Outcomes in adult recipients of right-sided liver grafts in split-liver procedures

Background:

The split-liver technique provides a good left lateral graft in children, but its results in adults remain controversial.

Methods:

From 1992 to 2007, 37 patients received 38 cadaveric right-sided grafts. Donors and recipients were selected for good quality grafts and elective indications; the latter included a high proportion of tumour cases and primary sclerosing cholangitis. Grafts included 31 extended right grafts (ERGs; segments IV–VIII and I and the inferior vena cava [IVC]) and seven right grafts (RGs; segments V–VIII) including five without the IVC and middle hepatic vein (MHV).

Results:

Mortality was 5% (two patients). There were four retransplantations (11%) for arterial thrombosis (1), portal vein thrombosis (2) and primary non-function (1). The retransplantation rate was higher in RG than in ERG (three vs. one patient; P= 0.015). Of the five patients without MHV, three were retransplanted and one had small-for-size syndrome leading to late death. After a mean follow-up of 5 years, 1-, 3- and 5-year graft and patient survival rates were 84%, 80% and 71%, and 91%, 88% and 78%, respectively. One-year patient and graft survival rates after ERG transplantation were 96% and 92%, respectively.

Conclusions:

Split-liver transplantation is a safe alternative to whole organ transplantation when an ERG is carried out. Right graft is associated with increased risk of graft loss, especially if the MHV is omitted. Split-liver transplantation with an ERG offers excellent outcomes and should be encouraged when good quality grafts are available.     

In vitro effects of L-carnitine on coronary artery bypass grafts

BACKGROUND:

The gold standard treatment for multivessel coronary revascularization is coronary artery bypass grafting. The internal mammary artery and saphenous vein grafts are the conduits most frequently used for these operations. Spasm of arterial and venous grafts is a significant problem during the operation.

OBJECTIVES:

To evaluate the acute in vitro effects of L-carnitine on internal mammary artery and saphenous vein grafts using a tissue bath.

METHODS:

Ten consecutive patients who underwent elective coronary artery bypass grafting were enrolled in the present study (nine men, one woman; mean [± SD] age 62±9.1 years). Samples from left internal mammary artery and saphenous vein grafts were collected from each patient. Submaximal smooth muscle contraction was achieved by adding 1 μM phenylephrine, and L-carnitine was then added to the solution. The concentration-response curves of the vasodilation response were obtained.

RESULTS:

In the internal mammary graft samples, the vasodilation response to L-carnitine was 64.3±11.1% at a concentration of 5 mM. In the saphenous vein graft samples, the vasodilation response to L-carnitine was 41.5±11.4% at a concentration of 5 mM. There was a statistically significant difference (P<0.001) between the response of the internal mammary artery and saphenous vein grafts in the in vitro tissue bath system.

CONCLUSIONS:

These results indicate that L-carnitine is a potential vasodilatory drug for internal mammary artery and saphenous vein grafts.     

Prosthetic graft interposition of the brachiocephalic veins or superior vena cava combined with resection of malignant tumours: graft patency and risk factors for graft occlusion

Background

We aimed to assess graft patency in patients undergoing prosthetic graft interposition of the brachiocephalic veins (BCVs) or the superior vena cava (SVC) combined with resection of malignant tumours.

Methods

A retrospective analysis was conducted on 16 patients who underwent prosthetic graft interposition of the BCVs or the SVC between 1998 and 2012.

Results

Among a total of 20 grafts in 16 patients (unilateral graft interposition in 12, bilateral graft interposition in 4), 8 grafts were occluded in 8 patients. Overall graft patency rate was 64.6%, 42.4% at the 2- and 5-year follow-up. Graft patency rate of the left BCV was significantly lower than that of the right BCV or the SVC (2-year patency, 38.1% vs. 81.8%, P=0.024). In univariate analysis, the superior anastomosis site [left BCV vs. right BCV; hazard ratio (HR) =2.312; 95% confidence interval (CI), 1.015–5.265; P=0.046], the inferior anastomosis site (right atrial appendage vs. SVC; HR =2.409; 95% CI, 1.124–5.161; P=0.024), and interruption of warfarin (HR =5.015; 95% CI, 1.106–22.734; P=0.037) were significant risk factors for graft occlusion. Graft occlusive symptoms were identified in 4 patients who underwent unilateral graft interposition.

