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Frontiers in Public Health 2024A patient-centered dialysis treatment option requires an understanding of patient preferences for alternative vascular accesses and nephrologists often face difficulties...
BACKGROUND
A patient-centered dialysis treatment option requires an understanding of patient preferences for alternative vascular accesses and nephrologists often face difficulties when recommending vascular access to end-stage kidney disease (ESKD) patients. We aimed to quantify the relative importance of various vascular access characteristics to patients, healthcare providers and general population, and how they affect acceptability for patients and healthcare providers.
METHODS
In a discrete choice experiment, patients with maintenance hemodialysis (MHD), healthcare providers, and individuals from the general population were invited to respond to a series of hypothetical vascular access scenarios that differed in five attributes: cumulative patency, infection rate, thrombosis rate, cost, and time to maturation. We estimated the respondents' preference heterogeneity and relative importance of the attributes with a mixed logit model (MXL) and predicted the willingness to pay (WTP) of respondents via a multinomial logit model (MNL).
RESULTS
Healthcare providers ( = 316) and the general population ( = 268) exhibited a favorable inclination toward longer cumulative patency, lower access infection rate and lower access thrombosis rate. In contrast, the patients ( = 253) showed a preference for a 3-year cumulative patency, 8% access infection rate, 35% access thrombosis rate and 1.5 access maturity time, with only the 3-year cumulative patency reaching statistical significance. Among the three respondent groups, the general population found cumulative patency less important than healthcare providers and patients did. Patients demonstrated the highest WTP for cumulative patency, indicating a willingness to pay an extra RMB$24,720(US$3,708) for each additional year of patency time.
CONCLUSION
Patients and healthcare providers had a strong preference for vascular access with superior patency. While the general population preferred vascular access with lower thrombosis rates. These results indicate that most patients prefer autogenous arteriovenous fistula (AVF) as an appropriate choice for vascular access due to its superior patency and lower complications than other vascular access types.
Topics: Humans; Renal Dialysis; Male; Female; Patient Preference; Middle Aged; Kidney Failure, Chronic; Aged; Health Personnel; Adult; Choice Behavior; Surveys and Questionnaires; Arteriovenous Shunt, Surgical; Vascular Patency
PubMed: 38784588
DOI: 10.3389/fpubh.2024.1047769 -
Bioactive Materials Aug 2024Biodegradable metals offer a promising means to ameliorate many of the long-term risks associated with vascular devices made of conventional biostable stent metals....
Biodegradable metals offer a promising means to ameliorate many of the long-term risks associated with vascular devices made of conventional biostable stent metals. While numerous biodegradable metal alloys have been developed and characterized in animal models, knowledge of their blood reactivity and thrombogenicity remains unknown. Metal hemocompatibility is particularly valuable because current generation drug-eluting stents pose a significant long-term thrombosis risk. In this study, four pure metals, widely used as degradable base materials (Fe, Zn, Mg, and Mo), and three alloys commonly used in cardiovascular devices [NiTi, CoCr, and stainless steel (SS)] were evaluated. This work examined how each of these metals activate platelets, coagulation factors, and inflammation using hemocompatibility assays and a clinically relevant non-human primate arteriovenous shunt model. Testing found that while all metals promoted a downstream activation of platelets and coagulation in flowing whole blood, platelet and fibrin attachment to Mg was markedly reduced. Additionally, Fe and Mo trended toward higher platelet attachment and contact pathway activation. Overall, the results suggest that Mg may delay clot initiation, but not eliminate clot formation, indicating the importance of understanding thrombosis in Mg alloys that are currently being developed for clinical use as biodegradable stents.
PubMed: 38774458
DOI: 10.1016/j.bioactmat.2024.05.002 -
Health Technology Assessment... May 2024Arteriovenous fistulas are considered the best option for haemodialysis provision, but as many as 30% fail to mature or suffer early failure. (Observational Study)
Observational Study
BACKGROUND
Arteriovenous fistulas are considered the best option for haemodialysis provision, but as many as 30% fail to mature or suffer early failure.
OBJECTIVE
To assess the feasibility of performing a randomised controlled trial that examines whether, by informing early and effective salvage intervention of fistulas that would otherwise fail, Doppler ultrasound surveillance of developing arteriovenous fistulas improves longer-term arteriovenous fistula patency.
DESIGN
A prospective multicentre observational cohort study (the 'SONAR' study).
SETTING
Seventeen haemodialysis centres in the UK.
PARTICIPANTS
Consenting adults with end-stage renal disease who were scheduled to have an arteriovenous fistula created.
INTERVENTION
Participants underwent Doppler ultrasound surveillance of their arteriovenous fistulas at 2, 4, 6 and 10 weeks after creation, with clinical teams blinded to the ultrasound surveillance findings.
