Extracorporeal Membrane Oxygenation after Heart Transplantation: Impact of Type of Cannulation.

BACKGROUND: Primary graft dysfunction (PGD) is a common cause of early death after heart transplantation (htx). The use of extracorporeal life support (ECLS) after htx has increased during the last years. It is still discussed controversially whether peripheral cannulation is favorable compared to central cannulation. We aimed to compare both cannulation techniques. METHODS: Ninety patients underwent htx in our department between 2010 and 2017. Twenty-five patients were treated with ECLS due to PGD (10 central extracorporeal membrane oxygenator [cECMO] and 15 peripheral extracorporeal membrane oxygenator [pECMO] cannulation). Pre- and intraoperative parameters were comparable between both groups. RESULTS: Thirty-day mortality was comparable between the ECLS-groups (cECMO: 30%; pECMO: 40%, p = 0.691). Survival at 1 year (n = 18) was 40 and 30.8% for cECMO and pECMO, respectively. The incidence of postoperative renal failure, stroke, limb ischemia, and infection was comparable between both groups. We also did not find significant differences in duration of mechanical ventilation, intensive care unit stay, or in-hospital stay. The incidence of bleeding complications was also similar (cECMO: 60%; pECMO: 67%). Potential differences in support duration in pECMO group (10.4 ± 9.3 vs. 5.7 ± 4.7 days, p = 0.110) did not reach statistical significance. CONCLUSIONS: In patients supported for PGD, peripheral and central cannulation strategies are safe and feasible for prolonged venoarterial ECMO support. There was no increase in bleeding after central implantation. With regard to the potential complications of a pECMO, we think that aortic cannulation with tunneling of the cannula and closure of the chest could be a good option in patients with PGD after htx.

Outcomes in buried versus non-buried peritoneal dialysis catheters: A retrospective cohort study.

AIMS: To compare the rates of infections (peritonitis and exit site infections) in patients undergoing non-buried versus buried peritoneal dialysis catheterisation for end-stage renal failure. METHODS: A retrospective review of all patients who underwent peritoneal dialysis catheter placement by one primary surgeon between January 2008 and August 2019. Information collected included, catheter characteristics, immediate post-operative complications, date of catheter exteriorisation, date of peritoneal dialysis commencement, rate of successful catheter function at initiation of peritoneal dialysis and rates of catheter-related complications (i.e. infection, revision status and obstruction). RESULTS: 110 peritoneal dialysis catheters were inserted (43 non-buried and 67 buried peritoneal dialysis catheters). The non-buried group was associated with a higher proportion acquiring an infection than the buried group (15% vs 30%, p = 0.054). Patients with buried catheters also had a 72% and 65% decreased likelihood of experiencing a catheter-related infection and peritonitis, respectively, over time compared to patients with non-buried catheters in the unadjusted (crude incidence rate ratio 0.28, 95% confidence interval 0.11, 0.70; P = 0.003). The proportion of catheter function at first use was 85% in the non-buried group and 78% in the buried group. Patients with non-buried versus buried catheters had similar proportions of complications, including: obstructions (25.6% vs 20.9%, p = 0.770), herniation (7.0% vs 4.0%, p = 0.327) and leaks (7.0% vs 1.5%, p = 0.134). CONCLUSION: The use of the buried peritoneal dialysis catheter technique as compared to the standard technique has revealed fewer overall catheter-related infections, particularly episodes of peritonitis and similar rates of mechanical complications in our series. In addition to that, the other benefits of buried peritoneal dialysis catheters such as lower healthcare cost, patient convenience and a viable option for patients in remote communities should prompt physicians to continue assessing suitable candidates for buried peritoneal dialysis catheters.

Outcome and Safety of Unplanned-Start Peritoneal Dialysis according to Break-In Periods: A Systematic Review and Meta-Analysis.

