Brachiocephalic Research Articles

Arteriovenous fistula access for dialysis using vessels of the arm

Background: Site selection, configuration of the access and technical performance of operation are keys to a successful arteriovenous fistula (AVF) for haemodialysis. Objective: To evaluate the primary success rate and complications of AVF performed in Port Harcourt using vessels of the arm. Materials and Methods: This was a prospective cross-sectional study on the success rate of the Arteriovenous fistulas done using vessels of the arm in patients with End Stage Renal Disease (ESRD) undergoing dialysis across public and private health facilities in Port Harcourt. The study was conducted between March 1, 2017, and February 29, 2024. Preoperatively, using a duplex scan (and sometimes through clinical examination) with and without a tourniquet, the selected vein size was ≥ 2.5mm and the artery ≥2mm with a healthy wall and good flow. Parameters monitored were thrill and bruit intra-operatively, immediate, one- week and 6-8 weeks post-operative periods; the size of the vein intra-operatively, one -week and 6-8 weeks post-operatively. In addition, the patients were monitored for complications. Data were analyzed using statistical packages for social sciences (SPSS) version 25. Th demographic data and medical information were summarized using descriptive statistics (mean, median, frequency percentage and standard deviation) as appropriate. Result: There were 87 patients during the period under review. The age range was 14-85years with mean age of 54 ± 6.4 years. Of these, 18 (20.69%) were females, and 69 (79.31%) were males; 92 AVFs were done in 87 patients (87 primary and 5 repeat) with ESRD for dialysis; 69 (75%) Brachiocephalic (BC) and 23 (25%) Brachiobasilic (BB)AVFs. The AVFs were primarily successful in 82 cases (94.25%), with 5 primary failures (5.75%), and a total of 5 repeat AVFs within this period, excluding secondary failures. Complications were 1 (1.15%) upper limb oedema, 6 (6.90%) delayed wound healing, 4 (4.60%) cases of seroma, 1 (1.15%) case of steal syndrome, 4 (4.60%) cases of spontaneous thrombosis and 3 (3.45%) cases of superficial wound infection. Conclusion: The primary success rate of AVF for dialysis in Port Harcourt using vessels of the arm is quite good with few complications.

An unintended connection – Radial arteriovenous fistula after coronary angiogram

Abstract The following case is of a 44-year-old female undergoing maintenance hemodialysis (MHD) due to chronic interstitial nephritis, utilizing a left brachiocephalic (BC) arteriovenous fistula (AVF). Following presentation with retrosternal anginal pain, diagnosed as high lateral wall myocardial infarction, coronary angiogram revealed normal coronaries. Subsequently, dilated veins along the right forearm were noticed, attributed to a patent right radiocephalic AVF. Despite being asymptomatic, the patient underwent a Doppler ultrasound confirming a blood flow of 400 ml/min through the AVF. No further intervention was planned as the patient continued MHD through the left BC AVF.

Relationship Between Quick of Blood with Arteriovenous Radiocephalic And Brachiocephalic Fistula to Blood Urea Nitrogen (BUN), Creatinine Serum, Neutrophil to Lymphocyte Ratio (NLR), And Hemoglobin in Patients Hemodialysis