MAIN OUTCOME MEASURES
Fistula maturation at week 10 defined according to ultrasound surveillance parameters of representative venous diameter and blood flow (wrist arteriovenous fistulas: ≥ 4 mm and > 400 ml/minute; elbow arteriovenous fistulas: ≥ 5 mm and > 500 ml/minute). Mixed multivariable logistic regression modelling of the early ultrasound scan data was used to predict arteriovenous fistula non-maturation by 10 weeks and fistula failure at 6 months.
RESULTS
A total of 333 arteriovenous fistulas were created during the study window (47.7% wrist, 52.3% elbow). By 2 weeks, 37 (11.1%) arteriovenous fistulas had failed (thrombosed), but by 10 weeks, 219 of 333 (65.8%) of created arteriovenous fistulas had reached maturity (60.4% wrist, 67.2% elbow). Persistently lower flow rates and venous diameters were observed in those fistulas that did not mature. Models for arteriovenous fistulas' non-maturation could be optimally constructed using the week 4 scan data, with fistula venous diameter and flow rate the most significant variables in explaining wrist fistula maturity failure (positive predictive value 60.6%, 95% confidence interval 43.9% to 77.3%), whereas resistance index and flow rate were most significant for elbow arteriovenous fistulas (positive predictive value 66.7%, 95% confidence interval 48.9% to 84.4%). In contrast to non-maturation, both models predicted fistula maturation much more reliably [negative predictive values of 95.4% (95% confidence interval 91.0% to 99.8%) and 95.6% (95% confidence interval 91.8% to 99.4%) for wrist and elbow, respectively]. Additional follow-up and modelling on a subset ( = 192) of the original SONAR cohort (the SONAR-12M study) revealed the rates of primary, assisted primary and secondary patency arteriovenous fistulas at 6 months were 76.5, 80.7 and 83.3, respectively. Fistula vein size, flow rate and resistance index could identify primary patency failure at 6 months, with similar predictive power as for 10-week arteriovenous fistula maturity failure, but with wide confidence intervals for wrist (positive predictive value 72.7%, 95% confidence interval 46.4% to 99.0%) and elbow (positive predictive value 57.1%, 95% confidence interval 20.5% to 93.8%). These models, moreover, performed poorly at identifying assisted primary and secondary patency failure, likely because a subset of those arteriovenous fistulas identified on ultrasound surveillance as at risk underwent subsequent successful salvage intervention without recourse to early ultrasound data.
CONCLUSIONS
Although early ultrasound can predict fistula maturation and longer-term patency very effectively, it was only moderately good at identifying those fistulas likely to remain immature or to fail within 6 months. Allied to the better- than-expected fistula patency rates achieved (that are further improved by successful salvage), we estimate that a randomised controlled trial comparing early ultrasound-guided intervention against standard care would require at least 1300 fistulas and would achieve only minimal patient benefit.
TRIAL REGISTRATION
This trial is registered as ISRCTN36033877 and ISRCTN17399438.
FUNDING
This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR135572) and is published in full in ; Vol. 28, No. 24. See the NIHR Funding and Awards website for further award information.
Topics: Humans; Renal Dialysis; Female; Male; Middle Aged; Ultrasonography, Doppler; Arteriovenous Shunt, Surgical; Prospective Studies; Kidney Failure, Chronic; Aged; Vascular Patency; United Kingdom; Adult
PubMed: 38768043
DOI: 10.3310/YTBT4172 -
JPGN Reports May 2024This case report presents a rare complication of hepatic cystic echinococcosis in a 12-year-old Latino male, residing in a nonendemic region, who developed long-term...
This case report presents a rare complication of hepatic cystic echinococcosis in a 12-year-old Latino male, residing in a nonendemic region, who developed long-term sequelae of portal vein thrombosis accompanied by the emergence of a hyper-vascular sigmoid colon mass. Portal vein involvement in hepatic cystic echinococcosis is exceedingly uncommon, with limited documented cases. The presentation of the patient included intermittent hematochezia, abdominal pain, and fatigue. Imaging revealed liver cysts and chronic portal vein thrombosis with cavernous transformation, resulting in portal hypertension. Notably, the patient also exhibited mesenteric venous thrombosis, further complicating the clinical picture. The diagnosis was confirmed through echinococcus serology testing. Treatment involved a six month course of Albendazole, puncture-aspiration-injection-reaspiration procedure, splenectomy, and splenorenal shunt to alleviate portal hypertension. This case underscores the significance of considering portal hypertension secondary to hepatic cystic echinococcosis, even in nonendemic regions, particularly in pediatric patients with unique clinical presentations.
