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Stove C, Kingsmore DB, Stevenson KS, Thomson PC, Nath A, Kasthuri R. The impact of stent-graft sizing on venous stenosis re-intervention and arteriovenous graft patency: Free-floating stent outflow is associated with improved outcomes. J Vasc Access 2024; 25:834-842. [PMID: 36428293 DOI: 10.1177/11297298221137152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Early cannulation arteriovenous grafts (ecAVG) for dialysis access are limited by reintervention for venous stenosis (VS) despite their good initial patency. Whilst stent-grafts (SG) have shown promise, the optimal sizing is unclear. Therefore, this study aims to determine if outflow vein diameter, SG diameter or these relative to each other (V:Sr) alters outcomes, and if so, which is more important. METHODS Retrospective analysis was performed of Gore® Acuseal® ecAVGs with VS treated with Gore® Viabahn® SG over a 7-year period. Primary patency (PP), time to thrombosis and functional patency were analysed by SG length/diameter, vein diameter and V:Sr. RESULTS We identified 114 ecAVGs with median follow-up 492 days (IQR 189-770). SG length and diameter did not correlate with PP, however, there was a significant relationship between vein diameter and PP (RR = 0.901 (0.832-0.975), p = 0.01) and between V:Sr and PP (RR = 0.462 (0.255-0.838), x2 = 5.866, p = 0.0015). The optimal V:Sr was ⩾1.4 (i.e. vein diameter at least 40% greater than the stent-graft; or 'free-floating' stent outflow) (RR = 2.759 (1.670-4.558), p < 0.001), translating to a difference in median PP of 252 versus 496 days (IQR: 188-316; 322-670). On multivariate analysis, absolute vein diameter lost significance, whilst V:Sr remained an independently significant predictor of PP (RR = 3.247 (1.560-6.759), p = 0.02). CONCLUSIONS Placement of the SG outflow into a relatively larger segment of vein was associated with a significant increase in PP independent of the absolute vein diameter. This suggests that larger calibre SG which are apposed to the vein wall are not required for optimal primary patency, and indeed should be actively avoided. Instead, a 'free-floating' stent outflow which is undersized relative to the recipient vein (whilst maintaining a minimum anchoring calibre) is recommended where possible. This should be considered during intervention and may require selection of longer devices, where practical, to bring the stent outflow into a larger vein segment. LEVEL OF EVIDENCE Level 3a, Non-randomised controlled cohort/follow-up study.
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Affiliation(s)
- Callum Stove
- Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - David B Kingsmore
- Vascular and Endovascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Karen S Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter C Thomson
- Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alex Nath
- Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
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Kingsmore DB, Edgar B, Aitken E, Calder F, Franchin M, Geddes C, Inston N, Jackson A, Jones RG, Karydis N, Kasthuri R, Mestres G, Papadakis G, Sivaprakasam R, Stephens M, Stevenson K, Stove C, Szabo L, Thomson PC, Tozzi M, White RD. Quality assurance in surgical trials of arteriovenous grafts for haemodialysis: A systematic review, a narrative exploration and expert recommendations. J Vasc Access 2024:11297298241236521. [PMID: 38501338 DOI: 10.1177/11297298241236521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Introducing new procedures and challenging established paradigms requires well-designed randomised controlled trials (RCT). However, RCT in surgery present unique challenges with much of treatment tailored to the individual patient circumstances, refined by experience and limited by organisational factors. There has been considerable debate over the outcomes of arteriovenous grafts (AVG) compared to AVF, but any differences may reflect differing practice and potential variability. It is essential, therefore, when considering an RCT of a novel surgical procedure or device that quality assurance (QA) is defined for both the new approach and the comparator. The aim of this systematic review was to evaluate the QA standards performed in RCT of AVG using a multi-national, multi-disciplinary approach and propose an approach for future RCT. METHOD The methods of this have been previously registered (PROSPERO: CRD420234284280) and published. In summary, a four-stage review was performed: identification of RCT of AVG, initial review, multidisciplinary appraisal of QA methods and reconciliation. QA measures were sought in four areas - generic, credentialing, standardisation and monitoring, with data abstracted by a multi-national, multi-speciality review body. RESULTS QA in RCT involving AVG in all four domains is highly variable, often sub-optimally described and has not improved over the past three decades. Few RCT established or defined a pre-RCT level of experience, none documented a pre-trial education programme, or had minimal standards of peri-operative management, no study had a defined pre-trial monitoring programme, and none assessed technical performance. CONCLUSION QA in RCT is a relatively new area that is expanding to ensure evidence is reliable and reproducible. This review demonstrates that QA has not previously been detailed, but can be measured in surgical RCT of vascular access, and that a four-domain approach can easily be implemented into future RCT.
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Affiliation(s)
- David B Kingsmore
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Ben Edgar
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Emma Aitken
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Francis Calder
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marco Franchin
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | - Colin Geddes
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nick Inston
- Renal and Transplant Surgery, University Hospital Birmingham, Birmingham, UK
| | - Andrew Jackson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rob G Jones
- Interventional Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Nikolaos Karydis
- Department of Renal and Transplant Surgery, University of Athens, Athens, Greece
| | - Ram Kasthuri
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Gaspar Mestres
- Department of Vascular Surgery, University of Barcelona, Barcelona, Spain
| | - Georgios Papadakis
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Mike Stephens
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Karen Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Callum Stove
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Lazslo Szabo
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Peter C Thomson
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Matteo Tozzi
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | - Richard D White
- Department of Interventional Radiology, University Hospital of Wales, Cardiff, UK
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Haslam P, McCafferty I, Lakshminarayan R, Kasthuri R, Johnston M, Hamady M. Physician associates in interventional radiology: a worrying paradigm. Clin Radiol 2024; 79:161-162. [PMID: 38142139 DOI: 10.1016/j.crad.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 12/25/2023]
Affiliation(s)
- P Haslam
- Interventional Radiology, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK.
| | - I McCafferty
- Interventional Radiology, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - R Lakshminarayan
- Interventional Radiology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - R Kasthuri
- Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - M Johnston
- Brighton and Sussex Medical School and University Hospitals, Sussex, UK
| | - M Hamady
- Department of Surgery and Cancer, Imperial College, London, UK
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Edgar B, Pearson R, Kasthuri R, Gillis K, Geddes C, Rostron M, Brady A, Hussey K, Roditi G, Delles C, McCallum L, Mark P, Kingsmore D. Correction: The impact of renal artery stenting on therapeutic aims. J Hum Hypertens 2024; 38:191. [PMID: 38228762 PMCID: PMC10844090 DOI: 10.1038/s41371-024-00893-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Ben Edgar
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK.
| | - Robert Pearson
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Keith Gillis
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Maggie Rostron
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Adrian Brady
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Keith Hussey
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Giles Roditi
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Christian Delles
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Linsay McCallum
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Patrick Mark
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - David Kingsmore
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
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Edgar B, Jones C, Aitken E, Stevenson K, Jackson A, Gaianu L, Thomson P, Kasthuri R, Stove C, Kingsmore D. What are the observed procedural costs of vascular access surgery? Protocol for a systematic review. BMJ Open 2024; 14:e079773. [PMID: 38272545 PMCID: PMC10824010 DOI: 10.1136/bmjopen-2023-079773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/09/2024] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION A central component in the introduction of a novel surgical procedure or technique is an evaluation of its cost efficiency when compared with a benchmark standard of care. Accurate assessment of costs is thus essential in ensuring appropriate allocation of resources within a healthcare system. The treatment of kidney failure requires a significant volume of resources, and vascular access provision is the main modifiable cost. The costs of providing this service are obscured by generic NHS reference costs, which lack adequate granularity to allow meaningful comparisons between treatments. The aim of this systematic review will be to assess the reporting of procedural costs in all published economic analyses of vascular access surgery and perform a comparison of the reported procedural costs involved in arteriovenous fistula (AVF) and arteriovenous graft (AVG) creation. This will provide an estimate as to the accuracy of the NHS reference costs in this field. METHODS AND ANALYSIS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines will be followed. A systematic search will be performed of the MEDLINE, Embase and Cochrane databases to identify full-text economic analyses of vascular access for haemodialysis in which the procedural cost of AVF or AVG creation is reported. Publications in English from 1 January 2000 to 30 August 2023, will be eligible for inclusion. Studies will be selected by title and abstract review, followed by a full-text review using inclusion and exclusion criteria. Studies not reporting the procedural costs of surgery will be excluded. Data collected will pertain to procedural costs of AVF and AVG creation. Costs will be adjusted to a common currency using a gross domestic product (GDP) deflator index and conversion rates based on purchasing power parities for GDP. Comparison with NHS reference costs will indicate their reliability for use in future economic analyses in this field. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER CRD42023458779.
