Randomised clinical study of the impact of routine preoperative Doppler ultrasound for the outcome of autologous arteriovenous fistulas for haemodialysis.

BACKGROUND: Arteriovenous fistulas are the gold standard of vascular accesses in haemodialysis; however, they have a considerable primary failure rate. This study evaluated the comparative reliability of routine preoperative Doppler ultrasound with an isolated physical examination of autologous arteriovenous fistulas within the Single Health System of Brazil and analysed the potential clinical benefit, improvement in primary failure rates and its economic impact. METHODS: A non-blind randomised clinical study group of patients undergoing a vessel mapping with preoperative Doppler ultrasound (ultrasound group) and a control group who had undergone only a physical examination (clinical group) before the vascular procedures was performed. The role of the arteriovenous fistula in dialysis and possible alterations was evaluated in both the groups and followed up for 6 months. RESULTS: Of the initial 248 eligible patients, there was a randomisation of 230 patients, 228 of whom were submitted for surgery, 114 in each group. In the clinical group, a significantly higher rate of primary failure was recorded, with 13.6% versus 4.4% in the ultrasound group (p = 0.002). The Kaplan-Meier curve with log-rank analysis showed a significantly higher primary patency in the ultrasound group (p = 0.042). Regarding the cost-effectiveness of the use of Doppler ultrasound, there was no increase in the final cost compared to the physical examination (US$1.28/fistula day × US$1.29/fistula day). CONCLUSION: It was concluded that Doppler ultrasound contributed to the reduction of primary failure, leading to a significantly superior primary patency of arteriovenous fistulas, and no increase in the final cost. This justifies its routine preoperative use in the Single Health System. Registration number RBR-474xhn (http://www.ensaiosclinicos.gov.br).

Randomized controlled clinical trial evaluating the efficacy of hyperbaric oxygen therapy in facilitating the healing of chronic foot ulcers in diabetic patients: the study protocol.

BACKGROUND: Diabetic limb ulcers are highly prevalent and contribute to a significant increase in cost for the treatment of these patients in health services. However, healing of these wounds is a major health problem and may even lead to amputation. The primary aim of the current study is to evaluate the efficacy of hyperbaric oxygen therapy (HBOT) in facilitating the healing of diabetic foot ulcers, in addition to secondarily evaluating whether it reduces the number of amputations and improves the quality of life in these patients. METHODS: A non-blind randomized clinical study will be conducted in the city of Imperatriz, Maranhão state, Brazil, from 2019 to 2020, in diabetic patients with chronic foot ulcers (classified as Wagner grades 2, 3 and 4, persisting for more than 1 month). The outpatient follow-up for diabetic foot patients will be done at the Unified Health System, with a sample size of 120 patients (the randomization allocation will be 1:1, being 60 patients for each arm). Half of the patients will receive standard treatment, i.e. dressings, debridement, antibiotics and load relief, along with HBOT (HBOT group), and the other half will receive only standard treatment (control group). The patients of the HBOT group will be evaluated upon admission, after 10, 20, 30 and 35 HBOT sessions, and after 6 months and 1 year. The patients of the control group will also be evaluated at equivalent periods (upon admission, after 2, 4, 6 and 7 weeks, 6 months and 1 year). The SF-36 quality of life questionnaire will be filled upon admission and after 3 months of follow-up in both groups. The primary and secondary endpoints will be assessed with 1 year of follow-up. DISCUSSION: Diabetic foot ulcers are a highly prevalent complication of diabetes with serious consequences. A study to assess the efficacy of HBOT in healing the ulcers and reducing the rate of amputations in diabetic patients is justified, which will eventually aid in the development of guidelines for treating these ulcers. TRIAL REGISTRATION: Registration number RBR-7bd3xy . Registered on 17 July 2019-Retrospectively registered.

The influence of a doppler ultrasound in arteriovenous fistula for dialysis failure related to some risk factors / Influência da Ultrassonografia Doppler nas Falhas de Fístulas Arteriovenosas de Diálise Relacionada a Alguns Fatores de Risco

