Nephrology@Point of Care: A New Journal for Hands-On Clinicians

Stenosis and thrombosis are common causes of prosthetic vascular access (pVA) failure. The role of arteriovenous fistula (AVF) surveillance is widely debated. The aim of this paper is to present a new real-time application designed for AVF surveillance called SPIDER. Surgical staff and hemodialysis nurses are responsible for data entry. SPIDER automatically analyses data and generates alerts in case of abnormal trends. Surgical evaluation and duplex Doppler ultrasonography are then immediately performed to confirm presence of stenosis or other possible pVA defects. Surgery can be performed if required. A preliminary analysis of results will be completed at 12 months after the program begins and subsequently after 24 months. Primary assisted patency will be compared with historical using multivariate analysis. Expected results are an improvement in primary assisted pVA patency and reduction of hospitalizations. Simultaneous management of a high number of patients can become difficult due to the large amount of data required for surveillance. We want to demonstrate whether a real-time automated system could help to prevent thrombosis and graft loss

what does early mean remarks on immediate prosthetic vascular access cannulation for urgent hemodialysis

Management of complicated vascular access. A step-by-step description of a case of hyperkalemia and vascular access failure in a patient receiving maintenance hemodialysis treated for numerous prev..

Endograft repair for pseudoaneurysms and penetrating ulcers of the ascending aorta

OBJECTIVE: The aim of this paper is to report midterm results of thoracic endovascular aortic repair (TEVAR) for ascending aortic pseudoaneurysms (AAPs) and penetrating aortic ulcers (PAUs) of the ascending aorta. METHODS: This study was retrospective and performed at tertiary centers. Eight patients with AAPs (n = 5) and PAUs (n = 3) received total endovascular repair of the ascending aorta. Patients with a history of type A aortic dissection or fusiform aneurysm were excluded. All patients analyzed were considered to be at high risk for open repair at the time of presentation. RESULTS: Urgent intervention was performed in 6 (75%) cases. Primary clinical success was achieved in 7 (87.5%) cases. A low-flow type 3 endoleak remained asymptomatic and was managed conservatively. No TEVAR-related in-hospital mortality, primary conversion, cerebrovascular accidents, valve impairment, or myocardial infarction occurred. All patients were discharged home, alive and independent, after a median length of stay of 6 (range: 5-24) days. No patient was lost at a mean follow-up of 40 \ub1 33 (range: 4-93) months. Ongoing primary clinical success was maintained in all but 1 patient (type 3 endoleak): aortically related reintervention was never required. No endograft breakage or migration was observed. At 1-year follow-up, 7 (87.5%) aortic lesions had significant reduction in diameter ( 655 mm). CONCLUSIONS: Ascending TEVAR was feasible, safe, and effective for AAPs and PAUs. In a very select subset of lesions, midterm results were favorable, with both standard and custom-designed endografts

Total endovascular treatment for extent type 1 and 5 thoracoabdominal aortic aneurysms

OBJECTIVE: The study objective was to describe the results of thoracic endovascular aortic repair with the intentional coverage of the celiac artery and distal supramesenteric landing zone for extent type 1 and type 5 thoracoabdominal aortic aneurysms. METHODS: Inclusion criteria were thoracic endovascular aortic repair with celiac artery coverage to treat elective or urgent extent type 1 and 5 thoracoabdominal aortic aneurysms. Primary end points were in-hospital and follow-up survival, freedom from aortic-related mortality, and freedom from reintervention. RESULTS: Thoracoabdominal disease extent was type 1 in 12 patients (71%) and type 5 in 5 patients (29%). Urgent repair was performed in 4 patients (23.5%). Primary technical success was 100%. Early mortality and visceral ischemia did not occur. Permanent spinal cord ischemia rate was 6% (n = 1). Follow-up ranged from 3 to 120 months (interquartile range, 12-36.5). Survival estimate was 85% \ub1 9% (95% confidence interval, 67-94) at 1 year and 49% \ub1 17% (95% confidence interval, 21-78) at 5 years. Cumulative freedom from aortic-related mortality was 94%, and estimated freedom from reintervention at 1 and 5 years was 93% \ub1 7% (95% confidence interval, 68-99). Neither type 1 endoleaks nor distal stent-graft migration causing superior mesenteric artery occlusion was detected. CONCLUSIONS: Thoracic endovascular aortic repair with intentional coverage of celiac artery for extent 1 and 5 thoracoabdominal aortic aneurysms had satisfactory results in selected patients at high risk for open repair. Visceral ischemia did not occur, but spinal cord ischemia is still high at 6%. At midterm follow-up, neither endoleak development nor aortic reintervention was related to the inadequate distal landing zone. Follow-up survival is satisfactory and comparable to open repair

Malignancy as a risk factor in single-stage combined approach for simultaneous elective surgical diseases

