RESUMO
Background: cardiovascular disease is the most common cause of death in patients with end-stage renal disease [ESRD]. This underlying ischemic heart disease must be addressed to allow uncomplicated symptom free dialysis or before Renal transplant to assure successful results without myocardial infarction
Objective: to study the outcome of coronary artery bypass grafting in terms of morbidity and mortality in patients with end-stage renal disease
Methods: this prospective study has been conducted at the Department of Cardiothoracic Surgery, Federal Postgraduate Medical Institute, Shaikh Zayed Hospital, Lahore between March 2005 to April, 2009. Sixty four patients undergoing coronary artery bypass surgery with end stage renal disease were included. We admitted our patients five days before surgery and carefully managed preoperatively with the renal replacement therapy to optimize the patients for surgery. Peroperatively we used hemofiltration to reduce the preload. Postoperatively we restricted fluid management only to urine out put, blood loss and insensible losses. Intravenous fluids are carefully given according to metabolic needs of the patient [500-700 ml/24 hours + volume to urine output if any]. Haemodialysis on 2nd postoperative day in intensive care unit and on 4th post-operative day in main dialysis department to keep serum creatinine
Results: there were 55 males and 9 females with mean age of 54.7+/-10.8 years. Fifty five patients were diabetics and hypertension was present in 62 patients. Mean preoperative ejection fraction was 39.4+/-6.4%. Triple vessel disease was present in 40 patients and 8 patients had severe left main stem coronary artery disease. The average number of grafts were 3.8 and bypass time was 142.3+/-17.8 minutes, Extubation time was 15-18 hours and length of stay in intensive care unit [ICU] was 4.03+/-0.7 days. Similarly length of hospital stay was 10.47+/-0.87 days. Overall mortality was 12.7% in these patients
Conclusion: midterm outcome of coronary artery bypass grafting in dialysis patients is although associated with a higher incidence of complications but can be performed with an acceptable operative mortality and gives good symptomatic relief of angina. It is excellent bridge for renal transplant surgery
RESUMO
Native arteriovenous fistula is the method of choice for chronic intermittent hemodialysis. When it is not possible, the options for vascular access are either brachio-basilic arteriovenous fistula with subcutaneous placement of basilic vein or the use of a prosthetic implant, as recommended by the Kidney Disease Outcome Quality Initiative [KDOQI] and European guidelines
Aim: to find out reasonable and economical alternate method of vascular access, in patients with previous multiple access failure
Methods: during the period from February 2008 to July 2009, 29 patients prospectively enrolled in the study and the patients were divided into two groups according to the selection criteria. Group1. Patients selected for insertion for PTFE graft. Group 2 Patients selected for Extra- Anatomical Subcutaneous placement of basilic vein [EASPBV]
Results: equal distributions were seen regarding the preoperative patient characteristics and other risk factors in the both groups. No immediate failure of AVF in the both groups. A primary early patency rate was 93.8% and 92.3% , twelve months patency rate was 87.5% and 84.6% ,and 22 months patency rates were 81.3% and 77% in group one and two respectively. In group 1, one patient with graft developed early symptoms of infection, managed with appropriate antibiotics. Two other patients in the same group had thrombosis and graft occlusion after eight months and one year respectively, after the first prick in the graft for hemodialysis. One female patient of this group developed distal ischemia of the hand and we had to remove the graft 15 days after its insertion. In group 2 male patient with diabetes and hypertension got wound infection, his basilic one vein thrombosed within few days resulting in failure of the fistula. A 23 years old patient got false aneurysm of the basilic vein 5 cm distal to the anastmosis at the puncture site of the arteriovenous fistula after 14 months, it is still functioning and is under follow up. The group one with AVF with graft shows more tendencies for bleeding, thrombosis, and distal ischemia of the limb while group to with AVF with EASPBV shows more tendencies towards false aneurysm formation. The arteriovenous fistula with subcutaneous placement of the basilica vein has significantly low cost
Conclusion: the both methods of vascular access have good comparable results. The AVF with EASPBV has advantage of less complications and being more cost effective