Stent placement in hemodialysis access: historical lessons, the state of the art and future directions.

Vascular access stenosis in patients undergoing chronic hemodialysis is a major issue that is associated with increased morbidity, mortality, and cost of medical care. Recent data have emphasized that endovascular stents could be used in the treatment of central as well as peripheral stenotic lesions. In general, a peripheral or central vein lesion that is elastic or recurs within a three-month period after an initially successful balloon angioplasty or a stenosis where surgical revision is not possible are some indications for intravascular stent placement. Recent reports have expanded the role of stents in the management of pseudoaneurysms associated with dialysis access. In this context, the utilization of these devices must take into account a fair comparison with the traditional (surgical) approaches regarding effectiveness as well as costs. This report describes the role of stents in arteriovenous dialysis access. In addition, some of the recent advances in the structure and complicating issues such as stent fracture, migration, and infection, as well cannulation through the stent, are discussed.

Hemophilia A pseudoaneurysm in a patient with high responding inhibitors complicating total knee arthroplasty: embolization: a cost-reducing alternative to medical therapy.

Joint hemorrhages are very common in patients with severe hemophilia. Inhibitors in patients with hemophilia are allo-antibodies that neutralize the activity of the clotting factor. After total knee replacement, rare intra-articular bleeding complications might occur that do not respond to clotting factor replacement. We report a 40-year-old male with severe hemophilia A and high responding inhibitors presenting with recurrent knee joint hemorrhage after bilateral knee prosthetic surgery despite adequate clotting factor treatment. There were two episodes of marked postoperative hemarthrosis requiring extensive use of substitution therapy. Eleven days postoperatively, there was further hemorrhage into the right knee. Digital subtraction angiography diagnosed a complicating pseudoaneurysm of the inferior lateral geniculate artery and embolization was successfully performed. Because clotting factor replacement therapy has proved to be excessively expensive and prolonged, especially in patients with inhibitors, we recommend the use of cost-effective early angiographic embolization.

Use of a collagen hemostatic closure device to achieve hemostasis after arterial puncture: a cost-effectiveness analysis.

PURPOSE: To evaluate whether a collagen hemostatic closure device is a safe, cost-effective alternative to manual compression for achieving hemostasis at arterial puncture sites. MATERIALS AND METHODS: A cost-effectiveness analysis, based on a meta-analysis of published data, was performed from the perspective of the health-care system. The gain in effectiveness was expressed as the decrease in rate of puncture-site complications that required treatment. Costs associated with achieving hemostasis and treating complications were included. RESULTS: Use of a collagen closure device decreased the number of puncture-site complications from 31:1,000 to 16:1,000. The average cost of using the device was $177 per patient compared with $42 per patient for manual compression. The incremental cost of averting one complication exceeded $9,000. CONCLUSION: Use of a collagen closure device to achieve hemostasis after an arterial puncture may reduce the complication rate, but the additional cost per complication averted is very high.