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Fertility and Sterility Oct 2021To quantify the efficacy of medical management of uterine arteriovenous malformation (AVM) and compare efficacy between different classes of medication. In addition, we... (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVE
To quantify the efficacy of medical management of uterine arteriovenous malformation (AVM) and compare efficacy between different classes of medication. In addition, we evaluated for factors associated with treatment success and pregnancy outcomes after medical management.
DESIGN
Systematic review and meta-analysis.
SETTING
Not applicable.
PATIENT(S)
Thirty-two studies representing 121 premenopausal women with medically-treated uterine AVM were identified via database searches of MEDLINE, Embase, Web of Science, and cited references.
INTERVENTION(S)
Medical treatment with progestins, gonadotropin-releasing hormone agonists (GnRH-a), methotrexate, combined hormonal contraception , uterotonics, danazol, or combination of the above.
MAIN OUTCOME MEASURE(S)
Primary outcome of treatment success was defined as AVM resolution without subsequent procedural interventions. Secondary outcome was treatment complication (readmission or transfusion).
RESULT(S)
The overall success rate of medical management was 88% (106/121). After adjusting for clustering effects, success rates for progestin (82.5%; 95% confidence interval [CI], 70.1%-90.4%), GnRH-a (89.3%; 99% CI, 71.4%-96.5%) and methotrexate (90.0%; 99% CI, 55.8%-98.8%) were significantly different from the null hypothesis of 50% success. The agents with the lowest adjusted proportion of complications were progestins (10.0%; 99% CI, 3.3%-26.8%) and GnRH-a (10.7%; 99% CI, 3.5%-28.4%). No clinical factors were found to predict treatment success. Twenty-six subsequent pregnancies are described, with no reported recurrences of AVM.
CONCLUSION(S)
Medical management for uterine AVM is a reasonable approach in a well selected patient. These data should be interpreted in the context of significant publication bias.
Topics: Arteriovenous Fistula; Blood Transfusion; Clinical Decision-Making; Female; Humans; Patient Readmission; Patient Selection; Pregnancy; Pregnancy Rate; Risk Assessment; Risk Factors; Treatment Outcome; Uterine Artery; Uterus
PubMed: 34130801
DOI: 10.1016/j.fertnstert.2021.05.095 -
The Cochrane Database of Systematic... Apr 2022Patients with kidney failure require vascular access to receive maintenance haemodialysis (HD), which can be achieved by an arteriovenous fistula or a central venous... (Review)
Review
BACKGROUND
Patients with kidney failure require vascular access to receive maintenance haemodialysis (HD), which can be achieved by an arteriovenous fistula or a central venous catheter (CVC). CVC use is related to frequent complications such as venous stenosis and infection. Venous stenosis occurs mainly due to trauma caused by the entrance of the catheter into the venous lumen and repeated contact with the vein wall. A biofilm, a colony of irreversible adherent and self-sufficient micro-organisms embedded in a self-produced matrix of exopolysaccharides, is associated with the development of infections in patients with indwelling catheters. Despite its clinical relevance, the treatment of catheter-related bloodstream infections (CRBSIs) in patients receiving maintenance HD remains controversial, especially regarding catheter management. Antibiotic lock solutions may sterilise the catheter, treat the infection and prevent unnecessary catheter procedures. However, such treatment may also lead to antibiotic resistance or even clinical worsening in certain more virulent pathogens. Catheter removal and delayed replacement may remove the source of infection, improving infectious outcomes, but this approach may also increase vascular access stenosis, thrombosis or both, or even central vein access failure. Catheter guidewire exchange attempts to remove the source of infection while maintaining access to the same vein and, therefore, may improve clinical outcomes and preserve central veins for future access.
OBJECTIVES
To assess the benefits and harms of different interventions for CRBSI treatment in patients receiving maintenance HD through a permanent CVC, such as systemic antibiotics alone or systemic antibiotics combined with either lock solutions or catheter guidewire exchange or catheter replacement.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Register of Studies up to 21 December 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.