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Affiliation(s)
- Ben Edgar
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Catrin Jones
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Emma Aitken
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Karen Stevenson
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Andrew Jackson
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Lucian Gaianu
- Independent Health Economist, Healthonomics UK Ltd, Reading, UK
| | - Peter Thomson
- Department of Renal Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Callum Stove
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - David Kingsmore
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
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Pisano U, Stevenson K, Kasthuri R, Kingsmore D. Cephalic arch stenosis: an analysis of outcome by type of first intervention. CVIR Endovasc 2024; 7:13. [PMID: 38240913 PMCID: PMC10798936 DOI: 10.1186/s42155-023-00424-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/21/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Cephalic arch stenoses (CAS) occur in near 70% of elbow arteriovenous fistulas. Percutaneous transluminal angioplasty (PTA) remains first-line treatment despite documented stent-grafts (SG) efficacy. The study aim is to report long-term outcomes based on initial treatment of CAS. METHODS Retrospective review of 12-year data in single tertiary centre. Outcomes included technical success, rupture rate, primary patency (PP), dialysis performance; categorical variables assessed via χ2 or Fisher's; nonparametric tests used for skewed data. Kaplan-Meier analysis used for PP and cumulative patency. Cox proportional hazard regression model to assess explanatory variables in PP. RESULTS One hundred one brachio- and radiocephalic fistulas with CAS were included. SG as first intervention had higher success than PTA (85% vs 61%, p = 0.003). Rupture occurred in 9/85 (10.6%) PTA vs 0% in SG (p = 0.046). In a subgroup with poor urea reduction rate (URR), both PTA and SG improved dialysis performance post-intervention (p = 0.002). SG demonstrated better PP than PTA (79,73,60% patency at 3, 6, 9 months; versus 71,51,47%; p = 0.195) and cumulative patency (73,61,61% at 1, 2, 3 years; versus 60,34,26%; p < 0.001). Of the variables analyzed, technical success of PTA was the only discriminating factor (coeff.-1.01; RR 35%, p = 0.035). Accesses that underwent secondary stenting performed better than primarily stented CAS (p = 0.01). CONCLUSIONS SG superiority is confirmed in CAS, particularly when angioplasty is unsuccessful. While PTA has short-lived benefits, it can improve dialysis performance. Other than higher success rate, primary CAS stenting did not have advantages compared to post-PTA stenting in our study. Other factors related to inflow, outflow, conduit characteristics are presumed to be involved in access longevity.
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Affiliation(s)
- Umberto Pisano
- Radiology Department, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Karen Stevenson
- Renal Transplant Surgery, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Ram Kasthuri
- Radiology Department, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - David Kingsmore
- Renal Transplant Surgery, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK
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7
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Kingsmore DB, Stevenson KS, Edgar B, Aitken E, Jackson A, Isaak A, Richarz S, Bainbridge L, Stove C, Kasthuri R, Thomson PC. Early-cannulation arteriovenous grafts: Multidisciplinary learning is essential to optimize outcomes. J Vasc Access 2023:11297298231212758. [PMID: 37997147 DOI: 10.1177/11297298231212758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND It is likely that there will be an increasing role for early-cannulation arteriovenous grafts (ecAVG) with a wider recognition of the need to tailor vascular access to avoid futile procedures and unnecessary TCVC. However, experience of these products is not common and limited to early surgical adopters, with little information on the systemic changes and multi-disciplinary care needed to optimize outcomes. The aim of this study was to report the impact of a multi-disciplinary approach on quantifiable outcomes. METHODS A retrospective analysis of a prospectively maintained database of 295 ecAVG implanted over an 8-year time-period was performed. Indicative outcomes were chosen to reflect nephrology (patient selection), nursing care (cannulation complications of infection and pseudoaneurysm) and radiology (thrombosis) on cumulative impact (functional patency) over three distinct time periods. RESULTS The incidence of ecAVG increased 10-fold over the three time periods. The use of ecAVG changed significantly from salvage tertiary access to TCVC avoidance and salvage of existing AVF. Nursing complications reduced markedly with significantly fewer over-cannulation episodes and pseudo-aneurysms. With an improved pro-active surveillance programme, the time to first thrombosis doubled and the risk of thrombosis halved. Ultimately this resulted in significantly improved functional patency with a risk of ecAVG loss less than one-third by the last time-period. CONCLUSIONS All aspects of ecAVG use require scrutiny and critical appraisal. Failure or success is not simply achieved by performing good technical surgery with an efficacious product, but by the care taken across a wide range of elements spanning case selection, implantation, use and maintenance.
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Affiliation(s)
- David B Kingsmore
- Department of Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Karen S Stevenson
- Department of Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ben Edgar
- Department of Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Emma Aitken
- Department of Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Andrew Jackson
- Department of Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Andrej Isaak
- Department of Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- Department of Vascular and Endovascular Surgery, University Hospital, Aarau-Basel, Switzerland
| | - Sabine Richarz
- Department of Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- Department of Vascular and Endovascular Surgery, University Hospital, Aarau-Basel, Switzerland
| | - Leigh Bainbridge
- Department of Vascular Access, Queen Elizabeth University Hospital, Glasgow, UK
| | - Callum Stove
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter C Thomson
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
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Edgar B, Kingsmore DB, Aitken E, Calder F, Franchin M, Geddes C, Inston N, Jackson A, Jones RG, Karydis N, Kasthuri R, Mestres G, Papadakis G, Sivaprakasam R, Stephens M, Stevenson K, Stove C, Szabo L, Thomson P, Tozzi M, White RD. Quality assurance in surgical trials of arteriovenous grafts for haemodialysis: protocol for a systematic review. BMJ Open 2023; 13:e071646. [PMID: 37419647 PMCID: PMC10335504 DOI: 10.1136/bmjopen-2023-071646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/11/2023] [Indexed: 07/09/2023] Open
Abstract
INTRODUCTION Decisions regarding the optimal vascular access for haemodialysis patients are becoming increasingly complex, and the provision of vascular access is open to variations in systems of care as well as surgical experience and practice. Two main surgical options are recognised: arteriovenous fistula and arteriovenous graft (AVG). All recommendations regarding AVG are based on a limited number of randomised controlled trials (RCTs). It is essential that when considering an RCT of a surgical procedure, an appropriate definition of quality assurance (QA) is made for both the new approach and the comparator, otherwise replication of results or implementation into clinical practice may differ from published results. The aim of this systematic review will be to assess the methodological quality of RCT involving AVG, and the QA measures implemented in delivering interventions in these trials. METHODS AND ANALYSIS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines will be followed. A systematic search will be performed of the MEDLINE, Embase and Cochrane databases to identify relevant literature. Studies will be selected by title and abstract review, followed by a full-text review using inclusion and exclusion criteria. Data collected will pertain to generic measures of QA, credentialing of investigators, procedural standardisation and performance monitoring. Trial methodology will be compared against a standardised template developed by a multinational, multispecialty review body with experience in vascular access. A narrative approach will be taken to synthesise and report data. ETHICS AND DISSEMINATION Ethical approval is not required as it is a protocol for a systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations, with the ultimate aim of providing recommendations for future RCT of AVG design.
