ABSTRACT
OBJECTIVE: A native arteriovenous fistula (NAF) is a widely used access location for hemodialysis (HD). Monitoring of the NAF followed by percutaneous transluminal angioplasty (PTA) as needed may reduce the incidence of NAF failure according to nonrandomized studies. The aim of this randomized study was to determine whether an interventional strategy consisting of clinical and duplex ultrasonographic (DUS) surveillance of NAFs followed by PTA reduces the rate of the need of central venous dialysis catheters (CVCs) and NAF thrombosis in patients undergoing HD. METHODS: A total of 108 patients with 111 functioning NAFs in an HD program were randomized to control and interventional strategy groups. The control group received standard care: clinical and hemodynamic NAF assessment followed by vascular surgeon consultation in cases of dysfunction. In the interventional group, the patients underwent clinical monitoring and systematic DUS surveillance every 3 months. Cases with access dysfunction underwent angiography followed by PTA for stenosis of 50% or greater. Primary outcomes were the need of temporary CVCs and fistula thrombosis. RESULTS: Fifty-eight NAFs were randomized to the control group, and 53 were randomized to the interventional group. Groups had similar baseline characteristics. The interventional strategy showed a significant reduction in the CVC need (25.9% versus 7.5% for control and interventional groups, respectively; P = .021). No significant difference was observed for thrombosis rates (24.1% versus 17.0%; P = .487). The composite end point of NAF thrombosis or CVC need was reduced by the interventional strategy (44.8% versus 20.8%; P = .033). CONCLUSIONS: This randomized study indicates the benefit of a surveillance program for maintenance of NAFs based on clinical and DUS surveillance followed by PTA of major stenosis.
Subject(s)
Arteriovenous Shunt, Surgical/methods , Renal Dialysis/adverse effects , Renal Dialysis/methods , Surgery, Computer-Assisted/methods , Ultrasonography, Interventional/methods , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/prevention & control , Female , Humans , Male , Middle Aged , Treatment Outcome , Venous Thrombosis/etiologyABSTRACT
Introduçao: É tema atual a realizaçao de procedimentos cirúrgicos por minitoracotomias que, inicialmente utilizadas para operaçoes de revascularizaçao do miocárdio, têm sido também propostas como acesso às operaçoes valvares. O objetivo deste trabalho é analisar resultados da minitoracotomia em relaçao à técnica tradicional nas intervençoes valvares, em estudo prospectivo. Casuística e Métodos: Entre novembro de 1996 e fevereiro de 1998, dois grupos, 8 pacientes operados por minitoracotomia (Grupo 1) e 8 controles (Grupo 2) equiparáveis nas variáveis sexo, idade, peso/altura, classe funcional pré-operatória, doença de base e operaçao proposta, foram submetidos a reparo ou troca valvar aórtica ou mitral. Os pacientes deo Grupo 1 foram operados através de incisao paraesternal direita de até 8 cm, com circulaçao estracorpórea (CEC) estabelecida através de canulaçao arterial e venosa femorais e os do Grupo 2 (controles) por esternotomia mediana. Ambos os grupos foram acompanhados até a alta hospitalar. Resultados. Os parâmetros avaliados no trans-operatório e pós-operatório, bem como a análise estatística constam nas Tabelas 1 e 2.
Subject(s)
Humans , Male , Female , Adult , Thoracotomy , Aortic Valve/surgery , Minimally Invasive Surgical ProceduresABSTRACT
O reconhecimento e tratamento do paciente em coma constitui uma emergência que exige correto atendimento. Os autores discutem sobre coma e conduta no paciente comatoso. Revisa-se a literatura pertinente, objetivando atualizar o tema e, consensualmente, protocolar um padräo de conduta exequível à realidade da prática médica diária
