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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In Spain&#44; the incidence and prevalence of chronic kidney disease patients who require renal replacement therapy have increased more than 100&#37; over the last 15 years<span class="elsevierStyleSup">1</span> &#40;from 61 and 392 patients per million in 1991 to 132 and 1009&#44; respectively&#44; in 2007&#41;&#46; The age group with the highest percentage increase is patients over 75 years of age &#40;from 8&#46;5&#37; of the patients prevalent in 1992 to 40&#37; currently&#41;&#46; In this group&#44; most patients are treated by haemodialysis &#40;94&#37; of incident patients&#41; and few change technique throughout their lives&#46; Approximately 10&#37; of haemodialysis patients in our setting are treated with prosthetic arteriovenous fistulas &#40;AVG&#41;&#46;<span class="elsevierStyleSup">2-5</span></p><p class="elsevierStylePara">AVG are a good option in patients whose superficial venous system is inadequate for creating an autologous fistula or fistulas after previous loss of fistulas&#46; They have the advantage of being easy to cannulate&#44; their early failure rate is low and they have a short maturation time&#46; However&#44; their complication rate is much higher than that of native arteriovenous fistulas &#40;n-AVF&#41; and their long-term patency is lower&#46; The treatment of AVG stenoses and thromboses can be performed by radiological or surgical methods&#46; Each centre should establish maintenance protocols in accordance with their resources in order to achieve healthcare quality indicators that comply with international recommendations&#46;<span class="elsevierStyleSup">6&#44;7</span></p><p class="elsevierStylePara">In our hospital&#44; we have a multidisciplinary haemodialysis vascular access team that has taken a particular interest in developing protocols and defining indicators in our setting&#46;<span class="elsevierStyleSup">8&#44;9</span></p><p class="elsevierStylePara">In this study&#44; we present our AVG maintenance protocol and the evaluation of its results after eight years of follow-up&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Prospective study on the application of a protocol for the treatment of AVG dysfunction &#40;stenosis and thrombosis&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Setting</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Our hospital provides haemodialysis vascular access service for a healthcare catchment area in the Community of Madrid of as well as regularly serving the units of the provinces of &#193;vila and Segovia &#40;250&#160;000 inhabitants&#41;&#46; Here&#44; the medical records are computerised and there is a specific protocol for interventions related to arteriovenous fistulas that the head surgeon completes at the end of intervention&#46; The interventions were performed by four surgeons of the service involved but not exclusively dedicated to it &#40;their activity is that of any general surgeon&#41; without specific shifts&#46; There is no urgent service for radiological procedures&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">During the 1999-2007 period&#44; 115 patients received 130 AVG &#40;15&#37; of the total arteriovenous fistulas performed&#41;&#46; We excluded 34 AVG patients from the study due to a lack of follow-up &#40;early failure or transfer to other centres&#41;&#46; In the rest &#40;96&#41;&#44; a multidisciplinary protocol was applied for the diagnosis and treatment of dysfunctions and thrombosis&#46; In the analysis of results&#44; we were assisted by computerised medical records and a specific surgical protocol in the case of vascular access for haemodialysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Surgical technique</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">It was decided to introduce a AVG after ruling out the possibility of creating an autologous fistula because of an inadequate superficial venous system or after failure of previous fistulas&#46; The material used in all cases was expanded polytetrafluoroethylene &#40;ePTFE 6mmx40cm&#41;&#46; The anatomical configuration of the AVG was decided on the basis of the calibre of the patient&#8217;s deep venous system&#44; using two approaches&#58;</p><li>Antebrachial loop &#40;bridge between the humeral artery and the basilic vein or humeral veins&#41;&#44; that we call LOOP&#46;</li><li>Curve in arm &#40;bridge between the humeral artery and axillary vein&#41;&#44; that we call HAX&#46;</li><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Follow-up</span></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">A fistulography was requested in cases of dysfunction of the AVG with dysfunction being considered as a dynamic venous pressure &#62;200mm&#47;Hg with flows of 300ml&#47;min&#44; Kt&#47;V &#60;0&#46;8 or recirculation &#62;25&#37;&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Protocol</span></p><p class="elsevierStylePara">The preferred initial treatment in the case of stenoses &#40;Figure 1&#41; of the AVG was percutaneous transluminal angioplasty &#40;PTA&#41; conducted by interventional radiologists&#44; except in the case of multiple or long stenoses or complete obstruction of the drainage vein&#46; The latter was carried out by antegrade puncture of the prosthetic fistula&#46; After studying the Doppler echogram and fistulogram&#44; the stenoses received a 0&#46;035&#8221; Terumo hydrophilic guidewire&#44; with a 6F feeder being positioned&#46; The PTA indication was based on a morphological study of the stenoses&#44; with pressure gradients only being measured in uncertain cases&#46; The balloon diameter was 6mm for intraprosthetic stenoses&#44; with diameters of 7mm to 8mm at the anastomoses or at native vein level&#46; In the case of resistant or recurrent