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Byun JH, Rennie A, Huang J, Raja J. Rotational thrombectomy versus balloon maceration in dialysis access salvage. J Vasc Access 2024:11297298241234990. [PMID: 38436294 DOI: 10.1177/11297298241234990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Although end stage renal disease patients who undergo hemodialysis frequently experience dialysis-associated thrombotic complications, there remains a paucity of literature comparing the efficacy of different endovascular salvage techniques for grafts and fistulas. This study aims to compare primary patency in dialysis access following salvage mechanical thrombolysis/thrombectomy with a rotational thrombolysis device versus balloon maceration. METHODS Using a database of patient records at a tertiary medical center, all patients who underwent rotational thrombectomy with the Cleaner XT™ Rotational Thrombectomy System for endovascular salvage of arteriovenous fistula or arteriovenous graft from August 2016 to July 2022 were included in the population. Fourteen patients who underwent balloon maceration for endovascular salvage were matched to the patients in the rotational thrombectomy group based on date of procedure. The primary patency of the fistula or graft for the two groups was measured. RESULTS A total of 13 patients who underwent dialysis access salvage with rotational thrombectomy (10 grafts, 3 fistulas) were matched with 14 patients who underwent balloon maceration for dialysis access salvage (10 grafts, 4 fistulas). Six patients in both groups required additional graft access salvage (46% rotational thrombectomy; 43% balloon maceration). The median time to next dialysis salvage was 51 days for rotational thrombectomy and 43.5 days for balloon maceration (W + 9, critical value 1; compatible with statistically significant difference). CONCLUSION Endovascular access salvage by rotational thrombectomy may provide longer primary patency compared to salvage by balloon maceration. However, a longer follow-up prospective study of a larger study population is necessary to clarify the safety and efficacy of rotational thrombectomy using the Cleaner XT™ device.
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Affiliation(s)
- Jee Hyuk Byun
- Department of Interventional Radiology, University of Alabama Birmingham, Birmingham, AL, USA
- CHA Bundang Medical Center, CHA University, Seongnam, Gyeonggi-do, Republic of Korea
| | - Andrew Rennie
- School of Medicine, Florida State University, Tallahassee, FL, USA
| | - Junjian Huang
- Department of Interventional Radiology, University of Alabama Birmingham, Birmingham, AL, USA
| | - Junaid Raja
- Department of Interventional Radiology, University of Alabama Birmingham, Birmingham, AL, USA
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2
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Gan CC, Tan RY, Cheong MA, Pang SC, Tng RKA, Tan CW, Lee LH, Ng HJ, Tay KH, Chong TT, Tan CS. Efficacy and safety of low dose, weight-based subcutaneous enoxaparin protocol in recurrent arteriovenous access thrombosis. J Vasc Access 2023:11297298231194102. [PMID: 37726986 DOI: 10.1177/11297298231194102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND This study aims to evaluate the safety and efficacy of a short-term, low dose, weight-based subcutaneous enoxaparin protocol (SEP) in maintaining the patency of arteriovenous (AV) access with recurrent thrombosis. METHODS Prospective follow-up of 25 patients who presented to a tertiary institution with recurrent AV access thrombosis and treated with anticoagulation according to SEP following successful thrombectomy. Patency and safety outcomes of SEP were studied. RESULTS The participants were 66.4 ± 10.2 years old and predominantly male (60%) and of Chinese ethnicity (72%). The AV accesses had a median age of 1.4 (0.6, 5.6) years with 60% being non-autogenous arteriovenous access while 40% were autogenous arteriovenous access. Thrombolytic agents (urokinase (72%) or alteplase (28%)) were used in all procedures while adjunct thrombectomy device was used in only four procedures. The mean dose of enoxaparin was 36.0 ± 8.2 mg or 0.64 ± 0.1 mg/kg/day for a mean duration 30.0 days (Interquartile range: 27.5, 31.0). One patient developed minor bleeding episode. Kaplan-Meier analysis demonstrated that the mean thrombosis-free survival pre- versus post-SEP adoption was 27.3 (95% CI 17.9-36.7) versus 183.5 (95% CI 100.1-266.9) days (p < 0.001). After adjusting for the type of thrombolytic agent, use of adjunct thrombectomy device, cutting balloon, drug-coated balloon, and stent graft, SEP remained a significant factor associated with longer thrombosis-free patency (HR 0.166: 95% CI 0.070-0.392, p < 0.001). DISCUSSION SEP appears to be a feasible and safe thromboprophylaxis method to improve thrombosis-free patency for AV access with recurrent thrombosis.