INTRODUCTION: The best timing of peritoneal dialysis (PD) initiation after catheter implantation is still controversial. It is necessary to explore whether there exists a waiting period to minimize the risk of complications. METHODS: A systematic review and meta-analysis were searched in multiple electronic databases published from inception to February 29, 2020, to identify cohort studies for evaluating the outcome and safety of unplanned-start PD (<14 days after catheter insertion). Risks of bias across studies were evaluated using Newcastle-Ottawa Quality Assessment Scale. RESULTS: Fourteen cohort studies with a total of 2,401 patients were enrolled. We found that early-start PD was associated with higher prevalence of leaks (RR: 2.67, 95% CI, 1.55-4.61) and omental wrap (RR: 3.28, 95% CI, 1.14-9.39). Furthermore, patients of unplanned-start PD in APD group have higher risk of leaks, while those in CAPD group have a higher risk of leaks, omental wrap, and catheter malposition. In shorter break-in period (BI) group, the risk of suffering from catheter obstruction and malposition was higher for patients who started dialysis within 7 days after the surgery than for patients within 7-14 days. No significant differences were found in peritonitis (RR: 1.00; 95% CI, 0.78-1.27) and exit-site infections (RR: 1.12; 95% CI, 0.72-1.75). However, shorter BI was associated with higher risk of mortality and transition to hemodialysis (HD) while worsen early technical survival, with pooled RR of 2.14 (95% CI, 1.52-3.02), 1.42 (95% CI, 1.09-1.85) and 0.95 (95% CI, 0.92-0.99), respectively. CONCLUSIONS: Evidence suggests that patients receiving unplanned-start PD may have higher risks of mechanical complications, transition to HD, and even mortality rate while worsening early technical survival, which may not be associated with infectious complications. Rigorous studies are required to be performed.

Comparison of Long-Term Outcomes of Endoscopic and Minimally Invasive Catheter Evacuation for the Treatment of Spontaneous Cerebellar Hemorrhage.

Recently, minimally invasive techniques, including endoscopic evacuation and minimally invasive catheter (MIC) evacuation, have been used for the treatment of patients with spontaneous cerebellar hemorrhage (SCH). However, credible evidence is still needed to validate the effects of these techniques. To explore the long-term outcomes of both surgical techniques in the treatment of SCH. Fifty-two patients with SCH who received endoscopic evacuation or MIC evacuation were retrospectively reviewed. Six-month mortality and the modified Rankin Scale (mRS) score were the primary and secondary outcomes, respectively. A multivariate logistic regression model was used to assess the effects of the different surgical techniques on patient outcomes. In the present study, the mortality rate for the entire cohort was 34.6%. Univariate analysis showed that the surgical technique and preoperative Glasgow Coma Scale (GCS) score affected 6-month mortality. However, no variables were found to be correlated with 6-month mRS scores. Further multivariate analysis demonstrated that 6-month mortality in the endoscopic evacuation group was significantly lower than that in the MIC evacuation group (OR = 4.346, 95% CI 1.056 to 17.886). The 6-month mortality rate in the preoperative GCS 9-14 group was significantly lower than that in the GCS 3-8 group (OR = 7.328, 95% CI 1.723 to 31.170). Compared with MIC evacuation, endoscopic evacuation significantly decreased 6-month mortality in SCH patients. These preliminary results warrant further large, prospective, randomized studies.

Effect of Early Cannulation with Plastic Cannula on Arteriovenous Fistula Patency in Hemodialysis Patients.

INTRODUCTION: Plastic cannulas have been used to cannulate arteriovenous fistulas (AVFs) for hemodialysis (HD) in Japan for many years. However, the effect of early cannulation with plastic cannulas on AVF patency is not known. OBJECTIVE: We analyzed the relationship between first cannulation time (FCT) and patency rates for AVFs cannulated with plastic cannulas and investigated whether early cannulation with plastic cannulas affects AVF patency. METHODS: In total, 122 patients who underwent primary AVF construction were divided into an early cannulation group (FCT <10 days) and a late cannulation group (FCT ≥10 days). The Kaplan-Meier method and multivariable Cox regression models were used to investigate AVF patency. RESULTS: Median FCT was 6 days. There was no statistically significant between-group difference in primary (p = 0.643) or secondary (p = 0.453) patency rates. Early or late cannulation was not significantly associated with primary patency (hazard ratio [HR] 1.21; 95% CI 0.71-2.05) or secondary patency (HR 0.46; 95% CI 0.08-2.77) after adjustment for age, sex, presence of diabetes mellitus or hypertension, and HD at baseline. CONCLUSIONS: Early AVF cannulation (<10 days from creation) with plastic cannulas does not affect access patency, and it may be possible to cannulate AVFs earlier than 10 days to decrease the need for use of a central venous catheter.

Hemodialysis and peritoneal dialysis access related outcomes in the pediatric and adolescent population.

