Significance of Blunted Venous Waveforms Seen on Upper Extremity Ultrasound.

BACKGROUND: Current guidelines recommend vascular mapping ultrasound (US) prior to arteriovenous fistula creation. Blunted venous waveforms (BVWs) suggest central venous stenosis; however, this relationship and one between BVWs and the presence of a central venous catheter (CVC) remain unclear. METHODS: All patients who received upper extremity vascular mapping US between January 2013 and October 2014 at a single institution were retrospectively reviewed. Patient demographics, comorbidities, US results, pacemaker history, and CVC status were collected. Waveforms were assessed at the proximal subclavian vein/distal axillary vein and interpreted by radiologists. Patients were determined to have central venous stenosis (CVS) if detected by venography within 6 months of US. RESULTS: There were 342 patients, of which 165 (48%) had a current CVC and 29 (8.5%) had BVW of at least 1 arm. Right-sided BVW were associated with a history of a prior ipsilateral CVC (odds ratio [OR] = 4.5, 95% confidence interval [CI] = 1.6-12.6, P = 0.009). Of the 342 patients, 69 (20%) had a venogram within 6 months. Seventeen (25%) of the 69 patients had CVS, with 7 involving the left subclavian vein, 8 the right subclavian vein, and 3 the superior vena cava (one patient had tandem stenoses). A BVW on the left side was not associated with any CVS. A BVW on the right side was associated with an ipsilateral CVS (OR = 5.8, 95% CI = 1.2-27.4, P = 0.04). This association persisted in the setting of a prior CVC (relative risk = 1.3, 95% CI = 0.9-2, P = 0.01). CONCLUSIONS: There are associations between right-sided BVW and an ipsilateral subclavian vein stenosis. We recommend that hemodialysis access planning includes venography to rule out central vein stenosis in patients with BVW, especially if right-sided and in the setting of a prior CVC.

A comparison of brachial artery-brachial vein arteriovenous fistulas with arteriovenous grafts in patients with poor superficial venous anatomy.

OBJECTIVE: The autogenous arteriovenous fistula (AVF) has been shown to be superior to the arteriovenous graft (AVG) with respect to cost, complications, and primary patency. Therefore, the National Kidney Foundation Disease Outcomes Quality Initiative guidelines recommend reserving AVGs for patients who do not have adequate superficial venous anatomy to support AVF placement. The brachial artery-brachial vein arteriovenous fistula (BVAVF) has emerged as an autologous last-effort alternative. However, there are limited data comparing BVAVFs and AVGs in patients who are otherwise not candidates for a traditional AVF. METHODS: Patients who received a BVAVF from July 2009 to July 2014 were compared with those who received an AVG during the same period. At our institution, BVAVF and AVG are only performed in patients with poor superficial venous anatomy. Patient demographic data, operative details, and subsequent follow-up were collected. BVAVFs were performed with a two-stage approach, with initial arteriovenous anastomosis, followed by delayed superficialization or transposition. Our primary outcome measure was primary functional assisted patency at 1 year. Patients lost to follow-up were excluded. A subgroup analysis was also performed for patients in whom the BVAVF or the AVG was their first hemodialysis access surgery. RESULTS: During the study period, 29 patients underwent BVAVF and 32 underwent AVG. There were no differences in age, gender, or presence of diabetes between the two groups. The median days to cannulation from the initial operation were 141 (interquartile range, 94-214) in the BVAVF group and 29 (interquartile range, 14-33) in the AVG group (P < .001). Fewer patients required interventions to maintain or re-establish patency in the BVAVF group than in the AVG group (10% v. 44%; P < .01). The 1-year primary patency was greater for BVAVF (62% vs 25%; P < .01); however, there was no difference in the functional assisted primary patency rates at 1 year (45% vs 25%; P = .1). Subgroup analysis demonstrated greater 1-year primary functional assisted primary patency (52% vs 19%; P < .05) in patients without prior access surgery. CONCLUSIONS: The BVAVF is a viable alternative to the AVG in patients with inadequate superficial venous anatomy, especially in access-naïve patients. The decision to perform BVAVF must be weighed against the delay in functional maturation expected compared with AVG.

Racial and Gender Differences in Arterial Anatomy of the Arm.

