Waldemar Letachowicz

Wroclaw Medical University, Wrocław, Lower Silesian Voivodeship, Poland

Are you Waldemar Letachowicz?

Claim your profile

Publications (22)46.65 Total impact

  • Cardiovascular and interventional radiology. 07/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: A profound knowledge of vascular anatomy and an understanding of vascular access functionality with respect to possible complications are critical in selecting the site for arteriovenous anastomosis. Outline of vasculature variations of the upper limb with prevalence reported in literature of at least 1%, which may affect access creation, is depicted in this review. Over a dozen arterial anatomical anomalies of the upper limb, the most common is "high origin" of the radial artery (12-20%). Superficial positions of brachial, ulnar and radial artery as well as accessory brachial are another possible anatomic variants (0.5-7%). The most variable venous layout on the upper arm is seen in the anatomy of the brachial vein and the basilic vein forming the axillary vein. Three types of basilic vein course on upper arm have been described. The mapping technique to assess vascular variants facilitate site selection for AVF creation even in cases with previously attempted failed access (misdiagnosed vascular variant could force to secondary options). Thus, a thorough understanding and evaluation of anatomy, taking into consideration the possible vascular variations of the forearm and upper arm, are necessary in the planning of AVF creation and increase the success of AVF procedures.
    The journal of vascular access 05/2014; 15 Suppl 7:70-5. · 1.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Elderly patients, defined as octogenarians and nonagenarians, are an increasing population entering renal replacement therapy. Advanced age appears as an exclusive factor negatively influencing dialysis practice. Elderly patients are referred late for the initiation of hemodialysis and more likely are offered catheters rather than arteriovenous fistulae (AVF), which increase mortality and negatively affect quality of life. We present our approach to the creation of vascular access for hemodialysis in this demanding population. In 2006-2012, 39 patients aged 85.9 ± 2.05 with end-stage renal disease, mainly resulting from ischemic nephropathy, were admitted to the Department of Nephrology to establish permanent vascular access for hemodialysis: preferably AVF. Temporary dialysis catheters were implanted in uremic emergency to bridge the time to fistula creation/maturation. AVF was attempted in 87.2% of the patients. Primary AVF function was achieved in 54% of the patients. Cumulative proportional survival of AVF at months 12 and 24 was 81.5%. Ninety-four percent of AVF were localized on the forearm: 74% in the distal and 20% in the proximal part. Mean duration of hemodialysis therapy was 20.80 ± 19.45 months. The mean time of AVF use was 15.9 ± 20.2 months. Until present, 38% have been dialyzed using AVF for 31.0 ± 18.8 months. Five patients died with functioning fistula. Eight patients initiated hemodialysis therapy with fistula. During further observation, the use of AVF increased to 62%. Elderly patients should not be denied creation of AVF as a rule. The outcome of AVF benefits more from acknowledging individual vascular conditions rather than age of the patient.
    Hemodialysis International 08/2013; · 1.44 Impact Factor
  • Heart (British Cardiac Society) 06/2012; 98(14):1106; author reply 1106-7. · 5.01 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose: The standard approach in patients with a clotted arteriovenous fistula (AVF) on the forearm is the creation of another vascular access on the arm using the patient’s own vessels or a prosthetic graft. Here we propose another option as secondary angioaccess for chronic hemodialysis (HD): superficialization of the radial artery. Methods: Indications for the procedure were 1) long-standing forearm AVF that has irreversibly clotted and/or central vein stenosis resistant to angioplasty; 2) patients who have no other prospect for forearm or even brachial AVF. The procedure was undertaken in 7 chronic HD patients dialyzed by forearm AVF for 27±26 months. Results: In one case the superficialization was abandoned intra-operatively due to small diameter of the artery (<4 mm). Five of 6 elevated arteries were patent and the follow-up period ranges from 11 to 15 (median 12) months. In 1 male patient with prothrombin G20210A mutation the artery clotted after 13 months of usage. Conclusions: Superficialized radial artery was successfully used for hemodialysis over one year. The only prerequisite for safe repeated puncture is a patent and enlarged radial artery. Due to avoidance of arteriovenous shunt this access type may be particularly suitable for patients with cardiac failure.
