ABSTRACT
PURPOSE: A lengthy healing and maturation period follows standard surgical preparation of a permanent arteriovenous access, often requiring or extending use of a venous catheter (VC) for hemodialysis. The InterGraft™ Anastomotic Connector System was developed for minimally invasive anastomosis of an arteriovenous graft (AVG). The venous and arterial InterGraft™ connectors are designed to provide optimized flow dynamics and may result in reduction of AVG stenosis. This pilot study evaluated placement procedure success, patency and safety of the InterGraft™ connectors. METHODS: Nine AVGs were implanted in nine patients currently receiving dialysis with a VC. The study allowed use of both connectors (n = 5) or use of the venous connector with a sutured arterial anastomosis (n = 4). Monthly ultrasound examinations were performed throughout the six-month follow-up. AVG angiography was performed at five months. Endpoints included procedure success (acceptable graft flow at end of procedure, without significant bleeding or need for emergent surgery), patency, and device-related major adverse events. RESULTS: Procedure success was attained in all patients. AVGs were used for dialysis within 17 days, on average, and VCs were removed. Three patients exited the study early for reasons unrelated to the InterGraft™ connectors. The remaining six patients had patent grafts: two with assisted and four with unassisted patency. AVG flow rates were greater than 1 L/minute. No dilatations or aneurysms were observed by angiography. There were no device-related major adverse events. CONCLUSIONS: The InterGraft™ connectors can be safely and successfully used for AVG anastomoses, with acceptable near-term patency. Further clinical evaluation is warranted.
Subject(s)
Arteriovenous Shunt, Surgical/instrumentation , Axillary Vein/surgery , Blood Vessel Prosthesis Implantation/instrumentation , Blood Vessel Prosthesis , Brachial Artery/surgery , Renal Dialysis , Adult , Aged , Arteriovenous Shunt, Surgical/adverse effects , Axillary Vein/diagnostic imaging , Axillary Vein/physiopathology , Blood Flow Velocity , Blood Vessel Prosthesis Implantation/adverse effects , Brachial Artery/diagnostic imaging , Brachial Artery/physiopathology , Female , Humans , Male , Middle Aged , Paraguay , Pilot Projects , Prospective Studies , Prosthesis Design , Regional Blood Flow , Time Factors , Treatment Outcome , Vascular PatencyABSTRACT
BACKGROUND: A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD+ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD+ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology. METHODS: This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3). RESULTS: Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR=1335; ACD+ITD=1403). Survival to HD with favorable neurologic function was greater with ACD+ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p=0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p=0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups. CONCLUSIONS: Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD+ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD+ITD, regardless of the etiology of the cardiac arrest.
Subject(s)
Cardiography, Impedance/instrumentation , Cardiopulmonary Resuscitation/instrumentation , Cardiopulmonary Resuscitation/methods , Heart Massage/instrumentation , Out-of-Hospital Cardiac Arrest/mortality , Out-of-Hospital Cardiac Arrest/therapy , Adolescent , Adult , Aged , Aged, 80 and over , Cardiopulmonary Resuscitation/mortality , Combined Modality Therapy , Confidence Intervals , Evaluation Studies as Topic , Female , Heart Massage/methods , Heart Massage/mortality , Hospital Mortality , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Odds Ratio , Patient Discharge/statistics & numerical data , Prospective Studies , Reference Values , Risk Assessment , Survival Rate , Treatment Outcome , Wounds and Injuries , Young AdultABSTRACT
PURPOSE: To analyze alteplase solutions following delivery through the AngioJet Xpeedior rheolytic thrombectomy device to characterize the viability of proteins exposed to high shear stress. METHODS: Alteplase solutions were prepared by reconstitution in sterile water to obtain a targeted concentration of 1.0 mg/mL. A baseline control sample was obtained. The AngioJet system was modified by occluding the return line to allow collection of the dispersed fluid volume. Alteplase solutions (n=5) were delivered through the 6-F, 120-cm Xpeedior catheter and collected. All samples were assayed and compared to baseline using qualitative visual inspection, ultraviolet spectrophotometry, size exclusion chromatography, and in vitro clot lysis assays. RESULTS: Analysis of the test solutions demonstrated a mean protein recovery of 98.0%+/-3.5% of targeted concentration; the collected protein was fully active, as determined by clot lysis assays (specific activity > or =100%). All samples were clear and colorless. No significant fragmentation or aggregation of protein was observed. CONCLUSIONS: Alteplase solutions, when delivered through the AngioJet Xpeedior rheolytic thrombectomy device, remain stable and biologically active in vitro. Further clinical investigation is warranted using this method as a novel approach for pharmacomechanical thrombolysis.
Subject(s)
Catheterization/methods , Thrombectomy/instrumentation , Tissue Plasminogen Activator/pharmacology , Drug Delivery Systems , Equipment Design , Equipment Safety , Humans , In Vitro Techniques , Pulsatile Flow , Sensitivity and Specificity , Thrombectomy/methods , Thrombosis/therapyABSTRACT
The objective of this study was to assess the feasibility, efficacy, and safety of rheolytic thrombectomy (RT) for treatment of coronary stent thrombosis. Stent thrombosis is an infrequent but potentially devastating complication. Conventional treatment with balloon angioplasty and/or thrombolysis has yielded suboptimal results. RT was used to treat 18 patients (mean age, 62 +/- 8 years; 72% male) with in-stent thrombosis (mean time to stent thrombosis, 2.4 +/- 1.8 days). Device success, procedure success, in-hospital and 30-day major cardiovascular events (MACE) were assessed in the hospital and at 30 days. Device success was obtained in 94% and procedure success was achieved in 100% of patients. Following RT, 11 patients underwent balloon angioplasty and 7 patients received additional stents. TIMI 3 coronary flow was obtained in 94.4% and all (100%) patients achieved either TIMI 2 or 3 coronary flow. The angiographic thrombus area decreased from 113.7 +/- 79 to 5.5 +/- 5.7 mm(2) after RT, and to 0.9 +/- 2.1 mm(2) (P < 0.001) after final treatment. Procedural complications were limited to transient no-reflow in five patients. Only one patient evolved a Q-wave MI. At 30 days of follow-up, no patients suffered death, emergent bypass surgery, or stroke. Our data suggest that the adjunctive use of rheolytic thrombectomy offers improved outcomes compared to prior results of intervention after coronary stent thrombosis and should be strongly considered as a treatment option for this complication.