stenosis&#44; cutting balloon catheters were used &#40;over a 0&#46;014&#8221; guidewire&#41;&#44; which were of a similar calibre to the conventional balloons&#46; A stent was introduced in cases of central stenosis whose surgical repair would require very invasive surgery&#46;</p><p class="elsevierStylePara">Indications for surgery on stenoses are limited to persistent stenoses &#40;a suboptimal result of percutaneous dilation&#41; or stenoses recurring in less than three months&#44; with an analysis of the stenotic area being performed in these cases by the surgical technique necessary in each case &#40;in the case of stenosis in the venous anastomosis&#44; proximal vein bypass was performed&#59; if the stenosis was intraprosthetic&#44; the prosthesis was partially replaced&#59; and if the stenosis was found at the arterial anastomosis&#44; a new proximal anastomosis was created provided there had been no stenosis in the distal artery &#91;due to the risk of aggravating the ischaemia&#93;&#41;&#46;</p><p class="elsevierStylePara">Thromboses &#40;Figure 2&#41; were treated urgently in order to avoid the use of unnecessary catheters&#46; Surgical thrombectomy was carried out with a Fogarty catheter&#46; If the surgeon did not find a reason for the thrombosis&#44; an urgent fistulography was carried out and the stenoses detected by PTA were treated&#46; If the surgeon found a reason for the latter&#44; it was corrected by a prosthetic bridge in the stenotic area&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Definitions and statistical analysis</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Primary survival&#58; time until the first thrombosis of AVG&#46;</p><p class="elsevierStylePara">Secondary survival&#58; time until the definitive thrombosis&#46;</p><p class="elsevierStylePara">Thrombosis rate&#58; episodes of thrombosis&#47;AVG at risk&#47;year&#46;</p><p class="elsevierStylePara">Number of admissions related to AVG thrombosis&#46;</p><p class="elsevierStylePara">After surgical repair due to thrombosis&#44; the AVG was considered to be patent if it could be used in the next dialysis session&#44; avoiding a central venous catheterisation &#40;CVC&#41;&#46;</p><p class="elsevierStylePara">Statistical analysis was carried out with the SPSS software using Kaplan-Meier survival curves and carrying out comparison by the log-rank test&#46;</p><p class="elsevierStylePara">No patient received antiplatelet or anticoagulant treatment as an indication for maintaining the patency of the vascular access&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">A total of 96 AVG in 88 patients were included in the study and follow-up using the protocol&#46; Thirty-six of the AVG were LOOP and 60 were HAX&#46;</p><p class="elsevierStylePara">During the study period&#44; in accordance with the protocol&#44; 131 PTA&#44; 15 stents&#44; 109 thombectomies and 52 proximal vein bridges were necessary to maintain the patency of the AVG&#46;</p><p class="elsevierStylePara">There were no procedure-related deaths &#40;either in the incorporation of the AVG or in their repair&#41; and there was only one infection after stenting&#44; requiring the removal of the stent&#46; There were no pulmonary embolisms&#44; including in the humeral artery&#46; The patency rate after surgical treatment of a thrombosis was 80&#37;&#44; with a CVC being avoided in 80&#37; of the thrombosis episodes&#46;</p><p class="elsevierStylePara">At the end of the study 63&#46;5&#37; &#40;n&#61;61&#41; of AVG were patent and 36&#46;4&#37; &#40;n&#61;35&#41; of fistulas were thrombosed&#46; 38&#46;5&#37; &#40;n&#61;37&#41; of the fistulas remained patent when the patient died&#46; 5&#46;1&#37; &#40;n&#61;5&#41; of patients were transplanted with patent AVG&#46; At the end of follow-up&#44; 19&#46;7&#37; &#40;n&#61;19&#41; remained patent and patients were on a haemodialysis programme&#46;</p><p class="elsevierStylePara">The annual rate of AVG thrombosis-related hospital admissions was 0&#46;03 admissions&#47;patient&#47;year&#46;</p><p class="elsevierStylePara">The annual thrombosis rate for AVG during this period was 0&#46;45&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Primary patency</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The overall mean primary patency &#40;Figure 3&#41; was 2&#46;55 years&#44; with a confidence interval &#40;CI&#41; of 95&#37; &#40;1&#46;91-3&#46;17&#41;&#46; One year survival was 73&#46;68&#37;&#44; at two years&#44; it was 60&#46;21&#37; and at three years&#44; it was 37&#46;52&#37;&#46; A LOOP type fistula had a mean survival of 2&#46;1 years &#40;0&#46;65 to 3&#46;55&#41;&#46; One year survival was 62&#46;99&#37;&#44; at two years it was 56&#46;7&#37; and at three years&#44; it was 41&#46;34&#37;&#46; A HAX type fistula had a median survival rate of 2&#46;6 years &#40;2&#46;02 to 3&#46;23&#41;&#46; One year survival was 79&#46;9&#37;&#44; at two years it was 61&#46;96&#37;&#44; and at three years it was 41&#46;59&#37; &#40;log-rank 0&#46;33&#44; <span class="elsevierStyleItalic">p</span>-value &#46;57&#41; &#40;Figure 4&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Secondary patency</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Mean secondary survival was 4&#46;65 years&#44; with a CI of 95&#37; &#40;3&#46;96-5&#46;34&#41;&#46; At one year&#44; the fistula survival rate was 89&#46;49&#37;&#44; the two-year survival rate was 84&#46;07&#37; and at three years 66&#46;84&#37; survived &#40;Figure 5&#41;&#46; The LOOP type fistulas had a mean survival of 4&#46;13 years &#40;1&#46;84-6&#46;43&#41;&#46; At one year 87&#46;88&#37; survived&#44; at two years 81&#46;06&#37; survived&#44; and at three years the survival rate was 50&#46;66&#37;&#46; The HAX type fistulas have a mean survival of 5&#46;71 years &#40;2&#46;63-8&#46;79&#41;&#46; At one year&#44; 