Prospective, randomized, multicenter clinical study comparing a self-expanding covered stent to percutaneous transluminal angioplasty for treatment of upper extremity hemodialysis arteriovenous fistula stenosis.

Use of a covered stent after percutaneous transluminal angioplasty (PTA) was compared to PTA alone for treatment of upper extremity hemodialysis patients with arteriovenous fistula (AVF) stenoses. Patients with AVF stenosis of 50% or more and evidence of AVF dysfunction underwent treatment with PTA followed by randomization of 142 patients to include a covered stent or 138 patients with PTA alone. Primary outcomes were 30-day safety, powered for noninferiority, and six-month target lesion primary patency (TLPP), powered to test whether TLPP after covered-stent placement was superior to PTA alone. Twelve-month TLPP and six-month access circuit primary patency (ACPP) were also hypothesis tested while additional clinical outcomes were observed through two years. Safety was significantly non-inferior while six- and 12-month TLPP were each superior for the covered stent group compared to PTA alone (six months: 78.7% versus 55.8%; 12 months: 47.9% versus 21.2%, respectively). ACPP was not statistically different between groups at six-months. Observed differences at 24 months favored the covered-stent group: 28.4% better TLPP, fewer target-lesion reinterventions (1.6 ± 1.6 versus 2.8 ± 2.0), and a longer mean time between target-lesion reinterventions (380.4 ± 249.5 versus 217.6 ± 158.4 days). Thus, our multicenter, prospective, randomized study of a covered stent used to treat AVF stenosis demonstrated noninferior safety with better TLPP and fewer target-lesion reinterventions than PTA alone through 24 months.

Prospective, Multicenter Clinical Study of the Covera Vascular Covered Stent in the Treatment of Stenosis at the Graft-Vein Anastomosis of Dysfunctional Hemodialysis Access Grafts.

PURPOSE: To study the use of the self-expanding Covera covered stent for the treatment of stenotic lesions at the venous anastomosis of hemodialysis arteriovenous grafts (AVGs). MATERIALS AND METHODS: A total of 110 patients with AVG venous anastomotic stenosis of ≥50% and access dysfunction were treated at 14 centers in the United States using percutaneous transluminal angioplasty followed by covered stent placement. The primary end points were 30-day safety and 6-month target lesion primary patency (TLPP). The secondary measures included access circuit primary patency, circuit cumulative patency, and the number of reinterventions through 24 months. RESULTS: Freedom from a primary safety event at 30 days was 96.4% while the 6-month TLPP rate was 70.3%. Seventy-five patients completed 24-month follow-up (68.2%). The TLPP rates were 54.2% at 365 days and 36.9% at 730 days while the access circuit primary patency rates were 16.7% at 365 days and 7.8% at 730 days (Kaplan-Meier analysis). The access circuit cumulative patency rates were 85.4% at 12 months and 73.6% at 24 months. The number of reinterventions to maintain the patency of the access circuit was 3.6 ± 3.1 at 24 months (1.6 ± 1.9 at the target lesion). CONCLUSIONS: Use of the Covera covered stent for hemodialysis graft-vein anastomotic stenosis provided a safe treatment option with a TLPP rate of 70.3% at 6 months and TLPP and cumulative access circuit patency rates of 36.9% and 73.6% at 2 years.

Continuation of Chronic Heart Failure Therapies During Heart Failure Hospitalization - a Review.

Randomized controlled trials have demonstrated the benefits of guideline-directed medical therapy in the outpatient setting for treatment of chronic heart failure. However, the benefits of continuation (or discontinuation) of major chronic heart failure therapies when treating acute heart failure during hospitalization are less clear. Real and anticipated worsening renal function, hyperkalemia and hypotension are the three major reasons for discontinuation of renin-angiotensin-aldosterone system inhibitors during hospitalization, and a failure to resume renin-angiotensin-aldosterone system inhibitors before discharge could worsen cardiovascular outcomes. Available data, mostly observational, shows that continuation or initiation of renin-angiotensin-aldosterone system inhibitors appears efficacious, safe, and well tolerated in majority of acute heart failure patients during hospitalization. Worsening renal function portends poor prognosis only if associated with congestion in acute heart failure, and clinicians should not de-escalate diuretic therapy routinely for worsening renal function.

