Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 2.394
Filtrar
2.
Clin Neurol Neurosurg ; 209: 106931, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34517166

RESUMO

OBJECTIVES: The collateral effect of the COVID-19 pandemic on interventional stroke care is not well described. We studied this effect by utilizing stroke device sales data as markers of interventional stroke case volume in the United States. METHODS: Using a real-time healthcare device sales registry, this observational study examined trends in the sales of thrombectomy devices and cerebral aneurysm coiling from the same 945 reporting hospitals in the U.S. between January 22 and June 31, 2020, and for the same months in 2018 and 2019 to allow for comparison. We simultaneously reviewed daily reports of new COVID-19 cases. The strength of association between the cumulative incidence of COVID-19 and procedural device sales was measured using Spearman rank correlation coefficient (CC). RESULTS: Device sales decreased for thrombectomy (- 3.7%) and cerebral aneurysm coiling (- 8.5%) when comparing 2019-2020. In 2020, thrombectomy device sales were negatively associated with the cumulative incidence of COVID-19 (CC - 0.56, p < 0.0001), with stronger negative correlation during April (CC - 0.97, p < 0.0001). The same negative correlation was observed with aneurysm treatment devices (CC - 0.60, p < 0.001), with stronger correlation in April (CC - 0.97, p < 0.0001). CONCLUSIONS: The decline in sales of stroke interventional equipment underscores a decline in associated case volumes. Future pandemic responses should consider strategies to mitigate such negative collateral effects.


Assuntos
COVID-19/epidemiologia , Comércio/tendências , Acidente Vascular Cerebral/epidemiologia , Trombectomia/tendências , Dispositivos de Acesso Vascular/tendências , COVID-19/prevenção & controle , Humanos , Aneurisma Intracraniano/epidemiologia , Aneurisma Intracraniano/terapia , Pandemias , Acidente Vascular Cerebral/terapia , Trombectomia/economia , Estados Unidos/epidemiologia , Dispositivos de Acesso Vascular/economia
4.
Pediatr Surg Int ; 37(11): 1621-1625, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34374819

RESUMO

PURPOSE: Osteogenesis imperfecta (OI) is a genetic disorder that causes skeletal fragility. For the most fragile infants and young children with OI, intravenous (IV) bisphosphonate administration is essential, but IV access attempts often cause fractures. Port-a-caths help prevent these events, but some surgeons are hesitant to insert these devices in these infants due to lack of data on their safety. METHODS: Retrospective study of pediatric patients with OI who underwent port-a-cath placement from 1999 to 2018; incidence of complications such as infection and thrombosis and need for reoperation or replacement are described. RESULTS: Port-a-caths were placed in 17 patients with OI (median age, 8 mos [5-23 mos]; median weight, 5.8 kg [3.96-9.08 kg]) and remained in place for a median of 53.5 mos (10-127 mos). One port-a-cath was replaced because of thrombosis. Two port-a-caths were removed because of malfunction, one for skin erosion, and one for infection. In these five cases, replacement was not needed because patients could safely tolerate IV access. Two patients have their port-a-cath in place and the remaining ten patients had theirs removed electively as it was no longer needed. CONCLUSION: Port-a-cath placement in pediatric patients with OI is safe and efficacious for durable central access, enabling reliable IV bisphosphonate delivery and reducing iatrogenic trauma.


Assuntos
Osteogênese Imperfeita , Trombose , Dispositivos de Acesso Vascular , Criança , Pré-Escolar , Humanos , Lactente , Infusões Intravenosas , Osteogênese Imperfeita/tratamento farmacológico , Estudos Retrospectivos
5.
Am J Crit Care ; 30(4): 295-301, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34195778

RESUMO

BACKGROUND: More than 1 billion peripheral vascular access devices are inserted annually worldwide with potential complications including infection, thrombosis, and vasculature damage. Vasculature damage can necessitate the use of central catheters, which carry additional risks such as central catheter-associated bloodstream infections. To address these concerns, one institution used expert nurses and a consult request system with algorithms embedded in the electronic medical record. OBJECTIVES: To develop a uniform process for catheter insertion by means of a peripheral vascular access service dedicated to selecting, placing, and maintaining all inpatient peripheral catheters outside of the intensive care units. METHODS: Descriptive analysis and χ2 analysis were done to describe the impact of the peripheral vascular access service. RESULTS: In 2018, 6246 consults were reviewed. Of these, 26% did not require vascular access. Similarly, in 2019, 7861 consults were reviewed, and 35.3% did not require vascular access. Use of central catheters decreased from 21% in 2017 to 17% in 2018 and 2019. CONCLUSIONS: The peripheral vascular access service allowed patients to receive appropriate peripheral vascular access devices and avoid unnecessary peripheral catheter placements. This may have preserved patients' peripheral vasculature and thus prevented premature central catheter placement and contributed to an overall decrease in central catheter days. With the peripheral vascular access service, peripheral vascular access devices were selected, placed, and maintained by experts with a standardized process that promoted a culture of quality and patient safety.