90&#46;54&#37; survived&#44; at two years 86&#46;07&#37; and at three years&#44; 75&#46;46&#37; &#40;log-rank 1&#46;94&#59; <span class="elsevierStyleItalic">P</span>-value &#46;1633&#41; &#40;Figure 6&#41;&#46; Although the patency of HAX was greater than that of LOOP&#44; there are no statistically significant differences&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In spite of displaying a higher rate of complications than n-AVF&#44; AVG may be an excellent solution for patients with an exhausted superficial venous system and in our experience&#44; they may also be the definitive access in elderly patients &#40;almost 40&#37; of our patients died with patent AVG&#41;&#46; Surgery is not much more complex than for an n-AVF and it can be performed under local anaesthetic on an outpatient basis&#46;<span class="elsevierStyleSup">10</span> Furthermore&#44; if maintenance protocol is applied&#44; it is possible to rescue most AVG&#44; achieving patency rates of 90&#37; at one year and over 50&#37; at three years&#46;<span class="elsevierStyleSup">10-12</span></p><p class="elsevierStylePara">In our centre&#44; there has been a multidisciplinary group of specialists in haemodialysis vascular access for 10 years made up of nephrologists&#44; radiologists and surgeons&#46; They have designed follow-up protocol and healthcare quality indicators&#46;<span class="elsevierStyleSup">8&#44;9</span> Furthermore&#44; a distribution of work has been carried out amongst the services involved&#58;</p><ul><li>The clinical follow-up of AVG&#44; as well as the diagnosis of dysfunctions&#44; is carried out by the Nephrology Service and a special effort has been made to detect dysfunctions at an early stage&#46;</li><li>Treatment of dysfunctions &#40;both stenosis and thrombosis&#41; of the AVG may be carried out by radiological or surgical methods&#46; In general&#44; the advantage of radiological techniques compared to surgical techniques is the &#8220;saving&#8221; of proximal vascular territory and its disadvantage is the requirement for a greater number of procedures to maintain AVG patency&#46;<span class="elsevierStyleSup">13-21</span></li></ul><p class="elsevierStylePara">The protocol designed in our centre is based on the DOQI recommendations and adapted to the availability of our means&#46; It was never our aim to compare techniques&#44; but rather to apply the most appropriate technique in each case&#44; in accordance with the means available and the experience of the doctors&#46;</p><p class="elsevierStylePara">Treatment of thrombosis has been considered an urgent procedure to avoid CVC&#46; The availability of the vascular radiology room in our centre is limited&#44; and urgent procedures are not able to be performed&#59; therefore&#44; the treatment of thrombosis was always carried out by the Surgery Service&#44; due to the availability of a 24-hour service&#46; The diagnosis and treatment of stenoses was in most cases carried out on a scheduled basis by the Radiology Service&#46; This approach has the advantage of performing the diagnosis and treatment of dysfunction in the same process&#44; reserving surgery for cases of persistence or relapse&#46;</p><p class="elsevierStylePara">In our experience&#44; the rigorous application of this protocol allows healthcare quality indicators to be maintained&#44; in accordance with those who demand national and international guidelines<span class="elsevierStyleSup">6&#44;7</span> for the treatment of AVG dysfunctions and thrombosis&#58; patent percentage at three years above 50&#37; and a thrombosis rate below 0&#46;5 episodes per patient and year&#46;</p><p class="elsevierStylePara">These data have repercussions on other healthcare indicators&#44; since AVF are a major source of morbidity and hospital admissions&#46; Thus&#44; in our centre&#44; the complications of vascular access are not the main reason for admission&#44; with 0&#46;1 episodes per patient and year&#44;<span class="elsevierStyleSup">9</span> that is&#44; half of the figures published in other series&#44;<span class="elsevierStyleSup">3</span> and specifically&#44; there are minimal hospital admissions related to thrombosis of AVG&#46;</p><p class="elsevierStylePara">We firmly believe that the best results in the maintenance of the AVG are obtained with a multidisciplinary approach&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48627&#95;en&#95;f1&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48627_en_f1_11898__1_copia.jpg" alt="Protocol for prosthetic arteriovenous fistula dysfunction due to stenosis"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Protocol for prosthetic arteriovenous fistula dysfunction due to stenosis</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48628&#95;en&#95;f2&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48628_en_f2_11898__1_copia.jpg" alt="Protocol for thrombosis of the prosthetic arteriovenous fistula"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Protocol for thrombosis of the prosthetic arteriovenous fistula</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48629&#95;en&#95;f3&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48629_en_f3_11898__1_copia.jpg" alt="Primary survival &#40;overall&#41;"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Primary survival &#40;overall&#41;</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48630&#95;en&#95;f4&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48630_en_f4_11898__1_copia.jpg" alt="Primary survival of antebrachial LOOP&#47;HAX"></img></a></p><p class="elsevierStylePara">Figure 4&#46; Primary survival of antebrachial LOOP&#47;HAX</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48631&#95;en&#95;f5&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48631_en_f5_11898__1_copia.jpg" alt="Secondary survival &#40;overall&#41;"></img></a></p><p