Conclusions

Prosthetic graft interposition between the left BCV and the right atrial appendage resulted in a significant rate of graft occlusion. Prosthetic graft interposition of the bilateral BCVs and long-term warfarin therapy may be necessary to prevent graft occlusive symptoms.     

The results of in situ saphenous vein bypass for infrainguinal arterial reconstruction: Comparison between two types of valvulotomes

PURPOSE:

To evaluate the authors’ experiences with in situ saphenous vein bypasses that were performed using two types of valvulotomes and to respectively compare their efficacy on the basis of the operative outcomes.

METHODS:

Between June 1993 and December 2008, 103 constructive in situ saphenous vein bypasses were performed, of which 53 were performed between 1993 and 2000 using an Insitucat valvulotome (B Braun Melsungen AG, Germany), and 50 were performed between 2000 and 2008 using a LeMaitre valvulotome (LeMaitre Vascular Inc, USA).

RESULTS:

There were no statistical differences with regard to age, sex and bypass procedures between the two groups. Critical limb ischemia (P=0.021) and diabetes (P=0.005) were more frequent in the LeMaitre group than the Insitucat group. Intraoperative graft revisions (P=0.079) and graft spasms (P=0.638) were less frequent in the LeMaitre group. Graft failures in the perioperative period or within the first year were less frequent in the LeMaitre group. The five-year cumulative primary patency rates were 63.2% and 59.8% in the LeMaitre and Insitucat groups, respectively (χ²=0.390, not significant). The five-year cumulative secondary patency rates were 91.9% and 81.7% in the LeMaitre and Insitucat groups, respectively (χ²=2.690, not significant).

CONCLUSIONS:

The results suggested that there were no significant differences in the outcome and adverse effects between the two types of valvulotomes for in situ saphenous vein bypass.     

All-in-one sleeve patch graft venoplasty for multiple hepatic vein reconstruction in living donor liver transplantation

Objectives

This paper presents an innovative technique to address complex multiple hepatic vein (HV) reconstruction in right lobe graft living donor liver transplantation (RL-LDLT).

Methods

A patient with hepatitis C virus-related cirrhosis underwent RL-LDLT. The graft had seven HVs, including: the right HV (17 mm); one segment VII HV (11 mm); two segment VI HVs (6 mm and 16 mm), and three segment V HVs. The graft weighed 663 g (53% of standard liver volume; ratio of graft weight to recipient body weight: 0.96). Each HV had significant drainage territory requiring reconstruction. A cryopreserved iliac vein graft was used to create a sleeve patch to incorporate the HV openings. The holes were anastomosed to their corresponding HV tributaries using continuous 6–0 polydioxanone (PDS) sutures. Two of the three segment V HVs were combined using a smaller iliac vein patch, which was anastomosed in an end-to-side fashion to a previously harvested recipient umbilical vein interposition graft. The other end of the umbilical vein graft was anastomosed to the larger iliac vein sleeve patch.

Results

Overall, six HV openings were incorporated in one sleeve patch to allow a single wide anastomosis with the recipient inferior vena cava. Doppler ultrasound after reconstruction showed adequate flow patterns in all the HVs.

Conclusions

All-in-one sleeve patch graft venoplasty simplifies the reconstruction of multiple HVs and reduces warm ischaemia time in RL-LDLT with excellent outcomes.     

The use of biological grafts for reconstruction of the inferior vena cava is a safe and valid alternative: results in 32 patients in a single institution

Background

Resection and reconstruction of the inferior vena cava (IVC) is occasionally required in the surgical treatment of intra-abdominal tumours. IVC reconstruction can be performed with biological or synthetic graft material, with most centres preferring synthetic grafts. In spite of the potential advantages of biological grafts in terms of handling characteristics, and safety, very limited data are available about their use in patients requiring an IVC resection.