PubMed: 38756114
DOI: 10.1002/jpr3.12066 -
Journal of Medical Case Reports May 2024An ascending aortic thrombus is exceedingly rare. Two instances have been reported in the setting of lung cancer, but only after cisplatin use, which is associated with...
BACKGROUND
An ascending aortic thrombus is exceedingly rare. Two instances have been reported in the setting of lung cancer, but only after cisplatin use, which is associated with hypercoagulability. We present the first case of a patient with lung cancer who developed an ascending aortic thrombus without structural risk factors or chemotherapy use.
CASE
A 60-year-old white female with significant smoking history presented with several weeks of malaise. A chest computed tomography scan revealed a 2.2-cm right upper lobe mass. As an outpatient, right hilar lymph node immunohistochemistry (IHC) samples via endobronchial ultrasound confirmed thyroid transcription factor-1 adenocarcinoma. After the procedure, the patient endorsed dyspnea and was advised to go to the emergency department. A chest computed tomography angiography identified a new 2.4 × 1.1 × 1.1 cm thrombus within the proximal aortic arch. No pulmonary emboli or intrapulmonary shunts were identified. A hypercoagulable workup was negative. Transthoracic echocardiogram was without left ventricular thrombus, akinesis or hypokinesis, left atrial dilation, or intracardiac shunts. A lower extremity ultrasound was negative for deep vein thrombosis. Given the procedural risk, thrombectomy was deferred. The patient was transitioned to enoxaparin, and a repeat computed tomography for resolution is in process.
CONCLUSION
To our knowledge, this is the only case detailing an in situ ascending aortic thrombus in the setting of lung cancer, without structural risk factors, chemotherapy use, or other hypercoagulable comorbidities. Optimal management for an aortic thrombus and malignant disease is less clear. Clinicians should be vigilant for unusual arterial thromboses in patients with high metastatic burden.
Topics: Humans; Female; Middle Aged; Lung Neoplasms; Cisplatin; Thrombosis; Adenocarcinoma of Lung; Aortic Diseases; Anticoagulants; Adenocarcinoma; Enoxaparin; Antineoplastic Agents; Computed Tomography Angiography; Aorta
PubMed: 38730499
DOI: 10.1186/s13256-024-04515-1 -
Cureus Apr 2024Intracranial aneurysms are common conditions that are usually asymptomatic and found incidentally, yet they can rupture and lead to subarachnoid hemorrhage, in addition...
Intracranial aneurysms are common conditions that are usually asymptomatic and found incidentally, yet they can rupture and lead to subarachnoid hemorrhage, in addition to causing mass effects, especially with larger aneurysms. Bilateral supraclinoid aneurysms are extremely rare and were reported in only two instances. These aneurysms can cause a range of symptoms and require careful management. We present the case of a 42-year-old man with no concomitant medical conditions who presented with a persistent headache and deteriorating visual acuity over time. Neurological examination was unremarkable. Connective tissue diseases were ruled out by clinical and laboratory testing. Bilateral large, partly thrombosed supraclinoid segment fusiform aneurysms of the internal carotid artery that are causing midbrain compression and obstructive hydrocephalus were shown by brain CT, CT angiography, MRI, and MR angiography (MRA). Both surgery and endovascular treatment were denied by the patient. However, a ventriculoperitoneal shunt was placed in an outside center and relieved the patient's symptoms. The patient is being followed up. In conclusion, bilateral giant aneurysms of the internal carotid artery present unique challenges and can lead to various clinical manifestations and effects on surrounding structures. In this case, we reported the first instance of obstructed hydrocephalus caused by the largest bilateral supraclinoid carotid aneurysms.
PubMed: 38715999
DOI: 10.7759/cureus.57780 -
European Heart Journal. Case Reports May 2024Coronary cameral fistula is a rare diagnosis, which may be picked up incidentally on cardiac imaging. While majority of cases is asymptomatic, they can be complicated by...
BACKGROUND
Coronary cameral fistula is a rare diagnosis, which may be picked up incidentally on cardiac imaging. While majority of cases is asymptomatic, they can be complicated by myocardial ischaemia, arrhythmias, heart failure, infective endocarditis, and rarely rupture or thrombosis of the fistula leading to sudden death.
CASE SUMMARY
A 73-year-old female presents with fever, lethargy, and examination finding of a continuous cardiac murmur. CT coronary angiogram confirmed the presence of a coronary cameral fistula, with an aneurysmal RCA seen arising from the right coronary sinus, following an extensive tortuous course wrapping around the heart, and terminating at the right atrium. While there was initial streptococcus bacteraemia identified on blood culture sampling, no obvious masses were detected on the valves, chambers, or along the course of the fistula. Over time, she develops anginal chest pain and heart failure symptoms, with progressive dilatation of the right ventricle and functional tricuspid regurgitation secondary to shunting of the fistula into the right chambers. Surgical intervention was then pursued and successfully addressed these complications.
