RESUMO
BACKGROUND: The competitive coronary flow is influenced by the severity of the stenosis and may affect graft patency. Transit time flow measurement (TTFM) enables intraoperative graft evaluation and cardiac magnetic resonance (MRI) allows for graft evaluation during follow-up. METHODS: Competitive flow and target vessel diameters were determined in 35 patients undergoing off-pump coronary bypass graft surgery (CABG) and correlated to TTFM. Cardiac function, ischemia, and graft flow were evaluated using cardiac MRI during the follow-up period to determine the impact of above-mentioned parameters on graft patency. RESULTS: Competitive flow led to reduced mean graft flow (MGF) and increased pulsatility index (PI) in arterial grafts. This effect to was not observed in veins. Smaller target coronary arteries (<1.5 mm) were associated with reduced MGF, more pronounced in veins, which presented increased PI and shortened diastolic flow fraction (DF). No death and no re-hospitalization for acute coronary syndrome occurred. Borderline values of TTFM (mean MGF 13±4 mL/min; PI 3.8±1) in left internal mammary artery (LIMA) were mainly observed due to increased native anterior descending artery (LAD) flow. These LAD's collateralized occluded right coronaries (RCA). The corresponding LIMA to LAD grafts showed a bypass flow increase at cardiac MRI follow-up. Two graft occlusions occurred: one in LIMA-to-LAD bypass with borderline TTFM, which did not collateralize the RCA and one in a vein graft with borderline TTFM bypassed on a narrow vascular target. CONCLUSIONS: Competitive flow has an impact on arteries contrary to veins. Veins are at risk for occlusion when grafted to smaller targets. Borderline LIMA flow should be considered as potentially dangerous, if satisfactory explanations are missing, e.g. in the absence of a large coronary target without flow competition.
Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea , Doença da Artéria Coronariana/cirurgia , Circulação Coronária , Estenose Coronária/cirurgia , Vasos Coronários/cirurgia , Imageamento por Ressonância Magnética , Imagem de Perfusão , Adulto , Idoso , Idoso de 80 Anos ou mais , Velocidade do Fluxo Sanguíneo , Angiografia Coronária , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
The presence of myocardial ischemia significantly affects prognosis of patients with coronary artery disease. The fractional flow reserve (FFR) allows interventional cardiologists to evaluate whether an equivocal coronary artery stenosis is associated or not with myocardial ischemia, and therefore deserve to be properly treated. The present article has the purpose to provide the readers with an overview about the role of FFR in the diagnosis and management of coronary artery disease, as well as the potential related controversies. The coronary physiology on the basis of this tool is also provided together with all the procedural aspects useful in the catheterization laboratory. In addition, the landmark trials on the basis of the FFR application in different clinical settings and coronary anatomies will be described, together with the main improvements aiming at favoring a more extensive use of this invasive tool.
Assuntos
Estenose Coronária/fisiopatologia , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Síndrome Coronariana Aguda/fisiopatologia , Angiografia Coronária , Estenose Coronária/diagnóstico , Oclusão de Enxerto Vascular/fisiopatologia , Homeostase/fisiologia , Humanos , Hiperemia/fisiopatologia , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/fisiopatologia , Valores de Referência , Vasodilatadores/farmacologiaRESUMO
This article described the current state of vascular access management for patients with end-stage renal disease in Singapore. Over the past 10 years, there has been a change in the demographics of end-stage renal disease patients. Aging population and the increase in prevalence of diabetes mellitus has led to the acceleration of chronic kidney disease and increase in incidence and prevalence of end-stage renal disease. Vascular access care has, therefore, been more complicated, with the physical, psychological, and social challenges that occur with increased frequency in elderly patients and patients with multiple co-morbidities. Arteriovenous fistula and arteriovenous graft are created by vascular surgeons, while maintenance of patency of vascular access through endovascular intervention has been a shared responsibility between surgeons, interventional radiologists, and interventional nephrologists. Pre-emptive access creation among end-stage renal disease patients has been low, with up to 80% of new end-stage renal disease patients being commenced on hemodialysis via a dialysis catheter. Access creation is exclusively performed by a dedicated vascular surgeon with arteriovenous fistula success rate up to 78%. The primary and cumulative patency rates of arteriovenous fistula and arteriovenous graft were consistent with the results from many international centers. Vascular access surveillance is not universally practiced in all dialysis centers due to its controversies, in addition to the cost and the limited availability of equipment for surveillance. Timely permanent access placement, with reduced dependence on dialysis catheters, and improved vascular access surveillance are the main areas for potential intervention to improve vascular access management.
