Effects of upper-extremity vascular access creation on cardiac events in patients undergoing coronary artery bypass grafting

Impact of coronary-subclavian steal after surgical myocardial revascularization with internal thoracic artery in chronic hemodialysis patients: A meta-analysis

Patients in hemodialysis with an arm arteriovenous fistula undergoing coronary artery bypass grafting (CABG) with an internal thoracic artery have been reported to suffer from coronary-subclavian steal (CSS) during dialysis session. However, its occurrence is still debated. A systematic literature review was performed to identify all studies investigating the occurrence of a CSS event in this subset of patients. The primary endpoint was the analysis of CSS and the following early and late survival outcomes. Independent determinants of CSS and the impact of the distance between the arteriovenous fistula (upper arm vs forearm) and the ipsilateral internal thoracic artery graft on CSS events and mortality were studied. Early and late survival outcomes were analyzed by comparing ipsilateral versus contralateral arteriovenous fistula. Of the 1,383 retrieved articles, 10 were included (n = 643 patients). The pooled event rate of CSS was 6.46% [95%CI=2.10-18.15], while of symptomatic CSS incidence was 3.99% [95%CI=0.95-15.25]. No survival differences were noted when comparing ipsilateral to contralateral arteriovenous fistula-internal thoracic artery combinations. On meta-regression, the upper arm was associated with more CSS events, while the forearm to lower late mortality rates. Independently from arteriovenous fistula-internal thoracic artery combination, CSS was not associated to higher mortality rates. Particular attention is warranted when selecting the type of conduits for CABG in patients with an arteriovenous fistula or if highly expected to need one in the near future after surgery. A contralateral arteriovenous fistula-internal thoracic artery combination is preferable. If this is not possible, a forearm arteriovenous fistula position should be preferred.

Coronary-subclavian steal syndrome causing myocardial infarction after arteriovenous fistula creation: a case report

Coronary subclavian steal syndrome (CSSS) caused by left subclavian artery (LSA) stenosis is a rare cause of myocardial infarction in patients having coronary artery bypass grafting (CABG), and it has also been observed after an arteriovenous fistula (AVF) was made. A 79-year-old woman who had undergone CABG years earlier and an AVF creation 1 month before experienced a non-ST-elevation myocardial infarction (NSTEMI). While selective catheterization of the left internal thoracic artery graft was impossible, a computed tomography scanner showed patency of all bypasses and proximal subocclusive LSA stenosis, and the digital blood pressure measurements objectified a haemodialysis-induced distal ischaemia. LSA's angioplasty and covered stent placement were successfully performed, resulting in symptom remission. A CSSS-induced NSTEMI due to a LSA stenosis aggravated by a homolateral AVF several years after CABG has been documented only infrequently. If vascular access is required in the presence of CSSS risk factors, the contralateral upper limb should be preferred.

Outcomes of arteriovenous access among cancer patients requiring chronic haemodialysis

Background

There are limited data focusing specifically on the types of arteriovenous (AV) access used and outcomes of AV access among cancer patients as a consequence of cancer. We aimed to describe outcomes of AV access among cancer patients requiring chronic haemodialysis, and also to compare outcomes between patients with and without cancer.

Methods

In this single-centre, retrospective, observational cohort study, 84 patients diagnosed with cancer before AV access placement were included; we analysed outcomes of AV access among these patients and compared these outcomes with our previous results. The study endpoints were AV access patency and early failure, defined as AV access abandonment within 12 months after AV access placement.

Results

Various cancer types, stages, and treatments were identified in our analysis. Autologous arteriovenous fistulas (AVFs) were used for 92.9% of this study population. Using our previous results for comparison, we found no significant difference in death-censored primary (P = 0.546) and secondary (P = 0.266) patency of AV access between patients with and without cancer; however, the rate of early AVF failure was statistically significantly higher among cancer patients (25.6% vs 13.9%; P = 0.008), and the most common cause of AVF failure was patient death. The rate of early failure was significantly higher among patients with advanced-stage cancer (59.1%) than among those with early-stage cancer (12.9%) (P <  0.001).

