Age-based outcomes of autogenous fistulas for hemodialysis access.

BACKGROUND: Hemodialysis (HD) dependence and autogenous fistula use for HD span the spectrum of age. This study examines age-related outcomes of autogenous fistulas for HD access in a large population-based cohort of patients. METHODS: A retrospective cohort study of all patients who initiated HD in the United States Renal Database System (2007-2014). χ2 tests, t tests, Kaplan-Meier, log-rank tests, multivariable logistic, and Cox regression analyses were employed to evaluate access maturation, interventions, patency, and mortality. RESULTS: Of the 303,281 patients studied, 48,892 (16.1%) were younger than 50 years, 55,817 (18.4%) were 50 to 59 years, 79,138 (26.1%) were 60 to 69 years, 75,200 (24.8%) were 70 to 79 years, and 44,234 (14.6%) were 80 years or older. There was a decrease in autogenous fistula maturation with increasing age. Primary patency at 5 years comparing patients <50 vs 50 to 59 vs 60 to 69 vs 70 to 79 vs 80+ years was 24% vs 23% vs 21% vs 20% vs 18% (P < .001). Primary assisted patency at 5 years was 38% vs 40% vs 37% vs 35% vs 33% (P < .001). Secondary patency at 5 years was 48% vs 50% vs 47% vs 45% vs 42% (P < .001). The risk-adjusted analyses revealed a progressive decrease in primary, primary assisted, and secondary patency with increasing age. As expected, patient survival decreased with increasing age. CONCLUSIONS: In this population-based cohort of HD patients, there was a decrease in autogenous fistula maturation, primary patency, primary assisted patency, secondary patency, and patient survival with increasing age. Despite the relative decline in outcomes associated with older age, decisions about arteriovenous access creation in older patients should be individualized, taking overall clinical status and outcomes of alternatives modes of access into consideration.

Gender-Based Utilization and Outcomes of Autogenous Fistulas and Prosthetic Grafts for Hemodialysis Access.

BACKGROUND: To evaluate gender-based patterns of utilization and outcomes of arteriovenous fistulas (AVFs) and grafts (AVGs) in a population-based cohort of hemodialysis (HD) patients. METHODS: A retrospective analysis of all patients in the United States Renal Data System who had an AVF or AVG placed for HD access (January 2007 to December 2014). Outcomes were access maturation, conduit patency, infection, and mortality. Chi-square, Student's t, Kaplan-Meier, and multivariable Cox regression analyses were employed accordingly. RESULTS: There were 456,693 (57%) males and 341,571 (43%) females who initiated HD via AVF (16%), AVG (4%) and HD catheter (80%). There was a 30% decrease in odds of initiating HD with AVF in females compared with males (adjusted odds ratio [aOR]: 0.70; 95% confidence interval [CI]: 0.69-0.71, P < 0.001). The use of HD catheter as a bridge to AVF was 36% higher in females compared with males (aOR: 1.36; 95% CI: 1.33-1.39, P < 0.001). Preemptive AVF maturation was 78% for males and 76% for females (P < 0.001). The risk-adjusted analyses showed a 7% decrease in AVF maturation comparing females with males (adjusted hazard ratio [aHR]: 0.93; 95% CI: 0.92-0.95, P < 0.001) but no difference in AVG maturation (aHR: 0.99; 95% CI: 0.97-1.01, P = 0.46) After risk adjustment, primary (AVF: aHR-0.87; AVG: aHR-0.96), primary-assisted (AVF: aHR-0.84; AVG: aHR-0.97), and secondary (AVF: aHR-0.85; AVG: aHR-0.98) patency were lower for females compared with males (all P < 0.05). Initiation of HD with a catheter and conversion to AVF was associated with lower patency in males (aHR: 0.29; 95% CI: 0.28-0.29; P < 0.001) and females (aHR: 0.31; 95% CI: 0.30-0.31; P < 0.001) compared with AVF initiates. Patient survival was higher for females compared with males who received AVF (aHR: 1.08; 95% CI: 1.07-1.09; P < 0.001) and AVG (aHR: 1.13; 95% CI: 1.11-1.15; P < 0.001). Initiation with HD catheter and subsequent conversion to AVF was associated with an increase in mortality for males (aHR: 1.45; 95% CI: 1.43-1.47; P < 0.001) and females (aHR: 1.44; 95% CI: 1.44-1.52; P < 0.001) compared with initiation via AVF. There was no significant difference in severe AVG infection comparing females with males (aHR: 1.05; 95% CI: 0.98-1.13; P = 0.16). CONCLUSIONS: Female gender is associated with a lower prevalence of preemptive AVF's, higher utilization of catheters as a bridge to AVF, and lower patency compared with males. There was no difference in access maturation but patient survival was higher for females compared with males.

