovascular Therapy of Dysfunctional Dialysis Grafts.

BACKGROUND: The deficiency of endothelial progenitor cells has been demonstrated to be associated with cardiovascular events in patients undergoing dialysis. However, their correlation with dialysis graft outcomes remains unknown. The objective of this study was to investigate the relationship between circulating endothelial progenitor cells and dialysis graft outcomes. METHODS: After excluding 14 patients with acute coronary syndrome, decompensated heart failure or graft thrombosis in the prior three months, a total of 120 patients undergoing dialysis who underwent endovascular therapy of dysfunctional dialysis grafts were prospectively enrolled. Blood was sampled from study subjects in the morning of a mid-week non-dialysis day. Surface makers of CD34, KDR, and CD133 were used in combination to determine the number of circulating endothelial progenitor cells. All participants were prospectively followed until June 2013. RESULTS: The median follow-up duration was 13 months, within which 62 patients experienced at least one episode of graft thrombosis. Patients with graft thrombosis had lower CD34+KDR+ cell counts compared with patients without graft thrombosis (median 4.5 vs. 8 per 105 mononuclear cells, p = 0.02). Kaplan-Meier analysis demonstrated thrombosis-free survival was lower in the low CD34+KDR+ cell count group (30%) than in the high CD34+KDR+ cell count group (61%; p = 0.007). Univariate analysis showed diabetes, high sensitive C-reactive protein, lesion length and CD34+KDR+ cell counts associated with graft thrombosis. Multivariate analyses confirmed an independent association between low CD34+KDR+ cell counts and graft thrombosis (hazard ratio, 2.52; confidence interval, 1.43-4.44; p = 0.001). CONCLUSIONS: Our study demonstrated an independent association between low circulating endothelial progenitor cell counts and dialysis graft thrombosis.

Right Heart Catheterization via Dialysis Arteriovenous Shunts in End-Stage Renal Disease Patients.

OBJECTIVES: Right heart catheterization is an important diagnostic tool but carries risks of adverse events. Little is known about the feasibility and safety of using dialysis arteriovenous (AV) shunts. We aim to evaluate the feasibility and safety of using dialysis AV shunts for access in right heart catheterization. METHODS: Hemodialysis patients who required right heart catheterization were prospectively enrolled. A 7 Fr sheath was inserted and a balloon-tipped pulmonary artery catheter was advanced for right heart catheterization. Patients were followed for 1 month, and technical success, procedure details, and complications were recorded. RESULTS: Thirteen patients received right heart catheterization via AV shunts. Three patients were evaluated for heart failure, and 10 were examined for pulmonary hypertension. Median patient age was 69 years (interquartile range [IQR], 58-77 years), and median shunt age was 50 months (IQR, 32-75 months). Five shunts were located in the upper arm, 2 were in the right arm, and 5 were native fistulas. All AV shunt punctures were successful on the first attempt. All right heart catheterizations were completed via AV shunts, and the technical success rate was 100%. Median fluoroscopy time was 6.9 minutes. No venous access complications or right heart catheterization-related complications occurred immediately after the procedure or during the 1-month follow-up period. CONCLUSIONS: AV dialysis shunts can be used for venous access for right heart catheterization with acceptable feasibility and patient tolerability. Further randomized studies are needed to confirm the benefits of this approach compared with other approaches.

Pulmonary Hypertension in Hemodialysis Patients Following Repeated Endovascular Thrombectomy.

BACKGROUND: The prevalence of pulmonary hypertension is unusually high in Taiwanese patients with end-stage renal disease. Thrombosis of hemodialysis grafts is common and pulmonary embolism has been reported after endovascular thrombectomy. The aim of this study was to evaluate the relationship between pulmonary hypertension and endovascular thrombectomy of hemodialysis grafts. METHODS: One hundred and ten patients on hemodialysis via arteriovenous grafts were enrolled in our study. The mean pulmonary artery pressure (PAP) was measured by right heart catheterization. Clinical information was collected by review of medical records. Comorbid cardiopulmonary disease was evaluated by echocardiography and chest X-ray. The history of patient vascular access thrombosis was reviewed from database, hemodialysis records, and interviews with staff at hemodialysis centers. RESULTS: Fifty-two participants (47%) had pulmonary hypertension diagnosed by right heart catheterization. There was no difference in the number of thrombectomy procedures between patients with and without pulmonary hypertension. Based on multivariate analysis, the number of prior endovascular thrombectomy procedures did not correlate with mean PAP (F-value = 1.10, p = 0.30) nor was it associated with pulmonary hypertension (odds ratio = 0.92, p = 0.17). CONCLUSIONS: Prior endovascular arteriovenous graft thrombectomies were not associated with pulmonary hypertension or increased mean PAP in end-stage renal disease patients on maintenance hemodialysis.