Comparison of autogenous fistula versus expanded polytetrafluoroethylene graft fistula for angioaccess in hemodialysis

Prevalence of thrombosis in patients undergoing dialysis treatment: A systematic review and meta-analysis

AIM

to determine the prevalence of thrombosis in dialysis patients.

BACKGROUND

Thrombosis is the most common cause of vascular access dysfunction in dialysis patients. Various studies have reported different prevalence rates of thrombosis, and no systematic study provides a comprehensive result on this subject.

METHODS

In this systematic review and meta-analysis, a search of available texts was conducted until the end of December 2023, using keywords such as Thrombosis, end-stage renal disease, end-stage kidney disease, hemodialysis, and dialysis in databases including Web of Science, PubMed, Scopus, ProQuest, Ovid, Science Direct, Clinical Key, EMBASE, CINAHL, SID, and MagIran. The random-effects model was used, and the heterogeneity of the studies was assessed using the I2 index. The quality of the selected studies was evaluated using the STROBE checklist. Meta-analysis was performed using CMA version 2 and STATA version 14 software. The study adhered to the guidelines stated in the PRISMA statement.

RESULTS

Out of 12,604 articles found, after removing duplicates and conducting evaluations, the full text of 415 articles was examined, and ultimately, 141 articles were included in the study. The overall prevalence of thrombosis was 14.2% (95% CI: 11.5-17.2). The prevalence of thrombosis was higher in dialysis patients under 50 years of age (17.1%, 95% CI: 11.3-23.8) and patients with vascular access (16.2%, 95% CI: 13.1-19.5), especially arteriovenous grafts (22.8%, 95% CI: 14.5-32.4). Additionally, the prevalence of late thrombosis was higher than that of early thrombosis (15.0% vs. 5.3%) (95% CI: 7.7-24.2 vs. 95% CI: 2.7-8.5).

CONCLUSIONS

The results indicate a relatively high prevalence of thrombosis in dialysis patients. The prevalence of thrombosis in patients with arteriovenous grafts was notable. Considering the risks of thrombosis, the adoption of preventive measures in hemodialysis patients, such as the use of anticoagulant drugs, is recommended.

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery

Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

Use of Basilic vein in arteriovenous fistulas construction for hemodialysis access. Is it a good option alternative to prosthetic arteriovenous grafts?

PURPOSE

For patients with a failed forearm autogenous fistula (AF) and an exhausted cephalic vein, there is controversy about whether a brachial basilic AF with transposition or an arteriovenous prosthetic bridging graft (BG) must be the second vascular access option. This work measured and compared these two modalities according to patency rates, complications, and revisions.

PATIENTS AND METHODS

A retrospective study of 104 cases that had either a brachial basilic AF (72) or an Arteriovenous BG (32). Technical success, operative complications, procedurerelated mortality, maturation time, functional primary, secondary, and overall patency rates were all assessed.

RESULTS

Technical success was obtained in all participants. No procedure-linked mortality. Maturation time for BGs was significantly shorter than AFs. The complication rate was significantly higher in BGs than in AFs. The most prevalent complication was access thrombosis. The functional primary patency rate was significantly higher in AF than in BG at 12-month followup: 77.7% vs 53.1% (p < 0.012). secondary patency rate was higher in AF than in BG at 1-year follow-up 62.5% vs 42.8% (p = 0.063), respectively. In addition, BGs required more interventions to preserve patency.

CONCLUSIONS

AF had higher primary, secondary and overall functional patency rates and needed fewer procedures to keep patency than BGs. Cases that need early vascular access as a result of central venous catheter complications or who have a reduced life expectancy may benefit from BGs.

Oversized balloon angioplasty for endovascular maturation of arteriovenous fistulae to accelerate cannulation and to decrease the duration of catheter use

BACKGROUND

The functional autologous arteriovenous fistula is considered the best vascular access for patients on hemodialysis. Some fistulae exhibit maturation problems after creation and do not reach adequate vessel diameter and flow in dialysis. The aim of this study was to describe our technique of oversized balloon angioplasty for assisted maturation of arteriovenous fistulae to accelerate the cannulation and to decrease the time of catheter use and its outcome.

METHODS

A retrospective analysis of balloon-assisted procedures for maturation failure was performed in a single center between October 2011 and January 2019. Patients underwent imaging procedures to identify stenosis, followed by angioplasty using oversized high-pressure balloons from the anastomosis to the deep venous outflow tract. The flow volume, time interval of use of the fistula and removal of the catheter, patency rates, and complications rates were evaluated.

