Autologous Breast Reconstruction With a Delay Procedure of the Deep Inferior Epigastric Artery Perforator Flap Because of Venous Congestion of the Flap on Pedicle: A Case Series.

The deep inferior epigastric artery perforator (DIEP) flap is one of the most used free flaps for the reconstruction of the breast after a mastectomy. Despite careful selection of the patients and preoperative imaging, difficulties in vascularization of the flap can occur in some cases. Although multiple vascular connections (bipedicled, turbocharged, or stacked) can be made in selected cases, there can still be venous congestion before the flap is transferred.Between 2016 and 2018, 4 cases in our series of 281 patients experienced such problems. Three of 4 patients had undergone preoperative imaging of the perforators by a magnetic resonance angiography or computed tomography angiography, in which a good perforator was seen. All 4 patients had a venous problem of blood circulation in the flap intraoperatively. The flaps were left to rest to decide on its venous status. Without improvement after this period of 20 to 30 minutes, the surgeons decided to withhold the translocation of the flap to the chest wall and sutured the flap back into the donor side. The final anastomosis of the DIEP flap occurred on average 8 days after the prefabrication. The translocation of the DIEP flap to the chest in this second operation went uncomplicated in all cases. Postoperatively, all patients had adequate arterial inflow and venous outflow of the flap. There were no postoperative complications.In case a DIEP flap shows venous problems before translocation, a delay procedure can be applied. In this way, the vascularization of the flap can be improved, and the translocation of the DIEP flap in a second operation can be successfully performed.

Lymphatico-venous anastomosis as treatment for breast cancer-related lymphedema: a prospective study on quality of life.

PURPOSE: Lymphedema is a chronic and disabling sequel of breast cancer treatment that can be treated by lymphatico-venous anastomosis (LVA). Artificial connections between the venous and lymphatic system are performed supermicrosurgically. This prospective study analyses the effect of LVA on quality of life. METHODS: A prospective study was performed between November 2015 and July 2016 on consecutive patients in the Maastricht University Medical Centre. Quality of life was considered as the primary outcome, and the Lymphedema International Classification of Functioning (Lymph-ICF) questionnaire was used. Discontinuation of compressive stockings and arm volume, using the Upper Extremity Lymphedema index (UEL-index), were the secondary outcomes. RESULTS: Twenty women with early-stage breast cancer-related lymphedema (BCRL) were included. The mean age was 55.9 ± 4 years and the median BMI was 25.1 [21-30] kg/m2. The mean follow-up was 7.8 ± 1.5 months. Statistically significant improvement in quality of life was achieved in the total score and for all the quality of life domains after one year of follow-up (p < 0.05). The discontinuation rate in compressive stockings use was 85%. The difference in mean relative volume did not show a statistically significant decrease. CONCLUSIONS: LVA for early-stage BCRL resulted in a significant improvement in quality of life and a high rate in stocking discontinuation.

Outcomes of vascularized versus non-vascularized lymph node transplant in animal models for lymphedema. Review of the literature.

Lymph node transfer has been performed to treat lymphedema for several years. The goal of this procedure is to provide a bridge between the lymphatic system distal and proximal to the lymph node dissection. There is a lack of consensus about the necessity of an additional vascular anastomosis for the transplanted lymph nodes. A systematic literature search in Cochrane Library database CENTRAL, MEDLINE, and EMBASE of animal studies using lymph node transplantation with and without additional vascularization was performed in March 2016. The strategy used for the search was: (("Models, Animal"[Mesh]) AND (("Lymphedema"[Mesh]) OR "Lymph Nodes"[Mesh]) OR "Lymph Node Excision"[Mesh])) AND ((vascularized lymph node transfer) OR ((non-vascularized lymph node transfer) OR lymph node graft)). The primary outcomes were: survival of transplanted lymph node and lymphatic vessel regeneration. Sixteen studies were included. Vascularization and the use of growth factors were significantly associated with lymph node survival. Lymphatic vessels regeneration was independent from vascularization. According to the results of the current study, additional vascular anastomosis might improve the transplanted lymph node survival. Further studies in both experimental and clinical setting are needed in order to support it. J. Surg. Oncol. 2017;115:32-36. © 2016 Wiley Periodicals, Inc.

Innervated full thickness grafts in distal finger amputations.