class="elsevierStylePara">Figure 5&#46; Secondary survival &#40;overall&#41;</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48632&#95;en&#95;f6&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48632_en_f6_11898__1_copia.jpg" alt="Secondary survival of antebrachial LOOP&#47;HAX"></img></a></p><p class="elsevierStylePara">Figure 6&#46; Secondary survival of antebrachial LOOP&#47;HAX</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Objetivo&#58; </span>An&#225;lisis de la aplicaci&#243;n de un protocolo multidisciplinar para el mantenimiento de las f&#237;stulas arteriovenosas para hemodi&#225;lisis prot&#233;sicas&#46; <span class="elsevierStyleBold">M&#233;todo&#58; </span>Recogida prospectiva de todas las intervenciones realizadas para el tratamiento de la disfunci&#243;n de las f&#237;stulas arteriovenosas prot&#233;sicas &#40;FAVP&#41; en el per&#237;odo 1999-2007 siguiendo un protocolo multidisciplinario&#46; Las estenosis se trataron mediante angioplastia&#44; &#40;ATP&#41; excepto en casos de persistencia o recurrencia antes de tres meses&#46; Las trombosis fueron tratadas siempre mediante trombectom&#237;a quir&#250;rgica y puente de PTFE si fue necesario&#46; Se analizan el n&#250;mero y el tipo de procedimientos&#44; las complicaciones&#44; la permeabilidad primaria y secundaria de las FAVP&#46;<span class="elsevierStyleBold"> Resultados&#58; </span>Se complet&#243; el seguimiento de 96 FAVP&#46; Todas fueron pr&#243;tesis de PTFE de 6x40 mm &#40;Gore-Tex<span class="elsevierStyleSup">&#174;</span>&#41;&#46; Treinta y seis se colocaron en el antebrazo con anastomosis humerobas&#237;lica en asa y 60 en el brazo con anastomosis humeroaxilar curva&#46; Durante el per&#237;odo de estudio fueron necesarios 131 angioplastias transluminales percut&#225;neas&#44; 15 <span class="elsevierStyleItalic">stents</span>&#44; 109 trombectom&#237;as y 52 puentes a vena proximal para el mantenimiento de la permeabilidad de las FAVP&#46; La permeabilidad primaria fue del 73&#44;68 &#37;&#44; 60&#44;21 &#37; y 37&#44;52 &#37; a 1&#44; 2 y 3 a&#241;os&#44; respectivamente&#46; La permeabilidad secundaria fue del 89&#44;49 &#37;&#44; 84&#44;07 &#37; y 66&#44;84 &#37; a 1&#44; 2 y 3 a&#241;os&#44; respectivamente&#46; Se consigui&#243; evitar la colocaci&#243;n de un cat&#233;ter central en el 80 &#37; de las intervenciones por trombosis&#46; No se produjeron muertes relacionadas con los procedimientos&#46; La tasa de ingresos hospitalarios relacionados con la trombosis de las FAVP fue de 0&#44;03 paciente&#47;a&#241;o&#46; <span class="elsevierStyleBold">Conclusiones&#58; </span>La aplicaci&#243;n de un protocolo multidisciplinar en el tratamiento de las disfunciones de las FAVP siguiendo las recomendaciones de las gu&#237;as internacionales prolonga la permeabilidad de las FAVP y disminuye el uso de cat&#233;teres centrales&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Purpose&#58; </span>To analize the clinic results of the implantation of a multidisciplinary protocol to maintain&#160; ermeability of the arteriovenous hemodialysis grafts &#40;AVG&#41;&#46; <span class="elsevierStyleBold">Methods&#58; </span>Prospective recording of all interventions &#40;radiological and surgical&#41; on AVG dysfunction in the 1999-2007 period&#46; The AVG stenosis were always treated by percutaneous angioplasty &#40;PA&#41; except&#160; stenosis recurrence in less than three months or persistence after PA&#46; The AVG thromboses were always treated by surgical thrombectomy plus PTFE bridge if necessary&#46; Complications&#44; primary and secondary AVG patency were reviewed&#46; <span class="elsevierStyleBold">Results&#58;</span> Ninety six dysfunction AVG were collected for study&#46; All of them were 6x40mm standard wall PTFE &#40;Gore-Tex<span class="elsevierStyleSup">&#174;</span>&#41;&#46; Thirty six of them were humero-basilic antebraquial loop and sixty were humero-axillary upper arm curve configuration&#46; During the study&#44; 52 PTFE bridges&#44; 109 surgical thrombectomies&#44; 131 PA&#44; and 15 stents were needed to maintain FAVP permeability&#46; Primay patency was 73&#46;68&#37;&#44; 60&#46;21&#37; and 37&#46;52&#37; at one&#44; two and three years respectively&#46; Secondary patency was 89&#46;49&#37;&#44; 84&#46;07&#37; and 66&#46;84&#37; at one&#44; two and three years respectively&#46; We avoid a central venous catheter &#40;CVC&#41; in the 80&#37; of&#160; intervention for thrombosis dysfunction&#46; No surgical or radiological related deaths occurred&#46; Median hospital admission related with AVG thrombosis was 0&#46;03&#47;patient&#47;year&#46; <span class="elsevierStyleBold">Conclusion&#58; </span>The application of a combined protocol for the treatment of AVG dysfunction and thrombosis&#44; according to DOQI recomendations obtains good results in AVG patency in our experience&#46;</p>"
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Multidisciplinary approach to hemodialysis graft dysfunction and thrombosis
Tratamiento multidisciplinar de la disfunción y la trombosis de las fístulas arteriovenosas protésicas para hemodiálisis
Pedro Jiménez-Almonacida, Enrique Grussb, Marta Jimenez-Toscanoc, Marta Jiménez-Toscanod, Manuel Lasalaa, Jose Antonio Ruedac, José A. Ruedaa, Laura Vegaa, Gil Rodrigueze, Gil Rodríguezf, Raul De la Cruzg, Raúl De la Cruzh, Mar Pardoa, Beatriz Fernándeza, Paula Lópezi, Paula Lópezb, Jaime Martin Cavanac, Jaime Martín-Cavanaa, Antonio Quintánsa
a Unidad de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid,
b Unidad de Nefrología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid,
c Unidad de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain,
d Unidad de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid,
e Unidad de Epidemiología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain,
