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      Multislice Computed Tomographic Angiography in Evaluating Dysfunction of the Vascular Access in Hemodialysis Patients

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          Aims: To introduce our preliminary experience in using multislice computed tomographic (CT) angiography (MSCTA) to assess stenoses of the hemodialysis vascular access and to guide revising operation or percutaneous transluminal angioplasty (PTA). Methods: Contrast-enhanced 16-slice spiral CT was used to examine 22 hemodialysis patients with various dysfunctions of their vascular access. The transverse source images were reformatted as maximum intensity projection, volume-rendering, and multiple/curved planar reconstruction images. Results: The whole spectrum of arteriovenous fistulas (AVF) with the feeding artery, anastomoses, and outflow tract up to the superior caval vein was clearly displayed in all patients. According to the results of MSCTA, AVF-revising surgery was done in 11 patients, and PTA under the guide of digital subtraction angiography (DSA) was done in 5 patients. The results of MSCTA coincide with the findings of surgery or DSA in these 16 patients. Conclusions: In our opinion, MSCTA is a good noninvasive diagnostic technique to detect various hemodialysis vascular access abnormalities. It is more economical than DSA in the present medical settings and could replace DSA in the imaging of hemodialysis vascular access and provide important information for further AVF-revising surgery or PTA.

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          Most cited references 8

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          Detection of intracranial aneurysms: multi-detector row CT angiography compared with DSA.

          To prospectively compare the effectiveness of multi-detector row computed tomographic (CT) angiography with that of conventional intraarterial digital subtraction angiography (DSA) used to detect intracranial aneurysms in patients with nontraumatic acute subarachnoid hemorrhage. Thirty-five consecutive adult patients with acute subarachnoid hemorrhage were recruited into the institutional review board-approved study and gave informed consent. All patients underwent both multi-detector row CT angiography and DSA no more than 12 hours apart. CT angiography was performed with a multi-detector row scanner (four detector rows) by using collimation of 1.25 mm and pitch of 3. Images were interpreted at computer workstations in a blinded fashion. Two radiologists independently reviewed the CT images, and two other radiologists independently reviewed the DSA images. The presence and location of aneurysms were rated on a five-point scale for certainty. Sensitivity and specificity were calculated independently for image interpretation performed by the two CT image readers and the second DSA image reader by using the first DSA reader's interpretation as the reference standard. A total of 26 aneurysms were detected at DSA in 21 patients, and no aneurysms were detected in 14 patients. Sensitivity and specificity for CT angiography were, respectively, 90% and 93% for reader 1 and 81% and 93% for reader 2. The mean diameter of aneurysms detected on CT angiographic images was 4.4 mm, and the smallest aneurysm detected was 2.2 mm in diameter. Aneurysms that were missed at initial interpretation of CT angiographic images were identified at retrospective reading. Multi-detector row CT angiography has high sensitivity and specificity for detection of intracranial aneurysms, including small aneurysms, in patients with nontraumatic acute subarachnoid hemorrhage. Copyright RSNA, 2003
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            Stenosis detection with MR angiography and digital subtraction angiography in dysfunctional hemodialysis access fistulas and grafts.

            To prospectively assess three-dimensional contrast material-enhanced magnetic resonance (MR) angiography for stenosis depiction in malfunctioning hemodialysis arteriovenous fistulas (AVFs) and grafts (AVGs), as compared with digital subtraction angiography (DSA). Ethical review board approval and written informed consent were obtained. MR angiography and DSA were performed in 51 dysfunctional hemodialysis fistulas and grafts in 48 consecutive patients. Vascular tree of accesses was divided into between three and eight segments depending on access type (AVF or AVG) and length of venous outflow. Images obtained with MR and DSA were interpreted by two MR radiologists and two interventional radiologists, respectively, who were blinded to information from each other and other studies. DSA was reference standard for stenosis detection. Sensitivity, specificity, and predictive values with 95% confidence intervals (CIs) of contrast-enhanced MR in detection of vascular segments containing hemodynamically significant (> or =50%) stenosis were calculated. Linear-weighted kappa statistic was calculated for contrast-enhanced MR and DSA to determine interobserver agreement regarding stenosis detection. A total of 282 vascular segments were evaluated. Contrast-enhanced MR depicted three false-positive stenoses and all but two of 70 significant stenoses depicted with DSA. Sensitivity, specificity, and positive and negative predictive values of MR in detection of vessel segments with significant stenoses were 97% (95% CI: 90%, 99%), 99% (95% CI: 96%, 100%), 96% (95% CI: 88%, 99%), and 99% (95% CI: 97%, 100%), respectively. MR demonstrated significant stenosis in four of five nondiagnostic DSA segments, whereas DSA showed no significant stenosis in four nondiagnostic MR segments. Linear-weighted kappa statistic for interobserver agreement regarding stenosis detection was 0.92 (95% CI: 0.89, 0.95) for MR and 0.95 (95% CI: 0.92, 0.97) for DSA. MR angiography depicts stenoses in dysfunctional hemodialysis accesses but has limited clinical value as result of current inability to perform MR-guided access interventions after stenosis detection. MR of dysfunctional access should be considered only if nondiagnostic vascular segment is present at DSA. (c) RSNA, 2005.
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              Preventing Vascular Access Dysfunction: Which Policy to Follow

              In the USA, three Clinical Performance Measures are currently in place: increasing the number of autologous arteriovenous fistulas (AVFs) among incident hemodialysis patients to 50% and to 40% in prevalent hemodialysis patients; to foster the surveillance of accesses with pre-emptive correction of problems before accesses thrombose or fail, and to reduce the use of catheters in prevalent patients to less than 10%. Reduction of catheters will automatically result from initiatives that increase the construction of AVFs and pre-emptive monitoring and surveillance of accesses for dysfunction. Therefore, policies that promote the latter two vascular access aspects are most important to develop and follow. Of these two, however, the most impact will be made by promoting a policy to increase AVF creation in the timeliest manner possible. Strategies and resources needed to achieve these policies are presented. The need for a team approach is emphasized.

                Author and article information

                Nephron Clin Pract
                Nephron Clinical Practice
                S. Karger AG
                September 2006
                21 June 2006
                : 104
                : 2
                : c94-c100
                Departments of aNephrology and bRadiology, Changzheng Hospital, Second Military Medical University, Shanghai, China
                93996 Nephron Clin Pract 2006;104:c94–c100
                © 2006 S. Karger AG, Basel

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                Figures: 9, References: 13, Pages: 1
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