Prior studies have shown racial and gender differences with respect to maturation of arteriovenous fistulas. Women and minorities have lower maturation rates for unclear reasons. Small arterial diameter and high brachial artery bifurcation (HBB) are also implicated in reduced maturation rates. We sought to correlate differences in upper extremity arterial anatomy to race and gender. All upper extremity vascular mapping ultrasounds from 2013 to 2014 were retrospectively reviewed. A total of 509 arms in 284 patients were evaluated. Men had significantly higher mean arterial diameters than women at the elbow brachial (4.7 vs 3.9 mm, P < 0.01) and wrist radial arteries (2.1 vs 1.9 mm, P = 0.03). There were 20 (7%) patients with HBB of at least one arm, and 7 (2.5%) patients with bilateral HBB. African-American patients had significantly higher rates of both unilateral HBB (15.9% vs 5.4%, P = 0.02) and bilateral HBBs (9.1% vs 1.3%, P = 0.01). In conclusion, men had significantly larger arteries than women, and African-Americans had a higher rate of HBB than non-African-Americans. Consideration should be given for routine preoperative ultrasound to assess arterial anatomy before arteriovenous fistulas creation, particularly in women and in African-Americans.

Pulsed dye laser treatment of primary cryptococcal laryngitis: A novel approach to an uncommon disease.

An 82-year-old supplemental oxygen dependent woman with severe COPD presented with an eight month history of worsening hoarseness and stridor. Office laryngoscopy revealed laryngeal edema and ulcerative masses throughout the larynx. In-office biopsies were positive for Cryptococcus neoformans. This report details a novel approach to the treatment of cryptococcal laryngitis, a combination of in-office pulsed-dye laser (PDL) ablation and medical therapy. Despite treatment with oral fluconazole, the recommended treatment for cryptococcal laryngitis the patient continued to be symptomatic with dysphonia and throat discomfort. Repeated laryngeal exam demonstrated persistent cryptococcal nodules. The patient was subsequently effectively treated with an in-office PDL laser. This case demonstrates the efficacy of in-office laser treatment for residual laryngeal Cryptococcus. For patients like this one, who have failed medical therapy and are unfit for general anesthetic, the in-office laser provides an excellent alternative treatment approach.

Effects of statin therapy on coronary artery plaque volume and high-risk plaque morphology in HIV-infected patients with subclinical atherosclerosis: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: HIV-infected patients have a high risk of myocardial infarction. We aimed to assess the ability of statin treatment to reduce arterial inflammation and achieve regression of coronary atherosclerosis in this population. METHODS: In a randomised, double-blind, placebo-controlled trial, 40 HIV-infected participants with subclinical coronary atherosclerosis, evidence of arterial inflammation in the aorta by fluorodeoxyglucose (FDG)-PET, and LDL-cholesterol concentration of less than 3.37 mmol/L (130 mg/dL) were randomly assigned (1:1) to 1 year of treatment with atorvastatin or placebo. Randomisation was by the Massachusetts General Hospital (MGH) Clinical Research Pharmacy with a permuted-block algorithm, stratified by sex with a fixed block size of four. Study codes were available only to the MGH Research Pharmacy and not to study investigators or participants. The prespecified primary endpoint was arterial inflammation as assessed by FDG-PET of the aorta. Additional prespecified endpoints were non-calcified and calcified plaque measures and high risk plaque features assessed with coronary CT angiography and biochemical measures. Analysis was done by intention to treat with all available data and without imputation for missing data. The trial is registered with ClinicalTrials.gov, number NCT00965185. FINDINGS: The study was done from Nov 13, 2009, to Jan 13, 2014. 19 patients were assigned to atorvastatin and 21 to placebo. 37 (93%) of 40 participants completed the study, with equivalent discontinuation rates in both groups. Baseline characteristics were similar between groups. After 12 months, change in FDG-PET uptake of the most diseased segment of the aorta was not different between atorvastatin and placebo, but technically adequate results comparing longitudinal changes in identical regions could be assessed in only 21 patients (atorvastatin Δ -0.03, 95% CI -0.17 to 0.12, vs placebo Δ -0.06, -0.25 to 0.13; p=0.77). Change in plaque could be assessed in all 37 people completing the study. Atorvastatin reduced non-calcified coronary plaque volume relative to placebo: median change -19.4% (IQR -39.2 to 9.3) versus 20.4% (-7.1 to 94.4; p=0.009, n=37). The number of high-risk plaques was significantly reduced in the atorvastatin group compared with the placebo group: change in number of low attenuation plaques -0.2 (95% CI -0.6 to 0.2) versus 0.4 (0.0, 0.7; p=0.03; n=37); and change in number of positively remodelled plaques -0.2 (-0.4 to 0.1) versus 0.4 (-0.1 to 0.8; p=0.04; n=37). Direct LDL-cholesterol (-1.00 mmol/L, 95% CI -1.38 to 0.61 vs 0.30 mmol/L, 0.04 to 0.55, p<0.0001) and lipoprotein-associated phospholipase A2 (-52.2 ng/mL, 95% CI -70.4 to -34.0, vs -13.3 ng/mL, -32.8 to 6.2; p=0.005; n=37) decreased significantly with atorvastatin relative to placebo. Statin therapy was well tolerated, with a low incidence of clinical adverse events. INTERPRETATION: No significant effects of statin therapy on arterial inflammation of the aorta were seen as measured by FDG-PET. However, statin therapy reduced non-calcified plaque volume and high-risk coronary plaque features in HIV-infected patients. Further studies should assess whether reduction in high-risk coronary artery disease translates into effective prevention of cardiovascular events in this at-risk population. FUNDING: National Institutes of Health, Harvard Clinical and Translational Science Center, National Center for Research Resources.