Assuntos
Infecções Relacionadas a Cateter , Cateterismo Venoso Central , Cateterismo Periférico , Cateteres Venosos Centrais , Dispositivos de Acesso Vascular , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Humanos , Unidades de Terapia Intensiva , Dispositivos de Acesso Vascular/efeitos adversos
6.
Cochrane Database Syst Rev ; 7: CD002786, 2021 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-34298589

RESUMO

BACKGROUND: People with end-stage renal disease (ESRD) often require either the formation of an arteriovenous fistula (AVF) or an interposition prosthetic arteriovenous graft (AVG) for haemodialysis. These access sites should ideally have a long life and a low rate of complications (e.g. thrombosis, infection, stenosis, aneurysm formation and distal limb ischaemia). Although some of the complications may be unavoidable, any adjuvant technique or medical treatment aimed at decreasing complications would be welcome. This is the fourth update of the review first published in 2003. OBJECTIVES: To assess the effects of adjuvant drug treatment in people with ESRD on haemodialysis via autologous AVFs or prosthetic interposition AVGs. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and ClinicalTrials.gov trials register to 6 August 2020. SELECTION CRITERIA: Randomised controlled trials of active drug versus placebo in people with ESRD undergoing haemodialysis via an AVF or prosthetic interposition AVG. DATA COLLECTION AND ANALYSIS: For this update, two review authors (IM, MFAK) independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the certainty of the evidence according to GRADE. We resolved disagreements by discussion or consultation with another review author (ADS). The primary outcome was the long-term fistula or graft patency rate. Secondary outcomes included duration of hospital stay; complications such as infection, aneurysm formation, stenosis and distal limb ischaemia; and number of related surgical or radiological interventions. MAIN RESULTS: For this update, one additional study was suitable for inclusion, making a total of 13 trials with 2080 participants. Overall the certainty of the evidence was low or moderate due to short follow-up periods, heterogeneity between trials, small sample sizes, and risk of bias due to incomplete reporting. Medical adjuvant treatments used in the included trials were aspirin, ticlopidine, dipyridamole, dipyridamole plus aspirin, warfarin, fish oil, clopidogrel, sulphinpyrazone and glyceryl trinitrate (GTN) patch.  All included studies reported on graft patency by measuring graft thrombosis. There was insufficient evidence to determine if there was a difference in graft patency in studies comparing aspirin versus placebo (odds ratio (OR) 0.40, 95% confidence interval (CI) 0.07 to 2.25; 3 studies, 175 participants; low-certainty evidence). The meta-analysis for graft patency comparing ticlopidine versus placebo favoured ticlopidine (OR 0.45, 95% CI 0.25 to 0.82; 3 studies, 339 participants; moderate-certainty evidence). There was insufficient evidence to determine if there was a difference in graft patency in studies comparing fish oil versus placebo (OR 0.24, 95% CI 0.03 to 1.95; 2 studies, 220 participants; low-certainty evidence); and studies comparing clopidogrel and placebo (OR 0.40, 95% CI 0.13 to 1.19; 2 studies, 959 participants; moderate-certainty evidence). Similarly, there was insufficient evidence to determine if there was a difference in graft patency comparing the effect of dipyridamole versus placebo (OR 0.46, 95% CI 0.11 to 1.94; 1 study, 42 participants, moderate-certainty evidence) and dipyridamole plus aspirin versus placebo (OR 0.64, CI 0.16 to 2.56; 1 study, 41 participants; moderate-certainty evidence); comparing low-intensity warfarin with placebo (OR 1.76, 95% CI 0.78 to 3.99; 1 study, 107 participants; low-certainty evidence); comparing sulphinpyrazone versus placebo (OR 0.43, 95% CI 0.03 to 5.98; 1 study, 16 participants; low-certainty evidence) and comparing GTN patch and placebo (OR 1.26, 95% CI 0.63 to 2.54; 1 study, 167 participants; moderate-certainty evidence). The single trial evaluating warfarin was terminated early because of major bleeding events in the warfarin group. Only two studies published data on the secondary outcome of related interventions (surgical or radiological); there was insufficient evidence to determine if there was a difference in related interventions between placebo and treatment groups. None of the included studies reported on the duration of hospital stay.  Most studies reported complications ranging from mortality to nausea. However, data on complications were limited and reporting varied between studies. AUTHORS' CONCLUSIONS: The meta-analyses of three studies for ticlopidine (an antiplatelet treatment), which all used the same dose of treatment but with a short follow-up of only one month, suggest ticlopidine may have a beneficial effect as an adjuvant treatment to increase the patency of AVFs and AVGs in the short term. There was insufficient evidence to determine if there was a difference in graft patency between placebo and other treatments such as aspirin, fish oil, clopidogrel, dipyridamole, dipyridamole plus aspirin, warfarin, sulphinpyrazone and GTN patch. The certainty of the evidence was low to moderate due to short follow-up periods, the small number of studies for each comparison, small sample sizes, heterogeneity between trials and risk of bias due to incomplete reporting. Therefore, it appears reasonable to suggest further prospective studies be undertaken to assess the use of these antiplatelet drugs in renal patients with an AVF or AVG.


Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/métodos , Falência Renal Crônica/terapia , Inibidores da Agregação Plaquetária/uso terapêutico , Grau de Desobstrução Vascular/efeitos dos fármacos , Quimioterapia Adjuvante , Óleos de Peixe/uso terapêutico , Oclusão de Enxerto Vascular/prevenção & controle , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Diálise Renal/métodos , Ticlopidina/uso terapêutico , Dispositivos de Acesso Vascular
7.
BMC Cardiovasc Disord ; 21(1): 326, 2021 07 03.
Artigo em Inglês | MEDLINE | ID: mdl-34217209

RESUMO

BACKGROUND: Drug-coated balloons (DCBs) have shown superiority in the endovascular treatment of short femoropopliteal artery disease. Few studies have focused on outcomes in long lesions. This study aimed to evaluate the safety and effectiveness of Orchid® DCBs in long lesions over 1 year of follow-up. METHODS: This study is a multicentre cohort and real-world study. The patients had lesions longer than or equal to 150 mm of the femoropopliteal artery and were revascularized with DCBs. The primary endpoints were primary patency, freedom from clinically driven target lesion revascularization (TLR) at 12 months and major adverse events (all-cause death and major target limb amputation). The secondary endpoints were the changes in Rutherford classification and the ankle brachial index (ABI). RESULTS: One hundred fifteen lesions in 109 patients (mean age 67 ± 11 years, male proportion 71.6%) were included in this study. The mean lesion length was 252.3 ± 55.4 mm, and 78.3% of the lesions were chronic total occlusion (CTO). Primary patency by Kaplan-Meier estimation was 98.1% at 6 months and 82.1% at 12 months. The rate of freedom from TLR by Kaplan-Meier estimation was 88.4% through 12 months. There were no procedure- or device-related deaths through 12 months. The rate of all-cause death was 2.8%. Cox regression analysis suggested that renal failure and critical limb ischaemia (CLI) were statistically significant predictors of the primary patency endpoint. CONCLUSION: In our real-world study, DCBs were safe and effective when used in long femoropopliteal lesions, and the primary patency rate at 12 months by Kaplan-Meier estimation was 82.1%.


Assuntos
Angioplastia com Balão/instrumentação , Materiais Revestidos Biocompatíveis , Artéria Femoral , Doença Arterial Periférica/terapia , Artéria Poplítea , Dispositivos de Acesso Vascular , Idoso , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/mortalidade , Pequim , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
8.
Lancet ; 398(10298): 403-415, 2021 07 31.
Artigo em Inglês | MEDLINE | ID: mdl-34297997

