Access In Elderly Patients Research Articles

Thoughts on the Integrated Management of Vascular Access in Elderly Patients with Maintenance Hemodialysis (MHD)

Thoughts on the Integrated Management of Vascular Access in Elderly Patients with Maintenance Hemodialysis (MHD)

Safety of elective enteral access in elderly patients: a comparative analysis of perioperative risk

BackgroundElderly patients can encounter torpid hospitalizations that are often characterized by malnutrition. In this setting, enteral feeding may facilitate improvement in nutritional status. The aim of this study is to compare perioperative outcomes of elderly (≥65 years-old) and non-elderly (<65 years-old) patients undergoing elective enteral access placement. MethodsAdult patients who underwent enteral access procedures between 2018-2020 at a tertiary care facility were reviewed retrospectively. Differences in baseline characteristics between non-elderly and elderly patients were adjusted using entropy-balanced weights. Subsequently, multivariable logistic and linear regressions were developed to evaluate the association between elderly status and outcomes of interest. Results914 patients with enteral access met inclusion criteria, of whom 471 (51.5%) were elderly. Compared to non-elderly patients, elderly individuals more commonly received percutaneous gastrostomy and had a higher burden of comorbidities as measured by the Charlson Index. Multivariable risk adjustment generated a strongly balanced distribution of baseline covariates between patient groups. After adjustment, despite no significant association with in-hospital mortality, reoperation, or time to goal feeds, elderly status was linked to an approximately 8-day reduction in length of stay (95%CI -14.28 to -2.30, p=0.007), as well as significantly lower odds of total parenteral nutrition (AOR 0.59, 95%CI 0.37-0.94, p=0.026) and non-elective readmission (AOR 0.65, 95%CI 0.49-0.86, p=0.003). Elderly status was also associated with significantly greater odds of non-home discharge (AOR 1.58, 95%CI 1.17-2.13, p=0.003). ConclusionDespite having more comorbidities than their non-elderly counterparts, elderly patients experienced favorable nutritional and perioperative outcomes after enteral access placement.

Radiocephalic Arteriovenous Fistula as A Possible Efficient Hemodialysis Access in Elderly Patients Above 60 Years

Radiocephalic Arteriovenous Fistula as A Possible Efficient Hemodialysis Access in Elderly Patients Above 60 Years

Transposed Brachiobasilic Fistula Versus Arteriovenous Graft as Tertiary Hemodialysis Access in Elderly Patients

People aged >65 years now account for 52% of hemodialysis (HD) patients in the United States. Well-functioning vascular access is crucial for successful HD therapy. Although radiocephalic and brachiocephalic arteriovenous fistulas remain preferred choices as primary and secondary vascular access for patients with adequate superficial veins, for those without, the choice of optimal tertiary access between arteriovenous graft (AVG) and transposed brachiobasilic fistula (BVT) remains unclear, especially for elderly patients.

Hemodialysis vascular access in elderly patients: A comprehensive review.

The number of elderly patients initiating hemodialysis (HD) increased considerably over the past decade. Arteriovenous fistulas (AVFs) are the preferred vascular access (VA) type in most HD patients. Choice of VA for older hemodialysis patients presents a challenge. The higher incidence of comorbidities, longer AVF maturation times, risk of primary failure, risk of patency loss, and shorter life expectancy are important factors to consider. In this review we provide a comprehensive analysis on maturation rates, primary failure, patency, and mortality regarding vascular access in patients older than 75 years of age.

Safety and efficacy of percutaneous coronary interventions performed via anatomical snuffbox access in elderly patients

