Retrospective Analysis of 77 Hemodialysis Patients Shows No Cases of Steal Syndrome from Graft Taper Reduction.

PURPOSE: To review the immediate flow response and incidence of steal syndrome after taper reduction of tapered dialysis grafts. MATERIAL AND METHODS: This was a retrospective review of a quality assurance database of all hemodialysis access interventions performed between 2005 and 2017. It identified 77 patients who underwent a taper reduction procedure, involving angioplasty of the arterial limb of the graft and the arterial anastomosis for graft thrombosis/poor flow. A subset of patients underwent 5-, 6-, or 7-mm balloon taper reduction angioplasty coupled with intravascular direct flow measurement (n = 15 with 16 dialysis grafts). A two-tailed Wilcoxon matched-pairs signed-rank test was used to compare pre- and post-taper reduction flows. Mean duration of follow-up was 3.5 years (range, 0-12.5 years). RESULTS: Mean access survival after taper reduction was 20.2 months (range, 0.10-94.4 months). Pre- and post-taper reduction access flows (mean Qb ± standard deviation) were 574 ± 315 ml/min and 929 ± 352 ml/min, respectively (P < .0001). The mean ratio of post- to pre-taper reduction flows was 1.6 (range, 1.1-10.2). No patients developed steal syndrome within 6 months after taper reduction. CONCLUSIONS: Dialysis graft arterial anastomotic taper reduction did not result in the development of steal syndrome within 6 months. In the subset of patients who underwent flow measurements, taper reduction was associated with nearly a 2-fold improvement in access flow, which is a key predictor of access function.

Significance of Echocardiographically Detected Central Venous Catheter Tip-Associated Thrombi.

PURPOSE: To explore significance, management, and outcomes of central venous catheter (CVC) tip-associated thrombi incidentally detected on echocardiography. MATERIALS AND METHODS: Echocardiogram data from all patients with CVCs from October 2009 to June 2011 were reviewed (N = 170). Patients with CVC tip-associated thrombi were selected (n = 49). Echocardiograms were reviewed for ejection fraction, presence of patent foramen ovale (PFO), presence of other intracardiac shunts, and mean thrombus size. Management decisions, thrombus extension, pulmonary embolism, paradoxical emboli, and stroke within 3 months were recorded. RESULTS: Mean thrombus size was 2.1 cm (range, 0.5-5.7 cm). Of patients with thrombi, 11 (22%) were already on anticoagulation, and there was no change in management. Anticoagulation was started without complications in 17 (35%) patients, the catheter was removed in 4 (8%) patients, and no new treatment was initiated in 17 (35%) patients. Of these 17 patients, 16 (94%) developed no complications. One (6%) patient with a PFO and right-to-left shunt experienced a stroke before PFO closure. After surgical closure of the PFO, the same patient developed catheter tip-associated thrombus without complication. There were no pulmonary emboli, strokes, or other detected embolic phenomena. CONCLUSIONS: In this sample with CVC tip-associated thrombi but without PFO or other intracardiac shunts, no embolic or other complications were detected, regardless of anticoagulation status. These data suggest a benign course for such thrombi and that anticoagulation, catheter removal, thrombectomy, and thrombolysis may be unnecessary when catheter tip-associated thrombi are incidentally detected on echocardiography.