Increased arterial inflammation relates to high-risk coronary plaque morphology in HIV-infected patients.

BACKGROUND: Mechanisms predisposing HIV-infected patients to increased cardiovascular disease (CVD) risk remain unclear. OBJECTIVE: To determine the interrelationship between arterial inflammation and high-risk coronary plaque morphology in HIV-infected patients with subclinical coronary atherosclerosis. METHODS: Forty-one HIV-infected patients on stable antiretroviral therapy without known CVD but with atherosclerotic plaque on coronary CT angiography were evaluated with F-FDG-PET. Patients were stratified into 2 groups based on relative degree of arterial inflammation [aortic target-to-background ratio (TBR)]. High-risk coronary atherosclerotic plaque morphology features were compared between groups. RESULTS: HIV-infected patients with higher and lower TBRs were similar with respect to traditional CVD risk parameters. Among HIV-infected patients with higher TBR, an increased percentage of patients demonstrated at least 1 low-attenuation coronary atherosclerotic plaque (40% vs. 10%, P = 0.02) and at least 1 coronary atherosclerotic plaque with both low attenuation and positive remodeling (35% vs. 10%, P = 0.04). Moreover, in the higher TBR group, both the number of low-attenuation plaques per patient (P = 0.02) and the number of vulnerability features in the most vulnerable plaque (P = 0.02) were increased. TBR grouping remained significantly related to the number of low-attenuation plaques/subject (ß = 0.35, P = 0.004), controlling for age, gender, low-density lipoprotein, duration of HIV, and CD4. CONCLUSIONS: These data demonstrate a relationship between arterial inflammation on F-FDG-PET and high-risk coronary atherosclerotic plaque features among HIV-infected patients with subclinical coronary atherosclerosis. Further studies are needed to determine whether arterial inflammation and related high-risk coronary morphology increase the risk of clinical CVD events in the HIV population.

High-density lipoprotein-mediated cholesterol efflux capacity is improved by treatment with antiretroviral therapy in acute human immunodeficiency virus infection.

BACKGROUND: Individuals infected with human immunodeficiency virus (HIV) have decreased high-density lipoprotein (HDL)-cholesterol and increased cardiovascular disease (CVD). Reverse cholesterol transport from macrophages may be inhibited by HIV and contribute to increased CVD. Human studies have not investigated longitudinal effects of HIV and antiretroviral therapy (ART) on cholesterol efflux. METHODS: Subjects with acute HIV infection were randomized to ART or not. Cholesterol efflux capacity was determined ex vivo after exposure of murine macrophages to apolipoprotein B-depleted patient sera obtained at baseline and after 12 weeks. RESULTS: After 12 weeks, HIV RNA decreased most in subjects randomized to ART. Available data on cholesterol demonstrated that efflux capacity from Abca1(+/+) macrophages was increased most by sera obtained from ART-treated subjects (20.5% ± 5.0% to 24.3 % ± 6.9%, baseline to 12 weeks, P = .007; ART group [n = 6] vs 18.0 % ± 3.9% to 19.1 % ± 2.9%, baseline to 12 weeks, P = .30; untreated group [n = 6] [P = .04 ART vs untreated group]). Change in HIV RNA was negatively associated with change in Abca1(+/+) macrophage cholesterol efflux (r = - 0.62, P = .03), and this finding remained significant (P = .03) after controlling for changes in HDL-cholesterol, CD4(+) cells, and markers of monocyte or macrophage activation. CONCLUSIONS: In subjects acutely infected with HIV, ATP-binding cassette transporter A1-mediated cholesterol efflux was stimulated to a greater degree over time by apolipoprotein B-depleted serum from subjects randomized to ART. The improvement in cholesterol efflux capacity is independently related to reduction in viral load.