A randomized controlled trial of the effect of postoperative hand exercise training on arteriovenous fistula maturation in patients with chronic kidney disease.

OBJECTIVE: Immature arteriovenous fistula (AVF) is a critical problem in patients with chronic kidney disease (CKD) after creation. Exercise with 30% maximum voluntary contraction (MVC) encourages vascular functions in other populations. It is unknown which exercise type is superior on maturation in the CKD population. We compare effects of isometric (ISM) and isotonic (IST) hand exercise training, both at 30% MVC, on AVF maturation and grip strength in patients with CKD. METHODS: Fifty patients with CKD were randomized into the ISM program or IST program (25 per group). Each group performed exercise program at intensity of 30% MVC every day for 10 weeks. Cephalic vein (CV) and brachial artery diameters, brachial blood flows, and grip strength were measured at weeks 0, 2, 6, and 10 of the program. The number of patients meeting clinical and ultrasound maturation were evaluated at weeks 2, 6, and 10. RESULTS: At weeks 6 and 10 of the programs, the ISM group had greater CV diameters (week 6, 7.1 ± 1.2 vs 6.2 ± 1.0 mm; week 10, 7.1 ± 1.0 vs 6.2 ± 1.1 mm) than the IST group. Compared with the IST group, the ISM group had a higher number of patients meeting ultrasound maturation at weeks 2 (IST/ISM, 8/2), 6 (IST/ISM, 16/8), and 10 (IST/ISM, 21/12), and clinical maturation at week 10 (IST/ISM, 25/18). No adverse events were observed throughout the study. CONCLUSIONS: At 30% MVC, ISM is more effective at promoting increases in CV diameter and maturation than IST. Both exercise types are feasible and safe for patients with CKD after AVF creation.

Long-Term Patency of Arteriovenous Fistulae Salvaged by Balloon Angioplasty with and without Accessory Vein Embolization: A Retrospective Study.

PURPOSE: To investigate whether accessory vein embolization (AVE) improves long-term performance of salvaged nonmaturing arteriovenous fistulae (AVFs). MATERIALS AND METHODS: This retrospective review included 72 patients who underwent percutaneous balloon angioplasty for salvage of nonmaturing AVFs between 2008 and 2014. AVE was performed on 32 patients between 2008 and 2011 (mean age, 59 y [range, 33-85 y]; men, n = 21; women, n = 11; upper arm, n = 17; forearm, n = 15), whereas the procedure was not performed on 40 patients after 2011 (mean age, 62 y [range, 28-85 y]; men, n = 26; women, n = 14; upper arm, n = 26; forearm, n = 14). Endpoints compared between groups included number of procedures required to achieve maturation, time to maturation, number of procedures required to maintain patency, and duration of primary and secondary patency after intervention. RESULTS: There was no statistically significant difference in number of procedures to achieve maturation (2.1 ± 1.4 vs 2.4 ± 1.2; P = .24) or time to maturation (26.1 d ± 56.2 vs 41.1 d ± 54.6; P = .072) between AVE and no embolization groups. Primary (P = .21) and secondary patency (P = .14) after intervention were not significantly different between groups. The number of procedures performed to maintain patency after maturation was significantly greater in the AVE group for patients with forearm AVFs (0.11 ± 0.098 vs 0.04 ± 0.064 per patient year; P = .039) but not for patients with upper arm AVFs. CONCLUSIONS: AVE of AVFs after balloon angioplasty does not lead to significantly improved long-term outcomes. Percutaneous salvage of nonmaturing AVFs in the forearm without AVE resulted in a decreased number of interventions to maintain patency.

Effect of a postoperative exercise program on arteriovenous fistula maturation: A randomized controlled trial.

