Cilostazol May Improve Maturation Rates and Durability of Vascular Access for Hemodialysis.

Cilostazol is effective in controlling pathophysiological pathways similar or identical to those involved in nonmaturation and failure of the arteriovenous access. This case-control study examined whether cilostazol would improve maturation rates and durability of vascular access for hemodialysis. The treatment group included 33 patients who received cilostazol for ≥30 days prior to creation of a dialysis access and continued with cilostazol therapy for ≥60 days after surgery. The matched (gender, age, race, diabetes, and the year of surgery) control group included 116 patients who underwent the same procedure but did not receive cilostazol prior to and at least 3 months after surgery. Primary outcomes were maturation and, for those that matured, time of functioning access, defined as the time from the first use to irreparable failure of the access. Secondary outcomes were time to maturation, complications, and time to first complication. Study group patients were 3.8 times more likely to experience fistula maturation compared to the controls (88% vs 66%, RR = 3.8, 95% confidence interval: 1.3-11.6, P = .016). Fewer patients in the study group had complications (76% vs 92%, P = .025), and the time from construction of the fistula to the first complication was longer (345.6 ± 441 days vs 198.3 ± 185.0 days, P = .025). Time to maturation was similar in both groups (119.3 ± 62.9 days vs 100.2 ± 61.7 days, P = .2). However, once matured, time to failure was significantly longer in the treatment group (903.7 ± 543.6 vs 381.6 ± 317.2 days, P = .001). Multivariate analysis confirmed that the likelihood of maturation was significantly higher in the treatment group patients. These results suggest that dialysis access patients may benefit from preoperative and postoperative cilostazol therapy. If confirmed by a randomized trial, this treatment will have a major beneficial impact on patients dependent on a well-functioning access for their hemodialysis.

Chronic venous insufficiency due to great saphenous vein incompetence treated with radiofrequency ablation: an effective and safe procedure in the elderly.

Chronic venous insufficiency (CVI) with the resultant clinical sequelae significantly reduces quality of life. Most elderly patients with CVI are treated nonoperatively owing to concerns of increased operative risk and therefore suffer more advanced disease. Radiofrequency ablation (RFA) has emerged as a minimally invasive procedure to treat patients with superficial venous insufficiency (SVI) due to great saphenous vein (GSV) incompetence. The purpose of this study was to review our experience using RFA of the GSV to treat CVI due to superficial disease in elderly patients compared to younger patients in terms of procedure-related morbidity and severity of disease at time of treatment. RFA treatment of the GSV was performed in 490 extremities of 421 patients with SVI between March 2001 and December 2002. Indications, medical history, and outcome (operative complications and hospital stay) were compared between 2 groups: Group I:41 extremities of 35 patients, 70 years if age or older (mean 75 +/-4); and Group II:449 limbs of 386 patients younger than 70 years (mean 47 +/-11). The incidence of skin pigmentation and healed/nonhealed ulcers (CEAP 4-6) was significantly higher in the elderly than in the younger group (41% vs 16%, p <0.05). Hypertension, diabetes, and previous myocardial infarction were 2.8, 5.4, and 6.7 times more prevalent in the elderly (p <0.05), respectively. There were no major postoperative complications in either group; 97% of all patients were discharged on the day of operation and there was no difference between the 2 groups in overnight hospital stay. There is a treatment bias against operative management in elderly patients with SVI, as evidenced by their more advanced disease at the time of definitive treatment than their younger cohort. However, operative morbidity is no different compared to the younger subset. RFA is a safe and effective procedure for older patients; therefore, the threshold for operative management of older patients should be lowered.

Ultrasound findings after radiofrequency ablation of the great saphenous vein: descriptive analysis.