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Affiliation(s)
- Chye Chung Gan
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke NUS Graduate Medical School, Singapore
| | - May Anne Cheong
- Duke NUS Graduate Medical School, Singapore
- Department of Hematology, Singapore General Hospital, Singapore
| | - Suh Chien Pang
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke NUS Graduate Medical School, Singapore
| | - Ren Kwang Alvin Tng
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke NUS Graduate Medical School, Singapore
| | - Chee Wooi Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke NUS Graduate Medical School, Singapore
| | - Lai Heng Lee
- Duke NUS Graduate Medical School, Singapore
- Department of Hematology, Singapore General Hospital, Singapore
| | - Heng Joo Ng
- Duke NUS Graduate Medical School, Singapore
- Department of Hematology, Singapore General Hospital, Singapore
| | - Kiang Hiong Tay
- Duke NUS Graduate Medical School, Singapore
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Tze Tec Chong
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke NUS Graduate Medical School, Singapore
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3
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Maßmann A, Hammer I, Ketteler M, Latus J. [Acute interventions-dialysis shunt recanalization]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:18-23. [PMID: 36443567 DOI: 10.1007/s00117-022-01089-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND An arteriovenous fistula is vital for patients who need regular hemodialysis. Continuous patency and sufficient functionality determine quality of life and associated morbidity and mortality of patients. PROBLEM Following successful hemodialysis shunt creation, intimal hyperplasia and consecutive thrombosis or complete occlusion may cause different types of shunt dysfunctionality or even critical failure. OBJECTIVE Immediate shunt recanalization and revision by using an endovascular-first approach is crucial for long-term survival of hemodialysis fistula. There are several mechanisms available for catheter-based thrombus removal to unmask the typically underlying shunt stenosis. METHODS Primary technical recanalization success rates are very similar for clot cleaning. Treatment of intimal hyperplasia is preferably addressed by using drug-coated balloon angioplasty to allow for increased shunt patency compared to plain old balloon angioplasty. Stents and stent grafts are only used for resistant or repeated short-term recurrence of severe stenosis. Finally, surgical revision has a classical role in case of repeated failure of endovascular measures.
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Affiliation(s)
- Alexander Maßmann
- Diagnostische & Interventionelle Radiologie und Nuklearmedizin, Robert-Bosch-Krankenhaus GmbH am Bosch Health Campus, Auerbachstr. 110, 70376, Stuttgart, Deutschland.
| | - Inga Hammer
- Allgemeine Innere Medizin und Nephrologie, Robert-Bosch-Krankenhaus GmbH am Bosch Health Campus, Stuttgart, Deutschland
| | - Markus Ketteler
- Allgemeine Innere Medizin und Nephrologie, Robert-Bosch-Krankenhaus GmbH am Bosch Health Campus, Stuttgart, Deutschland
- Altersmedizin und Rehabilitation, Robert-Bosch-Krankenhaus GmbH am Bosch Health Campus, Stuttgart, Deutschland
| | - Jörg Latus
- Allgemeine Innere Medizin und Nephrologie, Robert-Bosch-Krankenhaus GmbH am Bosch Health Campus, Stuttgart, Deutschland
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4
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Bogovic N, Doenecke A, Hart C, Lürken L, Heimerl S, Eissnert C, Schlitt HJ, Bitterer F. Covid19 vaccination-associated portal vein thrombosis-An interdisciplinary clinical challenge. Clin Res Hepatol Gastroenterol 2022; 46:101932. [PMID: 35504460 PMCID: PMC9055786 DOI: 10.1016/j.clinre.2022.101932] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/12/2022] [Accepted: 04/24/2022] [Indexed: 02/04/2023]
Abstract
Despite one of the largest vaccination campaigns in human history, the COVID-19 pandemic has not been yet defeated. More than 10 billion doses of COVID-19 vaccine have been administered worldwide. AstraZeneca's Vaxzevria (ChAdOx1 nCoV-19 / AZD1222) was approved as the first viral vector-based vaccine in the EU on 29 January 2021. Thromboembolic events are a rare complication of vaccination with ChAdOx1 nCoV-19 in the context of, now known as vaccine-induced immune thrombotic thrombocytopenia (VITT), with an incidence of 1.5-3 in 100,000 vaccinations. VITT is clinically as well as pathophysiologically comparable to heparin-induced thrombocytopenia. Illustrated by a fulminant patient case, a multidisciplinary step-by-step guideline was developed for the recognition, diagnosis, and management of patients with severe acute portosplanchic venous thrombosis with mesenteric ischemia due to vaccine-induced immunogenic thrombotic thrombocytopenia.