RESUMO

BACKGROUND: Hickman-type tunnelled catheters (Hickman), peripherally inserted central catheters (PICCs), and totally implanted ports (PORTs) are used to deliver systemic anticancer treatment (SACT) via a central vein. We aimed to compare complication rates and costs of the three devices to establish acceptability, clinical effectiveness, and cost-effectiveness of the devices for patients receiving SACT. METHODS: We did an open-label, multicentre, randomised controlled trial (Cancer and Venous Access [CAVA]) of three central venous access devices: PICCs versus Hickman (non-inferiority; 10% margin); PORTs versus Hickman (superiority; 15% margin); and PORTs versus PICCs (superiority; 15% margin). Adults (aged ≥18 years) receiving SACT (≥12 weeks) for solid or haematological malignancy from 18 oncology units in the UK were included. Four randomisation options were available: Hickman versus PICCs versus PORTs (2:2:1), PICCs versus Hickman (1:1), PORTs versus Hickman (1:1), and PORTs versus PICCs (1:1). Randomisation was done using a minimisation algorithm stratifying by centre, body-mass index, type of cancer, device history, and treatment mode. The primary outcome was complication rate (composite of infection, venous thrombosis, pulmonary embolus, inability to aspirate blood, mechanical failure, and other) assessed until device removal, withdrawal from study, or 1-year follow-up. This study is registered with ISRCTN, ISRCTN44504648. FINDINGS: Between Nov 8, 2013, and Feb 28, 2018, of 2714 individuals screened for eligibility, 1061 were enrolled and randomly assigned, contributing to the relevant comparison or comparisons (PICC vs Hickman n=424, 212 [50%] on PICC and 212 [50%] on Hickman; PORT vs Hickman n=556, 253 [46%] on PORT and 303 [54%] on Hickman; and PORT vs PICC n=346, 147 [42%] on PORT and 199 [58%] on PICC). Similar complication rates were observed for PICCs (110 [52%] of 212) and Hickman (103 [49%] of 212). Although the observed difference was less than 10%, non-inferiority of PICCs was not confirmed (odds ratio [OR] 1·15 [95% CI 0·78-1·71]) potentially due to inadequate power. PORTs were superior to Hickman with a complication rate of 29% (73 of 253) versus 43% (131 of 303; OR 0·54 [95% CI 0·37-0·77]). PORTs were superior to PICCs with a complication rate of 32% (47 of 147) versus 47% (93 of 199; OR 0·52 [0·33-0·83]). INTERPRETATION: For most patients receiving SACT, PORTs are more effective and safer than both Hickman and PICCs. Our findings suggest that most patients receiving SACT for solid tumours should receive a PORT within the UK National Health Service. FUNDING: UK National Institute for Health Research Health Technology Assessment Programme.


Assuntos
Antineoplásicos/administração & dosagem , Cateterismo Periférico , Cateteres de Demora , Cateteres Venosos Centrais , Neoplasias/tratamento farmacológico , Dispositivos de Acesso Vascular , Adulto , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Infecções Relacionadas a Cateter/etiologia , Cateterismo Periférico/efeitos adversos , Cateteres de Demora/efeitos adversos , Cateteres de Demora/economia , Cateteres Venosos Centrais/efeitos adversos , Cateteres Venosos Centrais/economia , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dispositivos de Acesso Vascular/economia , Adulto Jovem
9.
Br J Nurs ; 30(14): S14-S22, 2021 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-34288752

RESUMO

In the UK, the Medicines and Healthcare products Regulatory Agency classifies 'pre-filled syringes' for flushing Intravenous (IV) cannulas and IV access devices as 'borderline' devices and offers some advice on how control measures can help mitigate risks. The Medicines Act (1968) and Medical Device Regulations try to address the legal position of these devices and allow each employer to identify those groups of staff allowed to use them. In turn, this may help address anomalies around the need to prescribe and document their use. This article describes how one large university health board in Wales implemented a change in products and practice and explores the issues around adopting and using CE-marked pre-filled, sterile syringes of 0.9% sodium chloride in place of manually drawing up an IV flush (the CE mark indicates devices that conforms with European legal requirements). Whether the use of individual components or a single pre-filled device can lead to a streamlined and cost-effective way to manage the flushing of IV cannula and vascular access devices was explored. Additional risk factors were identified, and the legal status clarified in line with current guidelines and regulations. As 0.9% sodium chloride in ampoules and vials is classified as a prescription-only medicine, the administration needs control via formal prescription or a patient group direction. Adopting and using these pre-filled syringes as CE-marked medical devices requires careful consideration and sign-off from each employing authority, before implementing them for flushing IV cannulas and IV access devices.