    The journal of vascular access 05/2012; · 1.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Although catheter use exposes the patient to several complications, tunneled cuffed catheters are widely applied for temporary or long-term vascular access. The aim of the study was to establish the rate of tunneled dialysis catheter damage and report our experience with breakage repair. All 363 cuffed tunneled hemodialysis catheters inserted into 309 patients from May 2000 to December 2008 were followed up. When connector damage was encountered, repair with a two-piece adaptor for peritoneal dialysis was attempted. Mechanical breakage occurred in 33 (9.1%) of catheters with an incidence of 0.36/1000 catheter-days. The most frequent was connector damage, found in 25 cases (67.6%). Catheter repair using a peritoneal dialysis Luer adaptor was performed with good early and long-term outcome. Tunneled catheter breakage is a relatively rare complication. Catheter repair using the adaptor for peritoneal dialysis is easy to perform, safe, and cost-effective.
    The journal of vascular access 11/2011; 13(2):203-7. · 1.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Hemodialyzed patients are at risk of multiple catheterizations. Nephrologists performing such procedures need to be familiar with congenital and acquired vascular abnormalities. We describe a successful insertion and use of a cuffed-tunneled catheter in a patient with unusual anatomy of the central venous system. Computed tomography angiography revealed thrombosis of the right subclavian vein and bilateral occlusion of innominate veins. The left internal jugular and subclavian veins joined to form a large vessel that drained through the accessory hemiazygos and azygos veins into the superior vena cava. The catheter was implanted through the left internal jugular vein into the accessory hemiazygos vein. The presented case demonstrates that the catheter can be implanted into distended collateral, especially when no other location is possible.
    Hemodialysis International 10/2011; 16(2):310-4. · 1.44 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Management of failing tunneled hemodialysis catheters, sometimes the only vascular access for hemodialysis, presents a difficult problem. In spite of various techniques having been developed, no consensus has been reached about the preferred technique, associated with the longest catheter patency. We report disruption of the fibrin sheath covering dysfunctional tunneled hemodialysis catheter by means of angioplasty, followed by over guidewire catheter exchange. Following the procedure, the catheter placed in the recovered lumen of the vessel presented correct function. The described procedure allowed maintenance of vascular access in our patient. Additionally, dilatation of the concomitant central vein stenosis opens an option for another attempt for arteriovenous fistula creation.
    The journal of vascular access 09/2011; 13(1):111-4. · 1.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The function of vascular access has a key significance in hemodialysis treatment results. An overview of factors contributing to successful arteriovenous fistula (AVF) constructions and the effect of vascular access quality on the outcome of renal replacement therapy were analyzed, including our study observations. On the basis of the data obtained in the study, the creation of autogenous AVF was reported to be possible in 92.9% of the 213 investigated patients. In 81.2% of the patients, vascular access was found to be located on the forearm. Comorbidities, especially congestive heart failure and peripheral vascular disease, were the main factors that had a negative effect on AVF construction and quality. AVF abnormalities were detected on physical examination in 37% of the patients. Results from the physical examination were found to be consistent with those obtained from Doppler ultrasound, thermodilution, and intra-access pressure measurement. AVF stenosis significantly increased the risk for access thrombosis, catheter insertion, and vascular access-related hospitalization.