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Affiliation(s)
- Ben Edgar
- Department of Renal Surgery and Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - David B Kingsmore
- Department of Renal Surgery and Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Emma Aitken
- Department of Renal Surgery and Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Francis Calder
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marco Franchin
- Department of Vascular Surgery, University of Insubria, Varese, Italy
| | - Colin Geddes
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nick Inston
- Renal and Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Jackson
- Department of Renal Surgery and Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rob G Jones
- Interventional Radiology, Queen Elizabeth Hospital, Birmingham, UK
| | - Nikolaos Karydis
- Department of General and Transplant Surgery, University of Patras, Patra, Greece
| | - Ram Kasthuri
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Gaspar Mestres
- Department of Vascular Surgery, University of Barcelona, Barcelona, Spain
| | - Georgios Papadakis
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Mike Stephens
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Karen Stevenson
- Department of Renal Surgery and Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
| | - Callum Stove
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Lazslo Szabo
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Peter Thomson
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Matteo Tozzi
- Department of Vascular Surgery, University of Insubria, Varese, Italy
| | - Richard D White
- Department of Interventional Radiology, University Hospital of Wales, Cardiff, UK
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Edgar B, Pearson R, Kasthuri R, Gillis K, Geddes C, Rostron M, Brady A, Hussey K, Roditi G, Delles C, McCallum L, Mark P, Kingsmore D. The impact of renal artery stenting on therapeutic aims. J Hum Hypertens 2023; 37:265-272. [PMID: 36526895 PMCID: PMC10063438 DOI: 10.1038/s41371-022-00785-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022]
Abstract
Renal artery stenosis manifests as poorly-controlled hypertension, impaired renal function or pulmonary oedema, therefore the success of treatment is dependent on indication. This study aims to determine the outcomes of patients undergoing renal artery stenting (RASt) based on therapeutic aim compared to criteria used in the largest randomised trial. Retrospective case-note review of patients undergoing RASt between 2008-2021 (n = 74). The cohort was stratified by indication for intervention (renal dysfunction, hypertension, pulmonary oedema) and criteria employed in the CORAL trial, with outcomes and adverse consequences reported. Intervention for hypertension achieved significant reduction in systolic blood pressure and antihypertensive agents at 1 year (median 43 mmHg, 1 drug), without detrimental impact on renal function. Intervention for renal dysfunction reduced serum creatinine by a median 124 μmol/L, sustained after 6 months. Intervention for pulmonary oedema was universally successful with significant reduction in SBP and serum creatinine sustained at 1 year. Patients who would have been excluded from the CORAL trial achieved greater reduction in serum creatinine than patients meeting the inclusion criteria, with equivalent blood pressure reduction. There were 2 procedure-related mortalities and 5 procedural complications requiring further intervention. 5 patients had reduction in renal function following intervention and 7 failed to achieve the intended therapeutic benefit. Renal artery stenting is effective in treating the indication for which it has been performed. Previous trials may have underestimated the clinical benefits by analysis of a heterogenous population undergoing a procedure rather than considering the indication, and excluding patients who would maximally benefit.
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Affiliation(s)
- Ben Edgar
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK.
| | - Robert Pearson
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Keith Gillis
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Maggie Rostron
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Adrian Brady
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Keith Hussey
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Giles Roditi
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Christian Delles
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Linsay McCallum
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Patrick Mark
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - David Kingsmore
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
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Kingsmore D, White RD, Mestres G, Stephens M, Calder F, Papadakis G, Aitken E, Jackson A, Inston N, Jones RG, Geddes C, Stevenson K, Szabo L, Thomson P, Stove C, Kasthuri R, Edgar B, Tozzi M, Franchin M, Sivaprakasam R, Karydis N. Recruitment into randomised trials of arteriovenous grafts: A systematic review. J Vasc Access 2023:11297298231158413. [PMID: 36905207 DOI: 10.1177/11297298231158413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Although randomised controlled trials (RCT) are considered the optimal form of evidence, there are relatively few in surgery. Surgical RCT are particularly likely to be discontinued with poor recruitment cited as a leading reason. Surgical RCT present challenges over and above those seen in drug trials as the treatment under study may vary between procedures, between surgeons in one unit, and between units in multi-centred RCT. The most contentious and debated area of vascular access remains the role of arteriovenous grafts, and thus the quality of the data that is used to support opinions, guidelines and recommendations is critical. The aim of this review was to determine the extent of variation in the planning and recruitment in all RCT involving AVG. The findings of this are stark: there have been only 31 RCT performed in 31 years, the vast majority of which exhibited major limitations severe enough to undermine the results. This underlines the need for better quality RCT and data, and further inform the design of future studies. Perhaps most fundamental is the planning for a RCT that accounts for the intended population, the uptake of a RCT and the attrition for the significant co-morbidity in this population.
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Affiliation(s)
- David Kingsmore
- Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Richard D White
- Department of Interventional Radiology, University Hospital of Wales, Cardiff, UK
| | - Gaspar Mestres
- Department of Vascular Surgery, University of Barcelona, Spain
| | - Mike Stephens
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Francis Calder
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Georgios Papadakis
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Emma Aitken
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Andrew Jackson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nick Inston
- Renal and Transplant Surgery, University Hospital Birmingham, UK
| | - Rob G Jones
- Interventional Radiology, Queen Elizabeth Hospital Birmingham, UK
| | - Colin Geddes
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Karen Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Laszlo Szabo
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Peter Thomson
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Callum Stove
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | - Ben Edgar
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Matteo Tozzi
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | - Marco Franchin
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | | | - Nikolaos Karydis
- Department of Renal and Transplant Surgery, University Hospital of Patras, Greece
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11
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Kingsmore DB, Stevenson KS, Thomson PC, Kasthuri R, Knight S, Jackson A, Hussey K, Richarz S, Isaak A. Pre-emptive or reactive treatment, angioplasty or stent-graft? The outcome for interventions for venous stenosis in early-cannulation arteriovenous grafts. J Vasc Access 2023; 24:253-260. [PMID: 34219517 DOI: 10.1177/11297298211029413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Early-cannulation arteriovenous grafts (ecAVG) have good initial patency, but frequent episodes of reintervention for venous stenosis (VS) and thrombosis limit their use. Stent grafts (SG) have shown promise in reducing re-interventions and improving functional patency for dysfunctional ecAVG and recurrent VS. There is little data on the impact of stent grafts as the first elective procedure for VS. The aim of this study was to determine firstly, if treating VS whilst asymptomatic has a better outcome than treating after presentation with thrombosis; and secondly, to determine the best initial treatment for asymptomatic VS: SG or angioplasty. METHODS A retrospective study was performed of 259 ecAVG with a sutured anastomosis. The case-mix and outcomes of 153 who presented with VS was analysed by presentation (elective at surveillance or emergency following thrombosis), and then for only elective patients, by treatment (SG vs angioplasty). RESULTS There was no significant difference in case-mix and time to presentation by mode of presentation (100 elective and 53 with thrombosis) other than a higher rate of pro-thrombotic disorders in thrombosed ecAVG. Thrombosed ecAVG had poorer outcomes with increased re-intervention rates and thrombosis in the following year, and reduced long-term functional patency. In patients presenting electively, primary SG rather than angioplasty led to significantly reduced thrombosis rates, a longer time to re-intervention in the following year, and superior long-term functional patency. The use of SG was the same in both groups. Both the mode of presentation and the type of intervention performed were independently predictive of a poorer subsequent functional patency. CONCLUSIONS Primary elective stent-grafting may be the optimal strategy to reducing maintenance costs with ecAVG.
