BC HEALTH
Saved by @Alex1Powell

💥 Role of Stents in Dialysis Vascular Access - Tweetorial

⚡️Indications for Stent Use

⚡️Recent Clinical Trials of Stents in Dialysis Vascular Access

⚡️Complications associated with Stent Use

1/
@ASDINNews
#VascularAccessPearls

 ⚡️Arterio-venous (AV) Access
causes significant morbidity & mortality in patients on hemodialysis

⚡️Most AV access associated complications are due to vascular stenosis👇🏽
2/
⚡️Vascular Access care has evolved over the past 60 years:

-Scribner’s Shunt in 1960 ➡️
-Brescia-Cimino AVF in 1966 ➡️
-1st Balloon Angioplasty in 1981 ➡️
-1st Bare Metal Stent in 1988 ➡️
-1st Covered Stent in 1996 ➡️
-DCB use in 2012
3/
⚡️Despite these innovations, AV access stenosis remains a big problem

-Percutaneous Balloon Angioplasty (PTA) remains the 1st line therapy for stenosis but it is NOT very effective

-AVF patency after PTA is only 50% at 6-months & it is worse for AVGs👇🏽
4/
⚡️Neointimal Hyperplasia (NIH) causes vascular stenosis & it is due to:

-Hemodynamic stress
-Surgical trauma
-Cannulation needle trauma
-AVG

‼️But balloon angioplasty, the treatment for stenosis, can itself induce NIH & cause restenosis👇🏽
5/
⚡️Therefore, Endovascular Stents have been used to treat the vascular stenosis

⚡️What are Endovascular Stents?
They are scaffolds that provide mechanical endoluminal support to the vessel wall to maintain patency
6/
⚡️Types of Stents:

-1st generation stents were Bare-Metal Stents made of stainless steel

-Next generation of metal stents were Nitinol Stents made of nickel-titanium alloy

- Covered-Stents (Stent-Grafts) are Nitinol stents covered w/ ePTFE or Dacron
7/
⚡️Bare Metal Stents & Nitinol Stents have problems because the tissue in-growth through the bare metal causes restenosis

⚡️Covered Stents (Stent-Grafts) theoretically form a barrier, & prevent tissue in-growth through the stent & cause less restenosis👇🏽
8/
⚡️Recent clinical trials have tested the efficacy of Stent-Grafts for AV access stenosis
⚡️But before we get to the trials, let’s discuss the basic indications for Stent use:

☄️Rupture of the vessel
☄️Recoil (Residual stenosis)
☄️Restenosis
9/
⚡️Rupture of the vessel can occur during angioplasty of a severely stenotic lesion

⚡️In most cases, extravasation can be controlled w/ manual compression or balloon tamponade but if bleeding persists then stents can be used to control the bleeding👇🏽
10/
⚡️Another indication for Stent use is Recoil

⚡️Recoil is defined as residual stenosis of > 30% following angioplasty & is thought to occur due to elastic recoil of the vessel wall

⚡️Recoil is associated w/ poor AV access survival👇🏽
11/
⚡️Restenosis is the most common indication for stent use👇🏽

⚡️AVG patency post-angioplasty is very poor👇🏽

⚡️Most common site for AVG stenosis is at the graft-vein anastomosis, therefore recent clinical trials have tested the Stent-grafts at this site👇🏽
12/
⚡️Stent-Graft (SG)Trials in Dialysis Vascular Access

☄️Flair PIVOTAL Trial: Flair SG vs. PTA for AVG
☄️REVISE Trial: Viabahn SG vs PTA for AVG

⚡️Both trials showed better 6-month patency with SG use compared to PTA for graft-vein anastomosis stenosis👇🏽
13/
⚡️Stent-Grafts (SG) have also been tested for In-stent restenosis

☄️RESCUE Trial: Fluency SG vs PTA for In-stent restenosis in both AVF & AVG

⚡️RESCUE Trial showed better 6-month patency with SG compared to PTA👇🏽
14/
⚡️Summary of Stent Trials in Dialysis Vascular Access👇🏽
15/
⚡️Based on this data, KDOQI 2019 guidelines recommend Stent-Graft use for:

☄️Recurrent graft-vein anastomosis stenosis in AVG

☄️In-stent restenosis in AVF & AVG👇🏽

16/
⚡️Cost analysis of Stent-Grafts (SG) show that even though the initial cost of the SG is higher than the cost of balloon angioplasty, the overall cost was similar in the 2 groups at 24-months because the re-intervention rate was lower in the SG group👇🏽
17/
⚡️Complications associated with Stent use:

☄️Stent Migration
☄️Stent Fracture
☄️Stent Strut Protrusion
☄️Jailing of the veins
☄️Infection
18/
⚡️Stent Migration can cause downstream vein occlusion/stenosis & can impact future AV access options

⚡️Stent fracture & protrusion can occur due to repeated cannulation thru the stent👇🏽

⚡️Stent fracture can occur if stent is placed across a joint👇🏽
19/
⚡️Jailing of the Veins is a complication of stent placement & this can impact future AV access options

⚡️Hence, the operator must be very careful during stent deployment in order to avoid this complication👇🏽
20/
⚡️Stent associated infection is a serious complication & may require AV access excision

⚡️Stent associated AV access infections are more common when the stents are placed in the Pseudo-aneurysms 👇🏽
21/
⚡️Stent placement must be avoided in pseudo-aneurysms & in the cannulation zone due to high risk of infection & risk of stent fracture from needle trauma
⚡️KDOQI Guidelines state that stent placement for pseudo-aneurysm only be used as a ‘last resort’👇🏽
22/
💥Summary

⚡️Stent-Grafts are a viable therapeutic option for AV access stenosis but it’s use must be guided by scientific evidence

⚡️Balloon angioplasty remains the 1st line therapy for the majority of the AV access stenotic lesions

End/

More from Health

oatc
oatc
@_oatc_
@73inlancs @janethooton_ @ErinInTheMorn @fifi_EY 1/ The 🏴󠁧󠁢󠁥󠁮󠁧󠁿 government decided pediatric gender care in England would be a monopoly contract (a Labour minister, in 2008), despite all other NHS patients officially being entitled to a choice of providers, & second opinions on diagnoses & treatment, & gave it to GIDS, which has…

@janethooton_ @ErinInTheMorn @fifi_EY 2/…always advocated that trans minors & their families must have no alternative source of care, & subsequent Tory ministers have personally put their signature on renewals of it, and even personally rejected proposals for improvement that have been put forward by NHS England…

@janethooton_ @ErinInTheMorn @fifi_EY 3/…as a result of wider & public consultation. They & their civil servants listen only to GIDS on trans minors - it was GIDS advised against <18s being allowed #GenderRecognition in 2004, & since, on the basis that no one under 18 can be certain of their gender identity, just…

@janethooton_ @ErinInTheMorn @fifi_EY 4/…as many other staff at their trust wrote⬇️ to the press in 2002 (when the first instigator of this case, psychoanalyst Susan Evans was on staff too) that no trans people should be allowed that recognition but needed

@janethooton_ @ErinInTheMorn @fifi_EY 5/…to "cure" us instead. Yet GIDS proved incapable of defending its super-conservative protocol in court - no doubt because GIDS has always expected challenges to be from patients seeking care more like that elsewhere, arrogantly ignoring that services in countries where the…
HEALTH
Dr. Joolz Denby\U0001f499
Dr. Joolz Denby💙...
@JoolzDenby
We’ve done menstruation, let’s talk about the menopause! Because only women however they present can have the menopause although men who have had treatments for prostate cancer can have symptoms mimicking the menopause. There’s nothing scary about

the menopause. It’s a perfectly natural function of the body but it’s tied up with a thousand stereotypes of women, ageism and ‘old women are frightening’. True, old women are often very frightening to young men because look! A woman who doesn’t give a rat’s

arse what you think of her now all her mating hormones have gone and with it your charm as a potential mate. Now you’re just another annoying lad. That’s gotta hurt. Menopause means Wisdom, like it or not and it’s not always nice or cosy. Old women

are encouraged to refer to themselves as ‘young at heart’ and ‘as young as you feel’ and other such crap and told to ‘never give in to age’ which is ludicrous. Cosmetic surgery is now a thing but I can tell you what the surgeons and marketing

men won’t - it does not make you look young. You’re just an old woman who looks like at best, she’s had a great holiday and at worst like she was was trapped in a wind tunnel. Old is good. Old is meritorious. Old is survival. Old means you didn’t die young
HEALTH
Advertisement
Plum
Plum
@getplumhq
12 things you should look out for before buying health insurance

A thread 🧵

It’s a good idea to make sure your health is protected under an insurance policy so that you don’t shell out large sums of money for hospitalization and treatment. But buying an individual health insurance policy can be daunting in itself.