    Journal of Renal Nutrition 09/2010; 20(5 Suppl):S118-21. · 1.75 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Anatomical variations of the radial artery are of clinical importance in end-stage renal disease patients awaiting creation of native arteriovenous fistula for hemodialysis. As radial-cephalic direct wrist fistula is a vascular access of choice, atypical localization of the distal part of the radial artery may lead to the false assumption of severe atherosclerotic lesions and prevent creation of such an access, despite good vessel conditions and convenient surgical approach. We present 7 patients with radial artery variations. In 5 patients with superficial radial artery, radial-cephalic direct wrist access was created. One patient, due to an anomaly misdiagnosis, had radial-cephalic fistula created on the contra lateral wrist. In the patient with hypoplastic radial artery brachial-basilic upper arm transposition was created.
    Clinical nephrology 06/2009; 71(5):584-7. · 1.29 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Obesity, which is often associated with diabetes, is increasingly encountered in the haemodialysed population, and this may produce difficulty in autogenous arteriovenous fistula creation. Prosthetic angioaccess or catheters, when used in place of autogenous fistulas, increase thrombotic and infectious complications in these already challenged patients. This prospective study was undertaken to assess the feasibility of autogenous arteriovenous fistula creation in 71 obese patients (BMI 34.6 +/- 7.8). We performed a two-stage procedure, in which radio-cephalic fistula formation was followed by subcutaneous transposition of the venous component for safe and easy puncture. Fistulas suitable for puncture, having blood flows of 799 +/- 285 ml/min, and sufficient to perform adequate haemodialysis (Kt/V 1.24) were achieved in 85% of the patients. Primary patency rates were 65% and 59% at 6 and 12 months, respectively, and secondary patency rates were 83% both at 6 and 12 months. Obesity does not prevent successful autogenous arteriovenous fistula formation, and may protect forearm venous vessels from the iatrogenic damage that occurs before the onset of haemodialysis therapy.
    Nephrology Dialysis Transplantation 05/2008; 23(4):1318-22. · 3.37 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Arteriovenous fistulas (AVFs) are the solution of choice among diverse types of vascular access. The forearm basilic vein is rarely used for creating autogenous vascular access. Its use presents a valuable option when autogenous wrist radial-cephalic direct access cannot be created due to the destruction of forearm veins. Results obtained with autogenous wrist ulnar-basilic direct access and autogenous wrist radial-basilic transposition are presented below. In the decade 1993-2003, native fistulas utilizing the forearm basilic vein were performed in 27 patients (14 women, 13 men). The basilic vein was anastomosed to the ulnar artery or was transposed and anastomosed to the radial artery. AVF creation was successful in 22 patients (81.5%). The primary patency rate was 70.4% after 1 year, 61.6% after 2 years and 48.4% after 3 years. AVFs utilizing the forearm basilic vein can be considered for primary or secondary vascular access because of the acceptable survival rate and low incidence of hand ischemia. Transposition of the basilic vein is a valuable option in the reconstruction of a thrombosed or stenosed radial-cephalic fistula.
    Journal of nephrology 01/2008; 21(3):363-7. · 2.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The proximal forearm antecubital fistula described by Gracz is a valuable option for autogenous vascular access for hemodialysis in patients with destroyed forearm veins or advanced arteriosclerotic and calcified radial arteries. Results obtained with a variant of the Gracz fistula are presented. Patients with forearm vein destruction or failed distal radiocephalic fistulas were selected to have a variant of the Gracz fistula created and were followed up for 36 months. In each patient, the radial artery was anastomosed side to end or end to end to the perforating vein. Additionally, in some patients, the median cephalic or basilic vein was relocated subcutaneously to increase the accessibility of veins for puncture. Native arteriovenous fistulas (AVFs) in the cubital region using a perforating vein were created in 77 patients (34 women, 43 men) referred to the Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland, from 1992 to 2006. Percentages of successful fistula creation and primary patency rates, defined from fistula placement to any maintaining intervention, and cumulative patency, defined from placement to fistula abandonment, were assessed. AVF creation was successful in 56 patients (73%). Primary patency rates during the follow-up period were 47% after 1 year, 43% after 2 years, and 39% after 3 years. Cumulative patency rates were 67% after 1 year, 56% after 2 years, and 53% after 3 years. These results reflect performance of a single center and thus may not be generalizable to surgeons less experienced in this technique. Radial artery-perforating vein fistulas have an acceptable survival rate and do not produce circulatory complications. This method may be applicable for AVF creation in patients with forearm vein destruction/abnormalities and as a rescue procedure for an old clotted fistula after kidney transplant failure.