Assuntos
Padrões de Prática em Enfermagem , Solução Salina , Seringas , Irrigação Terapêutica , Cânula , Humanos , Padrões de Prática em Enfermagem/legislação & jurisprudência , Solução Salina/administração & dosagem , Irrigação Terapêutica/instrumentação , Irrigação Terapêutica/enfermagem , Dispositivos de Acesso Vascular , País de Gales
10.
Kidney Int ; 100(2): 278-280, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34294208

RESUMO

This commentary uses the negative results of the PAVE (Paclitaxel-coated Balloons and Angioplasty of Arteriovenous Fistulas) study to (i) discuss the role of drug-coated balloons in the armamentarium of therapies for dialysis vascular access stenosis and (ii) suggest a more patient centered, individualized, and precision medicine-based approach for the future care of patients with dialysis vascular access dysfunction.


Assuntos
Angioplastia com Balão , Derivação Arteriovenosa Cirúrgica , Fármacos Cardiovasculares , Preparações Farmacêuticas , Dispositivos de Acesso Vascular , Angioplastia com Balão/efeitos adversos , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Materiais Revestidos Biocompatíveis , Humanos , Diálise Renal/efeitos adversos , Resultado do Tratamento , Grau de Desobstrução Vascular
11.
J Clin Neurosci ; 90: 279-283, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34275564

RESUMO

BACKGROUND: Recently there is a trend for radial first which advocates radial artery access as the first choice to perform diagnostic and interventional neurovascular procedures. Although safer than the conventional common femoral artery access, it is associated with a high rate of radial artery occlusion. Distal radial artery access is recently proposed to avoid this complication. This study aims to assess the feasibility and safety of distal radial artery access across a wide range of interventional neurovascular procedures. MATERIALS AND METHODS: All Interventional neurovascular cases attempted via distal radial artery access from September 2019 till March 2021 were included in the study. Data regarding patient demographics, distal radial artery diameter, access site cannulation, size of the sheath, procedural details including success rate and complications were collected. RESULTS: During the study period, 102 patients underwent 114 procedures via the distal radial artery approach. The mean age of patients was 41.9 ± 15.2 years. Overall procedure success rate via DRA was 94.7% (108/114). 72 diagnostic cerebral angiograms and 36 interventional procedures were successfully completed while six procedures required switching to alternate access. CONCLUSION: Distal radial artery access is a safe and feasible option for diagnostic cerebral angiography and a wide range of neurovascular procedures.


Assuntos
Artéria Radial/diagnóstico por imagem , Radiografia Intervencionista/métodos , Adulto , Idoso , Angiografia Cerebral/métodos , Procedimentos Endovasculares/métodos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Artéria Radial/anatomia & histologia , Estudos Retrospectivos , Dispositivos de Acesso Vascular
13.
Am Heart J ; 239: 90-99, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34052211

RESUMO

BACKGROUND: Arterial hypertension is a common and life-threatening condition and poses a large global health burden. Device-based treatments have been developed as adjunctive or alternative therapy, to be used with or without antihypertensive medication for treating uncontrolled hypertension. The safety and feasibility of chemical renal denervation (RDN) using the Peregrine Catheter and alcohol were demonstrated in a first-in-man and open-label clinical trials, prompting the initiation of the ongoing TARGET BP OFF-MED and TARGET BP I trials. DESIGN: The TARGET BP trials are randomized, blinded, sham-controlled trials designed to assess the safety and efficacy of alcohol-mediated RDN for the treatment of uncontrolled hypertension in the absence of antihypertensive medications (TARGET BP OFF-MED) or in addition to prescribed antihypertensive medications (TARGET BP I). Subjects with confirmed uncontrolled hypertension and suitable renal artery anatomy are randomized (1:1) to receive either RDN using the Peregrine Kit with alcohol (0.6 mL per renal artery) infused through the Peregrine Catheter or diagnostic renal angiography only (sham procedure). TARGET BP OFF-MED completed enrollment and randomized 96 subjects. TARGET BP I will randomize approximately 300 subjects and will transition to an open-label safety cohort of approximately 300 subjects receiving RDN once the primary efficacy endpoint of the Randomized Controlled Trial (RCT) cohort has been met. Primary endpoints are change in mean 24-hour ambulatory systolic blood pressure from baseline to 8 weeks (TARGET BP OFF-MED) and 3 months (TARGET BP I) post-procedure. CONCLUSION: The TARGET BP trials are the first large-scale, international, randomized trials aimed to investigate the safety and BP lowering efficacy of a novel RDN method, with perivascular alcohol delivery using the Peregrine Kit.