Abstract Funding Acknowledgements Type of funding sources: None. Background Radial artery thrombosis is a potential complication of transradial catheterization. For elderly patients greater attention should be paid to preserve radial arteries due to rather common comorbidities, such as renal failure and systemic atherosclerosis. Radial arteries in such cases may be required for hemodialysis, coronary artery bypass grafting and vascular reconstruction surgery. Presumably, the distal radial access can provide additional benefits in reducing the incidence of radial artery occlusion. Purpose To evaluate the radial artery thrombosis incidence and other complications in elderly patients undergone a percutaneous coronary intervention via anatomical snuffbox radial access. Methods This research (Jan 2018 – Aug 2020) was conducted as a single-center, prospective study in 141 patients over the age of 75 who had a percutaneous coronary intervention via the conventional radial access (n = 57) and radial access in the anatomic snuffbox (n = 84). The primary endpoints were: thrombosis; radial artery spasm; cannulation site hematoma with a diameter larger than 1 cm; crossover to the different access. We also evaluated the time for access establishment and total duration of the procedure. Results The groups had no significant differences in age and sex (the mean age was 81.9 ± 4.6 years, 67.9% females). The percutaneous coronary intervention was performed for STEMI in 73 (51.2%) patients, NSTEMI in 39 (27.7%) patients, or CAD in 35 (21.1%) patients. Two (2.4%) cases of vascular access crossover were reported in the anatomical snuffbox group compared with two (2.6%) cases in the conventional radial access group (p = 0.684). There were no statistically significant differences in the access time between the groups. It was 3.43 ± 0.78 min in the conventional radial access group versus 3.28 ± 0.76 min (p = 0.891) in the anatomical snuffbox access group. The total duration of percutaneous coronary intervention was also comparable in two groups (44.1 ± 15.6 min versus 45.9 ± 16.5 min, p = 0.936). The radial artery occlusion incidence was significantly lower in the anatomical snuffbox access group compared with the conventional radial access group (2 (2.4%) versus 8 (14.5%), respectively, p = 0.008). Also, radial artery spasm occurred significantly less frequently in the anatomical snuffbox access group compared with the conventional one (2 (2.4%) versus 7 (12.7%), respectively, p = 0.018). The incidence of cannulation site hematoma was significantly lower in the anatomical snuffbox access group than in the conventional access group (5 (6%) versus 10 (18.2%), respectively, p = 0.025). Conclusion Access via the anatomical snuffbox reduces the incidence of radial artery occlusion, cannulation-related spasm, and cannulation site hematoma. So it may be considered preferred to conventional radial access in elderly patients. However, randomized studies are needed to further investigate these results.

Redo Hemodialysis Access in Elderly Patients has Acceptable Outcomes With Similar Patency of Arteriovenous Fistulas as Compared to Grafts

ObjectivesSelecting optimal hemodialysis access in elderly patients remains challenging, particularly in those requiring new options after failed initial access. We sought to describe the outcomes of redo hemodialysis access in elderly patients. MethodsAll patients aged ≥65 undergoing hemodialysis access placement from 2014-2019 were retrospectively identified in the electronic medical record. Characteristics and outcomes of those with initial versus redo access were compared. Patency was depicted utilizing Kaplan-Meier methods, with censoring at loss to follow-up or death, and unadjusted Cox regression. ResultsOverall, 211 elderly patients undergoing 257 procedures were included in the study. Of these, 116 (45.1%) were redo access procedures. There were no demographic or comorbidity differences between the two groups with the exception of central venous stenosis which was more common in the redo cohort (27.2% vs. 6.4%, P < 0.001). 91.5% of initial, vs. 60.3% of redo, procedures were arteriovenous fistulas (P < 0.001). Distribution of fistula type differed between the two groups with first time and redo procedures of 25.5% vs. 6.9% radiocephalic, 28.4% vs. 7.8% brachiocephalic, and 35.5% vs. 37.1% brachiobasilic respectively (P < 0.001). At 12 and 24 months, 63.6% and 44.0% of first-time accesses remained patent vs. 51% and 29.0% of redo accesses (HR 1.37, 95% CI 1.05-1.80, P = 0.02). However, there was no difference in primary patency between redo grafts and fistulas (48.7% fistulas vs. 55.0% grafts at 12 months, P = 0.47). ConclusionsThese results demonstrate acceptable outcomes of redo access in elderly patients. There is no evidence from this study that prosthetic grafts are preferential, suggesting elderly patients with meaningful life expectancy who require redo access should be offered autogenous options when possible.

Elderly patient: which vascular access? Choice and management of vascular access in the elderly patient

The optimal vascular access for elderly patients remains a challenge due to the difficult balance between risks and benefits in a population with increased comorbidity and decreased survival. Long dependence to central vein catheter, patient comorbidities, life expectancy, and complication rates are important influencing the indications for arteriovenous fistula or an arteriovenous graft. Although central vein catheters are simpler way to start a hemodialysis treatment, elderly patients are also at higher risk of death from infection or other complications associated with them more than for younger patients. The discussion revolves around the following key questions: What are the limiting factors for a vascular access in the elderly patients? Central venous catheter—is it still an option for elderly patients? Is still the autologous arteriovenous fistula playing a pivotal role as hemodialysis access in the elderly patients? Are there any real surgical contraindication to perform a vascular access in elderly patients? Is the old age a limiting factor for the vascular access management?