Assuntos
Derivação Arteriovenosa Cirúrgica/tendências , Falência Renal Crônica/terapia , Padrões de Prática Médica/tendências , Diálise Renal/tendências , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/economia , Oclusão de Enxerto Vascular/epidemiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Custos de Cuidados de Saúde/tendências , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/economia , Falência Renal Crônica/epidemiologia , Nefrologistas/tendências , Padrões de Prática Médica/economia , Prevalência , Radiologistas/tendências , Diálise Renal/efeitos adversos , Diálise Renal/economia , Fatores de Risco , Singapura/epidemiologia , Cirurgiões/tendências , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: We prospectively analyzed the effect of preexisting structural changes of the radial artery (RA) wall by histological examination on the wrist radiocephalic fistula (RCF) outcomes. METHODS: During RCF creation, one segment of the RA wall was collected and its histomorphometric analysis was performed. The RCF function was evaluated by measuring blood flow rate. RESULTS: At the end of follow-up, 75.7% of the thirty-seven patients enrolled were performing hemodialysis by using their successful RCF and 24.3% of them showed early RCF failure. Compared to patients with a healthy RA, the RCF of those with medial RA microcalcification reached up a lower flow and a shorter primary patency (P=0.005 and P=0.040, respectively). The RA microcalcification was predictive of the RCF function (coefficient -614.9, 95% CI: -994.7 to -235.1, P=0.003). Compared to patients with successful RCF, those with failed RCF had a greater frequency of weak RCF thrill after releasing the clamps (P=0.045). Dependence on hemodialysis during RCF placement was predictive of its early failure (OR: 23.2, 95% CI: 1.76 to 306.9, P=0.017). Both having at least one cardiovascular comorbidity (HR 4.30, 95% CI: 1.29 to 14.39, P=0.018) and a thicker media layer of the RA (HR 1.60, 95% CI: 1.87 to 2.15, P=0.002) were predictive of primary RCF patency. CONCLUSIONS: The function and survival of the successful RCF were related to preoperative RA abnormalities such as microcalcification and media layer thickness. Both dependence on hemodialysis during RCF placement and an attenuated RCF thrill were associated with early RCF failure.
Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Oclusão de Enxerto Vascular/etiologia , Esclerose Calcificante da Média de Monckeberg/complicações , Artéria Radial/patologia , Extremidade Superior/irrigação sanguínea , Grau de Desobstrução Vascular , Idoso , Idoso de 80 Anos ou mais , Feminino , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Esclerose Calcificante da Média de Monckeberg/fisiopatologia , Análise Multivariada , Estudos Prospectivos , Artéria Radial/cirurgia , Radiografia , Análise de Regressão , Diálise Renal , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , UltrassonografiaRESUMO
At the second Dialysis Access Symposium held in Nagoya, Japan, a proposal was made to investigate the differences in vascular access methods used in different countries. In this article, we describe the management of vascular access in Japan. The Japanese population is rapidly aging, and the proportion of elderly patients on dialysis is also increasing. There were 325,000 dialysis patients in Japan at the end of 2015, of whom 65.1% were aged 65 years or above. The number of patients with diabetic nephropathy or nephrosclerosis as the underlying condition is also increasing, whereas the number with chronic glomerulonephritis is steadily decreasing. The Japanese health insurance system enables patients to undergo medical treatment at almost no out-of-pocket cost. Percutaneous transluminal angioplasty suffers from a severe device lag compared with other countries, but although there are limitations on permitted devices, the use of those that have been authorized is covered by medical insurance. One important point that is unique to Japan is that vascular access is performed and managed by doctors involved in dialysis across a wide range of disciplines, including nephrologists, surgeons, and urologists. This may be one factor contributing to the good survival prognosis of Japanese dialysis patients.
Assuntos
Derivação Arteriovenosa Cirúrgica , Implante de Prótese Vascular , Nefropatias/terapia , Diálise Renal , Idoso , Angioplastia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/economia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/cirurgia , Custos de Cuidados de Saúde , Humanos , Japão/epidemiologia , Nefropatias/diagnóstico , Nefropatias/economia , Nefropatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Diálise Renal/efeitos adversos , Diálise Renal/economia , Fatores de Risco , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
PURPOSE: To compare reinterventions and associated costs to maintain arteriovenous graft hemodialysis access circuits after rescue with percutaneous transluminal angioplasty (PTA), with or without concurrent Viabahn stent grafts, over 24 months. MATERIALS AND METHODS: This multicenter (n = 30 sites) study evaluated reintervention number, type, and cost in 269 patients randomized to undergo placement of stent grafts or PTA alone. Outcomes were 24-month average cumulative number of reinterventions, associated costs, and total costs for all patients and in 4 groups based on index treatment and clinical presentation (thrombosed or dysfunctional). RESULTS: Over 24 months, the patients in the stent graft arm had a 27% significant reduction in the average number of reinterventions within the circuit compared to the PTA arm (3.7 stent graft vs 5.1 PTA; P = .005) and similar total costs ($27,483 vs $28,664; P = .49). In thrombosed grafts, stent grafts significantly reduced the number of reinterventions (3.7 stent graft vs 6.2 PTA; P = .022) and had significantly lower total costs compared to the PTA arm ($30,329 vs $37,206; P = .027). In dysfunctional grafts, no statistical difference was observed in the number of reinterventions or total costs (3.7 stent graft vs 4.4 PTA; P = .12, and $25,421 stent graft and $22,610 PTA; P = .14). CONCLUSIONS: Over 24 months, the use of stent grafts significantly reduced the number of reinterventions for all patients, driven by patients presenting with thrombosed grafts. Compared to PTA, stent grafts reduced overall treatment costs for patients presenting with thrombosed grafts and had similar costs for stenotic grafts.