Methods

Medical records of 32 patients who underwent an IVC resection and reconstruction from 1990 and 2011 with autogenous peritoneo-fascial (N = 22) and bovine pericardial (N = 10) grafts were reviewed.

Results

A tangential resection with patch repair was performed in 10 patients, whereas in the remaining 22 it was necessary to resect and replace a segment or all of the retrohepatic IVC. A concomitant liver resection was performed in 14 patients, nephrectomy in 10 and pancreaticoduodenectomy in 2 patients. There were no acute or late complications related to graft thrombosis or infection. Three patients died as a consequence of multi-organ failure. Overall survival at 1 and 5 years was 78% and 48%, respectively.

Conclusions

The preferential use of synthetic grafts in IVC replacement is not evidence based. Selection of an appropriate prosthetic graft for IVC reconstruction should be based on the safety and its handling features. The use of biological grafts for IVC repair is a valid alternative to current synthetic materials and may in fact be superior in terms of biocompatability, ease of handling, reduced rate of infection and improved long-term patency without permanent anticoagulation.     

Edaravone suppresses endothelial cell injury in vein grafts of a rat model

OBJECTIVE:

Postoperative intimal hyperplasia, the major cause of vein graft occlusion, is initiated by endothelial injury. Using a high-magnification scanning electron microscope (SEM), the surfaces of endothelial cells in vein grafts were examined to investigate the protective mechanism of the free radical scavenger edaravone (Radicut, Mitsubishi Tanabe Pharma Co, Japan) against endothelial injury in postoperative intimal hyperplasia.

METHODS:

In 10 male Lewis rats with a mean (± SD) weight of 495±28 g, a right epigastric vein graft was interposed into the common femoral artery. Five rats received preoperative intraperitoneal administration of edaravone (3.0 mg/kg; edaravone group). The other five received an equal volume of saline preoperatively (sham operation group). Unoperated right epigastric veins were also examined as controls. The vein grafts from each group were examined using an S-800 Hitachi SEM (Hitachi High-Technologies Co, Japan) at ×10,000 to ×20,000 magnification.

RESULTS:

Unoperated endothelial cells had smooth surfaces. While endothelial cells in the sham operation group had very rough surfaces with platelet adhesion, endothelial cells in the edaravone group had smooth surfaces without platelet adhesion, very similar to unoperated endothelial cells.

CONCLUSION:

These SEM results showed that edaravone may maintain the smooth surface of endothelial cells. The authors postulate that edaravone suppresses postoperative intimal hyperplasia by alleviating endothelial injury.     

Effects of Skeletonized versus Pedicled Radial Artery on Postoperative Graft Patency and Flow

Background

Radial artery (RA) was the second arterial graft introduced in clinical practice for myocardial revascularization. The skeletonization technique of the left internal thoracic artery (LITA) may actually change the graft''s flow capacity with potential advantages. This leads to the assumption that the behavior of the RA, as a coronary graft, is similar to that of the LITA, when skeletonized.

Objective

This study evaluated ''free'' aortic-coronary radial artery (RA) grafts, whether skeletonized or with adjacent tissues.

Methods

A prospective randomized study comparing 40 patients distributed into two groups was conducted. In group I, we used skeletonized radial arteries (20 patients), and in group II, we used radial arteries with adjacent tissues (20 patients). After the surgical procedure, patients underwent flow velocity measurements.

Results

The main surgical variables were: RA internal diameter, RA length, and free blood flow in the radial artery. The mean RA graft diameters as calculated using quantitative angiography in the immediate postoperative period were similar, as well as the flow velocity measurement variables. On the other hand, coronary cineangiography showed the presence of occlusion in one RA graft and stenosis in five RA grafts in GII, while GI presented stenosis in only one RA graft (p = 0.045).