BACKGROUND: There is paucity of comparative data on the objective performance of arteriovenous fistulas (AVF), grafts (AVG), hemodialysis (HD) catheter and peritoneal dialysis (PD) catheter in the pediatric population. METHODS: A retrospective analysis of all patients <21 years in the United States Renal Database System who had an AVF, AVG, HD catheter or PD catheter placed for dialysis access between 1/2007 and 12/2014 was performed. Multivariable cox regression was used to evaluate mortality, patency (primary, primary-assisted and secondary), maturation and catheter survival. RESULTS: The 11,575 patients studied comprised of 9445 (82%) HD, 1435 (12%) PD, 528 (4.6%) HD to PD and 167 (1.4%) PD to HD patients. The HD subcohort comprised of 1296 (13.7%) AVF initiates, 199 (2.1%) AVG initiates, 1347 (14.3%) AVF converts after initial HD catheter use, 292 (3.1%) AVG converts and 6311 (67%) patients who persistently utilized HD catheters. There was no difference between PD and HD in patients 0-5 (aHR: 1.36; 95% CI: 0.89-2.07; P = 0.15) and 6-12 years (aHR: 1.05; 95% CI: 0.72-1.52; P = 0.8). However, PD was associated with 73% and 76% increase in mortality relative to HD among patients in the 13-17 (aHR: 1.73; 95% CI: 1.35-2.21; P < 0.001) and 18-20 (aHR: 1.76; 95% CI: 1.38-2.24; P < 0.001) age categories. AVG was associated with 78% increase in mortality compared to AVF (aHR: 1.78; 95% CI: 1.41-2.25; P < 0.001). Persistent use of HD catheters was associated with 29% increase in mortality (aHR: 1.29; 95% CI: 1.07-1.57; P = 0.009) compared to initiation and persistent use of AVF. Conversion from HD catheter to AVF was associated with 66% decrease in mortality compared to persistent HD catheter use (aHR: 0.34; 95% CI: 0.28-0.40; P < 0.001). Primary, primary assisted and secondary patency were higher for AVF compared to AVG. CONCLUSION: There was no difference in risk adjusted mortality between HD and PD in children less than 13 years. PD is associated with higher mortality compared to HD in adolescents. Initiation of HD with AVF is associated with better patency and patient survival relative to AVG and persistent use of HD catheters in pediatric patients irrespective of transplant potential. Conversion from HD catheter to AVF or AVG in patients who inevitably initiate HD with a catheter is associated with better survival compared to persistent HD catheter use. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level II.

Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial.

BACKGROUND: Infected necrosis complicates 10% of all acute pancreatitis episodes and is associated with 15-20% mortality. The current standard treatment for infected necrotizing pancreatitis is the step-up approach (catheter drainage, followed, if necessary, by minimally invasive necrosectomy). Catheter drainage is preferably postponed until the stage of walled-off necrosis, which usually takes 4 weeks. This delay stems from the time when open necrosectomy was the standard. It is unclear whether such delay is needed for catheter drainage or whether earlier intervention could actually be beneficial in the current step-up approach. The POINTER trial investigates if immediate catheter drainage in patients with infected necrotizing pancreatitis is superior to the current practice of postponed intervention. METHODS: POINTER is a randomized controlled multicenter superiority trial. All patients with necrotizing pancreatitis are screened for eligibility. In total, 104 adult patients with (suspected) infected necrotizing pancreatitis will be randomized to immediate (within 24 h) catheter drainage or current standard care involving postponed catheter drainage. Necrosectomy, if necessary, is preferably postponed until the stage of walled-off necrosis, in both treatment arms. The primary outcome is the Comprehensive Complication Index (CCI), which covers all complications between randomization and 6-month follow up. Secondary outcomes include mortality, complications, number of (repeat) interventions, hospital and intensive care unit (ICU) lengths of stay, quality-adjusted life years (QALYs) and direct and indirect costs. Standard follow-up is at 3 and 6 months after randomization. DISCUSSION: The POINTER trial investigates if immediate catheter drainage in infected necrotizing pancreatitis reduces the composite endpoint of complications, as compared with the current standard treatment strategy involving delay of intervention until the stage of walled-off necrosis. TRIAL REGISTRATION: ISRCTN, 33682933 . Registered on 6 August 2015. Retrospectively registered.

Two-Year Outcomes of Early Cannulation Arteriovenous Grafts for End-Stage Renal Disease.