SELECTION CRITERIA
We included all randomised controlled trials (RCTs) and quasi-RCTs evaluating the management of CRBSI in permanent CVCs in people receiving maintenance HD.
DATA COLLECTION AND ANALYSIS
Two authors independently selected studies for inclusion, assessed their risk of bias, and performed data extraction. Results were expressed as risk ratios (RR) or hazard ratios (HR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with their 95% confidence intervals (CI). The certainty of the evidence was assessed using GRADE.
MAIN RESULTS
We identified two RCTs and one quasi-RCT that enrolled 760 participants addressing the treatment of CRBSIs in people (children and adults) receiving maintenance HD through CVC. No two studies compared the same interventions. The quasi-RCT compared two different lock solutions (tissue plasminogen activator (TPA) and heparin) with concurrent systemic antibiotics. One RCT compared systemic antibiotics alone and in association with an ethanol lock solution, and the other compared systemic antibiotics with different catheter management strategies (guidewire exchange versus removal and replacement). The overall certainty of the evidence was downgraded due to the small number of participants, high risk of bias in many domains, especially randomisation, allocation, and other sources of bias, and missing outcome data. It is uncertain whether an ethanol lock solution used with concurrent systemic antibiotics improved CRBSI eradication compared to systemic antibiotics alone (RR 1.61, 95% CI 1.16 to 2.23) because the certainty of this evidence is very low. There were no reported differences between the effects of TPA and heparin lock solutions on cure rates (RR 0.92, 95% CI 0.74 to 1.15) or between catheter guidewire exchange versus catheter removal with delayed replacement, expressed as catheter infection-free survival (HR 0.88, 95% CI 0.43 to 1.79). To date, no results are available comparing other interventions. Outcomes such as venous stenosis and/or thrombosis, antibiotic resistance, death, and adverse events were not reported.
AUTHORS' CONCLUSIONS
Currently, there is no available high certainty evidence to support one treatment over another for CRBSIs. The benefit of using ethanol lock treatment in combination with systemic antibiotics compared to systemic antibiotics alone for CRBSIs in patients receiving maintenance HD remains uncertain due to the very low certainty of the evidence. Hence, further RCTs to identify the benefits and harms of CRBSI treatment options are needed. Future studies should unify CRBSI and cure definitions and improve methodological design.
Topics: Adult; Catheter-Related Infections; Central Venous Catheters; Child; Heparin; Humans; Renal Dialysis; Sepsis
PubMed: 35363884
DOI: 10.1002/14651858.CD013554.pub2 -
Frontiers in Cardiovascular Medicine 2022Currently, percutaneous endovascular creation of arteriovenous fistula (AVF) shows excellent outcomes. However, few systematic research evidence to support clinical...
OBJECTIVE
Currently, percutaneous endovascular creation of arteriovenous fistula (AVF) shows excellent outcomes. However, few systematic research evidence to support clinical decision making on the benefit of endovascular AVF is available. The purpose of this study was to evaluate the efficacy and safety of endovascular AVF (endoAVF) in patients with renal failure.
METHODS
We searched the Medline, Embase, Cochrane Library, and ClinicalTrials.gov databases for studies on endovascular or endovascular versus surgery for the creation of AVF. Two reviewers independently selected studies and extracted data. A systematic review and meta-analysis were performed by Review Manager 5.4 software (Revman, The Cochrane Collaboration, Oxford, United Kingdom) and Stata 15.0 (Stata Corp, College Station, TX, United States).
RESULTS
A total of 14 case series and 5 cohort studies, with 1,929 patients, were included in this study. The technique success was 98.00% for endoAVF (95% CI, 0.97-0.99; = 16.25%). There was no statistically significant difference in 3 cohort studies between endovascular and surgical AVF for procedural success (OR = 0.69; 95% CI, 0.04-11.98; = 0.80; = 53%). The maturation rates of endoAVF were 87.00% (95% CI, 0.79-0.93; = 83.96%), and no significant difference was observed in 3 cohort studies between the 2 groups (OR = 0.73; 95% CI, 0.20-2.63; = 0.63; = 88%). Procedure-related complications for endoAVF was 7% (95% CI, 0.04-0.17; = 78.31%), and it did not show significant difference in 4 cohort studies between the 2 groups (OR = 1.85; 95% CI, 0.37-9.16; = 0.45; = 59%).
