Predictive factors of recurrent endovascular intervention for cephalic arch stenosis after percutaneous transluminal angioplasty.

OBJECTIVE: Cephalic arch stenosis (CAS) is an important and recurring problem arising in hemodialysis patients because of the requirement for repeated interventions to maintain patency. The aim of this study was to determine predictive factors for recurrence of CAS after successful angioplasty. METHODS: A retrospective, case-control study was conducted at two ambulatory vascular access (VA) centers. All patients with a dysfunctional VA referred for an angiographic procedure and with a documented CAS as evidenced during the endovascular intervention (EI) between January 1, 2013, and December 31, 2015, were enrolled; 15 patients in whom an efficacious intervention was not possible were excluded. The study thus concerned 375 EIs using percutaneous transluminal angioplasty without stent placement on 241 VAs for CAS (9% of all procedures performed) during a 3-year period. Patients were compared regarding the absence (group 1; n = 181) or presence (group 2; n = 60) of recurrent CAS. We defined recurrence as that which occurred within 180 days of the previous successful EI for CAS. Any CAS diagnosed and treated >180 days after a previous one was considered a novel CAS and not a recurrence. Multivariate analysis was performed to determine variables independently associated with recurrence of CAS. Kaplan-Meier analysis was performed for determination of primary and assisted primary patency in this population. RESULTS: The recurrence rate of CAS was high (25%). Patients in both groups had similar demographic characteristics, time on hemodialysis, and mean dialysis dose and access flow rate at referral (P > .05). Multivariate analysis provided a significant discriminatory influence pertaining to diabetes (hazard ratio [HR], 2.054; 95% confidence interval [CI], 1.22-3.46; P = .007), residual stenosis even though it was <30% (HR, 1.86; 95% CI, 1.005-3.439; P = .048), and the finding of an isolated CAS lesion (HR, 0.445; 95% CI, 0.219-0.905; P = .025) in comparing group 1 and group 2. All other variables lost statistical significance on multivariate analysis. Primary patency at 6 months was 72%, increasing to an assisted primary patency of 89% at 6 months. The median durations of primary patency and assisted primary patency were 9.5 months and 15.6 months, respectively. CONCLUSIONS: Multivariate analysis showed that diabetes and residual stenosis (albeit <30%) were predictive of recurrence, whereas the finding of an isolated CAS lesion as opposed to stenoses in multiple locations was shown to be negatively associated with recurrent CAS, appearing to be "protective".

The Role of Doppler Ultrassonography in Significant and Borderline Stenosis Definition.

BACKGROUND: The definition of significant stenosis (SS) remains controversial. METHODS: We retrospectively reviewed 1,040 consultations. SS was defined in the presence of clinical and echo-Doppler (DDU) criteria: Qa <500 mL/min or Qa decrease >25%; RI >0.7 in the feeding artery or absolute minimal luminal stenosis diameter <2.0 mm. Stenosis without any additional criteria were considered borderline stenosis (BS). RESULTS: Two hundred twenty-one arteriovenous fistulas (AVFs) were included: 58.8% had SS, 18.6% had BS, and 22.6% had no dysfunctional access (ND). SS had a significantly higher thrombotic events than BS and ND (13.1 vs. 4.4%, p = 0.018). The annual thrombosis rate was 0.007, 0.037, and 0.004 in the ND, SS, and BS, respectively. AVF cumulative survival at 5 years was significantly lower in SS (89.5%) compared to BS (100%) and ND (97.4%; p = 0.03). BS had an HR for AVF failure of 1.1, p = 0.955, while the SS presented an HR of 5.9, p = 0.09. CONCLUSION: AVF clinical monitoring with additional DDU criteria appear to be appropriate for therapeutic referral.

A new interministerial strategy for the promotion of healthy eating in Portugal: implementation and initial results.

