Repeated Endovascular Interventions Are Worthwhile, Even After Thrombosis, to Maintain Long-Term Use of Autogenous Dialysis Fistulas.

OBJECTIVES: Patients often require multiple access re-interventions to improve fistula patency and the overall usable lifespan of autogenous arteriovenous fistula (aAVF). There is no consensus on the appropriate number of re-interventions after which an access should be abandoned and new access placed. We evaluated whether repeated endovascular interventions for failing/failed aAVF are worthwhile or futile. METHODS: A retrospective review was performed on aAVFs created between 2009-2014. Fistula function was evaluated until January 2017. Functional fistula patency (FFP) was defined as the total time of functional fistula use for hemodialysis, from time of cannulation to time of measurement or fistula abandonment, including all interventions performed to maintain/reestablish patency. Primary outcomes were FFP duration and number of post-dialysis interventions. RESULTS: The study included 163 patients. Mean age was 67 (SD = 15.03). The only variable statistically different between functional fistulas and abandoned fistulas was obesity (p = 0.03). At the end of the study period, 145 (89.0%) patients continued to have functional fistulas, and 73 (44.8%) patients died, but had functional fistulas at time of death. Median FFP for the functional group was 3.18 years (range 0.01-7.01 years) and median number of interventions was 1 (range 0-13). In 18 patients (11%), the fistula was abandoned, most commonly due to thrombosis (47.1%), followed by infection (23.5%). No fistula was abandoned because of an unacceptable rate of reintervention. Median FFP in the abandoned group was 0.91 years (range 0.03-5.30 years), and median number of interventions was 0 (range of 0-5). CONCLUSIONS: Through repeated interventions on aAVFs, none of the patients in our study exhausted all hemodialysis access options prior to transplantation, death or loss to follow-up. These results may indicate repeated and/or more frequent revisions do not negatively affect the FFP nor do they increase the overall risk for abandonment of aAVFs.

Training in vascular medicine for vascular surgeons--what is it and how will we accomplish it?

The goal of vascular surgery training program should be the training of a complete vascular surgeon proficient not only in the management of established peripheral vascular disease but also in the prevention of the atherosclerotic process through management of risk factors. In addition, vascular surgeons should develop expertise in the treatment of nonatherosclerotic arterial disease, nonoperative management of acute and chronic venous disease, lymphedema, and the treatment of various coagulation disorders. To accomplish these goals, we should establish a comprehensive, patient-centered vascular medicine curriculum and appropriate methods for its implementation.

Endovascular repair of traumatic thoracic aortic disruption.

In a patient with multiple trauma, blunt thoracic trauma with concomitant aortic disruption is often eminently lethal, ranking second to head injury as the most common cause of trauma-related deaths. Open surgical repair of the aortic lesion has morbidity and mortality rates that are among the highest in the field of cardiovascular surgery. Results with thoracic endovascular aortic repair for traumatic aortic disruption are promising. The facility requirements, technique, and early results of thoracic endovascular aortic repair for the treatment of this difficult aortic injury are presented.

Transforming growth factor-beta and wound healing.

Acute and chronic wounds are a source of significant morbidity for patients, and they demand a growing portion of health-care time and finances to be devoted to their care. Transforming growth factor-beta (TGF-beta) has surfaced from abundant research as a key signal in orchestrating wound repair. In beginning this review, we discuss the inflammatory, proliferative, and maturational phases of wound healing. We then focus on TGF-beta by first discussing the pathway from its production to the target cell where Smad proteins execute an intracellular signaling cascade. To review TGF-beta's role in wound healing, we discuss the actions of it individually on keratinocytes, fibroblasts, endothelial cells, and monocytes, which are the major cell types involved in wound repair. From illustrating these cellular actions of TGF-beta, we summarize its multipotent role in the process of wound repair. As a clinical correlation, we also review research dedicated to the involvement of TGF-beta in venous stasis ulcers.

Clinical and anatomic outcomes of endovenous radiofrequency ablation performed on symptomatic small-diameter great saphenous veins.

OBJECTIVE: The efficacy of radiofrequency ablation (RFA) for symptomatic varicose veins is well established. Alternatively, there is less consensus and little data on outcomes when treating great saphenous veins (GSV) of small diameter (≤5 mm). The purpose of this study is to assess clinical and anatomical outcomes of RFA on symptomatic patients with small GSV. METHODS: A retrospective analysis was performed on our symptomatic patients who received RFA of incompetent GSV without any concomitant adjunctive procedures between January 2008 and December 2011. Limbs with GSV thigh diameter ≤5 mm and >5 mm on duplex while standing were subject to review. Clinical success was defined as an improvement in Venous Clinical Severity Score (VCSS) at 3 months. Anatomic success was defined as absence of venous flow ≤3 cm distal to the saphenofemoral junction on duplex ultrasound examination. Changes in CEAP class were noted. RESULTS: In 307 patients, 55 limbs in 44 patients met inclusion criteria. Baseline median VCSS was 4 (interquartile range [IQR], 4, 5) for those patients with diameter ≤5 mm. Clinical success was seen in 83% of limbs at 3 months with a median VCSS change of -2 (IQR, -3, -1). None of the treated limbs had phlebectomy for symptomatic refluxing GSV varicosities prior to 3-month follow up. One phlebectomy was performed for cosmesis at 78 days postprocedure. Anatomic success was achieved in 96% of limbs at 3 months. Baseline median CEAP was 2 (IQR, 2, 2). The median CEAP change at 3 months was 0 (IQR, -1, 0). One patient experienced thrombus extension into the saphenofemoral junction at 4 days. CONCLUSIONS: In our experience, RFA of symptomatic small-diameter GSV provides comparable clinical and anatomic outcomes to that of current published data. Our findings suggest that these patients benefit clinically from RFA.