George E. Smith

Factors affecting the patency of arteriovenous fistulas for dialysis access

BACKGROUNDnThe autologous arteriovenous fistula (AVF) is the accepted gold standard mode of repeated vascular access for hemodialysis in terms of access longevity, patient morbidity, and health care costs. This review assesses the current evidence supporting the role of various patient and surgeon factors on AVF patency.nnnMETHODSnThe literature was searched to identify the current evidence available for patient characteristics, methods of AVF planning, and anatomic factors that may affect patency outcomes after AVF formation. The use of adjuvant medications, surgical techniques, and policies for AVF maintenance are discussed in relation to AVF patency.nnnRESULTSnCurrent literature supports patient factors, such as increasing age, presence of diabetes, smoking, peripheral vascular disease, predialysis hypotension, and vessel characteristics, as directly influencing AVF patency. Vessels of small caliber (<2 mm) or demonstrating reduced distensibility are unlikely to create a functional AVF. Current evidence does not support altered patency due to sex or raised body mass index (<35 kg/m(2)). Factors such as early referral for AVF, preoperative ultrasound vessel mapping, use of vascular staples, and intraoperative flow measurements affected AVF patency, but the use of medical adjuvant therapies did not. Programs of surveillance and various needling techniques to maintain patency are not supported by current evidence. Novel techniques of infrared radiotherapy and topical glyceryl trinitrate are possible future strategies to increase AVF patency rates. The limitations of available evidence include a lack of large, randomized controlled trials and meta-analysis data to support current practice.nnnCONCLUSIONSnThere is a complex interaction of factors that may affect the patency of an individual AVF. These need to be carefully considered when selecting surgical site or technique, adjuvant treatments, and follow-up protocols for AVFs.

Clinical outcomes and quality of life 5 years after a randomized trial of concomitant or sequential phlebectomy following endovenous laser ablation for varicose veins.

Endovenous laser ablation (EVLA) is a popular treatment for superficial venous insufficiency. Debate continues regarding the optimal management of symptomatic varicose tributaries following ablation of the main saphenous trunk. This randomized trial compared the 5‐year outcomes of endovenous laser therapy with ambulatory phlebectomy (EVLTAP) with concomitant ambulatory phlebectomy, and EVLA alone with sequential treatment if required following a delay of at least 6u2009weeks.

A Systematic Review of the Uptake and Adherence Rates to Supervised Exercise Programs in Patients with Intermittent Claudication

BACKGROUNDnIntermittent claudication (IC) is a common and debilitating symptom of peripheral arterial disease and is associated with a significant reduction in a sufferers quality of life. Guidelines recommend a supervised exercise program (SEP) as the primary treatment option; however, anecdotally there is a low participation rate for exercise in this group of patients. We undertook a systematic review of the uptake and adherence rates to SEPs for individuals with IC.nnnMETHODSnThe MEDLINE, Embase, and PubMed databases were searched up to January 2015 for terms related to supervised exercise in peripheral arterial disease. The review had 3 aims: first, to establish the rates of uptake to SEPs, second, the rates of adherence to programs, and finally to determine the reasons reported for poor uptake and adherence. Separate inclusion and/or exclusion criteria were applied in selecting reports for each aim of the review.nnnRESULTSnOnly 23 of the 53 potentially eligible articles for uptake analysis identified on literature searches reported any details of screened patients (nxa0=xa07,517) with only 24.2% of patients subsequently recruited to SEPs. Forty-five percent of screen failures had no reason for exclusion reported. Sixty-seven articles with 4,012 patients were included for analysis of SEP adherence. Overall, 75.1% of patients reportedly completed an SEP; however, only one article defined a minimal attendance required for SEP completion. Overall, 54.1% of incomplete adherence was due to patient withdrawal and no reason for incomplete adherence was reported for 16% of cases.nnnCONCLUSIONSnReporting of SEP trials was poor with regard to the numbers of subjects screened and reasons for exclusions. Only approximately 1 in 3 screened IC patients was suitable for and willing to undertake SEP. Levels of adherence to SEPs and definitions of satisfactory adherence were also lacking in most the current literature. Current clinical guidelines based on this evidence base may not be applicable to most IC patients and changes to SEPs may be needed to encourage and/or retain participants.