BACKGROUND: Almost 80% of patients with end-stage renal disease (ESRD) initiate dialysis via a central venous catheter (CVC). CVCs are associated with multiple complications and a high cost of care. The purpose of our project is to determine the impact of early cannulation arteriovenous grafts (ECAVGs) on quality of care and costs. METHODS: The dialysis access modality, complications, secondary interventions, hospital outcomes, and detailed costs were tracked for 397 sequential patients who underwent access creation between July 2014 and October 2018. Complications were grouped into deep vein thrombosis, line infections, sepsis, pneumothorax, and other. Secondary interventions included angioplasty, angioplasty and stent grafting, thrombectomy, surgical revision, and explantation. Hospital outcomes included length of stay, inpatient mortality, 30-day readmission, and discharge disposition. Costs included supplies, medications, laboratory tests, labor, and other direct costs. All variables were measured at the time of the index procedure, 30 days, 90 days, 180 days, 270 days, 1 year, 18 months, and 2 years. RESULTS: There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who received ECAVG for dialysis access. The total cost of care per patient was $17,523 for AVF and $5,894 for ECAVG at 1 year (P < 0.01). Primary-assisted patency for AVF was 49.3% versus 81.4% for ECAVG (P = 0.027), and secondary-assisted patency for AVF was 63.8% versus 85.4% for ECAVG at 1 year (P = 0.011). There was a survival advantage for ECAVGs at 1 year (78.6% for AVF vs 85.0% for ECAVG, P = 0.034). Patients who received ECAVG had fewer CVC days (2.3% vs 19.1% for AVF, P < 0.001), fewer complications (1.6% vs. 21.5% for AVF, P < 0.001), and fewer secondary interventions (17.0% vs 52.5% for AVF, P < 0.001). CONCLUSIONS: This is the first study on patients with ESRD to report detailed outcomes and cost analysis as it relates to AVF versus ECAVG. ECAVGs have an advantage over AVFs due to lower overall cost and better clinical outcomes at 1 year. Implementation of an urgent start dialysis access program centered around ECAVGs may help achieve the national goal of better health care at a lower cost for patients with ESRD.

Innominate vs. axillary artery cannulation in aortic surgery: a systematic review and meta-analysis

Abstract Objective: To investigate whether axillary artery cannulation has supremacy over innominate artery cannulation in thoracic aortic surgery. Methods: A comprehensive search was undertaken among the four major databases (PubMed, Excerpta Medica dataBASE [EMBASE], Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing axillary to innominate artery cannulation in thoracic aortic surgery. Databases were evaluated and assessed up to March 2017. Results: Only three studies fulfilled the criteria for this meta-analysis, including 534 patients. Cardiopulmonary bypass time was significantly shorter in the innominate group (P=0.004). However, the innominate group had significantly higher risk of prolonged intubation > 48 hours (P=0.04) than the axillary group. Further analysis revealed no significant difference between the innominate and axillary groups for deep hypothermic circulatory arrest time (P=0.06). The relative risks for temporary and permanent neurological deficits as well as in-hospital mortality were not significantly different for both groups (P=0.90, P=0.49, and P=0.55, respectively). Length of hospital stay was similar for both groups. Conclusion: There is no superiority of axillary over innominate artery cannulation in thoracic aortic surgery in terms of perioperative outcomes; however, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing optimal arterial cannulation site.

Innominate vs. Axillary Artery Cannulation in Aortic Surgery: a Systematic Review and Meta-Analysis.

OBJECTIVE: To investigate whether axillary artery cannulation has supremacy over innominate artery cannulation in thoracic aortic surgery. METHODS: A comprehensive search was undertaken among the four major databases (PubMed, Excerpta Medica dataBASE [EMBASE], Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing axillary to innominate artery cannulation in thoracic aortic surgery. Databases were evaluated and assessed up to March 2017. RESULTS: Only three studies fulfilled the criteria for this meta-analysis, including 534 patients. Cardiopulmonary bypass time was significantly shorter in the innominate group (P=0.004). However, the innominate group had significantly higher risk of prolonged intubation > 48 hours (P=0.04) than the axillary group. Further analysis revealed no significant difference between the innominate and axillary groups for deep hypothermic circulatory arrest time (P=0.06). The relative risks for temporary and permanent neurological deficits as well as in-hospital mortality were not significantly different for both groups (P=0.90, P=0.49, and P=0.55, respectively). Length of hospital stay was similar for both groups. CONCLUSION: There is no superiority of axillary over innominate artery cannulation in thoracic aortic surgery in terms of perioperative outcomes; however, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing optimal arterial cannulation site.

Is Axillary Better Than Femoral Artery Cannulation in Repair of Acute Type A Aortic Dissection?