Innervated full thickness graft will be presented as an option to reconstruct a fingertip defect which might result in better sensibility than standard reconstruction using a full thickness graft without innervation. Also, anastomosing the nerve stumps can decrease the chance of developing neuroma.

Registration of finger implants in the Dutch arthroplasty registry (LROI).

Finger arthroplasty is commonly used to treat pain in the finger joints due to osteoarthritis or rheumatoid arthritis. Despite the procedure having existed for a relatively long time, it is still unknown which characteristics influence implant survival. The Dutch Arthroplasty Registry (LROI) is one of the 4 registries worldwide registering finger arthroplasties. This study aimed to investigate impact factors for implant survival regarding finger joint arthroplasty and assess registration completeness using the national healthcare claims database to compare. A total of 951 primary arthroplasties and 84 revision arthroplasties of the finger joints were registered. A higher likelihood of primary and revision surgery was found in female patients. The third and fourth proximal interphalangeal (PIP) joints were the most frequently operated in primary surgery; however, the metacarpophalangeal (MCP) joints were the most frequently revised joints. Silicone implants were used in most cases and evenly throughout all digits. Suboptimal registration completeness was shown for plastic surgeons with just 35.5%-37.4% of all surgeries registered. Although orthopedic surgeons do not perform most surgeries on the hand, they registered 76.5%-78.2% of surgeries. No statistical analyses were justified, considering the low completeness and limited follow-up. Female gender and PIP joint disease are possible risk factors for primary arthroplasty. MCP arthroplasties showed higher revision rates. However, participation rates and, therefore, data completeness were not optimal. To optimize participation, improving ease of registration should be explored. Furthermore, we urge readers who deal with joint implants to register their surgeries in the LROI database because only optimal registration completeness leads to high-quality data.

Risk factors for unplanned reoperation during the expansion phase in two-stage breast reconstruction in the Dutch Breast Implant Registry.

BACKGROUND: The majority of postmastectomy breast reconstructions (PMBRs) are currently performed in two stages using a tissue expander (TE). However, complications during the expansion phase occur regularly, leading to unplanned reoperations and/or reconstruction failure. This study aimed to identify risk factors for unplanned reoperation after TE placement, assessed the time until unplanned and planned reoperation, and investigated indications for unplanned reoperation. METHODS: Patient and surgery-related characteristics of patients who underwent two-stage PMBR between 2017 and 2021 were collected from the Dutch Breast Implant Registry (DBIR). Unplanned reoperation was defined as TE explantation followed by either no replacement or replacement with the same or a different TE. Co-variate adjusted characteristics associated with unplanned reoperation were determined using backward stepwise selection and multivariable logistic regression analyses. RESULTS: In total, 2529 patients (mean age, 50.2 years) were included. Unplanned reoperation occurred in 19.4 percent of all registered TEs (n=3190). Independent factors associated with unplanned reoperation were BMI≥25 kg/m 2 (adjusted Odds Ratio [aOR]=1.63;99% Confidence Interval [99%CI]=1.20-2.57 for BMI 25-29.9 kg/m2, aOR=2.57;99%CI=1.74-3.78 for BMI≥30 kg/m 2), low institutional volume (aOR=1.51;99%CI=1.06-2.18), no drains (aOR=2.06;99%CI=1.15-3.60), subcutaneous TE placement (aOR=5.71;99%CI=3.59-9.10), and partial pectoralis major muscle coverage (aOR=1.35;99%CI=1.02-1.79). Age<40 years (aOR=0.49;99%CI=0.32-0.74) and delayed PMBR (aOR=0.35;99%CI=0.19-0.60) reduced the risk of unplanned reoperation. Median time until reoperation was 97 days for unplanned and 213 days for planned reoperation. Deep wound infections were most often registered as indication for unplanned reoperation (34.4 percent). CONCLUSION: This study identified several risk factors for unplanned reoperation which may be used to reduce complications in expander-based PMBR.

Visualization of Both the Superficial and Deep Lymphatic System of the Upper Extremity Using Magnetic Resonance Lymphography.