Assuntos
Angioplastia com Balão , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Oclusão de Enxerto Vascular/cirurgia , Diálise Renal , Stents , Trombose/cirurgia , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/economia , Derivação Arteriovenosa Cirúrgica/economia , Prótese Vascular/economia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Redução de Custos , Análise Custo-Benefício , Oclusão de Enxerto Vascular/economia , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Custos de Cuidados de Saúde , Humanos , Estudos Prospectivos , Diálise Renal/economia , Reoperação , Fatores de Risco , Stents/economia , Trombose/economia , Trombose/etiologia , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
Due to the implementation of the National Health Insurance system in 1995, the number of patients receiving maintenance dialysis has increased rapidly. This contributed to Taiwan to be in an unfortunate position of possessing the highest prevalence of end-stage renal disease globally. Although the age-standardized incidence of end-stage renal disease gradually decreased to -1.1% in 2014, the huge economic burden that comes with dialysis is detrimental to the quality of dialysis treatment. To achieve a balance between economy and quality of care requires multidisciplinary cooperation. Through a variety of chronic kidney disease-related care projects, we have gradually reversed this situation and achieved good results. Further promotion of kidney transplantation and hospice care for terminal patients will improve the situation. With respect to vascular access, the "fistula first" policy is carried out and percutaneous transluminal angioplasty is the mainstay of treatment to resolve vascular access dysfunction. The medical expenses for dialysis and vascular access management are both fully paid for by the National Health Insurance, and patients do not have to worry about the medical expenses. However, the statistics and vascular access monitoring are relatively insufficient in the past. The comprehensive integration of vascular access management into public policy related to kidney disease will complete the missing piece of the puzzle of overall care.
Assuntos
Derivação Arteriovenosa Cirúrgica/tendências , Implante de Prótese Vascular/tendências , Cateterismo Venoso Central/tendências , Falência Renal Crônica/terapia , Diálise Renal/tendências , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/economia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/economia , Bases de Dados Factuais , Procedimentos Endovasculares/tendências , Oclusão de Enxerto Vascular/economia , Oclusão de Enxerto Vascular/epidemiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/cirurgia , Custos de Cuidados de Saúde/tendências , Gastos em Saúde/tendências , Humanos , Incidência , Reembolso de Seguro de Saúde/tendências , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/economia , Falência Renal Crônica/epidemiologia , Transplante de Rim/tendências , Prevalência , Diálise Renal/efeitos adversos , Diálise Renal/economia , Fatores de Risco , Taiwan/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
INTRODUCTION:: Malnutrition is a well-recognized risk factor for all-cause mortality in hemodialysis patients. However, its role for arteriovenous fistulas outcome has not been exhaustively investigated. Our aim was to point out the impact of Subjective Global Assessment-Dialysis Malnutrition Score as independent predictor of arteriovenous fistulas thrombosis (vascular access thrombosis) and/or significant stenosis (vascular access stenosis). In addition, we compared it with the widespread Charlson Comorbidity Index. METHODS:: We assessed 57 hemodialysis patients for a 2-year interval and evaluated the incidence of vascular access thrombosis and/or stenosis. Linear regression analysis was used to test the relation of variables with Subjective Global Assessment-Dialysis Malnutrition Score at baseline. Logistic and Cox regression analysis evaluated markers as predictors of both vascular access thrombosis and stenosis. Receiver operating characteristic curve analysis was used to compare area under the curve values of Subjective Global Assessment-Dialysis Malnutrition Score, Charlson Comorbidity Index, and modified Charlson Comorbidity Index. RESULTS:: Age and Charlson Comorbidity Index were positively related to Subjective Global Assessment-Dialysis Malnutrition Score: B = 0.06 (95% CI = 0.01; 0.11) and B = 0.31 (95% CI = 0.01; 0.63). Higher albumin and normalized protein catabolic rate levels had a protective role against vascular access failure: OR = 0.67 (95% CI = 0.56; 0.81) and OR = 0.46 (95% CI = 0.32; 0.67), respectively. Higher Subjective Global Assessment-Dialysis Malnutrition Score and Charlson Comorbidity Index values were significant risk factors: HR = 1.42 (95% CI = 1.04; 1.92) and HR = 1.48 (95% CI = 1.01; 2.17), respectively. Area under the curve of Subjective Global Assessment-Dialysis Malnutrition Score was significantly higher than those of both Charlson Comorbidity Index and modified Charlson Comorbidity Index: 0.70 (95% CI = 0.50; 0.88) versus 0.61 (95% CI = 0.41; 0.80) and 0.55 (95CI% = 0.41; 0.70). CONCLUSION:: Subjective Global Assessment-Dialysis Malnutrition Score, as well as Charlson Comorbidity Index, are useful tools to predict vascular access failure and should be carefully and periodically evaluated in order to check significant variations that may compromise vascular access survival.
