Samuel N. Steerman

Outcomes comparison of HeRO and lower extremity arteriovenous grafts in patients with long-standing renal failure

OBJECTIVE The Hemodialysis Reliable Outflow (HeRO) graft is becoming a recognized alternative to lower extremity arteriovenous grafts (LEAVGs) as an option for patients who have exhausted traditional upper extremity access; however, which should be applied preferentially is unclear. METHODS A retrospective review of LEAVG and HeRO implants from January 2004 to August 2010 was performed. Patient demographics, medical history, procedural data, and outcomes were evaluated. RESULTS Within the time periods, 60 HeROs were placed in 59 patients and 22 LEAVGs were placed in 21 patients. Demographics were similar between the two groups for many factors; however, the patients who underwent HeRO placement had significantly higher body mass index compared with the LEAVG group. Mean follow-up was 13.9 months for the HeRO group and 11.9 months for the LEAVG group. The HeRO patients underwent a mean of 6.3 previous tunneled dialysis catheter insertions and 3.1 previous AVG/arteriovenous fistula placements. The LEAVG patients underwent placement of a mean of 4.1 previous tunneled dialysis catheters and 2.6 previous AVG/arteriovenous fistulas. The principal difference was the number of interventions to maintain patency, which was 2.21 per year in the HeRO group and 1.17 per year in the AVG group (P = .003) Secondary patency at 6 months was 77% for the HeRO patients and 83% for the LEAVG patients (P = .14). The HeRO and LEAVG groups had no difference in infection rate per 1000 days (0.61 vs 0.71; P = .77) or mortality rate (22% vs 19% respectively; P = .22) at 6 months. CONCLUSIONS In access challenged patients, LEAVG and HeRO offer similar rates of secondary patency, infection, and all-cause mortality. The LEAVG required fewer interventions to maintain patency, and the HeRO maintains the benefit of utilizing the upper extremity site of venous drainage. In our practice, we prefer the HeRO to LEAVG, especially in patients with peripheral arterial disease and in the obese population, because it preserves lower extremity access options.

Analysis of vascular closure devices after transbrachial artery access.

Introduction: We seek to determine whether vascular closure devices (VCDs) are safe and effective for brachial artery access. Methods: A retrospective review of brachial artery access using either manual compression (MC) or a VCD for hemostasis from November 2005 to February 2011 was performed. Results: Brachial artery access was performed on 154 limbs: MC on 134 limbs and VCD on 20 limbs. The incidence of thrombotic (VCD n = 0 [0%] vs MC n = 7 [5.2%], P = .37), hemorrhagic complications (VCD n = 1 [5%] vs MC n = 7 [5.2%], P = .72), or major adverse events (VCD n = 1 [5%] vs MC n = 16 [12%], P = .32) was not significantly different between the techniques. After univariate and multivariate analysis, female sex (P = .07, relative risk [RR] = 5.7), sheath size > 6F (P = .008, RR = 14.6), and diagnostic versus interventional procedure (P = .04, RR = 0.4) all impacted the occurrence of thrombosis. Conclusions: Use of VCD in the brachial artery following an endovascular procedure showed equivalence to MC.

Grayscale median analysis of primary stenosis and restenosis after carotid endarterectomy

BACKGROUND Several studies have reported that echolucent carotid lesions, as determined by grayscale median (GSM) analysis, are associated with increased perioperative embolic complications during carotid artery stenting (CAS). However, there is limited research of the predictive value of GSM analysis comparing values for primary atherosclerotic lesions in the carotid artery with those for recurrent lesions after carotid endarterectomy (CEA). METHODS Retrospective data were collected and analyzed from all patients undergoing CAS from November 2005 to August 2010. Available preoperative images amenable to GSM analysis were processed in Adobe Photoshop (version CS4; San Jose, Calif). Statistical analysis included t-test, Fischer exact test, and generation of a receiver operating characteristic curve. RESULTS With at least 29 days of follow-up, 212 patients underwent 228 CAS procedures. There were 189 stents placed for primary lesions (CAS for primary stenosis group) and 39 stents placed for restenosis after CEA (CAS for restenosis group). GSM analysis was feasible for 47 patients, and the mean GSM was 45.6 (n = 34; 95% confidence interval, ± 8.3) for the primary stenosis group and 20.5 (n = 13; 95% confidence interval, ±9.6) for the restenosis group (P < .01). The mean time from CEA to CAS intervention for the restenosis group was 8.6 years. There was no statistical difference in procedural individual and combined complications of ipsilateral stroke, 30-day stroke, or 30-day mortality between the CAS for primary stenosis group and the CAS for restenosis group. In the primary stenosis group, the mean GSM was lower in those with procedural complications compared with those without complications (15 ± 22 vs 49 ± 8; P = .02). CONCLUSIONS A low GSM value was associated with increased perioperative risk when CAS was performed for native carotid lesions, but a low GSM value was not associated with higher procedural risk when carotid stenting was performed for carotid stenosis after CEA (restenosis). GSM analysis for restenosis may be altered by the time interval from CEA to restenosis.

SS06. Efficacy of Surgical Correction of Dialysis Access Steal Syndrome

reduced preoperative amplitude in median motor nerves. The diabetic and HD effects are depicted in Fig 1. Decreased amplitude, CV, and increased F-latency of the median and ulnar motor nerves were linearly associated with worsening grip strength and peg board measurements, as shown in Fig 2. Whereas Disabilities of the Arm, Shoulder, and Hand score changes did not consistently correlate with significant linear changes in NCS, the trend of increased subjective dysfunction and decreased nerve function was frequently observed. These signatures were most robust in the median and ulnar motor distributions. Hand dominance and AVF configuration did not significantly influence change in neurophysiologic or biomechanical outcomes. Conclusions: This is the first description of the temporal changes in neurologic, biomechanical, and patient-perceived hand outcomes after AVF placement. Diabetes and dialysis status at time of access placement have significant effects on hand outcomes. Predictable associations between nerve parameters and objective measures of hand function are identified and provide novel insight into underlying mechanisms causing hand dysfunction after hemoaccess surgery.

INTRAVASCULAR ULTRASOUND ARTERIAL MEASUREMENTS PREDICT VASCULAR ACCESS SITE COMPLICATIONS IN TRANSFEMORAL AORTIC VALVE REPLACEMENT

Vascular complications of Transcatheter Aortic Valve Replacement (TAVR) have been recognized since the procedure’s inception. Studies have shown that CTA measurements of the femoral artery predict vascular complications. This study was designed to evaluate intravascular ultrasound (IVUS) arterial