OBJECTIVE: We compared early and late outcomes of patients who underwent femoral versus axillary artery cannulation for repair of acute type A aortic dissection. METHODS: Between 2004 and 2017, we retrospectively evaluated the clinical outcomes of 135 consecutive patients who underwent emergency surgery for acute type A aortic dissection repair. Patients were divided into 2 groups: those who underwent femoral ( n = 84) and those who underwent right axillary ( n = 51) artery cannulation. Mean patient age was 63 ± 13 years and 88 (65%) were male. RESULTS: Overall operative mortality was 12.6% (axillary 15.7%, femoral 10.7%; P = 0.564). Patients who underwent axillary compared to femoral artery cannulation had a statistically nonsignificant higher operative mortality rate among both stable and unstable patients (13% vs. 6.5%, P = 0.405 and 40% vs. 22.7%, P = 0.818, respectively). While there was no difference in major complication rates, such as stroke, low cardiac output, and surgical revision for bleeding/tamponade, there was a higher incidence of renal failure that required dialysis in patients who underwent axillary cannulation (12% vs. 1%, P = 0.022). Multivariate analysis demonstrated that predictors for the composite endpoint of operative mortality or severe organ malperfusion, such as renal failure or cerebrovascular accident, were hemodynamic instability on admission (OR 3.87; 95% CI, 1.23 to 12.63; P = 0.021), lower preoperative creatinine clearance (OR 0.94; 95% CI, 0.90 to 0.97; P < 0.001); and the use of axillary artery cannulation (OR 4.1; 95% CI, 1.43 to 12.78; P = 0.011). Among those discharged from hospital, the 3-year survival rate was 91% in the axillary group and 87% in the femoral group ( P = 0.772). CONCLUSIONS: Based on our experience, emergent surgery for both stable and unstable patients with acute type A aortic dissection demonstrated similar survival rates and significantly less renal impairment when using the femoral cannulation approach.

Prognostic factors in patients undergoing early-start peritoneal dialysis within 24 h after catheter insertion.

This study aimed to investigate the clinical characteristics, prognosis, and factors for survival of patients who underwent early-start peritoneal dialysis (PD) within 24 h after catheter insertion three years after PD. This study was conducted from January 1, 2013 to December 31, 2017. All adult patients who were diagnosed with end-stage renal disease (ESRD) and underwent PD for the first time within 24 h after catheter insertion in our hospital were included. All patients with PD were followed-up until they withdrew from PD, switching to hemodialysis, were transferred to other medical centers, underwent renal transplantation, died or were lost to follow-up, or continued to undergo dialysis until the end of the study period. The follow-up observation lasted three years. The number of eligible patients was 110, and switching to hemodialysis and death were the main reasons for patients to withdraw from PD. The 1-, 2-, and 3-year technical survival rates of patients were 89.1, 79.1, and 79.1% respectively, while the 1-, 2- and 3-year survival rates were 90, 81.8, and 81.8%, respectively. The Charlson comorbidity index, age, hemoglobin, serum albumin, diabetic nephropathy, chronic glomerulonephritis, and hypertensive renal damage were independent risk factors that affected the prognosis of PD patients. Under the condition of ensuring the quality of the PD catheter insertion, early-start PD within 24 h after catheter insertion is a safe treatment approach for ESRD patients.

Prognostic factors in patients undergoing early-start peritoneal dialysis within 24 h after catheter insertion

This study aimed to investigate the clinical characteristics, prognosis, and factors for survival of patients who underwent early-start peritoneal dialysis (PD) within 24 h after catheter insertion three years after PD. This study was conducted from January 1, 2013 to December 31, 2017. All adult patients who were diagnosed with end-stage renal disease (ESRD) and underwent PD for the first time within 24 h after catheter insertion in our hospital were included. All patients with PD were followed-up until they withdrew from PD, switching to hemodialysis, were transferred to other medical centers, underwent renal transplantation, died or were lost to follow-up, or continued to undergo dialysis until the end of the study period. The follow-up observation lasted three years. The number of eligible patients was 110, and switching to hemodialysis and death were the main reasons for patients to withdraw from PD. The 1-, 2-, and 3-year technical survival rates of patients were 89.1, 79.1, and 79.1% respectively, while the 1-, 2- and 3-year survival rates were 90, 81.8, and 81.8%, respectively. The Charlson comorbidity index, age, hemoglobin, serum albumin, diabetic nephropathy, chronic glomerulonephritis, and hypertensive renal damage were independent risk factors that affected the prognosis of PD patients. Under the condition of ensuring the quality of the PD catheter insertion, early-start PD within 24 h after catheter insertion is a safe treatment approach for ESRD patients.

Direct Femoral Cannulation in Minimal Invasive Pediatric Cardiac Surgery: Our Experience With Midterm Result.