Assuntos
Derivação Arteriovenosa Cirúrgica , Indicadores Básicos de Saúde , Nefropatias/terapia , Desnutrição/diagnóstico , Avaliação Nutricional , Estado Nutricional , Diálise Renal , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Comorbidade , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Nefropatias/complicações , Nefropatias/diagnóstico , Nefropatias/fisiopatologia , Masculino , Desnutrição/complicações , Desnutrição/fisiopatologia , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Trombose/etiologia , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: This study examines the utilization and outcomes of vascular access for long-term hemodialysis in the United States and describes the impact of temporizing catheter use on outcomes. We aimed to evaluate the prevalence, patency, and associated patient survival for pre-emptively placed autogenous fistulas and prosthetic grafts; for autogenous fistulas and prosthetic grafts placed after a temporizing catheter; and for hemodialysis catheters that remained in use. METHODS: We performed a retrospective study of all patients who initiated hemodialysis in the United States during a 5-year period (2007-2011). The United States Renal Data System-Medicare matched national database was used to compare outcomes after pre-emptive autogenous fistulas, preemptive prosthetic grafts, autogenous fistula after temporizing catheter, prosthetic graft after temporizing catheter, and persistent catheter use. Outcomes were primary patency, primary assisted patency, secondary patency, maturation, catheter-free dialysis, severe access infection, and mortality. RESULTS: There were 73,884 (16%) patients who initiated hemodialysis with autogenous fistula, 16,533 (3%) who initiated hemodialysis with prosthetic grafts, 106,797 (22%) who temporized with hemodialysis catheter prior to autogenous fistula use, 32,890 (7%) who temporized with catheter prior to prosthetic graft use, and 246,822 (52%) patients who remained on the catheter. Maturation rate and median time to maturation were 79% vs 84% and 47 days vs 29 days for pre-emptively placed autogenous fistulas vs prosthetic grafts. Primary patency (adjusted hazard ratio [aHR], 1.26; 95% confidence interval [CI], 1.25-1.28; P < .001) and primary assisted patency (aHR, 1.36; 95% CI, 1.35-1.38; P < .001) were significantly higher for autogenous fistula compared with prosthetic grafts. Secondary patency was higher for autogenous fistulas beyond 2 months (aHR, 1.36; 95% CI, 1.32-1.40; P < .001). Severe infection (aHR, 9.6; 95% CI, 8.86-10.36; P < .001) and mortality (aHR, 1.29; 95% CI, 1.27-1.31; P < .001) were higher for prosthetic grafts compared with autogenous fistulas. Temporizing with a catheter was associated with a 51% increase in mortality (aHR, 1.51; 95% CI, 1.48-1.53; P < .001), 69% decrease in primary patency (aHR, 0.31; 95% CI, 0.31-0.32; P < .001), and 130% increase in severe infection (aHR, 2.3; 95% CI, 2.2-2.5; P < .001) compared to initiation with autogenous fistulas or prosthetic grafts. Mortality was 2.2 times higher for patients who remained on catheters compared to those who initiated hemodialysis with autogenous fistulas (aHR, 2.25; 95% CI, 2.21-2.28; P < .001). CONCLUSIONS: Temporizing catheter use was associated with higher mortality, higher infection, and lower patency, thus undermining the highly prevalent approach of electively using catheters as a bridge to permanent access. Autogenous fistulas are associated with longer time to catheter-free dialysis but better patency, lower infection risk, and lower mortality compared with prosthetic grafts in the general population.
Assuntos
Derivação Arteriovenosa Cirúrgica/tendências , Implante de Prótese Vascular/tendências , Cateterismo Venoso Central/tendências , Padrões de Prática Médica/tendências , Diálise Renal/tendências , Grau de Desobstrução Vascular , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/mortalidade , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Prótese Vascular/efeitos adversos , Prótese Vascular/estatística & dados numéricos , Prótese Vascular/tendências , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Implante de Prótese Vascular/estatística & dados numéricos , Infecções Relacionadas a Cateter/etiologia , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/mortalidade , Cateterismo Venoso Central/estatística & dados numéricos , Cateteres Venosos Centrais/efeitos adversos , Cateteres Venosos Centrais/estatística & dados numéricos , Cateteres Venosos Centrais/tendências , Bases de Dados Factuais , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Auditoria Médica , Medicare , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/etiologia , Diálise Renal/efeitos adversos , Diálise Renal/mortalidade , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
INTRODUCTION: Arteriovenous fistulae remain the gold standard of vascular access in haemodialysis. There is currently no consensus on standardised methods of monitoring arteriovenous fistulae. Assessment techniques and practice remain widely variable. The purpose of this study is to determine whether existing evidence supports physical assessment as an effective tool and a good predictor of arteriovenous fistulae dysfunction to allow for timely intervention and improve outcomes. METHODS: A literature search was performed using CINAHL, PubMed, Medline and BNI databases and relevant search terms. Studies included were peer-reviewed, published after 2008, in English and related to arteriovenous fistulae only. Six key papers were identified and critically analysed for validity and relevance, in relation to outcomes, assessor experience, training duration and nurses' ability to perform physical assessment. RESULTS: Physical assessment has been shown to be effective in detecting arteriovenous fistulae dysfunction and comparable to technology-based surveillance. Physical assessment techniques generally adopt a 'look, listen and feel' approach to identify arteriovenous fistulae dysfunction that includes stenosis, thrombosis, ischaemia and infections. Physical assessment is a skill that can be taught with studies showing that skill-specific training is more effective than experience alone. Cost-effectiveness analysis is lacking. CONCLUSION: The analysis of evidence demonstrates that physical assessment of arteriovenous fistulae is an effective method of detecting arteriovenous fistulae dysfunction and is a skill that can be taught. A structured physical assessment and its implementation may be significant in routine care, but research into the most effective physical assessment techniques and its impact on clinical practice in haemodialysis is required.