Chronic kidney disease (CKD) is a chronic disease with a high prevalence worldwide. In 2017, an estimated 1.2 million people died from CKD globally. There are 713,783 CKD sufferers (0.38%) in Indonesia aged 15 years who have been registered nationally. Hemodialysis (HD) is one of three renal replacement therapies for managing CKD. Adequate vascular access is required in patients undergoing HD. Vascular access is ideal if it causes minor complications when used for hemodialysis. Arteriovenous fistula (AVF) is a common vascular access used during HD. The main options for AVF are radiocephalic (RC) and brachiocephalic (BC) fistula, with their respective advantages and disadvantages. This cross-sectional study compares QB in patients with RC and BC fistula and with hematological parameters pre and post-HD. There were 18 RC subjects and 18 BC subjects involved in this study. Subjects were then examined for hematological parameters and QB before and after HD. The results of this study showed that QB in the RC group was not significantly different from the BC group (p=0.126). The mean comparative test showed that the levels of Hb, BUN, and SC were significantly different before and after HD both in the RC group (p=0.005; p=<0.001; p=<0.001) and BC (p=0.001; p =<0.001; p=<0.001). The correlation test results showed that QB only correlated with SC pre-HD levels (p=0.030; r=0.361). Multivariate tests showed that the decrease in BUN levels with AV fistula BC was higher than with RC (p=0.015). This study proves that QB is unrelated to the type of AV fistula used, but QB is positively correlated with serum creatinine levels in patients undergoing HD. BC fistula were also found to lower BUN levels better than RC fistula.

Comparison between radiocephalic and brachiocephalic arteriovenous fistula in octogenarians: A retrospective single center study.

The number of older patients who need vascular access for end-stage renal disease is rapidly increasing. However, determining the optimal vascular access for older patients is difficult. We aimed to compare the outcomes of radiocephalic (RC) and brachiocephalic (BC) arteriovenous fistula (AVF) in patients aged >80 years. This study included 94 patients undergoing hemodialysis who underwent the procedure for the first time between 2013 and 2019 in Korea University Guro Hospital. The primary outcomes were primary patency (PP) and cumulative patency (CP). The secondary outcome was maturation failure and death with functional vascular access. Of the 94 patients (mean age, 83.9 ± 2.97 years), 66 (70.2%) and 28 (29.8%) patients belonged to the RC and BC AVF groups, respectively. One-year PP was worse in the RC AVF group than in the BC AVF group (59.6% vs. 87.4%, p = 0.013). However, no significant difference was observed in 1-year CP between the groups (87.4% vs. 91.2%, p = 0.441). The unassisted maturation rate was higher in the BC AVF group than in the RC AVF group (74.2% vs. 96.4%, p = 0.011). During follow-up (649 ± 612 days), only 6 (6.4%) patients required secondary fistula placement. Eighteen patients (19.1%), all of whom had functional AVF, died. BC AVF showed better PP and a smaller number of interventions than RC AVF in octogenarians. Therefore, BC AVF could be a primary choice of vascular access in the octogenarian patient. However, further research is warranted to confirm these findings.

Outcomes of Arterio-venous Fistula Reconstruction in Chronic Kidney Disease Patients Presenting in Tertiary Care Hospital in Eastern Nepal

Introduction: Renal Replacement Therapy is the treatment modality for the chronic kidney disease (CKD) which ranges from hemodialysis, peritoneal dialysis to the renal transplantation, the latter being the best form of treatment. But, renal transplantation is available at limited centers only so hemodialysis is the most commonly used treatment modality of chronic kidney disease which requires a vascular access. But there are limited vascular surgeons in the region so most of the arterio-venous (AV) fistulas are reconstructed by Urologist/Surgeons exposed to vascular surgery during their residency/training period. Objectives: To know the factors influencing the site selection, to assess the success rate and to document the complications of AV fistula reconstruction. Methodology: This is a hospital based prospective observational study conducted in the Birat Medical College – Teaching Hospital, Morang, Nepal from June 2021 to May 2022. We included the CKD patients requiring vascular access for hemodialysis with Color Doppler available for vascular mapping. Patients with brachial sites previously used and without Color Doppler were excluded from the study. AVF was reconstructed under local anesthesia and outcomes were recorded. Results: Thirty one patients of CKD underwent AVF reconstruction over the study period. Male and female ratio was 1.33 (57% and 43%). The mean age was 42.14 ± 11.34 years (Range 26-65 years). The mean diameter of radial artery (RA) and cephalic vein (CV) at wrist were 1.92 ± 0.56mm and 1.91 ± 0.20 mm respectively. Similarly, the mean diameter of brachial artery (BA) and CV at elbow were 3.66 ± 0.87mm and 3.57 ± 0.55 mm respectively. The fistula reconstructed were Lt RC (radio-cephalic) – 50% (14), Lt BC (brachio-cephalic) -35.71% (10) and Lt BB ( brachio-basalic) - 14.29% (4) respectively. Complications occurred in 4 cases (14.28%). Conclusion: Selection of type of AVF creation is influenced by the vessel diameter as well as previous fistula surgery status and AVF access for hemodialysis has adequate patency with acceptable complications.