Hemodialysis arteriovenous fistula as first option not necessary in elderly patients

Kidney Disease Outcomes Quality Initiative guidelines recommend arteriovenous fistulas as the preferred access for hemodialysis patients. However, this may not hold across all populations of patients, especially the elderly, given their comorbidities and relatively reduced life expectancy. Therefore, we investigated whether fistulas held benefit over arteriovenous grafts as hemodialysis access in elderly patients. We retrospectively searched a vascular access database to compare the outcomes for 138 fistulas and 44 grafts that were placed in elderly patients (≥75years old) during a 4-year period at a tertiary medical center. The primary failure rate was higher for the fistulas compared with the grafts (odds ratio, 2.89; P= .008), and more fistulas required one or more interventions before their successful use compared with grafts (31% vs 10%, respectively; P= .03). In addition, the time to catheter-free dialysis was longer for fistulas than for grafts (P< .001). However, the primary and secondary patency rates were comparable between the fistulas and grafts and between the different access locations. The all-cause mortality rates were also comparable between the fistula and graft groups. Despite the Fistula First Initiative recommendations, grafts need not be discounted as a first-line hemodialysis access option in select elderly patients.

Radial versus femoral access for elderly patients with acute coronary syndrome undergoing coronary angiography and intervention: insights from the RIVAL trial

Radial access for percutaneous coronary intervention is associated with lower rates of access site complications and bleeding. However, elderly patients have more complex vascular anatomy and radial access may be more challenging in this population. There remains uncertainty regarding the role of radial access in elderly patients undergoing cardiac catheterization. The RIVAL trial randomized patients with acute coronary syndromes undergoing cardiac catheterization to radial versus femoral access. In this analysis, the rates of access site complications and access site cross-over were compared across different age groups. Among the 7,021 patients, 1035 (15%) were ≥75 years of age. Across all age categories, radial access was consistently associated with higher rates of access site cross over and lower rates of major access site complications, with no significant interaction between age and access site. Radial access was associated with lower rates of major vascular access site complications in patients ≥75 years of age (3.6% vs 6.6%; P = .03) and in patients <75 years of age (1.0% vs 3.2%; P < .001; P value for interaction = .2). The rates of access site crossover were higher with radial access among patients ≥75 (12.5% vs 2.6%; P < .001) and <75 (6.7% vs 1.9%; P < .001; P value for interaction = .9). There were no significant differences in the primary composite outcome (death, myocardial infarction, stroke or non coronary artery bypass graft major bleeding) or its individual components in either age group. In patients ≥75 years of age undergoing primary percutaneous coronary intervention, there was no significant difference in procedure time (120 vs 115 minutes; P = .3). Consistent with the overall RIVAL trial population, elderly patients undergoing cardiac catheterization have lower rates of major bleeding or access site complications and higher rates of access site crossover with radial access compared to femoral access.

Radial vs. Femoral Artery Access in Elderly Patients Undergoing Percutaneous Coronary Intervention

Background: Studies demonstrate that radial artery access reduces the risk of vascular and bleeding complications associated to percutaneous coronary intervention. Our objective was to evaluate in-hospital results of the transradial approach in elderly patients undergoing percutaneous coronary intervention. Methods: Prospective registry including patient's ≥ 70 years of age; safety and efficacy endpoints were compared for the radial and femoral artery access groups. Results: We included 255 patients, 117 (52%) treated using the radial approach and 108 using the femoral approach. Except for age, the remaining clinical characteristics did not show differences between groups. Male patients prevailed (60%), 36.7% were diabetic and over one third were diagnosed with acute coronary syndrome. Angiographic and procedure-related variables did not show differences between groups. When vascular complication rates were compared only hematomas < 5 cm (5.1% vs. 17.6%; p < 0.01) were more prevalent with the femoral access. Major bleedings, according to the ACUITY criteria (zero vs. 5.6%; p = 0.01) and minor bleedings, according to the TIMI criteria (zero vs. 7.4%; p < 0.01), were also more frequent in the femoral group. In-hospital clinical endpoints, death (0.9% vs. 5.6%; p = 0.06) and non-fatal infarction (zero vs. 3.7%; p = 0.05) were more frequent in patients treated by the femoral access. Conclusions: In a non-selected patient population ≥ 70 years of age, percutaneous coronary intervention by radial access was associated to a lower incidence of in-hospital clinical endpoints, especially of bleeding events related to the vascular access route.