Assuntos
Derivação Arteriovenosa Cirúrgica , Exame Físico , Diálise Renal , Grau de Desobstrução Vascular , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Competência Clínica , Oclusão de Enxerto Vascular/diagnóstico , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Curva de Aprendizado , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Intraoperative graft assessment in coronary artery bypass (CAB) grafting is important to avoid early graft failure. This study aimed to evaluate the accuracy of fluorescent cardiac imaging (FCI) for intraoperative qualitative angiographic and quantitative myocardial perfusion assessment during graded CAB stenosis compared to coronary angiography (CA). After CAB grafting to the left anterior descending coronary artery, graded distal bypass stenoses were created in ten pigs by 25, 50, 75, and 100% flow reduction assessed by transit-time flow measurement (TTFM). Visual angiographic assessment was performed by FCI and CA during baseline and graded bypass stenoses. Altered myocardial perfusion was assessed by quantitative intraoperative fluorescence intensity (QIFI) derived from FCI and correlated to TTFM. Patent bypass grafts and graft occlusion were visualized successfully by FCI and CA, while discrimination between various graded bypass stenosis was possible in 73.3%. The degree of CAB stenosis was overestimated in 16.7% and underestimated in 10.0% by FCI compared to CA. Graded CAB stenosis reduced regional myocardial perfusion quantified by decreased QIFI value (p < 0.001). Mean QIFI value was 76.8 (95% CI 67.2-86.3) during baseline, 55.6 (95% CI 45.3-65.9) during 25% flow-reduction, 30.6 (95% CI 22.3-39.0) during 50% flow-reduction, 20.3 (95% CI 15.4-25.3) during 75% flow-reduction, and 0 during CAB occlusion (p < 0.001) with a significant correlation to TTFM (r = 0.955; p < 0.0001). Solely visual assessment of CAB quality using FCI is limited as compared to CA. Additional QIFI assessment identified graded CAB stenosis and occlusion with a significant correlation to TTFM.
Assuntos
Angiografia Coronária/métodos , Ponte de Artéria Coronária/efeitos adversos , Circulação Coronária , Oclusão de Enxerto Vascular/diagnóstico por imagem , Imagem de Perfusão do Miocárdio/métodos , Imagem Óptica , Animais , Velocidade do Fluxo Sanguíneo , Constrição Patológica , Modelos Animais de Doenças , Feminino , Corantes Fluorescentes/administração & dosagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Verde de Indocianina/administração & dosagem , Medições Luminescentes , Masculino , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Sus scrofa , Grau de Desobstrução VascularRESUMO
OBJECTIVE: Basilic vein transposition (BVT) fistulas may be performed as either a one-stage or two-stage operation, although there is debate as to which technique is superior. This study was designed to evaluate the comparative clinical efficacy and cost-effectiveness of one-stage vs two-stage BVT. METHODS: We identified all patients at a single large academic hospital who had undergone creation of either a one-stage or two-stage BVT between January 2007 and January 2015. Data evaluated included patient demographics, comorbidities, medication use, reasons for abandonment, and interventions performed to maintain patency. Costs were derived from the literature, and effectiveness was expressed in quality-adjusted life-years (QALYs). We analyzed primary and secondary functional patency outcomes as well as survival during follow-up between one-stage and two-stage BVT procedures using multivariate Cox proportional hazards models and Kaplan-Meier analysis with log-rank tests. The incremental cost-effectiveness ratio was used to determine cost savings. RESULTS: We identified 131 patients in whom 57 (44%) one-stage BVT and 74 (56%) two-stage BVT fistulas were created among 8 different vascular surgeons during the study period that each performed both procedures. There was no significant difference in the mean age, male gender, white race, diabetes, coronary disease, or medication profile among patients undergoing one- vs two-stage BVT. After fistula transposition, the median follow-up time was 8.3 months (interquartile range, 3-21 months). Primary patency rates of one-stage BVT were 56% at 12-month follow-up, whereas primary patency rates of two-stage BVT were 72% at 12-month follow-up. Patients undergoing two-stage BVT also had significantly higher rates of secondary functional patency at 12 months (57% for one-stage BVT vs 80% for two-stage BVT) and 24 months (44% for one-stage BVT vs 73% for two-stage BVT) of follow-up (P < .001 using log-rank test). However, there was no significant difference between groups in use of interventions (58% for one-stage BVT vs 51% for two-stage BVT; P = .5) to maintain patency. These findings were confirmed in multivariate analysis, in which two-stage BVTs were associated with a significantly lower rate of failure (hazard ratio, 0.39; 95% confidence interval, 0.2-0.8; P < .05) than one-stage BVTs after controlling for confounding variables. Finally, the two-stage BVT was more cost-effective (3.74 QALYs for two-stage BVT vs 3.32 QALYs for one-stage BVT) during 5 years, with an incremental cost-effectiveness ratio of $4681 per QALY. CONCLUSIONS: Our data show that two-stage BVTs are more durable and cost-effective than one-stage procedures, with significantly higher patency and lower rates of failure among comparable risk-stratified patients. These findings suggest that additional upfront costs and resources associated with creating two-stage BVTs are justified by their long-term outcomes.