Artery-to-Fistula Diameter Ratio as a Predictor of Early Re-Occlusion of Immature Right Radio-Cephalic Arteriovenous Fistula after Primary PTA

Percutaneous transluminal angioplasty (PTA) is widely performed for arteriovenous fistula (AVF) that fails to mature after initial formation. We observed that some immature AVFs re-occlude earlier than others. We sought to investigate the predictors for early post-intervention failure of immature fistulas after primary PTA. We retrospectively reviewed the records and angiographic images of patients who had immature fistulas and thereby received PTA between 2013 and 2019 at our center. We investigated the short-term post-intervention outcomes of the patients within 90 days post-PTA. Patients who had re-occlusion within the period were defined as the early failure group and the rest as the patent group. We investigated factors associated with early failure. There were 80 eligible patients with 22 brachio-cephalic (BC) and 58 radio-cephalic (RC) AVFs. The median age of the patients was 64 years [range, 38–87]. There were 51 (63%) males and 29 (36%) females. Among the 58 RC AVFs, 10 (17%) patients had early failure. Logistic regression analysis showed that a larger artery to fistula (A/F) diameter ratio was the sole independent predictor of early failure after primary PTA (odd ratio 2.29 [1.023–5.147], p value = 0.044). Although further studies on a larger scale are required to confirm the clinical significance, a larger A/F diameter ratio was a potential predictor of early re-occlusion in immature fistulas after primary PTA.

Comparison of primary patency of radiocephalic and brachiocephalic arteriovenous fistula in East Borneo, Indonesia

Background: There is still very limited study available for patency of arteriovenous fistulas (AVF) from developing country, specifically in East Borneo, Indonesia. The aim of this study is to compare the primary patency rate between radiocephalic (RC) and brachiocephalic (BC) AVF and to analyze the risk factors involved in the primary patency results of AVF RC and BC for hemodialysis. Methods: This study is a retrospective cohort study with a total of 154 patients underwent AVF from February 2017 until august 2018 and were monitored until august 2019. The patient’s primary patency of AVF was evaluated by the Kaplan-Meier survival curve. Each of the risk factors that were predicted to influence patency was analyzed for each AVF. Result: The mean age of 154 patients was 52.9 ± 9.5 years old. RC AVF was made in 130 patients (84.4%) and BC AVF was made in 24 patients (15.6%). There was no significant difference between the estimated primary patency for the RC group and BC AVF, the log-rank test (p=0.15). Risk factors for age, gender, hypertension, DM, and frequency of hemodialysis in both AVF showed statistically insignificant for primary patency. Conclusion: Our study showed there was no significant difference in the primary patency rate between the RC AVF and BC AVF group and other risk factors not significantly affecting primary patency in either type of AVF.

Demography and Outcomes of Arteriovenous Fistula: Challenges and Future Directions.