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Affiliation(s)
- Niklas Bogovic
- Department of Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Axel Doenecke
- Department of Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Christina Hart
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Lukas Lürken
- Department of Radiology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Susanne Heimerl
- Department of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Eissnert
- Department of Anaesthesia, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Hans J Schlitt
- Department of Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Florian Bitterer
- Department of Surgery, University Hospital Regensburg, 93053 Regensburg, Germany.
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5
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Bong TSH, Aw DKL, Cheng SC, Choke ETC, Tay JS. Cleaner XT Rotational Thrombectomy: An Efficacious Endovascular Technique for Salvage of Thrombosed Arteriovenous Access and a 12 Month Outcome Analysis. J Endovasc Ther 2022; 30:401-409. [DOI: 10.1177/15266028221083222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: This study aims to describe an efficacious method using Cleaner XT rotational thrombectomy with catheter-directed thrombolysis and drug-eluting balloon angioplasty for the salvage of thrombosed arteriovenous fistulae and grafts. Materials and Methods: Retrospective analysis of all patients with thrombosed hemodialysis accesses who underwent endovascular salvage using the Cleaner XT rotational thrombectomy system at a single institution between June 2019 and September 2020 was performed. Patency was presented as Kaplan-Meier survival curves, and regression analysis was performed to examine predictors of postintervention primary patency and assisted primary patency based on Cox proportional-hazards model. Results: Thirty-four patients with thrombosed accesses underwent Cleaner XT rotational thrombectomy between June 2019 and September 2020. Technical and clinical success were both 100%. Mean procedure time was 62 ± 20 minutes. Mean postintervention primary patency time was 152 ± 51 days; 30, 90, 180, and 365 day postintervention primary patency rates were 89%, 80%, 68%, and 56%, respectively. Mean postintervention-assisted primary patency time was 157 ± 59 days; 30, 90, 180, and 365 day postintervention-assisted primary patency rates were 91%, 82%, 71%, and 59%, and 180 and 365 day secondary patency rates were 97.2% and 94.4%, respectively. Conclusion: The Cleaner XT rotational thrombectomy device demonstrates excellent clinical and technical success rates, with good patency results at all time points up to 12 months postintervention.
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Affiliation(s)
| | | | | | | | - Jia Sheng Tay
- Department of Surgery, Sengkang General Hospital, Singapore
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6
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Almehmi A, Sheta M, Abaza M, Almehmi SE, El Khudari H, Shaikh A. Endovascular Management of Thrombosed Dialysis Vascular Circuits. Semin Intervent Radiol 2022; 39:14-22. [PMID: 35210728 PMCID: PMC8856780 DOI: 10.1055/s-0041-1740941] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A functional hemodialysis vascular access is the lifeline for patients with end-stage kidney disease and is considered a major determinant of survival and quality of life in this patient population. Hemodialysis therapy can be performed via arteriovenous fistulas, arteriovenous grafts, and central venous catheters (CVCs). Following dialysis vascular access creation, the interplay between several pathologic mechanisms can lead to vascular luminal obstruction due to neointimal hyperplasia with subsequent stenosis, stasis, and eventually access thrombosis. Restoration of the blood flow in the vascular access circuit via thrombectomy is crucial to avoid the use of CVCs and to prolong the life span of the vascular access conduits. The fundamental principles of thrombectomy center around removing the thrombus from the thrombosed access and treating the underlying culprit vascular stenosis. Several endovascular devices have been utilized to perform mechanical thrombectomy and have shown comparable outcomes. Standard angioplasty balloons remain the cornerstone for the treatment of stenotic vascular lesions. The utility of drug-coated balloons in dialysis vascular access remains unsettled due to conflicting results from randomized clinical trials. Stent grafts are used to treat resistant and recurrent stenotic lesions and to control extravasation from a ruptured vessel that is not controlled by conservative measures. Overall, endovascular thrombectomy is the preferred modality of treatment for the thrombosed dialysis vascular conduits.