OBJECTIVE: One of the major challenges faced in minimally invasive pediatric cardiac surgery is cannulation strategy for cardiopulmonary bypass. Central aortic cannulation through the same incision has been the usual strategy, but it has the disadvantage of cluttering of the operative field. We hereby present the results of femoral cannulation in minimally invasive pediatric cardiac surgery in terms of adequacy and safety. METHODS: From January 2013 to June 2016, 200 children (122 males) with mean ± SD age of 9.2 ± 4.51 years (median = 6 years, range = 3-18 years) and weight of 19.22 ± 8.49 kg (median = 15 kg, range = 8-45 kg) were operated for congenital cardiac defects through anterolateral thoracotomy. The most common diagnosis was atrial septal defect (144 patients). In all the patients, femoral artery and femoral vein were cannulated along with direct superior vena cava cannulation for institution of cardiopulmonary bypass. RESULTS: There were no deaths or any major complications related to femoral cannulation. Femoral artery cannulation provided adequate arterial inflow, whereas femoral vein with direct superior vena cava cannulation provided adequate venous return in all the patients. No patient required vacuum-assisted venous drainage. No patient required conversion to sternotomy or developed vascular, neurological complications. At discharge and at 1-year follow-up, both femoral artery and vein were patent without a significant stenosis on color Doppler ultrasonography in all the patients. At mean ± SD follow-up period of 30.63 ± 10.09 months, all the patients were doing well without any wound-related, neurological, or vascular complications. CONCLUSIONS: Femoral arterial and venous cannulation is a feasible, reliable, and efficient method for institution of cardiopulmonary bypass in minimally invasive pediatric cardiac surgery.

Surgical pulmonary embolectomy and catheter-based therapies for acute pulmonary embolism: A contemporary systematic review.

OBJECTIVES: Mortality in acute pulmonary embolism (PE) is believed to be principally due to the subgroup of PEs that are massive. Systemic thrombolysis is the therapeutic mainstay for acute massive PE, despite evidence suggesting limited survival benefits. Both catheter-based therapies (CBT) and surgical pulmonary embolectomy (SE) are well-accepted alternatives to treat acute PE. However, the comparative effectiveness of these approaches is difficult to study. We conducted a systematic review of CBT and SE for acute PE. METHODS: The PubMed database was queried for CBT- and SE-related publications between January 1998 and June 2017. A minimum of 10 patients undergoing intervention(s) was required for inclusion, and studies must not have excluded patients with massive PE. End points examined included hospital mortality, and additionally for CBT, procedural success rate. RESULTS: A total of 75 studies (41 of CBT, 34 of SE) were identified, with 1650 patients undergoing CBT and 1101 undergoing SE. Patients undergoing SE were more critically ill than those undergoing CBT (massive PE, 545 out of 975 [55.9%] for SE vs 742 out of 1553 [47.8%] for CBT). Cardiopulmonary resuscitation (CPR) was required in 217 out of 1015 patients undergoing SE (21.4%) versus 38 out of 983 patients undergoing CBT (4.0%). The hospital mortality of SE was 14.0%, versus 5.6% for CBT, in the entire patient group. However, the hospital mortality of SE in patients with pre-SE CPR was 46.3%, whereas it was 6.8% in those patients without pre-SE CPR. Although CPR was associated with an increased risk of mortality both for CBT and SE, it accounted for all of the mortality effect on SE (the adjusted odds ratio for CPR in a random effects model with treatment considered was 9.79 (95% confidence interval, 4.98-19.17; P < .0001). The adjusted odds ratio for mortality for SE relative to CBT was 1.36 (95% confidence interval, 0.80-2.32; P = .84). Moreover, CBT was associated with a procedural failure rate of 8.3%. CONCLUSIONS: Both CBT and SE were associated with satisfactory published outcomes. SE is associated with greater absolute postprocedure mortality than CBT, but has been undertaken in more critically ill populations. The markedly higher incidence of CPR in SE accounts for the differential mortality between the patients undergoing SE and those undergoing CBT. Decision making with respect to best therapy must take into account potential needs for periprocedure artificial mechanical right ventricle and lung support, institutional experience and outcomes, anticipated therapeutic efficacy and benefit, and approach-specific risks.

Long-term effects of oxygen-enriched high-flow nasal cannula treatment in COPD patients with chronic hypoxemic respiratory failure.