Background: The lymphatic system consists of the superficial and deep lymphatic system. Several diagnostic methods are used to assess the lymphatic system. Lymphoscintigraphy and indocyanine green lymphography are widely applied, both showing disadvantages, such as a poor resolution and lack of field of view. Magnetic resonance lymphography (MRL) shows satisfactory temporal and spatial resolution. The aim of this study was to assess both the superficial and deep lymphatic system in the upper extremity of healthy subjects, using an MRL protocol. Methods and Results: Ten healthy volunteers underwent an MRL examination, using a three Tesla MRI unit. Water-soluble gadolinium was used as a contrast agent. MRL images were evaluated by an experienced radiologist on image quality, enhancement of veins and lymphatic vessels, and characteristics of the latter. Overall image quality was good to excellent. In all subjects, veins and lymphatic vessels could be distinguished. Superficial and deep lymphatic vessels were seen in 9 out of 10 subjects. Lymphatic vessels with a diameter between 0.9 and 4.3 mm were measured. Both veins and lymphatic vessels showed their characteristic appearance. Enhancement of veins was seen directly after contrast agent injection, which decreased over time. Lymphatic vessel enhancement slowly increased over time. Mean total MRL examination (room) time was 110 minutes (81 minutes scan time). Conclusions: The MRL protocol accurately visualizes both deep and superficial lymphatic vessels showing their characteristic appearances with high spatial resolution, indicating the MRL can be of value in diagnosing and staging peripheral lymphedema.

Variation in the use of infection control measures and infection-related revision incidence after breast implant surgery in the Netherlands.

Background: The use and effect of most infection control measures (ICMs) in breast implant surgery are still debated, likely resulting in undesired variation in current practices. Objectives: This study investigated the relationship between the number and combinations of ICMs used and the infection-related revision incidence after breast implant surgery. Additionally, national variation between Dutch healthcare institutions in ICM use was evaluated. Methods: For this multicentre, population-based study, all patients who received a primary breast implant or tissue expander for breast augmentation or reconstruction between 2015 and 2019 were identified from the Dutch Breast Implant Registry. Seven prospectively collected ICMs were investigated: preoperative antibiotics, implant and/or pocket irrigation, glove change, nipple guards, insertion sleeve, postoperative drains, and postoperative antibiotics. Results: This study included 52,415 implants (85% augmentation, 15% reconstruction).The median (IQR) number of ICMs used was 3 (3-4) for augmentation and 4 (4-5) for reconstruction. Median follow-up was 30 months for augmentation and 34 months for reconstruction. Infection-related revision incidence was 0.1% for augmentation and 2.1% for reconstruction. Most infection-related revisions occurred within 2 months for augmentation and 2.5 months for reconstruction. The impact of ICM use on infection-related revision incidence remained unclear, given its low incidence. A significant variation was observed between institutions in the use of postoperative antibiotics and drains. Conclusions: Although the use of different ICMs varied considerably between institutions, the infection-related revision incidence after breast implant surgery was generally low. Most surgeons used four ICMs for breast reconstruction and three ICMs for breast augmentation. Further studies on the causes and effects of the observed variation are needed.

[De Quervain's tenosynovitis: Clinical aspects and diagnostic techniques]. / Het syndroom van De Quervain.

De Quervain's tenosynovitis is a tendon sheath inflammation of the musculus abductor pollicis longus (APL) and the musculus extensor pollicis brevis (EPB) in the first extensor compartment of the wrist. Typically, patients present with pain symptoms on the radial side of the wrist as a result of repetitive moments and consequent overload of the tendons. During physical examination, De Quervain's tenosynovitis is easily distinguishable from other wrist injuries. Early recognition is of utmost importance for treatment decisions due to the fact that it is very well treatable, especially in the acute phase. A multimodal approach with conservative management is the most effective. Surgical intervention is usually not necessary.

Improving the quality of life of patients with breast cancer-related lymphoedema by lymphaticovenous anastomosis (LVA): study protocol of a multicentre randomised controlled trial.