f Unidad de Epidemiología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid,
g Unidad de Radiología Vascular, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain,
h Unidad de Radiología Vascular, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid,
i Unidad de Nefrología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In Spain&#44; the incidence and prevalence of chronic kidney disease patients who require renal replacement therapy have increased more than 100&#37; over the last 15 years<span class="elsevierStyleSup">1</span> &#40;from 61 and 392 patients per million in 1991 to 132 and 1009&#44; respectively&#44; in 2007&#41;&#46; The age group with the highest percentage increase is patients over 75 years of age &#40;from 8&#46;5&#37; of the patients prevalent in 1992 to 40&#37; currently&#41;&#46; In this group&#44; most patients are treated by haemodialysis &#40;94&#37; of incident patients&#41; and few change technique throughout their lives&#46; Approximately 10&#37; of haemodialysis patients in our setting are treated with prosthetic arteriovenous fistulas &#40;AVG&#41;&#46;<span class="elsevierStyleSup">2-5</span></p><p class="elsevierStylePara">AVG are a good option in patients whose superficial venous system is inadequate for creating an autologous fistula or fistulas after previous loss of fistulas&#46; They have the advantage of being easy to cannulate&#44; their early failure rate is low and they have a short maturation time&#46; However&#44; their complication rate is much higher than that of native arteriovenous fistulas &#40;n-AVF&#41; and their long-term patency is lower&#46; The treatment of AVG stenoses and thromboses can be performed by radiological or surgical methods&#46; Each centre should establish maintenance protocols in accordance with their resources in order to achieve healthcare quality indicators that comply with international recommendations&#46;<span class="elsevierStyleSup">6&#44;7</span></p><p class="elsevierStylePara">In our hospital&#44; we have a multidisciplinary haemodialysis vascular access team that has taken a particular interest in developing protocols and defining indicators in our setting&#46;<span class="elsevierStyleSup">8&#44;9</span></p><p class="elsevierStylePara">In this study&#44; we present our AVG maintenance protocol and the evaluation of its results after eight years of follow-up&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Prospective study on the application of a protocol for the treatment of AVG dysfunction &#40;stenosis and thrombosis&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Setting</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Our hospital provides haemodialysis vascular access service for a healthcare catchment area in the Community of Madrid of as well as regularly serving the units of the provinces of &#193;vila and Segovia &#40;250&#160;000 inhabitants&#41;&#46; Here&#44; the medical records are computerised and there is a specific protocol for interventions related to arteriovenous fistulas that the head surgeon completes at the end of intervention&#46; The interventions were performed by four surgeons of the service involved but not exclusively dedicated to it &#40;their activity is that of any general surgeon&#41; without specific shifts&#46; There is no urgent service for radiological procedures&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">During the 1999-2007 period&#44; 115 patients received 130 AVG &#40;15&#37; of the total arteriovenous fistulas performed&#41;&#46; We excluded 34 AVG patients from the study due to a lack of follow-up &#40;early failure or transfer to other centres&#41;&#46; In the rest &#40;96&#41;&#44; a multidisciplinary protocol was applied for the diagnosis and treatment of dysfunctions and thrombosis&#46; In the analysis of results&#44; we were assisted by computerised medical records and a specific surgical protocol in the case of vascular access for haemodialysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Surgical technique</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">It was decided to introduce a AVG after ruling out the possibility of creating an autologous fistula because of an inadequate superficial venous system or after failure of previous fistulas&#46; The material used in all cases was expanded polytetrafluoroethylene &#40;ePTFE 6mmx40cm&#41;&#46; The anatomical configuration of the AVG was decided on the basis of the calibre of the patient&#8217;s deep venous system&#44; using two approaches&#58;</p><li>Antebrachial loop &#40;bridge between the humeral artery and the basilic vein or humeral veins&#41;&#44; that we call LOOP&#46;</li><li>Curve in arm &#40;bridge between the humeral artery and axillary vein&#41;&#44; that we call HAX&#46;</li><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Follow-up</span></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">A fistulography was requested in cases of dysfunction of the AVG with dysfunction being considered as a dynamic venous pressure &#62;200mm&#47;Hg with flows of 300ml&#47;min&#44; Kt&#47;V &#60;0&#46;8 or recirculation &#62;25&#37;&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Protocol</span></p><p class="elsevierStylePara">The preferred initial treatment in the case of stenoses &#40;Figure 1&#41; of the AVG was percutaneous transluminal angioplasty &#40;PTA&#41; conducted by interventional radiologists&#44; except in the case of multiple or long stenoses or complete obstruction of the drainage vein&#46; The latter was carried out by antegrade puncture of the prosthetic fistula&#46; After studying the Doppler echogram and fistulogram&#44; the stenoses received a 0&#46;035&#8221; Terumo hydrophilic guidewire&#44; with a 6F feeder being positioned&#46; The PTA indication was based on a morphological study of the stenoses&#44; with pressure gradients only being measured