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Affiliation(s)
- David B Kingsmore
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Vascular and Endovascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Karen S Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter C Thomson
- Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Stephen Knight
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Andrew Jackson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Keith Hussey
- Vascular and Endovascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Sabine Richarz
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Vascular and Endovascular Surgery, University Hospital, Aarau-Basel, Switzerland
| | - Andrej Isaak
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Vascular and Endovascular Surgery, University Hospital, Aarau-Basel, Switzerland
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12
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Morgan R, Cleveland T, Hamady M, Oberoi R, Haslam P, Kasthuri R, Johnston M, McCafferty I. Interventional radiology in the 21st century: planning for the future. Clin Radiol 2021; 76:865-869. [PMID: 34776043 DOI: 10.1016/j.crad.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/07/2021] [Indexed: 11/29/2022]
Affiliation(s)
- R Morgan
- Department of Radiology, St George's University of London and St George's University Hospitals NHS Foundation Trust, London, UK.
| | - T Cleveland
- Department of Interventional Radiology, Sheffield Vascular Institute, Sheffield Teaching Hospitals, Sheffield, UK
| | - M Hamady
- Department of Interventional Radiology, Imperial College Healthcare NHS Trust, London, UK
| | - R Oberoi
- Department of Interventional Radiology, Oxford University Hospitals, Oxford, UK
| | - P Haslam
- Department of Interventional Radiology, Freeman Hospital, Newcastle, UK
| | - R Kasthuri
- Department of Interventional Radiology, Greater Glasgow & Clyde NHS, Queen Elizabeth University Hospital, Glasgow, UK
| | - M Johnston
- Department of Interventional Radiology, University Hospitals Sussex and Brighton and Sussex Medical School, Brighton, UK
| | - I McCafferty
- Department of Interventional Radiology, University Hospital Birmingham, Birmingham and Women's NHS Trust, Birmingham, UK
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13
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Kingsmore DB, Stevenson KS, Richarz S, Isaak A, Jackson A, Kasthuri R, Thomson PC. Patient characteristics predict patency of early-cannulation arteriovenous grafts. Sci Rep 2021; 11:10743. [PMID: 34031434 PMCID: PMC8144603 DOI: 10.1038/s41598-021-87750-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/16/2021] [Indexed: 11/09/2022] Open
Abstract
There is a new emphasis on tailoring appropriate vascular access for hemodialysis to patients and their life-plans, but there is little known about the optimal use of newer devices such as early-cannulation arteriovenous grafts (ecAVG), with studies utilising them in a wide variety of situations. The aim of this study was to determine if the outcome of ecAVG can be predicted by patient characteristics known pre-operatively. This retrospective analysis of 278 consecutive ecAVG with minimum one-year follow-up correlated functional patency with demographic data, renal history, renal replacement and vascular access history. On univariate analysis, aetiology of renal disease, indication for an ecAVG, the number of previous tunnelled central venous catheters (TCVC) prior to insertion of an ecAVG, peripheral vascular disease, and BMI were significant associates with functional patency. On multivariate analysis the number of previous TCVC, the presence of peripheral vascular disease and indication were independently associated with outcome after allowing for age, sex and BMI. When selecting for vascular access, understanding the clinical circumstances such as indication and previous vascular access can identify patients with differing outcomes. Importantly, strategies that result in TCVC exposure have an independent and cumulative association with decreasing long-term patency for subsequent ecAVG. As such, TCVC exposure is best avoided or minimised particularly when ecAVG can be considered.
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Affiliation(s)
- David B Kingsmore
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK. .,Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK.
| | - Karen S Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - S Richarz
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Vascular and Endovascular Surgery, University Hospital, Aarau-Basel, Switzerland
| | - Andrej Isaak
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Vascular and Endovascular Surgery, University Hospital, Aarau-Basel, Switzerland
| | - Andrew Jackson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter C Thomson
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
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14
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Crowe K, White B, Khanna N, Cooke B, Kingsmore DB, Jackson A, Stevenson KS, Kasthuri R, Thomson PC. Epidemiology of bloodstream infections in a Scottish haemodialysis population with focus on vascular access method. J Hosp Infect 2021; 110:37-44. [PMID: 33484781 DOI: 10.1016/j.jhin.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Infection is the second highest cause of mortality in end-stage renal disease, with a significant proportion relating to haemodialysis (HD) vascular access-related infection (VARI). AIM To report the rate and antimicrobial resistance (AMR) of all-source bloodstream infections (BSIs) by vascular access type in a Scottish HD cohort. METHODS Retrospective analysis was undertaken of data on adult patients attending seven HD units during 2017. Total HD days for each vascular access type were calculated. BSIs were analysed with rates expressed per 1000 HD days. AMR was verified using health board microbiology databases. FINDINGS Excluding contaminant organisms, there was an overall BSI rate of 0.57 per 1000 HD days. The highest all-source and vascular access-related infection (VARI) BSI rates per 1000 HD days were in the non-tunnelled central venous catheter (CVC) group (3.11 and 2.07 respectively), followed by tunnelled CVC (1.10 and 0.67), arteriovenous graft (0.51 and 0.31), and finally arteriovenous fistula (0.29 and 0.02). The non-VARI BSI rates were lowest in the arteriovenous graft group. Staphylococci comprised the majority of events, with Staphylococcus aureus implicated in 29%. Gram-negative BSIs were prevalent, particularly in CVC groups, and associated with higher mortality. Multidrug-resistant (MDR) S. aureus and carbapenem resistance were relatively low. MDR Gram-negatives were high compared with the Scottish population. CONCLUSION Arteriovenous fistula access is confirmed as having lowest all-source and VARI BSI rates, and arteriovenous graft access the lowest non-VARI BSI rates. Staphylococci remain the prevailing genus; however, the contributions of Gram-negative BSIs, the higher mortality, and proportion of MDR organisms in this group are notable.
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Affiliation(s)
- K Crowe
- Queen Elizabeth University Hospital, Glasgow, UK.
| | - B White
- Queen Elizabeth University Hospital, Glasgow, UK
| | - N Khanna
- Queen Elizabeth University Hospital, Glasgow, UK
| | - B Cooke
- Forth Valley Royal Hospital, Larbert, UK
| | | | - A Jackson
- Queen Elizabeth University Hospital, Glasgow, UK
| | | | - R Kasthuri
- Queen Elizabeth University Hospital, Glasgow, UK
| | - P C Thomson
- Queen Elizabeth University Hospital, Glasgow, UK
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15
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Dunne PDJ, Sinha R, Stanley AJ, Lachlan N, Ireland H, Shams A, Kasthuri R, Forrest EH, Hayes PC. Letter: improve survival! Place early pre-emptive TIPSS in high-risk variceal bleeders-Authors' reply. Aliment Pharmacol Ther 2020; 52:929-930. [PMID: 32852823 DOI: 10.1111/apt.15953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Philip D J Dunne
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Rohit Sinha
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Niel Lachlan
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Aman Shams
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK.,Department of Gastroenterology, Queen Margaret Hospital, Dunfermline, UK
| | - Ram Kasthuri
- Department of Radiology, Glasgow Royal Infirmary, Glasgow, UK
| | - Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
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16
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Martin L, Pearson R, Shumeyko V, Kasthuri R, Reynolds BC. Direct venous pressure assessment pre-renal transplantation to optimise graft venous drainage. Pediatr Nephrol 2020; 35:1525-1528. [PMID: 31834489 DOI: 10.1007/s00467-019-04443-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Renal transplantation is the modality of choice in the treatment of end-stage kidney disease. Surgically challenging aspects of renal transplantation may include creation of vascular anastomoses where there is complex vascular anatomy. We present a paediatric case of living-related donor (LRD) renal transplantation in whom direct intravenous pressure measurement guided the management of the vascular anastomoses in the context of inferior vena cava (IVC) obstruction. CASE-DIAGNOSIS/TREATMENT During venography for transplant assessment, 150 mL of 0.9% sodium chloride was infused for over 20 s into well-developed collateral paravertebral veins to simulate the anticipated high-volume venous return from an implanted kidney. Direct venous pressure measurements were 20 mmHg in the right paravertebral vein and 19 mmHg in the left paravertebral vein. We were reassured by this result that the collateralised venous system could sustain the high venous drainage and maintain the arteriovenous (AV) gradient required for adequate graft perfusion. Intra-operative measurement at the time of transplantation, following release of venous clamps, of 22 mmHg supported the validity of this approach. CONCLUSIONS In children with complex venous anatomy pre-transplant, direct intravenous pressure measurement may provide a useful adjunct in deciding which vessel is most suitable for transplant anastomosis.