Coronary Revascularization in Chronic and End-Stage Renal Disease: A Systematic Review and Meta-analysis.

Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) on dialysis have an increased risk for cardiovascular mortality and morbidity secondary to occlusive coronary artery disease. Optimal revascularization strategy is unclear in this high-risk population. We have performed a meta-analysis to compare coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with ESRD and CKD. We searched PubMed, Ovid, MEDLINE, CINAHL, and EMBASE (1980-2013) and found 17 trials (N = 33,584) in the ESRD arm and 6 studies (n = 15,493) in the CKD arm. Two investigators independently collected the data. All the studies were retrospective trials. In the ESRD and CKD groups, we found significantly reduced early mortality with the PCI group with the odds ratio of 2.08 (1.90-2.26; P < 0.00001) and 2.55 (1.45-4.51; P = 0.001), respectively. Contrary to the early mortality results, we found decreased late mortality with the CABG group when compared with the PCI group [odds ratio: 0.86 (0.83-0.89; P < 0.000001) and 0.82 (0.76-0.88; P < 0.00001)] in the ESRD and CKD arm, respectively. When compared with PCI, there was decreased cardiovascular mortality with an odds ratio of 0.61 (0.40-0.92; P = 0.02) in patients who underwent CABG in ESRD population. Similar trends were observed in the incidence of myocardial infarction and repeat revascularization. There is a strong trend for decreased risk of stroke with PCI when compared with CABG in ESRD and CKD populations.

Percutaneous Peritoneal Dialysis Catheter Placement in Patients with Complex Abdomen.

Peritoneal dialysis (PD) is an effective treatment for end-stage renal disease. There are several techniques of percutaneous PD catheter placement including trocar or Seldinger techniques. Placement can be performed with fluoroscopy and/or sonography or as a blind percutaneous procedure. Historically, percutaneous PD catheters have been placed in patients even if they had prior abdominal surgeries. The outcomes of percutaneous PD catheter placement in patients with complex abdomen (patients with two or more abdominal surgeries or known adhesions) are unknown. This study was carried out to determine the outcomes of percutaneous PD catheter placements using Seldinger technique with sonography and fluoroscopy in patients with complex abdomen. Preprocedure sonography was also used to identify site of adhesions and blood vessels. The goal was to see if ultrasound and fluoroscopy would support placement of PD catheters in patients with complex abdomens. There were total of 10 catheter placements in 10 patients with complex abdomen. The initial success rate was 100%. The patients had an average of 2.8 abdominal surgeries. The mean BMI was 28.4. There were no incidences of perforation or failed placements. One catheter was replaced due to outflow failure and one patient discontinued PD due to peri-catheter leak. One year catheter survival was 80%. Our study demonstrates benefits of using ultrasonography and fluoroscopy during percutaneous PD catheter placement by the Seldinger technique in patients with complex abdomen.

Mild Renal Artery Stenosis Can Induce Renovascular Hypertension and is Associated with Elevated Renal Vein Renin Secretion.

Renovascular hypertension is a syndrome which encompasses the physiological response of the kidney to changes in renal blood flow and renal perfusion pressure. Such physiological changes can occur with renal artery occlusion irrespective of the severity of the lesion. We have analyzed hypertensive patients with mild renal artery stenosis and compared them to patients with no stenosis. Renal vein renin sampling from catheterization of the renal vein was performed in all these patients. Patients with mild stenosis had higher renal vein renin ratio (3.01 ± 1.5) than the patients with no stenosis (1.10 ± 0.29; p = 0.002). Patients with mild stenosis were also found to have higher diastolic blood pressure and renal artery resistive indices when compared to patients with no stenosis. We therefore conclude that mild stenosis can precipitate renin-mediated hypertension in renovascular stenosis and also emphasis that parameters pertinent to renal physiology need to be evaluated before considering treatment options in patients with renal artery stenosis and medical management with RAAS blockade is the preferred modality of therapy for patients with renin-mediated hypertension.