Conclusion

These results show that the morphological and pathological features, as well as the hemodynamic performance of the free radial artery grafts, whether prepared in a skeletonized manner or with adjacent tissues, are similar. However, a larger number of non-obstructive lesions may be observed when RA is prepared with adjacent tissues.     

Biliary complications after right lobe living donor liver transplantation: a single-centre experience

Background

Biliary complications that developed after right lobe liver transplantation from living donors were studied in a single centre.

Methods

From 2004 to 2010, 200 consecutive living donor right lobe liver transplantations were performed. The database was evaluated retrospectively. Biliary complications were diagnosed according to clinical, biochemical and radiological tests. The number of biliary ducts in the transplanted graft, the surgical techniques used for anastomosis, biliary strictures and bile leakage rates were analysed.

Results

Of a total of 200 grafts, 117 invloved a single bile duct, 77 had two bile ducts and in six grafts there were three bile ducts. In 166 transplants, the anastomosis was performed as a single duct to duct, in 21 transplants double duct to ducts, in one transplant, three duct to ducts and in 12 transplants as a Roux-en-Y reconstruction. In all, 40 bile leakages (20%) and 17 biliary strictures (8.5%) were observed in 49 patients resulting in a total of 57 biliary complications (28.5%). Seventeen patients were re-operated (12 as a result of bile leakages and five owing to biliary strictures).

Conclusion

Identification of more than one biliary orifice in the graft resulted in an increase in the complication rates. In grafts containing multiple orifices, performing multiple duct-to-duct (DD) or Roux-en-Y anastomoses led to a lower number of complications.     

Ischaemic preconditioning of the graft in adult living related right lobe liver transplantation: impact on ischaemia�Creperfusion injury and clinical relevance

Background

Ischaemic preconditioning (IPC) of the right liver graft in the donor has not been studied in adult-to-adult living related liver transplantation (LRLT).

Objective

To assess the IPC effect of the graft on ischaemia reperfusion injury in the recipient and compare recipient and donor outcomes with and without preconditioned grafts.

Patients and methods

Alternate patients were transplanted with right lobe grafts that were (n =22; Group _Precond) or were not (n =22; Group _Control) subjected to IPC in the living donor. Liver ischaemia–reperfusion injury, liver/kidney function, morbidity/mortality rates and outcomes were compared. Univariate and multivariate analyses were performed to identify factors predictive of the aspartate aminotransferase (AST) peak and minimum prothrombin time.

Results

Both groups had similar length of hospital stay, morbidity/mortality, primary non-function and acute rejection rates. Post-operative AST (P =0.8) and alanine aminotransferase (ALT) peaks (P =0.6) were similar in both groups (307 ± 189 and 437 ± 302 vs. 290 ± 146 and 496 ± 343, respectively). In univariate analysis, only pre-operative AST and warm ischemia time (WIT) were significantly associated with post-operative AST peak (in recipients). In multivariate analysis, the graft/recipient weight ratio (P =0.003) and pre-operative bilirubin concentration (P =0.004) were significantly predictive of minimum prothrombin time post-transplantation.

Conclusions

Graft IPC in the living related donor is not associated with any benefit for the recipient or the donor and its clinical value remains uncertain.     

Cost-benefit comparison of hemodialysis access creation in a developing country and North American centres

OBJECTIVE:

It has been suggested that vascular access operations should only be performed in high-volume centres to ensure good outcomes. Vascular access operations have been routinely performed in the Cayman Islands since 2005. However, with an estimated population of 45,000 persons, only a small number of patients require vascular access in any given interval. A cost-benefit analysis of this practice was performed.

METHODS:

All patients who had vascular access operations over four years were retrospectively identified. Two groups were defined – the local group, who had operations performed by surgeons in the Cayman Islands, and the offshore group, who were transferred off the island and had operations overseas. Cumulative cost, morbidity, patency and failure rates were compared. Significance was considered present with a two-tailed P≤0.05.