CONCLUSION
The endovascular creation of AVF is potentially effective and safe. These important data may provide evidence to support clinicians and patients in making decisions with endovascular AVF. But further research is great necessary due to lack of randomized controlled studies.
PubMed: 36148078
DOI: 10.3389/fcvm.2022.978285 -
Kidney & Blood Pressure Research 2022Risk factors like female sex, fistula location, hypertension, albumin, diabetes, arteriovenous graft (AVG), age, and other factors are related to arteriovenous fistula... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Risk factors like female sex, fistula location, hypertension, albumin, diabetes, arteriovenous graft (AVG), age, and other factors are related to arteriovenous fistula thrombus (AVFT), but the consistency and magnitude of their associations have not been confirmed by meta-analysis.
OBJECTIVES
The purpose of this study was to provide a comprehensive and up-to-date synthesis of evidence on the association between potential risk factors and AVFT.
METHODS
In this systematic review and meta-analysis, PubMed, Embase, Cochrane Library, and Web of Science databases were searched for articles published up to April 20th, 2022, and cohort, cross-sectional, and case-control studies examining the association (odds ratio [OR]) between potential risk factors and AVFT were identified. The other inclusion criteria were sufficient data for analysis and nonoverlapping datasets, excluding reviews, meta-analyses, and articles with overlapping datasets. Extracted variables included first author, publication year, study type, sample size, percentage of women, vascular access type, risk or protective factors, and measure of association (adjusted estimates of effect of all risk factors). The study protocol is registered at PROSPERO (CRD42020201884) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
RESULTS
Among the 27 identified studies, data from 24 cohort, 2 case-control, and 1 cross-sectional study were included in this review. When compared to non-AVFT, our data showed that the significant risk factors were AVG (pooled OR = 6.28, 95% CI = 1.79-22.02, p = 0.004, I2 = 87%), age (pooled OR = 1.06, 95% CI = 1.00-1.13, p = 0.05, I2 = 98%), female sex (pooled OR = 2.62, 95% CI = 2.56-2.69, p < 0.00001, I2 = 0%), C-reactive protein (pooled OR = 1.18, 95% CI = 1.08-1.30, p = 0.0005, I2 = 90%), fistula site (distal) (pooled OR = 3.64, 95% CI = 1.74-7.62, p = 0.0006, I2 = 47%), hypertension (pooled OR = 1.21, 95% CI = 1.00-1.47, p = 0.05, I2 = 46%), CD34+KDR+ cell (pooled OR = 1.85, 95% CI = 1.33-2.57, p = 0.0002, I2 = 0%), and eprex use (pooled OR = 5.36, 95% CI = 1.82-15.77, p = 0.002, I2 = 0%).
CONCLUSIONS
The meta-analysis suggests that AVG, age, female sex, CRP level, fistula site (distal), hypertension, CD34+KDR+ cell, and the use of eprex are independent risk factors for AVFT. Therefore, clinical medical staff should treat these risk factors carefully, identify them early, and prevent them early to reduce the occurrence of AVFT.
Topics: Female; Humans; Arteriovenous Fistula; Cross-Sectional Studies; Epoetin Alfa; Hypertension; Risk Factors; Thrombosis; Male
PubMed: 36116428
DOI: 10.1159/000526768 -
Kidney Medicine Mar 2022To facilitate the process of dialysis for patients with kidney failure, an arteriovenous fistula (AVF) is created using either a surgical or percutaneous approach. We...