Assuntos
Derivação Arteriovenosa Cirúrgica/métodos , Diálise Renal , Extremidade Superior/irrigação sanguínea , Veias/cirurgia , Centros Médicos Acadêmicos , Adulto , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/economia , Distribuição de Qui-Quadrado , Pesquisa Comparativa da Efetividade , Análise Custo-Benefício , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Custos de Cuidados de Saúde , Humanos , Estimativa de Kaplan-Meier , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Modelos Econômicos , Análise Multivariada , Modelos de Riscos Proporcionais , Anos de Vida Ajustados por Qualidade de Vida , Diálise Renal/economia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Utah , Grau de Desobstrução Vascular , Veias/diagnóstico por imagem , Veias/fisiopatologiaRESUMO
OBJECTIVE: The durability of cryopreserved allograft has been previously demonstrated in the setting of infection. The objective of this study was to examine the safety, efficacy, patency, and cost per day of graft patency associated with using cryopreserved allograft (vein and artery) for hemodialysis access in patients with no autogenous tissue for native fistula creation and with arteriovenous graft infection or in patients at high risk for infection. METHODS: Patients implanted with cryopreserved allograft for hemodialysis access between January 2004 and January 2014 were reviewed using a standardized, multi-institutional database that evaluated demographic, comorbidity, procedural, and outcomes data. RESULTS: There were 457 patients who underwent placement of cryopreserved vein (femoral: n = 337, saphenous: n = 11) or artery (femoral: n = 109) for hemodialysis access at 20 hospitals. Primary indications for allograft use included high risk of infection in 191 patients (42%), history of infected prosthetic graft in 169 (37%), and current infection in 97 (21%). Grafts were placed more frequently in the arm (78%) than in the groin, with no difference in allograft conduit used. Mean time from placement to first hemodialysis use was 46 days (median, 34 days). Duration of functional graft use was 40 ± 7 months for cryopreserved vein and 21 ± 8 months for cryopreserved artery (P < .05), and mean number of procedures required to maintain patency at follow-up of 58 ± 21 months was 1.6 for artery and 0.9 for vein (P < .05). Local access complications occurred in 32% of patients and included late thrombosis (14%), graft stenosis (9%), late infection (9%), arteriovenous access malfunction (7%), early thrombosis (3%), and early infection (3%). Early and late infections both occurred more frequently in the groin (P = .030, P = .017, respectively), and late thrombosis occurred more frequently with cryopreserved artery (P < .001). Of the 82 patients (18%) in whom the cryopreserved allograft was placed in the same location as the excised infected prosthetic graft, 13 had infection of the allograft during the study period (early: n = 4; late: n = 9), with no significant difference in infection rate (P = .312) compared with the remainder of the study population. The 1-, 3-, and 5-year primary patency was 58%, 35%, and 17% for cryopreserved femoral vein and 49%, 17%, and 8% for artery, respectively (P < .001). Secondary patency at 1, 3, and 5 years was 90%, 78%, and 58% for cryopreserved femoral vein and 75%, 53%, and 42% for artery, respectively (P < .001). Mean allograft fee per day of graft patency was $4.78 for cryopreserved vein and $6.97 for artery (P < .05), excluding interventional costs to maintain patency. CONCLUSIONS: Cryopreserved allograft provides an excellent conduit for angioaccess when autogenous tissue is not available in patients with current or past conduit infection. Cryopreserved vein was associated with higher patency and a lower cost per day of graft patency. Cryopreserved allograft allows for immediate reconstruction through areas of infection, reduces the need for staged procedures, and allows early use for dialysis.
Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/instrumentação , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular/efeitos adversos , Criopreservação , Veia Femoral/transplante , Infecções Relacionadas à Prótese/cirurgia , Diálise Renal , Veia Safena/transplante , Idoso , Aloenxertos , Derivação Arteriovenosa Cirúrgica/economia , Prótese Vascular/economia , Implante de Prótese Vascular/economia , Criopreservação/economia , Bases de Dados Factuais , Feminino , Artéria Femoral/transplante , Veia Femoral/fisiopatologia , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/economia , Infecções Relacionadas à Prótese/microbiologia , Diálise Renal/economia , Estudos Retrospectivos , Fatores de Risco , Veia Safena/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Grau de Desobstrução VascularRESUMO
PURPOSE: Stenosis is the main cause of arteriovenous fistula (AVF) failure. It is still unclear whether surveillance based on vascular access blood flow (QA) enhances AVF function and longevity. METHODS: We conducted a three-year follow-up randomized, controlled, multicenter, open-label trial to compare QA-based surveillance and pre-emptive repair of subclinical stenosis with standard monitoring/surveillance techniques in prevalent mature AVFs. AVFs were randomized to either the control group (surveillance based on classic alarm criteria; n = 104) or to the QA group (QA measured quarterly using Doppler ultrasound [M-Turbo®] and ultrasound dilution [Transonic®] added to classic surveillance; n = 103).The criteria for intervention in the QA group were: 25% reduction in QA, QA<500 mL/min or significant stenosis with hemodynamic repercussion (peak systolic velocity [PSV] more than 400 cm/sc or PSV pre-stenosis/stenosis higher than 3). RESULTS: At the end of follow-up we observed a significant reduction in the thrombosis rate in the QA group (0.025 thrombosis/patient/year in the QA group vs. 0.086 thrombosis/patient/year in the control group [p = 0.007]). There was a significant improvement in the thrombosis-free patency rate (HR, 0.30; 95% CI, 0.11-0.82; p = 0.011) and in the secondary patency rate in the QA group (HR, 0.49; 95% CI, 0.26-0.93; p = 0.030), with no differences in the primary patency rate between the groups (HR, 0.98; 95% CI, 0.57-1.61; p = 0.935).There was greater need for a central venous catheter and more hospitalizations associated with vascular access in the control group (p = 0.034/p = 0.029).Total vascular access-related costs were higher in the control group (227.194 vs. 133.807; p = 0.029). CONCLUSIONS: QA-based surveillance combining Doppler ultrasound and ultrasound dilution reduces the frequency of thrombosis, is cost effective, and improves thrombosis free and secondary patency in autologous AVF.
Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Oclusão de Enxerto Vascular/prevenção & controle , Diálise Renal , Trombose/prevenção & controle , Ultrassonografia Doppler , Grau de Desobstrução Vascular , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/economia , Velocidade do Fluxo Sanguíneo , Redução de Custos , Análise Custo-Benefício , Feminino , Oclusão de Enxerto Vascular/diagnóstico , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Fluxo Sanguíneo Regional , Diálise Renal/economia , Fatores de Risco , Espanha , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler/economiaRESUMO
BACKGROUND: Percutaneous transluminal angioplasty (PTA) and fistula reconstruction surgery are therapeutic options for vascular access occlusion in hemodialysis patients. However, owing to its convenience, PTA has gradually become the preferred therapeutic option for fistula stenosis or occlusion. This study investigated the effects of the two therapeutic methods on the vascular access maintenance duration (number of days) and maintenance costs of fistula in dialysis patients from different dialysis units. METHODOLOGY: In this study, 544 hemodialysis patients from 2 dialysis units in a teaching hospital in the southern area of Taiwan were included in the analysis of the frequency of PTA or revascularization surgery and the use of related medical resources by conducting a retrospective chart review. RESULTS: The frequency of PTA in the patients undergoing long-term hemodialysis was not significantly associated with their demographic characteristics. The efficacy of PTA has declined with shorter maintenance duration with increasing PTA frequency. The cost profile of PTA was more expensive than that of fistula revascularization surgery. CONCLUSIONS: In this study, PTA was found to be just a temporary solution for fistula thrombosis, whereas fistula reconstruction surgery is inexpensive and improves survival time. Therefore, dialysis units should establish an appropriate standard of care to avoid over-reliance on PTA in order to reduce the fistula failure rate, improve the dialysis efficacy, and reduce the psychological stress in patients, as well as to reduce the maintenance costs and rationalize the medical expenses.
Assuntos
Angioplastia com Balão , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular , Oclusão de Enxerto Vascular/terapia , Diálise Renal , Trombose/terapia , Idoso , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/economia , Derivação Arteriovenosa Cirúrgica/economia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Implante de Prótese Vascular/instrumentação , Análise Custo-Benefício , Feminino , Oclusão de Enxerto Vascular/economia , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Custos Hospitalares , Hospitais de Ensino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taiwan , Trombose/economia , Trombose/etiologia , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
PURPOSE: The HyperEye Medical System (HEMS) uses indocyanine green (ICG) to visualize blood vessels in coronary artery bypass grafting (CABG). We performed quantitative HEMS assessment to detect grafts at risk of occlusion. METHODS: We assessed the HEMS angiograms of 177 grafts from 69 patients who underwent CABG and compared the results with those of fluoroscopic coronary angiography, by measuring the increasing rate of ICG intensity, average acceleration value, and time to peak luminance intensity. RESULTS: Grafts in the patent and failed groups showed significant differences in their increasing rate of intensity and average acceleration value. The average accelerations value of ICG intensity of internal thoracic artery (ITA) and saphenous vein (SV) grafts were 112.3 and 144.9 intensity/s2 in the patent group, and 71.0 and 91.8 intensity/s2 in the failed group. The time to peak luminance intensity was 1.7 and 1.4 s in the patent group and 2.3 and 1.9 s in the failed group; these values were not significantly different. CONCLUSION: Significant reductions in the ICG intensity rate and average acceleration value can occur in failed grafts. Therefore, quantifiable changes in ICG intensity may help detect minute changes in blood flow.
Assuntos
Angiografia/métodos , Ponte de Artéria Coronária , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/prevenção & controle , Artéria Torácica Interna/diagnóstico por imagem , Monitorização Intraoperatória/métodos , Veia Safena/diagnóstico por imagem , Idoso , Velocidade do Fluxo Sanguíneo , Feminino , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Verde de Indocianina , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Risco , Grau de Desobstrução VascularRESUMO
BACKGROUND: Duplex ultrasound (DU)-based graft surveillance remains controversial. The aim of this study was to assess the ability of a recently proposed decision tree in identifying high-risk grafts which would benefit from DU-based surveillance. MATERIALS AND METHODS: Consecutive patients undergoing infrainguinal vein graft bypass from January 2008 to December 2015 were identified from the National Vascular registry and enrolled in a duplex surveillance program. An early postoperative DU was performed at a median of 6 weeks (range: 4-9 weeks). Grafts were classified into high risk or low risk based on the findings of the earliest postoperative scan and 4 established risk factors for graft failure (diabetes, smoking, infragenicular distal anastomosis, and revision bypass surgery) using a classification and regression tree (CRT). The accuracy of the CRT model was evaluated using area under receiver operator characteristic (AROC) curve. RESULTS: About 278 vein graft bypasses were performed; 29 grafts had occluded by the first surveillance visit; 249 vein grafts were entered into surveillance. Sixty-four (23%) developed critical stenosis. Overall 30-month primary patency, primary-assisted patency, and secondary patency rates were 71.2%, 77.2%, and 80.1%, respectively. AROC for prediction of graft stenosis or occlusion was 83% (95% confidence interval [CI]: 78-87%). The sensitivity and specificity of the CRT model for prediction of graft stenosis or occlusion were 95% (95% CI: 88-98%) and 52.2% (95% CI: 45-60%). CONCLUSIONS: A prediction model based on commonly recorded clinical variables and early postoperative DU scan is accurate at identifying grafts which are at high risk of failure. These high-risk grafts may benefit from DU-based surveillance.
