dialysis shunt [keywords]
- Umbilical hernia in patients with liver cirrhosis: A surgical challenge. [Journal Article, Review]
- World J Gastrointest Surg 2016 Jul 27; 8(7):476-82.
Umbilical hernia occurs in 20% of the patients with liver cirrhosis complicated with ascites. Due to the enormous intraabdominal pressure secondary to the ascites, umbilical hernia in these patients has a tendency to enlarge rapidly and to complicate. The treatment of umbilical hernia in these patients is a surgical challenge. Ascites control is the mainstay to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis. Intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary to control ascites. Hernia repair is indicated in patients in whom medical treatment is effective in controlling ascites. Patients who have a good perspective to be transplanted within 3-6 mo, herniorrhaphy should be performed during transplantation. Hernia repair with mesh is associated with lower recurrence rate, but with higher surgical site infection when compared to hernia correction with conventional fascial suture. There is no consensus on the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or underlay. Many studies have demonstrated several advantages of the laparoscopic umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment.
- New Insights into Dialysis Vascular Access: What Is the Optimal Vascular Access Type and Timing of Access Creation in CKD and Dialysis Patients? [JOURNAL ARTICLE]
- Clin J Am Soc Nephrol 2016 Jul 11.
Optimal vascular access planning begins when the patient is in the predialysis stages of CKD. The choice of optimal vascular access for an individual patient and determining timing of access creation are dependent on a multitude of factors that can vary widely with each patient, including demographics, comorbidities, anatomy, and personal preferences. It is important to consider every patient's ESRD life plan (hence, their overall dialysis access life plan for every vascular access creation or placement). Optimal access type and timing of access creation are also influenced by factors external to the patient, such as surgeon experience and processes of care. In this review, we will discuss the key determinants in optimal access type and timing of access creation for upper extremity arteriovenous fistulas and grafts.
- Outcomes of neonates requiring prolonged stay in the intensive care unit after surgical repair of congenital heart disease. [JOURNAL ARTICLE]
- J Thorac Cardiovasc Surg 2016 Apr 19.
After neonatal cardiac surgery, a number of patients need a prolonged stay in the intensive care unit (ICU). Those patients require tremendous resources and strain the capacity of cardiac units. To date, little knowledge of early and late survival for this challenging population exists.From 2002 to 2012, 108 neonates required a postoperative ICU stay >30 days. Multivariable regression analyses examined factors associated with hospital death and late survival. Comparison of late outcomes in hospital survivors was made between those who had prolonged ICU stay (n = 82) and contemporaneous neonates who did not (n = 1329).Hospital mortality occurred in 26 of 108 patients (24%). On multivariable analysis, factors associated with mortality were use of extracorporeal membrane oxygenation (odds ratio, 3.4 [95% confidence interval, 1.3-9.1], P = .014) and renal failure that required dialysis (odds ratio, 3.1 [95% confidence interval, 1.0-10.0], P = .056). Overall survival at 1 and 8 years was 57% and 51%. Comparison of late outcomes for hospital survivors showed that neonates who required prolonged postoperative stay in the ICU had significantly worse 8-year survival (69% vs 92%; P < .001) and that the effect of prolonged stay in the ICU on diminished survival was more pronounced in neonates with 2 ventricles (68% vs 95%, hazard ratio, 8.0 [95% confidence interval, 4.2-15.1], P < .001) than in those with single ventricle (66% vs 81%; hazard ratio, 2.0 [95% confidence interval, 1.1-3.5], P = .021). Overall, 77% of single-ventricle hospital survivors who required prolonged stay in the ICU progressed to Glenn, with 82% of them reaching or qualifying for subsequent Fontan.Prolonged postoperative stay in the ICU is associated with high hospital and significant postdischarge mortality, mainly during the first year. In neonates with single ventricle, prolonged stay in the ICU was associated with high hospital and interstage mortality and usual progression subsequent to Glenn shunt. In contrast, prolonged stay in the ICU in neonates with 2 ventricles was associated with high hospital mortality and considerable decrease in late survival, suggesting a more pronounced deviation from expected survival in those patients.
- Salvaging the 'life-threatening life line': repair not recreate. [Case Reports, Journal Article]
- Br J Hosp Med (Lond) 2016 Apr; 77(4):252.
- Vertebral and internal mammary artery steal syndrome in patients with hemodialysis access. [Journal Article]
- Vasa 2016; 45(2):163-8.