INTRODUCTION: Early breast cancer detection and advancements in treatment options have resulted in an increase of breast cancer survivors. An increasing number of women are living with the long-term effects of breast cancer treatment, making the quality of survivorship an increasingly important goal. Breast cancer-related lymphoedema (BCRL) is one of the most underestimated complications of breast cancer treatment with a reported incidence of 20%. A microsurgical technique called lymphaticovenous anastomosis (LVA) might be a promising treatment modality for patients with BCRL. The main objective is to assess whether LVA is more effective than the current standard therapy (conservative treatment) in terms of improvement in quality of life and weather it is cost-effective. METHODS AND ANALYSIS: A multicentre, randomised controlled trial, carried out in two academic and two community hospitals in the Netherlands. The study population includes 120 women over the age of 18 who have undergone treatment for breast cancer including axillary treatment (sentinel lymph node biopsy or axillary lymph node dissection) and/or axillary radiotherapy, presenting with an early stage lymphoedema of the arm, viable lymphatic vessels and received at least 3 months conservative treatment. Sixty participants will undergo the LVA operation and the other sixty will continue their regular conservative treatment, both with a follow-up of 24 months. The primary outcome is the health-related quality of life. Secondary outcomes are societal costs, quality adjusted life years, cost-effectiveness ratio, discontinuation rate of conservative treatment and excess limb volume. ETHICS AND DISSEMINATION: The study was approved by the Ethics Committee of Maastricht University Medical Center (METC) on 19 December 2018 (NL67059.068.18). The results of this study will be disseminated in presentations at academic conferences, publications in peer-reviewed journals and other news media. TRIAL REGISTRATION NUMBER: NCT02790021; Pre-results.

Evaluation of a Novel Water-Based Volumetric Device for Measuring Upper Limb Lymphedema: First Experience with Healthy Volunteers.

Background: Lymphedema is a chronic, progressive disease consisting of tissue swelling resulting from excessive retention of lymphatic fluid. Measuring upper limb volume is crucial in patients to detect disease progression and to study the effects of treatment. The aim is to assess the validity and reliability of a newly developed system, Peracutus Aqua Meth, for measuring the upper limb volume compared with the gold standard water volumetry device. (In this study, the Bravometer was used). Methods and Results: Healthy volunteers were recruited in October 2017. Three measurements were performed per device. The obtained data were recorded per measurement, device, and researcher. Primary outcome was to determine the validity and reliability of the Peracutus Aqua Meth. Secondary outcomes were intra- and interrater reliability, measurement time, self-reported participant satisfaction, and influence of body mass index (BMI). Thirty-nine healthy volunteers were included. Mean differences in the validity in the Peracutus Aqua Meth and Bravometer were 47.26 and 78.16 mL, respectively (p = 0.04), with a Pearson's r of 0.99. Intra- and interrater reliability of the Peracutus Aqua Meth were both 0.99, in the Bravometer 0.96 and 0.97, respectively (p < 0.01). The Peracutus Aqua Meth required more time to measure and obtained lower scores in the participant satisfaction questionnaire. BMI was statistically associated with the measurements (p < 0.01). Conclusions: The first prototype of the Peracutus Aqua Meth is proven to be an accurate and reliable device for measuring the volume of the arm. Further improvements are needed in case of usability, time management, and participant satisfaction.

Quality of Life Questionnaires in Breast Cancer-Related Lymphedema Patients: Review of the Literature.

PURPOSE: Lymphedema of the arm is one of the most common and underestimated side effects of breast cancer treatment. It is known to negatively affect the quality of life (QoL) in breast cancer survivors. However, there are multiple questionnaires used to measure QoL in lymphedema patients. The current study aimed to determine the most complete and accurate questionnaire. METHODS: A systematic literature search in Cochrane Library database CENTRAL, MEDLINE, and EMBASE was conducted in August 2016 by two independent researchers. The strategy used for the search was: (("Lymphedema"[Mesh]) AND ("Quality of life"[Mesh])). All QoL questionnaires for patients with breast cancer-related lymphedema (BCRL) were included. An overview of the assessed QoL domains and arm symptom-specific questions was made, to assess the most complete and accurate questionnaire. RESULTS: A total of 142 studies were identified, of which 49 met the inclusion criteria and 15 different questionnaires were extracted. The Lymphedema Quality of Life Inventory (LyQLI), assesses all QoL domains, except for the possibility of wearing the clothes of choice, and assess all specific arm symptoms. The Lymphedema Functioning, Disability, and Health (Lymph-ICF) Questionnaire assesses all QoL domains, except for sexual functioning, and does assess all specific arm symptoms. CONCLUSION: According to the results obtained, the LyQLI and Lymph-ICF questionnaires were the two most complete and accurate questionnaires to assess QoL in patients with BCRL, because these questionnaires assess the largest number of QoL domains and specific arm symptoms.

Near-infrared fluorescence image-guidance in plastic surgery: A systematic review.