RESULTS:

There were 14 patients in the local group and 22 in the offshore group. The mean cost of access creation was 6.9 times greater in the offshore group (US$26,883.36 versus US$3,913.33; P<0.001). The likelihood of the use of arteriovenous grafts was significantly greater in the offshore group (P=0.04). When therapeutic outcomes were compared, there were no differences in primary or secondary failure, primary or secondary patency, or overall access-specific morbidity.

CONCLUSIONS:

In the present setting, vascular access creation exceeded all the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. Compared with overseas centres, this is being achieved at a significantly lower cost, with a greater likelihood of native fistula use and similar therapeutic outcomes.     

Off-pump coronary artery bypass grafting using a bilateral internal mammary artery Y graft

Objectives To evaluate the outcome of off-pump coronary artery bypass grafting (OPCABG) using a bilateral internal mammary artery (BIMA) Y configuration graft to achieve total arterial myocardial revascularization. Methods From October 2002 to December 2008, 208 patients (196 males and 12 females) underwent OPCABG using a BIMA Y configuration graft. The average age of the patients was 56.5 ± 11.3 years, with an age range of 33–78 years. A total of 167 (80.2%) cases had triple-vessel disease. Left main stem disease was found in 33 (15.9%) cases, and double-vessel disease was found in 8 (3.9%) cases. The semi-skeletonization technique was used to harvest the two internal mammary arteries (IMAs), and then the free right internal mammary artery was connected end-to-side to the left internal mammary artery (LIMA) in situ to complete the Y configuration graft. Off-pump and sequential anastomosis methods were used to perform coronary artery bypass surgery in all patients. Graft patency was assessed intra-operatively with the HT311 transit time flowmeter. Results A total of 728 distal anastomoses were performed in 208 patients, with the average being 3.5 ± 1.3 per person. No one died or experienced recurrent angina within 30 days after the operation. Conclusions OPCABG using the BIMA Y graft was safe and effective to achieve total arterial revascularization. This method avoids surgical operation on the ascending aorta and other incisions.     

A multicentre, randomized, double-blind placebo-controlled trial evaluating rosiglitazone for the prevention of atherosclerosis progression after coronary artery bypass graft surgery in patients with type 2 diabetes. Design and rationale of the VeIn-Coronary aTherOsclerosis and Rosiglitazone after bypass surgerY (VICTORY) trial

BACKGROUND:

The number of patients with coronary artery disease and type 2 diabetes will increase dramatically over the next decade. Diabetes has been related to accelerated atherosclerosis and many patients with diabetes will require coronary artery bypass graft (CABG) surgery utilizing saphenous vein grafts. After CABG, accelerated atherosclerosis in saphenous vein grafts leads to graft failure in approximately 50% of cases over a 10-year period. Rosiglitazone, a peroxisome proliferator-activated receptor-gamma agonist, has been shown to improve multiple metabolic parameters in patients with type 2 diabetes. However, its role in the prevention of atherosclerosis progression is uncertain.

STUDY DESIGN:

VeIn-Coronary aTherOsclerosis and Rosiglitazone after bypass surgerY (VICTORY) is a cardiometabolic trial in which patients with type 2 diabetes, one to 10 years after CABG, will be randomly assigned to receive rosiglitazone (up to 8 mg/day) or a placebo after qualifying angiography and intravascular ultrasound of a segment of one vein graft with or without a native anastomosed coronary artery. A comprehensive set of athero-thrombo-inflammatory markers will be serially assessed during the 12-month follow-up period. Body fat distribution and body composition will be assessed by computed tomography and dual energy x-ray absorptiometry, respectively, at baseline, six months and 12 months follow-up. For atherosclerosis progression evaluation, repeat angiography and intravascular ultrasound will be performed after 12 months follow-up. The primary end point of the study will be the change in atherosclerotic plaque volume in a 40 mm or longer segment of one vein graft.