OBJECTIVE: To describe the implementation, main intervention areas and initial results of the Integrated Strategy for the Promotion of Healthy Eating (EIPAS) in Portugal. METHODS: EIPAS was published as a Law, in December of 2017, as a result of a collaboration between several ministries, including the Finance, Internal Affairs, Education, Health, Economy, Agriculture, and Sea Ministries, aiming at improving the dietary habits of the Portuguese population. The working group, led by the Ministry of Health, developed this strategy for over a year. The framework produced was based on WHO and European Commission recommendations as well as on relevant data from the last Portuguese dietary intake survey (2015/2016). EIPAS also reflects the results of a public hearing, including the food industry, among others, and the experience gathered, since 2012, through the National Programme for the Promotion of Healthy Eating. It considers the 'health in all policies' challenge set by WHO and has four different strategic areas, namely (1) creation of healthier food environments, (2) improvement of the quality and accessibility of healthy food choices for consumers, (3) promotion and development of literacy, in order to encourage healthy food choices, and (4) promotion of innovation and entrepreneurship. In order to achieve these goals, a set of 51 actions was established and assigned to the seven ministries involved. RESULTS: Under the scope of this strategy, Portugal has already implemented several actions, including (1) definition of standards for food availability at all public healthcare institutions; (2) implementation of a sugar tax on sweetened beverages; (3) implementation of a voluntary agreement with the food industry sector for food reformulation (work in progress); (4) design of a proposal for an interpretative model of front-of-pack food labelling; (5) improvement of the nutritional quality of food aid programmes for low-income groups; and (6) regulation of marketing of unhealthy foods to children. CONCLUSIONS: For the first time, Portugal has a nutrition policy based on the WHO concept of 'health in all policies' and on the national data on food intake. The implementing process of all 51 actions and the inherent complexities and difficulties found so far have made this process be an authentic political and social laboratory that deserves to be followed.

Assessing the approach to a thrombosed AV graft.

The patency of the vascular access (VA) is a fight for the attending nephrologist. A retrospective observational study was conducted to compare the success rate of surgical versus endovascular technique percutaneous transluminal angioplasty (PTA) for graft thrombosis treatment. Of 3008 patients, 22.1% patients were dialyzed through grafts. Forty-five percent of all prevalent patients referred due to VA malfunction had a graft. For 18 months, 336 thrombosed grafts were submitted to surgery in 228 cases and to PTA in 126. PTA for thrombolysis included the Pharmaco-Mechanical Technique and the Arrow-Trerotola Device. Procedures were performed as outpatient, with an average delay of 1 day. Immediate success was 100% for surgery and 87.3% for PTA. The unassisted patency for thrombosed grafts for surgery/PTA was 265.12 ± 15.30/230.59 ± 19.83 days respectively, favoring surgery. The primary patency for thrombosed grafts treated by surgery/PTA at 30, 90, and 180 days was, respectively, 74.1%/81%, 63.2%/67.5%, and 53.9%/55.6% all in favor of PTA. AV grafts have a much higher rate of thrombosis than fistulas. Graft thrombosis can be dealt either by surgery or PTA, with identical success.

Does pre- and post-angioplasty Doppler ultrasound evaluation help in predicting vascular access outcome?

BACKGROUND: Kidney Disease - Improving Global Outcomes (KDIGO) recommends post-percutaneous transluminal angioplasty (PTA) <30% residual stenosis (RS) and hemodynamic parameters improvement. Primary end point: how post-PTA access blood flow (ABF) improvement predicts vascular access (VA) outcome. Secondary: compare Doppler ultrasound (DU) and angiography diagnostic accuracy; determine how other factors predict outcome. METHODS: Eighty patients. DU evaluation performed pre- and post-PTA. Several parameters recorded. Secondary patency verified after 6 months. RESULTS: Initial ABF 537 ± 248 mL/min; final ABF 1013 ± 354 mL/min. Number and location of stenosis was highly correlated between DU and angiography (p<0.001); central vessels mismatching. First semester overall survival was 63%; significantly better for fistulas (76%) than grafts (51.7%), p 0.044. Final RS>30% associated to better survival, p 0.038. Initial ABF<500 mL/min and multiple stenosis did not affect outcome (p>0.05). A >2-fold ABF increase had no significant impact on fistulas (p>0.05) but was significantly associated with worst outcomes in grafts (23.1% vs. 73.5%, p 0.009). Grafts had lower survival (HR 3.3, p 0.034). CONCLUSIONS: Although less accurate for central lesions, DU has a key role on VA surveillance, allowing a morphologic and hemodynamic assessment. Angioplasty is effective in preserving VA; however, it may increase restenosis due to accelerated neointimal hyperplasia. Current parameters are not useful. Trials addressing this issue are needed.

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.

Efficacy of preventing hemodialysis catheter infections with citrate lock.