BACKGROUND: This study investigated the long-term effects of humidified high-flow nasal cannula (HFNC) in COPD patients with chronic hypoxemic respiratory failure treated with long-term oxygen therapy (LTOT). PATIENTS AND METHODS: A total of 200 patients were randomized into usual care ± HFNC. At inclusion, acute exacerbation of COPD (AECOPD) and hospital admissions 1 year before inclusion, modified Medical Research Council (mMRC) score, St George's Respiratory Questionnaire (SGRQ), forced expiratory volume in 1 second (FEV1), 6-minute walk test (6MWT) and arterial carbon dioxide (PaCO2) were recorded. Patients completed phone interviews at 1, 3 and 9 months assessing mMRC score and AECOPD since the last contact. At on-site visits (6 and 12 months), mMRC, number of AECOPD since last contact and SGRQ were registered and FEV1, FEV1%, PaCO2 and, at 12 months, 6MWT were reassessed. Hospital admissions during the study period were obtained from hospital records. Hours of the use of HFNC were retrieved from the high-flow device. RESULTS: The average daily use of HFNC was 6 hours/day. The HFNC group had a lower AECOPD rate (3.12 versus 4.95/patient/year, p<0.001). Modeled hospital admission rates were 0.79 versus 1.39/patient/year for 12- versus 1-month use of HFNC, respectively (p<0.001). The HFNC group had improved mMRC scores from 3 months onward (p<0.001) and improved SGRQ at 6 and 12 months (p=0.002, p=0.033) and PaCO2 (p=0.005) and 6MWT (p=0.005) at 12 months. There was no difference in all-cause mortality. CONCLUSION: HFNC treatment reduced AECOPD, hospital admissions and symptoms in COPD patients with hypoxic failure.

Weaning adult patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation by pump-controlled retrograde trial off.

BACKGROUND: There is a lack of consensus on the timing of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) liberation. VA-ECMO weaning usually consists of serial decrements until an idling flow is achieved, supported by echocardiographic and haemodynamic assessments. Even with minimal idling flow, right ventricular (RV) preload is reduced and, hence, right heart function is not fully tested under adequate loading conditions. Following the use of a novel technique called Pump Controlled Retrograde Trial Off (PCRTO) in neonate VA-ECMO weaning, we report the use of this technique in seven adult patients on VA-ECMO. METHODS: We retrospectively reviewed all adult VA-ECMO patients treated at a tertiary teaching hospital in Hong Kong since 2010. Clinical data, including diagnosis, echocardiography findings, ECMO configuration, PCRTO settings, survival after veno-arterial ECMO (SAVE) score and outcomes, were collected. Mortality and death due to cardiac failure was compared between PCRTO and conventional weaning. RESULTS: Seven patients underwent PCRTO, with a mean SAVE score of -4.4 ± 5.9. All seven patients were successfully decannulated without haemodynamic deterioration. In all cases, no clots or fibrin deposits were found in the circuit after the trial. There was no difference in mean SAVE scores among the seven patients in PCRTO and the 23 patients in the conventional group (-3.6, 95% CI -8.8 to 1.5). The number of deaths due to cardiac failure in the PCRTO group and the conventional group were 0 and 3, respectively (0% vs. 13%, p=0.99). Mortality after decannulation for PCRTO was 42.9% vs. conventional weaning 34.8% (p=0.99). CONCLUSION: Our study suggests that PCRTO is a simple, safe and reversible alternative weaning method. It may have a particular role in the assessment of patients who have marginal recovery and right heart failure. Prospective controlled studies are needed to establish the potential role of PCRTO in the liberation of patients from VA-ECMO support.

Peritoneal dialysis catheter function and survival are not adversely affected by obesity regardless of the operative technique used.

BACKGROUND: Obesity has been considered a relative contraindication to peritoneal dialysis (PD). Surprisingly, PD catheter dysfunction rates and longevity have not been studied in the growing obese ESRD population. The aim of this study was to determine the effect of patient weight on PD catheter survival in the three insertion technique categories of advanced laparoscopy (AL), basic laparoscopy (BL), and open. METHODS: We examine retrospectively collected data on 231 consecutive PD catheter insertions at the NorthShore University HealthSystem between 2004 and 2014. Three cohorts were created based on the catheter insertion technique: open, BL using selective adhesiolysis, and AL using rectus sheath tunnel, selective omentopexy, and adhesiolysis. Primary outcomes included catheter dysfunction and catheter dysfunction-free survival for each cohort by BMI: normal weight (18.5-24.9), overweight (25-29.9), obese (≥30). Nominal variables were compared using Chi-square test, continuous variables using ANOVA or Kruskal-Wallis tests, and catheter survival was assessed using the Kaplan-Meier method with log-rank test. Statistical significance was established at 0.05. RESULTS: For the three BMI categories, there were no statistically significant differences in patient demographics. There were no statistically significant differences in catheter dysfunction or peri-operative complications by BMI category among all patients. This was also true in the AL cohort. Among all patients, similar 2-year dysfunction-free catheter survival was noted for normal weight, overweight, and obese patients (log-rank p = 0.79). This was also true across all insertion techniques: open (log-rank p = 0.87), BL (log-rank p = 0.41), AL (log-rank p = 0.43). In the obese cohort, the 2-year dysfunction-free catheter survival was 91.1% in AL, 83.5% in BL, and 65.7% in open (log-rank p = 0.58). CONCLUSION: Obesity does not increase complications or shorten dysfunction-free PD catheter survival regardless of the operative technique used. Obesity should not be considered as a relative contraindication to PD catheter placement as it confers similar technique success to normal- and overweight individuals.