RATIONALE & OBJECTIVE
To facilitate the process of dialysis for patients with kidney failure, an arteriovenous fistula (AVF) is created using either a surgical or percutaneous approach. We sought to compare the efficacy and procedural outcomes in creating an AVF percutaneously using Ellipsys (Avenu Medical) or WavelinQ (Becton Dickinson Medical) with surgery in all patients with kidney failure requiring a permanent AVF for dialysis.
STUDY DESIGN
Systematic review and meta-analysis.
SETTING & STUDY POPULATIONS
All patients requiring a permanent AVF for dialysis.
SELECTION CRITERIA FOR STUDIES
We included studies that compared either the Ellipsys device or WavelinQ directly with surgery to create an AVF for long-term dialysis.
DATA EXTRACTION
Two reviewers independently reviewed the studies and extracted the data. Conflicts were resolved with a discussion and approval from the senior author.
ANALYTICAL APPROACH
Fixed-effects or random-effects models were used to pool the fixed sizes and 95% CIs based on the level of heterogeneity.
RESULTS
There was no statistically significant difference observed between surgical AVF and endovascular AVF when comparing the primary outcomes of procedural success (OR = 1.44; 95% CI, 0.35, 5.88; = 0.61; I = 0%), complications (OR = 0.28; 95% CI, 0.06, 1.46; = 0.13; I = 69%), and the secondary outcomes of interest that included follow-up time (mean difference [MD] = -17.71; 95% CI, -189.53, 154.12; = 0.84; I = 94%), failure rate (OR = 1.03; 95% CI, 0.21, 5.13; = 0.97; I = 85%), and time to 2-needle cannulation (MD = -5.40; 95% CI, -38.88, 28.08; = 0.75; I = 0%). However, a statistically significant difference was seen among the 2 groups for procedural time (MD = -54.25; 95% CI, -59.78, -48.71; < 0.001; I = 98%), number of interventions needed to maintain patency (OR = 1.73; 95% CI, 1.22, 2.45; < 0.01; I = 94%), and primary patency rate (OR = 0.34; 95% CI, 0.23,0.52; < 0.001; I = 0%).
LIMITATIONS
The total number of studies included in this review was limited, with 3 of the 4 included studies being retrospective and only 1 being prospective. There was a lack of heterogeneity and randomization.
CONCLUSIONS
Percutaneous fistula creation using Ellipsys or WavelinQ is a unique and safe alternative with outcomes comparable to surgery. Future studies are needed, including observational studies in current clinical practice, to evaluate the efficacy and outcomes of endovascular AVF creation in clinical populations.
PubMed: 35386608
DOI: 10.1016/j.xkme.2021.100406 -
International Journal of Environmental... Oct 2022Hemorrhage of arteriovenous malformation (AVM) is a rare condition during pregnancy. This study was proposed to pool the proportion of AVM hemorrhage per pregnancy. A... (Meta-Analysis)
Meta-Analysis Review
Hemorrhage of arteriovenous malformation (AVM) is a rare condition during pregnancy. This study was proposed to pool the proportion of AVM hemorrhage per pregnancy. A systematic review and meta-analysis with three databases were performed to review the studies published until April 2022. The Newcastle Ottawa Scale was used for risk assessment of data quality. The meta-analysis was conducted by a generic inverse variance of double arcsine transformation with a random model using Stata software. Twelve studies were included in this review. The pooled proportion of AVM hemorrhage per pregnancy was 0.16 (95% CI: 0.08, 0.26). The subgroup analyses were carried out based on world regions and study designs, and the study duration with the highest proportion of each subgroup was Europe [0.35 (95% CI: 0.02, 0.79)], with retrospective review [0.18 (95% CI: 007, 0.32)] and 10 to 20 years of study duration [0.37 (95% CI: 0.06, 0.77)]. The AVM hemorrhage per pregnancy in this review was considered low. However, the conclusion must be carefully interpreted since this review had a small study limitation.