in uncertain cases&#46; The balloon diameter was 6mm for intraprosthetic stenoses&#44; with diameters of 7mm to 8mm at the anastomoses or at native vein level&#46; In the case of resistant or recurrent stenosis&#44; cutting balloon catheters were used &#40;over a 0&#46;014&#8221; guidewire&#41;&#44; which were of a similar calibre to the conventional balloons&#46; A stent was introduced in cases of central stenosis whose surgical repair would require very invasive surgery&#46;</p><p class="elsevierStylePara">Indications for surgery on stenoses are limited to persistent stenoses &#40;a suboptimal result of percutaneous dilation&#41; or stenoses recurring in less than three months&#44; with an analysis of the stenotic area being performed in these cases by the surgical technique necessary in each case &#40;in the case of stenosis in the venous anastomosis&#44; proximal vein bypass was performed&#59; if the stenosis was intraprosthetic&#44; the prosthesis was partially replaced&#59; and if the stenosis was found at the arterial anastomosis&#44; a new proximal anastomosis was created provided there had been no stenosis in the distal artery &#91;due to the risk of aggravating the ischaemia&#93;&#41;&#46;</p><p class="elsevierStylePara">Thromboses &#40;Figure 2&#41; were treated urgently in order to avoid the use of unnecessary catheters&#46; Surgical thrombectomy was carried out with a Fogarty catheter&#46; If the surgeon did not find a reason for the thrombosis&#44; an urgent fistulography was carried out and the stenoses detected by PTA were treated&#46; If the surgeon found a reason for the latter&#44; it was corrected by a prosthetic bridge in the stenotic area&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Definitions and statistical analysis</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Primary survival&#58; time until the first thrombosis of AVG&#46;</p><p class="elsevierStylePara">Secondary survival&#58; time until the definitive thrombosis&#46;</p><p class="elsevierStylePara">Thrombosis rate&#58; episodes of thrombosis&#47;AVG at risk&#47;year&#46;</p><p class="elsevierStylePara">Number of admissions related to AVG thrombosis&#46;</p><p class="elsevierStylePara">After surgical repair due to thrombosis&#44; the AVG was considered to be patent if it could be used in the next dialysis session&#44; avoiding a central venous catheterisation &#40;CVC&#41;&#46;</p><p class="elsevierStylePara">Statistical analysis was carried out with the SPSS software using Kaplan-Meier survival curves and carrying out comparison by the log-rank test&#46;</p><p class="elsevierStylePara">No patient received antiplatelet or anticoagulant treatment as an indication for maintaining the patency of the vascular access&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">A total of 96 AVG in 88 patients were included in the study and follow-up using the protocol&#46; Thirty-six of the AVG were LOOP and 60 were HAX&#46;</p><p class="elsevierStylePara">During the study period&#44; in accordance with the protocol&#44; 131 PTA&#44; 15 stents&#44; 109 thombectomies and 52 proximal vein bridges were necessary to maintain the patency of the AVG&#46;</p><p class="elsevierStylePara">There were no procedure-related deaths &#40;either in the incorporation of the AVG or in their repair&#41; and there was only one infection after stenting&#44; requiring the removal of the stent&#46; There were no pulmonary embolisms&#44; including in the humeral artery&#46; The patency rate after surgical treatment of a thrombosis was 80&#37;&#44; with a CVC being avoided in 80&#37; of the thrombosis episodes&#46;</p><p class="elsevierStylePara">At the end of the study 63&#46;5&#37; &#40;n&#61;61&#41; of AVG were patent and 36&#46;4&#37; &#40;n&#61;35&#41; of fistulas were thrombosed&#46; 38&#46;5&#37; &#40;n&#61;37&#41; of the fistulas remained patent when the patient died&#46; 5&#46;1&#37; &#40;n&#61;5&#41; of patients were transplanted with patent AVG&#46; At the end of follow-up&#44; 19&#46;7&#37; &#40;n&#61;19&#41; remained patent and patients were on a haemodialysis programme&#46;</p><p class="elsevierStylePara">The annual rate of AVG thrombosis-related hospital admissions was 0&#46;03 admissions&#47;patient&#47;year&#46;</p><p class="elsevierStylePara">The annual thrombosis rate for AVG during this period was 0&#46;45&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Primary patency</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The overall mean primary patency &#40;Figure 3&#41; was 2&#46;55 years&#44; with a confidence interval &#40;CI&#41; of 95&#37; &#40;1&#46;91-3&#46;17&#41;&#46; One year survival was 73&#46;68&#37;&#44; at two years&#44; it was 60&#46;21&#37; and at three years&#44; it was 37&#46;52&#37;&#46; A LOOP type fistula had a mean survival of 2&#46;1 years &#40;0&#46;65 to 3&#46;55&#41;&#46; One year survival was 62&#46;99&#37;&#44; at two years it was 56&#46;7&#37; and at three years&#44; it was 41&#46;34&#37;&#46; A HAX type fistula had a median survival rate of 2&#46;6 years &#40;2&#46;02 to 3&#46;23&#41;&#46; One year survival was 79&#46;9&#37;&#44; at two years it was 61&#46;96&#37;&#44; and at three years it was 41&#46;59&#37; &#40;log-rank 0&#46;33&#44; <span class="elsevierStyleItalic">p</span>-value &#46;57&#41; &#40;Figure 4&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Secondary patency</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Mean secondary survival was 4&#46;65 years&#44; with a CI of 95&#37; &#40;3&#46;96-5&#46;34&#41;&#46; At one year&#44; the fistula survival rate was 89&#46;49&#37;&#44; the two-year survival rate was 84&#46;07&#37; and at three years 66&#46;84&#37; survived &#40;Figure 5&#41;&#46; The LOOP type fistulas had a mean survival of 4&#46;13 years &#40;1&#46;84-6&#46;43&#41;&#46; At one year 87&#46;88&#37; survived&#44; at two years 