Targeted Duplex Ultrasound in a One-Stop Dialysis Vascular Access Assessment Clinic

BACKGROUNDnMany duplex detectable factors have been shown to correlate with upper limb arteriovenous fistula (AVF) outcomes, and many practitioners now request preoperative duplex vessel mapping routinely before AVF surgery. We report outcomes from a one stop AVF assessment clinic in which the operating surgeons perform their own targeted preoperative ultrasound examinations.nnnMETHODSnAll patients undergoing assessment for formation of a new AVF were included in this prospective observational study. A plan was made for surgery based on the results of the physical examination performed by the surgeon and then reviewed in light of the findings from a targeted duplex ultrasound (DUS) that was performed by the surgeon in the clinic on portable ultrasound equipment. Ultimate choice of surgical site and the influence of the DUS were recorded along with postoperative outcomes.nnnRESULTSnIn all, 39 patients were included. Four (10%) of the patients received a more distal AVF and eight (20%) were converted to more proximal AVF because of unexpected adverse findings after targeted DUS. In one patient, no site could be confidently selected by physical examination alone. There was a 13% early failure rate with cumulative patency rates of 86% and 73% at 3 and 6 months, respectively.nnnCONCLUSIONnTargeted DUS identified findings that might adversely affect fistula function in one of four patients in this series, whereas one in 10 patients was able to have more distal fistulae formed because of improved confidence in the quality of distal vessels. Early failure and patency rates are comparable with those in units using formal routine ultrasound. These results would suggest that routine targeted DUS, performed quickly by surgeons in an outpatient clinic, can alter surgical planning in one of the three patients and is therefore advocated as a quick, relatively inexpensive and important adjunct to AVF planning.

Dialkylcarbamoyl chloride (DACC)-coated dressings in the management and prevention of wound infection: A systematic review

OBJECTIVEnDialkylcarbomoyl chloride (DACC)-coated dressings (Leukomed Sorbact and Cutimed Sorbact) irreversibly bind bacteria at the wound surface that are then removed when the dressing is changed. They are a recent addition to the wound care professionals armamentarium and have been used in a variety of acute and chronic wounds. This systematic review aims to assess the evidence supporting the use of DACC-coated dressings in the clinical environment.nnnMETHODnWe included all reports of the clinical use of DACC-coated dressings in relation to wound infection. Medline, Embase, CENTRAL and CINAHL databases were searched to September 2016 for studies evaluating the role of DACC-coated dressings in preventing or managing wound infections.nnnRESULTSnWe identified 17 studies with a total of 3408 patients which were included in this review. The DACC-coating was suggested to reduce postoperative surgical site infection rates and result in chronic wounds that subjectively looked cleaner and had less bacterial load on microbiological assessments.nnnCONCLUSIONnExisting evidence for DACC-coated dressings in managing chronic wounds or as a surgical site infection (SSI) prophylaxis is limited but encouraging with evidence in support of DACC-coated dressings preventing and treating infection without adverse effects.

Great saphenous vein transposition to the forearm for dialysis vascular access; an under used autologous option?

Purpose The recommended site for the next autologous vascular access in patients without suitable cephalic vein for fistula formation is basilic vein transposition. This study aims to compare outcomes from great saphenous vein transpositions to the forearm with that of basilic vein transposition. Comparison is reported in terms of primary and secondary patency, intervention, and complication rates in our unit. Method A retrospective search of a prospectively maintained vascular database identified 24 consecutive patients undergoing great saphenous vein transposition (GSVT) and 34 consecutive patients having basilic vein transposition (BVT) were included for comparison. Primary and secondary patency details were obtained from hospital case notes and dialysis unit review records. Patency was studied using a Kaplan Meier analysis and compared using log rank testing. Results No significant difference was identified in primary or secondary patency between the procedures (P=0.745). Primary patency at 6, 12 and 24 months: for GSVT this was 62%, 41%, and 20%; for BVT this was 44%, 32%, and 15% respectively. Secondary patency at 6, 12, and 24 months; for GSVT this was 75%, 50%, and 41%; for BVT this was 65% respectively. Requirements for intervention were similar between groups. Complications were more common in the BVT group. Conclusion Acceptable patency rates can be achieved using GSVT, thus adding another autologous option for upper limb dialysis access. Our results would suggest GSVT could be performed prior to BVT as the basilic vein may benefit from prior partial arterialization and can subsequently be used if GSVT fails.