AbstractObjectiveTo identify morbidity and mortality risk factors in patients with synchronous diseases who underwent single-stage combined (SSC) surgery.MethodsWe considered data of 328 patients, each with multiple, elective, synchronous surgical problems treated by a SSC operation. By univariate and multivariate analysis we evaluated many patient-, disease - or treatment-related variables with respect to post-operative mortality, morbidity, and hospital stay.ResultsTwo combined procedures were synchronously performed in 283 patients (86%), 3 combined procedures in 45 patients (14%). Post-operative mortality and morbidity rates were 3% and 24%, respectively, and median duration of hospital stay was 9 days. The occurrence of a surgical oncology procedure emerged as the most important independent risk factor for post-operative mortality and morbidity.ConclusionsThe safety of SSC surgery for the treatment of synchronous problems appears similar to that of multi-stage procedures. The understanding of risk factors for this surgical approach could be useful in order to improve patient selection

Thoracic Endovascular Aortic Repair for Type B Acute Aortic Dissection Complicated by Descending Thoracic Aneurysm

OBJECTIVES: To analyse the results and review the literature about thoracic aortic endovascular repair (TEVAR) for type B acute aortic dissection (TBAAD) complicated by descending thoracic aortic aneurysm (DTA) in the hyperacute or acute phases. METHODS: This was a multicentre, observational descriptive study. Inclusion criteria were TBAAD with a DTA of 6550 mm, TBAAD on an already known aneurysmal descending thoracic aorta, and TBAAD presenting with an enlarged aorta with a total diameter <50 mm, but with >50% diameter increase compared with a previous computed tomography angiography (CTA) showing a non-dissected aorta with normal sizing. Primary endpoints were early and long-term survival, freedom from TEVAR and aortic related mortality (ARM), and freedom from re-intervention. RESULTS: Twenty-two patients were included in the analysis. The mean aortic diameter was 66 \ub1 26 mm (range 42-130; IQR 51-64). The in hospital TEVAR related mortality was 14% (n = 3). The mean radiological follow-up was 56 \ub1 45 months (range 6-149; IQR 12-82), and the follow-up index 0.97 \ub1 0.1. All surviving patients were available for follow-up. During follow-up the cumulative mortality was 26% (n = 5) and TEVAR related mortality was 5% (n = 1). Overall the estimate of survival was 82% (95%CI: 61.5-93) at 1 year, and 64% at 5 years. Ongoing primary clinical success was 79% (re-intervention n = 4). Freedom from aortic related mortality was 86% (95%CI: 66-95) at 1 and 5 year, while freedom from re-intervention was 95% (95%CI: 75.5-95) at 1 year, and 77% (95%CI: 50-92) at 5 years. CONCLUSIONS: In our experience, DTA is a frequent complication from the very beginning of the clinical onset of TBAAD. In this high-risk cohort, TEVAR showed satisfactory results, better than those predicted by the risk score for open repair, with favourable stability of the aortic diameter and no aortic related adverse events during follow-up

arteriovenous access graft infection standards of reporting and implications for comparative data analysis

Abstract There is presently a lack of organization and standardized reporting schema for arteriovenous graft (AVG) infections. The purpose of this paper is to evaluate the various types of treatment modalities for access site infections through an analysis of current publications on AVG. Key proposals are made to support standardization in a data-driven manner to make infection reporting more uniform and thereby facilitate more meaningful comparisons between various dialysis modalities and AVG technologies

Tomotherapy after Pleurectomy/Decortication or Biopsy for Malignant Pleural Mesothelioma Allows the Delivery of High Dose of Radiation in Patients with Intact Lung

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Low-dose radiotherapy in diffuse large B-cell lymphoma

Low-dose radiotherapy (LDRT) given in 2 x 2 Gy is a highly effective and safe treatment for palliation of indolent lymphomas. Otherwise, very little regarding the use of LDRT for diffuse large B-cell lymphoma (DLBCL) has been investigated. We designed a phase 2 trial of LDRT in patients with DLBCL with indication for palliative radiation. Low-dose radiotherapy was administered on symptomatic areas only. Clinical response was assessed 21 days after LDRT and defined as reduction >50% of maximum diameter of the radiated lesions. Quality of life was scored by the European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire. Tumor subtype (germinal center B-cell type versus activated B-cell type) and the presence of TP53 mutations in pathologic specimens of the target lesion were also evaluated. Twenty-three of twentyfive radiated patients were evaluable for response. and 2 died of disease before the visit at 21 days. The overall response rate was 70% (16 of 23 patients), with 7 complete responses and 9 partial responses (mean duration of response. 6 months; range, 1-39 months). Fifteen patients answered to the QLQ-C30 questionnaires, and an improved quality of life was documented in 9 cases. TP53 mutations were detected in 2 of 6 (33%) nonresponders and in none of the responders (P = .12). Germinal center B-cell type responded better than activated B-cell type (response rate was 83% and 29%, respectively, P = .01). These findings indicate that LDRT is effective for palliation in patients with DLBC