Radial artery deviation and reimplantation inhibits venous juxta-anastomotic stenosis and increases primary patency of radial-cephalic fistulas for hemodialysis.

OBJECTIVE: Although the end cephalic vein-to-side radial artery arteriovenous fistula is the "gold standard" procedure for primary hemodialysis access, it is associated with high rates of primary failure because of the development of neointimal hyperplasia and juxta-anastomotic stenosis. We report initial results of a new approach to perform radial-cephalic fistulas, radial artery deviation and reimplantation (RADAR), designed to avoid juxta-anastomotic stenosis. METHODS: RADAR patients' data were prospectively maintained and retrospectively reviewed and compared with a historical control group of traditional radial-cephalic fistulas created in the same center. Duplex ultrasound was used to monitor maturation (flow ≥500 mL/min and venous diameter ≥5 mm) and to diagnose juxta-anastomotic stenosis. Study end points were rates of maturation, juxta-anastomotic stenosis, reintervention, and primary and secondary patency. RESULTS: There were 53 RADAR fistulas performed (follow-up, 10.5 ± 2.6 months) and compared with 73 control fistulas (follow-up, 12.0 ± 6.6 months). RADAR fistulas had increased rates of maturation compared with control fistulas (75% vs 45% at 6 weeks, P = .001; 92% vs 71% at 3 months, P = .003) and decreased incidence of juxta-anastomotic venous stenoses (2% vs 41%; P = .001). At 6 months, RADAR fistulas had increased primary patency (93% vs 53%; P < .0001) and secondary patency (100% vs 89%; P = .0003) and decreased incidence of reinterventions (10% vs 74%; P = .001) compared with control fistulas. No RADAR fistulas caused ischemic symptoms. CONCLUSIONS: The RADAR technique is associated with less juxta-anastomotic stenosis, increased maturation and patency, and fewer secondary interventions. These improved outcomes suggest that RADAR may be the preferred surgical technique to perform radial-cephalic arteriovenous fistula.

Early surgical thrombectomy improves salvage of thrombosed vascular accesses.

OBJECTIVE: The timing and urgency of salvage attempts for acutely thrombosed hemodialysis vascular accesses remain poorly defined. We examined the outcome of early surgical thrombectomy after acute access thrombosis to assess the influence of expedited timing on access salvage. METHODS: Between January 2007 and October 2012, 114 surgical thrombectomy attempts were performed on 82 patients to salvage 89 accesses. The time between the diagnosis of thrombosis and admission to the operative suite (T1), the time between diagnosis and the following dialysis session (T2), and clinical and biologic parameters were collected prospectively. Data were retrospectively compared between the early (T1 <6 hours) and later (T1 >6 hours) treatment groups. The main outcome measure was technical success. Kaplan-Meier survival analysis was used to estimate functional patency rates. RESULTS: Mean patient follow-up was 22 ± 18 months. The mean time from referral to procedure (T1) was 5.7 ± 4.5 hours. The mean time T1 was 3.6 ± 1.2 hours in the early group and 10.3 ± 5.4 hours in the later group. The mean time to dialysis (T2) was 14.3 ± 6.5 hours in the early group and 23.9 ± 9.4 hours in the later group. Thrombectomy performed ≤ 6 hours after diagnosis (T1 <6 hours) had significantly higher technical success of 86% compared with 69% for thrombectomy performed later (T1 >6 hours; P = .04). The two groups did not differ significantly in patient comorbidities, type of access, or adjunctive procedures performed (P ≥ .1). At 12 months, the primary patency rate for all index cases, including technical failures, was 55% ± 7.1% in the early group and 33% ± 9.7% in the later group (P = .13). The secondary patency rate was 67% ± 6.8% in the early group and 50% ± 9.9% in the later group (P = .05). CONCLUSIONS: After acute access thrombosis, early surgical thrombectomy was associated with higher technical success and potentially improved midterm patency.

Robotic resection of an obturator schwannoma with preservation of normal nerve fascicles and function.

An asymptomatic pelvic tumor was incidentally found in a 27-year-old man. A CT-guided needle biopsy with a pathologic examination confirmed the diagnosis of a benign schwannoma. We describe the complete robotic resection with the conservation of normal fascicles. The postoperative course was uneventful. No neurological deficit occurred, and the electromyogram was normal 6 weeks and 7 months later.