Topics: Pregnancy; Female; Humans; Intracranial Arteriovenous Malformations; Arteriovenous Fistula; Cerebral Hemorrhage; Retrospective Studies; Europe
PubMed: 36293763
DOI: 10.3390/ijerph192013183 -
World Neurosurgery: X Jul 2023The coexistence of meningioma and dural arteriovenous fistula (dAVF) is a rare, but highly complex condition. Various pathophysiological mechanisms underlie intracranial... (Review)
Review
BACKGROUND
The coexistence of meningioma and dural arteriovenous fistula (dAVF) is a rare, but highly complex condition. Various pathophysiological mechanisms underlie intracranial meningiomas with continuous or distant dAVFs. We describe a case of coexisting meningioma and dAVF with a systematic review of the literature.
RESULT
Including the present case, there are 21 reported cases of coexisting intracranial dAVF and meningioma. The patients' ages ranged from 23 to 76 years, with a mean age of 61 years. The most common presenting symptom was headache. The dAVFs were commonly located at the transverse-sigmoid sinus (43%) and superior sagittal sinus (24%). The most common meningioma locations were the tentorium and parietal convexity. In 76% of the cases, the meningioma occluded the sinus. The most common dAVF treatment was transcatheter arterial embolization, followed by tumor resection (52%). Among the 20 cases with available outcome data, 90% reported favorable outcomes.
CONCLUSION
This report highlights some of the features of coexisting dAVF and meningioma and presents a systematic review of other reports on this phenomenon. Through an in-depth analysis of the literature, we highlight some of the leading theories regarding the causes of concomitant dAVF and meningiomas. Our report supports one of the leading theories that impaired venous return, whether through the occlusion of sinuses or sinus manipulation during surgery, plays a role in the development of dAVF. Further understanding may help guide future clinical decision-making and surgical planning.
PubMed: 37235061
DOI: 10.1016/j.wnsx.2023.100217 -
Child's Nervous System : ChNS :... Jun 2024Pediatric non-galenic pial arteriovenous fistulas (pAVFs) are rare vascular malformations that are characterized by a pial arterial-venous connection without an... (Review)
Review
INTRODUCTION
Pediatric non-galenic pial arteriovenous fistulas (pAVFs) are rare vascular malformations that are characterized by a pial arterial-venous connection without an intervening capillary bed. Outcomes and treatment strategies for pAVFs are highly individualized, owing to the rarity of the disease and lack of large-scale data guiding optimal treatment approaches.
METHODS
We performed a systematic review of pediatric patients (< 18 years at diagnosis) diagnosed with a pAVF by digital subtraction angiogram (DSA). The demographics, treatment modalities, and outcomes were documented for each patient and clinical outcome data was collected. Descriptive information stratified by outcome scores were classified as follows: 1 = excellent (no deficit and full premorbid activity), 2 = good (mild deficit and full premorbid activity), 3 = fair (moderate deficit and impaired activity), 4 = poor (severe deficit and dependent on others), 5 = death.
RESULTS
A total of 87 studies involving 231 patients were identified. Median age at diagnosis was 3 years (neonates to 18 years). There was slight male preponderance (55.4%), and 150 subjects (81.1%*) experienced excellent outcomes after treatment. Of the 189 patients treated using endovascular approaches, 80.3% experienced excellent outcomes and of the 15 patients surgically treated subjects 75% had an excellent outcome. The highest rate of excellent outcomes was achieved in patients treated with Onyx (95.2%) and other forms of EvOH (100%). High output heart failure and comorbid vascular lesions tended to result in worse outcomes, with only 54.2% and 68% of subjects experiencing an excellent outcome, respectively. *Outcomes were reported in only 185 patients.
CONCLUSION
pAVFs are rare lesions, necessitating aggregation of patient data to inform natural history and optimal treatment strategies. This review summarizes the current literature on pAVF in children, where children presenting with heart failure as a result of high flow through the lesion were less likely to experience an excellent outcome. Prospective, large-scale studies would further characterize pediatric pAVFs and enable quantitative analysis of outcomes to inform best treatment practices.