Overview of aortic aneurysm management in the endovascular era.

Management of aortic aneurysm disease has changed in the endovascular era, with the majority of patients opting for stent-graft repair of abdominal and thoracic aneurysms. An understanding of this vascular condition is important for primary care, emergency medicine, medicine specialists, and vascular surgeons alike. Awareness of the patient risk factors for aneurysmal degeneration, sac rupture, and medical management allows physicians to screen appropriate patient populations, which decreases aneurysm-related mortality due to rupture. The evolving endovascular techniques available today have made more patients eligible for this less-invasive repair, which has lower mortality and morbidity compared with open surgery with aorta replacement. This review provides contemporary information on the etiology, natural history, evaluation, and management of aortic aneurysm disease. The complications of prior aortic repair, whether performed via endovascular or open surgery intervention, are equally important to understanding not only for vascular surgeons performing these procedures, but also for primary care, emergency department, and medicine specialists who are evaluating these patients in an office or hospital setting.

Aggressive Costoclavicular Junction Decompression in Patients with Threatened AV Access.

BACKGROUND: A substantial number of patients with threatened arteriovenous (AV) access are found to have stenoses at the costoclavicular junction (CCJ), which frequently are resistant to angioplasty and stenting. We believe that stenoses in this location will not resolve unless bony decompression is performed to relieve the extrinsic compression on the vein. This article describes our short- to medium-term results following such decompression in patients with failing fistulae. METHODS: We reviewed a prospectively maintained database to identify all patients with threatened AV access operated on for stenoses at the CCJ. Pre- and postoperative course along with long-term follow-up were analyzed. RESULTS: Between July 2012 and December 2013, 24 patients with threatened access were operated on for CCJ stenoses at our institution. Fifteen had highly dysfunctional AV fistulae otherwise felt to need ligation, 10 had significant arm and/or head swelling, and 3 required access but had no contralateral options. In 6 patients, the subclavian vein was occluded and 18 stenotic; 5 of these had stents in place through the CCJ. Decompression was performed via claviculectomy in 3 patients, 2 of whom underwent reconstruction (one jugular vein, one prosthetic bypass) and 1 was stented. The other 21 patients underwent first rib resection, 20 via an infraclavicular exposure and 1 via a supraclavicular rib resection. A variety of interventions were performed in the arm, including aneurysm plication, cephalic to deep bypass, one prophylactic distal revascularization interval ligation, and several primary fistulae. 30-Day mortality was minimal: there was one significant hematoma and one hemothorax in a patient who underwent on-table thrombolysis and there were no deaths or cardiac, neurologic, or other significant morbidity. Median length of stay was 2 days. At follow-up up to 20 (median 10) months, 4 patients died of unrelated causes and 1 patient undergoing central reconstruction with prosthetic bypass required excision of this for infection and ligation of his fistula. Two other fistulae failed. One-year assisted primary patency of the fistula was 85%, and of the central bypass, 89%. At last follow-up, the index arm continued to be used for access in 85% of patients, and overall survival was 68%. Virtually all patients experienced dramatic symptom relief. CONCLUSIONS: In this group of high-risk patients whose access was judged otherwise nonsalvageable, excellent symptom relief and long-term fistula and ipsilateral arm use can be achieved with aggressive decompression of the bony CCJ followed by endovascular intervention as needed.

Renal cell carcinoma accompanied by venous invasion and inferior vena cava thrombus: classification and operative strategies for the vascular surgeon.

Venous invasion is a common characteristic of renal cell carcinoma, manifesting as tumor thrombus with possible extension into the renal vein and, in extensive cases, the thrombus can reach from the renal vein to the right atrium. Currently, cytoreductive nephrectomy and tumor thrombectomy are the foundations for improving quality of life and survival in the treatment of renal cell carcinoma, and a role has emerged for a vascular specialist to become an integral part of operative planning and therapy.