BACKGROUND: Near-infrared fluorescence (NIRF) imaging technique, after administration of contrast agents with fluorescent characteristics in the near-infrared (700-900 nm) range, is considered to possess great potential for the future of plastic surgery, given its capacity for perioperative, real-time anatomical guidance and identification. This study aimed to provide a comprehensive literature review concerning current and potential future applications of NIRF imaging in plastic surgery, thereby guiding future research. METHODS: A systematic literature search was performed in databases of Cochrane Library CENTRAL, MEDLINE, and EMBASE (last search Oct 2017) regarding NIRF imaging in plastic surgery. Identified articles were screened and checked for eligibility by two authors independently. RESULTS: Forty-eight selected studies included 1166 animal/human subjects in total. NIRF imaging was described for a variety of (pre)clinical applications in plastic surgery. Thirty-two articles used NIRF angiography, i.e., vascular imaging after intravenous dye administration. Ten articles reported on NIRF lymphography after subcutaneous dye administration. Although currently most applied, general protocols for dosage and timing of dye administration for NIRF angiography and lymphography are still lacking. Three articles applied NIRF to detect nerve injury, and another three studies described other novel applications in plastic surgery. CONCLUSIONS: Future standard implementation of novel intraoperative optical techniques, such as NIRF imaging, could significantly contribute to perioperative anatomy guidance and facilitate critical decision-making in plastic surgical procedures. Further investigation (i.e., large multicenter randomized controlled trials) is mandatory to establish the true value of this innovative surgical imaging technique in standard clinical practice and to aid in forming consensus on protocols for general use.Level of Evidence: Not ratable.

Effect of Lymphaticovenous Anastomosis in Breast Cancer-Related Lymphedema: A Review of the Literature.

BACKGROUND: Lymphedema affects ∼15% of all patients after breast cancer treatment. The aim of this review was to assess the clinical effects (improvement in arm circumference and quality of life) of lymphaticovenous anastomosis (LVA) in treating breast cancer-related lymphedema (BCRL). METHODS AND RESULTS: A systematic literature search was conducted in Medline, Embase and the Cochrane Library in July 2017, to identify all studies on LVA for the treatment of BCRL. The primary outcome was limb volume or circumference reduction and the secondary outcome was the improvement of quality of life. The search yielded 686 results, of which 15 articles were included in this review. All studies reported on BCRL in terms of volume or circumference reduction. Thirteen out of the included studies reported a positive surgical effect on reduction in volume or circumference. Twelve articles mentioned qualitative measures, being symptom improvement and improvement in quality of life. The number of patients who experienced symptoms relief ranged from 50% to 100% in the studies. CONCLUSIONS: The current review showed that the effects of LVA for the treatment of BCRL are variable among studies, although overall LVA seems effective in early stage BCRL. Higher quality studies are needed to confirm the effectiveness of LVA.

A randomized multicenter study of the outcome of brachial-basilic arteriovenous fistula and prosthetic brachial-antecubital forearm loop as vascular access for hemodialysis.

BACKGROUND: Vascular access is a necessity for patients with end-stage renal disease who need chronic intermittent hemodialysis. According to Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, radial-cephalic (RC) and brachial-cephalic (BC) arteriovenous fistulas (AVF) are the first and second choice for vascular access, respectively. If these options are not possible, an autogenous brachial-basilic fistula in the upper arm (BBAVF) or a prosthetic brachial-antecubital forearm loop (PTFE loop) may be considered. Until now, it was not clear which access type was preferable. We have performed a randomized study comparing BBAVF and prosthetic implantation in patients without the possibility for RCAVF or BCAVF. METHODS: Patients with failed primary/secondary access or inadequate arterial and/or venous vessels were randomized for either BBAVF or PTFE loop creation. The numbers of complications and interventions were recorded. Kaplan-Meier method was used to calculate primary, assisted-primary and secondary patency rates. The patency rates were compared with the log-rank test. Complication and intervention rates were compared with the Mann-Whitney test. RESULTS: A total of 105 patients were randomized for a BBAVF or PTFE loop (52 vs 53, respectively). Primary and assisted-primary 1-year patency rates were significantly higher in the BBAVF group: 46% +/- 7.4% vs 22% +/- 6.1% (P = .005) and 87% +/- 5.0% vs 71% +/- 6.7% (P = .045) for the BBAVF and PTFE group, respectively. Secondary patencies were comparable for both groups; 89% +/- 4.6% vs 85% +/- 5.2% for the BBAVF and PTFE group, respectively. The incidence rate of complications was 1.6 per patient-year in the BBAVF group vs 2.7 per patient-year in the PTFE group. Patients in the BBAVF group needed a total of 1.7 interventions per patient-year vs 2.7 per patient-year for the PTFE group. CONCLUSION: These data show a significantly better primary and assisted-primary patency in the BBAVF group compared with the PTFE group. Furthermore, in the BBAVF group, fewer interventions were needed. Therefore, we conclude that BBAVF is the preferred choice for vascular access if RCAVF or BCAVF creation is impossible, or when these types of access have already failed.

