RESUMEN
BACKGROUND: Percutaneous arteriovenous fistula (pAVF) has been recently developed as an alternative to surgical AVF (sAVF). We report our experience with pAVF in comparison with a contemporaneous sAVF group. METHODS: Charts of all 51 patients with pAVF performed at our institution were analyzed retrospectively, in addition to 51 randomly selected contemporaneous patients with sAVF (2018-2022) with available follow-up. Outcomes of interest were (i) procedural success rate, (ii) number of maturation procedures required, (iii) fistula maturation rates, and (iv) rates of tunneled dialysis catheter (TDC) removal. For patients on hemodialysis (HD), sAVF and pAVF were considered mature when the AVF was used for HD. For patients not on HD, pAVF were considered mature if flow rates of ≥500 mL/min were documented in superficial venous outflow; for sAVF, documentation of maturity based on clinical criteria was required. RESULTS: Compared patients with sAVF, patients with pAVF were more likely to be male (78% vs 57%; P = .033) and less likely to have congestive heart failure (10% vs 43%; P < .001) and coronary artery disease (18% vs 43%; P = .009). Procedural success was achieved in 50 patients with pAVF (98%). Fistula angioplasties (60% vs 29%; P = .002) and ligation (24% vs 2%; P = .001) or embolization (22% vs 2%; P = .002) of competing outflow veins were more frequently performed on patients with pAVF. The surgical cohort had more planned transpositions (39% vs 6%; P < .001). When all maturation interventions were combined, pAVF required more maturation procedures, but this was not statistically significant (76% vs 53%; P = .692). When planned second-stage transpositions were excluded, pAVF had a statistically significant higher rate of maturation procedures (74% vs 24%; P < .001). Overall, 36 pAVF (72%) and 29 sAVF (57%) developed mature fistulas. This difference, however, was not statistically significant (P = .112). At the time of AVF creation, 26 patients with pAVF and 40 patients with sAVF were on HD, all through use of a TDC. Catheter removal was recorded in 15 patients with pAVF (58%) and 18 patients with sAVF (45%) (P = .314). The mean time until TDC removal in pAVF group was 146 ± 74 days, compared with 175 ± 99 in the sAVF group (P = .341). CONCLUSIONS: Compared with sAVF, rates of maturation after pAVF seem to be similar, but this result may be related to the higher intensity of maturation procedures and patient selection. An analysis of appropriately matched patients will assist in elucidating the possible role of pAVF vis-a-vis sAVF.
Asunto(s)
Fístula Arteriovenosa , Derivación Arteriovenosa Quirúrgica , Femenino , Humanos , Masculino , Derivación Arteriovenosa Quirúrgica/efectos adversos , Derivación Arteriovenosa Quirúrgica/métodos , Diálisis Renal/métodos , Estudios Retrospectivos , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Venas/diagnóstico por imagen , Venas/cirugíaRESUMEN
OBJECTIVE: Catheter-directed interventions (CDIs) have been increasingly used for selected patients with acute intermediate-risk (submassive) pulmonary embolism (sPE) to prevent decompensation, mortality, and potentially long-term sequelae. The purpose of the present study was to determine whether the choice of anesthetic during these interventions has an effect on the postprocedural outcomes. METHODS: Patients who had undergone CDI for acute sPE from 2009 to 2019 were identified and grouped according to the intraprocedural use of propofol. The primary outcome was in-hospital intra- or postprocedural major adverse events, defined as the need for intubation, progression to massive pulmonary embolism, and in-hospital death. Major bleeding events (ie, intracerebral hemorrhage, transfusion of ≥2 U, the need for reintervention) were also assessed. Multivariate logistic regression analysis was used to evaluate the predictors of the studied outcomes. RESULTS: During the study period, 340 patients (age, 58.74 ± 15.22 years; 51.2% men) had undergone CDI for sPE (85 standard thrombolysis, 229 ultrasound-assisted thrombolysis, 26 suction thrombectomy). Propofol had been used for 36 patients (10.6%); the remaining 304 patients (89.4%) had received midazolam plus fentanyl, morphine, or hydromorphone for anesthesia. The baseline characteristics of both groups were similar, except for age, hypertension, American Society of Anesthesiologists class, and procedure type, with ultrasound-assisted thrombolysis the predominant procedure for the no-propofol group (74%). Overall, 18 patients had experienced ≥1 events of the composite outcome (ie, 10 intubations, 11 decompensations, 2 surgical conversions, 3 deaths). The propofol group had a significantly greater adverse event rate (13.8%; n = 5) compared with the no-propofol group (4.2%; n = 13; P = .015). On multivariate analysis, propofol was still a predictive factor for adverse events (odds ratio, 3.79; 95% confidence interval, 1.11-12.93; P = .03). A total of 16 patients had experienced major bleeding or other procedure-related events, including stroke in 4 (1.17%), coronary sinus perforation in 1, tricuspid valve rupture in 1, and the need for transfusion in 10 patients. The type of intervention (ie, standard thrombolysis, ultrasound-assisted thrombolysis, suction thrombectomy) was not a predictive factor for any studied outcome. CONCLUSIONS: CDIs are low-risk procedures with minimal postoperative morbidity and mortality in the setting of acute sPE. However, the use of propofol for intraprocedural sedation should be avoided because it can have detrimental effects.