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Affiliation(s)
- Ammar Almehmi
- Department of Radiology and Medicine, University of Alabama at Birmingham, Birmingham, Alabama,Address for correspondence Ammar Almehmi, MD Department of Radiology and Medicine, University of Alabama at BirminghamBirmingham, AL 35294
| | - Mohamed Sheta
- Department of Nephrology, University of Texas at Houston, Houston, Texas
| | - Masa Abaza
- Department of Biology, University of Alaska at Anchorage, Anchorage, Alaska
| | - Sloan E. Almehmi
- Department of Biology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Husam El Khudari
- Division of Interventional Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aisha Shaikh
- Renal Service, Memorial Sloan Kettering Cancer Center, New York, New York
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7
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Ates OF, Taydas O. Modified lyse and wait technique for the treatment of dialysis fistula thrombosis: Percutaneous thrombolytic therapy with a 27-G dental needle. Semin Dial 2021; 35:522-527. [PMID: 34963036 DOI: 10.1111/sdi.13047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The lyse and wait technique is a percutaneous endovascular technique in the treatment of thrombosed dialysis fistulas. In this study, our aim was to introduce a more easily applicable modification of the lyse and wait technique and present our results. METHODS A total of 84 patients (56 male; 66.6%), with a mean age of 61 years, were included in the study. The treatment was performed in patients presenting with dialysis fistula thrombosis no more than 1 week before the procedure, whose thrombosed segment length was less than 10 cm. A 27-G dental needle was inserted into the thrombosed segment under ultrasonography guidance, and 5 mg of alteplase was injected in a controlled manner. After about 6 to 12 h, the patients were taken to the angiography unit, and balloon angioplasty was performed. RESULTS The technical and clinical success of the procedure was 98.8%. Technical and clinical failure occurred in only one patient. The median primary patency duration was 13.5 months. None of the patients had major complications. At the end of 12 months, the primary patency rate was 66.6%, and the secondary patency rate was 80%. CONCLUSIONS Our technique has shown to have high technical and clinical success and patency.
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Affiliation(s)
- Omer Faruk Ates
- School of Medicine, Department of Radiology, Sakarya University, Sakarya, Turkey
| | - Onur Taydas
- School of Medicine, Department of Radiology, Sakarya University, Sakarya, Turkey
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8
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Application Value and Relevance Analysis of the Risk Evaluation System for Arteriovenous Fistula Puncture in Thrombosis after Puncture. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:6919979. [PMID: 34900199 PMCID: PMC8660209 DOI: 10.1155/2021/6919979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/18/2022]
Abstract
Objective To analyze the application value and relevance of risk evaluation system for arteriovenous fistula (AVF) puncture in thrombosis after puncture. Methods The clinical data of 180 patients treated with hemodialysis in the hemodialysis center of our hospital from November 2017 to November 2019 were retrospectively analyzed. After puncture, all patients received the digital subtraction angiography (DSA) examination, and based on whether they had AVF thrombosis, they were divided into the nonthrombosis group (n = 102) and thrombosis group (n = 78), and then, according to the parity of their admission numbers, the patients in the thrombosis group were subdivided into the study group (n = 39) and the reference group (n = 39), so as to analyze the risk factors of thrombosis after AVF puncture and the application value of the risk evaluation system for AVF puncture in preventing and treating thrombosis. Results Compared with the reference group after intervention, the study group had significantly higher mean internal fistula blood flow volume (P < 0.001) and significantly lower total incidence rate of vascular complications in fistulas (P < 0.05); according to the multifactor binary logistic regression analysis, it was found that diabetes, systolic blood pressure reduction, hemoglobin, low-density lipoprotein cholesterol (LDL-C), ultrafiltration rate, and elevation of blood phosphorus and platelet levels were the risk factors of thrombosis after AVF puncture in hemodialysis patients. Conclusion When risk factors of thrombosis are found in patients treated with hemodialysis, timely detection and intervention shall be applied in the early stage. Adopting the AVF puncture risk evaluation system has an extremely high application value in the clinic and is of important meaning in prolonging the service life of fistulas.
