2014 Oral Presentations
SCIENTIFIC SESSION VII: CARDIOVASCULAR/THORACIC
HEMODIALYSIS ACCESS IN THE ELDERLY: DO THE RESULTS JUSTIFY
FOLLOWING THE KIDNEY DISEASE OUTCOME QUALITY
INITIATIVE(KDOQI)GUIDLINES?
Houssam K. Younes, MD; Charudatta Bavare, MD, Hosam F. EL Sayed, MD; Mark G.
Davies, MD, PhD, MBA; Eric K. Peden, MD, Methodist DeBakey Heart & Vascular
Center
Background
The KDOQI guidelines have succeeded in increasing fistula implantation to secure long
term dialysis access. However the role of these guidelines in the elderly population
(>70yrs old) is unclear. The aim of this study is to examine the outcomes of access
creation in the elderly population in relation to KDOQI
Methods
We retrospectively reviewed all patients that were older than 70 years old who
underwent upper extremity arteriovenous fistula (AVF) or graft (AVG) creation at our
dialysis access center between 2006-2010. Kaplan-Meier method was used to calculate
primary, assisted-primary and secondary patency rates. The patency, complication and
intervention rates were compared.
Results
161 elderly patients underwent access creation (121 AVF and 40 AVG). 52% were male
with a mean age of 74yrs. At the time of access creation, 65% of the AVF and 70 % of
the AVG group were on catheter based hemodialysis. During follow-up, there was a
trend towards improved primary 1-year and 5 years patency rates for the AVF over
AVG: (88±3% vs. 81±8% at 1 yr and 56±1% vs. 41±13% at 5yrs , AVF vs. AVG, P =
0.06). Secondary patencies were comparable in both groups. Patients in the AVF group
required a total of 1.03 interventions per patient vs. 3.85 per patient for the AVG group
to maintain long term access (P<0.05. While the overall morbidity is 52% for both
groups, the 30 days mortality is 0.02% and 0.05 % for AVF and AVG respectively
Conclusion
Vascular access whether it is an AVF or an AVG in the elderly patient results in
comparable patency and functionality. They generally only require one successful
access creation before death. However, as would be expected, AVGs are associated
with increased number of complications and significantly more interventions during
follow up.
INCREASED RATE OF MYOCARDIAL INFARCTION WITH CAROTID
ENDARTERECTOMY UNDER GENERAL ANESTHESIA: A POPULATION-BASED
STUDY
Benarroch-Gampel J, Sheffield KM, Choi L, Duncan CB, Riall TS, Silva Jr. MB, Killewich
LA, Universty of Texas Medical Branch
Background
To determine if the incidence of stroke, myocardial infarction (MI) or death is different in
patients undergoing carotid endarterectomy (CEA) under general (GA) versus
locoregional (LRA) anesthesia.
Methods
33,291 patients who underwent CEA were identified from the National Surgical Quality
Improvement Program (NSQIP, 2005-2010). The associations between type of
anesthesia (GA vs LRA) and incidence of perioperative stroke, MI and death were
evaluated.
Results
27,844 (83.63%) patients received GA, and were more likely than those receiving LRA
to have symptomatic carotid disease (43.9 vs 40.5%, P<0.0001). No difference in
baseline cardiovascular comorbidities was seen between groups (42.2 vs 41.2%,
P=0.63). In the overall cohort, 1.51% patients had a stroke, 0.66% had an MI, and
0.60% died within 30 days of surgery. In the overall cohort and subgroup analyses, the
postoperative MI rate was significantly higher in patients who underwent GA compared
to LRA. In multivariate models adjusted for patient demographics and clinical
characteristics, patients receiving GA were 2.2 times more likely to have an MI
compared to those receiving LRA (OR=2.20, 95% CI = 1.36–3.58). No differences
between groups were found in the incidence of perioperative stroke or death.
Conclusion
For patients undergoing CEA, the risk of MI is lower when the procedure is performed
under LRA compared to GA. Consideration should be given to performing CEA under
LRA in patients considered high risk for MI