Should fistulas really be first in the elderly patient?

BACKGROUND: The Kidney Disease Outcomes and Quality Initiative (K/DOQI) has developed guidelines from available data suggesting that arteriovenous fistulas (AVF) be performed in the majority of patients. Patient demographics were not included nor suggested in their recommendations. The purpose of this study is to analyze the outcomes of elderly patients, age greater than 70, undergoing first-time permanent access surgery. METHODS: A retrospective review of consecutive patients undergoing new, first time access procedures from January 2005 through December 2005 was performed. Patients with previous attempts at permanent Arteriovenous (AV) access were removed from analysis. Standard statistical methods were used and patency was determined with Kaplan-Meier curves. RESULTS: One hundred and sixty eight patients underwent first time AVF, 48 of whom were older than 70 years of age. Comparing elderly patients to younger ones, the 12 month primary assisted patency was 35% and 67%, respectively (p=0.002) and secondary patency was 36% and 67%, respectively (p=0.004). Of the 48 elderly patients, 48% had died in the subsequent follow up period as compared to just 20% of the 120 patients younger than 70. The 18-month survival for the elderly group was 50% versus 74% for the younger patients (p=0.004). Of the elderly group who died, the average time to death was 13.1 months and only 8 AVF were able to be accessed. Similar intervention rates per year were seen in both groups. DISCUSSION: With an aging population, more patients older than 70 are being evaluated for permanent vascular access. This group poses a difficult dilemma for surgeons attempting to adhere to K/DOQI guidelines. In light of the increased mortality and decreased patency of AVF, this data questions which form of permanent access should be first-line treatment in this subgroup of patients. CONCLUSION: This data suggest in the elderly patients, autogenous fistulas may not be the best option for this set of patients.

Subintimal angioplasty: Our experience in the treatment of 506 infrainguinal arterial occlusions.

OBJECTIVE: The treatment of patients with chronic arterial occlusions involving the superficial femoral artery has changed significantly with the incorporation of subintimal angioplasty (SIA) into vascular surgery practice. To more clearly define technical feasibility, patency, and clinical outcomes of SIA, we reviewed our cumulative experience. METHODS: A retrospective review of all patients who underwent SIA of arterial occlusions originating in the superficial femoral artery was performed. Patient history, demographics, procedural details, and follow-up information were collected and analyzed. Patency, limb salvage, sustained improvement in claudication, freedom from surgical bypass, and survival were determined by Kaplan-Meier analysis. RESULTS: From December, 2002, through July, 2006, 506 infrainguinal SIA procedures were performed in 472 patients with chronic arterial occlusion involving the superficial femoral artery. The mean age of patients treated was 69.4 +/- 11.9 years and the indication for intervention was critical limb ischemia in 63% of limbs (n = 317) and disabling claudication in 37% (n = 189). Forty-seven percent of limbs (n = 237) had isolated SFA occlusions, 40% (n = 205) had femoropopliteal occlusions, and 13% of limbs had occlusions beginning in the SFA and extending into the tibial arteries (n = 64). Technical success was achieved in 87% of procedures. Following successful SIA, the mean ankle-brachial index increased by 54%, from 0.50 +/- 0.16 to 0.77 +/- 0.23 (P < .0001). Median follow-up was 12.4 months (0-48 months) and 30-day mortality was 0.8%. Primary patency at 12 and 36 months was 45% (SE 3.0%) and 25% (SE 3.6%) respectively. Secondary patency was 76% (SE 2.6%) and 50% (SE 4.8%) at 12 and 36 months. Factors associated with reduced primary patency included femorotibial occlusions (HR 1.57, CI 1.05-2.36) and the presence of critical limb ischemia (HR 1.39, CI 1.02-1.89). Limb salvage in patients with critical limb ischemia was 75% (SE 5.9%) at 36 months. Freedom from surgical bypass in patients with either critical limb ischemia or disabling claudication was 77% (SE 4.1%) at 36 months. CONCLUSION: SIA is an effective percutaneous technique for the revascularization of patients with lower extremity chronic arterial occlusions involving the superficial femoral artery. The procedure is successfully performed in all segments of the lower extremity with minimal morbidity or mortality. Rates of limb salvage and improvement in claudication are similar to those achieved by open surgical bypass, while modest reductions in limb salvage and primary patency are experienced in limbs with femorotibial occlusions.

The natural history of autologous fistulas as first-time dialysis access in the KDOQI era.

