Hemodialysis vascular access: how do practice patterns affect outcomes?

There are significant international differences in the type of vascular accesses that are routinely used in the hemodialysis population. Most U.S. hemodialysis patients dialyze with grafts or catheters, while most European and Japanese patients dialyze with the preferable native arteriovenous (A-V) fistulae. Recent analyses suggest that several practice patterns that can be significantly affected by nephrology nurses may help increase both the use of native A-V fistulae and vascular access longevity in the U.S.     

Carotid endarterectomy with internal carotid artery segmental resection, temporary shunt and vein patch angioplasty: early and mid-term results.

AIM: The authors report an alternative procedure to carotid endarterectomy with internal carotid artery (ICA) segmental resection and end-to-end anastomosis associated with temporary shunt and venous patch angioplasty. Design: prospective cohort study. METHODS: Between May 1995 and December 2004, 192 patients underwent 200 primary CEAs for significant ICA stenosis. There were 131 men and 61 women with a mean age of 72.4+/-8.4 years. The indications for CEA were asymptomatic lesions in 51.5%, transient ischemic attack in 27.5% and stroke in 21%. RESULTS: The combined early morbidity and mortality rate was 2%. Two patients died, one due to fatal intracerebral hemorrhage and the second patient died of acute mesenteric ischemia. Neurological complications occurred in 2 patients, including 1 TIA and 1 nondisabling cerebrovascular accident. Non-neurological complications occurred in 26 patients (13.5%). Seventeen patients (8.8%) developed hypertension, 3 neck hematomas (1.5%) required surgical evacuation, 1 patient had reversible supraventricular arrhythmia (0.5%) and 1 patient had pneumonia (0.5%). Furthermore, 1 asymptomatic carotid occlusion was identified (0.5%) and 3 patients suffered permanent cranial nerve injury (1.5%). Mean follow-up was 45.7 months and there were 41 late deaths (21.8%). Survival rates at 1 and 5 years were 96.7+/-1.2% and 73.58+/-4.2%, respectively. CONCLUSIONS: CEA with ICA shortening and reanastomosis is a safe and reliable procedure without any increase in morbidity or mortality.     

The usefulness of transesophageal echocardiography in the diagnosis of pulmonary thromboembolism]

Three cases with suspected pulmonary artery embolism are presented, in which transesophageal echocardiography showed a mass in the right pulmonary artery consistent with thrombus. The relevant diagnostic contributions of transesophageal echocardiography are discussed.