Christopher G. Carsten

Prosthetic thigh arteriovenous access: outcome with SVS/AAVS reporting standards

PURPOSE Differences in the reporting methods of results for arteriovenous (AV) access can dramatically affect apparent outcome. To enable meaningful comparisons in the literature, the Society for Vascular Surgery and the American Association for Vascular Surgery (SVS/AAVS) recently published reporting standards for dialysis access. The purpose of the present study was to determine infection rates, patency rates, and possible predictive factors for prosthetic thigh AV access outcomes with the reporting standards of the SVS/AAVS. METHODS A retrospective analysis was performed of all patients who underwent placement of thigh AV access by the Surgical Teaching Service at Greenville Memorial Hospital between 1989 and 2001. Outcomes were determined based on SVS/AAVS Standards for Reports Dealing with AV Accesses. The rate of revision per year of access patency was also determined; this end point more accurately reflects the true cost and morbidity associated with AV access than do patency or infection rates alone. RESULTS One hundred twenty-five polytetrafluoroethylene thigh AV accesses were placed in 100 patients. Nine accesses were excluded from the study, six because there was no patient follow-up and 3 as a result of deaths unrelated to the access procedure and which occurred less than 30 days after access placement. There were six (4%) late access-related deaths. There were 18 (15%) early access failures, related to infection in 14 cases (12%), thrombosis in three cases (2%), and steal in one case (1%). Early failure was more common in patients with diabetes mellitus (P =.036). The primary and secondary functional patency rates were 19% and 54%, respectively, at 2 years. Infection occurred in 48 (41%) accesses. The patency and infection rates were not influenced by patient age, gender, body mass index, or diabetes mellitus. The median number of interventions per year of access patency was 1.68, and this outcome was positively correlated with body mass index (P <.001). CONCLUSIONS Prosthetic AV access in the thigh is associated with higher morbidity compared with that reported for the upper extremity, and should be considered only if no upper extremity AV access option is available. Early access failure and the requirement for an increased number of interventions to reestablish and maintain access patency are more common in patients with diabetes mellitus and obesity. The number of interventions per year of access patency is a valuable end point when assessing the outcome of AV access procedures.

Can the Perclose suture-mediated closure system be used safely in patients undergoing diagnostic and therapeutic angiography to treat chronic lower extremity ischemia?

PURPOSE Mechanical closure devices for arterial hemostasis after angiography, such as the Perclose suture-mediated closure system, are designed to decrease time to ambulation and improve patient comfort. Although these devices are safe and efficacious, to date there has been little reported about use of the Perclose device in a cohort consisting exclusively of patients with lower extremity peripheral vascular disease. The purpose of this study was to determine the safety and efficacy of routine use of the Perclose system in patients with documented peripheral vascular disease undergoing angiography to treat chronic lower extremity ischemia. METHODS The Perclose device was placed for arterial closure after femoral artery access in 500 consecutive patients with documented peripheral vascular disease (ankle-brachial index, <0.8) who underwent diagnostic angiography or percutaneous intervention because of chronic lower extremity ischemia. These 500 patients composed 91% of all patients who underwent angiography because of chronic lower extremity ischemia between January 1, 2001, and April 1, 2002. All complications associated with the Perclose device were identified and reviewed. RESULTS Of the 500 arteries, 54% were accessed for diagnostic angiography and 46% for intervention. Perclose device placement was successful in 475 attempts (95%). Overall major complication rate was 1.4% (7 of 500 arteries). Complications included one death from retroperitoneal hemorrhage; three episodes of limb ischemia, two requiring operation and one requiring lytic therapy; two pseudoaneurysms; and one hematoma, which prolonged hospitalization. The hematoma was the only complication in the 25 patients with failed Perclose device placement. There were no infections requiring admission or operation. CONCLUSION The Perclose suture-mediated closure device is efficacious and can be used safely in selected patients with documented peripheral vascular disease. Complications associated with this device tend to be more severe than those historically reported for manual compression. Substantial experience with use of this device is required to achieve excellent results in patients with difficult anatomy.