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Affiliation(s)
- Laura Martin
- Queen Elizabeth University Hospital, Glasgow, UK
| | | | | | - Ram Kasthuri
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Ben C Reynolds
- Department of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, UK.
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17
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Stoumpos S, Tan A, Hall Barrientos P, Stevenson K, Thomson PC, Kasthuri R, Radjenovic A, Kingsmore DB, Roditi G, Mark PB. Ferumoxytol MR Angiography versus Duplex US for Vascular Mapping before Arteriovenous Fistula Surgery for Hemodialysis. Radiology 2020; 297:214-222. [PMID: 32692301 DOI: 10.1148/radiol.2020200069] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Duplex US is performed routinely for vascular mapping prior to arteriovenous fistula (AVF) creation for hemodialysis but cannot demonstrate the central vasculature. Ferumoxytol, an iron oxide nanoparticle, provides an alternative to gadolinium contrast material for MR angiography for safe use in chronic kidney disease (CKD). Purpose To assess the clinical utility of ferumoxytol-enhanced MR angiography compared with duplex US for vascular mapping before upper limb AVF creation in participants with CKD. Materials and Methods In a prospective comparative study (ClinicalTrials.gov: NCT02997046) from December 2016 to August 2018, participants with CKD underwent ferumoxytol-enhanced MR angiography and duplex US. Two independent readers evaluated vessels for diameter, stenosis or occlusion, arterial disease, and central stenosis. Intraclass correlation coefficients (ICCs) and Bland-Altman plots were used to assess intra- and interreader variability. On the basis of accepted standards for AVF creation, an algorithm was developed to predict AVF outcome based on imaging findings. Multivariable regression models used AVF success as the dependent variable and age, sex, and duplex US or ferumoxytol-enhanced MR angiography findings as independent variables. Results Fifty-nine participants with CKD (mean age, 59 years ± 13 [standard deviation]; 30 women) were evaluated. A total of 51 fistulas were created, of which 24 (47%) were successful. Ferumoxytol-enhanced MR angiography showed excellent inter- and intrareader repeatability (ICC, 0.84-0.99) for all variables assessed. In addition to revealing 15 central vasculature stenoses, ferumoxytol-enhanced MR angiography resulted in characterization of 88 of 236 (37%) of the arterial sections examined as unsuitable for AVF creation compared with 61 of 236 (26%) sections with duplex US (P = .01). Ferumoxytol-enhanced MR angiography independently predicted AVF success in models including (odds ratio, 6.5; 95% confidence interval: 1.7, 25; P = .006) and those excluding (odds ratio, 4.6; 95% confidence interval: 1.3, 17; P = .02) the central vasculature. Conclusion In addition to enabling identification of central vessel pathologic features, ferumoxytol-enhanced MR angiography revealed peripheral arterial disease not recognized with duplex US and was more predictive than duplex US of the outcome of arteriovenous fistula surgery. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Finn in this issue.
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Affiliation(s)
- Sokratis Stoumpos
- From the Renal and Transplant Unit (S.S., K.S., P.C.T., D.B.K., P.B.M.) and Department of Radiology (A.T., P.H.B., R.K., G.R.), Queen Elizabeth University Hospital, Glasgow, Scotland; and Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TD, Scotland (S.S., A.R., P.B.M.)
| | - Alfred Tan
- From the Renal and Transplant Unit (S.S., K.S., P.C.T., D.B.K., P.B.M.) and Department of Radiology (A.T., P.H.B., R.K., G.R.), Queen Elizabeth University Hospital, Glasgow, Scotland; and Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TD, Scotland (S.S., A.R., P.B.M.)
| | - Pauline Hall Barrientos
- From the Renal and Transplant Unit (S.S., K.S., P.C.T., D.B.K., P.B.M.) and Department of Radiology (A.T., P.H.B., R.K., G.R.), Queen Elizabeth University Hospital, Glasgow, Scotland; and Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TD, Scotland (S.S., A.R., P.B.M.)
| | - Karen Stevenson
- From the Renal and Transplant Unit (S.S., K.S., P.C.T., D.B.K., P.B.M.) and Department of Radiology (A.T., P.H.B., R.K., G.R.), Queen Elizabeth University Hospital, Glasgow, Scotland; and Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TD, Scotland (S.S., A.R., P.B.M.)
| | - Peter C Thomson
- From the Renal and Transplant Unit (S.S., K.S., P.C.T., D.B.K., P.B.M.) and Department of Radiology (A.T., P.H.B., R.K., G.R.), Queen Elizabeth University Hospital, Glasgow, Scotland; and Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TD, Scotland (S.S., A.R., P.B.M.)
| | - Ram Kasthuri
- From the Renal and Transplant Unit (S.S., K.S., P.C.T., D.B.K., P.B.M.) and Department of Radiology (A.T., P.H.B., R.K., G.R.), Queen Elizabeth University Hospital, Glasgow, Scotland; and Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TD, Scotland (S.S., A.R., P.B.M.)
| | - Aleksandra Radjenovic
- From the Renal and Transplant Unit (S.S., K.S., P.C.T., D.B.K., P.B.M.) and Department of Radiology (A.T., P.H.B., R.K., G.R.), Queen Elizabeth University Hospital, Glasgow, Scotland; and Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TD, Scotland (S.S., A.R., P.B.M.)
| | - David B Kingsmore
- From the Renal and Transplant Unit (S.S., K.S., P.C.T., D.B.K., P.B.M.) and Department of Radiology (A.T., P.H.B., R.K., G.R.), Queen Elizabeth University Hospital, Glasgow, Scotland; and Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TD, Scotland (S.S., A.R., P.B.M.)
| | - Giles Roditi
- From the Renal and Transplant Unit (S.S., K.S., P.C.T., D.B.K., P.B.M.) and Department of Radiology (A.T., P.H.B., R.K., G.R.), Queen Elizabeth University Hospital, Glasgow, Scotland; and Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TD, Scotland (S.S., A.R., P.B.M.)
| | - Patrick B Mark
- From the Renal and Transplant Unit (S.S., K.S., P.C.T., D.B.K., P.B.M.) and Department of Radiology (A.T., P.H.B., R.K., G.R.), Queen Elizabeth University Hospital, Glasgow, Scotland; and Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TD, Scotland (S.S., A.R., P.B.M.)
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18
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Dunne PDJ, Sinha R, Stanley AJ, Lachlan N, Ireland H, Shams A, Kasthuri R, Forrest EH, Hayes PC. Randomised clinical trial: standard of care versus early-transjugular intrahepatic porto-systemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding. Aliment Pharmacol Ther 2020; 52:98-106. [PMID: 32452561 DOI: 10.1111/apt.15797] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/20/2020] [Accepted: 04/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Early-transjugular intrahepatic porto-systemic shunt (TIPSS) has been recommended in international guidelines for high-risk patients with oesophageal variceal bleeding. AIM To validate the results of a previous randomised control trial which supports use of early-TIPSS. METHODS In a two-centre open-label parallel-group randomised control trial, patients with cirrhosis and acute variceal bleeding were recruited following haemostasis with vaso-active drugs and endoscopic band ligation. Participants were randomised to standard of care or early-TIPSS. The primary outcome was 1-year survival, secondary outcomes included early and late rebleeding, and complications of portal hypertension. RESULTS Fifty-eight patients (58 ± 11.12 years; 32.7% female) were randomised. After one year, seven patients died in the standard of care group and six in the early-TIPSS group, a 1-year survival of 75.9% vs 79.3% respectively (P = 0.79). Variceal rebleeding occurred in eight patients in the standard of care group compared with three patients in the early-TIPSS group (P = 0.09). Not all participants randomised to early-TIPSS received the intervention in time. For those receiving TIPSS per-protocol, variceal rebleeding rates were reduced (0% vs 27.6%, P = 0.04) but this had no effect on survival (76.9% vs 75.9%, P = 0.91). Serious adverse events were similar in both treatment groups, except that rates of hepatic encephalopathy were higher in patients receiving TIPSS (46.1% vs 20.7%, P < 0.05). CONCLUSIONS Early-TIPSS reduced variceal rebleeding, increased encephalopathy but had no effect on survival in high-risk patients with oesophageal variceal bleeding. Early-TIPSS may not be feasible in many centres however, larger studies are needed. ClinicalTrials.gov reference: NCT02377141.