Increased flow in the subclavian artery feeding a vascular access for hemodialysis can induce steal phenomena in the vertebral (VA) and internal mammary artery (IMA). The aim of this study was to describe the hemodynamic effects of access flow on the VA and IMA in patients with native fistulas and grafts.Peak systolic (PSV) and end diastolic (EDV) velocity measurements of the VA, IMA and carotid arteries, as well as flow volume measurements of the subclavian artery, were performed. Flow measurements at the side of the vascular access were compared with the contralateral side. Fifty-five patients were consecutively included, most with a radio-cephalic fistula on the left arm with a mean shunt volume of 1156 ml/min.Pathologic flow patterns were observed in the ipsilateral VA in four patients (7.3 %); contralateral VA flow was normal in all patients. Peak systolic velocity of the VA was significantly decreased at the side of the shunt arm with a PSV of 42.6 ± 11.8 cm/s compared to 48.4 ± 15.6 cm/s contralateral (p < 0.05). The IMA flow pattern were normal in all patients. The PSV of the IMA was significantly decreased (p < 0.01) at the side of the shunt arm (87.5 ± 29.1 cm/s) compared to the non-shunt arm (95.9 ± 27.4 cm/s).We describe significant hemodynamic effects of fistulas to the vertebral and internal mammary arteries. Doppler spectral analysis of the vertebral and internal mammary arteries should be integrated in ultrasound, especially in patients with cerebrovascular or cardiac symptoms.
- PREDICTIVE PARAMETERS FOR SUCCESSFUL FUNCTIONAL MATURATION OF NATIVE ARTERIOVENOUS FISTULA. [Journal Article]
- J Ayub Med Coll Abbottabad 2015 Oct-Dec; 27(4):821-4.
Successful arteriovenous fistula (AVF) significantly reduces both the morbidity as well as mortality of the patients who have end stage renal disease, and significantly improve their survival rate. The objective of the study was to high light the role of various parameters in the functional maturation of arteriovenous fistula (AVF).This descriptive analytical study conducted at Department of Vascular Surgery, Combined Military Hospital Lahore from January 2014 to January 2015. All consecutive patients who underwent creation of AVF and had pre and post-operative Duplex scan to assess the arteries and veins of the upper limbs, were included. The AVFs were created at wrist, forearm and arm under local anaesthesia. The data was collected from radiology department and dialysis centre and correlated with the data from operation theatre.A total of 127 patients (89 males and 38 females) were included in this study. Only 57.5% (n = 73) patients showed functional maturation of their AVFs. Of these, only 14 (36.8%) were females. Arterial and venous diameters of more than 2.5 mm (p = 0.0001 and 0.001 respectively), fistulae created at elbow (p = 0.001), presence of on-table thrill (p = 0.003), presence of on-table bruit (p = 0.001), patients having their AVFs created before the start of dialysis (p = 0.0037) and kidney transplant (p = 0.0042) were all positive predictors for successful functional maturation of AVFs. Female gender was a negative predictor and was responsible for non-maturation (p-value 0.003).Maturation of AVFs is a complex process influenced by a lot of factors. Although in our study various parameters proved to have positive impact on AVFs maturation, large prospective multi-centre studies are needed to provide well defined outcome.
- Patency of the Viabahn stent graft for the treatment of outflow stenosis in hemodialysis grafts. [Journal Article]
- Am J Surg 2016 Mar; 211(3):551-4.
To evaluate arteriovenous graft patency when failing grafts are treated with Viabahn covered stents vs percutaneous angioplasty (PTA) alone.A retrospective review of all patients that underwent endovascular interventions for failing grafts at a single institution between January 2010 and July 2013 was performed. Forty-four patients were identified who were treated with PTA alone (11) and with Viabahn stent grafts (33) for stenoses in the venous to graft anastomoses. Patient demographics, procedural success, and intraoperative complications were recorded as well as graft patency at 3, 6, and 12 months. Graft patency was reviewed and compared with PTA alone.There was no statistically significant difference between the 2 groups regarding gender, frequency of diabetes, hypertension, coronary artery disease, or peripheral arterial disease. Primary technical success defined as residual stenosis 10% or less was achieved in 100% of the cases. Follow-up was determined by flow velocities during dialysis and ultrasound imaging in the vascular laboratory. At 12 months 87.8% (29/33) grafts with stents were functional vs 36.4% (4/11) of those with PTA alone. Primary patency of the stent group was 61%, 52%, and 42% at 3, 6, and 12 months respectively vs the PTA group 64%, 45%, and 9%.Grafts treated with Viabahn covered stents for outflow stenosis have a superior patency to PTA alone, 12 months after treatment; although earlier post treatment results are comparable.
