Earl S. Schuman

Percutaneous Transluminal Angioplasty versus Endovascular Stent Placement in the Treatment of Venous Stenoses in Patients Undergoing Hemodialysis: Intermediate Results

PURPOSE This report describes intermediate findings from an ongoing prospective randomized trial comparing the results of percutaneous transluminal angioplasty (PTA) with results of endovascular stent placement in patients undergoing hemodialysis. PATIENTS AND METHODS Among 87 consecutive patients with venous stenoses or occlusions, 47 (54%) were treated with PTA alone and 40 (46%) were treated with PTA and stent placement. RESULTS For peripheral sites, the primary patency rates for PTA at 60, 180, and 360 days were 55%, 31%, and 10%, respectively, and for stents were 36%, 27%, and 11%, respectively (P = .6528). The secondary patency rates for PTA at 60, 180, and 360 days were 94%, 80%, and 71%, respectively, and for stents were 73%, 64%, and 64%, respectively (P = .1677). For central sites, the primary patency rates for PTA at 60, 180, and 360 days were 81%, 23%, and 12%, respectively, and for stents were 67%, 11%, and 11%, respectively (P = .4595). The secondary patency rates for PTA were 100% at each interval, and for stents were 100%, 89%, and 78%, respectively (P = .5408). CONCLUSION Intermediate results suggest that, overall, there is no difference in the patency rates for peripheral venous stenoses in dialysis patients treated with PTA or PTA and endovascular stent placement. At this time, the numbers of patients are too small to conclude if certain sites such as larger central veins will respond better to one treatment or the other.

Management of hickman catheter sepsis

Hickman catheters have been shown to be efficacious and durable. We believe their performance can be safely prolonged with aggressive management of complications. One hundred sixty-five consecutive patients with catheters were followed prospectively and 28 episodes of sepsis in 24 patients were evaluated. At least 90 percent of septic catheters were salvaged with a combination of antibiotics and thrombolytic agents. When our protocol was followed, all episodes of sepsis were successfully treated. This included gram-positive and gram-negative organisms as well as one case of fungal sepsis. Since treatment can be handled mostly on an outpatient basis, there are benefits in regard to patient comfort as well as health care costs.

Long-term patency of polytetrafluoroethylene graft fistulas.

Polytetrafluoroethylene grafts have been the mainstay for hemoaccess at our dialysis unit since 1976. Of 528 grafts placed in the forearm, 81 were evaluated for long-term patency and complication rates. When appropriate diagnostic studies and clinical signs delineate the cause of graft problems, a variety of surgical techniques can be used to maintain graft patency. The overall patency rate was 81 percent at 4.47 years. There were 3.5 complications per graft and 1 procedure per 1.25 years of follow-up. Over two thirds of the grafts had minimal complications and showed a 95 percent patency rate at 4.76 years. Impra grafts seemed to fare better than Gore-tex grafts, but their patency and duration were similar. Polytetrafluoroethylene grafts are easy to use, easy to revise and repair, have a long shelf life, and can withstand repeated dialysis access for many years.

Surgery in long-term dialysis patients: Experience with more than 300 cases☆☆☆

Three hundred twelve surgical procedures in patients with chronic renal failure have been characterized. There is a high incidence of operation in this expanding population. Multiple procedures for each patient were found in our 10 year study. Operative mortality was 1 percent and late mortality was about 10 percent per year. The survival curve predicted an 81 percent 2 year rate and a 60 percent 5 year survival rate. The high late mortality was likely related to the underlying disease process and the high proportion of complicating associated illnesses. The gross complication rate was high (64 percent), with the most frequent one being hyperkalemia. Other frequent complications were hemodynamic instability, infections, and fluid overload. A pattern of postoperative time to onset for the various complications was identified. Perioperative management requires aggressive, but appropriate metabolic, hematologic, and pharmaceutical intervention.

Thrombolysis Versus Thrombectomy for Occluded Hemodyalisis Grafts

Graft thrombosis is the most frequent complication of polytetrafluoroethylene grafts for hemodialysis. Many of these patients arrive at the dialysis unit with fluid and metabolic abnormalities that require prompt dialysis. Rapid declotting of the graft is important to avoid having to create temporary access. Thrombolysis with urokinase has been evaluated by recent retrospective studies and found to be successful in 60% to 90% of cases. Our prospective, randomized trial was initiated to compare thrombolysis with standard surgical thrombectomy; and to evaluate the safety, effectiveness, efficiency, and durability of these modalities. In this study, 15 patients underwent thrombolysis and 16 had thrombectomy. The success rate was 67% for the thrombolysis group compared with 94% for the surgical group. Patency rates were similar for both modalities, but the complication rates were higher and the time to completion longer with thrombolysis. Although both treatments can be used successfully, surgical thrombectomy remains the optimal choice for treating occluded dialysis grafts.