    American Journal of Kidney Diseases 06/2007; 49(6):824-30. · 5.29 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Kidney recipients with failing allograft function face the vascular access problem again before returning to hemodialysis. An autologous arteriovenous fistula (AVF), according to the recent Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, is the optimal vascular access and the use of prosthetic grafts and catheters should be limited. The objective of this study was to assess the feasibility of AVF reconstruction in patients reentering hemodialysis after kidney allograft failure. Two hundred and forty-one transplant recipients reentered hemodialysis between 1990 and 2005. Before kidney transplantation, 221 patients had a functioning AVF on the forearm. Fistula reconstruction was attempted in 112 (51%) patients because of AVF thrombosis. Three strategies were applied according to forearm vein patency: a new radial-cephalic fistula, a radial-perforating vein fistula, or a radial-basilic forearm transposition was created. Forearm AVFs were successfully reconstructed in 85 of the 112 patients (73%). The primary patency of the reconstructed AVFs was 57.6% and 44% at 12 and 24 months. Secondary patency was 64.9% and 54.9% at 12 and 24 months, respectively. The reconstruction of an old, thrombosed AVF is possible in kidney recipients returning to dialysis, even if the time from thrombosis to fistula repair is a few years.
    Clinical Transplantation 01/2007; 22(2):185-90. · 1.63 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: There are controversies regarding the feasibility of autogenous vascular access creation in elderly hemodialysis (HD) patients. The aim of this retrospective study was to evaluate the results of creating different types of autogenous arteriovenous fistulas (AVFs) in a consecutive series of HD patients over 75 years of age. The analysis was performed in 131 patients (65 females, 66 males, average age 79.1 +/- 3.6 years) in whom the creation of an autogenous AVF was considered within a 6-year period (February 1998 to February 2004). Among them, 26.7%were diabetics, 66.3% had hypertension, 30.7% were smokers, and 35.6% were obese. Patient survival and primary and secondary AVF patency were assessed. The survival rates for patients were 94, 88, 66, and 45% at 6 months and at 1, 3, and 5 years, respectively. Successful autogenous AVF formation was finally achieved in 107 patients (81.6%): in 99 patients in the forearm and in 8in the upper arm. A Kaplan-Meier analysis showed primary AVF patency rates of: 74 +/- 4.3% (+/- SE) at 1 month; 70 +/- 4.7% at 6 months; 59 +/- 4.9% at 1 year; 59 +/- 4.9% at 2 years; 59+/- 4.9% at 3 years; 59 +/- 4.9% at 4 years, and 58 +/- 4.9% at 5 years. The secondary patency rates were: 95 +/- 2.0; 92 +/- 2.2; 84 +/- 3.3; 79 +/- 4.0; 72 +/- 4.3; 71 +/- 4.4, and 69 +/- 4.5% in the corresponding periods, respectively. All postoperative complications in 10 patients were treated surgically, if applicable, without endovascular techniques. By exploiting all suitable types of autogenous AVF it is possible to establish the best form of vascular access even in the majority of elderly patients.
