Lipoprotein apheresis in the management of severe hypercholesterolemia and hyperlipoproteinemia(a)-The Portuguese experience.

BACKGROUND: Low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) (Lp(a)) are established causal risk factors for cardiovascular disease (CVD). Lipoprotein apheresis is often required for treatment of patients with a high risk for CVD due to hypercholesterolemia and/or hyperlipoproteinemia(a). AIM: To describe our experience with lipoprotein apheresis in patients with severe hypercholesterolemia or with hyperlipoproteinemia(a). METHODS: We retrospectively investigated patients treated with Lipoprotein apheresis using direct adsorption of lipoproteins (DALI) technique, between December 2008 and March 2018, in our center. Adverse events, acute and long term reductions in lipid parameters were analyzed. RESULTS: Between December 2008 and March 2018, a total of 950 treatments were performed in five patients, four with heterozygous familial hypercholesterolemia (HeFH), all on maximally tolerated cholesterol-lowering drug therapy and in one patient with hyperlipoproteinemia(a) and progressive CVD. In the four patients with HeFH we obtained mean acute reductions in LDL-C and non-high-density lipoprotein cholesterol (non-HDL-C) of 62.0 ± 7.8% and 60.4 ± 6.8%, respectively. Regarding long-term efficacy we achieved a mean reduction of 43.1% in LDL-C and of 41.2% in non-HDL-C. In the patient with hyperlipoproteinemia(a) we attained mean acute reductions of 60.4 ± 6.4% in Lp(a) and of 75.4 ± 7.3% in LDL-C per session and long term reductions in Lp(a) and LDL-C of 67.4% and 40.5%, respectively. Adverse events were recorded in only 1.2% of treatments. CONCLUSION: Lipoprotein apheresis is an efficient and safe treatment in severely hypercholesterolemic patients who are refractory to conservative lipid-lowering therapy or with hyperlipoproteinemia(a) and progressive CVD.

Stenosis and thrombosis-unveiled complications of buttonhole cannulation.

The vascular access is the mainstay of hemodialysis. Arteriovenous fistula has been prioritized as the first choice of long-term vascular access for its inferior rate of complications and improved patient survival. Rope ladder and buttonhole venipuncture are the most common techniques for arteriovenous fistulae cannulation. Much of the concern regarding buttonhole cannulation is the increased risk for potentially severe systemic infections. Increased risk for stenosis and thrombosis has been addressed but not confirmed. We discuss two cases of stenosis and thrombosis related to buttonhole puncture which heralded angiography intervention, raising awareness for the demand of close surveillance of arteriovenous fistulae when using buttonhole cannulation.

Preoperative vessel mapping in chronic kidney disease patients - a center experience.

PURPOSE: Hemodialysis (HD) is the main treatment modality in stage 5 chronic kidney disease, and vascular access planning is a crucial step in the path to dialysis treatment. Beyond detailed patient history and physical examination, duplex ultrasound (DU) evaluation is essential in preoperative vascular mapping. METHODS: A retrospective descriptive nonrandomized study was performed and included 108 end-stage kidney disease patients referred from eight HD centers to be assessed for creation of an arteriovenous (AV) access (AV fistula or AV graft). We assessed primary failure, primary unassisted patency (PP) and primary assisted patency (PAP) rates and cumulative survival of AV accesses at 6 and 12 months. RESULTS: We created 86 AV accesses of which 79 (91.9%) were AV fistulas (AVFs) (29 distal AVFs, 49 proximal AVFs and 1 femorofemoral AVF) and 7 (8.1%) arteriovenous grafts (AVGs). Fifteen percent (15%) (n = 12) of primary failure occurred in the AVF group. Any case of primary failure was observed between AVGs.In the AVF group, PP at 6 months was 63.8 % and at 12 months was 48.3%, PAP was 80.7% at 6 and 12 months. PP excluding primary failures was 73.0% and 55.3% at 6 and 12 months, respectively. The cumulative survival at 6 and 12 months was 80.7%.In the AVG group, PP at 6 months and 12 months was 66.7%, PAP and cumulative survival at 6 and 12 months were of 100%. CONCLUSIONS: This study demonstrates that preoperative vascular mapping with a patient-centered approach may be critical to achieve good outcomes allowing the increase in AVF access.

LDL apheresis in the treatment of familial hypercholesterolemia: experience of Hospital Santo António, Porto.

INTRODUCTION: High plasma levels of low-density lipoprotein (LDL) cholesterol are a risk factor for the development of premature atherosclerosis. Direct adsorption of lipoproteins (DALI) is an apheresis technique by which LDL cholesterol is selectively removed from whole blood. OBJECTIVE: The present study describes our experience with DALI LDL apheresis in severely hypercholesterolemic patients. METHODS: Three hypercholesterolemic patients suffering from atherosclerotic complications were treated fortnightly by DALI apheresis, in a total of 308 sessions between December 2008 and January 2013. All patients were on the highest tolerated dose of statins and other lipid-lowering drugs. RESULTS: The sessions were essentially uneventful, adverse events being recorded in only 3.6% of them. A mean 63.3% acute reduction in LDL cholesterol was obtained. CONCLUSION: DALI apheresis proved to be a simple, safe and efficient method of lipid apheresis in hypercholesterolemic patients refractory to conservative lipid-lowering therapy.