Effect of first cannulation time and dialysis machine blood flows on survival of arteriovenous fistulas.

Background: To study the effect of cannulation time on arteriovenous fistula (AVF) survival. Methods. Analysis of two prospective databases of access operations and dialysis sessions from 12 January 2002 through 4 January 2015 with follow-up until 4 January 2016. First cannulation time (FCT), defined from operation to first cannulation, was categorized as <2 weeks, 2-4 weeks, 4-8 weeks, 8-16 weeks and ≥16 weeks. Early cannulation was defined as FCT within 4 weeks. AVF survival was defined as the date until the AVF was abandoned. Maximum machine blood flow rate (BFR) for the first 29 dialysis sessions on AVF was analysed. Results: Altogether, 1167 AVF with functional dialysis use were analysed: 667 (57%) radial cephalic AVF, 383 (33%) brachiocephalic AVF and 117 (10%) brachiobasilic AVF. The 631 (54%) AVF created in on-dialysis patients were analysed separately from 536 (46%) AVF created in pre-dialysis patients. AVF survival was similar between cannulation categories for both pre-dialysis patients (P = 0.19) and on-dialysis patients (P = 0.83). Early cannulation was associated with similar AVF survival in both pre-dialysis patients (P = 0.82) and on-dialysis patients (P = 0.17). Six consecutive successful cannulations from the start were associated with improved AVF survival (P = 0.0002). A below-median BFR at the start of dialysis was associated with better AVF survival (P < 0.0001). A below-median increase in BFR in the first 2 months was associated with worse AVF survival (P = 0.007). The type of AVF, diabetes, pre-dialysis state at operation and six successful cannulations from the start were independent predictors for AVF survival. Conclusions: FCT is not associated with AVF survival. Failures to achieve six successful cannulations from the start of dialysis and higher machine BFR in the first week of dialysis are associated with decreased AVF survival.

Robot-assisted Laparoscopic Implantation of Brachytherapy Catheters in Bladder Cancer.

BACKGROUND: Robot-assisted laparoscopic (RAL) implantation of brachytherapy catheters (BTCs) can be a minimally invasive alternative to open retropubic implantation. Descriptions of the surgical technique and outcomes are sparse. OBJECTIVE: To describe our technique and perioperative outcomes for RAL BTC implantation in urothelial carcinoma (UC) and urachal carcinoma (UraC). DESIGN, SETTING AND PARTICIPANTS: Between June 2011 and May 2016, 26 patients with cN0M0 solitary T1G3 or T2G1-3 UC of ≤5cm or cN0M0 UraC were scheduled for external beam radiotherapy (20×2Gy), RAL BTC implantation, and pulsed-dose (29×1.04Gy) or high-dose rate brachytherapy (10×2.50Gy). Median follow-up was 12 mo (interquartile range 4-20). SURGICAL PROCEDURE: RAL BTC implantation with or without pelvic lymph node dissection and/or partial cystectomy. MEASUREMENTS AND STATISTICAL ANALYSIS: Perioperative data, complications, disease-free-survival (DFS), local recurrence-free survival (LRFS), and cystectomy-free survival (CFS) were evaluated as well as the feasibility of the technique. RESULTS AND LIMITATIONS: BTC implantation was successful in 92% of the patients. Median hospitalisation was 5 d (interquartile range 4-7) and blood loss <50ml in all cases. DFS was 74% at 1 yr and 63% at 2 yr. LRFS was 80% at 1 and 2 yr, and CFS was 87% at 1 and 2 yr. Early (≤30 d) high-grade complications (Clavien-Dindo ≥3) occurred in 8% of the patients. The study is limited by the small sample size and short follow-up time. CONCLUSIONS: RAL BTC implantation is technically feasible and could serve as safe, minimally invasive alternative to open surgery in selected patients. The results of this study should be confirmed in larger studies. PATIENT SUMMARY: Brachytherapy catheter (BTC) implantation is traditionally carried out via open retropubic surgery. We describe robot-assisted laparoscopic BTC implantation as a minimally invasive alternative. Perioperative outcomes are described and confirm the safety and feasibility of this procedure.