Fistula Elevation Procedure: Experience with 295 Consecutive Cases During a 7-Year Period

BACKGROUND Up to 50% of AV fistulas fail to mature, primarily because of problems with fistula cannulation. Fistula elevation procedure (FEP) is a simple superficialization procedure where the fistula is surgically exposed, mobilized, and elevated into a more superficial position for the purpose of facilitating AV fistula cannulation. The purpose of this study is to review use of FEP as an adjunct to fistula maturation. STUDY DESIGN Two hundred ninety-five FEPs were performed between February 1999 and December 2005. FEP was performed if the fistula was considered too deep to cannulate or if nurses were unable to cannulate the fistula. Kaplan-Meier life-table analysis was used to determine patency and for a subanalysis by location of FEP performed (172 brachial-cephalic, 70 brachial-basilic, 46 radial-cephalic, 7 superficial femoral vein). Survival curves were compared using log-rank test. RESULTS Functional primary patency rates for patients undergoing an adjunctive FEP were 73% at 6 months, 60% at 1 year, and 46% at 2 years. Secondary functional patency rates were 81% at 6 months, 71% at 1 year, and 59% at 2 years. There was no statistical significance in any outcomes based on anatomic site of elevation. CONCLUSIONS AV fistulas that might otherwise have been abandoned because of excessive depth or tortuosity can be successfully salvaged by an adjunctive FEP and achieve satisfactory longterm functional patency. FEP is a valuable adjunct to AV fistula creation, which will enhance fistula maturation rates.

Do Current Outcomes Justify More Liberal Use of Revascularization for Vasculogenic Claudication? A Single Center Experience of 1,000 Consecutively Treated Limbs

BACKGROUND The purpose of this study was to reconsider current recommended treatment guidelines for vasculogenic claudication by examining the contemporary results of surgical intervention. STUDY DESIGN We performed a retrospective review of 1,000 consecutive limbs in 669 patients treated for medically refractory vasculogenic claudication and prospectively followed. Outcomes measured included procedural complication rates, reconstruction patency, limb salvage, maintenance of ambulatory status, maintenance of independent living status, survival, symptom resolution, and symptom recurrence. RESULTS Of the 1,000 limbs treated, endovascular therapy was used in 64.3% and open surgery in 35.7% of patients; aortoiliac occlusive disease was treated in 70.1% and infrainguinal disease in 29.9% of patients. The overall 30-day periprocedural complication rate was 7.5%, with no notable difference in complication rates when comparing types of treatment or levels of disease. Overall reconstruction primary patency rates were 87.7% and 70.8%; secondary patencies were 97.8% and 93.9%; limb salvage, 100% and 98.8%; and survivals, 95.4% and 76.9%, at 1 and 5 years, respectively. More than 96% of patients maintained independence and ambulatory ability at 5 years. Overall symptom resolution occurred in 78.8%, and symptom recurrence occurred in 18.1% of limbs treated, with slightly higher resolution and recurrence noted in patients treated with endovascular therapy. CONCLUSIONS Contemporary treatment of vasculogenic claudication is safe, effective, and predominantly endovascular. These data support a more liberal use of revascularization for patients with claudication and suggest that current nonoperative treatment guidelines may be based more on surgical dogma than on achievable outcomes.

Evaluation of the Diameter of the Proximal Descending Thoracic Aorta with Age: Implications for Thoracic Aortic Stent Grafting

BACKGROUND Long-term anatomical changes of the thoracic aorta which may affect long-term outcome of blunt aortic injuries treated with endovascular stent grafts are unknown. The purpose of this study was to examine the natural history of thoracic aortic diameter with progressing age. METHODS One thousand consecutive thoracic computed tomographic scans performed for nonthoracic aortic pathology on patients aged 15-99 (mean 59.4) were examined, and thoracic aortic diameter immediately adjacent to the left subclavian artery was measured. Factors possibly influencing diameter, including age by decade of life, race, gender, history of hypertension (HTN), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), and tobacco use, were examined. Factors were compared using Students t-test. RESULTS The differences in mean diameters of the thoracic aorta by gender (male=27.1 vs. female=26.0, p=0.87), race (Caucasian=26.6 vs. non-Caucasian=26.3, p=0.10), presence of HTN (yes=25.8 vs. no=24.9, p=0.36), COPD (yes=26.3 vs. no=25.4, p=0.21), DM (yes=26.1 vs. no=25.3, p=0.12), and tobacco use (yes=26.3 vs. no=25.0, p=0.18) were not significant. However, differences in mean diameter increased significantly over time with age. Patients under 40 years old had mean aortic diameters of 22.92 mm compared to 27.09 mm (p<0.001) for patients over 40. The mean aortic isthmus diameter showed an approximately 1cm increase when comparing octogenarians to teenagers. CONCLUSION The diameter of the aortic isthmus increases substantially with age. These findings suggest that long-term surveillance is warranted for trauma patients with aortic stent grafts, to monitor the natural history and to assess for possible late complications.