CONCLUSIONS:

The VICTORY trial is the first cardiometabolic study to evaluate the antiatherosclerotic and metabolic effects of rosiglitazone in post-CABG patients with type 2 diabetes.     

Suppression of postoperative intimal hyperplasia of vein grafts with edaravone in rat models - a scanning electron microscope study

PURPOSE

Postoperative intimal hyperplasia, the most common cause of vein graft occlusion, is initiated by endothelial injury. In the present study, the mechanism by which the free radical scavenger edaravone (Radicut, Mitsubishi Tanabe Pharma Co, Japan) protects against endothelial injury in postoperative intimal hyperplasia was investigated.

METHODS

In 18 male Lewis rats, a right epigastric vein graft was interposed into the common femoral artery. Nine rats received a pre-operative intraperitoneal administration of edaravone (3.0 mg/kg, edaravone group) and the other nine rats received an equal volume of saline (saline group). After 1 h, five vein grafts from each group were treated with Verhoeff-van Gieson elastica stain and subjected to a histological examination. The other four vein grafts from each group were examined with an S-800 Hitachi scanning electron microscope (SEM) (Hitachi High-Technologies Co, Japan) at ×1000 magnification, as were three unoperated right epigastric veins (unoperated vein group). The endothelial areas of the vein grafts were measured using computerized planimetry of the SEM images (ImageJ version 1.37, National Institutes of Health, USA). The mean endothelial areas (%) were compared between the two groups.

RESULTS

Verhoeff-van Gieson elastica stain revealed no significant differences between the two groups. SEM showed that endothelial cells in the unoperated epigastric vein had a cobblestone-like appearance. In the saline group, the endothelial cells were comb-shaped and had adherent monocytes. In the edaravone group, however, the cobblestone-like appearance of endothelial cells was well preserved, with little monocyte adhesion. Moreover, the mean (± standard error of the mean) endothelial area was significantly higher in vein grafts from the edaravone group than in those from the saline group (74±1.8% versus 56±4.3%, P<0.05), and was similar to those in the unoperated epigastric veins (72±1.9%).

CONCLUSION

These findings show that endothelial injury is present soon after placement of the interposition graft. The authors believe that edaravone suppresses postoperative intimal hyperplasia by alleviating endothelial injury.     

Biliary complications following orthotopic liver transplantation: a 10-year audit

Background

Biliary complications following liver transplantation result in major morbidity. We undertook a 10-year audit of the incidence, management and outcomes of post-transplant biliary complications at the New Zealand Liver Transplant Unit.

Methods

Prospectively collected data on 348 consecutive liver transplants performed between February 1998 and October 2008 were reviewed. The minimum follow-up was 6 months.

Results

A total of 309 adult and 39 paediatric transplants were performed over the study period. Of these, 296 (85%) were whole liver grafts and 52 (15%) were partial liver grafts (24 split-liver, eight reduced-size and 20 live-donor grafts). There were 80 biliary complications, which included 63 (18%) strictures and 17 (5%) bile leaks. Partial graft, a paediatric recipient and a Roux-en-Y biliary anastomosis were independent predictors of biliary strictures. Twenty-five (40%) strictures were successfully managed non-operatively and 38 (60%) required surgery (31 biliary reconstructions, three segmental resections and four retransplants). Seven (41%) bile leaks required surgical revision and 10 (59%) were managed non-operatively. There was no mortality related directly to biliary complications.

Conclusions

Biliary complications affected one in five transplant recipients. Paediatric status, partial graft and Roux-en-Y anastomosis were independently associated with the occurrence of biliary strictures. Over half of the affected patients required surgical revision, but no mortality resulted from biliary complications.     

Autologous Peripheral Blood Stem Cell Transplantation Improves Portal Hemodynamics in Patients with Hepatitis B Virus-related Decompensated Cirrhosis

Background:

Chronic hepatitis B virus (HBV) infection may eventually lead to decompensated liver cirrhosis, which is a terminal illness.

