Grzegorz Styczynski

A High Red Blood Cell Distribution Width Predicts Failure of Arteriovenous Fistula

In hemodialysis patients, a native arteriovenous fistula (AVF) is the preferred form of permanent vascular access. Despite recent improvements, vascular access dysfunction remains an important cause of morbidity in these patients. In this prospective observational cohort study, we evaluated potential risk factors for native AVF dysfunction. We included 68 patients with chronic renal disease stage 5 eligible for AVF construction at the Department of General and Vascular Surgery, Central Clinical Hospital Ministry of Internal Affairs, Warsaw, Poland. Patient characteristics and biochemical parameters associated with increased risk for AVF failure were identified using Cox proportional hazards models. Vessel biopsies were analyzed for inflammatory cells and potential associations with biochemical parameters. In multivariable analysis, independent predictors of AVF dysfunction were the number of white blood cells (hazard ratio [HR] 1.67; 95% confidence interval [CI] 1.24 to 2.25; p<0.001), monocyte number (HR 0.02; 95% CI 0.00 to 0.21; p = 0.001), and red blood cell distribution width (RDW) (HR 1.44; 95% CI 1.17 to 1.78; p<0.001). RDW was the only significant factor in receiver operating characteristic curve analysis (area under the curve 0.644; CI 0.51 to 0.76; p = 0.046). RDW>16.2% was associated with a significantly reduced AVF patency frequency 24 months after surgery. Immunohistochemical analysis revealed CD45-positive cells in the artery/vein of 39% of patients and CD68-positive cells in 37%. Patients with CD68-positive cells in the vessels had significantly higher white blood cell count. We conclude that RDW, a readily available laboratory value, is a novel prognostic marker for AVF failure. Further studies are warranted to establish the mechanistic link between high RDW and AVF failure.

Automated oscillometric measurement of the ankle–brachial index in patients with coronary artery disease

Automated oscillometric ankle–brachial index (ABI) devices were designed to measure ABI in a primary-care setting to increase the peripheral artery disease (PAD) detection rate. However, ABI measurements obtained with an automated oscillometric device may differ from those obtained using a standard ultrasound Doppler method in the general population. The purpose of this study was to compare PAD detection by the Doppler method and the automated WatchBP Office ABI system in a high-risk population with coronary artery disease (CAD). Eighty consecutive patients with confirmed CAD were included. ABI was measured by automated oscillometry followed by conventional Doppler evaluation. PAD was defined as an ABI⩽0.9. Each lower extremity was analyzed separately. The Doppler method detected an ABI⩽0.9 in 56 lower extremities, whereas the automated method detected an ABI⩽0.9 in 28 lower extremities (P<0.0001). A Bland–Altman plot showed poor agreement between the two methods. The mean ABI values obtained by the automated and Doppler methods were significantly different (1.11±0.20 vs. 0.95±0.24; P<0.00001). The sensitivity of the automated ABI device in detecting an ABI⩽0.9 was 46.3% and the specificity was 98.0%. The positive and negative predictive values for diagnosing an ABI⩽0.9 using the automated oscillometric method were 92.8% and 76.9%, respectively. In conclusion, the automated WatchBP Office ABI system should be used with caution for PAD detection and screening in patients with CAD, and this system should not replace the Doppler method in populations at high risk of cardiovascular disease.

Dilated Inferior Vena Cava in Young Adults With Vasovagal Syncope

ber 2008, with or without accounting for patients’ willingness to be vaccinated. Uptake and missed opportunity rates were weighted to be nationally representative using the Current Population Survey. Estimated numbers of vaccinated and unvaccinated adults were obtained by scaling up estimated vaccination and missed opportunity rates as well as disease prevalence based on the size of the total adult population as of November 1, 2008. All calculations were performed using STATA SE version 10.1 software (StataCorp, College Station, Texas).

INTERNAL JUGULAR VEIN VALVE INSUFFICIENCY IN COUGH SYNCOPE

A 53-year-old man with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea was admitted to the hospital for the evaluation of recurrent syncopal episodes induced by paroxysmal cough. Loss of consciousness was brief, and preceded by the sensation of “fullness in the head.” Syncope was provoked also by prolonged expiration during spirometry, which revealed severe bronchial obstruction. However, oxygen saturation on room air and blood gases were within normal limits. To reproduce reported symptoms, the Valsalva maneuver (VM) was performed with the patient in the supine position with noninvasive, continuous blood pressure monitoring (Finapres, Ohmeda) and finger pulse oximetry. This resulted in a brief loss of consciousness, although no desaturation, decrease in blood pressure, or bradycardia was noted. Transthoracic echocardiography revealed normal left and right ventricular function, mild tricuspid insufficiency, and no evidence of pulmonary hypertension. There was no right-to-left shunt detected on the bubble-contrast study. Neurologic assessment, MRI of the brain, and EEG were unremarkable. Duplex-Doppler examination of extracranial carotid and vertebral arteries showed no stenosis. However, evaluation of the internal jugular veins (IJVs) with the use of color Doppler revealed right internal jugular valve insufficiency with flow reversal during inspiration (figure …

Significance of cytomegalovirus infection in the failure of native arteriovenous fistula

High cytomegalovirus (CMV) IgG levels have been identified as a risk factor for arteriovenous fistula (AVF) failure. None of the 68 patents in our study were CMV IgM positive, although 96% were CMV IgG positive. CMV antigens were detected in the radial artery or cephalic vein of 46% of patients who received an AVF. The presence of CMV antigens or high serum CMV IgG levels had no prognostic value for AVF failure.

Iatrogenic Aortic Coarctation

A 35-year-old male was admitted because of arterial hypertension in the upper part of the body (230/100 mm Hg on the right arm) with a pressure difference of 50 mm Hg between the right and left arms and 80 mm Hg between the right arm and right leg. Three weeks earlier, he had undergone emergency aortic stenting for traumatic dissection at the aortic isthmus after …