The incidence and prevalence rates of treated end-stage kidney disease (ESKD) patients are on the rise worldwide. Hemodialysis remains the main modality of providing renal replacement therapy for the ESKD patients, and the preferred vascular access is an arteriovenous fistula (AVF). The objective is to assess the patency rates and primary failures of the AVF. All patients who attended the Royal Hospital in Muscat, Oman, from January 2010 to December 2014 for AVF creation were included in this study. Data were extracted from the hospital's electronic medical record system where data are entered prospectively. During the period of study from 2010 to 2014, 465 primary fistulae were created in 427 patients. The mean age of the patient was 58 years. Only 6% needed general anesthesia, while the rest were done under regional or local anesthesia. Fifty-one percent of the patients were diabetic. Preemptive AVF was constructed in only 12% of patients. Most cases (47%) had left brachiocephalic (BC) fistulae. The left radiocephalic (RC) fistulae constituted 25.7% and the left brachiobasilic fistulae 9.9%. The remaining were constructed in the right upper limb. The total patency was achieved in 80% of fistulae and the failure rate was 20% at 6 months. Whereas, at 12 months, the total patency rate was 71% and the failure rate was 29%. Thus, we can conclude that more than 50% of patients, half of them being females, were diabetics. This resulted in more fistulae being constructed in the arm, namely left BC fistulae and left RC fistulae. Furthermore, it is important to note that only a very small percentage of patients had an established preemptive AVF. These factors may be responsible for a failure rate of 20% and 29% of the AVFs at 6 months and 12 months, respectively.

Assessment of Proximal Radio-median Cubital/Radio-Cephalic Arterio-venous Fistula

The present study aims to conducted the Assessment of Proximal radio-median cubital/radio-cephalic Arterio-venous Fistula. Arterio-venous Fistula is life line for long-term hemodialysis for end stage renal disease patients. The order of preference as per National Kidney Foundation/ Kidney Disease Out Come Quality Initiative (KDOQI) is distal Radio Cephalic fistula is considered as gold standard followed by elbow Brachio Cephalic Fistula, transposed Brachio-Basilic Fistula, forearm arterio-venous graft. This is a cross sectional-prospective interventional study, 05/2017 to 04/2019, JNMC, Wardha, MH, with sample size of 66 cases. Out of 66 cases 25 % patients had diabetes mellitus, 48% cases were suffering from chronic glomerulonephritis, 15 % cases were suffering hypertension, 6 % cases had COPD and another 6 % cases had some cardiovascular disease. About 54 % cases had previous access failure. In our study the mean flow volume for AV fistula in proximal forearm was 485± 291 ml/minon postoperative day1, 695 ± 298 on postoperative day 7 and 755± 347 ml/min. Overall postoperative complications in 12% cases was reported in our case study though Yilmiz et al reported postoperative complications in 15% cases.

Arteriovenous fistula maturation: Physical exam versus flow study

The purpose of this study was to determine the utility of routine duplex flow study 4 to 6 weeks after primary AVF creation and to compare physical exam against a duplex flow study in predicting fistula maturation. A surveillance algorithm was established to evaluate the naïve fistula after primary creation. This was a single institution retrospective review of 155 veterans with primary autogenous AVF creation from 2016 to 2018. All patients received a duplex flow study evaluation after primary creation. A comparison was made between physical exam (PE) and flow study at 4 to 6 weeks post creation. Sensitivities and specificities of physical exam and duplex flow study were compared head-to-head in predicting unassisted fistula maturation. A mature AVF was defined as a fistula that could be repetitively cannulated and provided adequate flow for dialysis. Failure of maturation was defined as an AVF that was never usable for dialysis. An abnormal duplex included thrombosis, stenosis (> 50% on gray scale imaging), inadequate vein diameter (< 4 mm), inadequate vein length or superficialization, or poor flow (< 500 ml/min). Bivariate comparisons were conducted using Pearson's χ², Fishers exact test, and Wilcoxon test depending on distribution. Significance was defined as P < 0.05. There were 53 patients with radiocephalic (RC) fistulas, 41 patients with brachiocephalic (BC) fistulas, and 6 patients with brachiobasilic (BB) fistulas. Of patients with a confirmed abnormal duplex ultrasound, 53% had an abnormal PE (sensitivity 53%; PPV 96.3%, P < 0.001). Of the patients with a confirmed normal duplex, 98% had a normal PE (specificity 98%; NPV 68.5%, P < 0.001). An abnormal duplex flow study had a 67% sensitivity for predicting AVF failure or need for reintervention while an abnormal physical examination had a 42% sensitivity in predicting AVF failure or need for reintervention (P < 0.001). In total, 48 fistulas needed reintervention, however only 20 (42%) were associated with an abnormal physical examination. Of those 48 reinterventions, 20 (42%) fistulas exhibited primary assisted maturation (P < 0.001). On duplex flow study alone, 32 patients had hemodynamically significant lesions necessitating reintervention, which went on to afford 9 (28%) primary assisted mature fistulas (P=0.69). Abnormal duplex flow studies have a better sensitivity for detecting AVF failure or the need for reintervention compared to physical exam alone. An abnormal duplex correlates more with needing a reintervention to achieve maturation than physical exam. Therefore, we advocate routine use of a postoperative duplex flow study to identify potentially correctable issues and optimize fistula maturation.