Objectives:

The aim of this study was to investigate the therapeutic efficacy of autologous peripheral blood stem cell (APBSC) transplantation to improve portal vein hemodynamics in patients with HBV-related decompensated cirrhosis.

Patients and Methods:

This prospective study included 68 hospitalized patients who were diagnosed with HBV-related decompensated cirrhosis. These patients were divided into two groups: the transplantation group included 33 patients, while the control group included 35. Both groups received conventional medical treatment simultaneously, and APBSC transplantation was performed on the patients in the transplantation group. We evaluated the effects of APBSC transplantation on postoperative liver function using the following indices: total bilirubin, serum prothrombin and albumin, spleen size, and portal vein hemodynamics. Postoperatively, all of the patients were followed up at 24, 36, and 48 weeks.

Results:

The transplantation group had no serious reactions. Compared with the control group, albumin and prothrombin activity in the transplantation group was significantly improved at 24, 36, and 48 weeks after the procedure, and spleen length and portal vein diameter were substantially reduced at 48 weeks. The velocity of peak portal vein blood flow and mean maximum portal vein blood flow were greatly increased in the APBSC transplantation group at 36 and 48 weeks, respectively; however, there was also decreased portal vein diameter, which reduced portal vein pressure in patients with HBV-related decompensated cirrhosis.

Conclusions:

APBSC transplantation greatly benefits HBV-linked decompensated cirrhosis patients and should be recommended in clinical practice.     

Selective two-stage basilic and cephalic vein transpositions can significantly improve the rate of fistula construction

INTRODUCTION:

Modified proximal radial artery arteriovenous fistula (MPRAVF) can be used to improve the success and patency of basilic vein transposition (BVT) and cephalic vein transposition (CVT). In the present study, surgical experience with patients requiring a two-stage BVT or CVT using MPRAVF as the first stage was reviewed.

METHODS:

All two-stage BVTs and CVTs performed between September 2004 and October 2006 were retrospectively reviewed. The median follow-up for this cohort was 23.7 months. One-year secondary patency of all transpositions was assessed.

RESULTS:

Two hundred nineteen MPRAVFs were constructed. Twelve MPRAVFs failed and underwent a second procedure. Ninety-eight patients required no further procedures and their upper arm cephalic vein was matured and used for dialysis. Of 121 patients whose MPRAVFs were functioning but unusable due to their depth, 87 underwent BVT and 34 underwent CVT. The Kaplan-Meier one-year secondary patencies (± standard error) for BVTs and CVTs were 0.90±0.03 and 0.82±0.06, respectively. At one year, 87% of all transpositions remained patent.

CONCLUSIONS:

Use of MPRAVF as the first stage of a two-stage BVT or CVT can significantly improve the patency rate of autogenous hemodialysis access placement beyond the 66% set forth by the Fistula First guidelines.     

Access surgery for hemodialysis in the Cayman Islands: Preliminary results of a vascular access service

OBJECTIVE:

In the Cayman Islands, a vascular access service was created in 2005 to facilitate the creation of vascular access for hemodialysis by local surgeons. The present retrospective audit aims to establish the outcomes of this practice in the Cayman Islands.

METHODS:

Data from the operative log of the Cayman Islands Hospital was collected over a period of 36 months. The data were analyzed using SPSS version 12.0 (SPSS Inc, USA). Statistical analyses were performed using Student’s t tests and Fisher’s exact tests.

RESULTS:

A total of 19 operative procedures were performed to create vascular accesses in 12 men and seven women. Thirteen procedures (68%) created autogenous arteriovenous fistulas (AVFs) and six (32%) involved the insertion of a prosthetic arteriovenous graft (AVG). There were six incident dialysis patients, all of whom had an AVF created. The remaining 13 prevalent dialysis patients had new accesses in the form of AVFs (n=7) or AVGs (n=6).The statistical analyses were limited by sample size, but with AVFs, there were trends toward reduced incidence of secondary failure (four of 13 versus four of six), thrombosis (four of 13 versus two of six), infectious morbidity (zero versus two of six) and less demand for interventions to maintain patency (one of 13 versus two of six) with AVFs. There were also trends toward superior primary (461 days versus 227 days) and secondary (803 days versus 205 days) patency rates for AVFs.

