Complications of arteriovenous hemodialysis access: Recognition and management

English language citations reporting complications of arteriovenous access for hemodialysis are critically reviewed and discussed. Venous hypertension, arterial steal syndrome, and high-output cardiac failure occur as a result of hemodynamic alterations potentiated by access flow. Uremic and diabetic neuropathies are common but may obfuscate recognition of potentially correctable problems such as compression or ischemic neuropathy. Mechanical complications include pseudoaneurysm, which may develop from a puncture hematoma, degeneration of the wall, or infection. Dysfunctional hemostasis, hemorrhage, noninfectious fluid collections, and access-related infections are, in part, manifestations of the adverse effects of uremia on the function of circulating hematologic elements. Impaired erythropoiesis is successfully managed with hormonal stimulation; perhaps, similar therapies can be devised to reverse platelet and leukocyte dysfunction and reduce bleeding and infectious complications

One hundred twenty-five concomitant endovascular and open procedures for lower extremity arterial disease

AbstractObjective: Although the results of staged endovascular and open surgical reconstructions have been well documented, the safety and efficacy of concomitant procedures in the operating room are less well defined. Suboptimal performance of endovascular procedures in an operative setting, or inappropriate reliance on endovascular techniques, might theoretically compromise graft patency. We questioned whether late graft thrombosis is frequently attributable to failure at the endovascularly treated site in this setting. Materials and Methods: Between May 1, 1993, and June 30, 2001, we performed 125 concomitant endovascular and open arterial reconstructions (73 primary reconstructions, 52 graft revisions) in 106 patients. Endovascular techniques were used to treat inflow lesions in 72 cases, outflow lesions in 14 cases, both in four cases, and the graft itself in 35 cases. Fifty-five iliac, 18 femoral, 13 popliteal, six tibial, and 35 graft lesions were treated. For primary bypasses, 33 were to the popliteal level (21 prosthetic, 12 autogenous), 19 were to the tibial or pedal arteries (16 autogenous, three prosthetic or composite), and 12 were to the femoral arteries (one autogenous, 11 prosthetic). Nine patch angioplasties (eight femoral, one popliteal) were performed. For graft revisions, endovascular intervention was for inflow in 13 cases, outflow in three cases, both in one case, and of the graft itself in 35 cases. Surgical revisions involved segmental grafts in 33 cases, patch angioplasty in 18 cases, and both in one case. Results: In the primary group, the initial technical success rate of the endovascular procedure was 93% (68/73), with five patients needing open conversion. The 30-day mortality rate was 1.4%, and the morbidity rate was 11.0%. Of the 19 grafts in the primary group that occluded during the follow-up period (mean, 11.9 months), five thromboses could possibly be attributed to failure at the endovascular site. In the revision group, the initial technical success rate of the endovascular procedure was 88% (46/52), with six patients undergoing conversion to open procedure. The 30-day mortality rate was 0%, and the morbidity rate was 15.4%. Of 22 late graft occlusions in the revision group, only three were attributed to failure at the endovascular site. Conclusion: This largest report to date of concomitant lower extremity endovascular and open revascularization procedures shows the approach to be safe. Few late graft occlusions were attributable to failure at the endovascularly treated site. The concomitant approach offers the efficiency and convenience of single stage therapy and allows immediate treatment for inadequate endovascular results or their complications and potential cost savings. (J Vasc Surg 2003;37:316-22.

Duplex ultrasound imaging alone is sufficient for midterm endovascular aneurysm repair surveillance: A cost analysis study and prospective comparison with computed tomography scan

ObjectiveEarly in our experience with endovascular aortic aneurysm repair (EVAR) we performed both serial computed tomography scans and duplex ultrasound (DU) imaging in our post-EVAR surveillance regimen. Later we conducted a prospective study with DU imaging as the sole surveillance study and determined cost savings and outcome using this strategy.MethodsFrom September 21, 1998, to May 30, 2008, 250 patients underwent EVAR at our hospital. Before July 1, 2004, EVAR patients underwent CT and DU imaging performed every 6 months during the first year and then annually if no problems were identified (group 1). We compared aneurysm sac size, presence of endoleak, and graft patency between the two scanning modalities. After July 1, 2004, patients underwent surveillance using DU imaging as the sole surveillance study unless a problem was detected (group 2). CT and DU imaging charges for each regimen were compared using our 2008 health system pricing and Medicare reimbursements. All DU examinations were performed in our accredited noninvasive vascular laboratory by experienced technologists. Statistical analysis was performed using Pearson correlation coefficient.ResultsDU and CT scans were equivalent in determining aneurysm sac diameter after EVAR (P < .001). DU and CT were each as likely to falsely suggest an endoleak when none existed and were as likely to miss an endoleak. Using DU imaging alone would have reduced cost of EVAR surveillance by 29% ($534,356) in group 1. Cost savings of$1595 per patient per year were realized in group 2 by eliminating CT scan surveillance. None of the group 2 patients sustained an adverse event such as rupture, graft migration, or limb occlusion as a result of having DU imaging performed as the sole follow-up modality.ConclusionSurveillance of EVAR patients can be performed accurately, safely, and cost-effectively with DU as the sole imaging study