Persistent Median Artery As A Cause Of Nonmaturing AV Fistula.

A 68-year-old right handed male with End-Stage Renal Disease with a left radiocephalic fistula created 8 months ago was referred for the evaluation of a nonmaturing access. Patient had an arterial anastomosis lesion that underwent successful angioplasty. Diagnostic arteriogram of the AV access extremity revealed the presence of a short radial artery and dominant common interosseous artery manifesting as a persistent median artery in the distal forearm and was anastomosed to the fistula and then continues as the median-ulnar superficial arch in the palm. Balloon angioplasty of the common interosseous artery led to a complication when the distal 30 cm of the 0.018 guide wire fractured and had to be retrieved using a snare device. In addition to anticipating and treating the common complications of vascular access procedures, it is also important to be aware of the anomalies of the distal forearm arterial anatomy and perform a detailed arterial evaluation prior to creating the arterio-venous anastomosis.

Self-centering, split-tip catheter has better patency than symmetric-tip tunneled hemodialysis catheter: single-center retrospective analysis.

The performance and safety of a new self-centering, split-tip hemodialysis tunneled catheter was compared with a symmetric-tip catheter. The new catheter has a greater separation between the arterial and venous tips, with dual apertures designed to permanently face the center of the blood vessel. The design is intended to improve dialysis efficiency by increasing flow rates while decreasing recirculation, fibrin sheath formation, thrombosis, and vessel wall occlusions. The study results indicated that the self-centering, split-tip catheter had statistically greater patency after 3 months with similar clearance, blood flow, and safety.

Utility of a ML analytics on real time risk stratification and re-intervention risk prediction on AV access outcomes and cost.

BACKGROUND: Vascular access is the lifeline for patients on hemodialysis. The average survival rates of dialysis dependent patients have been improving over the last 5 years and hence their dialysis access needs longevity for uninterrupted optimal dialysis. With the lack of genomic vascular access failure predictors, there is an unmet need for predicting an event and the appropriate approach to mitigate recurrence of the event that could have cost and outcome implications. METHODS: We performed a single center experience that extracted relevant clinical (access flow, laboratory data and CKD details), access intervention (prior interventions, type & location of lesion, type of balloon used, use of stents etc.) and demographic (age, vintage on dialysis, sex, social determinants, other medical conditions) data in real time and feeds it into validated ML algorithms to predict risk of reintervention. (Plexus EMR LLC). RESULTS: About 200 prevalent hemodialysis patients with a AV graft or AV fistula were included for this analysis. Need for re-intervention and use of stent/ flow reduction/new access creation were the outcomes analyzed. Plexus EMR is a licensed Azure based platform. R software was used to develop the ML algorithms. Regression factors were developed to assess and test the validity of individual attributes across all the data attributes. Each patient had a real time risk calculator available to the interventionalist on risk of reintervention/ year. Of the 200 patients, 148 had a AV fistula and the remaining 52 had a AV graft. Mean interventions in the year prior to analysis was 1.8 in patients with AV fistulas and 3.4 in AV grafts which decreased to 1.1 in AV fistulas and to 2.4 in AV grafts (p < 0.01) post tool deployment. There were 62 AV graft thrombectomies done in the observation year and 62% of those were repeat thrombectomies. Stent utilization increased to 37 (22 in AV grafts and 15 in AV fistulas) and 2 patients had AV access flow reduction surgery. The cumulative cost (predicted) preintervention was $712,609 and decreased to $512,172 post intervention. Stent utilization increased by 68% in the evaluation year and 89% of the stents used were PTFE coated stents. CONCLUSION: Utilizing AI with ML based algorithms that includes clinical, demographic and patency maintenance variables could become new standards of care to optimally manage AV accesses and lower cost of care.