Assuntos
Etanol/administração & dosagem , Hipertensão , Artéria Renal/diagnóstico por imagem , Simpatectomia , Dispositivos de Acesso Vascular , Adulto , Anti-Hipertensivos/uso terapêutico , Determinação da Pressão Arterial/métodos , Sistemas de Liberação de Medicamentos/instrumentação , Sistemas de Liberação de Medicamentos/métodos , Desenho de Equipamento , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/terapia , Masculino , Avaliação de Resultados em Cuidados de Saúde/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Soluções Esclerosantes/administração & dosagem , Simpatectomia/instrumentação , Simpatectomia/métodos , Resultado do Tratamento
16.
Am J Kidney Dis ; 78(1): 116-124, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33965296

RESUMO

In the United States, hemodialysis remains the most common treatment modality for kidney failure, chosen by almost 90% of incident patients. A functioning vascular access is key to providing adequate hemodialysis therapy. Recently, major innovations in devices and technology for hemodialysis vascular access care have rapidly changed the landscape. Novel endovascular devices for creation of arteriovenous fistulas may offer a solution to the barriers encountered in initiating maintenance hemodialysis with a permanent vascular access rather than a central venous catheter (CVC). Furthermore, in the prevalent hemodialysis population, the minimally invasive endovascular arteriovenous fistula procedure should help improve long wait times for vascular access creation, which remains a major barrier to reducing CVC dependence. Bioengineered grafts are being developed and may offer another option to polytetrafluoroethylene grafts. Early studies with these biocompatible grafts are promising, as additional studies continue to evaluate their clinical outcomes in comparison to cryopreserved or synthetic options. Prolonging the vascular access patency with appropriate use of devices such as drug-coated balloons and stent grafts may complement the novel techniques of creating arteriovenous access. Finally, innovative solutions to treat stenosed and occluded thoracic central veins can provide an approach to creating a vascular access and allow patients with exhausted vasculature to remain on hemodialysis. The robust developments in hemodialysis vascular access are likely to change practice patterns in the near future.


Assuntos
Falência Renal Crônica/terapia , Diálise Renal/instrumentação , Diálise Renal/métodos , Dispositivos de Acesso Vascular , Desenho de Equipamento , Humanos
20.
J Surg Res ; 265: 33-41, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33882377

RESUMO

BACKGROUND AND OBJECTIVES: Though patient factors are frequently linked to hemodialysis vascular access selection and outcomes, variability by surgeon and surgeon specialty may play a role as well. The objective of this study is to examine the extent to which individual surgeons influence selection of vascular access type, removal of tunneled hemodialysis catheter (THC), and repeat vascular access. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A national claims database was used to identify patients initiating hemodialysis via a THC between 2011 and 2017. Likelihood of repeat AVF/AVG was analyzed using mixed-effects logistic regression. Time from initial arteriovenous fistula (AVF)/graft (AVG) to THC removal and time to repeat AVF/AVG were analyzed using Weibull proportional hazard models. Individual surgeon identifier served as the random effect in all models. RESULTS: 6,908 AVF/AVG met the inclusion criteria: 5366 (78%) AVF and 1,542 (22%) AVG. Surgeon specialty only had a significant influence on access type, with vascular surgeons having 26% greater odds of performing AVG compared to general surgeons (P = 0.006). Relative to the other independent variables, individual surgeon identifier had the greatest magnitude of effect on access type (median odds ratio, 2.36; 95% CI, 2.09-2.72). Individual surgeon identifier had the second greatest magnitude of effect likelihood of THC removal (median hazard ratio, 1.66; 95% CI, 1.58-1.77) and second access (median hazard ratio, 1.83; 95% CI, 1.66-2.05), in both cases second only to the effect of AVG, which was associated with greater likelihood of THC removal (hazard ratio 1.91; 95% CI, 1.77-2.07) and lower likelihood of second access (hazard ratio 0.44; 95% CI, 0.38-0.52). CONCLUSION: Individual surgeons are associated with greater variation in vascular access type and likelihood of repeat access than surgeon specialty and measurable patient demographics/co-morbidities. Future research should focus on identifying which surgeon factors are associated with improved outcomes.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Renal/instrumentação , Estudos Retrospectivos , Dispositivos de Acesso Vascular
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...