CONCLUSIONS:

In this setting, the rate of AVF creation exceeds the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. To ensure continued delivery of modern quality care, further audits of the local practice will be required at regular intervals.     

Early Failure of Dialysis Access among the Elderly in the Era of Fistula First

Background and objectives

Recent evidence indicates that fistula maturation and patency may be compromised in the elderly dialysis population compared with younger patients. The objective of this study was to characterize the short-term outcomes of arteriovenous fistulas and arteriovenous grafts for hemodialysis access in the Medicare population.

Design, setting, participants, & measurements

This was a retrospective cohort study performed using Medicare Part A and B claims data from 2006 through 2011. The study population included 16,464 dialysis-dependent patients age ≥66 years undergoing arteriovenous fistula and arteriovenous graft creation. The primary outcome measure was incidence of repeat fistula/graft creation and tunneled catheter placements in the 12 months after arteriovenous fistula and graft creation.

Results

In the 12 months postindex fistula/graft, the mortality in the fistula group was 28.2% versus 29.9% in the graft group (P=0.03). A repeat fistula/graft creation was required in 26.9% of patients in the fistula group and 16.7% in the graft group (P<0.001). There was no significant difference in the proportion of patients who required a tunneled hemodialysis catheter in the 12 months after an index fistula creation (fistula 28.4% versus graft 27.3%, P=0.19). In the index fistula group, 44.4% of patients required a repeat fistula/graft creation and/or a tunneled catheter, compared with 33.7% in the graft group (P<0.001). At 365 days after the index fistula/graft, the repeat fistula/graft/catheter-free survival was 39.7% in the fistula group versus 46.0% in the graft group (P<0.001). Index fistula was associated with a higher risk of loss of repeat fistula/graft/catheter-free survival with an odds ratio of 1.19 (95% confidence interval, 1.13 to 1.24).

Conclusions

Fistulas were associated with a somewhat lower mortality than grafts in the first 12 months after creation. However, the incidence of repeat fistula/graft creation and tunneled catheter placement is substantially higher in the first 12 months after fistula creation compared with grafts. One-year repeat fistula/graft/catheter-free survival is lower after fistula creation than grafts.     

Paradoxical Embolism after Declotting of Hemodialysis Fistulae/Grafts in Patients with Patent Foramen Ovale

Summary

Background and objectives

The safety of percutaneous endovascular declotting procedures for thrombosed hemodialysis fistulae/grafts is well described in the general population; however, its safety in the presence of a patent foramen ovale (PFO) is not known. The objective of this study is to assess the incidence of symptomatic paradoxical embolic events associated with declotting procedure of thrombosed arteriovenous (AV) graft or fistula in patients with documented PFO.

Design, setting, participants, & measurements

This was a retrospective study in a hospital-based, academic practice. It included 23 patients (10 men; mean age, 65) with PFO and thrombosed hemodialysis graft/fistula who underwent a standardized declotting procedure with 2 mg of Alteplase and balloon thrombectomy. Twenty patients (87%) had AV grafts, and three (13%) had AV fistulae. The PFO shunt was right to left in two (9%), left to right in eight (34%), and bidirectional in ten (44%). The shunt direction was not specified in three patients (13%). The technical success of the declotting procedure and the frequency of clinically manifested paradoxical embolic events in this patient population were calculated.

Results

Fifty declotting procedures were performed on 23 patients with a technical success rate of 96% (48 of 50, 96%). No symptomatic paradoxical embolic events were found in any of the 23 patients with PFO.

Conclusions

Symptomatic paradoxical embolic events after percutaneous endovascular declotting procedures of thrombosed AV grafts and fistulae in patients with documented PFO are rare. This procedure appears to be safe in patients with a PFO.