Topics: Humans; Child; Arteriovenous Fistula; Pia Mater; Child, Preschool; Adolescent; Infant; Female; Infant, Newborn; Treatment Outcome; Male; Intracranial Arteriovenous Malformations
PubMed: 38506930
DOI: 10.1007/s00381-024-06352-5 -
European Journal of Vascular and... Apr 2020Aneurysms arising from arteriovenous fistulae are a common finding among dialysed patients and pose a risk of acute bleeding. The aim of this study was to perform a... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Aneurysms arising from arteriovenous fistulae are a common finding among dialysed patients and pose a risk of acute bleeding. The aim of this study was to perform a systematic review and meta-analysis evaluating the surgical options for the treatment of aneurysmal arteriovenous fistulae.
METHODS
A systematic review and meta-analysis of articles published between January 1973 and March 2019 describing the surgical treatment of arteriovenous fistulae aneurysms.
RESULTS
A total of 794 records were identified. After duplicate and low quality studies were removed, 72 full text articles were reviewed and from these 13 were included in the meta-analysis. The total number of patients was 597. Aneurysms were located in the upper arm in 289 (59%) cases and the smallest diameter of a treated aneurysm was 15 mm. The most frequent indication for treatment was bleeding prevention in 513 (86%) cases. Aneurysmorrhaphy was the surgical method of choice in all 13 studies. The pooled primary patency at 12 months was 82% (95% CI 69%-90%, 12 studies, I = 84%, p < .01). The 12 month primary patency rates were similar for aneurysmorrhaphy with external prosthetic reinforcement (85%, 95% CI 71%-93%, two studies, I = 0%, p = .33) and aneurysmorrhaphy performed using a stapler (74%, 95% CI 61%-83%, four studies, I = 0%, p = .48) and without a stapler (82%, 95% CI 60%-94%, six studies, I = 92%, p < .01).
CONCLUSION
Aneurysmorraphy of arteriovenous fistulae is a procedure with acceptable short and long term results, with a low complication and aneurysm recurrence rate.
Topics: Aneurysm; Arteriovenous Shunt, Surgical; Humans; Renal Dialysis; Time; Upper Extremity; Vascular Patency
PubMed: 31879147
DOI: 10.1016/j.ejvs.2019.07.033 -
Archives of Academic Emergency Medicine 2023This systematic review and meta-analysis aimed to summarize the evidence regarding the impact of needle direction and distance of arteriovenous fistula (AVF) cannulation... (Review)
Review
INTRODUCTION
This systematic review and meta-analysis aimed to summarize the evidence regarding the impact of needle direction and distance of arteriovenous fistula (AVF) cannulation on KT/V (where k is the dialyzer urea clearance, t, the duration of dialysis, and V, the volume of distribution of urea) and access recirculation (AR) as hemodialysis (HD) adequacy criteria.
METHODS
A comprehensive systematic search was performed on international and domestic electronic databases from the earliest to June 4, 2022 using keywords. Analysis was performed in STATA software v.14.
RESULTS
Three randomized control trials (RCTs) and four non-RCT articles were included in the final review. Six studies reported the effects of direction, while four mentioned the effects of distances of AVF cannulation on outcomes of HD adequacy based on KT/V or AR. Results of three non-RCT studies showed that retrograde direction decreased KT/V more than antegrade direction (ES: 0.44, 95% CI: -0.38 to 1.27). Two non-RCT studies showed that antegrade decreased AR compared to the retrograde direction (ES: -0.64, 95%CI: -1.94 to 0.67). However, the results of two RCTs indicated uncertainty about this issue. Two of the four studies suggested that a distance of 5 cm or more in arterial and venous needles had greater adequacy than a distance of less than 5 cm. However, other studies did not confirm this finding.
CONCLUSION
Overall comparison of the results qualitatively and quantitatively indicated uncertainty about the effects of direction and distance of AVF cannulation on HD adequacy outcomes. More studies with high-quality designs, such as RCTs, are required to better understand and adjudicate the effects of needle direction and distance of AVF cannulation on HD adequacy outcomes.
PubMed: 37609532
DOI: 10.22037/aaem.v11i1.1943