ABSTRACT Introduction: The increasing prevalence of chronic kidney disease has increased the demand for arteriovenous fistula (AVF) care. The objective of this study was to assess the relationship between some risk factors for AVF failure (advanced age, female sex, diabetes, obesity, central venous catheter, previous fistula, and hospitalization) and having a Doppler ultrasound performed preoperatively. Methods: A prospective study was performed with 228 dialysis patients from Imperatriz, Maranhão. Half of the sample was randomly selected to receive preoperative Doppler ultrasound and the other half did not, from the period of October 2016 to September 2018. Results: There were 53 total failures corresponding to 23.2% of our sample, which is almost double that of the patients in the clinical group. Considering the failures and risk factors associated with the overall sample, there was a statistically significant association between a central venous catheter on the same side of the AVF with P = 0.04 (Odds Ratio 1.24) and obesity with P = 0.05 (Odds Ratio 1.36), which was not repeated in the Doppler ultrasound group individually. There was no statistically significant difference between the Doppler group and clinical group with respect to the amount of days of previous AVF hospitalization and failure. Conclusions: We concluded that the reduction of failures with an introduction of the Doppler was statistically significant in the overall sample, but establishing a relationship between specific risk factors and failure was only possible with two of the risk factors in the study - obesity and central venous catheter on the same side of the AVF.

RESUMO Introdução: A crescente prevalência de doença renal crônica aumentou a demanda por confecção de fístula arteriovenosa (FAV). O objetivo do presente estudo foi avaliar a relação entre alguns fatores de risco para falha da FAV (idade avançada, sexo feminino, diabetes, obesidade, cateter venoso central, fístula prévia e hospitalização) e a realização de ultrassonografia Doppler no pré-operatório. Métodos: Estudo prospectivo com 228 pacientes em diálise em Imperatriz, MA. Metade da amostra foi randomizada para receber ultrassonografia Doppler no pré-operatório. A outra metade dos pacientes não foi submetido a exame ultrassonográfico. O estudo incluiu pacientes atendidos no período de outubro de 2016 a setembro de 2018. Resultados: Houve 53 falhas (23,2%) em nossa amostra, quase o dobro do número dos pacientes no grupo clínico. Considerando as falhas e os fatores de risco associados à amostra geral, houve associação estatisticamente significativa entre catéter venoso central do mesmo lado da FAV (P = 0,04; Razão de Chances: 1,24) e obesidade (P = 0,05; Razão de Chances: 1,36), o que não foi reproduzido no grupo de ultrassonografia Doppler individualmente. Não houve diferença estatisticamente significativa entre o grupo Doppler e o grupo clínico em relação à quantidade de dias de internação e falha da FAV. Conclusões: A redução de falhas com a introdução do Doppler foi estatisticamente significativa na amostra geral, mas só foi possível estabelecer uma relação entre fatores de risco específicos e falha em dois dos fatores estudados, obesidade e catéter venoso central no mesmo lado da FAV.

The influence of a doppler ultrasound in arteriovenous fistula for dialysis failure related to some risk factors.

INTRODUCTION: The increasing prevalence of chronic kidney disease has increased the demand for arteriovenous fistula (AVF) care. The objective of this study was to assess the relationship between some risk factors for AVF failure (advanced age, female sex, diabetes, obesity, central venous catheter, previous fistula, and hospitalization) and having a Doppler ultrasound performed preoperatively. METHODS: A prospective study was performed with 228 dialysis patients from Imperatriz, Maranhão. Half of the sample was randomly selected to receive preoperative Doppler ultrasound and the other half did not, from the period of October 2016 to September 2018. RESULTS: There were 53 total failures corresponding to 23.2% of our sample, which is almost double that of the patients in the clinical group. Considering the failures and risk factors associated with the overall sample, there was a statistically significant association between a central venous catheter on the same side of the AVF with P = 0.04 (Odds Ratio 1.24) and obesity with P = 0.05 (Odds Ratio 1.36), which was not repeated in the Doppler ultrasound group individually. There was no statistically significant difference between the Doppler group and clinical group with respect to the amount of days of previous AVF hospitalization and failure. CONCLUSIONS: We concluded that the reduction of failures with an introduction of the Doppler was statistically significant in the overall sample, but establishing a relationship between specific risk factors and failure was only possible with two of the risk factors in the study - obesity and central venous catheter on the same side of the AVF.

Perviedade e complicações no seguimento de cateteres venosos totalmente implantáveis para quimioterapia / Patency and complications in the follow-up of totally implantable catheters for chemotherapy