Exercises after arteriovenous fistula (AVF) creation may help to improve maturation; however, their usefulness has only been examined in indirect, non-comparative studies or small trials. Between June 2013 and November 2014, we included all ambulatory patients with stages 5-5D chronic kidney disease who were candidates for the creation of a native AVF in our center. After surgery, all patients were randomized to an exercise group or a control group with single-blind control. At 1 month postoperatively, clinical maturation (expert nurse inspection) and ultrasonographic maturation (flow >500 mL/min, venous diameter >5 mm and depth <6 mm) were assessed in all patients. A total of 72 patients were randomized, 3 were lost to follow-up, and 69 were finally analyzed. The mean age was 66.8 years (standard deviation 13.8), 70.0% were men, and 65.2% were in pre-dialysis. After surgery (42.0% had distal AVF), the patients were randomized (31 controls, 38 exercise group). At 1 month after surgery, global clinical and ultrasonographic maturation was assessed in 88.4% and 78.3% of AVF, respectively (kappa = 0.539). Non-significant differences in clinical or ultrasonographic maturation were seen between exercise and control group (94.7% vs. 80.6%, P = 0.069; 81.6% vs. 74.2%, P = 0.459). A stepwise logistic regression was performed to control previously analyzed asymmetrically distributed confounding factors (AVF localization), revealing that the exercise group showed greater clinical, but not ultrasonographic, maturation (odds ratio [OR] 5.861, 95% confidence interval: 1.006-34.146 and OR 2.403, 0.66-8.754). A postoperative controlled exercise program after AVF creation seems to increase 1-month clinical AVF maturation in distal accesses. Furthermore, exercise programs should be taken into account, especially in distal accesses.

Utilización shunt arteriovenoso en Cirugía Reconstructiva / Use of arteriovenous shunt in Reconstructive surgery

La reconstrucción secundaria determinada por traumatismos severos de alta energía y procedimientos oncológicos con grandes pérdidas de cobertura cutánea requiere la transferencia con microcirugía para aportar un tejido sano vascularizado al sector comprometido. Sin embargo, debido a procesos cicatriciales y traumáticos, no siempre es posible hallar los vasos receptores para la transferencia. Una solución a dicha dificultad es la utilización de injertos venosos y arteriales o la confección de una fístula arteriovenosa cercana a la pérdida de sustancia. Se crea una fístula arteriovenosa temporalmente y luego se dividirá aportando los vasos necesarios para el colgajo libre. Desde agosto 2007 a agosto 2011 se realizaron 28 fístulas arteriovenosas en 27 pacientes que han sido utilizadas para transferencia de 22 colgajos libres. Las edades de los pacientes van desde los 12 a los 65 años de edad, con una media de 40,44 años. el tiempo de seguimiento de estos pacientes va desde los 2 hasta los 48 meses. De las 28 fístulas realizadas, 22 han podido ser utilizadas para transferir colgajos libres en forma exitosa. Las otras 6 fallaron. Las fístulas arteriovenosas determinaron cambios fisiológicos y en las características de flujo que permitió mayor seguridad en el momento de la transferencia de los colgajos. La utilización de fístulas arteriovenosas permite no sólo tener vasos receptores de buena calidad próximos a la lesión, sino también conseguir con ellas, un mayor flujo sanguíneo arterial y disminución de las resistencias periféricas gracias a cambios fisiológicos e histológicos que se producen a nivel del puente arteriovenoso.

[Reconstruction of vascular bed in the affected segment of the leg in patients with defects of the crural bones complicated by chronic osteomyelitis]. / Vosstanovlenie sosudistogo rusla v porazhennom segmente u bolnykh s defektami kostei goleni, oslozhnennymi khronicheskim osteomielitom.

The article analyses the results of medical rehabilitation of 176 patients with defects in the leg bones complicated by chronic osteomyelitis by methods of transosseous osteosynthesis. In average hospitalization terms of 380.8 +/- 15.6 days, medical rehabilitation was achieved in 88.6% of patients. The results of complex clinical and laboratory examination of 46 patients by means of angiographic, radionuclide, and physiological methods confirm gradual correction of the initial regional arterial insufficiency which was combined with anatomical and physiological rehabilitation of the affected leg by the end of treatment. It was established that the high clinical result of the developed methods of transosseous osteosynthesis is based on the formation of a new zone of the vascular channel in the affected limb segment.