- Preoperative radial artery volume flow is predictive of arteriovenous fistula outcomes. [Journal Article]
- J Vasc Surg 2016 Feb; 63(2):429-35.
Guidelines recommend the creation of a wrist radiocephalic arteriovenous fistula (RAVF) as initial hemodialysis vascular access. This study explored the potential of preoperative ultrasound vessel measurements to predict AVF failure to mature (FTM) in a cohort of patients with end-stage renal disease in Northern Ireland.A retrospective analysis was performed of all patients who had preoperative ultrasound mapping of upper limb blood vessels carried out from August 2011 to December 2014 and whose AVF reached a functional outcome by March 2015.There were 152 patients (97% white) who had ultrasound mapping and an AVF functional outcome recorded; 80 (54%) had an upper arm AVF created, and 69 (46%) had a RAVF formed. Logistic regression revealed that female gender (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.12-5.55; P = .025), minimum venous diameter (OR, 0.6; 95% CI, 0.39-0.95; P = .029), and RAVF (OR, 0.4; 95% CI, 0.18-0.89; P = .026) were associated with FTM. On subgroup analysis of the RAVF group, RAVFs with an arterial volume flow <50 mL/min were seven times as likely to fail as RAVFs with higher volume flows (OR, 7.0; 95% CI, 2.35-20.87; P < .001).In this cohort, a radial artery flow rate <50 mL/min was associated with a sevenfold increased risk of FTM in RAVF, which to our knowledge has not been previously reported in the literature. Preoperative ultrasound mapping adds objective assessment in the clinical prediction of AVF FTM.
- POSTOPERATIVE ARTERIAL RELAXATION AND INTRAOPERATIVE VENOUS DILATION AS INTERCONNECTED PROGNOSTIC FACTORS FOR THE MATURATION OF ARTERIOVENOUS FISTULAS. [Comparative Study, Journal Article]
- Rev Med Chir Soc Med Nat Iasi 2015 Oct-Dec; 119(4):1077-82.
To investigate if immediate arterial distention can be used as a predictive factor for the development of a good fistula.Over a 5-months period (January- May 2015) all the patients who underwent an arteriovenous fistula between the radial artery and the cephalic vein of the forearm at the Second Surgical Clinic of the Iasi Regional Cancer Institute and were willing to participate were enrolled in the study. The diameters of the vessels were measured 1 hour and 8 weeks after surgery.We found statistically significant differences for all measured diameter variations between the calcified artery and normal artery groups (p < 0.001 for the arterial distention at 1 hour and 8 weeks after surgery and p = 0.002 for the venous distention 8 weeks after surgery). A linear regression also showed that the degree of arterial distention immediately after surgery and the venous distention 8 weeks after surgery were statistically correlated.Arterial distention immediately after surgery and therefore the lack of it due to the presence of arterial calcifications can be used to predict whether or not a good fistula can be achieved at a 1% statistical significance level.
- Outcomes for forearm and upper arm arteriovenous fistula creation with the transposition technique. [Journal Article]
- J Vasc Surg 2016 Mar; 63(3):764-71.
To study the outcomes of three different types of arteriovenous fistula (AVF) transpositions (forearm cephalic vein transposition [FACVT], upper arm cephalic vein transposition [UACVT], and upper arm basilic vein transposition [UABVT]) for dialysis patients in a single center.A 6-year retrospective review, from 2006 to 2012, was conducted at a single institution in which the surgical outcomes for three different types of AVF transposition were reviewed. Preoperative duplex vein mapping was obtained in all patients to choose the best vein for access.There were 165 patients identified with 77 FACVTs, 52 UACVTs, and 36 UABVTs. Primary access maturation rates for the FACVT, UACVT, and UABVT groups were 86%, 90%, and 97%, respectively (P = .19). All transposed, matured primary AVFs were used after a mean of 9.9 weeks, without additional intervention. Primary 1-year patency for the FACVT, UACVT, and UABVT groups were 63%, 61%, and 70%, respectively (P = .71). Primary assisted 1-year patency for the FACVT, UACVT, and UABVT groups were 93%, 93%, and 100%, respectively (P > .999). Mean operating room times and time to intervention were not significantly different between the groups. The postoperative hematoma rate was 2% and wound infection rate was 2%. Multivariate analysis indicated no significant predictors of time to failure (P > .05).With low primary failure rates, reduced need for secondary interventions before maturation, and 1-year primary assisted patency rates in excess of 93%, our study showed that the transposition technique, in our experience, is superior to previously published literature in hemodialysis access creation.