81&#46;06&#37; survived&#44; and at three years the survival rate was 50&#46;66&#37;&#46; The HAX type fistulas have a mean survival of 5&#46;71 years &#40;2&#46;63-8&#46;79&#41;&#46; At one year&#44; 90&#46;54&#37; survived&#44; at two years 86&#46;07&#37; and at three years&#44; 75&#46;46&#37; &#40;log-rank 1&#46;94&#59; <span class="elsevierStyleItalic">P</span>-value &#46;1633&#41; &#40;Figure 6&#41;&#46; Although the patency of HAX was greater than that of LOOP&#44; there are no statistically significant differences&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">In spite of displaying a higher rate of complications than n-AVF&#44; AVG may be an excellent solution for patients with an exhausted superficial venous system and in our experience&#44; they may also be the definitive access in elderly patients &#40;almost 40&#37; of our patients died with patent AVG&#41;&#46; Surgery is not much more complex than for an n-AVF and it can be performed under local anaesthetic on an outpatient basis&#46;<span class="elsevierStyleSup">10</span> Furthermore&#44; if maintenance protocol is applied&#44; it is possible to rescue most AVG&#44; achieving patency rates of 90&#37; at one year and over 50&#37; at three years&#46;<span class="elsevierStyleSup">10-12</span></p><p class="elsevierStylePara">In our centre&#44; there has been a multidisciplinary group of specialists in haemodialysis vascular access for 10 years made up of nephrologists&#44; radiologists and surgeons&#46; They have designed follow-up protocol and healthcare quality indicators&#46;<span class="elsevierStyleSup">8&#44;9</span> Furthermore&#44; a distribution of work has been carried out amongst the services involved&#58;</p><ul><li>The clinical follow-up of AVG&#44; as well as the diagnosis of dysfunctions&#44; is carried out by the Nephrology Service and a special effort has been made to detect dysfunctions at an early stage&#46;</li><li>Treatment of dysfunctions &#40;both stenosis and thrombosis&#41; of the AVG may be carried out by radiological or surgical methods&#46; In general&#44; the advantage of radiological techniques compared to surgical techniques is the &#8220;saving&#8221; of proximal vascular territory and its disadvantage is the requirement for a greater number of procedures to maintain AVG patency&#46;<span class="elsevierStyleSup">13-21</span></li></ul><p class="elsevierStylePara">The protocol designed in our centre is based on the DOQI recommendations and adapted to the availability of our means&#46; It was never our aim to compare techniques&#44; but rather to apply the most appropriate technique in each case&#44; in accordance with the means available and the experience of the doctors&#46;</p><p class="elsevierStylePara">Treatment of thrombosis has been considered an urgent procedure to avoid CVC&#46; The availability of the vascular radiology room in our centre is limited&#44; and urgent procedures are not able to be performed&#59; therefore&#44; the treatment of thrombosis was always carried out by the Surgery Service&#44; due to the availability of a 24-hour service&#46; The diagnosis and treatment of stenoses was in most cases carried out on a scheduled basis by the Radiology Service&#46; This approach has the advantage of performing the diagnosis and treatment of dysfunction in the same process&#44; reserving surgery for cases of persistence or relapse&#46;</p><p class="elsevierStylePara">In our experience&#44; the rigorous application of this protocol allows healthcare quality indicators to be maintained&#44; in accordance with those who demand national and international guidelines<span class="elsevierStyleSup">6&#44;7</span> for the treatment of AVG dysfunctions and thrombosis&#58; patent percentage at three years above 50&#37; and a thrombosis rate below 0&#46;5 episodes per patient and year&#46;</p><p class="elsevierStylePara">These data have repercussions on other healthcare indicators&#44; since AVF are a major source of morbidity and hospital admissions&#46; Thus&#44; in our centre&#44; the complications of vascular access are not the main reason for admission&#44; with 0&#46;1 episodes per patient and year&#44;<span class="elsevierStyleSup">9</span> that is&#44; half of the figures published in other series&#44;<span class="elsevierStyleSup">3</span> and specifically&#44; there are minimal hospital admissions related to thrombosis of AVG&#46;</p><p class="elsevierStylePara">We firmly believe that the best results in the maintenance of the AVG are obtained with a multidisciplinary approach&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48627&#95;en&#95;f1&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48627_en_f1_11898__1_copia.jpg" alt="Protocol for prosthetic arteriovenous fistula dysfunction due to stenosis"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Protocol for prosthetic arteriovenous fistula dysfunction due to stenosis</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48628&#95;en&#95;f2&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48628_en_f2_11898__1_copia.jpg" alt="Protocol for thrombosis of the prosthetic arteriovenous fistula"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Protocol for thrombosis of the prosthetic arteriovenous fistula</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48629&#95;en&#95;f3&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48629_en_f3_11898__1_copia.jpg" alt="Primary survival &#40;overall&#41;"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Primary survival &#40;overall&#41;</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48630&#95;en&#95;f4&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48630_en_f4_11898__1_copia.jpg" alt="Primary survival of antebrachial LOOP&#47;HAX"></img></a></p><p class="elsevierStylePara">Figure 4&#46; Primary survival of antebrachial