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9
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Ghidini F, De Corti F, Leon FF, Trojan D, Parolin M, Tognon C, Castagnetti M, Vidal E, Gamba P. Bench thrombolysis and "autotransplantation" as a rescue treatment for venous thrombosis after living-donor kidney transplantation. Pediatr Transplant 2021; 25:e14074. [PMID: 34159692 DOI: 10.1111/petr.14074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/06/2021] [Accepted: 06/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Allograft venous thrombosis is a severe complication after kidney transplantation (KT). Early diagnosis and prompt treatment are crucial in preserving the survival of the allograft. In this study, we aimed to describe an emergent strategy for the management of acute allograft venous thrombosis. CASE PRESENTATION A 4-year-old girl, weighing 13.5 kg, was diagnosed with bilateral congenital renal hypodysplasia, urogenital sinus and anorectal malformation. The patient was referred to our department for living-donor KT. Her mother was eligible as a donor, presenting a body weight ratio of 1:4.5. Thrombosis of the inferior vena cava (ICV) was also identified, without any predisposing factor for thrombophilia. KT was performed by an extraperitoneal approach without complications. Venous anastomosis required a human vascular graft sutured to the ICV, and renal artery was anastomosed to the aorta. On postoperative day (POD) 8, acute abdominal pain and hematuria led to the diagnosis of an allograft venous thrombosis. An emergent laparotomy was required to explant the allograft, followed by bench surgery. The allograft was irrigated with thrombolytic agents and lactated Ringer's solution and then after removing the venous vascular graft, it was reimplanted through vascular anastomosis with the ICV and aorta. The recovery of perfusion and function was good with diuresis since day 4 after re-surgery. At 2-year follow-up, the child presented normal allograft function with an estimated GFR of 65 ml/min/1.73 m2 . CONCLUSION According to our experience, explantation of the kidney allograft, followed by irrigation with thrombolytics in bench surgery, and reimplantation resulted in unexpected optimal outcomes in the case of allograft venous thrombosis.
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Affiliation(s)
- Filippo Ghidini
- Pediatric Urology, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy.,Pediatric Surgery, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy.,Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Federica De Corti
- Pediatric Surgery, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Francesco Fascetti Leon
- Pediatric Surgery, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | | | - Mattia Parolin
- Pediatric Nephrology Dialysis and Transplantation, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Costanza Tognon
- Pediatric Anesthesiology, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Marco Castagnetti
- Pediatric Urology, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy.,Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
| | - Enrico Vidal
- Division of Pediatrics, Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
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Maksimov AV, Gaĭsina ÉA, Feĭskhanov AK. [Complications of permanent vascular access for haemodialysis]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:165-174. [PMID: 35050263 DOI: 10.33529/angio2021411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Permanent vascular access is the basis of renal replacement therapy by the method of programmed haemodialysis, on whose stable functioning depends the life of patients with end-stage renal disease. At the present time, there is significant deficit of scientific and methodological Russian-language literature on this problem, with no Russian consensus documents concerned. This article is a review of the contemporary world literature dedicated to the problem of permanent vascular access, including currently in force European (2018) and North American (2019) guidelines for good clinical practice, also discussing the problems of strategy and tactics of creating a permanent vascular access, monitoring its dysfunction, pathophysiology of functioning of arteriovenous fistulas. Presented herein are unified approaches to diagnosis and treatment of thrombolytic and haemorrhagic complications associated with the access, as well as local infectious and non-infectious complications. Special attention is paid to indications for the operation and rational therapeutic decision-making.