Prevalent use of tunneled dialysis catheters can reach 30%. Infection remains the most serious catheter-related problem. Catheter locks are increasingly used for prevention, but are not yet recommended either by the Food and Drug Association or European Medicines Agency, on the basis of increasing bacterial resistance or lock toxicity. The aim was to test safety and effectiveness of citrate. A prospective, interventional study was conducted to assess the safety and efficacy of a 30% citrate lock in preventing catheter-related bacteremia (CRB). A total of 157 prevalent tunneled catheters were locked with citrate and prospectively followed during a 1-year period. The primary endpoint was first CRB diagnosed according to two of the diagnostic criteria for Catheter Infection of Centers for Disease Control and Prevention (CDC), namely definite and probable infection. The CDC criterion of possible but not proved infection was not considered. This citrate lock cohort (n = 157) had 10 episodes of CRB. We observed 0.49 CRB episodes/1000 patient-days and the mean infection-free catheter day was 130.6 ± 100.9. No clinically relevant adverse events were observed. No proved tunnel or exit site infection was observed and no patients died because of CRB. Catheter obstruction episodes were reported on 69 occasions out of 14 catheters. These results were compared with an historical cohort from a previous study of catheter locking with low-dose gentamicin and did not show significant difference in efficacy. Citrate lock is effective in preventing CRB. No toxicity was observed. The use of citrate lock may have advantages over antibiotic locks: no reported bacterial resistance, lower industrial cost, and less manipulation.

Bandagem do tronco pulmonar / Pulmonar artery banding

A bandagem do tronco pulmonar foi realizada em 38 pacientes portadores de cardiopatias congênitas com hiperfluxo pulmonar. A idade variou de 13 dias a 20 meses, média de 5,3 meses, sendo que 19 crianças (50%) estavam abaixo de 3 meses. As anomalias cardíacas dominantes foram: CIV com 13 casos (34,2%), isolada em apenas 5, canal A-V forma total com 8 casos (21%), TGA/CIV com 7(18,4%), ventrículo único com 6 pacientes, dupla via de saída de VD e anomalia complexa com dois casos cada. A técnica da bandagem pulmonar, após mediçäo prévia da pressäo pulmonar, tomou como base as regras de Trusler, obtendo-se uma reduçäo pressórica média de 40%. Como procedimento associado executaram-se 10 ligaduras de canal arterial patente, 5 correçöes de coarctaçäo de aorta e uma de interrupçäo de arco aórtico e uma septectomia atrial, num total de 17 pacientes (44,7%). Os resultados foram considerados bons em 29 pacientes (76,3%) e regulares em 6 (15,8%). A mortalidade hospitalar foi de 7,9% (3 casos). No seguimento, 3 pacientes já sofreram com éxito a correçäo cirúrgica definitiva

Metodologia diagnóstica em cardiopatias na idade pediátrica / Diagnostic methodology in heart diseases in pediatrics

Nossa metodologia diagnóstica näo tem a pretensäo de incluir todas as causas de transtornos cardíacos na idade pediátrica. Acreditamos que possa orientar os que iniciam no campo da cardiologia pediátrica, aproximando, de uma maneira sistemática, os diangósticos, que se apresentam com mais freqüência, principalmente no período neonatal

Anastomose sistêmio-pulmonar tipo Blalock-Taussig: comparaçäo entre a operaçäo original e a modificada / Systemic-pulmonary anastomosis type Blalock-Taussig: comparison between the original and the modified surgery

No período de Jan 80 a Jul 86, foram submetidos a cirurgia de derivaçäo sistêmico-pulmonar, tipo Blalock-Taussig e modificado, 57 pacientes portadores de cardiopatia congênita cianótica com hipofluxo pulmonar. A idade variou de 4 dias e 8 anos, com média de 13 meses, e sendo que 6 (10,5%) estavam com menos de 1 mês, 18 se situavam na faixa de 1 a 6 meses (31,6%), e 13 (22,8%) de 7 a 12 meses. Eram do sexo masculino 54,4% das crianças. Quanto à patologia cardíaca básica a Tétrade de Fallot teve 18 casos (31,6%), 11 pacientes (19,4%) tinham atresia tricúspide, a atresia pulmonar teve 8 casos (14,0%) bem como o ventrículo único com estenose pulmonar; os restantes 21 por cento relacionavam-se a transposiçäo das grandes artérias, canal atrio-ventricular, dupla via de saída de VD e VE, cardiopatia complexa e estenose pulmonar associada em todos. A cirurgia de Blalock-Taussig original foi realizada em 28 casos, enquanto que o tubo de PTFE foi usado em 29 pacientes numa distribuiçäo relativamente homogênea. A mortalidade hospitalar global foi de 7 casos (12,3%) nenhum relacionado à tétrade de Fallot. Seis pacientes já foram submetidos à correçäo cirúrgica definitiva. Ambas as técnicas se mostraram efetivas em nossas mäos