LOOP&#47;HAX</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48631&#95;en&#95;f5&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48631_en_f5_11898__1_copia.jpg" alt="Secondary survival &#40;overall&#41;"></img></a></p><p class="elsevierStylePara">Figure 5&#46; Secondary survival &#40;overall&#41;</p><p class="elsevierStylePara"><a href="grande&#47;11898&#95;16025&#95;48632&#95;en&#95;f6&#95;11898&#95;&#95;1&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11898_16025_48632_en_f6_11898__1_copia.jpg" alt="Secondary survival of antebrachial LOOP&#47;HAX"></img></a></p><p class="elsevierStylePara">Figure 6&#46; Secondary survival of antebrachial LOOP&#47;HAX</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Objetivo&#58; </span>An&#225;lisis de la aplicaci&#243;n de un protocolo multidisciplinar para el mantenimiento de las f&#237;stulas arteriovenosas para hemodi&#225;lisis prot&#233;sicas&#46; <span class="elsevierStyleBold">M&#233;todo&#58; </span>Recogida prospectiva de todas las intervenciones realizadas para el tratamiento de la disfunci&#243;n de las f&#237;stulas arteriovenosas prot&#233;sicas &#40;FAVP&#41; en el per&#237;odo 1999-2007 siguiendo un protocolo multidisciplinario&#46; Las estenosis se trataron mediante angioplastia&#44; &#40;ATP&#41; excepto en casos de persistencia o recurrencia antes de tres meses&#46; Las trombosis fueron tratadas siempre mediante trombectom&#237;a quir&#250;rgica y puente de PTFE si fue necesario&#46; Se analizan el n&#250;mero y el tipo de procedimientos&#44; las complicaciones&#44; la permeabilidad primaria y secundaria de las FAVP&#46;<span class="elsevierStyleBold"> Resultados&#58; </span>Se complet&#243; el seguimiento de 96 FAVP&#46; Todas fueron pr&#243;tesis de PTFE de 6x40 mm &#40;Gore-Tex<span class="elsevierStyleSup">&#174;</span>&#41;&#46; Treinta y seis se colocaron en el antebrazo con anastomosis humerobas&#237;lica en asa y 60 en el brazo con anastomosis humeroaxilar curva&#46; Durante el per&#237;odo de estudio fueron necesarios 131 angioplastias transluminales percut&#225;neas&#44; 15 <span class="elsevierStyleItalic">stents</span>&#44; 109 trombectom&#237;as y 52 puentes a vena proximal para el mantenimiento de la permeabilidad de las FAVP&#46; La permeabilidad primaria fue del 73&#44;68 &#37;&#44; 60&#44;21 &#37; y 37&#44;52 &#37; a 1&#44; 2 y 3 a&#241;os&#44; respectivamente&#46; La permeabilidad secundaria fue del 89&#44;49 &#37;&#44; 84&#44;07 &#37; y 66&#44;84 &#37; a 1&#44; 2 y 3 a&#241;os&#44; respectivamente&#46; Se consigui&#243; evitar la colocaci&#243;n de un cat&#233;ter central en el 80 &#37; de las intervenciones por trombosis&#46; No se produjeron muertes relacionadas con los procedimientos&#46; La tasa de ingresos hospitalarios relacionados con la trombosis de las FAVP fue de 0&#44;03 paciente&#47;a&#241;o&#46; <span class="elsevierStyleBold">Conclusiones&#58; </span>La aplicaci&#243;n de un protocolo multidisciplinar en el tratamiento de las disfunciones de las FAVP siguiendo las recomendaciones de las gu&#237;as internacionales prolonga la permeabilidad de las FAVP y disminuye el uso de cat&#233;teres centrales&#46;</p>"
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Article information
ISSN: 20132514
Original language: English
The statistics are updated each day
Year/Month Html Pdf Total
2024 October 49 36 85
2024 September 62 20 82
2024 August 73 71 144
2024 July 60 31 91
2024 June 68 36 104
2024 May 62 34 96
2024 April 75 29 104
2024 March 42 28 70
2024 February 37 39 76
2024 January 47 27 74
2023 December 53 28 81
2023 November 91 61 152
2023 October 97 70 167
2023 September 73 40 113
2023 August 68 23 91
2023 July 97 25 122
2023 June 70 22 92
2023 May 76 35 111
2023 April 86 15 101
2023 March 90 19 109
2023 February 107 29 136
2023 January 48 16 64
2022 December 89 28 117
2022 November 111 32 143
2022 October 55 56 111
2022 September 55 25 80
2022 August 73 50 123
2022 July 48 47 95
2022 June 59 37 96
2022 May 90 39 129
2022 April 77 56 133
2022 March 75 48 123
2022 February 47 45 92
2022 January 58 34 92
2021 December 42 45 87
2021 November 44 41 85
2021 October 66 37 103
2021 September 87 47 134
2021 August 70 51 121
2021 July 84 34 118
2021 June 58 30 88
2021 May 53 28 81
2021 April 143 32 175
2021 March 85 36 121
2021 February 54 17 71
2021 January 58 19 77
2020 December 69 24 93
2020 November 74 20 94
2020 October 67 17 84
2020 September 73 13 86
2020 August 62 11 73
2020 July 85 15 100
2020 June 76 15 91
2020 May 72 16 88
2020 April 59 16 75
2020 March 89 21 110
2020 February 64 18 82
2020 January 84 20 104
2019 December 91 30 121
2019 November 73 32 105
2019 October 49 8 57
2019 September 66 28 94
2019 August 51 24 75
2019 July 72 27 99
2019 June 56 25 81
2019 May 64 27 91
2019 April 137 44 181
2019 March 73 17 90
2019 February 43 21 64
2019 January 33 14 47
2018 December 145 36 181
2018 November 125 17 142
2018 October 126 21 147
2018 September 121 16 137
2018 August 70 20 90
2018 July 70 21 91
2018 June 74 11 85
2018 May 74 14 88
2018 April 69 6 75
2018 March 123 10 133
2018 February 61 9 70
2018 January 88 6 94
2017 December 70 11 81
2017 November 85 14 99
2017 October 52 8 60
2017 September 52 12 64
2017 August 84 18 102
2017 July 71 18 89
2017 June 75 10 85
2017 May 79 18 97
2017 April 62 7 69
2017 March 75 13 88
2017 February 63 10 73
2017 January 44 15 59
2016 December 96 10 106
2016 November 130 10 140
2016 October 165 14 179
2016 September 253 10 263
2016 August 274 9 283
2016 July 238 9 247
2016 June 164 0 164
2016 May 163 0 163
2016 April 153 0 153
2016 March 86 0 86
2016 February 135 0 135
2016 January 130 0 130
2015 December 145 0 145
2015 November 111 0 111
2015 October 97 0 97
2015 September 102 0 102
2015 August 93 0 93
2015 July 90 0 90
2015 June 50 0 50
2015 May 66 0 66
2015 April 7 0 7
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Idiomas
Nefrología (English Edition)