DISCUSSION
This case report highlights the importance of advanced imaging modalities for accurate diagnosis of coronary cameral fistulae, addressing late manifestations of the disease and the necessity for a collaborative, multidisciplinary approach in managing complex cardiac anomalies.
PubMed: 38715625
DOI: 10.1093/ehjcr/ytae207 -
Cureus Apr 2024Lung perfusion scintigraphy is a common nuclear medicine exam performed for the evaluation of pulmonary emboli, often in the emergency setting. There can be confusion...
Lung perfusion scintigraphy is a common nuclear medicine exam performed for the evaluation of pulmonary emboli, often in the emergency setting. There can be confusion when a radiotracer is located outside of the normal physiologic distribution. This can occur due to improper radionuclide tagging or may be due to anatomic variations. We present a case where a patient presented with bilateral lower extremity deep vein thrombosis and a nuclear medicine lung perfusion scintigraphy showing a complete right-to-left shunt related to a rare anatomical variant of a duplicated superior vena cava (SVC) with the right SVC draining directly into the systemic circulation via the left atrium.
PubMed: 38711729
DOI: 10.7759/cureus.57702 -
CVIR Endovascular May 2024Arteriovenous fistulas involving the anterior abdominal wall can result from trauma. Such fistulas may remain asymptomatic and undetected for a prolonged duration of...
BACKGROUND
Arteriovenous fistulas involving the anterior abdominal wall can result from trauma. Such fistulas may remain asymptomatic and undetected for a prolonged duration of time. They tend to recruit multiple arterial feeders with remodelling in the feeding arteries, making them challenging to treat.
CASE PRESENTATION
We discuss a rare case of a 60-year-old male who presented with complaints of a progressive painless swelling in right lower abdomen. There was a history of blunt injury to abdomen at the same site during alleged road traffic accident 3 years ago. On CT angiography, an arteriovenous fistula was localised to the anterior abdominal wall arising predominantly from the right inferior epigastric artery with a giant venous sac and terminating as a tortuous single venous channel into the right external iliac vein. Few other small feeders were also seen arising from branches of right superior epigastric artery along Winslow's pathway. The main challenge in endovascular management of this patient was embolization of a high flow shunt with a large venous sac and multiple arterial feeders. The dominant arterial feeder was embolized using vascular plug. The superficial location of the lesion offered an additional percutaneous window besides endovascular approach. The venous sac was percutaneously accessed and embolized using n-butyl cyanoacrylate after balloon occlusion of outflow vein. On follow up ultrasonographic evaluation at 3 months, near complete thrombosis of the venous sac was achieved.
CONCLUSIONS
Traumatic arteriovenous fistulas involving the inferior epigastric vessels are rare clinical entities. CT angiogram and digital subtraction angiography help in the optimal diagnosis and treatment planning. The use of mechanical embolization devices to cause flow arrest offers an opportunity to use liquid embolic agents which offer better percolation within the lesion. Interventional radiology offers an ideal management of these complex high flow fistulas with a good technical success and acceptable safety profile.
PubMed: 38709345
DOI: 10.1186/s42155-024-00455-5 -
Heliyon May 2024Acute liver failure is an uncommon presentation in the clinic. Common causes for acute liver failure include viral hepatitis and drug-related hepatotoxicity. However,...
Acute liver failure is an uncommon presentation in the clinic. Common causes for acute liver failure include viral hepatitis and drug-related hepatotoxicity. However, acute liver failure due to Budd-Chiari syndrome is rare. This case highlights the importance of necessary constrast-enhanced imaging studies to rule out vascular etiologies of acute liver failure, in addition to common causes like viral or drug-induced hepatic failure. We present a case of a male Chinese patient who presented with nausea, vomiting, fatigue, and fever after eating a large amount of fatty food. Six days after hospitalization, the patient developed acute liver failure and hepatic encephalopathy. Contrast-enhanced computerized tomography and ultrasound examinations revealed thromboses in the hepatic veins and inferior vena cava. Further testing also showed decreased protein C activity. Therefore, a diagnosis of Budd-Chiari syndrome secondary to protein C deficiency was made. He received supportive care and a transjugular intrahepatic portal shunt. Hepatic function, coagulation panel results, and clinical presentations gradually returned to normal. Budd-Chiari syndrome from protein C deficiency could be a rare but valid cause of acute liver failure in Chinese patients.
PubMed: 38707271
DOI: 10.1016/j.heliyon.2024.e29776