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Affiliation(s)
- A V Maksimov
- Department of Vascular Surgery, Republican Clinical Hospital of the Ministry of Public Health of the Republic of Tatarstan, Kazan, Russia; Kazan State Medical Academy - Branch of the Russian Medical Academy of Continuous Professional Education under the RF Ministry of Public Health, Kazan, Russia
| | - É A Gaĭsina
- Department of Vascular Surgery, Republican Clinical Hospital of the Ministry of Public Health of the Republic of Tatarstan, Kazan, Russia
| | - A K Feĭskhanov
- Department of Vascular Surgery, Republican Clinical Hospital of the Ministry of Public Health of the Republic of Tatarstan, Kazan, Russia
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11
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Huan KWSJ, Tan CS, Chua D, Yap CJQ, Tan RY, Chong TT, Tang TY. The Cleaner XT™ Device as an Endovascular Adjunct for Pharmacomechanical Thrombolysis of Thrombosed Arteriovenous Fistulas and Grafts. Ann Vasc Dis 2020; 13:390-396. [PMID: 33391556 PMCID: PMC7758596 DOI: 10.3400/avd.oa.20-00046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: This paper documents our experience using the Cleaner XT™ device (Argon Medical Devices, Plano, TX, USA) for pharmacomechanical thrombolysis (PMT) of thrombosed haemodialysis arteriovenous grafts (AVG) and fistulas (AVF). Materials and Methods: This was a retrospective case series (n=17) over six months at Singapore General Hospital. We evaluated demographics, procedural data, technical and procedural success, patency rates and complications. Results: There were 8 (47%) males and the patients' mean age was 66 (± 5.7) years. The mean age of AVF/AVG was 1605 (± 1099) days. All procedures were performed under local anaesthetic. PMT was performed within a mean time of 40 (±34.3) hours from the presentation. Technical, clinical and procedural success was 15/17 (88%). The thrombolysis agents used were tissue plasminogen activator (52.9%) and urokinase (41.2%). Mean primary patency time was 114 (± 116) days, with a 65% 1-month and 47% 3-month primary patency rates. The mean secondary patency time was 155 (±132) days, with 76% one-month and 65% three-month secondary patency rates, respectively. AVF rupture occurred in 3/17 (18%) cases but did not involve loss of the access circuit. Conclusion: The Cleaner XT™ device is a safe, minimally invasive endovascular tool for PMT in thrombosed AVF/AVG, with relatively high success and low complication rates.
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Affiliation(s)
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Deborah Chua
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Charyl Jia Qi Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
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12
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Tan RY, Pang SC, Tng ARK, Ng HJ, Teh SP, Tan SG, Tang TY, Foo MWY, Gogna A, Chong TT, Tan CS. Effect of short-term low molecular weight heparin on patency following successful salvage of arteriovenous access with recurrent thrombosis. Nephrology (Carlton) 2020; 26:350-357. [PMID: 33207041 DOI: 10.1111/nep.13834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 11/01/2020] [Accepted: 11/11/2020] [Indexed: 11/26/2022]
Abstract
AIM This study aims to investigate the effect of low molecular weight heparin (LMWH) in maintaining the patency of arteriovenous (AV) access with recurrent thrombosis. METHODS Following successful thrombectomy, 66 patients with recurrent thrombosis were included in the study. The primary, assisted primary and secondary patency rates of patients who received LMWH (n = 24) were compared with those who did not receive anticoagulant (n = 42) using Kaplan-Meier analysis. Cox-regression analysis was performed to investigate potential predictors of patency rates. RESULTS The mean dose of enoxaparin used was 40 ± 13.1 mg or 0.74 ± 0.2 mg/kg daily for a median duration of 14 (IQR 7,28) days. The mean trough anti-Xa concentrations measured after two doses of LMWH was 0.17 ± 0.13 IU/mL. Kaplan-Meier analyses for mean primary, assisted primary and secondary patency rates of LMWH vs no anticoagulation groups were 149 (95% CI: 91 - 207) vs 87 (95% CI: 42-132) days (P < .006), 230 (95% CI: 142-320) vs 107 (95% CI: 62-150) days (P = .01) and 438 (299-579) vs 294 (95% CI: 197-392) days (P = .08) respectively. LMWH remained a significant protective predictor of primary (HR: 0.49; 95% CI: 0.25-0.86; P = .02) and assisted primary patency rates (HR: 0.51; 95% CI: 0.27-0.98; P = .04) after adjusting for patient age, access age, type of AV access, presence of peripheral vascular disease and haemoglobin levels. CONCLUSION LMWH may improve short and mid-term patency rates for AV accesses with recurrent thrombosis.