Perforation of the colon in the immunocompromised patient

Perforation of the colon in the immunocompromised patient is a catastrophic and usually fatal event. The immunocompromised patient, like all patients, may suffer from the more common causes of colonic perforation, including diverticulitis, chronic inflammatory bowel disease, presence of a foreign body, and trauma. There also appears to be in these patients the unusual occurrence of spontaneous perforation, particularly in patients with renal allografts or on dialysis. In a retrospective multi-hospital review, 10 cases of apparent spontaneous perforation were found. The pathogenesis is unclear, but predisposing factors include immunosuppressive medications, uremia, discrete colon ulcerations, and fecal impaction. The reported mortality rate approaches 100 percent due to delayed recognition and impaired host defense mechanisms. In our patients, mortality was 40 percent. We attribute this improved survival to prompt surgical intervention and aggressive postoperative management, including daily dialysis, parenteral hyperalimentation, broad-spectrum antibiotics, and a high index of suspicion for ongoing sepsis with early repeat exploration.

Patency and flow characteristics using stapled vascular anastomoses in dialysis grafts1

BACKGROUND Improving patency of hemodialysis grafts is challenging. Vascular stapling creates nonpenetrating anastomoses, possibly decreasing intimal hyperplasia. We investigated patency and flow characteristics of stapled hemodialysis grafts. METHODS Eighty-six grafts (41 stapled, 45 sewn) were placed in 84 patients (prospective, randomized). The groups had comparable demographics. RESULTS Thirty-six grafts were functioning at the study endpoint. Complications in both groups were similar. The primary patency (stapled, 342 days versus sewn, 382 days; P = 0.67) and secondary patency (stapled, 513 days versus sewn, 507 days; P = 0.76) had no significant differences. Flow characteristics were similar between the groups. Thrombectomies per patient-year were 1.01 for stapled grafts and 1.12 for sewn grafts (not significant). Stapling decreased the average operating time by 4.5 minutes. CONCLUSIONS Stapled and sewn anastomoses have similar primary and secondary patency and flow characteristics, with minimal operative time differences. Stapled anastomoses are safe but had no advantage over sewn anastomoses in this study.

Vascular access options for outpatient cancer therapy.

Knowledge of the abilities and limitations of various access devices can help the surgeon decide which is best matched to an individual cancer patient receiving outpatient therapy. Implanted ports have become the mainstay of long-term treatment. Hickman catheters are useful for long-term nutritional support and pain control when parenteral narcotics are required. Long-arm catheters and central venous catheters can be utilized for short-term therapy. Proper utilization of the various vascular access devices can optimize patient care in a cost-effective manner.

Does the use of erythropoietin in hemodialysis patients increase dialysis graft thrombosis rates

Erythropoietin (EPO) is highly efficacious in the treatment of the anemia of chronic renal failure. Evidence for a reported serious side effect, increased dialysis graft thrombosis, is equivocal. Sixty-four hemodialysis patients utilizing polytetrafluoroethylene (PTFE) grafts were treated with EPO. The patients served as their own historical controls. There were 1.188 thrombectomies and 0.222 mechanical problems per 1,000 patient-days prior to the initiation of EPO treatment. With EPO, the values were 0.656 and 0.222, respectively. Patients were separated into low-, medium-, and high-dose EPO groups and analyzed within groups for the effect of EPO and between groups for a dose-dependent response. According to an analysis of variance procedure, there was no statistically significant differences between the groups, which suggests that EPO is not thrombogenic to dialysis grafts.

Repeat parathyroid operation associated with renal disease.

One hundred ten patients who had undergone operation for secondary and tertiary hyperparathyroidism have been described. Ninety patients had secondary disease and 20 patients had tertiary disease after renal transplantation. From these two groups, 18 patients had repeat operations for control of recurrent or persistent disease. The incidence of repeat operations was 14 percent. Causes were graft-dependent hyperparathyroidism, supernumerary glands in the neck or mediastinum, and incomplete identification of glands in the neck. The most important risk factor is continued long-term dialysis in functionally anephric patients. We recommend that patients with hyperparathyroidism associated with chronic renal failure undergo total parathyroidectomy with autotransplantation. If repeat operation is necessary, a reduction in glandular mass with autotransplantation is preferred. In selected patients, total parathyroidectomy can be considered because of the increased risk of aluminum bone disease.