Primary patency of native arteriovenous fistula in elderly at Abdul Wahab Sjahranie Hospital, Samarinda, Indonesia

Introduction. Arteriovenous fistula (AVF) is preferred to be selected by the patient and clinician due to long term survival and fewer complications than other vascular access. Radiocephalic (RC) fistula is the first choice for dialysis access and should be performed in elderly renal failure patients. Several authors have advocated that the brachiocephalic (BC) fistula should be considered the surgeons' first option. We aim to analyze the primary patency of RC and BC AVF in the elderly. Method. This prospective cohort study was conducted from June 2018 to March 2020, which included 58 elderly patients who underwent surgery to create AVF. Demographic data were collected from medical records. Meanwhile, information about patient’s primary patency of RC and BC AVF were followed up to first access dysfunction or any intervention by phone. The survival data were analyzed using the Kaplan-Meier method Result. There were 58 elderly patients divided into 51 (87.9 %) patients with RC, 4 (6.9%) patients with BC, and 3 (5.2%) patients with Basilic Vein Transposition (BVT). The survival rate of RC was 70.5 % after six months and 29.4 % after 12 months. Meanwhile, 50% of BC patients survived in the first six months, and 25% survive for a year. On the other hand, 1 of 3 patients died in the BVT group in the first month after access placement due to hemodialysis complication, and the remaining two BVT patients survived in three months. Conclusion. RC has a patency rate of 70.5% in six months and 29.4% in a year. Choosing the right type and site of the anastomosis is essential as life expectancy increases in the elderly to preserve the veins for future access site.

Comparative Study of Autologous Radiocephalic and Brachiocephalic Arteriovenous Fistula in Patients with End Stage Renal Disease

Introduction: End-stage renal disease requires treatment with dialysis or renal transplantation. For the dialysis, autologous radiocephalic (RC) or brachiocephalic (BC) arteriovenous fistula (AVF) is the better option for vascular access for hemodialysis. Aims: The aim of this study is to find out the outcome between RC AVF and BC AVF. Methods: This is the retrospective study, conducted for the period of 24 months from September 2017 to September 2019 in the department of Cardiothoracic and Vascular Surgery of Bir Hospital, Nepal. RC and BC AVF were created for the assess of hemodialysis. Outcome and different complications were taken into consideration. Results: The total number of patients included in this study was 400. The overall failure rate of autologous AV fistula was 12.75%. Out of these, the failure rate was more in RC AV fistula group, 34 (17%) than in BC AV fistula group, 17 (8.5%). The most common complication was bleeding in both groups having an overall rate of 39 (9.75%). The limb edema was more common in BC AV fistula group 16 (8.0%) then in RC AV fistula group 7(3.5%). The overall infection rate was 4.5%. Overall patency rate was 87.25%. Conclusion: Autologous RC AVF and BC AVF are the choices for vascular access for hemodialysis in patients with end-stage renal disease. BC AVF has a better patency rate than RC AVF but with the slight higher risk of complications.

