Peter R. Bream

Hemodialysis Reliable Outflow (HeRO) device in end-stage dialysis access: a decision analysis model

BACKGROUND The Hemodialysis Reliable Outflow (HeRO) dialysis access device is a permanent tunneled dialysis graft connected to a central venous catheter and is used in patients with end-stage dialysis access (ESDA) issues secondary to central venous stenosis. The safety and effectiveness of the HeRO device has previously been proven, but no study thus far has compared the cost of its use with tunneled dialysis catheters (TDCs) and thigh grafts in patients with ESDA. MATERIALS AND METHODS A decision analytic model was developed to simulate outcomes for patients with ESDA undergoing placement of a HeRO dialysis access device, TDC, or thigh graft. Outcomes of interest were infection, thrombosis, and ischemic events. Baseline values, ranges, and costs were determined from a systematic review of the literature. Total costs were based on 1 year of post-procedure outcomes. Sensitivity analyses were conducted to test model strength. RESULTS The HeRO dialysis access device is the least costly dialysis access with an average 1-year cost of

In-center thrombolysis for clotted AV access: a cohort review.

6521. The 1-year cost for a TDC was

Update on Insertion and Complications of Central Venous Catheters for Hemodialysis

8477. A thigh graft accounted for

Treatment of SVC syndrome and hemoptysis in a patient with mediastinal fibrosis.

9567 in a 1-year time period. CONCLUSIONS The HeRO dialysis access device is the least costly method of ESDA. The primary determinants of cost in this model are infection in TDCs and leg ischemia necessitating amputation in thigh grafts. Further study is necessary to incorporate patient preference and quality of life into the model.

Use of an ECG-based confirmatory technique for bedside placement of reverse-tunneled cuffed dialysis catheters in three morbidly obese patients

Thrombosis is the leading cause of arteriovenous (AV) access failure for hemodialysis patients requiring frequent interventions. We describe a novel approach to the lyse‐and‐wait technique in thrombosed AV access using nurse‐administered thrombolytics in a hospital‐based hemodialysis unit. All patients at a single‐center, large, urban, tertiary care hospital, who underwent in‐center thrombolysis via alteplase instilled directly into a thrombosed AV access by inpatient hemodialysis unit staff between January 1, 2003 and December 31, 2007, were eligible. Included subjects were at least 18 years old and did not have known or suspected infection or trauma to the AV access site. Primary outcome measure was successful thrombolysis defined as hemodialysis performed immediately or after the interventional radiology (IR) procedure. Adverse events related to the procedure were collected. A total of 321 procedures, performed on 145 subjects (77 (53%) male, 68 (47%) female) remained for analysis. Successful instillation occurred in 317 of 321 procedures (98.8%). Successful thrombolysis occurred in 237 of 321 procedures (73.8%). Adverse events (8 major and 10 minor) occurred in 18 procedures, yielding a complication rate of 5.6%. In‐center thrombolysis with alteplase administration by hemodialysis unit nursing staff under physician supervision is safe and effective with an adverse outcome rate similar to the literature. Thus, this modified lyse‐and‐wait protocol can be adopted with appropriate IR and surgical backup in place.

The State of Medical Student Teaching of Interventional Radiology: Implications for the Future

Central venous catheters are a popular choice for the initiation of hemodialysis or for bridging between different types of access. Despite this, they have many drawbacks including a high morbidity from thrombosis and infection. Advances in technology have allowed placement of these lines relatively safely, and national guidelines have been established to help prevent complications. There is an established algorithm for location and technique for placement that minimizes harm to the patient; however, there are significant short- and long-term complications that proceduralists who place catheters should be able to recognize and manage. This review covers insertion and complications of central venous catheters for hemodialysis, and the social and economic impact of the use of catheters for initiating dialysis is reviewed.

Venous catheters: a practical manual

Mediastinal fibrosis can present with a multitude of symptoms, most commonly cough, dyspnea and hemoptysis. We describe a case of mediastinal fibrosis secondary to histoplasmosis, which presented with both superior vena cava syndrome (SVCS) and hemoptysis. Our patient was successfully treated with bronchial artery embolization followed by SVC stent placement during a brief hospital stay.

Use of percutaneous drainage to treat hepatic abscess after radiofrequency ablation of metastatic pancreatic adenocarcinoma.

We are currently in the midst of a worldwide obesity epidemic, including in patients with end-stage kidney disease. Placing hemodialysis catheters is a particular challenge in patients with extreme obesity. Here we describe the merging of two technologies to place catheters in patients who are too heavy (over 225 kg) to be placed safely on a procedure table for fluoroscopic guidance. The first technology is ECG-guided placement of catheters, well established for guidance of peripherally inserted central catheters (PICCs) and tunneled and nontunneled central venous catheters. The second is reverse-tunneling dialysis catheters, which allow precise placement of the tip of the catheter before creating the tunnel. We successfully placed catheters in three morbidly obese patients with acute kidney injury and followed them until their kidneys recovered and the catheters were removed. The catheters were placed in the patients bed in a procedure room with subsequent confirmatory chest radiographs. Catheter performance based on blood flow rates was excellent and there were no complications. We suggest placement of ECG-guided tunneled hemodialysis catheters using a reversed-tunneling technique in those patients with extreme obesity who are too heavy to place on a fluoroscopy procedure table.

Removal of a Günther Tulip retrievable inferior vena cava filter after 147 days in a pediatric patient.

INTRODUCTION The formation of integrated interventional radiology (IR) residency programs has changed the training paradigm. This change mandates the need to provide adequate exposure to allow students to explore IR as a career option and to allow programs to sufficiently evaluate students. This study aims to highlight the availability of medical student education in IR and proposes a basic framework for clinical rotations. MATERIALS AND METHODS The Liaison Committee on Medical Education (LCME) website was utilized to generate a list of accredited medical schools in the United States. School websites and course listings were searched for availability of IR and diagnostic radiology rotations. The curricula of several well-established IR rotations were examined to identify and categorize course content. RESULTS In all, 140 LCME-accredited medical schools had course information available. Of those schools, 70.5% offered an IR rotation; 84.6% were only available to senior medical students and only 2% were offered for preclinical students; and 8.1% of courses were listed as subinternships. Well-established IR clerkships included a variety of clinical settings, including preprocedure evaluation, experience performing procedures, postprocedure management, and discharge planning. CONCLUSION Medical student exposure to IR is crucial to the success of integrated IR residency programs. Current research shows few institutions with formal IR subinternship rotations. Although 70.5% of institutions have some form of nonstandardized IR course, 84.6% are available only to fourth-year students, and 2% are offered to preclinical students. This suggests there is a significant opportunity for additional formal exposure to IR through increasing availability of IR rotations and exposure during the clinical and preclinical years.

Multidisciplinary team approach to end-stage dialysis access patients

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