OBJECTIVE: As an emerging endovascular alternative to ligation and stripping of the incompetent greater saphenous vein (GSV), radiofrequency ablation was monitored with ultrasound scanning to evaluate anatomic results. Neovascularization and inflammation are potential consequences that lead to the appearance of small vessels. The natural history of the below-knee untreated GSV segment may be important in our understanding of ongoing chronic venous disease. An ultrasound follow-up study was conducted to determine the prevalence of small vessel networks, defined as veins and arteries less than 2 mm in diameter, adjacent to the saphenofemoral junction (SFJ); prevalence of small vessel networks adjacent to the treated GSV in the thigh; and fate of the below-knee untreated GSV distal to the ablated segment. METHODS: One hundred six extremities with radiofrequency ablation of the GSV for treatment of superficial venous insufficiency were followed up with high-resolution ultrasound imaging 4 to 25 months (median, 9 months) after the procedure. Ninety-three limbs had concomitant ligation and division of the SFJ and its tributaries, and 13 limbs underwent radiofrequency ablation without SFJ ligation. Ultrasound was used to evaluate patients for small vessel networks, and concomitant findings of small vessel networks and recanalization at the SFJ and adjacent to the treated GSV. The status of the below-knee segment of untreated GSV was evaluated for patency and reflux. Data analysis compared the findings in the ligation group with those in the no-ligation group, with the chi 2 test and Fisher exact test. RESULTS: We found small vessel networks in 65% (n = 69) of extremities: 15% (n = 16) at the SFJ only, 26% (n = 28) in the thigh only, and 24% (n = 25) at both the SFJ and thigh, resulting in a small vessel network prevalence of 39% (n = 41) at the SJF and 50% (n = 53) in the thigh. The prevalence of small vessel networks at the SFJ was significantly less after radiofrequency ablation with SFJ ligation (34%, 32 of 93) than after radiofrequency ablation without ligation (69%, 9 of 13; P = .035). Small vessel networks and GSV recanalization at the SFJ was more common in patients undergoing radiofrequency ablation without ligation (46%, 6 of 13) than after radiofrequency ablation with ligation (14%, 13 of 93; P = .014). The prevalence of small vessel networks in the thigh was not affected by SFJ ligation. The below-knee GSV was patent in 79% (84 of 106), and 58% (61 of 106) demonstrated reflux, a decrease from the pre-radiofrequency ablation rate of 71% (75 of 106), possibly because thrombosis extended distally beyond the ablated segment in 16% (17 of 106) of the legs. CONCLUSIONS: Small vessel networks were detected adjacent to or in connection with most of the radiofrequency ablation-treated GSVs. SFJ ligation was associated with fewer small vessel networks and proximal GSV recanalization. Most below-knee untreated GSV segments remained patent, and most exhibited reflux.

Factors related to short length of stay after carotid endarterectomy.

In the past decade, expected in-hospital length of stay (LOS) after carotid endarterectomy (CEA) has decreased from 4 days to 1. Long LOS is associated with known complications and factors affecting severity of the patient's condition. Factors affecting an intermediate stay of 2 to 4 days need further clarification. The vascular registry at Jobst Vascular Center includes data on manifestation of disease; cardiovascular history; operation and discharge dates; surgeon; surgical details such as patching, shunting, and completion arteriography; and complications. Univariate chi-square and ANOVA and multivariate logistic regression were applied to analyze 635 CEAs performed in 1998, 1999, and 2000. Statistical significance was at a p value less than 0.05 (two-sided). Overall morbidity rate was 8.2% with three (0.5%) in-hospital neurologic complications and one death for a 0.16% mortality rate. Fifty-eight percent of the patients were discharged in 1 day. Patients staying 1 day were 3 years younger. Female gender and prior cerebrovascular accident were factors extending LOS to 2 and 3 days. History of angina, heart failure, valve disease, and vein patch or no patch contributed to LOS of 3 or 4 days. Completion arteriography had an association with LOS of 2 days. The relative percentage of patients with complications increased with LOS. No significant relationship was found for symptoms, smoking, myocardial infarction, atrial fibrillation, cardiac revascularization, or surgeon. Insulin-treated diabetes mellitus, cardiac risk factors, cerebrovascular accident, and vein patch or no patch correlated with prolonged hospitalization. Factors were identified that may alter a clinical pathway designed for discharge 1 day after CEA. Focused management of patients with cardiac and cerebrovascular accident history or requiring vein patch and a better understanding of CEA in women may further increase the percentage of patients discharged 1 day after CEA.