Assuntos
Técnicas de Apoio para a Decisão , Árvores de Decisões , Oclusão de Enxerto Vascular/diagnóstico por imagem , Doença Arterial Periférica/cirurgia , Veia Safena/diagnóstico por imagem , Veia Safena/transplante , Ultrassonografia Doppler Dupla , Enxerto Vascular/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia , Angioplastia com Balão/instrumentação , Área Sob a Curva , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Valor Preditivo dos Testes , Curva ROC , Sistema de Registros , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Veia Safena/fisiopatologia , Stents , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento , Reino Unido , Grau de Desobstrução VascularRESUMO
A functioning vascular access is a critical requirement to improve the quality of life in hemodialysis patients, so monitoring and surveillance of vascular access play key roles in identifying all dysfunctions and reducing the huge economic cost as well as adequacy of dialysis.In our five-year experience, a study protocol has been used and improved with the help of ultrasonography.Doppler ultrasound is an excellent and sensitive modality for hemodialysis access evaluation, one of techniques employed for arteriovenous fistulae (AVF) study, not only as a preoperative tool, but also in post-operative monitoring of AVF maturation. In addition, the current guidelines recommend AVF surveillance by access blood flow measurement and the correction of hemodynamic stenosis in order to prolong access survival. Doppler ultrasound is readily available, directly used by nephrologists, non-invasive, safe, inexpensive, reproducible, although it requires more clinical skill and time to perform and proper equipment. Ultrasonography imaging can substantially reduce the number of subsequent invasive angiographic procedures. In our opinion, Doppler ultrasound should have a crucial place in the interdisciplinary cooperation in AVF monitoring and it should be included as part of an integrated vascular access management program.
Assuntos
Derivação Arteriovenosa Cirúrgica , Diálise Renal , Ultrassonografia Doppler em Cores , Grau de Desobstrução Vascular , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Velocidade do Fluxo Sanguíneo , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Valor Preditivo dos Testes , Fluxo Sanguíneo Regional , Reprodutibilidade dos Testes , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Duplex ultrasound (DU) remains the gold standard for identification and grading of infrainguinal vein graft stenosis. However, DU-based graft surveillance remains controversial. The aim of this study was to develop a decision tree to identify high-risk grafts which would benefit from DU-based surveillance. METHODS: Consecutive patients undergoing infrainguinal vein graft bypass were enrolled in a DU surveillance program. An early postoperative DU was performed at a median of 6 weeks (range 4-9). Based on the findings of this scan and 4 established risk factors for graft failure (diabetes, smoking, infragenicular distal anastomosis, revision bypass surgery), a classification and regression tree (CART) was created to stratify grafts into grafts which are at high and low risk of developing severe stenosis or occlusion. The accuracy of the CART model was evaluated using area under receiver operator characteristic curve (ROC). RESULTS: Of 796 vein graft bypasses performed (760 patients), 64 grafts were occluded by the first surveillance visit and 732 vein grafts were entered into surveillance program. The CART model stratified 299 grafts (40.8%) as low-risk and 433 (59.2%) as high-risk grafts. One hundred twenty-six (17.2%) developed critical vein graft stenosis. Overall, 30-month primary patency, primary-assisted and secondary patency rates were 76.2%, 83.6%, and 85.3%, respectively. The area under ROC curve for the CART model was 0.88 (95% confidence interval 0.81-0.94). Primary graft patency rates were higher in low-risk versus high-risk grafts (log rank 186, P < 0.0001). Amputation rates were significantly higher in the high-risk grafts compared with low-risk ones (log rank 118, P < 0.0001). CONCLUSION: A clinical decision rule based on readily available clinical data and the findings of significant flow abnormalities on an early postoperative DU scan successfully identifies grafts at high risk of failure and will contribute to safely improving the efficacy of infrainguinal vein graft surveillance services.
Assuntos
Técnicas de Apoio para a Decisão , Árvores de Decisões , Oclusão de Enxerto Vascular/diagnóstico por imagem , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Ultrassonografia Doppler Dupla , Veias/diagnóstico por imagem , Veias/transplante , Adulto , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Bases de Dados Factuais , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Isquemia/diagnóstico por imagem , Isquemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Valor Preditivo dos Testes , Curva ROC , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Escócia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Veias/fisiopatologiaRESUMO
Advantages and shortcomings of aortocoronary bypass grafting on the beating heart and in the conditions of artificial circulation (AC) have long been discussed. The data on patency of bypass grafts in the remote period are indicative of comparable results of operations with and without AC or advantages of using AC. In order to determine benefits of each method it is necessary to reveal intraoperative predictors of bypass grafts occlusion in the remote period. We analyzed the results of ultrasound flowmetry of the blood flow through the left internal thoracic artery during bypass grafting of the anterior descending artery with the use of AC and on the beating heart. A retrospective study included a total of 352 patients subdivided into 2 groups: Group One was composed of 120 patients undergoing surgery in the conditions of AC and Group Two comprised 232 patients subjected to similar operations on the beating heart. Blood flow was measured with the help of flowmeter VeryQ MediStim® after termination of AC and inactivation of heparin by protamine, with systolic pressure of 100-110 mm Hg. There were no statistically significant differences between the groups by the diameter and degree of stenosis of the anterior descending artery, diameter of the left internal thoracic artery. The mean volumetric blood flow velocity (Qmean) along the shunts in Group One was higher (p=0.01). No statistically significant differences by the pulsatility index (PI) between the groups were revealed (p=0.2). A conclusion was drawn that coronary bypass grafting of the anterior descending artery by the left internal thoracic artery in the conditions of artificial circulation made it possible to achieve higher volumetric velocity of blood flow through the conduit as compared with operations on the beating heart, with similar resistance index. The immediate results of the operations with the use of the both techniques did not differ.