Arterial revascularization in patients with hand pain dialyzing with upper arm Arteriovenous (AV) fistulas: A single center experience.

BACKGROUND: Distal hand ischemia syndrome (DHIS) is a well reported adverse outcome in patients with upper arm AV access. 25%-40% of these patients have been reported to be due to primary arterial disease complicated with significant arterial calcification. The effectiveness of revascularization of the distal arterial circulation on symptom resolution has not been reported yet. METHODS: Retrospective single center analysis of patients evaluated for hand/forearm pain in patients with upper arm AV access who had arterial revascularization between 01/2016 and 12/2020 were included for the analysis. Fifty-one patients met inclusion criteria. Stenotic lesions greater than 70% in the subclavian, axillary, brachial, radial, or ulnar artery were treated with balloon angioplasty. Institutional approval was obtained to review charts. OUTCOMES: Successful revascularization, improvement in pain in 48 h, 1 month, and 3 months. RESULTS: Seventy six percent of patients had an upper arm Arteriovenous Fistula (AVF) and 24% patients had an upper arm Arteriovenous Graft (AVG). Mean access flow was 1210 (556) ml/min. 55% of patients had radial or ulnar arterial stenosis, 45% had brachial/axillary or subclavian artery stenosis. 45% patients had lesions in both radial and ulnar arteries, 88% of patients were successfully revascularized. 76% (18) of patients had improvement in symptoms within 48 h and 68% remained symptom free in 3 months. Mean DHIS stage was 3.1 before intervention and improved to 1.1 post intervention (p < 0.001). Patient satisfaction with their AV access improved from 34% to 72% (p < 0.01). Multiple regression analysis did not reveal statistically significant correlations between time on dialysis vintage and other chronic medical conditions on post procedure symptom improvement. CONCLUSIONS: DHIS with occlusive arterial disease can be successfully revascularized to improve symptoms. Complete evaluation of the inflow arterial segment and optimal endovascular revascularization could decrease the need for access revision procedures or access abandonment.

Myeloma light chain-induced renal injury in mice.

We investigated the effects of human light chain (LC) protein-overload in mice kidney to gain further insights into the molecular mechanisms involved in the pathogenesis of myeloma kidney. Intact male C57BL/6, 10- to 12-week-old mice were given daily intraperitoneal (i.p.) injections of 1 ml of human κ-LCs (1.5 mg/ml, low dose), or (100 mg/ml, high dose) to uninephrectomized mice for 2 weeks. Intact, sham-operated or uninephrectomized control animals were given the same volume (1 ml/day) of saline, human serum albumin (10 mg/ml) or bovine serum albumin (100 mg/ml) i.p. for 2 weeks in place of LCs. The low-dose LC-treated mice had human LCs in their urine and a significant increase in monocyte chemoattractant protein-1 (MCP-1) mRNA in the kidneys. Uninephrectomized mice treated with high-dose κ-LCs showed tubule casts, and foci of intracytoplasmic rhomboid crystals within the proximal tubules, along with cytoskeletal disruptions and alterations in the brush-border membrane, and high concentrations of human κ-LC were present in their sera. High-dose LC treatment also led to increases in serum creatinine and tumor necrosis factor-α levels, and marked increases in interleukin-6 and MCP-1 expression as well as cellular apoptosis in the kidneys. These studies demonstrate that myeloma LC overload over a range of LC concentrations in mice causes significant functional and morphological kidney injury. The model should be helpful in investigating pathophysiologic mechanisms and exploring therapeutic interventions for myeloma kidney and other LC-associated renal disorders.

American Association of Kidney Patients survey of patient preferences for hemodialysis vascular access.