Websites and policy documents can be overwhelming. There’s a lot of loaded terms, there’s a whole bunch of things that your policy may or may not cover. It’s important to know and understand the details though, so you’re not surprised later.

In this thread, we'll talk about the things you absolutely need to watch out for when buying an individual health insurance policy for yourself or your family members :)

If you take an individual health insurance policy and the insurance company offers to pay up to ₹15 lakhs during the year whenever you’re diagnosed with a disease or meet an accident, that amount is the 'sum insured'.
HEALTH
Hypertroph | Fitness Coach
Hypertroph | Fitness C...
@CoachHypertroph
I transformed my body in 6 months.

People charge INR 25,000+ for this information. It should be free.

Just follow these simple fat loss rules:


Exercise:
• 3-4x per week
• Weights > Cardio
• Compound movements first
• Cardio after weights

Don't focus on burning calories focus on getting stronger

Video

Nutrition:
• 20-25% calorie deficit
• 1.6-1.8 g/Kg Protein
• 2x fruits & veggies daily
• Limit eating out

Food quantity determines weight loss. Food quality determines health.

Video

Sleep:
• Fix wake up time
• Sleep 8 hrs
• No caffeine after 2 pm
• Dinner 2-3 hours before bed

Have a routine, and be consistent. Routines save your time and maximise your energy.

Video

Simple is beautiful.

Don't bookmark and forget.

• Commit to the end goal
• Disappear for 6 months
• Build yourself in private

Before you go, I would love to give you 10 bonus tips to make you unstoppable-

(with step-by-step video tutorials)
ALL , HEALTH
(Cyriac) Abby Philips
(Cyriac) Abby Philips
@drabbyphilips
On 18.12.2020, computer engineer @FitTuber shared @YouTube video titled "10 Safe & Useful Ayurvedic Tablets to Replace Allopathic Pills (Instant Relief)". The drugs he promoted were by @baidyanathgroup, not sure if it was paid promotion. I bought them:
https://t.co/w6Sh2pMvJf


10 drugs, details, batch numbers R given in pic👇. All by @baidyanathgroup exept 1 by https://t.co/tg46sBhJr2
We did GCMSMS, ICP-OES and FTIR analyses on these samples. Here are my 10 safer modern medicine alternatives 2 @FitTuber's untested, potentially harmful #Ayurvedic drugs


Kanthsudharak Vati by Unjha Pharma
@FitTuber: 4 sorethroat, cold, cough
Analysis: Lead 0.54 mg/kg, Cadmium 0.4 mg/kg, Thallium 0.71 mg/kg and industrial phenols.
Low values, but not ideal.

Safe alternative: Levocetrizine & non-sedative cough syrup Levodropropizine


Baidyanath Rajbati
@Fittuber: for bloating, gas
Analysis:
Mercury 1.2 mg/kg
Arsenic 2.25 mg/kg
Male anabolic hormone - hydroxy testosterone+
Curcumin
Talc powder

Safer alternative: activated charcoal+simethicone (non-absorbed, no side effects) or short course esomeprazole.


Baidyanath Bilwadi Choorna
@Fittuber - 4 diarrhoea
Analysis
Thallium 3.68 mg/kg
[fun fact: 10-15 mg/kg is lethal dose for humans. Death can occur at lower dosages] https://t.co/9ozOKROhCK
Fenretinide - synthetic anti-cancer drug
Liver toxic chromium phosph.

Safer: Racecadotril
HEALTH

You May Also Like

Vibhu Vashisth
Vibhu Vashisth
@VIBHU_Tweet
ANCIENT BHARAT WAS CALLED VISHWAGURU, AND IT REALLY DESERVED IT.

India had a well developed education system centuries before the westerners arrived and called us uncivilized. Education was always given a great importance in Indian civilisation since times immemorial.


Ancient India had the Gurukulas and Ashramas as the epicentres of the knowledge and enlightenment. Bigger Gurukulas served as the centres of higher education called universities. Besides these universities, temples also emerged as the major learning centres.

Studying the Holy Scriptures, character building, personality development, responsibilities towards self,family and society,discipline and preservation of the ancient culture and heritage were the key embodiments of education.

This kind of education system made ancient India, a centre of knowledge all over the world. Many foreign students came to India for education and India was called the 'Vishwaguru'.
Takshshila and Nalanda were the two prominent universities of ancient India.


But were these only Universities of ancient India?The answer is 'No'.Let's learn about these gems of our education system that flourished across ancient India & be proud.