Forearm cephalic vein cross-sectional area changes at incremental congestion pressures: towards a standardized and reproducible vein mapping protocol.

OBJECTIVES: Duplex ultrasonography assessment of superficial forearm veins is frequently used before a hemodialysis arteriovenous fistula (AVF) is created. There is, however, no standardized preoperative duplex ultrasonography protocol. This study assessed B-mode image analysis reproducibility and reproducibility of repeated forearm superficial venous diameter measurements on different days at different venous congestion pressures (VCPs). METHODS: Diameters were determined using B-mode ultrasonography in 10 healthy male volunteers on days 1 and 14 at incremental VCP values (10 to 80 mm Hg). Intra- and interobserver agreement was assessed for B-mode image analysis by calculating interclass correlation coefficients (ICC). Reproducibility of repeated diameter measurements (maximum and minimum diameter at days 1 and 14), cross-sectional area size increase, and shape change due to incremental VCPs were determined by calculating ICC values. RESULTS: Analysis of intraobserver agreement of B-mode image interpretation yielded ICC values of 0.97 (95% confidence interval [CI], 0.94 to 0.99) and 0.97 (95% CI, 0.96 to 0.99) for determination of maximum and minimum diameters, respectively. Interobserver agreement analysis yielded ICC values of 0.95 (95% CI, 0.92 to 0.97) and 0.96 (95% CI, 0.96 to 0.99) for determination of maximum and minimum diameters, respectively. Reproducibility of repeated diameter measurements on days 1 and 14 improved substantially at incremental VCP values, with best reproducibility at VCPs >40 mm Hg. Repeated determination of cross-sectional area size increase and shape change due to VCP increase from 10 to 80 mm Hg yielded ICC values of 0.49 (95% CI, 0.19 to 1.00) and 0.09 (95% CI, 0.00 to 0.92), respectively. Maximum and minimum diameters as well as cross-sectional area size increased significantly (P < .01) due to VCP increase during both sessions. Cross-sectional area shape changed significantly (P < .01) due to VCP increase during both sessions. CONCLUSIONS: Diameter measurements on B-mode images are largely observer independent. Superficial venous cross-sectional area shape is noncircular, and cross-sectional area size depends on VCP. Both maximum and minimum venous diameters should be determined at VCPs >40 mm Hg to attain the best reproducibility. Further studies are needed to determine whether a standardized preoperative vein mapping protocol can reduce AVF nonmaturation rates.

Impact of a quality improvement programme based on vascular access flow monitoring on costs, access occlusion and access failure.

BACKGROUND: Vascular access thrombosis is a substantial source of morbidity in chronic haemodialysis patients. Periodical access flow measurements can predict the presence of vascular access stenosis and provide an opportunity for early intervention to prevent subsequent vascular access thrombosis. By this system of quality improvement, vascular access-related costs might be reduced. The aim of this study was to analyse the cost impact of a quality improvement programme based on periodic access flow measurements. METHODS: The number and costs of vascular access interventions (summary of angiography, percutaneous transluminal angioplasty, catheter placement, hospitalization days and costs for surgery) in the period 2001-2003 (quality improvement period; QIP, 218.6 patient-years observed) were retrospectively compared with a reference period (RP, 1996-1998, 214.4 patient-years observed) during which no access flow was measured. All access flow measurements were done on a regular base and interventions were performed according to the Kidney Disease Outcome Quality Initiative. RESULTS: Surgical thrombectomy procedures were significantly less during the QIP (0.25 +/- 0.57 events/patient-year) compared with RP (0.63 +/- 1.06 events/patient-year; P = 0.000), whereas access loss was not significantly different. During the QIP, 205 radiological interventions were performed (0.88 +/- 1.16 events/patient-year), and in the RP around 48 (0.33 +/- 0.65 events/patient-year; P = 0.000). Access-related costs tended to be lower during the QIP compared with the RP. The cost reduction appeared to be limited to patients with arteriovenous graft (AVG), in which access-related costs were significantly lower during the QIP (2360.95 euro +/- 2838.17 euro patient-year) compared with the RP (4003.96 euro +/- 3810.92 euro patient-year; P = 0.012), but not in patients with arteriovenous fistula (AVF). CONCLUSION: A quality improvement programme based on periodical access flow measurement reduced the number of acute vascular access failures due to thrombotic events and also significantly reduced health care costs in patients with AVG, but not in patients with AVF. The quality improvement programme had no effect on access survival.