“Intermittent claudication a real pain in the calf”—Patient experience of diagnosis and treatment with a supervised exercise program

Intermittent claudication (IC) is a common condition which has severe impacts on quality of life, physical function, and mental health. Supervised exercise is the recommended first-line treatment for patients with this condition; however, these are not always feasible or accessible to patients. As the proportion of patients who have this treatment remains suboptimal, it is important to better understand the perception of exercise in this population. A gap in the literature exists about the barriers and facilitators to exercise in patients completing, dropping out of, or declining an exercise program. A qualitative analysis was undertaken to understand this further. Twenty-five patients were interviewed face to face, 10 who had completed exercise, 10 who had declined, and 5 who had dropped out of an exercise program. Three major themes emerged from the data, IC, and perception to exercise and experience or beliefs of the exercise program.Addressing the barriers and facilitators to exercise in patients with IC is crucial in optimizing the delivery and uptake of exercise programs. More education or time investment is needed with these patients during initial diagnostic to help overcome perceived barriers and emphasis healthy behavioral changes.

A systematic review and meta-analysis of systemic intraoperative anticoagulation during arteriovenous access formation for dialysis

Purpose Surgical arteriovenous fistula (AVF) or graft (AVG) is preferred to a central venous catheter for dialysis access. Surgical access may suffer thrombosis early after placement and systemic anticoagulation during surgical access formation may increase patency rates but would be expected to increase bleeding-related complications. A systematic review and meta-analysis of randomised controlled trials was conducted to examine the impact of systemic anticoagulation on access surgery perioperative bleeding and patency rates. Methods We included randomised controlled trials testing systemic anticoagulation during access formation versus a control group without systemic anticoagulation reporting bleeding complications and access patency. Medline, Embase, CENTRAL and CINAHL were searched up to March 2015. Risk of bias was assessed using the Cochrane risk of bias tool and the Jadad score. Meta-analysis was performed using Cochrane Revman® software. Results Searches identified 445 reports of which four randomised studies involving 411 participants were included. Three studies pertained to AVF only and one included both AVF and AVG. Systemic anticoagulation led to increased bleeding events in all access [four trials; risk ratio (RR) 7.18; confidence interval (CI), 2.41 to 21.38; p<0.001]. Patency was not improved for all access (four trials; RR, 0.64; CI, 0.37 to 1.09; p = 0.10) but was improved when AVF analysed alone (three trials; RR, 0.57; CI, 0.33 to 0.97; p = 0.04). Conclusions The use of intraoperative systemic anticoagulation during access formation is associated with a highly significant increased risk of bleeding-related complications. A significant improvement in AVF patency was seen, though not when AVF and AVG were analysed together.