OBJECTIVES: To determine the vascular access modalities used for hemodialysis, the reasons for choosing them, and determinants of satisfaction with vascular access among patients with end-stage renal disease. METHODS: The American Association of Kidney Patients Center for Patient Research and Education used the American Association of Kidney Patients patient engagement database to identify eligible adult hemodialysis patients. Participants completed an online survey consisting of 34 demographic, medical history, and hemodialysis history questions to determine which vascular access modalities were preferred and the reasons for these preferences. RESULTS: Among 150 respondents (mean age 54 years, 53% females), hemodialysis was most frequently initiated with central venous catheter (64%) while the most common currently used vascular access was arteriovenous fistula (66%). Most (86%) patients previously received an arteriovenous fistula, among whom 77% currently used the arteriovenous fistula for vascular access. Older patients and males were more likely to initiate hemodialysis with an arteriovenous fistula. The factors most frequently reported as important in influencing the selection of vascular access modality included infection risk (87%), physician recommendation (84%), vascular access durability (78%), risk of complications involving surgery (76%), and impact on daily activities (73%); these factors were influenced by patient age, sex, and race. Satisfaction with current vascular access was 90% with arteriovenous fistula, 79% with arteriovenous graft, and 67% with central venous catheter. CONCLUSION: Most end-stage renal disease patients continue to initiate hemodialysis with central venous catheter despite being associated with the lowest satisfaction rates. While arteriovenous fistula was associated with the highest satisfaction rate, there are significant barriers to adoption that vary based on patient demographics and perception of procedure invasiveness.

Patient selection, education, and cannulation of percutaneous arteriovenous fistulae: An ASDIN White Paper.

End-stage kidney disease patients who are candidates for surgical arteriovenous fistula creation commonly experience obstacles to a functional surgical arteriovenous fistula, including protracted wait time for creation, poor maturation, and surgical arteriovenous fistula dysfunction that can result in significant patient morbidity. The recent approval of two endovascular devices designed to create a percutaneous arteriovenous fistula enables arteriovenous fistula creation to be placed in the hands of interventionalists, thereby increasing the number of arteriovenous fistula providers, reducing wait times, and allowing the patient to avoid surgery. Moreover, current studies demonstrate that patients with percutaneous arteriovenous fistula experience improved time to arteriovenous fistula maturation. Yet, in order to realize the potential advantages of percutaneous arteriovenous fistula creation within our hemodialysis patient population, it is critical to select appropriate patients, ensure adequate patient and dialysis unit education, and provide sufficient instruction in percutaneous arteriovenous fistula cannulation and monitoring. In this White Paper by the American Society of Diagnostic and Interventional Nephrology, experts in interventional nephrology, surgery, and interventional radiology convened and provide recommendations on the aforementioned elements that are fundamental to a functional percutaneous arteriovenous fistula.

The effects of body mass index on graft survival in adult recipients transplanted with single pediatric kidneys.

BACKGROUND: There is insufficient data on the impact of recipient body mass index (BMI) on the long-term graft survival of adult patients transplanted with single pediatric kidneys. METHODS: We performed a retrospective analysis of adult patients transplanted with single pediatric kidneys at our center. The recipients were classified into 2 groups: group 1 (BMI > or =30) and group 2 (BMI <30). Donor/recipient demographics, postoperative outcomes and survival rates were compared between the 2 groups. RESULTS: There was no significant difference in donor/recipient demographics between the 2 groups. In group 1, the death-censored graft survival (DCGS) at 1, 3 and 5 years was 90% at all 3 time points, and in group 2 it was 86, 68 and 60%, respectively (p = 0.05). The mean glomerular filtration rate (with standard deviation in parentheses) at 1, 3 and 5 years was, respectively, 55 (15), 59 (19) and 55 (28) ml/min for group 1, compared to 65 (28), 69 (23) and 67 (20) ml/min in group 2 (p = NS). Multivariate analysis revealed a hazard ratio of 5.12 (95% confidence interval 1.06-24.7; p = 0.04) for graft loss in nonobese patients when compared to obese patients. Obese patients had an increased risk for acute rejections within the first month of transplant (p = 0.02). CONCLUSION: Patients with a BMI > or =30 transplanted with single pediatric kidneys have better DCGS rates when compared to nonobese patients.

