MILLER Banding Procedure for Treatment of Dialysis Access-Related Steal Syndrome, Pulmonary Hypertension, and Heart Failure.

A Minimally Invasive Limited Ligation Endoluminal-assisted Revision (MILLER) banding procedure has been used for treating patients with dialysis access-related steal syndrome (DASS) and high-flow vascular access-related pulmonary hypertension (PHT) and heart failure (HF).We performed a retrospective analysis of patients undergoing the MILLER procedure performed for DASS, HF, and PHT from our Vascular Access Database from September 2017 to October 2019. Outcomes included primary patency of banding, primary assisted patency, and secondary patency, using time-to-event analyses with Kaplan-Meier curves and life tables to estimate 6- and 12-month rates.A total of 13 patients (6 men and 7 women, mean age 60 ± 14 years) underwent the MILLER procedure, 6 patients for DASS and 7 patients for pulmonary hypertension and heart failure (PHT/HF). Technical success was achieved in all patients. The longest duration of follow-up was 28 months (median 12 months [IQR 7, 19]). One patient died at 1 month after the intervention due to stroke. One patient developed access thrombosis of the graft 3 days after the procedure. Repeat banding was required in 1 patient 8 months after the first procedure. The 6-month primary patency rate of banding following this procedure was 83% while the 12-month rate was 66%. The 6- and 12-month secondary patency rates were 87% and 75%, respectively.The MILLER procedure can be performed for DASS and PHT/HF with improvement of symptoms and good long-term patency rates. Additional interventions to maintain patency and efficacy are required on long-term follow-up.

Effectiveness of an Evidence-Based Induction Therapy Protocol Revision in Adult Kidney Transplant Recipients.

STUDY OBJECTIVE: Induction immunosuppression significantly improves graft outcomes after kidney transplantation, but protocols vary among transplant centers due to the lack of data identifying an optimal induction agent. The objective of this study was to assess the effectiveness of an evidence-based protocol change in induction therapy in adult kidney transplant recipients. DESIGN: Retrospective cohort study. SETTING: Large tertiary care academic medical center. PATIENTS: A total of 349 patients transplanted between August 2011 and December 2013 were included in the study. A protocol revision in 2012 reserved the use of lymphocyte-depleting induction therapy to a select group of traditionally high-risk patients based on the findings of a previous randomized controlled trial performed at this center. MEASUREMENTS AND MAIN RESULTS: The primary outcome was biopsy-proved acute rejection and graft loss. The use of nondepleting induction therapy increased significantly after the protocol revision, with no significant differences in rejection or infection rates identified between protocols. When comparing graft survival between the protocol cohorts, there was no significant difference. A cost-minimization analysis indicated that the revised protocol was associated with considerable medication cost savings. CONCLUSION: A protocol targeting the use of lymphocyte-depleting induction to a select group of high-risk recipients appears to have equivalent efficacy and safety and is less costly compared with a more traditional induction protocol.