Conclusions

Although AV access patency rates were similar among patients with and without cancer in the death-censored analysis, cancer patients were more prone to early AVF failure, mainly due to cancer-associated deaths, and this consideration needs to be carefully balanced against individual patients’ life expectancies, according to cancer type and stage.

Effects of patient age on patency of chronic hemodialysis vascular access

BACKGROUND

In this single-center, retrospective observational study, we assessed the long-term patency of vascular access (VA) after first VA placement to uncover independent risk factors associated with VA patency in Asian hemodialysis (HD) patients stratified by age. We also investigated factors associated with VA patency among older HD patients according to the type of VA in the overall study population.

METHODS

The study period was from January 2011 to December 2013. A total of 651 chronic HD patients with confirmed first upper-extremity VA placement were enrolled, and their records were analyzed retrospectively. A total of 445 patients (68.4%) made up the nonelderly group (< 65 years), and 206 patients (31.6%) were in the elderly group (≥ 65 years). Study outcomes were defined as primary or secondary VA patency.

RESULTS

Autologous arteriovenous fistula (AVF) was more common in the nonelderly group (P <  0.01). Kaplan-Meier curve survival analysis indicated that primary patency was longer in the nonelderly group (P <  0.01); secondary patency, however, was similar between groups (P = 0.37). The multivariate analysis of factors associated with primary VA patency revealed that increased age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P <  0.01) was associated with shorter primary patency, and AVF (HR, 0.38; 95% CI, 0.28-0.51; P <  0.01) was associated with longer primary patency. AVF (HR, 0.57; 95% CI, 0.37-0.87; P = 0.010) and diabetes mellitus (HR, 1.56; 95% CI, 1.07-2.29; P = 0.02) were independently associated with longer and shorter secondary patency periods, respectively; however, increased age was not a risk factor for decreased secondary patency.

CONCLUSIONS

Increased age was associated with shorter primary patency but not secondary patency, whereas AVF placement was associated with longer primary and secondary patency. Considering the similar rates of secondary patency between groups and the superior patency of AVF compared to arteriovenous graft, a fistula-first strategy should be applied to appropriate older patients.

Comparison of outcomes between type 2 diabetic and non-diabetic incident hemodialysis patients with functioning arteriovenous fistulas

This study compared clinical outcomes of patient survival and arteriovenous fistula (AVF) patency between incident hemodialysis patients with and without type 2 diabetes mellitus (T2DM).Between January 2011 and December 2013, 384 consecutive incident hemodialysis patients with confirmed first upper-extremity AVF placement were divided into a T2DM group (n = 180, 46.9%) and a non-DM group (n = 204, 53.1%) and analyzed retrospectively. The primary outcome was all-cause mortality, and secondary outcome was AVF patency.Patients in the T2DM group had a higher prevalence of hypertension (P = .02), smoking (P < .01), cardiovascular disease (P < .01), history of cerebrovascular accident (CVA) (P < .01), and peripheral arterial occlusive disease (P < .01) than those in the non-DM group. On Kaplan-Meier survival analysis, the overall survival and AVF patency rates were significantly higher in the non-DM group relative to the T2DM group (both P < .01). In the adjusted model, older age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.02-1.06; P < .01), T2DM (HR, 1.76; 95% CI, 1.12-2.77; P = .014), and history of CVA (HR, 1.76; 95% CI, 1.04-2.98; P = .04) were significantly associated with an increased risk of mortality. Older age and T2DM were independently associated with decreased primary (HR, 1.03; 95% CI, 1.02-1.04; P < .01, HR, 1.69; 95% CI, 1.22-2.33; P < .01, respectively) and secondary (HR, 1.03; 95% CI, 1.01-1.04; P < .01, HR, 2.07; 95% CI, 1.42-3.00; P < .01, respectively) AVF patency during follow-up.Compared with patients in the non-DM group, patients in the T2DM group had a higher mortality rate and worse AVF patency rates.

