Factors influencing maturation time of native arteriovenous fistulas.

BACKGROUND: To determine the factors influencing the maturation time of native arteriovenous fistulas. METHODS: A retrospective review was performed of hemodialysis patients from a single university-associated dialysis center from 2004 to 2009. Demographics, comorbidities, and insurance status were recorded. Maturation time was defined as the time from access creation until the access was able to be used regularly for hemodialysis for a period of 2 weeks. RESULTS: A total of 249 patients were identified during the study period who had an arteriovenous fistula created that successfully matured; 104 (42%) patients were women and 145 (58%) were men. Most of the patients were Hispanic (82%). Ninety-seven (39%) of the patients had Medicaid-type insurance and 133 (53%) had Medicare. The mean age was 51 years, and 190 (76%) of the patients had diabetes. The overall mean maturation time was 79 days. Women had a significantly longer time to fistula maturation than males (91.9 days vs. 70.5 days, P = 0.0028). Diabetics also had a significantly longer maturation time than nondiabetics (92.5 days vs. 75.4 days, P = 0.0004). Age did not have an effect on maturation time. On multivariable analysis, sex remained significant (P = 0.007), however, diabetes lost its significance. CONCLUSIONS: In this predominantly Hispanic hemodialysis population, women require longer fistula maturation times than men. The exact reasons for this are unknown based on this data. More study is required to determine the etiology of this gender discrepancy.

Agreement among observers in the assignment of TransAtlantic Inter-Society Consensus classification and runoff score.

OBJECTIVE: Productive communication among clinical practitioners is essential if recommendations regarding practice are to exist. The durability of vascular procedures is often influenced by factors such as lesion classification and runoff quality. It is the purpose of this article to determine how reproducible these measures are in the hands of various specialists who deal extensively with peripheral arterial disease. METHODS: The peripheral arteriograms of 100 patients undergoing percutaneous intervention were distributed to six specialists (three vascular surgeons, two interventional radiologists, and one interventional cardiologist). Each was provided with the reference document describing TASC II classification, Society for Vascular Surgery (SVS) runoff score, and simplified runoff score. With no further instruction, each individual was asked to assign each angiogram a TASC II class, SVS runoff score, and a simplified runoff score. Comparisons between the scores assigned were made using kappa statistic. RESULTS: When using the simplified runoff score for grading peripheral arterial disease, there was excellent correlation among readers (k = 0.81; P = .001), even across different specialties. When using TASC II class to grade lesions, there was a greater degree of variation when compared with the simplified runoff score (k = 0.44; P < .05). Finally, there was poor correlation between readers when using the SVS runoff score (k = 0.10; P < .05) and the modified SVS runoff score (k = 0.26; P = .001). CONCLUSIONS: Descriptors of clinical disease severity are not universally reproducible. The simplified runoff score is reproducible when interpreted by multiple readers across different specialties and can be used without further modification. The TASC II classification may need minor alterations in description to obtain good correlation among readers. Before the SVS runoff score can be universally adapted, it will need to be described in much better detail or significantly modified.

Endoscopic vein harvest for infrainguinal arterial bypass.

BACKGROUND: Endoscopic harvest of saphenous vein for infrainguinal arterial bypass decreases incision length and was initially documented to decrease wound complications without adversely affecting patency. However, recent studies have shown lower patency without a wound complication benefit. We sought to further define the wound complication and patency rates of endoscopic harvest compared with open harvest in infrainguinal arterial bypass procedures. METHODS: Infrainguinal bypasses performed from 2000 to 2011 were analyzed. Only procedures using a single segment of great saphenous vein were included. Cases were grouped according to endoscopic or open harvest and were frequency-matched for body mass index and diabetes. Baseline characteristics were compared. Univariate and multivariate analysis was performed to determine correlation of baseline data and harvest method on wound complications and patency. RESULTS: The study included 76 bypasses; 35 in the endoscopic harvest group and 41 in the open harvest group. Baseline characteristics between the endoscopic and open harvest groups were not significantly different, with the exception of mean age, which was older in the endoscopic harvest group, and carotid artery disease, which was more common in the open harvest group. There was no significant difference between endoscopic and open harvest in 30-day wound complication rates (29% vs 27%; P = .87) or in the other perioperative variables, aside from decreased narcotic use in the endoscopic harvest group (P = .01). Mean follow-up was 747 days. There was no significant difference in 3-year primary (47% vs 49%; P = .8), 3-year primary-assisted (88% vs 73%; P = .1), or secondary patency rates (92% vs 76%; P = .09) at 3 years between the endoscopic and open harvest groups. High body mass index improved primary patency in the endoscopic harvest group (P = .02), but had no effect on patency in the open harvest group (P = .15). Patients requiring hemodialysis had increased risk for loss of primary assisted patency in both groups (endoscopic, P = .02; open, P = .02) and decreased secondary patency in the open harvest group (P = .04). CONCLUSIONS: Endoscopic and open harvest techniques for infrainguinal arterial bypass provide similar rates of wound complications and bypass patency, whereas hemodialysis negatively affects patency after both harvest methods. Endoscopic harvest is associated with the need for less perioperative narcotics, suggesting a potential benefit of endoscopic harvest that deserves further study.