Diagnosis of multifocal atherosclerosis using the Celermajer test

Aim. To study the effectiveness of determining atherosclerosis and its severity in the brachiocephalic (BCA), coronary (CA) and femoral (FA) arteries based on the endothelial function test proposed by Celermajer DS. Material and methods . The study included 216 patients: 115 men and 101 women aged 24-87 years (mean age, 61,5±10,73 years). All patients underwent coronary angiography to assess the presence and severity of coronary artery atherosclerosis, and duplex ultrasound of BCA and FA atherosclerosis. The functional activity of the endothelium was assessed using the Celermajer test. Results. Depending on the presence and severity of atherosclerosis in each arterial region (BCA, CA and FA), patients were divided into the following groups: group 1 — patients with intact arteries, group 2 — patients with moderate atherosclerosis, group 3 — patients with severe atherosclerosis. Comparative analysis of brachial artery diameters identified by the Celermajer test revealed a significant difference between the groups. Comparison of Celermajer test results in CA groups was as follows: groups 1 and 2 (p=0,34), groups 1 and 3 (p<0,0001), groups 2 and 3 (p<0,0001). The results of comparing the three BCA groups were as follows: groups 1 and 2 (p<0,05), groups 1 and 3 (p<0,001), groups 2 and 3 (p<0,001); for FA — groups 1 and 2 (p=0,008), groups 1 and 3 (p<0,0001), groups 2 and 3 (p<0,0001). Conclusion . The results showed the applicability of Celermajer test for preliminary assessment of presence and severity of atherosclerosis of BCA, CA and FA. Using Celermajer test, severe atherosclerotic lesion can be verified in all studied arterial systems. Moderate atherosclerosis of BCA and FA was also revealed. However, no reliable results were obtained for detecting moderate CA atherosclerosis with Celermajer test.

Our arteriovenous fistula experiences with grafts in hemodialysis patients

Aim: In patients whose life is dependent on hemodialysis, the most suitable vascular access routes are arteriovenous fistulas made with native vessels. However, in patients whose natural vessels are depleted, or not suitable, arteriovenous fistulas can be opened with artificial grafts. Our aim is to examine arteriovenous fistulas opened with synthetic grafts in hemodialysis patients who do not have native vascular access in the upper extremity and share our results.Methods: Patients who underwent opening of an arteriovenous fistula with a synthetic graft to the upper extremities in Adıyaman University Faculty of Medicine, Cardiovascular Surgery Clinic between December 2012 and December 2018 were examined in this retrospective cohort study. They were screened for age, gender, end-stage renal failure etiology, complications in vascular access site, postoperative follow-up, and duration of use. Primary and secondary patency rates were determined.Results: It was determined that synthetic grafts were used in 33 (15 males, 18 females) out of 436 arteriovenous fistulas (AVF) opened to 372 patients. The mean age was 59.2 (17) years. Left radiocephalic (RC) straight graft fistula was opened in 2 patients, left brachiocephalic (BC) straight graft fistula was opened in 12, left BC distal loop AVF in 13, right BC distal loop AVF in 1, left brachioaxillary (BA) distal loop AVF in 3 and right BA distal loop was used to open an AVF in 2 patients. Primary cumulative patency rates were as follows: 72% in the 3rd month, 65% in the 6th month, 42.24% in the 12th month. The secondary patency rates were 33.9% in the 60th month, 12% in the 60th month, 96.96% in the 12th and 24th months, 90.28% in the 36th and 48th months, 59.12% in the 60th month and 43.11% in the 72nd month.Conclusion: In chronic renal failure patients who do not have a natural vascular access routes or whose natural routes have been exhausted, AVFs that are opened to the upper extremities with a synthetic graft are suitable vascular access routes for long-term dialysis.