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Affiliation(s)
- Philip D J Dunne
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Rohit Sinha
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Neil Lachlan
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Aman Shams
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK.,Department of Gastroenterology, Queen Margaret Hospital, Dunfermline, UK
| | - Ram Kasthuri
- Department of Radiology, Glasgow Royal Infirmary, Glasgow, UK
| | - Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
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19
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Stoumpos S, Rankin A, Hall Barrientos P, Thomson P, Kasthuri R, Kingsmore D, Roditi G, Mark P. P1322EFFECTS OF HAEMODIALYSIS ARTERIOVENOUS FISTULA CREATION ON CARDIAC STRUCTURE AND FUNCTION. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p1322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background and Aims
Arteriovenous fistula (AVF) is considered the preferred type of access for maintenance haemodialysis. The creation of an AVF may contribute to maladaptive cardiovascular remodelling. We conducted a study to evaluate the effect of AVF creation on cardiac structure and function in patients with end-stage renal disease (ESRD).
Method
In this prospective cohort study, patients with ESRD listed for AVF creation underwent cardiac magnetic resonance imaging at baseline and at 6 weeks. All participants had ultrasound measurements of AVF blood flow at 6 weeks. The primary outcome was the change in left ventricular (LV) mass. Secondary outcomes included changes in LV volumes, left atrial volume, LV ejection fraction, LV global longitudinal strain, cardiac output/index, and septal thickness.
Results
A total of 65 patients were enrolled, of whom 40 had an AVF creation and completed both scans. Patients were divided into 2 groups based on AVF blood flows: 22 in the high flow group (≥ 600mL/min) and 18 in the low flow group (< 600mL/min). On the second cardiac magnetic resonance scan, a mean increase of 7.4 g (95% CI, 1.1–13.7, P=0.02) was observed in LV mass; in the high flow group the mean increase was 15.5 g (95% CI, 7.3–23.8) compared with a small decrease of 2.5 g (95% CI, −10.6 to 5.6) in the low flow group (P=0.003). Significant increases in LV end-diastolic volumes, cardiac output, and cardiac index were also seen after AVF creation (P<0.04). No significant changes were observed in LV ejection fraction (P=0.52), LV end-systolic volumes (P=0.12), and LV global longitudinal strain (P=0.21).
Conclusion
Creation of AVF in adults with ESRD resulted in significant increase of LV myocardial mass early after surgery.
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Affiliation(s)
- Sokratis Stoumpos
- University of Glasgow, Cardiovascular Research Centre, Glasgow, United Kingdom
- Queen Elizabeth University Hospital, Renal and Transplant Unit, Glasgow, United Kingdom
| | - Alastair Rankin
- University of Glasgow, Cardiovascular Research Centre, Glasgow, United Kingdom
| | | | - Peter Thomson
- Queen Elizabeth University Hospital, Renal and Transplant Unit, Glasgow, United Kingdom
| | - Ram Kasthuri
- Queen Elizabeth University Hospital, Radiology, Glasgow, United Kingdom
| | - David Kingsmore
- Queen Elizabeth University Hospital, Renal and Transplant Unit, Glasgow, United Kingdom
| | - Giles Roditi
- Queen Elizabeth University Hospital, Radiology, Glasgow, United Kingdom
| | - Patrick Mark
- University of Glasgow, Cardiovascular Research Centre, Glasgow, United Kingdom
- Queen Elizabeth University Hospital, Renal and Transplant Unit, Glasgow, United Kingdom
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Stoumpos S, Hall Barrientos P, Black DH, Stevenson K, Hennessy M, Vesey AT, Strauss W, Kasthuri R, Radjenovic A, Kingsmore DB, Roditi G, Mark PB. Ferumoxytol MR Angiography: A Novel Technique for Assessing Iliac Vasculature in Potential Kidney Transplant Recipients. JACC Cardiovasc Imaging 2020; 13:1847-1848. [PMID: 32417328 DOI: 10.1016/j.jcmg.2020.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 02/06/2020] [Accepted: 02/27/2020] [Indexed: 01/31/2023]
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MacKenzie DJ, Isaak A, Nash J, Meldrum AD, Stevenson K, Kasthuri R, Tan A, Kingsmore DB. Early Cannulation ePTFE Arteriovenous Access Grafts are Associated with a Low Incidence of Pseudoaneurysm Formation. Ann Vasc Surg 2020; 64:270-275. [DOI: 10.1016/j.avsg.2019.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/03/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022]
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Murray E, Eid M, Traynor JP, Stevenson KS, Kasthuri R, Kingsmore DB, Thomson PC. The first 365 days on haemodialysis: variation in the haemodialysis access journey and its associated burden. Nephrol Dial Transplant 2019; 33:1244-1250. [PMID: 29401294 DOI: 10.1093/ndt/gfx380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 12/14/2017] [Indexed: 11/14/2022] Open
Abstract
Background The modality by which haemodialysis (HD) is delivered [arteriovenous fistula (AVF), arteriovenous graft (AVG) or central venous catheter (CVC)] varies widely and is influenced by clinical evidence, patient factors and the prevailing service configuration. The aim of this study was to determine the outcome and impact of access strategy on patient outcome by mapping out the HD journey in a cohort of incident patients. Methods A 2-year cohort of consecutive incident HD patients from the point of referral for first dialysis access to completion of the first 365 days of HD was prospectively reviewed. Data were sought on access type; radiological, surgical and other access-related activity; bacteraemic events; admission rates and cumulative financial cost. Results A total of 144 patients started RRT for the first time with HD over the 2-year period. All were followed up to 1 year after starting HD, generating a total of 47 753 observed HD days. Activity prior to starting HD for the full cohort was found to average 0.92 arteriovenous (AV) access creation procedures, 0.40 CVC insertions, 0.14 interventional radiology procedures and 0.41 ultrasound examinations per patient. The small number of patients who started on an AVG had a tendency towards higher pre-HD surgical and imaging activity than those who started on an AVF or CVC. Activity after starting HD varied greatly with the access type used at the start of HD, with AVF patients experiencing less hospitalization, procedure and imaging activity and financial costs compared with those who start HD with a CVC. Patients who started on an AVG had a tendency towards lower surgical activity rates and financial costs than those who started on a CVC. Conclusions Providing, maintaining and dealing with the complications of HD vascular access places a significant burden of activity that is shared across nephrology, surgery and imaging services. A well-functioning AVF is associated with the lowest burden, whereas a failed AVF or CVC access is associated with the highest burden. Patient journeys are shaped by the vascular access that they use and we suggest that the contemporary pursuit of HD access should focus on delivering personalized access solutions.