    Blood Purification 02/2006; 24(2):190-5. · 2.06 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Conventional brachiobasilic fistula creation consists of the mobilization and preparation of the brachial part of the basilic vein along its whole length, the vein transposition on the anterior surface of the arm and anastomosis using the brachial artery. In case of late thrombosis, the reparation of such a fistula is almost impossible. To avoid total vein clotting in the case of thrombosis we decided to prepare only a short part of the vein in our method and not to mobilize the other part of the vein. The brachiobasilic fistula with our modification was performed as a two-stage procedure in 18 patients (8 females and 10 males), aged from 37-78 yrs (60 +/- 13.6 yrs). In two patients early thrombosis occurred. The reparation procedure was not performed in two patients (the first patient died due to pneumonia; the second patient did not give his permission for further intervention). In 16 patients brachiobasilic fistula creation was successful. Late thrombotic complications occurred in three patients (in the 3rd, 8th and 12th months). A new successful fistula, a few centimeters proximally to the original one, was per-formed in 2 patients 24hr and in 1 patient 48 hr after fistula clotting. On the following day after the procedure the fistula was ready to be used. The primary, assisted primary and cumulative secondary patency rates after 12 months of follow-up were 74, 89 and 100%, respectively. In comparison with standard brachiobasilic techniques our method offers the possibility of a reparation procedure in the case of late thrombosis, which could improve the long-term patency of brachiobasilic fistulas. However, a prospective controlled study is necessary to establish if this new technique is superior to the traditional surgical procedure.
    The journal of vascular access 01/2006; 7(2):74-6. · 1.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The aim of the study was to assess the molecular background of the alloimmune response by the detection of low-abundance mRNA of cytokines in 34 core needle biopsies from kidney allografts with histopathological findings of acute rejection (AR). Recipients were immunosuppressed with a calcineurin inhibitor (CNI), cyclosporine or tacrolimus, and prednisone and azathioprine or mycophenolate mofetil (MMF). Tubular and glomerular expression of IL-2, IL-6, IL-10, IFN-gamma, TGF-beta1, and PDGF-B mRNA were assessed using semiquantitative evaluations of RT-PCR in situ on paraffin tissue sections. This procedure resulted in light microscopy visualization of granular precipitates at the sites of the corresponding mRNA chains. The tubular expression of mRNA for IL-6 and TGF-beta1 was significantly lower in biopsies with AR (n = 34) obtained from patients treated with MMF (n = 12) than in biopsies obtained from patients treated with azathioprine (n = 22) (P < .02). Responsiveness to corticosteroids tended to be more frequent among the MMF group (11 of 12 recipients vs 15 of 22 recipients, P = ns). Moreover, 8 of 12 recipients in the MMF-treated group displayed serum creatinine levels equal or less than 167 mmol/L 1 year after biopsy compared to 7 of 22 recipients in the azathioprine-treated group. There was no significant difference between the groups that had or had not received corticosteroids or between those treated with each type of CNI. These results suggest stronger inhibition of humoral responses and down-regulation of fibrosis by MMF among recipients with AR.
    Transplantation Proceedings 04/2005; 37(2):770-2. · 0.95 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The aim of our study was to correlate intragraft mRNA expression of cytokines and growth factors with histopathologic features in renal allograft biopsies. Fifty-six core biopsies performed in 51 kidney transplant recipients were assessed by the Banff '97 classification. Tubular and glomerular expressions of IFN-gamma, TGF-beta1, and PDGF-B as well as IL-2, IL-6, and IL-10 mRNA were assessed using semiquantitative RT-PCR in situ. No significant differences were noted between acute cellular and vascular rejection with regard to the glomerular and tubular mRNA expression of cytokines examined. We observed a positive correlation between tubular and glomerular IL-10 and IFN-gamma mRNAs during acute rejection. In chronic rejection the mRNA expression levels of IFN-gamma and IL-2, IL-6, and IL-10 did not differ from those of acute rejection; moreover, the glomerular expression of mRNA for TGF-beta1 (P < .05) and PDGF-B (P < .1) was even lower than during acute rejection episodes. Both tubular and glomerular IL-2, TGF-beta1, and PDGF-B mRNA expression levels in biopsies with acute rejection were significantly higher than in acute tubular necrosis (ATN). Biopsy samples with borderline changes exhibited the lowest levels of cytokine gene expression and were close to the intensity of control specimens obtained from living donor kidney biopsies taken during organ harvest. Our data failed to show a dichotomy between Th1 and Th2 cytokine activation in biopsy specimens from kidney allograft recipients; both Th1- and Th2-derived cytokines were involved to similar extents in rejection processes.