Preoperative color Doppler ultrasound parameters for surgical decision-making in upper arm arteriovenous fistula maturation

ObjectiveCurrent scientific evidence is insufficient to determine the best vascular access for each patient. It is an unmet clinical need because vascular access dysfunction accounts for 20% to 30% of hospital admissions. Our aim was to evaluate preoperative color flow Doppler ultrasound (CDUS)-derived parameters (vein diameter and brachial artery flow and diameter) and their effect interaction with comorbidities as predictors of brachiocephalic (BC) and brachiobasilic (BB) arteriovenous fistula (AVF) maturation. MethodsA prospective analysis was performed of patients who underwent BC and BB AVF as primary definitive vascular access between January 2016 and May 2017. Variables included patients' demographics, comorbidities, medication, preoperative blood pressure, and CDUS-derived parameters. Outcomes were patency 48 hours after surgery and fistula maturation at 6 and 12 weeks. Nonparametric descriptive and univariate statistics were used. Logistic regression models and receiver operating characteristic curve analyses were performed. ResultsThere were 132 patients (91 with BC AVF and 41 with BB AVF) included. The 48-hour patency was 91.7%. AVF maturation at 6 weeks was observed in 71.3%, and AVF maturation at 12 weeks was observed in 66.3%. There were no associations in univariate and multivariate logistic regression analysis between AVF maturation and comorbidities. Systolic blood pressure was an independent predictor of 48-hour patency with an optimized cutoff of 154 mm Hg (area under the curve, 0.73; P = .013; Youden index, 0.40). Vein diameter with tourniquet was an independent predictor of AVF maturation at 6 and 12 weeks with an optimized cutoff of 3.9 mm (area under the curve, 0.74; P < .001; Youden index, 0.38). ConclusionsAVF maturation was independent of comorbidities. Systolic blood pressure ≥154 mm Hg and vein diameter with tourniquet ≥3.9 mm were the associated conditions that better predicted BC and BB AVF maturation. There were no effect interactions between CDUS-derived parameters and associated comorbidities.

Correlation Between Tendon Xanthomas And Atherosclerotic Disease In Coronary And Brachiocephalic Arteries In Patients With Familial Hypercholesterolemia

Background and Aims: Presence of tendon xanthomas (TX) is a pathognomonic sign of familial hypercholesterolemia (FH) and reportedly linked to accelerated development of atherosclerosis. We aimed to investigate association of TX with coronary (CA) and brachiocephalic (BA) atherosclerosis separately and in context of conventional cardiovascular risk factors.

Polyvascular disease in patients with myocardial infarction and chronic kidney disease

To study polyvascular disease in patients with myocardial infarction (MI) and chronic kidney disease (CKD). A total of 954 patients older than 18 years old with ST-segment elevation MI (STEMI) up to 24 hours of pain onset were included in the study. Clinical and demographic data were collected for all patients, including physical examination, 16-lead electrocardiogram recording, echocardiography, laboratory assessment with the measurements of cardiospecific enzymes and serum creatinine. Glomerular filtration rate (GFR) was estimated according to the CKD-EPI equation. Of them, 771 (81%) underwent coronary angiography, duplex scanning of the brachiocephalic (BCA) and lower extremity arteries (LEA). Patients with stage 1-4 CKD diagnosed according to the criteria provided by the Russian Society of Nephrologists were allocated into a separate group (n=281; 36.5%). CKD stages were determined with the level of GFR. Patients with stage 5 CKD were excluded from the study. Renal dysfunction was defined as the presence of an estimated GFR less than 60 ml/min/1.73 m2. The results of the study indicate a high prevalence of PolyVD in patients with CKD. Every second patient had LEA stenosis (p.

Can pre and postoperative vein diameter and postoperative flow velocities influence the patency of vascular access in hemodialysis patients?