Association between vascular access type and patient mortality among elderly patients on hemodialysis in Canada

Optimal vascular access in elderly patients requires consideration of the benefits and risks in a population with increased comorbidity and mortality. Our objective was to examine the association between vascular access type and patient mortality by age category among incident adult hemodialysis patients registered in the Canadian Organ Replacement Register between 2001 and 2010. We also describe the secular trend in incident and prevalent vascular access use. We used a Cox proportional hazards model to evaluate the overall mortality in patients aged less than 65, 65-74, 75-85, and greater than 85 years who initiated hemodialysis using a central venous catheter (catheter) or arteriovenous (AV)-access (fistula or graft) using an intention-to-treat approach. The cohort of 39,721 patients consisted of 42%, 27%, 26%, and 5% of patients aged <65, 65-74, 75-85, and >85, respectively. Patients who initiated hemodialysis using an AV-access constituted 21%, 22%, 20%, and 15% of each age category. AV access use was associated with lower adjusted mortality compared with catheter use in each age category (Hazard Ratios [HR], 0.67; 95% Confidence Interval [0.62-0.72]; HR, 0.76 [0.63-0.91]; HR, 0.77 [0.64-0.93], HR, 0.73 [0.56-0.96], respectively). In Canada, use of an AV-access is associated with lower mortality across all age categories, even in the very elderly. Further studies are required to understand the patient preference, complications, and resource use when selecting access type in the elderly.

Vascular access in elderly patients with end-stage renal disease

During the last few years, the number of elderly patients with end-stage renal disease (ESRD) has been increasing worldwide. Establishment of a viable vascular access is of primary importance in these patients. This review discusses the advantages and disadvantages of the available vascular access modalities [namely arteriovenous (AV) fistulae, AV grafts, and central venous catheters (CVCs)] in elderly ESRD patients. AV fistulae seem to be superior when compared with other vascular access alternatives with respect to patency, morbidity and mortality rates. On the other hand, due to the age-related advanced atherosclerosis in the elderly, higher failure rates for AV fistulae in this age group have been described. Two controversial issues, namely the higher infection and thrombosis rates in elderly ESRD patients, are also discussed. Current evidence suggests that old age should not comprise a drawback when selecting the appropriate vascular access modality (AV fistula, AV graft or CVC) for the performance of hemodialysis. The possible vascular access options in elderly ESRD patients should not be different from younger individuals.

Epilepsy in a rural elderly population

The first goal of this study was to describe the characteristics of elderly patients with epilepsy and the antiepileptic drugs used to treat them. Next, the factors (such as epilepsy type, seizure frequency, medical comorbidities, etc.) influencing antiepileptic drug choice and living situation were explored. Retrospective chart review of patients older than 70 with epilepsy seen in a rural health care system. This yielded 449 patients with epilepsy, 54 patients with isolated seizures and 38 patients with syncope as the primary diagnosis. The most commonly used antiepileptic drug was phenytoin. New generation AED's which had fewer side effects were used much less frequently than old generation AED's but the probability of using new generation AED's was increased in patients with renal failure and congestive heart failure as well as in patients that had seen a neurologist. Patients with acute symptomatic seizures, dementia, chronic obstructive pulmonary disease, frequent seizures and advanced age were less likely to be independent. Patients that had seen a neurologist as an outpatient were more likely to live independently. The elderly are a vulnerable population because of difficulty communicating their symptoms and their needs. This leads to the suboptimal use of AED's as well as poor outcomes. Careful attention to seizure control and medication side effects is critical in promoting good outcomes in this patient group. This retrospective study suggests that access of elderly patients with epilepsy to specialty care improves outcomes in terms of living status. This important information needs to be confirmed by prospective studies.

