Hemodialysis Access: Initial Considerations and the Difficult Patient

The population requiring hemodialysis (HD) in the United States continues to grow, with recent studies reporting over 370,000 Americans with end stage renal disease (ESRD) who are HD-dependent. The creation of functional HD access is often the limiting step in utilization of renal replacement therapy (RRT). Since the 1960s, the creation of hemodialysis access has become one of the most commonly performed procedures in the United States with over 500,000 vascular access procedures performed per year. This represents approximately 8% of the annual Medicare budget allocated to patients with ESRD. The magnitude of the associated economic and human costs is further exemplified by the fact that up to 25% of patients with ESRD will die due to inadequate hemodialysis access. This clinical situation and societal burden makes understanding the basic management steps and options for hemodialysis access of key importance to all healthcare professionals involved in the care of patients who require HD

Transarterial chemoembolization is ineffective for neuroendocrine tumors metastatic to the caudate lobe: a single institution review.

BACKGROUND: Caudate lobe liver metastases occur commonly in patients with neuroendocrine tumors. It is unknown, however, how these lesions respond to regional therapy and how their presence impacts outcomes. We reviewed our experience treating these lesions using transarterial chemoembolization (TACE). METHODS: We reviewed radiographic response to TACE in 86 patients with metastatic neuroendocrine tumors to the liver. We determined the impact of caudate lesions on outcomes in comparison to the cohort of patients without caudate lesions, as well as response of caudate lesions to TACE versus lesions elsewhere in the liver. RESULTS: Caudate lesions were identified in 45 (52%) patients. All patients had disease in other liver segments. Only seven caudate lesions (12.3%) had a radiographic response to TACE, whereas 82% of lesions elsewhere in the liver demonstrated a response. The presence or absence of a caudate lesion did not impact the overall radiographic (82.2% vs. 82.9%), symptomatic (64.4% vs. 56.1%), or biochemical (97.6% vs. 88.9%) response to TACE (P \u3e 0.1 for all). However, median overall survival was reduced in those presenting with caudate lesions (87.1 vs. 45.6 months, P = 0.031). CONCLUSIONS: Metastatic neuroendocrine tumors to the caudate lobe respond poorly to TACE. Symptomatic or threatening caudate lobe lesions should be considered for palliative resection in spite of additional inoperable liver metastases

Yttrium-90 microsphere induced gastrointestinal tract ulceration

© 2008 South et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

Persistent left superior vena cava: Review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients

Persistent left superior vena cava (PLSVC) represents the most common congenital venous anomaly of the thoracic systemic venous return, occurring in 0.3% to 0.5% of individuals in the general population, and in up to 12% of individuals with other documented congential heart abnormalities. In this regard, there is very little in the literature that specifically addresses the potential importance of the incidental finding of PLSVC to surgeons, interventional radiologists, and other physicians actively involved in central venous access device placement in cancer patients. In the current review, we have attempted to comprehensively evaluate the available literature regarding PLSVC. Additionally, we have discussed the clinical implications and relevance of such congenital aberrancies, as well as of treatment-induced or disease-induced alterations in the anatomy of the thoracic central venous system, as they pertain to the general principles of successful placement of central venous access devices in cancer patients. Specifically regarding PLSVC, it is critical to recognize its presence during attempted central venous access device placement and to fully characterize the pattern of cardiac venous return (i.e., to the right atrium or to the left atrium) in any patient suspected of PLSVC prior to initiation of use of their central venous access device

Hemodialysis Access: Initial Considerations and the Difficult Patient

The population requiring hemodialysis (HD) in the United States continues to grow, with recent studies reporting over 370,000 Americans with end stage renal disease (ESRD) who are HD-dependent. The creation of functional HD access is often the limiting step in utilization of renal replacement therapy (RRT). Since the 1960s, the creation of hemodialysis access has become one of the most commonly performed procedures in the United States with over 500,000 vascular access procedures performed per year. This represents approximately 8% of the annual Medicare budget allocated to patients with ESRD. The magnitude of the associated economic and human costs is further exemplified by the fact that up to 25% of patients with ESRD will die due to inadequate hemodialysis access. This clinical situation and societal burden makes understanding the basic management steps and options for hemodialysis access of key importance to all healthcare professionals involved in the care of patients who require HD

Best radiological response to trans‐arterial chemoembolization for hepatocellular carcinoma does not imply better outcomes

AbstractIntroductionRegional therapy with trans‐arterial chemoembolization (TACE) is a common treatment for unresectable hepatocellular carcinoma (HCC). Outcomes were examined in patients with the best radiological response (BR) after the initial TACE.MethodsThis was a retrospective cohort study of patients who underwent TACE as the initial treatment for HCC between the years 2000 and 2010. BR was defined as complete disappearance of the tumour or no enhancement with contrast on the first cross‐sectional imaging study after the initial TACE.ResultsSeventy‐eight out of 104 total consecutive patients were identified with the potential for a BR to TACE therapy for unresectable HCC, and 24 met the criteria for BR. Patients with BR had a median survival of 12.8 months (2.2–54.9) compared with 18.9 months(1.3–56.7) for the entire cohort (P= 0.313). The median time to progression was 10.6 months (1.2–24.3) in the BR group and 3.2 months (0.7–49.2) in the patients without a BR (P= 0.003).DiscussionBR to initial TACE for unresectable HCC is associated with comparable survival to those without BR in spite of a longer time to cancer progression. It may be reasonable to consider further therapy such as repeat TACE or biological/systemic therapy in patients with HCC even when the radiological response to the initial TACE is favourable