Prospective Evaluation of Ischemia in Brachial–Basilic and Forearm Prosthetic Arteriovenous Fistulas for Hemodialysis

Ischemia is a devastating complication after arteriovenous fistula (AVF) creation. When not timely corrected, it may lead to amputation. Symptomatic ischemia occurs in 3.7–5% of the hemodialysis population. Upper arm AVFs have a higher incidence of ischemia compared to forearm AVFs. As more patients may need upper arm AVFs in the growing and older hemodialysis population, occurrence of symptomatic ischemia may increase. The purpose of this study is to identify predictors for occurrence of ischemia.MethodsA prospective evaluation of ischemia was performed in patients randomised for either a brachial–basilic (BB-) AVF or a prosthetic forearm loop AVF. Clinical parameters, preoperative vessel diameters, access flows, digital blood pressures, digit-to-brachial indices (DBI) and interventions for ischemia were recorded.ResultsSixty-one patients (BB-AVF 28) were studied. Seventeen patients (BB-AVF 8) developed ischemic symptoms. Six patients (BB-AVF 3) needed interventions for severe symptoms. Age, history of peripheral arterial reconstruction and radial artery volume flow were significant predictors for the occurrence of ischemia.ConclusionSymptomatic ischemia occurred in 28% of patients with brachial–basilic and prosthetic forearm AVFs. Age, history of peripheral arterial reconstruction and radial artery volume flow might be important for prediction of ischemia

Impact of a quality improvement programme based on vascular access flow monitoring on costs, access occlusion and access failure

Vascular access thrombosis is a substantial source of morbidity in chronic haemodialysis patients. Periodical access flow measurements can predict the presence of vascular access stenosis and provide an opportunity for early intervention to prevent subsequent vascular access thrombosis. By this system of quality improvement, vascular access-related costs might be reduced. The aim of this study was to analyse the cost impact of a quality improvement programme based on periodic access flow measurements. METHODS: The number and costs of vascular access interventions (summary of angiography, percutaneous transluminal angioplasty, catheter placement, hospitalization days and costs for surgery) in the period 2001-2003 (quality improvement period; QIP, 218.6 patient-years observed) were retrospectively compared with a reference period (RP, 1996-1998, 214.4 patient-years observed) during which no access flow was measured. All access flow measurements were done on a regular base and interventions were performed according to the Kidney Disease Outcome Quality Initiative. RESULTS: Surgical thrombectomy procedures were significantly less during the QIP (0.25 +/- 0.57 events/patient-year) compared with RP (0.63 +/- 1.06 events/patient-year; P = 0.000), whereas access loss was not significantly different. During the QIP, 205 radiological interventions were performed (0.88 +/- 1.16 events/patient-year), and in the RP around 48 (0.33 +/- 0.65 events/patient-year; P = 0.000). Access-related costs tended to be lower during the QIP compared with the RP. The cost reduction appeared to be limited to patients with arteriovenous graft (AVG), in which access-related costs were significantly lower during the QIP (euro2360.95 +/- 2838.17 patient-year) compared with the RP (euro4003.96 +/- 3810.92 patient-year; P = 0.012), but not in patients with arteriovenous fistula (AVF). CONCLUSION: A quality improvement programme based on periodical access flow measurement reduced the number of acute vascular access failures due to thrombotic events and also significantly reduced health care costs in patients with AVG, but not in patients with AVF. The quality improvement programme had no effect on access survival

Variation in the use of infection control measures and infection-related revision incidence after breast implant surgery in the Netherlands

Background: The use and effect of most infection control measures (ICMs) in breast implant surgery are still debated, likely resulting in undesired variation in current practices. Objectives: This study investigated the relationship between the number and combinations of ICMs used and the infection-related revision incidence after breast implant surgery. Additionally, national variation between Dutch healthcare institutions in ICM use was evaluated. Methods: For this multicentre, population-based study, all patients who received a primary breast implant or tissue expander for breast augmentation or reconstruction between 2015 and 2019 were identified from the Dutch Breast Implant Registry. Seven prospectively collected ICMs were investigated: preoperative antibiotics, implant and/or pocket irrigation, glove change, nipple guards, insertion sleeve, postoperative drains, and postoperative antibiotics. Results: This study included 52,415 implants (85% augmentation, 15% reconstruction).The median (IQR) number of ICMs used was 3 (3-4) for augmentation and 4 (4-5) for reconstruction. Median follow-up was 30 months for augmentation and 34 months for reconstruction. Infection-related revision incidence was 0.1% for augmentation and 2.1% for reconstruction. Most infection-related revisions occurred within 2 months for augmentation and 2.5 months for reconstruction. The impact of ICM use on infection-related revision incidence remained unclear, given its low incidence. A significant variation was observed between institutions in the use of postoperative antibiotics and drains. Conclusions: Although the use of different ICMs varied considerably between institutions, the infection-related revision incidence after breast implant surgery was generally low. Most surgeons used four ICMs for breast reconstruction and three ICMs for breast augmentation. Further studies on the causes and effects of the observed variation are needed. (c) 2022The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.Analysis and support of clinical decision makin