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Affiliation(s)
- Eleanor Murray
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mahmoud Eid
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jamie P Traynor
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Karen S Stevenson
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - David B Kingsmore
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter C Thomson
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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Stoumpos S, Tan A, Hennessy M, Kasthuri R, Radjenovic A, Kingsmore D, Roditi GH, Mark P. FO019FERUMOXYTOL MR ANGIOGRAPHY VS DOPPLER US FOR VASCULAR MAPPING BEFORE HAEMODIALYSIS ARTERIOVENOUS ACCESS CREATION. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz096.fo019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Alfred Tan
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Martin Hennessy
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Ram Kasthuri
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | | | - David Kingsmore
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
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Stoumpos S, Barrientos P, Black D, Stevenson K, Hennessy M, Vesey A, Kasthuri R, Radjenovic A, Kingsmore D, Roditi GH, Mark P. FO039FERUMOXYTOL MR ANGIOGRAPHY VS CT ANGIOGRAPHY FOR THE ASSESSMENT OF POTENTIAL KIDNEY TRANSPLANT RECIPIENTS. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz096.fo039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Douglas Black
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Karen Stevenson
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Martin Hennessy
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Alex Vesey
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Ram Kasthuri
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | | | - David Kingsmore
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
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Stoumpos S, Traynor JP, Metcalfe W, Kasthuri R, Stevenson K, Mark PB, Kingsmore DB, Thomson PC. A national study of autogenous arteriovenous access use and patency in a contemporary hemodialysis population. J Vasc Surg 2019; 69:1889-1898. [DOI: 10.1016/j.jvs.2018.10.063] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 10/03/2018] [Indexed: 10/27/2022]
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Yeung BPM, Craig C, Morris J, Christie A, Kasthuri R, Stuart W, Stanley AJ. Endoscopic therapy for upper gastrointestinal bleeding: less is more? Frontline Gastroenterol 2018; 9:208-209. [PMID: 30046426 PMCID: PMC6056088 DOI: 10.1136/flgastro-2017-100911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/30/2017] [Accepted: 12/05/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
| | - Carol Craig
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Andrew Christie
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Wesley Stuart
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
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Thomson PC, Kingsmore DB, Kasthuri R. Vascular access: pearls and pitfalls. Nephrol Dial Transplant 2018; 33:5032059. [PMID: 29868842 DOI: 10.1093/ndt/gfy141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 04/24/2018] [Indexed: 02/28/2024] Open
Affiliation(s)
- Peter C Thomson
- Glasgow Renal and Transplant Unit, The Queen Elizabeth University Hospital, Glasgow, UK
| | - David B Kingsmore
- Glasgow Renal and Transplant Unit, The Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Department of Radiology, The Queen Elizabeth University Hospital, Glasgow, UK
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Stoumpos S, Traynor J, Metcalfe W, Kasthuri R, Stevenson K, Mark P, Kingsmore D, Thomson P. FP562ARTERIOVENOUS FISTULA USE AND PATENCY IN A CONTEMPORARY HAEMODIALYSIS POPULATION: A NATIONAL OBSERVATIONAL STUDY. Nephrol Dial Transplant 2018. [DOI: 10.1093/ndt/gfy104.fp562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sokratis Stoumpos
- Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Jamie Traynor
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Wendy Metcalfe
- Renal Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Ram Kasthuri
- Radiology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Karen Stevenson
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Patrick Mark
- Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - David Kingsmore
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Peter Thomson
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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Stoumpos S, Hennessy M, Vesey AT, Radjenovic A, Kasthuri R, Kingsmore DB, Mark PB, Roditi G. Ferumoxytol-enhanced magnetic resonance angiography for the assessment of potential kidney transplant recipients. Eur Radiol 2017; 28:115-123. [PMID: 28677065 PMCID: PMC5717122 DOI: 10.1007/s00330-017-4934-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/16/2017] [Accepted: 06/08/2017] [Indexed: 11/13/2022]
Abstract
Objectives Traditional contrast-enhanced methods for scanning blood vessels using magnetic resonance imaging (MRI) or CT carry potential risks for patients with advanced kidney disease. Ferumoxytol is a superparamagnetic iron oxide nanoparticle preparation that has potential as an MRI contrast agent in assessing the vasculature. Methods Twenty patients with advanced kidney disease requiring aorto-iliac vascular imaging as part of pre-operative kidney transplant candidacy assessment underwent ferumoxytol-enhanced magnetic resonance angiography (FeMRA) between December 2015 and August 2016. All scans were performed for clinical indications where standard imaging techniques were deemed potentially harmful or inconclusive. Image quality was evaluated for both arterial and venous compartments. Results First-pass and steady-state FeMRA using incremental doses of up to 4 mg/kg body weight of ferumoxytol as intravenous contrast agent for vascular enhancement was performed. Good arterial and venous enhancements were achieved, and FeMRA was not limited by calcification in assessing the arterial lumen. The scans were diagnostic and all patients completed their studies without adverse events. Conclusions Our preliminary experience supports the feasibility and utility of FeMRA for vascular imaging in patients with advanced kidney disease due for transplant listing, which has the advantages of obtaining both arteriography and venography using a single test without nephrotoxicity. Key Points • Evaluation of vascular disease is important in planning kidney transplantation. • Standard vascular imaging methods are often problematic in kidney disease patients. • FeMRA has the advantage of arteriography and venography in a single test. • FeMRA is safe and non-nephrotoxic. • FeMRA is not limited by arterial calcification.
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Affiliation(s)
- Sokratis Stoumpos
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK. .,Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK.
| | - Martin Hennessy
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alex T Vesey
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Aleksandra Radjenovic
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Ram Kasthuri
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - David B Kingsmore
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TA, UK
| | - Giles Roditi
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
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Stoumpos S, Hennessy M, Vesey A, Radjenovic A, Kasthuri R, Roditi G, Thomson P, Mark P, Kingsmore D. MO050FERUMOXYTOL-ENHANCED MAGNETIC RESONANCE ANGIOGRAPHY FOR THE ASSESSMENT OF PATIENTS WITH COMPLEX ANATOMY DUE FOR VASCULAR ACCESS CREATION. Nephrol Dial Transplant 2017. [DOI: 10.1093/ndt/gfx122.mo050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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31
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Stoumpos S, Hennessy M, Vesey A, Radjenovic A, Kasthuri R, Kingsmore D, Roditi G, Mark P. MP817FERUMOXYTOL-ENHANCED MAGNETIC RESONANCE ANGIOGRAPHY FOR THE ASSESSMENT OF POTENTIAL KIDNEY TRANSPLANT RECIPIENTS. Nephrol Dial Transplant 2017. [DOI: 10.1093/ndt/gfx182.mp817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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32
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Aitken E, Thomson P, Bainbridge L, Kasthuri R, Mohr B, Kingsmore D. A randomized controlled trial and cost-effectiveness analysis of early cannulation arteriovenous grafts versus tunneled central venous catheters in patients requiring urgent vascular access for hemodialysis. J Vasc Surg 2017; 65:766-774. [DOI: 10.1016/j.jvs.2016.10.103] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 10/19/2016] [Indexed: 11/16/2022]
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Martin K, Kasthuri R, Mooberry MJ, Chen SL, Key NS, Ma AD. Lower doses of recombinant porcine factor VIII maintain excellent haemostatic efficacy. Haemophilia 2016; 22:e549-e551. [PMID: 27704655 DOI: 10.1111/hae.13038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2016] [Indexed: 12/30/2022]
Affiliation(s)
- K Martin
- Department of Medicine, Division of Hematology Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - R Kasthuri
- Department of Medicine, Division of Hematology Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - M J Mooberry
- Department of Medicine, Division of Hematology Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - S-L Chen
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - N S Key
- Department of Medicine, Division of Hematology Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - A D Ma