CONTEXTO: A disponibilidade de acesso venoso nos pacientes que recebem cursos prolongados de terapia citotóxica é de grande importância para o sucesso do tratamento. Os cateteres totalmente implantáveis vêm sendo cada vez mais utilizados para a referida terapia, proporcionando melhoria na qualidade de vida dos doentes. OBJETIVO: Avaliar a perviedade e complicações dos cateteres venosos totalmente implantáveis instalados nos pacientes oncológicos. MÉTODOS: Estudo longitudinal retrospectivo com 74 pacientes submetidos a colocação de cateter totalmente implantável de janeiro de 2004 a fevereiro de 2007. RESULTADOS: Foram inseridos cateteres venosos totalmente implantáveis em 74 pacientes com idade média 48,9 anos, predominando o sexo feminino. As neoplasias mais prevalentes foram mama (40,5 por cento), cólon (20,8 por cento) e linfoma (18,9 por cento). Houve predomínio do acesso venoso pela via cervical (74,3 por cento), com utilização da veia jugular interna em 45,9 por cento dos casos. Somente 13,5 por cento dos acessos ocorreram por punção da veia subclávia. A duração média de uso dos cateteres foi de 335,33 dias. Trinta e seis doentes (48,6 por cento) mantiveram-se com o cateter após o término da quimioterapia. Sessenta e sete doentes (90,5 por cento) não apresentaram complicações. Entre as complicações precoces, houve um (1,4 por cento) pneumotórax e um (1,4 por cento) hematoma na loja de implantação. Entre as complicações tardias, ocorreram cinco (6,7 por cento) infecções. Foram retirados 10 (13,5 por cento) cateteres, cinco devido às complicações e cinco por término do tratamento. Houve 11 (14,9 por cento) óbitos de pacientes em decorrência do câncer, com o cateter funcionante. CONCLUSÃO: Os resultados obtidos demonstram baixa taxa de complicações, confirmando a segurança e conveniência do uso dos acessos totalmente implantáveis em paciente em regime de quimioterapia.

BACKGROUND: Availability of venous access for patients that receive long-term cytotoxic therapy is of great importance to the success of treatment. Totally implantable devices have been increasingly more used for this therapy, providing improvement in the quality of life of patients. OBJECTIVE: To evaluate patency and complications of totally implantable catheters inserted in oncological patients. METHODS: Retrospective longitudinal study of 74 patients that underwent placement of totally implantable catheter from January 2004 throughout February 2007. RESULTS: Totally implantable catheters were placed in 74 patients with mean age of 48.9 years; the female gender was predominant. The most prevalent neoplasms were breast (40.5 percent), colon (20.8 percent) and lymphoma (18.9 percent). Cervical access (74.3 percent) was prevalent, using the internal jugular vein in 45.9 percent of cases. Only 13.5 percent of accesses were inserted via subclavian vein puncture. Mean duration of catheter use was 335.33 days. Thirty six (48.6 percent) patients remained with the catheter after the chemotherapy was discontinued. There were no complications in 67 (90.5 percent) patients. Among early complications, there was one (1.4 percent) pneumothorax and one (1.4 percent) hematoma. Among late complications, there were five (6.7 percent) infections. Ten (13.5 percent) catheters were removed, five due complications and five after ending the treatment. Eleven (14.9 percent) patients died from cancer, and the catheters were still functioning. CONCLUSION: The outcomes obtained show low rate of complications, confirming that use of totally implantable catheters is safe and effective for patients undergoing chemotherapy.

Recanalização espontânea tardia de carótida interna: relato de caso / Late spontaneous recanalization of internal carotid artery: case report

A recanalização espontânea tardia da carótida interna é um evento incomum e pouco estudado. Os autores relatam o caso de paciente de 73 anos, masculino, hipertenso, com antecedente de acidente vascular cerebral há 3 anos, com seqüela motora e sensitiva em membro superior direito, apresentando ao mapeamento dúplex e arteriografia oclusão total da carótida interna. Evoluiu após 2 anos com novos episódios de ataques isquêmicos transitórios de repetição. Submetido a novos exames de imagem para avaliação da circulação cerebral extra e intracraniana, evidenciou-se recanalização do vaso, com estenose severa. Foi realizada endarterectomia de carótida esquerda, sem intercorrências. Paciente evoluiu sem novos episódios após 1 mês de seguimento. Considerando a raridade do caso e a parca literatura sobre recanalização tardia de carótida, passível de reparo cirúrgico, optamos pela apresentação do caso enfocando a importância do acompanhamento de oclusões carotídeas.

Late spontaneous recanalization of internal carotid artery is an unusual event that has received little attention. The authors report a case of a 73-year-old male patient, hypertensive, with previous history of cerebral vascular accident 3 years ago, with sensorimotor sequela in the right upper limb. Duplex scanning and arteriography showed total occlusion of the internal carotid artery. The patient progressed after 2 years with new episodes of recurrent transient ischemic attacks. When submitted to new imaging examinations to assess extra- and intracranial circulation, vessel recanalization was demonstrated, with severe stenosis. Left carotid endarterectomy was uneventfully performed. The patient progressed without new episodes after a 1-month follow-up. Considering the case rarity and the lack of literature on late carotid artery recanalization that can be surgically repaired, we decided to present this case focusing on the importance of following carotid artery occlusions.