Procedural comparison of a standard PTA balloon for fistula and graft maintenance procedures with the novel Chameleon™ PTA balloon catheter.

INTRODUCTION: The incidence of cephalic arch (CA) and central venous (CV) stenosis has been reported in the range of 30% in the literature. The purpose of this study is to compare contrast use, fluoroscopy time, and procedure time between standard imaging by injection of contrast through the access sheath versus injection of contrast through a novel PTA balloon with an integrated injection port. METHODS: A multi-centered, retrospective evaluation of consecutive patients treated for CA and CV stenosis was performed. Data captured included demographics, co-morbidities, lesion characteristics/location, procedural details, volume of contrast used, fluoroscopy time, and procedure time. The control group was imaged and treated using standard practice with pre and post imaging performed through the sheath and intervention using standard PTA balloon. Imaging and treatment were performed using the Chameleon™ PTA catheter in the treatment arm. RESULTS: A total of 68 consecutive patients were included. There were 34 patients in Group A and 34 patients in Group B. Average age was 65.2 versus 66.5 (p = 0.284), respectively. There were no significant gender differences between groups. Prevalence of co-morbidities of hypertension, coronary artery disease, and diabetes was similar to national rates in both groups. Contrast volume, fluoroscopy time, and procedure time in Group B were significantly less when compared by multiple regression to Group A, correcting for potential confounders (p = 0.0001, 0.0180, and 0.0008, respectively). CONCLUSION: Use of a PTA balloon with an integrated injection port shows potential for significant reduction in contrast dose, fluoroscopy time, and procedure time.

Dialysis catheters and their common complications: an update.

Tunneled dialysis catheters (TDCs) are associated with the highest rate of complications, morbidity, and mortality when compared to arteriovenous fistulas or grafts, and this relates to higher costs in their management. Over time, catheters are prone to higher rates of infection, thrombosis, and central venous stenosis, and, thereby, catheter dysfunction. Lower blood flow rates are a consequence of the dysfunction. Despite efforts to reduce incident and prevalent rates of catheter use for dialysis by the National Kidney Foundation and Fistula First Initiative, they remain a common modality of hemodialysis. The management of common TDC-related complications is discussed, in addition to ways to reduce and prevent morbidity associated with their use.

Clinical improvement of nephrogenic systemic fibrosis after kidney transplantation.

Nephrogenic systemic fibrosis (NSF) has been observed with increased frequency in recent years. Progressive hardening of the skin advancing to severe woody induration and the development of thickened hyperpigmented plaques on the extremities and the trunk are the main clinical features. Further progression of the disease results in flexion contractures of the upper and lower extremities, resulting in immobilization and severe morbidity. In this study, we reviewed our experience with seven end-stage renal disease patients who were referred to our center between January 2004 and June 2005 for kidney transplant evaluation or for diagnosis and treatment of their deteriorating condition. Diagnosis in all patients was confirmed by skin and muscle biopsy. Three of these patients underwent renal transplantations, and softening of the skin and improved mobility of the joints was noted after kidney transplantation. Three of the four patients who remained on dialysis showed further deterioration of their NSF despite a trial of immunosuppressive therapy. Improvement after transplantation could be secondary to immunosuppression, increased renal clearance and/or more effective fluid management.

Polymyalgia rheumatica in a renal transplant patient.

A 56-year-old African American woman who was on triple immunosuppressive therapy (which includes tacrolimus, mycophenolate mofetil, and prednisone) for a renal transplant that she had received 10 years ago presented with malaise, low-grade fevers and severe bilateral pain in her shoulder, neck and thigh muscles. There was serological evidence of an acute inflammatory syndrome, including a very high erythrocyte sedimentation rate (ESR) and high interleukin-6 and C-reactive protein levels. An extensive workup for infection and malignancy was negative, and a muscle biopsy was normal. Under a working diagnosis of polymyalgia rheumatica (PMR) her prednisone dose was increased, leading to a complete remission.; her symptoms resolved and the ESR normalized. The occurrence of PMR in an immunosuppressed patient is unusual, but should be considered in the differential diagnosis in the appropriate clinical setting.

Hemodialysis access success: beyond the operating room.

BACKGROUND: Publication of the Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines has reinforced an already increased focus within the Veterans Health Administration (VHA) on arteriovenous (AV) hemodialysis (HD) vascular access. Meeting these KDOQI goals has been the responsibility of individual VHA centers. We responded by organizing a dedicated HD AV clinic to provide preoperative evaluation and postoperative follow-up. METHODS: The records of 130 patients referred from January 2004 through June 2006 to our AV HD clinic were retrospectively reviewed. A minimum of 6 months of postoperative follow-up was required. RESULTS: AV fistulae were performed in 71% of the patients, with approximately 45% being Brescia-Cimino fistulae. Importantly, only 38% of AV fistulae matured and were used without secondary intervention. The remaining 62% of AV fistulae each required 2.2 +/- .3 interventions. The final AV fistula use rate was approximately 85%. CONCLUSIONS: To meet these KDOQI guidelines, the VHA should continue to support the concept of dedicated AV HD teams and clinics. This is essential because the majority of our new AV fistulae required secondary intervention for AV fistulae maturation and use. A dedicated HD access team should better be able to assess AV fistula maturation and organize subsequent intervention to promote AV fistulae use.