Comparative analysis of beta-blockers with other antihypertensive agents on cardiovascular outcomes in hypertensive patients with diabetes mellitus: a systematic review and meta-analysis.

OBJECTIVES: To analyze the effects of beta-blockers (BBs) on cardiovascular (CV) outcomes in diabetic patients with hypertension. DATA SOURCE: Literature search was performed with relevant search words using PubMed and Ovid Gateway search engines for trials published in English from June 1996 to July 2007. REVIEW METHODS: Systematic reviews of randomized control trials that used BBs as treatment or control therapy in diabetic patients with hypertension were included for the analysis. All the included studies use intention-to-treat analysis. Two individual authors procured the data. Myocardial infarction, stroke, CV mortality, and total mortality were the outcomes analyzed. Relative risk across the different groups was calculated using Mantel-Haenszel random- and fixed-effects model. Interstudy heterogeneity was computed by chi(2) test. Results were calculated with 95%confidence intervals (CIs) and were considered significant with double-sided alpha error less than 0.05. Funnel plot was used to assess for publication bias. RESULTS: Eight trials (N = 130,270) met the inclusion criteria for the analysis. The relative risks for myocardial infarction, stroke, CV mortality, and total mortality were 1.08 (95% CI 0.82-1.42; P = 0.6), 1.13 (95% CI 0.95-1.36; P = 0.1), 1.15 (95% CI 0.83-1.6; P = 0.3), and 1.16 (95% CI 0.92-1.47; P = 0.2), respectively. BBs were associated with increased risk for CV mortality 1.39 (95% CI 1.07-1.804; P ,0.01) when compared with renin angiotensin blockade (RAS) therapy. CONCLUSION: BBs have increased risk for CV mortality when compared with RAS blockade therapy in diabetic patients with hypertension. BBs do not have increased risk for myocardial infarction, stroke, CV mortality, and total mortality when compared with control antihypertensive therapy in diabetic patients with hypertension.

Calcific constrictive pericarditis with refractory hypokalemia in a patient with Gitelman's syndrome.

Calcific constrictive pericarditis can be idiopathic or associated with radiation therapy, surgery, infection, or autoimmune disorders. Gitelman's syndrome is a distal renal tubular defect involving the thiazide-sensitive luminal sodium chloride cotransporter and has been associated with nephrolithiasis and chondrocalcinosis. There has not been any case of calcific constrictive pericarditis reported so far in association with Gitelman's syndrome. We have reported a male patient with persistent hypokalemia and refractory ascites diagnosed with calcific constrictive pericarditis and Gitelman's syndrome.

Renin angiotensin system blockade and cardiovascular outcomes in patients with chronic kidney disease and proteinuria: a meta-analysis.

