Risha Gohil

Factors affecting the patency of arteriovenous fistulas for dialysis access

BACKGROUND The 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. METHODS The 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. RESULTS Current 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. CONCLUSIONS There 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.

Electrical stimulation vs. standard care for chronic ulcer healing: a systematic review and meta-analysis of randomised controlled trials

We conducted a systematic review to investigate the effect of electrical stimulation on ulcer healing compared to usual treatment and/or sham stimulation. This systematic review also aimed to investigate the effect of different types of electrical stimulation on ulcer size reduction.

Effect of supervised exercise on physical function and balance in patients with intermittent claudication

The aim of the study was to identify whether a standard supervised exercise programme (SEP) for patients with intermittent claudication improved specific measures of functional performance including balance.

A comparison of the effectiveness of treating those with and without the complications of superficial venous insufficiency.

Objective:To test the hypothesis that patients with soft tissue changes related to superficial venous insufficiency (SVI) have greater benefits from treatment than those with only symptomatic varicose veins. Background:A commonly held view is that SVI is only a minor ailment, yet randomized clinical trials (RCTs) show that treatment improves quality of life (QoL) and is cost-effective. In an effort to curb the treatment costs of this common disorder, rationing is applied in many health care systems, often limiting the reimbursement of treatment to those with soft tissue changes. Methods:This cohort study draws its data from an interventional RCT. After informed consent, consecutive patients with symptomatic unilateral SVI were randomized to receive surgical ligation and stripping or endovenous laser ablation. This analysis differentially studies the outcomes of patients with simple varicose veins (C2: n = 191) and soft tissue complications (C3–4: n = 76). Effectiveness outcomes measured up to 1 year included the following: Qol [short form 36 (SF36), EuroQol, and the Aberdeen Varicose Veins Questionnaire], clinical recurrence, and the need for secondary procedures. Multivariable regression analysis was used to control for potential confounding factors. Results:Both groups saw significant improvements in QoL. All improvements were equal between groups apart from the SF36 domain of Bodily Pain, where C2 saw an improvement of 12.8 [95% confidence interval (CI): 4.8–20.8] points over C3–4 participants (P = 0.002), who also suffered more recurrence [odds ratio (OR) = 2.7, 95% CI: 1.2–6.1, P = 0.022] and required more secondary procedures (OR = 4.4, 95% CI: 1.2–16.3, P = 0.028). Conclusions:This study suggests that rationing by clinical severity contradicts the evidence. Delaying treatment until the development of skin damage leads to a degree of irreversible morbidity and greater recurrence. Trial registration:NCT00759434 Clinicaltrials.gov

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.

Computerized dynamic posturography for postural control assessment in patients with intermittent claudication.

Computerized dynamic posturography with the EquiTest is an objective technique for measuring postural strategies under challenging static and dynamic conditions. As part of a diagnostic assessment, the early detection of postural deficits is important so that appropriate and targeted interventions can be prescribed. The Sensory Organization Test (SOT) on the EquiTest determines an individuals use of the sensory systems (somatosensory, visual, and vestibular) that are responsible for postural control. Somatosensory and visual input are altered by the calibrated sway-referenced support surface and visual surround, which move in the anterior-posterior direction in response to the individuals postural sway. This creates a conflicting sensory experience. The Motor Control Test (MCT) challenges postural control by creating unexpected postural disturbances in the form of backwards and forwards translations. The translations are graded in magnitude and the time to recover from the perturbation is computed. Intermittent claudication, the most common symptom of peripheral arterial disease, is characterized by a cramping pain in the lower limbs and caused by muscle ischemia secondary to reduced blood flow to working muscles during physical exertion. Claudicants often display poor balance, making them susceptible to falls and activity avoidance. The Ankle Brachial Pressure Index (ABPI) is a noninvasive method for indicating the presence of peripheral arterial disease and intermittent claudication, a common symptom in the lower extremities. ABPI is measured as the highest systolic pressure from either the dorsalis pedis or posterior tibial artery divided by the highest brachial artery systolic pressure from either arm. This paper will focus on the use of computerized dynamic posturography in the assessment of balance in claudicants.