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Affiliation(s)
- Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Suh Chien Pang
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Heng Joo Ng
- Department of Haematology, Singapore General Hospital, Singapore
| | - Swee Ping Teh
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Seck Guan Tan
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | | | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
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13
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Zhang Z, Phang CC, Tan RY, Pang SC, Chandramohan S, Zhuang KD, Sulaiman MS, Tay KH, Chong TT, Tan CS. Does reducing radiation levels for procedures affect image quality and radiation to proceduralists? A double-blinded randomised study of two protocols. Clin Radiol 2020; 76:157.e1-157.e10. [PMID: 32993879 DOI: 10.1016/j.crad.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/01/2020] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the ultra-lose dose imaging protocol (ULDP), compared to the standard low-dose imaging protocol (LDP), which are used for haemodialysis access, in terms of radiation exposure and image quality. MATERIAL AND METHODS This was a single-centre, institutional review board-approved, prospective, double-blinded randomised controlled study to compare radiation exposure and image quality of the ULDP and LDP. Ten proceduralists, two radiographers, and 11 nurses were enrolled. Radiation exposure during 80 procedures (40 angioplasties and 40 thrombolysis) was recorded (direct radiation to patients from protocol report and scattered radiation to participants from the RaySafe i2 real-time dosimetry system). Baseline characteristics of procedure were recorded. Image quality was assessed subjectively using questionnaires based on the five-point Likert scale after each procedure. RESULTS Compared with LDP, the use of ULDP was associated with a significantly lower rate of radiation exposure to proceduralists, patients, and scrub nurses (0.506±0.430 versus 0.847±0.965 μSv/s, p=0.044; 0.571±1.284 versus 1.284±1.007 mGy/s, p<0.001; and 0.052±0.071 versus 0.141±0.185 μSv/s, p=0.005, respectively). No significant difference in image quality or duration of procedure was observed (all p values >0.05). CONCLUSION Compared with LDP, the use of ULDP was associated with a significantly lower rate of radiation exposure to proceduralists, patients, and scrub nurses without compromising the image quality or duration of procedure.
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Affiliation(s)
- Z Zhang
- Duke-NUS Medical School, National University of Singapore, 169857, Singapore.
| | - C C Phang
- Department of Renal Medicine, Singapore General Hospital, 169608, Singapore
| | - R Y Tan
- Department of Renal Medicine, Singapore General Hospital, 169608, Singapore
| | - S C Pang
- Department of Renal Medicine, Singapore General Hospital, 169608, Singapore
| | - S Chandramohan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, 169608, Singapore
| | - K D Zhuang
- Department of Vascular and Interventional Radiology, Singapore General Hospital, 169608, Singapore.
| | - M S Sulaiman
- Department of Radiology, Singapore General Hospital, 169608, Singapore
| | - K H Tay
- Department of Vascular and Interventional Radiology, Singapore General Hospital, 169608, Singapore
| | - T T Chong
- Department of Vascular Surgery, Singapore General Hospital, 169608, Singapore
| | - C S Tan
- Department of Renal Medicine, Singapore General Hospital, 169608, Singapore
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14
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Tan RY, Tan CW, Pang SC, Foo MWY, Tang TY, Gogna A, Chong TT, Tan CS. Study protocol of a pilot study on sirolimus-coated balloon angioplasty in salvaging clotted arteriovenous graft. CVIR Endovasc 2020; 3:34. [PMID: 32627114 PMCID: PMC7335758 DOI: 10.1186/s42155-020-00123-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/11/2020] [Indexed: 11/29/2022] Open
Abstract
Background In arteriovenous graft (AVG) for haemodialysis, the primary cause of failure is venous stenosis of the graft-vein junction from neointimal hyperplasia (NIH), resulting in thrombosis. While interventions to salvage clotted AVG are known to have high clinical success rates, long-term patency rates have been suboptimal. Drug-coated balloon (DCB) has been used to treat stenosed arteriovenous access in recent years with encouraging results but data on its effect in clotted AVG is unavailable. Methods This is an investigator-initiated, single-center, single-arm prospective pilot study to determine the safety and outcome of the sirolimus-coated balloon (SCB) in the salvage of thrombosed AVG. Twenty patients who undergo successful percutaneous thrombectomy will receive treatment with SCB at the graft vein junction. The patients will be followed-up for 6-months. The primary endpoint is the patency rates at 3-month while the secondary endpoints are the patency rates and the number of interventions needed to maintain patency at 6-month. Discussion Unremitting efforts have been made to prolong the patency of AV accesses over the years. DCB angioplasty combines mechanical and biological treatment for vascular stenosis. Sirolimus, being a cystostatic anti-proliferative agent, has been successfully used in coronary artery interventions. As the primary pathology of vascular stenosis in the dialysis circuit is neointimal hyperplasia, the use of sirolimus in balloon angioplasty may be effective. With this prospective study, we evaluate the efficacy and safety of SCB in patients with clotted AVG. Trial registration ClinicalTrials.gov Identifier: NCT03666208 on 11 September 2018.