Asunto(s)
Anestésicos Intravenosos/efectos adversos , Propofol/efectos adversos , Embolia Pulmonar/terapia , Trombectomía/efectos adversos , Terapia Trombolítica/efectos adversos , Adulto , Anciano , Anestésicos Intravenosos/administración & dosificación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Propofol/administración & dosificación , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Trombectomía/mortalidad , Terapia Trombolítica/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Outcomes of carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS) for asymptomatic disease in patients on dialysis are not well characterized, with questionable stroke prevention and survival. This study reports outcomes of carotid revascularization in asymptomatic dialysis patients in the United States. METHODS: Using United States Renal Data System (USRDS) databases, we identified all dialysis patients who underwent CEA or CAS for asymptomatic disease from 2005 to 2008. CEA and CAS were identified by Current Procedural Terminology (American Medical Association, Chicago, Ill) codes, and symptom status and comorbidities by International Classification of Diseases-9th Revision, Clinical Modification codes. Primary outcomes were stroke, cardiac complications, and death at 30 days and at 1 and 3 years. Predictors of death were identified using multivariate regression models. RESULTS: Of 738,561 dialysis patients, 2131 asymptomatic patients underwent carotid revascularization (1805 CEA, 326 CAS). The mortality rate was 4.7% at 30 days (4.6% CEA, 4.9% CAS; P = .807). Kaplan-Meier estimates of survival were 75.1% at 1 year (75.9% CEA, 70.7% CAS) and 43.4% at 3 years (43.7% CEA, 41.6% CAS). The stroke rate was 6.5% at 30 days (6.4% CEA, 6.9% CAS; P = .774) and 13.6% at 1 year (13.3% CEA, 15.0% CAS; P = .490). Cardiac complications occurred in 22.0% of patients (3.3% myocardial infarction) at 30 days (22.2% CEA, 20.6% CAS; P = .525). The combined stroke or death rate was 10.2% at 30 days (10.1% CEA, 10.9% CAS; P = .490) and 33.5% at 1 year (32.2% CEA, 39.6% CAS; P = .025). Age >70 years at the time of surgery and increased time on dialysis were predictive of death, whereas a history of renal transplant was a protective factor. CONCLUSIONS: Patients on dialysis have high perioperative and long-term stroke or death rates after CEA or CAS for asymptomatic stenosis, with a median survival that is less than recommended by current guidelines. As a result, carotid intervention in these patients appears to be inappropriate.
Asunto(s)
Angioplastia/efectos adversos , Estenosis Carotídea/terapia , Endarterectomía Carotidea/efectos adversos , Fallo Renal Crónico/terapia , Diálisis Renal/efectos adversos , Factores de Edad , Anciano , Angioplastia/instrumentación , Angioplastia/mortalidad , Enfermedades Asintomáticas , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/mortalidad , Distribución de Chi-Cuadrado , Comorbilidad , Bases de Datos Factuales , Endarterectomía Carotidea/mortalidad , Femenino , Cardiopatías/etiología , Cardiopatías/mortalidad , Humanos , Estimación de Kaplan-Meier , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/mortalidad , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Selección de Paciente , Diálisis Renal/mortalidad , Medición de Riesgo , Factores de Riesgo , Stents , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: Elective abdominal aortic aneurysm (AAA) repair in suitable candidates is a standard modality. The outcomes of AAA repair in patients with end-stage renal disease on dialysis are not well characterized, and there is questionable survival advantage in such patients with limited life expectancy. We sought to describe outcomes after AAA repair in U.S. dialysis patients. METHODS: The United States Renal Data System was used to collect data on intact asymptomatic AAA repair procedures in dialysis patients in the United States between 2005 and 2008. Endovascular AAA repair (EVAR) and open aortic repair (OAR) were identified by Current Procedural Terminology codes. Primary outcomes were perioperative (30-day) mortality and long-term survival. Predictors of mortality were identified by multivariate regression models. RESULTS: A total of 1557 patients were identified who had undergone elective AAA repair: 261 OAR and 1296 EVAR. The 30-day mortality was 11.3% (EVAR, 10.3%; OAR, 16.1%; P = .010), with increased age associated with increased mortality (odds ratio, 1.04; 95% confidence interval [CI], 1.02-1.07; P = .001). Kaplan-Meier survival estimates were 66.5% at 1 year (EVAR, 66.2%; OAR, 68%) and 37.4% at 3 years (EVAR, 36.8%; OAR, 40%; P = .33). Median survival was 25.3 months after EVAR and 27.4 months after OAR. Women had a higher mortality rate at 1 year (38.7%) compared with men (32.0%) (P = .015). There was no significant mortality difference at 1 year in comparing type of procedure in both men (EVAR, 31.6%; OAR, 34%; P = .55) and women (EVAR, 39.3%; OAR, 36%; P = .60). A Cox proportional hazards model demonstrated that male gender (hazard ratio [HR], 0.75; 95% CI, 0.62-0.92; P = .005), increased time on dialysis (HR for each year on dialysis, 0.79; 95% CI, 0.75-0.83; P < .001), kidney transplantation history (HR, 0.62; 95% CI, 0.43-0.88; P = .008), and diagnosis of hypertension (HR, 0.60; 95% CI, 0.48-0.75; P < .001) were protective against mortality. Increased age (HR, 1.02; 95% CI, 1.01-1.03; P < .001) and diabetes diagnosis (HR, 1.39; 95% CI, 1.13-1.71; P = .002) predicted increased mortality. CONCLUSIONS: AAA patients on dialysis have high perioperative and 1-year mortality rates after EVAR or OAR, particularly diabetics, women, and the elderly. This raises questions about the indications for intact AAA repair in dialysis patients, in whom the size threshold may need to be raised. Dialysis patients may be best served by deferring repair of AAA until AAAs reach large size or become symptomatic, especially if OAR is required, given the higher perioperative mortality compared with EVAR.