OBJECTIVE: The role of renin angiotensin system (RAS) blockade in controlling hypertension and the positive impact on cardiovascular (CV) outcomes is well known. However, the role of RAS blockade in improving CV outcomes in patients with chronic kidney disease (CKD) is still unclear. METHODS: Randomized controlled trials that analyzed CV outcomes in patients with CKD/proteinuria treated with RAS blockade (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers) were included in our study. The relative risk across all study groups was computed using Mantel-Hanszel random effects model. Results were calculated with 95% CI and was considered statistically significant if 2-sided alpha error was <.05. Renin angiotensin system blockade-based therapy was compared with placebo and control (beta-blocker, calcium-channel blockers and other antihypertensive-based therapy) therapy in the study. RESULTS: Twenty-five trials (N = 45758) were used for analysis. Renin angiotensin system blockade decreased the risk for heart failure in patients with diabetic nephropathy when compared with placebo 0.78 (95% CI 0.66-0.92, P = .003) and control therapy (0.63, 95% CI 0.47-0.86, P = .003). The risk for CV outcomes was decreased with RAS blockade (0.56, 95% CI 0.47-0.67, P < .001) in nondiabetic nephropathy patients with CKD when compared with control therapy. There was also a significant reduction of CV outcomes (0.84, 95% CI 0.78-0.91, P < .0001), myocardial infarction (0.78, 95% CI 0.65-0.97, P = .03), and heart failure (0.74, 95% CI 0.58-0.95, P = .02) when we pooled all the patients with CKD and compared RAS blockade to placebo. CONCLUSIONS: A pooled analysis of all causes of CKD revealed a reduction in the risk for myocardial infarction, heart failure, and total CV outcomes when RAS blockade was compared with placebo. RAS blockade decreases the risk for CV outcomes and heart failure when compared with control therapy in patients with proteinuria. There were also benefits with RAS blockade in reducing the risk of CV outcomes and heart failure in patients with diabetic nephropathy when compared with placebo.

Pioglitazone and the risk of myocardial infarction and other major adverse cardiac events: a meta-analysis of randomized, controlled trials.

A recent meta-analysis suggested that the use of rosiglitazone increases the risk of myocardial infarction (MI) in patients with type 2 diabetes mellitus. It is unclear whether this is a class effect of thiazolidinediones (TZD). We did a meta-analysis to evaluate cardiovascular outcomes with the use of pioglitazone. Randomized, controlled trials in which pioglitazone was compared with placebo or other hypoglycemic agents were considered for analysis. Studies were included if the data for MI were available. Studies were identified with use of relevant search words in Medline, Pubmed, EMBASE, CINAHL, and Cochrane databases. Data abstraction was done by 2 individual authors using a standardized protocol. The relative risk across all study groups was computed by the Mantel-Haenszel method, and interstudy heterogeneity was assessed by the chi method. All results were computed according to 95% confidence intervals. Five trials (N = 9965) met the inclusion criteria for analysis. The relative risk for MI was 0.86 (0.69-1.07; P = 0.17). The relative risks for stroke and revascularization were 0.79 (0.61-1.02; P = 0.07) and 0.40 (0.13-1.23; P = 0.11), respectively. Pioglitazone does not increase the risk for MI and may decrease the risk for stroke and revascularization.

Clinical predictors of recurrent stenosis and need for re-intervention in the cephalic arch in patients with brachiocephalic AV fistulas.

INTRODUCTION: Cephalic arch stenosis is one of the most common reasons for repeated endovascular intervention and eventual abandonment of access in hemodialysis patients. There is no prediction model to identify risk factors for recurrent cephalic arch stenosis. We have developed a mathematical model to predict the need for reintervention in brachiocephalic (BC) fistulas with recurrent cephalic arch stenosis. METHODS: Single-center retrospective analysis of 143 patients with a BC fistula referred to the vascular clinic for access dysfunction who underwent cephalic arch angioplasty were included for the analysis. Twelve-month post-index angioplasty data were analyzed using parametric, non-parametric and multiple regression models using SPSS software. RESULTS: The mean need for re-intervention in 1 year since first index visit was 2.46 ± 1.404. Statistically significant correlation (p≤0.001) for re-intervention was observed with the severity of stenosis at index visit, access flow, vessel wall diameter proximal to the stenosis, average venous pressure >50% of the delivered blood flow rate and prolonged bleeding for >30 minutes as a reason for referral. Three equations have been derived for calculating the need for re-intervention based on the diameter of the vessel wall proximal to the stenosis. CONCLUSIONS: Risk stratification of BC fistulas utilizing the above parameters could enable clinicians to identify accesses that are at risk for multiple re-interventions. Early identification of accesses that are at high risk for re-interventions at the cephalic arch might prolong access survival and reduce the cost for intervention by utilizing alternate strategies.