Long-Term Outcomes in Coronary Artery Bypass Graft Patients Using Internal Thoracic Artery with Ipsilateral Arteriovenous Shunt for Hemodialysis

Background

The goal of this study was to evaluate the long-term results of coronary artery bypass grafting (CABG) using internal thoracic artery (ITA) grafts in hemodialysis (HD) patients with arteriovenous (AV) fistulae or AV grafts involving the ipsilateral or contralateral brachial artery or radial artery.

Methods

From March 2007 to May 2017, 76 end-stage renal disease (ESRD) patients with an upper limb AV fistula or graft for HD underwent CABG at a single center. Group A included 23 patients who underwent CABG using an ITA graft ipsilateral to the AV vascular access (AVVA); Group B included 22 patients who underwent CABG using a contralateral ITA with AVVA; and Group C included 29 patients who underwent CABG with AVVA without the use of an ITA graft. The primary end-point was death from any cause.

Results

The average follow-up period was 34.4 ± 26.9 months. Death from any cause occurred in 6 (26.09%) patients in Group A, 8 (36.36%) patients in Group B, and 17 (58.62%) patients in Group C (log-rank p = 0.04). There was no significant difference in death rate between Groups A and B. The risk of death was lower in the patients with CABG using an ITA graft (ITA CABG) compared to the patients without ITA CABG [HR 0.41 (95% CI, 0.20-0.84), p = 0.015].

Conclusions

The HD patients who underwent CABG with an ipsilateral location of the ITA and AVVA did not have an increased risk of death compared to the patients who underwent CABG with a contralateral location of the ITA and AVVA. In addition, the use of ITA in CABG resulted in better outcomes in the HD patients.

Patency rates of arteriovenous fistulas created before versus after hemodialysis initiation

In an incident hemodialysis (HD) population, we aimed to investigate whether arteriovenous fistula (AVF) creation before HD initiation was associated with improved AVF patency compared with AVF creation from a central venous catheter (CVC), and also to compare patient survival between these patients. Between January 2011 and December 2013, 524 incident HD patients with identified first predialysis vascular access with an AVF (pre-HD group, n = 191) or an AVF from a CVC (on-HD group, n = 333) were included and analyzed retrospectively. The study outcome was defined as AVF patency and all-cause mortality (time to death). On Kaplan-Meier survival analysis, primary and secondary AVF patency rates did not differ significantly between the two groups (P = 0.812 and P = 0.586, respectively), although the overall survival rate was significantly higher in the pre-HD group compared with the on-HD group (P = 0.013). On multivariate analysis, well-known patient factors were associated with decreased primary (older age and diabetes mellitus [DM]) and secondary (DM and peripheral arterial occlusive disease) AVF patency, whereas use of a CVC as the initial predialysis access (hazard ratios, 1.84; 95% confidence intervals, 1.20-2.75; P = 0.005) was significantly associated with worse survival in addition to well-known patient factors (older age, diabetes mellitus, and peripheral arterial occlusive disease). Worse survival in the on-HD group was likely confounded by selection bias because of the retrospective nature of our study. Therefore, the observed lower mortality associated with AVF creation before HD initiation is not fully attributable to CVC use, but rather, affected by other patient-level prognostic factors. There were no CVC-related complications in the pre-HD group, whereas 10.2% of CVC-related complications were noted in the on-HD group. In conclusion, among incident HD patients, compared with patients who underwent creation of an AVF from a CVC, initial AVF creation showed similar primary and secondary AVF patency rates, but lower mortality risk. We also observed that an initial CVC use was an independent risk factor associated with worse survival. A fistula-first strategy might be the best option for incident HD patients who are good candidates for AVF creation.