- Department of Medicine, Division of Hematology Oncology, University of North Carolina, Chapel Hill, NC, USA
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Stoumpos S, Murray EC, Kingsmore DB, Kasthuri R, Thomson PC. MO036A FRAMEWORK FOR TARGETING QUALITY IMPROVEMENT IN HAEMODIALYSIS VASCULAR ACCESS. Nephrol Dial Transplant 2016. [DOI: 10.1093/ndt/gfw136.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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35
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Fogarty PF, Mancuso ME, Kasthuri R, Bidlingmaier C, Chitlur M, Gomez K, Holme PA, James P, Kruse-Jarres R, Mahlangu J, Mingot-Castellano ME, Soni A. Presentation and management of acute coronary syndromes among adult persons with haemophilia: results of an international, retrospective, 10-year survey. Haemophilia 2015; 21:589-97. [DOI: 10.1111/hae.12652] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2015] [Indexed: 01/01/2023]
Affiliation(s)
- P. F. Fogarty
- Penn Comprehensive Hemophilia and Thrombosis Program; Philadelphia PA USA
| | - M. E. Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico; Milan Italy
| | - R. Kasthuri
- Division of Hematology and Oncology; Hemophilia and Thrombosis Center; University of North Carolina; Chapel Hill NC USA
| | | | - M. Chitlur
- Children's Hospital of Michigan; Detroit MI USA
| | | | - P. A. Holme
- Department of Haematology; Oslo University Hospital, Rikshospitalet; Oslo Norway
| | - P. James
- Queen's University; Kingston ON Canada
| | | | - J. Mahlangu
- Faculty of Health Sciences; University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital; Johannesburg South Africa
| | | | - A. Soni
- Children's Hospital of Orange County; Orange CA USA
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Aitken E, Geddes C, Thomson P, Kasthuri R, Chandramohan M, Berry C, Kingsmore D. Immediate access arteriovenous grafts versus tunnelled central venous catheters: study protocol for a randomised controlled trial. Trials 2015; 16:42. [PMID: 25885054 PMCID: PMC4343055 DOI: 10.1186/s13063-015-0556-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 01/07/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Autologous arteriovenous fistulae (AVF) are the optimal form of vascular access for haemodialysis. AVFs typically require 6 to 8 weeks to "mature" from the time of surgery before they can be cannulated. Patients with end-stage renal disease needing urgent vascular access therefore traditionally require insertion of a tunnelled central venous catheter (TCVC). TCVCs are associated with high infection rates and central venous stenosis. Early cannulation synthetic arteriovenous grafts (ecAVG) provide a novel alternative to TCVCs, permitting rapid access to the bloodstream and immediate needling for haemodialysis. Published rates of infection in small series are low. The aim of this study is to compare whether TCVC ± AVF or ecAVG ± AVF provide a better strategy for managing patients requiring immediate vascular access for haemodialysis. METHODS/DESIGN This is a prospective randomised controlled trial comparing the strategy of TCVC ± AVF to ecAVG ± AVF. Patients requiring urgent vascular access will receive a study information sheet and written consent will be obtained. Patients will be randomised to receive either: (i) TCVC (and native AVF if this is anatomically possible) or (ii) ecAVG (± AVF). 118 patients will be recruited. The primary outcome is systemic bacteraemia at 6 months. Secondary outcomes include culture-proven bacteraemia rates at 1 year and 2 years; primary and secondary patency rates at 3, 6, 12 and 24 months; stenoses; re-intervention rates; re-admission rate; mortality and quality of life. Additionally, treatment delays, impact on service provision and cost-effectiveness will be evaluated. DISCUSSION This is the first randomised controlled trial comparing TCVC to ecAVG for patients requiring urgent vascular access for haemodialysis. The complications of TCVC are considered an unfortunate necessity in patients requiring urgent haemodialysis who do not have autologous vascular access. If this study demonstrates that ecAVGs provide a safe and practical alternative to TCVC, this could instigate a paradigm shift in nephrology thinking and access planning. TRIAL REGISTRATION This study has been approved by the West of Scotland Research Ethics Committee 4 (reference no. 13/WS/0087, 28 August 2013) and is registered with the International Standard Randomised Controlled Trial Number Register (reference no. ISRCTN80588541 , 27 May 2014).
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Affiliation(s)
- Emma Aitken
- Department of Renal Surgery, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
- School of Medical, Veterinary and Life Science, University of Glasgow, University Avenue, Glasgow, G12 8TA, UK.
| | - Colin Geddes
- Department of Nephrology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
| | - Pete Thomson
- Department of Nephrology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
| | - Ram Kasthuri
- Department of Radiology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
| | - Mohan Chandramohan
- Department of Radiology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
| | - Colin Berry
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, University Avenue, Glasgow, G12 8TA, UK.
| | - David Kingsmore
- Department of Renal Surgery, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
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Gomathy K, Thangavel K, Balakrishnan M, Kasthuri R. Effect of Ohmic Heating on the Electrical Conductivity, Biochemical and Rheological Properties of Papaya Pulp. J FOOD PROCESS ENG 2015. [DOI: 10.1111/jfpe.12172] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- K. Gomathy
- Department of Food and Agricultural Process Engineering; Agricultural Engineering College and Research Institute; Tamil Nadu Agricultural University; Coimbatore 641 003 India
| | - K. Thangavel
- Department of Food and Agricultural Process Engineering; Agricultural Engineering College and Research Institute; Tamil Nadu Agricultural University; Coimbatore 641 003 India
| | - M. Balakrishnan
- Department of Food and Agricultural Process Engineering; Agricultural Engineering College and Research Institute; Tamil Nadu Agricultural University; Coimbatore 641 003 India
| | - R. Kasthuri
- Department of Food and Agricultural Process Engineering; Agricultural Engineering College and Research Institute; Tamil Nadu Agricultural University; Coimbatore 641 003 India
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Aitken EL, Jackson AJ, Hameed H, Chandramohan M, Kasthuri R, Kingsmore DB. Cephalic arch stenosis: angioplasty to preserve a brachiocephalic fistula or new brachiobasilic fistula?: a cost-effectiveness study. Ren Fail 2014; 36:1550-8. [DOI: 10.3109/0886022x.2014.949763] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Aniesrani Delfiya D, Thangavel K, Natarajan N, Kasthuri R, Kailappan R. Microencapsulation of Turmeric Oleoresin by Spray Drying and In Vitro
Release Studies of Microcapsules. J FOOD PROCESS ENG 2014. [DOI: 10.1111/jfpe.12124] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D.S. Aniesrani Delfiya
- Department of Food and Agricultural Process Engineering; Tamil Nadu Agricultural University; Coimbatore 641 003 India
| | - K. Thangavel
- Department of Food and Agricultural Process Engineering; Tamil Nadu Agricultural University; Coimbatore 641 003 India
| | - N. Natarajan
- Department of Nano Science and Technology; Tamil Nadu Agricultural University; Coimbatore 641 003 India
| | - R. Kasthuri
- Department of Food and Agricultural Process Engineering; Tamil Nadu Agricultural University; Coimbatore 641 003 India
| | - R. Kailappan
- Department of Food and Agricultural Process Engineering; Tamil Nadu Agricultural University; Coimbatore 641 003 India
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Kasthuri R, Karunaratne D, Andrew H, Sumner J, Chalmers N. Day-case peripheral angioplasty using nurse-led admission, discharge, and follow-up procedures: arterial closure devices are not necessary. Clin Radiol 2007; 62:1202-5. [PMID: 17981169 DOI: 10.1016/j.crad.2007.05.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Revised: 04/26/2007] [Accepted: 05/01/2007] [Indexed: 10/22/2022]
Abstract
AIM To audit the safety of day-case peripheral arterial intervention without the use of arterial-closure devices using nurse-led admission, discharge, and follow-up procedures. MATERIALS AND METHODS Patients referred for elective, peripheral vascular intervention were selected for day-case care according to pre-determined criteria using telephone triage. Post-procedure haemostasis was achieved using manual compression. After 3h bed-rest, patients were mobilized and discharged at 5h. Patients were contacted by telephone next working day to audit complications. RESULTS One hundred and eighty-three elective day-case peripheral interventions were performed over 2 years, predominantly using 6 F sheaths. No closure devices were used. Five patients (2%) returned to the department because of persistent groin symptoms the next day. One of these had a false aneurysm. Four required no further treatment. A single patient returned at day 6 with a delayed false aneurysm. CONCLUSION Day-case peripheral vascular intervention can be safely performed in appropriately selected patients without the use of arterial closure devices. Specialist radiology nurses have a major role in the counselling, care, and follow-up of these patients.
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Affiliation(s)
- R Kasthuri
- Department of Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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