Comparison of surgical and radiological interventions for thrombosed arteriovenous access.

INTRODUCTION:: To compare open surgical and radiological interventions for thrombosed arteriovenous access for dialysis. METHODS:: A retrospective analysis of access procedures and dialysis episodes from 1 December 2002 to 30 November 2015 with follow-up up to 1 August 2016. Hospital records and dialysis database interrogated for further interventions and length of functional use. RESULTS:: Some 128 surgical and 27 radiological thrombectomies were compared. Radiological treatment was successful in 24 (89%) cases and surgical interventions in 65 cases (51%; p < 0.001). In all, 82 (64%) of the 128 surgical thrombectomies had no additional treatment, 43 (34%) had a surgical revision and 3 cases (2%) had an on-table balloon angioplasty. All 27 interventional thrombectomies had an additional balloon angioplasty. Success rate was significantly increased after a surgical revision (74%) or balloon angioplasty (87%) compared to no adjuvant procedure (38%; p < 0.001). There was a trend towards higher primary failure rates of arteriovenous fistula thrombectomies in the upper arm (57%) compared to the arteriovenous fistula thrombectomies in forearm (40%) and arteriovenous graft thrombectomies (33%; p = 0.056). Assisted primary patency was better after interventional treatment compared to surgery (p = 0.02) and significantly better after thrombectomy with additional treatment (p = 0.005). Patency after surgical revision or balloon angioplasty of the access was similar (p = 0.15). More procedures were required to maintain the access after balloon angioplasty than after surgical revision, and intervention-free survival was better after surgical revision (p = 0.02). CONCLUSION:: Revision procedures significantly increase success rate of access thrombectomies. Radiological thrombectomies have higher success rates but lower intervention-free survival and need more additional procedures to maintain patency.

Conservation of the axilla: an audit of sentinel lymph node biopsy after a new start.

BACKGROUND: Four hundred twenty-eight patients with a diagnosis of breast cancer were assessed. All patients underwent axillary ultrasonographic scanning preoperatively or at the time of initial breast imaging. Suspicious axillary glands underwent core needle biopsy under ultrasonographic guidance. PATIENTS AND METHODS: The majority of patients were in the age range of 40 to 80 years. Sentinel lymph node biopsy (SLNB) was performed in 360 patients. RESULTS: Sixty-eight patients had axillary clearance as a first axillary procedure. Of these patients, 55 had a preoperative diagnosis of a positive axillary gland in the axilla on ultrasonographically guided core needle biopsy, and 13 had clinically palpable axillary lymph glands. Seventy-one patients (21%) had a positive sentinel lymph node on histopathologic examination after hematoxylin and eosin (H & E) staining. Preoperative scans of the axilla had been reported as normal in these patients. In 68 patients, further axillary surgery was performed to clear the axilla; 24 of these patients (35%) had more positive glands in the axilla. In 44 patients (65%) the sentinel lymph glands were the only positive glands. Of 224 patients with a tumor size ≤ 20 mm, there were 30 patients (14%) who had a positive sentinel node. Of 136 patients with a tumor size > 20 mm, there were 41 patients (33%) with positive sentinel nodes. CONCLUSIONS: Sentinel lymph node biopsy in breast cancer allowed conservation of the axilla in 80% (289/360) of patients with negative sentinel lymph nodes in this study. Preoperative ultrasonographically guided core needle biopsy reduced the need for a second operation in 55 patients (13%).