Randomized Clinical Trial of the Use of Glyceryl Trinitrate Patches to Aid Arteriovenous Fistula Maturation

Abstract

Conclusions:In the UK National Health Service (NHS) abdominal aortic aneurysm (AAA) screening programs are effective in detecting AAA and lead to effectively treating men with AAA.Summary: Approximately 3000 to 4000 people die from ruptured AAA each year in England and Wales. Most of the deaths occur in men over 65 years of age. Population screening of men $65 years of age for AAA in the UK began in 2009 and was implemented in all of England by April 2013. The current study presented here reviews the results of the first 5 years of screening among 65 year old men who had attended an ultrasound screening and the first cohort of men referred for treatment of a large aneurysm over 5.47 cm. The goal was to check the systems and processes of the AAA screening program. In the program men aged 65 years were invited for a single abdominal ultrasound scan. Data were entered into a bespoke database (AAA SMaRT). This paper represents a planned analysis after the first 5 years of the program. Summation analysis involves the first 700,000 men screened and the first 1000 men with a large AAA referred for possible treatment. The prevalence of AAA defined as an aortic diameter larger than 2.9 cm in 65 year old men was 1.34%. The mean uptake was 78.1% and varied from 61.7 to 85.8% across the UK. Based on the index of multiple deprivation, uptake was 65.1% in the most deprived vs 84.1% in the least deprived areas. Of the first 1000 men referred for possible treatment of an AAA the false positive rate was 3.2%. 770 men underwent a planned AAA intervention (non-intervention rate 9.2%) with 7 deaths for a perioperative mortality rate of 0.8%.Comment: Use of the screening program varied among regions in the UK with those from less affluent areas and having to travel greater distances making less use of the screening program (Crilly M, et al Br J Surg 2015;102:916-23). Perhaps patients who place a less priority on their own health have an increased prevalence of AAA so the prevalence of AAA may be higher than indicated. False negative rates of screening are unknown. Nevertheless, at the moment it appears from this analysis, screening for AAA is effective both from a medical and cost effectiveness point of view.

Medical Adjuvant Therapy in Reducing Thrombosis With Arteriovenous Grafts and Fistulae Use: A Meta-Analysis of Randomized Controlled Trials

“…There is little favorable evidence of locally applied glyceryl trinitrate transdermal patch with supporting evidence from small observational studies. 31 However, our findings demonstrate no benefit of glyceryl trinitrate in supporting AVF maturation.…”

Clinical practice guideline on peri- and postoperative care of arteriovenous fistulas and grafts for haemodialysis in adults

“…In addition to these reviews, we identified six RCTs published after 2013 and not included in any of the considered systematic reviews, assessing various adjuvant medical treatments for improving AV access patency [24][25][26][27][28][29].…”

“…Glyceryl trinitrate was tested in a placebo-controlled clinical trial including 200 participants [27]. An active or a placebo patch was applied 5 cm proximal to the AV anastomosis immediately after completing the surgical procedure and left in place for 24 h. The trial provided moderate-certainty evidence for no meaningful difference in patency at 6 weeks or change in venous diameter as a surrogate for maturation.…”