Distal Arteriovenous Fistulas in Elderly Hemodialysis Patients

Dialysis access procedures and complications are an important cause of morbidity and hospitalization for chronic hemodialysis patients. Subjects over 65 years old have a higher incidence of co-morbid factors (diabetes mellitus, atheros clerosis, neoplasms, heart failure), therefore the correct choice in terms of timing and type of permanent access is extremely important. As elbow fistulas are often complicated by heart failure and PTFE grafts have a higher risk of thrombosis, we decided to evaluate the success rate of distal fistula as primary dialysis access in elderly patients. We carried out a retrospective study to identify survival predictors and actual vascular network saving. Between January 1991 and September 2000, 277 vascular access procedures were performed on 198 elderly patients (age 65 or older). The first anastomosis was positioned as peripherally as possible. In cases of patients with poor peripheral vasculature or three co-morbid factors, vascular access was first created at the origin of radial artery (Toledo-Pereyra fistula). Survival (Kaplan - Meyer analysis) was significantly higher for Toledo-Pereyra fistulas compared to wrist and snuff-box ones, in spite of the presence of a high incidence of co-morbid factors. We conclude that Toledo-Pereyra fistula is an efficient primary choice in elderly patients.

Dialysis Prescription in Elderly Hemodialysis Patients

A growing number of elderly patients have started dialytic treatment in recent years. In spite of this fact, there is very little literature on dialysis prescription in these patients. In this paper, the authors examine the single variables of Kt/V index and report on their own experience when prescribing the dialytic dose in elderly patients. Regarding dialyzer clearance (Kd), it is known that in order to obtain a high Kd we need an adequate vascular access. In our experience, with a radiocephalic fistula elderly patients showed less (but not significantly so) Qac than younger patients (738 +/- 350 ml/min versus 892 +/- 491 ml/min). We can therefore consider this type of fistula as the first vascular access in elderly patients also. As far as Kr is concerned, its rate of decline (0.4+/-0.4 ml/min/month) in these patients, excluding those with diabetes or a history of heart failure, is not different from that of younger patients. Treatment time remains a crucial point for adequacy. In order to avoid hypotensive episodes, especially in the elderly, we suggest T = 180 minutes minimum, and ultrafiltration rates should not exceed 0.6-0.8 kg/h. As regards V, it can be stated that these patients have a reduced lean body mass and total body water, and could therefore require smaller dialysis doses. However, we think that the target of Kt/V in malnourished elderly patients requires further study. What our data on Kt/V delivered to a large group of patients shows is that the elderly received the same adequate dialytic dose (Kt/V > 1.3) as that of younger patients.

6 The management of leukaemia in the elderly

Leukaemia is relatively common in the elderly compared to the general population, with over half of all cases of leukaemia occurring in patients aged 65 and over. Special problems are associated with treating patients in this age group. The leukaemias may be intrinsically different, in part because of the high incidence of preceding myelodysplasia. There is increased likelihood of coincident disease. There is lower tolerance to toxic complications, such as infection and bleeding, associated with a decreased resilience of normal haematopoiesis. There is more difficulty in obtaining intravenous access in elderly patients. These problems render patients ineligible for marrow transplants. Myelodysplastic syndromes occur predominantly in the elderly. There are a number of myelodysplastic syndromes now identified, each with its characteristic natural history. Management decisions are based on accurate diagnosis of the specific syndrome, consideration of prognostic features, a period of observation, and conservative treatment principles. More than half the cases of acute myeloblastic leukaemia also occur in the elderly. Prognostic factors must be examined and the literature carefully scrutinized for results pertinent to the elderly patient. In some patients treatment may be justifiably withheld, others may benefit from low dose cytosine arabinoside and some patients should receive aggressive combination chemotherapy. Management of the chronic leukaemias in the elderly is a less controversial area. Chronic lymphocytic leukaemia is the most common of the leukaemias in this age group. Prognostic factors can be determined using staging criteria. observation alone is indicated in many patients. Chlorambucil and prednisone are the most widely used drugs for symptomatic disease. Aggressive combination chemotherapy may benefit a few patients with advanced or refractory CLL. Hairy cell leukaemia is a rare disorder but many of the patients are over age 65. The elderly male patient may have a particularly benign course and require no therapy. Splenectomy is the standard first line of therapy, but recombinant alpha-interferon is sufficiently effective and non-toxic that it should be the treatment of choice in some patients. Deoxycoformycin is also effective in preliminary trials and may soon be routinely indicated. It is not often appreciated that half of all patients with chronic myelogenous leukaemia are aged 65 and over.(ABSTRACT TRUNCATED AT 400 WORDS)