BACKGROUND: Patients on hemodialysis depend on durable, easily maintained vascular access. The autologous arteriovenous fistula (AVF) has been the gold standard since the introduction of the Brecia-Cimino fistula in 1966 and is echoed in the current Kidney Disease Outcomes and Quality Initiative (KDOQI) guidelines. The purpose of this study is to determine the natural history of AVF in patients requiring first-time permanent access in a large academic vascular surgery practice. METHODS: We performed a retrospective review of patients undergoing new access creation from January 1, 2005 to June 30, 2005. The study group consisted of patients with no prior permanent access that underwent AVF creation. Categorical data was compared using chi2 analysis, nominal data was compared using Student t-test, and patency was determined by Kaplan-Meier curves. RESULTS: During the 6-month period, there were 80 first time AVF creations. The majority of patients were male (69%), African American (55%), and a history of diabetes (55%) and hypertension (96%). Seventy-five percent of patients were already undergoing hemodialysis via catheter access. Seventy-six percent of patients underwent preoperative vein mapping with a mean vein diameter of 3.1 mm. Twenty-six radiocephalic AVF (RCAVF) and 54 brachiocephalic AVF (BCAVF) were created with a mean follow-up of 278 days. At the end of follow-up, 38 (48%) AVF were being used for hemodialysis and only nine (11%) matured without the need for additional intervention. Mean time for AVF maturation was 146 days. Thirty AVF (37%) were abandoned, 16 (20%) of which were primary failures. Mean time to abandonment was 162 days. Twelve (15%) AVF remained patent but were never cannulated. The intervention rate was 1.33 interventions/patient/year and 75% of interventions were percutaneous. Kaplan-Meier analysis determined primary, primary-assisted, and secondary patency was 36% +/- 8.3, 55% +/- 6.5, and 55% +/- 6.5 at 1 year, respectively. Cumulative functional patency was 63% at 1 year. CONCLUSIONS: In patients receiving a first time permanent access, we found that the majority were AVF and they resulted in low primary patency rates at 1 year and long maturation times. KDOQI encourages AVF creation in order to increase AVF use for dialysis, but the strategy of simply increasing the number being created may not lead to the desired result and potentially lead to an increase in catheter dependence.

Treatment of symptomatic lower extremity acute deep venous thrombosis: role of mechanical thrombectomy.

Systemic anticoagulation with heparin or its unfractionated derivatives followed by warfarin therapy has been the mainstay of treatment in patients with lower extremity deep venous thrombosis (DVT). Although heparin is an effective treatment modality in preventing thrombus propagation, it provides minimal therapeutic effect in dissolving preexisting venous thrombus. The clinical consequence of DVT, owing in part to loss of venous endothelial and valvular function, is postphlebitic syndrome or chronic venous insufficiency. Current advances in endovascular therapy have resulted in various endovascular thrombectomy systems that can effectively remove a large venous thrombus burden, which may represent a potential advantage of preserving venous valvular function and thereby reduce the likelihood of postphlebitic syndrome. In this article, we review a variety of surgical and interventional methods in venous thrombus removal. Current treatment modalities using mechanical thrombectomy devices and pharmacomechancial thrombectomy strategy are also discussed.

Subintimal angioplasty for the treatment of claudication and critical limb ischemia: 3-year results.

OBJECTIVE: Subintimal angioplasty (SIA) is an increasingly used method of lower extremity revascularization for patients with chronic arterial occlusions. To assess the technical feasibility, safety, and 3-year outcomes of patients treated with SIA, we performed a retrospective review of our early experience. METHODS: Patient information-including demographics, indications, procedures, noninvasive arterial studies, and postprocedural events-was recorded in a database. Outcomes were determined on an intention-to-treat basis, as well as by technical success, by using Kaplan-Meier survival analysis. Continuous data were compared by using the Student t test, and survival curves were compared by log-rank testing. RESULTS: From December 2002 through December 2003, 104 patients (105 limbs) underwent SIA of 159 occlusive lesions involving the iliac (n = 10), superficial femoral (n = 85), popliteal (n = 48), or tibial (n = 16) arteries. Sixty-six (62.9%) patients were treated for critical limb ischemia, and 39 patients (37.1%) were treated for disabling claudication. Technical success was achieved in 91 procedures (86.7%) and resulted in a mean increase in ankle-brachial index of 0.36 +/- 0.16. The mean follow-up was 23.4 months (range, 0-46 months). During this period, 18 patients (17.0%) died, and 15 amputations (14.3%) were performed, 6 of which were performed for patients on whom SIA had been unsuccessful. In patients undergoing successful SIA, the primary patency was 55%, 43%, and 35% at 12, 24, and 36 months, respectively. Twenty-one patients underwent a total of 23 percutaneous procedures to maintain or restore patency of the SIA during the study period. This resulted in secondary patency rates of 71%, 63%, and 51% at 12, 24, and 36 months, respectively. Multivariate analysis revealed critical limb ischemia to be the only predictor of reduced primary patency. Fifteen patients with inoperable critical limb ischemia underwent successful SIA. Limb salvage in this group was 54% and 43% at 12 and 36 months, respectively. Limb salvage in operative candidates was 100% and 88% at the same intervals. In patients with disabling claudication, 94% experienced improvement in symptoms 3 months after the procedure, and 68% of patients reported sustained improvement at 36 months. In all operative candidates successfully treated with SIA, freedom from surgical bypass was 83% and 73% at 12 and 36 months, respectively. CONCLUSIONS: SIA for the treatment of lower extremity chronic arterial occlusions is technically feasible, results in minimal morbidity, and provides satisfactory revascularization without surgical bypass. Secondary patency is comparable to that of autologous vein bypass and is achieved with a low rate of reintervention. When used as first-line therapy, SIA provides most patients with limb salvage and freedom from surgical bypass at 3 years.