Outcomes of arteriovenous fistula for hemodialysis in octogenarian population.

Introduction Guidelines have been recommending the use of arteriovenous fistula among the hemodialysis population, but no clear conclusion has emerged with regard to the adequate access type in octogenarians. In this paper, the outcomes of arteriovenous fistula in octogenarian cohort were presented for death-censored cumulative patency rate, complications, and patients' survival rate. Methods A retrospective review of 88 consecutive arteriovenous fistula interventions in 70 octogenarian patients were performed at one referral institution between January 2010 and June 2014. The patients' records were analyzed and postoperative complications were documented. Death-censored cumulative arteriovenous fistula patency rates were calculated, and Kaplan-Meier method was used to analyze patient survival for 24 months. FINDINGS: Eighty-eight arteriovenous fistula constructions and six salvage procedures were performed in 70 octogenarians. Fifty-four (61.3%) forearm and 34 (38.7%) upper arm fistulas were created. All types of fistulas had 6-, 12-, 18-, and 24-month death-censored cumulative patency rates of 63.6%, 58.3%, 48.8%, and 41.4%, respectively. The primary failure rate was 40.9%. A total of 15 complications were documented as edema, hematoma/bleeding, infection, distal ischemia, and venous aneurysm, all of which had been treated. Patient survival rates for 12 and 24 months were 68.5% and 58.5%, respectively. DISCUSSION AND CONCLUSION: This analysis regarding arteriovenous fistula in octogenarian end-stage renal disease patients figured out equal death-censored cumulative patency compared to nonelderly, and two-year survival rate was acceptable. This study strengthens the argument that arteriovenous fistula should be the best proper choice in selected octogenarians; older age only should not be considered as an absolute contraindication for arteriovenous fistula creation in octogenarians; and patient-based approach should be applied.

Myocardial injury during off-pump surgery. The effect of intraoperative risk factors.

OBJECTIVE: To achieve better outcomes, the degree of myocardial injury due to off-pump coronary artery bypass surgery (OPCAB) must be reduced. We studied the factors that render patients scheduled for OPCAB vulnerable to myocardial injury, using troponin T (cTnT) as a marker of myocardial injury. METHODS: We prospectively investigated 123 patients being operated by a group of surgeons with off-pump technique between January 2001 and June 2006 in Siyami Ersek Thoracic and Cardiovascular Surgery Center. Myocardial injury occurring during surgery was assessed by post-operative cTnT measurement. Then, the relation between intraoperative factors and postoperative cTnT release were statistically evaluated. RESULTS: Blood samples for cTnT measurement were taken from all patients before operation, immediately after arrival at the intensive care unit, then at 6, 12, and 24 hours after distal revascularization. When regarding the intraoperative risk factors, we found that the heart rate, blood pressure and anastomosis time are the main determinant of myocardial cell injury occurring during OPCAB surgery. CONCLUSION: Although aortic cross-clamp and cardioplegic arrest were not used in off-pump myocardial revascularization, the ischemic myocardial cell destruction was also inevitable in off-pump technique. Therefore, management of heart rate and myocardial contractility was desirable not only for precise anastomosis but also for myocardial protection during OPCAB surgery.