Effects of EDC-PEI heparinization on allogeneic vascular antigens and inflammation levels via a rat abdominal aorta transplantation model

The objective of this study was to investigate the possibility of increasing the remote patency rate of allogeneic vessel transplantation through studying the effects of N-ethyl-N-(3-dimethylaminopropyl)-carbodiimide and polyethyleneimine (EDC-PEI) heparinization on allogeneic vascular antigens and inflammation levels. Forty rats were randomly divided into the control group, the EDC group, the PEI group and the EDC-PEI group. The rat abdominal aorta was used as the object of study, and the transplanted blood vessels were pretreated with EDC as the water-soluble cross-linking agent and PEI as the heparin-coated carrier. A rat abdominal aorta allogeneic transplantation model was established. Ultrasonic examination was used for observation of patency of proximal and distal anastomosis in each group. The tissue repair after abdominal aorta transplantation in each group was examined by H&E staining. The biomechanics, denaturation temperature and blasting strength of each group were compared. The levels of IL-1, IL-6 and TNF-α in serum of rats were measured by ELISA method, and the expression of MHC-II and α-GAL antigens in blood vessels were detected by immunohistochemistry. There were different degrees of thickening and inflammatory cell aggregation in the abdominal aorta of rats in the control, EDC and PEI groups, but there was no obvious lesion in the EDC-PEI group. Compared with the four groups, the mechanical characteristics of the EDC group decreased significantly, and the stenosis rate of anastomotic stoma in the EDC group was higher than that in the EDC-PEI and PEI groups (P<0.05). The denaturation temperature of the PEI group was lower than that of the EDC and EDC-PEI groups (P<0.05). The mechanical property and vascular bursting strength in the EDC-PEI group were similar to those in the control group. At the same time, it has more significant advantages than the other three groups in removing the vascular antigens MHC-II and α-GAL and reducing the level of inflammatory reaction, thus increasing the remote patency rate of allogeneic vascular transplantation. The inflammatory response and vascular antigenicity after transplantation are effectively reduced via the rat abdominal aorta transplantation model treated with allogeneic EDC-PEI heparinization, which has a higher remote patency rate.

Impact of transvenous cardiac implantable electronic devices in chronic hemodialysis patients: a single-center, observational comparative study

Background

We investigated the impact of a transvenous cardiac implantable electronic device (CIED) placement on outcomes and arteriovenous vascular access (VA) patency among chronic hemodialysis patients.

Methods

This is a single-center, observational comparative study between chronic hemodialysis patients with ipsilateral and contralateral CIED and VA. Forty-two consecutive patients who underwent both CIED placement and upper-extremity VA for hemodialysis, regardless of the sequence and time interval between these 2 procedures, were identified between January 2001 and December 2017. Patients with ipsilateral (n = 22, 52%, the ipsilateral group) and contralateral (n = 20, 48%, the contralateral group) CIED and VA were compared retrospectively; the primary outcome was any-cause mortality and cardiac mortality or the composite of any systemic complications, defined as central venous stenosis or occlusion, any device infections or tricuspid regurgitation; the secondary outcome was CIED or VA malfunction.

Results

During the median follow-up period of 101 months, primary outcome incidence was significantly higher in the ipsilateral group than the contralateral group (73% vs 40%, P = 0.03), although the incidences of any-cause mortality (P = 0.28) and cardiac mortality (P > 0.99) were similar between the groups. Secondary outcome incidence did not differ significantly between the 2 groups (55% vs 30%, P = 0.36). Kaplan–Meier survival analysis revealed similar primary and secondary VA patency rates in both groups. On subgroup analysis, patients with upper arm VA had similar primary and secondary patency to those with forearm VA.

Conclusions

Despite some notable limitations of the study, the retrospective study design and small sample size, we found that the any-cause mortality incidence and VA patency did not differ between the 2 groups, but primary outcome incidence was significantly higher among patients with ipsilateral CIED and VA.