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Affiliation(s)
- Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore.
| | - Chee Wooi Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Suh Chien Pang
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Marjorie Wai Yin Foo
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
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15
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Mendes TC, dos Reis Lívero FA, de Souza P, Gebara KS, Junior AG. Cellular and Molecular Mechanisms of Antithrombogenic Plants: A Narrative Review. Curr Pharm Des 2020; 26:176-190. [DOI: 10.2174/1381612825666191216125135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/02/2019] [Indexed: 02/08/2023]
Abstract
Heart attack, stroke, and deep vein thrombosis are among the conditions that alter blood coagulation
and are modulated by antithrombogenic drugs. Natural products are an important source of antithrombogenic
agents and have been considered remarkable alternatives with greater efficacy and usually with fewer side effects.
However, the efficacy and toxicity of many of these plants that are used in traditional medicine must be scientifically
tested. Despite a large number of published articles that report that plants or plant-derived components may
act as antithrombogenic agents, few studies have investigated the mechanism of action of medicinal plants. This
review presents the current knowledge about the major cellular and molecular mechanisms of antithrombogenic
plants and their main components. Many well-established mechanisms (e.g., platelet aggregation, coagulation
factors, and thrombolysis) are related to the antithrombogenic activity of many natural products. However, the
central pathways that are responsible for their activity remain unclear. Further studies are needed to clarify the
central role of each of these pathways in the pleiotropic response to these agents.
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Affiliation(s)
- Tatiane C. Mendes
- Laboratory of Preclinical Research of Natural Products, Graduate Program in Animal Science with Emphasis on Bioactive Products, Paranaense University, Umuarama, PR, Brazil
| | - Francislaine Aparecida dos Reis Lívero
- Laboratory of Preclinical Research of Natural Products, Graduate Program in Animal Science with Emphasis on Bioactive Products, Paranaense University, Umuarama, PR, Brazil
| | - Priscila de Souza
- Graduate Program in Pharmaceutical Sciences, Nucleus of Chemical- Pharmaceutical Investigations (NIQFAR), University of Vale do Itajaí, Itajaí, SC, Brazil
| | - Karimi S. Gebara
- Laboratory of Electrophysiology and Cardiovascular Pharmacology, Faculty of Health Sciences, Federal University of Grande Dourados, Dourados, MS, Brazil
| | - Arquimedes Gasparotto Junior
- Laboratory of Electrophysiology and Cardiovascular Pharmacology, Faculty of Health Sciences, Federal University of Grande Dourados, Dourados, MS, Brazil
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16
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Tan RY, Pang SC, Teh SP, Ng CY, Lee KG, Foo MWY, Gogna A, Chong TT, Tan CS. Outcomes of endovascular salvage of clotted arteriovenous access and predictors of patency after thrombectomy. J Vasc Surg 2019; 71:1333-1339. [PMID: 31492611 DOI: 10.1016/j.jvs.2019.07.056] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study aimed to report the outcomes of endovascular salvage of clotted arteriovenous (AV) accesses and to determine potential predictors of poor patency rates after thrombectomy. METHODS Records of hemodialysis patients who underwent endovascular salvage of clotted AV access were reviewed retrospectively. Technical and clinical success rates, complication rates, and 3- and 6-month patency rates were determined. Multivariate analysis was performed to determine the predictors of patency after thrombectomy. RESULTS A total of 294 patients underwent endovascular salvage of clotted AV access during the study period; 156 patients had arteriovenous fistula, whereas the remaining 138 were arteriovenous grafts (AVGs). The technical and clinical success rates were 96.3% and 93.2%; the major and minor complication rates were 0.7% and 9.9%. Post-thrombectomy primary, assisted primary, and secondary patency rates were 62.9%, 76.2%, and 77.6% at 3 months and 43.9%, 59.5%, and 61.6% at 6 months. The patency rates were significantly better for arteriovenous fistula than for AVG except for 6-month assisted primary and secondary patency. Multivariate Cox regression analysis showed that prior thrombosis within 90 days was significantly associated with loss of primary patency (hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.21-2.98; P < .01), assisted primary patency (HR, 2.42; 95% CI, 1.42-4.13; P < .01), and secondary patency (HR, 2.52; 95% CI, 1.40-4.53; P < .01). Having an AVG was also negatively associated with primary patency. CONCLUSIONS Most clotted AV accesses can be salvaged by endovascular technique. Recurrent thrombosis within 90 days is associated with poor short- and long-term patency even after successful endovascular reinterventions.
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Affiliation(s)
- Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore.
| | - Suh Chien Pang
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Swee Ping Teh
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Chee Yong Ng
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Kian Guan Lee
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
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