Diameter measurements of the forearm cephalic vein prior to vascular access creation in end-stage renal disease patients: graduated pressure cuff versus tourniquet vessel dilatation.

BACKGROUND: Preoperative assessment of forearm superficial venous diameter may predict early failure of newly created arteriovenous fistulas for haemodialysis access. However, early failure and non-maturation rates remain high (up to 30%) and reported cut-off diameters are inconsistent. We hypothesize that this inconsistency is due to differences in the methods used to achieve venous dilatation prior to diameter measurements and daily variation in superficial venous diameter. We furthermore hypothesize that the use of a cuff will lead to a better inter-observer agreement since the applied pressure can be precisely determined. The purpose of this study was to determine inter-observer agreement of superficial venous diameter measurement under venous congestion by using either a graduated pressure cuff or tourniquet and furthermore, to determine daily variations in superficial venous diameter. METHODS: Diameter measurements were performed by two observers on days 1 and 3, in 21 end-stage renal disease patients using either a cuff (60 mmHg) or tourniquet. Measurements were carried out in random order and observers were blinded for each other's results. Inter-observer agreement was expressed as interclass correlation coefficients. Variance components analysis was used to determine possible causes of disagreement. RESULTS: Using a cuff, mean venous diameter was 1.8 mm (range, 0.7-3.3 mm). When a tourniquet was used, the mean diameter was 1.8 mm (range, 0.6-3.2 mm). Interclass correlation coefficients between observers were 0.76 and 0.74 for the use of a cuff and tourniquet, respectively. Diameter measurements were revealed to be observer independent. Variations in venous diameter were determined by the patient and the interaction of patient and day. Repeated assessment of venous diameter on different days revealed a variation coefficient of 26.4% when using a cuff, and 26.5% when using a tourniquet. CONCLUSIONS: Venous diameter assessment is observer and congestion method independent. Daily variations in forearm superficial venous diameters should be taken into account when defining and using cut-off diameters prior to vascular access surgery.

Excellent performance of one-stage brachial-basilic arteriovenous fistula.

BACKGROUND: According to the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) and the European Guidelines, the first and second choice for vascular access for haemodialysis are the radial-cephalic and brachial-cephalic arteriovenous fistula (AVF). Autogenous fistulas have a longer functional lifetime, less thrombotic complications and a lower infection risk compared with prosthetic implants. If it is impossible to create a brachial-cephalic AVF or after failure, either a brachial-basilic (BB) or a prosthetic forearm loop AVF may be considered. To determine the outcome of BB-AVFs, we retrospectively surveyed the results of this type of vascular access. METHODS: All BB-AVF patient records over a 6 year period were subtracted from an academic hospital registry. Primary failure and primary, assisted primary and secondary patency rates were calculated with the Kaplan-Meier method. Sex, diabetes mellitus (DM), pre-operative duplex diameters, complications and interventions were recorded and correlated with the patency rates. RESULTS: A total of 31 BB-AVFs were created in a one-stage surgical procedure. Of the patients, 36% were male and 19% had DM. Only one patient had a primary failure, leaving 30 (97%) of the BB-AVFs functional for dialysis treatment. Four patients died within 1 year after the operation, one of them from a catheter sepsis. Primary, assisted primary and secondary patency rates after 1 year were, 58, 83 and 90%, respectively. Patient characteristics and pre-operative duplex parameters did not influence patency rates. CONCLUSION: The BB-AVF is an excellent third choice option for vascular access.