Introduction: All end-stage renal disease patients have to undergo renal replacement therapy or renal transplantation. Patients require vascular access for hemodialysis. Autologous arteriovenous fistula (AVF) is the gold standard to maintain vascular access for hemodialysis. Methods: This is a prospective study. A total of 187 patients were evaluated in this study. Correlation with pre- and postoperative vein diameter and flow velocities on the outcomes of the AVFs was studied. Pre- and postoperative vein diameter and postoperative flow velocities were measured on the 1st-postoperative day in vein and across anastomosis using duplex Doppler study. Results: Flow velocities across the anastomosis and the vein were significant in both radiocephalic (RC) and brachiocephalic (BC) group. P = 0.010 and 0.013 for RC and 0.046 and 0.004 for the BC group, respectively. Increase in the postoperative vein diameter between functioning and nonfunctioning group was significant, with P = 0.029 in the BC group. Flow velocities in vein and across anastomosis between functioning and failure group were significant in brachiobasilic (BB) fistulas with P = 0.0220 and 0.0143, respectively. Increase in the postoperative vein diameter between functioning and nonfunctioning group is not significant, with P = 0.446. Conclusion: The increase in vein diameter after anastomosis predicts the success of fistula in BC AVF. Flow velocities in vein and across anastomosis have strong prediction in RC, BC, and BB AVF.

Clinical predictors of recurrent stenosis and need for re-intervention in the cephalic arch in patients with brachiocephalic AV fistulas.

Cephalic arch stenosis is one of the most common reasons for repeated endovascular intervention and eventual abandonment of access in hemodialysis patients. There is no prediction model to identify risk factors for recurrent cephalic arch stenosis. We have developed a mathematical model to predict the need for reintervention in brachiocephalic (BC) fistulas with recurrent cephalic arch stenosis. Single-center retrospective analysis of 143 patients with a BC fistula referred to the vascular clinic for access dysfunction who underwent cephalic arch angioplasty were included for the analysis. Twelve-month post-index angioplasty data were analyzed using parametric, non-parametric and multiple regression models using SPSS software. The mean need for re-intervention in 1 year since first index visit was 2.46 ± 1.404. Statistically significant correlation (p≤0.001) for re-intervention was observed with the severity of stenosis at index visit, access flow, vessel wall diameter proximal to the stenosis, average venous pressure >50% of the delivered blood flow rate and prolonged bleeding for >30 minutes as a reason for referral. Three equations have been derived for calculating the need for re-intervention based on the diameter of the vessel wall proximal to the stenosis. Risk stratification of BC fistulas utilizing the above parameters could enable clinicians to identify accesses that are at risk for multiple re-interventions. Early identification of accesses that are at high risk for re-interventions at the cephalic arch might prolong access survival and reduce the cost for intervention by utilizing alternate strategies.

Outcomes of primary arteriovenous fistulas in patients older than 70 years

The population of elderly hemodialysis patients is increasing, yet the most suitable approach for providing permanent hemodialysis access remains unclear. Here we report outcomes using an approach aimed predominantly at creating radiocephalic (RC) fistulas. A single-center retrospective cohort study was performed in which access outcomes for primary arteriovenous fistulas created between January 1, 2005, and December 31, 2012, in patients aged 70years or older were compared. During the study period, 204 RC, 1 brachiobasilic, and 9 brachiocephalic (BC) primary fistulas were created initially for patients requiring dialysis. Immediate failure rates for RC fistulas were lower than for BC fistulas but not significantly so (12% vs 22%; Fisher's exact text, P= .319). One-year primary and secondary patency for RC fistulas was54% and 66%, respectively, and similar for those created in patients between 70 and 80years old and in those olderthan 80years. The secondary patency rate at 1year for RC fistulas using cephalic vein of diameter<2.5mm waslower than for fistulas created with cephalic vein >2.5mm (49% vs 72%; log-rank test, P= .005). Creation of a BCfistula was associated with a significantly higher incidence of steal syndrome than with an RC fistula (10% vs 2%; Fisher's exact text, P= .009). RC fistulas formed in the elderly carry a lower risk of steal syndrome than BC fistulas and offer the potential for further revision surgery, such that acceptable secondary patency is achieved for RC fistulas formed using even small (<2.5mm) cephalic veins.