RESUMEN

BACKGROUND: Thrombosis of arteriovenous (AV) grafts caused by stenosis at the venous anastomosis is a well-described problem. Surgical thrombectomy and conventional angioplasty with mechanical thrombectomy have provided good success rates in achieving immediate graft patency but with generally dismal graft survival rates in the range of 11% to 36% at 6 months' follow-up. The role of intravascular stents in patients who have failed angioplasty or surgical revision at the venous anastomosis has not been fully elucidated, particularly in older grafts that have previously undergone multiple procedures. METHODS: In this series, 34 patients had self-expanding nitinol stents placed at the venous anastomosis following graft thrombectomy and angioplasty procedures. Patients were selected for stent placement if conventional angioplasty alone was unsuccessful due to immediate elastic recoil or residual stenosis. All patients were followed after stent placement and evaluated for duration of graft patency and need for repeated endovascular procedures. RESULTS: The average graft age at the time of stent placement was 17.9 months. Eight-eight percent of grafts were functioning at 6 months' follow-up, and 63% of the entire group had survived without the need for additional procedures. Among those with need for repeat interventions, 81% had new lesions outside of the stent, and 57% had new lesions within the stent. In 38% of cases, new stenoses were located both outside and within the stent. Among grafts no longer being used, only 19% of the time was it due to disease recurring within the stent. CONCLUSION: Polytetrafluoroethylene (PTFE) graft longevity is improved when venous anastomosis stenoses are treated with stents in selected cases of older grafts that would have normally undergone abandonment or surgical revision.

Asunto(s)

Derivación Arteriovenosa Quirúrgica/efectos adversos , Oclusión de Injerto Vascular/terapia , Diálisis Renal/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Oclusión de Injerto Vascular/etiología , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Politetrafluoroetileno , Terapia Recuperativa , Stents

RESUMEN

Presternally exiting peritoneal dialysis (PD) catheters have been described as advantageous compared to abdominally exiting catheters with regard to infection, wound healing, and other complications. Placement of such catheters has only been described with open surgical techniques and not by percutaneous means. In this article we describe 15 patients who received percutaneously placed PD catheters with a presternal exit site. These patients received their procedures in an outpatient procedure room performed by an interventional nephrologist. In all but one case, immediate technical success was achieved. In only one case was peritonitis documented. All catheters are still functional, including some with follow-up as long as 15 months. Percutaneous placement of presternally exiting PD catheters is technically straightforward and can avoid an open surgical procedure.

Asunto(s)

Cateterismo/métodos , Catéteres de Permanencia , Fallo Renal Crónico/terapia , Diálisis Peritoneal/métodos , Radiografía Intervencional , Abdomen , Adulto , Anciano , Atención Ambulatoria , Cateterismo/efectos adversos , Diseño de Equipo , Seguridad de Equipos , Femenino , Estudios de Seguimiento , Humanos , Fallo Renal Crónico/diagnóstico , Masculino , Persona de Mediana Edad , Diálisis Peritoneal/efectos adversos , Diálisis Peritoneal/instrumentación , Medición de Riesgo , Muestreo , Esternón , Resultado del Tratamiento

RESUMEN

Conventional angioplasty of stenoses at the venous anastomosis has been demonstrated to be an important endovascular adjunct to mechanical thrombectomy of clotted arteriovenous dialysis grafts. In some cases, however, severe venous anastomosis stenosis is resistant to angioplasty. Cutting balloon angioplasty may have an advantageous role in these difficult situations in order to avoid surgical revision. In this series of 350 patients receiving percutaneous, endovascular declotting procedures, 9 patients had high-grade venous anastomotic stenoses (opening less than 2 mm) that could not be remedied with either conventional or high-pressure noncompliant peripheral angioplasty balloons. These nine patients had the lesions opened with the use of 4 mm x 10 mm cutting balloons and placement of self-expanding nitinol stents at the venous anastomosis during the same angiography procedure. Patients were followed for patency and functionality of the graft. In all cases, immediate technical success occurred. Among these patients, the vessels have remained patent for as long as 20 months of follow-up and grafts have remained functional. Cutting balloon angioplasty may have a potential therapeutic role in resistant venous anastomotic stenoses.

Asunto(s)

Angioplastia de Balón/instrumentación , Derivación Arteriovenosa Quirúrgica/efectos adversos , Oclusión de Injerto Vascular/terapia , Angioplastia de Balón/métodos , Diseño de Equipo , Oclusión de Injerto Vascular/etiología , Humanos , Diálisis Renal , Stents , Trombectomía

RESUMEN

Nephrogenic fibrosing dermopathy (NFD) is a rare clinical entity affecting patients with renal failure, often on chronic dialysis or after transplantation. The patient profile at risk for this debilitating condition is undefined. Lack of awareness of the condition has hampered epidemiologic work in identifying the etiology. We present four chronic hemodialysis (HD) patients who developed this disease. The patients' ages ranged from 26 to 75 years, and they had received HD from between 20 months and 10 years before the diagnosis of NFD. Two patients had a history of renal transplantation. All patients had progressive thickening and woody induration of the skin associated with contractures, leading to difficult ambulation, and permanent disability within weeks of the diagnosis. In one case, the diaphragm, psoas muscle, and pericardium were involved. The latter is likely the first report of pericardial involvement of NFD. In all four patients, the skin findings were restricted to the extremities, sparing the trunk and face. Skin biopsy findings included thickened dermis with particularly thickened collagen bundles, fibroblast proliferation, minimal mucin deposition, and nearly absent inflammation. The pathologic findings were distinct from scleromyxedema and scleroderma. We found no laboratory evidence of autoimmune disease or thyroid dysfunction to account for alternate etiologies. CD34-positive cells were documented in the skin biopsies as well as in the diaphragm, psoas muscle, and pericardial tissue of the concerned case. NFD is a novel fibrosing disorder of progressively debilitating nature which needs further clinical characterization and recognition to guide investigation of its pathogenesis.