TP5.2.4 Patency of radiocephalic versus brachiocephalic arteriovenous fistula in a major tertiary hospital

Introduction The patency of brachiocephalic fistulae is generally considered to be superior to radiocephalic fistulae. We have explored this in a major tertiary hospital. Method This was a retrospective review of fistulae created between 1st January 2015 and 31st July 2020. Index cases were identified from a prospectively maintained vascular access database. Patient demographics, procedure details and subsequent interventions are described. Results There were 915 fistulae created on 813 patients (528 males and 285 females). There were 388 radiocephalic fistulae created on 374 patients and 363 brachiocephalic fistulae were formed on 301 patients. Both groups had 315 fistulae with patency data available. Age and a diagnosis of diabetes were comparable. There were significantly fewer female patients in the radiocephalic cohort (p = 0.004). Primary patency at 3 months, 1 year and 3 years were 84.6%, 58.1% and 37.9% for radiocephalic and 87.9%, 63.1% and 37.0% for brachiocephalic fistula (p = 0.273). Primary assisted patency at 3 months, 1 year and 3 years were 92.3%, 87.0%, 77.4% for radiocephalic and 96.1%, 88.6%, 79.9% for brachiocephalic fistulas (p = 0.295). Secondary patency at 3 months, 1 year and 3 years were 93.3%, 88.3% and 81.5% for radiocephalic fistulas and 97.4%, 90.6% and 85.7% for brachiocephalic fistulas (p = 0.134). Conclusion We have demonstrated similar primary, primary-assisted and secondary patency for radiocephalic and brachiocephalic fistulae. Pre-operative ultrasound vein mapping, selective ultrasound surveillance, surgical expertise and careful patient selection may contribute to the high secondary patency and absence of difference between the groups.

Surveillance for hepatocellular carcinoma in people of African ancestry with HIV and Hepatitis B

Current guidelines recommend six-monthly ultrasound surveillance for hepatocellular carcinoma (HCC) in high risk, non-cirrhotic people with HIV and hepatitis B co-infection (HBV). African or Asian ethnicity is considered a risk factor for the development of HCC. Risk stratification scores for HCC have been generated in HBV mono-infected Caucasian and Asian populations, however they not been validated in people with HIV or those of African ancestry. We undertook an audit of HCC surveillance in HIV/HBV co-infected individuals of African ancestry who participated in the GEN-AFRICA study. Electronic patient records were reviewed for liver disease characteristics. REACH-B and PAGE-B scores were calculated to ascertain whether individuals at greatest risk of developing HCC were being targeted for ultrasound surveillance. 76 individuals (median age 51 years, 96% HIV RNA < 200 copies/mL, 87% HBV DNA <20 IU/mL) were included. 7% of participants had undergone six-monthly HCC surveillance by liver ultrasound (5% of those at low risk; 9% at intermediate or high risk). Adherence to HCC surveillance was poor and not targeted to those at highest risk. Lack of an evidence base for intensive HCC screening of non-cirrhotic, HIV/HBV co-infected individuals of African ancestry may have contributed to the poor uptake of biannual HCC ultrasound surveillance.

Longitudinal Assessment of Quality of Life Following Molecular Testing for Indeterminate Thyroid Nodules

Background Molecular testing can refine the risk of malignancy in cytologically indeterminate thyroid nodules and can reduce the need for diagnostic thyroidectomy. However, quality of life (QOL) in patients mananged with molecular testing is not well studied. Objective We aimed to assess the QOL of patients undergoing surveillance after a benign molecular test result, or thyroidectomy after a suspicious molecular test result. Methods This prospective longitudinal follow-up of the Effectiveness of Molecular Testing Techniques for Diagnosis of Indeterminate Thyroid Nodules randomized trial utilized the Thyroid-Related Patient-Reported Outcome, 39-item version (ThyPro-39) to assess the QOL of patients with indeterminate cytology on thyroid fine needle aspiration (FNA) biopsy. All patients underwent molecular testing at the time of initial FNA. A mixed-effect model was used to determine changes in QOL over time. Results Of 252 eligible patients, 174 completed the assessment (69% response rate). Molecular test results included 72% (n = 124) benign and 28% (n = 50) suspicious. ThyPro-39 scores of benign molecular test patients were unchanged from baseline (following initial FNA and molecular test results) to 18 months of ultrasound surveillance. Baseline symptoms of goiter, anxiety, and depression were more severe for patients with suspicious compared with benign molecular test results. At a median of 8 months after thyroidectomy, suspicious molecular test patients reported improved symptoms of goiter, anxiety, and depression. Conclusion A benign molecular test provides sustained QOL throughout ultrasound surveillance, without worsening anxiety or depression relating to the risk of malignancy. Definitive surgery results in improvement of QOL in patients with suspicious molecular tests.

The role of Doppler ultrasonography in vascular access surveillance—controversies continue

Chronic hemodialysis therapy required regular entry into the patient’s blood stream with adequate flow. The use of arteriovenous fistulas and grafts is linked with lower morbidity and mortality than the use of catheters. However, these types of accesses are frequently affected by stenoses, which decrease the flow and lead to both inadequate dialysis and access thrombosis. The idea of duplex Doppler ultrasound surveillance is based on the presumption that in-time diagnosis of an asymptomatic significant stenosis and its treatment prolongs access patency. Details of performed trials are conflicting, and current guidelines do not support ultrasound surveillance. This review article summarizes the trials performed and focuses on the reasons of conflicting results. We stress the need of precise standardized criteria of significant access stenosis and the weakness of the metaanalyses performed.