    Transplantation Proceedings 04/2005; 37(2):767-9. · 0.95 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Arteriovenous fistula (AVF) creation for hemodialysis (HD) could predispose to local arterial insufficiency of the hand (steal syndrome). Patients with diabetes mellitus, peripheral arterial disease and elderly patients tend to have a higher risk of hand ischemia. To estimate the influence of AVF on the blood supply to the hands in the elderly population and to identify steal syndrome cases by non-invasive diagnostics (finger photoplethysmography (PPG), pulse volume recording (PVR), Doppler analysis and pulseoxymetry). The evaluation was carried out in 25 random patients (10 females, 15 males) >75 yrs of age (79.6 +/- 3.87 yrs), whose functioning autologous AVFs had been placed at least 1 month previously. Mean PPG and PVR amplitudes did not differ in statistical analysis (p > 0.05) between hands with and without an AVF. One patient (4%) with end-to-side anastomosis was diagnosed with steal syndrome (typical manifestation confirmed in PPG, Doppler and pulseoxymetry). Two other patients with high brachio-cephalic anastomosis presented subclinical steal syndrome (only low PPG and PVR). Even in the very elderly, AVF creation should be considered due to a lesser influence on the blood supply to the hands. Non-invasive diagnostics used by us seemed to be useful in identifying steal syndrome after AVF creation.
    The journal of vascular access 01/2005; 6(2):83-7. · 1.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The increase in number of obese people seen in the general population, is also what is seen in the hemodialyzed population. It is generally believed that the location of deep forearm vessels in the subcutaneous fat tissue makes primary arteriovenous fistula (AVF) a disadvantage because of difficulties in vessel puncturing. For obese patients, it is suggested that a fistula with PTFE is created or a central catheter inserted, but these solutions increase already high morbidity rate and significantly increase mortality rate. Methods: The deep location of veins situated on the anterior part of the forearm involved 57 patients (45 female and 12 male) aged 13–87 years (mean 67 ± 15.2 years). Patients’ body mass index (BMI) ranged from 29.1 to 53.73 (mean 34.6 ± 7.8). The causes of the renal failure were diabetic nephropathy in 30 patients, chronic glomerulonephritis in 4, hypertensive nephrosclerosis in 5, lupus nephritis in 2, interstitial nephritis in 4, primary amyloidosis in 1, polycystic kidney disease in 3, and unknown in 3 patients.Two‐step surgical procedure was performed in all patients. In the first stage, the standard distal radiocephalic AVF in the wrist region was created. In case of its failure, the next attempt was performed above the point of the first intervention. In the second stage, superficialization of the venous part of AVF was performed in the mode described by us (Kidney 2002;.1:1170). Results: The first stage of the procedure was successful in 46 patients. In 6 cases it was necessary to perform a second attempt, and 2 cases required three operations. The second stage was undertaken in all of these patients (n = 54), and complete success was achieved in 51. In 3 cases, in spite of superficialization, AVF was not suitable for puncturing because of poor blood flow. The causes of failure of the first stage procedure in 2 patients were severe arteriosclerosis and venous anomaly. All patients had non‐altered cephalic veins in the wrist region, as opposed to patients with cannulated veins. In 51 pts (90%) an efficient flow of the blood through AVF was successfully obtained and allowed satisfactory dialyses. Conclusions: The primary AVF creation on the forearm is feasible in 90% of obese patients. This result is similar to the general population of chronic renal disease patients of our center (95%)(NDT 1998;13:527) and is possible thanks to the location of the veins deep in the subcutaneous fat tissue, which protects against repeated cannulation and hence mechanical destruction in the pre‐dialysis period.
    Hemodialysis International 01/2005; 9(1):73-73. · 1.44 Impact Factor