Fistulas in Octogenarians: Are They Beneficial?

BACKGROUND The incidence of end-stage renal disease is increasing most rapidly in patients aged older than 75 years. Meanwhile, their 5-year survival rate remains the lowest of any dialysis cohort. The purpose of this study was to evaluate the benefit of arteriovenous fistula (AVF) construction in octogenarians, as the data regarding the effects of age on fistula success are conflicting. METHODS Using our hemodialysis database, we performed a retrospective review of all AVFs placed between 1 November, 2007, and 17 July, 2013, in patients aged 80 years or older. Patient demographics, presence of catheters, time to first fistula use, fistula interventions, fistula patency, and time to patient death were all evaluated. RESULTS We placed 32 fistulas in 31 patients. Our average patient was 82-year-old, men (75%) and Caucasian (71%). Three patients were excluded, as they never required dialysis. One patient required 2 fistulas; the second fistula was excluded from analysis. Of the remaining 28 patients, 22 (78%) were used for hemodialysis and 19 (68%) required catheter-based dialysis before fistula use. The mean length of catheter use was 166 days, and the median time to first fistula use was 109 days. Primary functional patency was 51% at year 1 and 38% at year 2, respectively. Secondary patency was 75% at year 1 and year 2. Of the 22 patients, 17 (77%) required intervention to achieve or maintain patency. The median time to death was 26 months. CONCLUSIONS With substantial effort, successful fistula utilization can be achieved in an extremely elderly patient population. Our patients experienced significant catheter utilization and over 3 quarters required secondary interventions to achieve or maintain fistula utilization. Given this groups limited survival and the fact that 21% of their survival time was spent dialyzing with a catheter, the benefit of a functioning fistula to a patient older than 80 years can be questioned.

The role of the prosthetic axilloaxillary loop access as a tertiary arteriovenous access procedure

PURPOSE In the last decade, the Dialysis Outcome Quality Initiative (DOQI) Guidelines have enhanced the longevity of patients with end-stage renal disease (ESRD) on hemodialysis. Consequently, surgeons are increasingly challenged to provide vascular access for patients in whom options for access in the upper extremity have been expended. This situation is even more problematic in the morbidly obese patient on hemodialysis. Our group previously reported a high rate of infection and need for secondary interventions in obese patients with prosthetic femorofemoral accesses. We now report a series of patients who underwent placement of a prosthetic axilloaxillary loop access. This study presents our technique and evaluates our results, particularly as they relate to the obese patient. METHODS From January 1998 to May 2006, 34 prosthetic axilloaxillary loop accesses were placed in 32 patients with ESRD. Eleven patients (12 accesses) were obese, as defined by a body mass index >/=30 kg/m(2). Median follow-up was 16 months. Kaplan-Meier analysis was used to determine primary and secondary patency as well as patient survival for the entire cohort and for the obese and nonobese patient cohorts. Survival curves were compared using the log-rank test for equality over strata. RESULTS The secondary patency rate was 59% at 1 year (median, 18 months). The 1-year patient survival was 69%. Infection occurred in 15% patients. Comparison of the obese vs nonobese cohorts demonstrated no statistically significant difference in 1-year primary patency (36% vs 10%, P = .17) or secondary patency (71% vs 65%, P = .34). There were no infections in the obese cohort. CONCLUSION These data show that the prosthetic axilloaxillary loop access has acceptable outcomes and should be considered the tertiary vascular access procedure of choice in the obese patient on hemodialysis.

VESS14. Early Validation of a Tool to Standardize Vascular Access Procedure Selection for Hemodialysis

Variable Bypass (n 1⁄4 200) Endovascular (n 1⁄4 138) P value Age, years 74.1 6 12.3 76.1 6 11.4 .12 Male 117 (58.5) 79 (57.3) .82 Ethnic origin White 173 (86.5) 113 (81.9) .25 Black 27 (13.5) 25 (18.1) Diabetes 122 (61.0) 100 (72.5) .03 Chronic renal insufficiency 37 (18.5) 59 (42.8) <.001 End-stage renal disease 12 (6.0) 24 (17.4) .001 Hypertension 174 (87.0) 125 (90.6) .31 Hyperlipidemia 105 (52.5) 78 (56.5) .47 Coronary artery disease 121 (60.5) 95 (68.8) .12 History of myocardial infarction 29 (14.5) 37 (26.8) .005 Chronic obstructive pulmonary disease 43 (21.5) 22 (15.9) .2