Quality of life in patients with intermittent claudication

BackgroundIntermittent claudication (IC) is axa0common condition that causes pain in the lower limbs when walking and has been shown to severely impact the quality of life (QoL) of patients. The QoL is therefore often regarded as an important measure in clinical trials investigating intermittent claudication. To date, no consensus exits on the type of life questionnaire to be used. This review aims to examine the QoL questionnaires used in trials investigating peripheral arterial disease (PAD).Material and methodsAxa0systematic review of randomised clinical trials including axa0primary analysis of QoL via questionnaire was performed. Trials involving patients with diagnosed PAD were included (either clinically or by questionnaire). Any trial which had QoL as the primary outcome data was included with no limit being placed on the type of questionnaire used.ResultsThe search yielded axa0total of 1845 articles of which 31xa0were deemed appropriate for inclusion in the review. In total, 14 different QoL questionnaires were used across 31xa0studies. Of the questionnaires 24.06% were missing at least one domain when reported in the results of the study. Mean standard deviation varied widely based on the domain reported, particularly within the SF36.DiscussionDespite previous recommendations for Europewide standardisation of quality of life assessment, to date no such tool exists. This review demonstrated that axa0number of different questionnaires remain in use, that their completion is often inadequate and that further evidence-based guidelines on QoL assessment are required to guide future research.ZusammenfassungHintergrundDie Claudicatio intermittens (CI) ist eine häufige Erkrankung, die beim Gehen Schmerzen in der unteren Extremität verursacht und die Lebensqualität (QoL) der Patienten nachweislich beeinträchtigt. Daher wird die QoL oft als wichtiges Messinstrument in klinischen Studien angesehen, welche die Claudicatio intermittens untersuchen. Bis heute gibt es keinen Konsens bezüglich der Art des zu verwendenden Lebensqualitätsfragebogens. Ziel dieses Reviews ist es, die Fragebögen zur Lebensqualität zu untersuchen, die in Studien zur peripheren arteriellen Verschlusskrankheit (PAVK) zum Einsatz kommen.Material und MethodenEin systematischer Review von randomisierten klinischen Studien einschließlich einer QoL-Primäranalyse mittels Fragebogen wurde durchgeführt. Studien an Patienten mit diagnostizierter PAVK wurden eingeschlossen (entweder klinisch oder mittels Fragebogen). Jede Studie, die QoL als primären Endpunkt hatte, wurde eingeschlossen, ohne Limitierung hinsichtlich der Art des verwendeten Fragebogens.ErgebnisseDie Suche ergab insgesamt 1845 Artikel, von denen 31 für den Einschluss in die Studie als geeignet befunden wurden. Insgesamt 14 verschiedene QoL-Fragebögen kamen in den 31 Studien zum Einsatz. Bei 24,06% der Fragebögen fehlte mindestens eine Domäne in den berichteten Studienergebnissen. Die mittlere Standardabweichung fiel, je nach berichteter Domäne, sehr unterschiedlich aus, insbesondere im SF36.DiskussionTrotz früherer Empfehlungen für eine europaweite Standardisierung der Beurteilung der Lebensqualität, existiert hierfür bis heute kein Instrument. Dieser Review zeigte, dass weiterhin etliche verschiedene Fragebögen verwendet werden, dass deren Vollständigkeit häufig inadäquat ist und dass weitere evidenzbasierte Leitlinien zur Beurteilung der Lebensqualität notwendig sind, um für die zukünftige Forschung wegweisend zu sein.

Use of photograph-based telemedicine in postoperative wound assessment to diagnose or exclude surgical site infection

OBJECTIVEnThis study aims to assess whether a clinician reviewing photographs of a wound was an acceptable substitute for clinical review in order to identify or exclude surgical site infection (SSI).nnnMETHODnWe undertook a mixed methods study consisting of a qualitative public involvement exercise and a prospective, non-randomised, single-centre study of patients undergoing clean or clean-contaminated vascular surgery. For the qualitative study, two semi-structured focus group interviews were conducted. For the prospective study, patients were invited to attend a wound review at 5-7 days and 30 days postoperatively. At review, wounds were scored by a study nurse or doctor, according to the ASEPSIS scale. Anonymised wound photographs were taken and independently reviewed, and ASEPSIS scored by two independent investigators blinded to the original clinical review ASEPSIS score.nnnRESULTSnIn the qualitative study, three female patients were interviewed across two dates. Emerging themes included the burden of SSI, hospital follow-up and telemedical follow-up. A total of 37 patients with a mean age of 61.14 years were included in the quantitative analysis. There was a total of 53 wound reviews. There was >85% agreement between photograph and clinical reviewers in all categories except erythema. The specificity of photograph review for diagnosis of SSI was 90%. The intraclass correlation coefficient for total ASEPSIS score was R=0.806 (95% CI 0.694, 0.881), indicating strong reliability between reviewers.nnnCONCLUSIONnOur data shows that, in the assessment of SSI, there is good correlation between face-to-face clinical and remote photographic review. Incorporating this method of wound assessment into a postoperative follow-up care pathway may save patients and clinicians from unnecessary hospital visits, particularly when conducting health research.