Effectiveness of non-invasive positive pressure ventilation differs between decompensated chronic restrictive and obstructive pulmonary disease patients.

OBJECTIVE: To compare the efficiency of non-invasive positive pressure ventilation (NPPV) in decompensated patients with either chronic obstructive pulmonary disease (COPD) or chronic restrictive pulmonary disease. DESIGN: Retrospective study. SETTING: A 17-bed intensive care unit in a university teaching hospital. SETTING: Sixty-four patients with COPD (age: 70+/-13 years, sex ratio: 37 male to 27 female patients, forced expiratory volume in 1 s: 31+/-13% predicted) and 20 patients with chronic restrictive pulmonary disease (age: 75+/-9 years, sex ratio: 9 male to 11 female patients, total lung capacity: 57+/-17% predicted) consecutively treated with NPPV (facial mask, pressure support ventilation (PSV) +/- PEEP) for acute respiratory failure. MEASUREMENTS AND RESULTS: There were no statistically significant differences between COPD and patients with chronic restrictive pulmonary disease in terms of cause of exacerbation, use of oxygen therapy or NPPV at home, severity of acute respiratory failure (ARF), mean delay from intensive care admission to initiation of NPPV and total duration of NPPV. Patients with chronic restrictive pulmonary disease had a lower success rate on NPPV (without need of tracheal intubation) than COPD (35% vs 67%, p=0.01). Causes of NPPV failure were not different between COPD and patients with restrictive disease. After 12 h of NPPV, restrictive patients who succeeded with NPPV had similar respiratory rate, minute ventilation and arterial blood gas to COPD patients. At the 3rd and 12th h of NPPV, improvements in pH and PaCO(2) were predictive of NPPV success in COPD, but not in restrictive patients. CONCLUSION: The results of this retrospective study suggest that the effectiveness of NPPV for acute decompensation is less in patients with chronic restrictive pulmonary disease as compared to COPD.

Incidence of anaemia, and use of epoetin therapy in pre-dialysis patients: a prospective study in 403 patients.

BACKGROUND: Recent American and European guidelines recommend that epoetin therapy should be considered whenever the blood haemoglobin (Hb) level is <10-11 g/dl in dialysis patients and in pre-dialysis patients. Thus, data on the current prevalence of anaemia with respect to the degree of chronic renal insufficiency are needed in order to determine the potential indications of epoetin therapy in the pre-dialysis period. METHODS: We prospectively studied 403 consecutive ambulatory pre-dialysis patients whose serum creatinine (Scr) was 200 micro mol/l or more at their first passage at our out-patient clinic between January 1 and June 30, 1999. Hb and Scr values were determined at each visit until June 30, 2000, or until the start of maintenance dialysis. Patients had a clinical and laboratory evaluation every 2-3 months, and monthly when treated with epoetin. RESULTS: The mean (+/-SD) age of patients was 60.9+/-17.2 years at presentation. The Hb level was <11 g/dl in 62% of patients with Scr > or =400 micro mol/l, and in 58% of patients with an estimated creatinine clearance (Ccr) <20 ml/min/1.73 m(2). The proportion of anaemic patients was higher for any given Ccr value in females than in males. A total of 136 patients were treated with epoetin during the observation period. At the start of epoetin, their mean Hb value was 9.5+/-0.6 g/dl and Ccr level 13.9+/-4.9 ml/min/1.73 m(2). Among the 123 patients who began maintenance dialysis therapy during the observation period, 85 (or 69%) received epoetin therapy before the start of dialysis. Their mean Hb value at the start of dialysis was 10.8+/-1 g/dl compared with 10.5+/-1.1 g/dl in the 41 dialysed patients who did not require epoetin therapy during the pre-dialysis period. CONCLUSIONS: Based on the data gained in a large cohort of patients receiving regular pre-dialysis nephrological care, the proportion of subjects with a Hb level <11 g/dl may be estimated at approximately 60% when the Ccr is <20 ml/min/1.73 m(2). If the Hb level is to be maintained at no less than 11 g/dl, at least two-thirds of patients at this advanced stage of chronic renal failure should require pre-dialysis epoetin therapy.