NALANDA UNIVERSITY
This was the oldest university of ancient India.Situated in Nalanda distt. of Bihar...
ALL
Billy Bostickson \U0001f3f4\U0001f441&\U0001f441 \U0001f193
Billy Bostickson 🏴👁&👁 ...
@BillyBostickson
Tip from the Monkey
Pangolins, September 2019 and PLA are the key to this mystery
Stay Tuned!


1. Yang


2. A jacobin capuchin dangling a flagellin pangolin on a javelin while playing a mandolin and strangling a mannequin on a paladin's palanquin, said Saladin
More to come tomorrow!


3. Yigang Tong
https://t.co/CYtqYorhzH
Archived: https://t.co/ncz5ruwE2W


4. YT Interview
Some bats & pangolins carry viruses related with SARS-CoV-2, found in SE Asia and in Yunnan, & the pangolins carrying SARS-CoV-2 related viruses were smuggled from SE Asia, so there is a possibility that SARS-CoV-2 were coming from
ALL
Advertisement
Dr Fish Philosopher Todd (Dr FPT)\U0001f41f
Dr Fish Philosopher To...
@ZoeSTodd
1. I was walking in the woods yesterday and I had an epiphany. It wasn’t one I wanted to have. I was thinking about today’s class, where we are reading Kimmerer’s ‘Gathering Moss’. I’ve taught Braiding Sweetgrass in multiple classes every year since 2016. It’s eminently teachable

2. Both books are beautifully written. Students uniformly enjoy them as assigned reading. They do a great job communicating to non-Indigenous folks the contours of basic Indigenous relationships to more-than-human beings. They’re wildly popular with white readers.

3. I’ve found Braiding Sweetgrass to be a great entry point for non-Indigenous folks to Indigenous scholarship. But this is where yesterday’s epiphany comes in. Neither Braiding Sweetgrass or Gathering Moss tends to the deep deep lineages of Indigenous scholarship in Canada or US

4. As the popularity of ‘Braiding Sweetgrass’ has soared, I’ve seen more and more white folks wax on about ‘braiding knowledge’. But they often don’t know any of the lineages of these concepts beyond what is presented in this one book. They confidently run with this.

5. Kimmerer does a commendable job of weaving in her own experiences, her family stories+nods to some very important knowledge keepers who deserve to be celebrated for their work. But Braiding Sweetgrass does not tend to the citational politics Sara Ahmed & others teach us about
SOCIETY
Anshul Pandey
Anshul Pandey
@Anshulspiritual
TYPES OF SINS(PAAP) AS PER SKAND PURAN.

There are three types of Adharma- Sthool, Sukshma and Ati Sukshma. The group of Sins in the Sthul section carries you to Narak. These sins are committed through your thoughts, words and deeds.


It is of four types.

1)First is the sin committed by your mental state-
Thinking about woman other then your spouse.

A)Resolution to amass wealth from others.

B)Thinking ill about others.

C)Thinking of doing a forbidden or unworthy deed.

2)Second is the sin that you commit through your words :-

A)Talking irrelevant things.

B)Telling a lie.

C)Speaking harshly.

D)Talking ill about others.

3)Third type of sin is committed through your body actions-

A)Eating food not prescribed to you or forbidden.

B)Violence.

C)Eating fancier food.

D)Acquiring other's wealth.

So these twelve types of sins.

There are six types of sinners or Mahapatak

1)One not bowing his head in front of a temple.

2)Never praise Shiva.

3)People who behave untowardly way in front of Ishwar.

4)People who do not show respect to Ishwar, guru or one who are undignified.

5)One who do not behave properly.

6)One who is jealous of other bhakts.

Below is the list of sins which people may commit.

1)One who does not help a needy person or a person in pain,
RELIGION
Erik Torenberg
Erik Torenberg
@eriktorenberg
1/ Some initial thoughts on personal moats:

Like company moats, your personal moat should be a competitive advantage that is not only durable—it should also compound over time.

Characteristics of a personal moat below:


2/ Like a company moat, you want to build career capital while you sleep.

As Andrew Chen noted:


3/ You don’t want to build a competitive advantage that is fleeting or that will get commoditized

Things that might get commoditized over time (some longer than


4/ Before the arrival of recorded music, what used to be scarce was the actual music itself — required an in-person artist.

After recorded music, the music itself became abundant and what became scarce was curation, distribution, and self space.

5/ Similarly, in careers, what used to be (more) scarce were things like ideas, money, and exclusive relationships.

In the internet economy, what has become scarce are things like specific knowledge, rare & valuable skills, and great reputations.
LIFE