Use of unconventional dialysis access in patients with no viable alternative.

BACKGROUND: Hemodialysis patients who have exhausted all of the conventionally used veins for vascular access, including arteriovenous fistula, arteriovenous graft, and traditional catheter access sites, present a challenge to the treating physician. Transhepatic and translumbar inferior vena cava catheters have been used in these patients who have no other access site option. The objective of the study was to examine our experience with translumbar and transhepatic approach for catheter-based hemodialysis access in patients who have exhausted all other options. METHODS: A retrospective review was performed from June 2000 to May 2011 of all patients who underwent transhepatic or translumbar inferior vena cava catheter placement for the purpose of hemodialysis. Data abstracted included previous access procedures, duration of use and patency of dialysis catheters, catheter-related complications, and mortality. RESULTS: Seven patients were identified. Four patients underwent transhepatic access and three underwent translumbar access. Five patients were female and two were male. The mean age was 44 years. The etiology of renal failure was diabetes in four patients, congenital hypoplastic kidneys in two patients, and acute glomerulonephritis in one patient. A mean of 14 (range: 11-18) dialysis access procedures were performed before catheter placement by transhepatic/translumbar interventions. The initial device service interval for all patients ranged from 15 to 658 days, with a mean of 295 days and a median of 245 days. Total access site service interval ranged from 15 to 790 days, with a mean of 380 days and a median of 245 days. CONCLUSION: Translumbar and transhepatic venous access is a viable long-term alternative route for catheter-based hemodialysis access in patients who have exhausted conventional options.

Prosthetic infection: lessons from treatment of the infected vascular graft.

Surgical prosthetics provide unquestioned benefit to patients in maintenance of life and limb. However, complications associated with prosthetic devices continue to represent a significant source of morbidity and mortality. Even as the surgeon becomes more adept at management of infections, the bacterial characteristics change in favor of increased virulence and greater resistance to antimicrobials. Excision or retention of the prosthesis depends on the time of presentation, the microbial isolates recovered, and the extent of surrounding tissue destruction. Recent work shows improving results with in situ replacement.

Retrocecal appendix location and perforation at presentation.

Retrocecal appendicitis has been theorized to follow a more insidious course than other anatomic variants. To determine the influence of retrocecal anatomy on clinical course of appendicitis, 200 adult patients treated at a major university medical center with the diagnosis of appendicitis from 2001 to 2004 were retrospectively studied. Computed tomography (CT) scans of adult patients with an ultimate diagnosis of appendicitis were analyzed to determine an association between retrocecal appendix and perforation of the appendix at presentation. A higher perforation rate in the retrocecal group would imply patient delay in presentation from more tolerable symptoms. CT scans were examined for retrocecal location and perforation. No significant association was found between retrocecal anatomy and perforation rates at presentation (chi-square = 2.1, P = 0.15, odds ratio = 1.6, 95% confidence interval [0.8-3.0]). However, the risk of perforation was 60 per cent higher in the retrocecal group. By regression analysis, age and the presence of a fecalith on CT scan were predictors of appendix perforation. Appendix location was not. In this study, we found no significant association between retrocecal appendix anatomy and perforation at presentation.