RESULTS

Seventy-eight patients underwent 124 balloon angioplasty procedures. Technical and clinical success was achieved in 91% of the cases. In patients in whom maturation was successful, the fistula was cannulated in a mean time of 5 days after the procedure (range, 1-20 days). On average, catheter removal was performed 14 days (range, 5-33 days) after the maturation procedure. The mean flow volume in the fistula before the procedure was 276 ml/min (range, 122-488 ml/min) and 24 h after the maturation was 1014 ml/min (range, 760-1800 ml/min).The primary patency rate at 3, 6, and 12 months was 87.3%, 66.2%, and 50.7%, respectively. Assisted primary patency was 100% at 3 months, 92.9% at 6 months, and 90.0% at 12 months. Minor complications occurred in 18% of cases, and major complications in 4.8%.

CONCLUSIONS

The oversized balloon-assisted arteriovenous fistula maturation technique is safe and effective, allowing the cannulation of the fistulae a few hours or days after the procedure and decreasing the time of catheter use.

Interest of surgical vascular reconstructions aiming at preserving hemodialysis access

BACKGROUND

Vascular hemodialysis access is a very precious asset for patients with end-stage renal failure. Ideally complications in these accesses should be detected early in order to treat them in time. The aim of this study was to evaluate the effectiveness of vascular reconstructions to preserve the vascular access for hemodialysis and to examine their benefits in terms of conserving the venous network, using hemodialysis catheters, time of cannulation after surgery, patency and postoperative morbi-mortality, by comparing them to those of newly created arterio-venous fistula (AVF).

METHODS

This was a retrospective, descriptive and comparative study, performed from September 2012 to February 2015. It concerned patients operated for complications of their native AVF. Two groups were compared: reconstructed AVF (group 1) and newly created AVF (group 2). Demographic characteristics, comorbidities, preoperative clinical and paraclinical data, surgical techniques and outcomes were recorded. This data was analyzed and compared between the two groups.

RESULTS

We collected 151 surgical interventions divided into two groups: 55 surgical reconstructions and 96 new AVF. The average age was 59.9±1.3 years [19.1-88.9], with a male predominance (59.6%). The two groups were comparable in terms of age, gender and comorbidities. Reconstructions were mostly indicated for stenosis (47.3%) and new vascular accesses for venous thrombosis (92.7%). Reconstruction had significantly better successful exploitation rates (95.7%) and time of cannulation (26.6 days) (respectively P=0.025 and P=0.000). Its primary failure rate was null. Its primary patency and primary functional patency were respectively 94.2% and 97.7% at 1 month and 82.2% and 87.1% at 2 years. Morbidity's global rates were comparable between both groups (41.8% vs. 43.8%). The rates of early morbidity and stenosis were significantly higher for reconstructions (respectively P=0.037 and P=0.047), while late morbidity and thrombosis' rates were significantly higher for new AVF (respectively P=0.021 and P=0.023). Mid-term permeabilities were better for reconstructions, but the differences were not statistically significant.

CONCLUSION

Surgical reconstructions seem to be an effective alternative for the treatment of complicated AVF. Our results appear to be comparable to those of the literature. The benefits of these surgical techniques in terms of conserving venous network, use of hemodialysis catheters, time for cannulation after surgery, patency and postoperative morbi-mortality appear to be undeniable.

Pediatric hemodialysis access

Pediatric hemodialysis access is a demanding field. Procedures are infrequent, technically challenging, and associated with high complication and failure rates. Each procedure affects subsequent access and transplants sites. The choice is made easier and outcomes improved when access decisions are made by a multidisciplinary, pediatric, hemodialysis access team. This manuscript reviews the current literature and offers technical suggestions to improve outcomes.

Predictors of Mortality within 24 Months of Initial Arteriovenous Access Creation

INTRODUCTION

End Stage Renal Disease is increasingly common, with approximately 785,880 patients currently dialysis dependent in the United States. 86% of these patients utilize hemodialysis. Arteriovenous (AV) access with either a fistula or graft is preferred over a catheter due to lowered complication risk. The purpose of this paper is to identify mid- term predictors of mortality to guide the type of AV access in patients with suboptimal cephalic veins.

METHODS

This is a retrospective review of patient characteristics at the time of initial AV access placement. All patients receiving first time AV access were reviewed. Mortality data was found via electronic medical records review, social security death index review, and internet search. Patients in whom mortality data could not be found were excluded from the final analysis. Univariate analysis using Chi-Squared testing and Student T-Test was performed. Binary logistic regression analysis was also performed for multivariate investigation.

RESULTS

A total of 176 patients underwent first time AV access during the study period. Two year mortality data was available for 149 of these patients. Mortality occurred within 2 years for 27% of patients. Advanced age (70 vs. 61, P < 0.01), arrhythmia (48% vs. 24%, P < 0.01), abnormal EKG (36% vs.14%, P < 0.01), CHF (47% vs. 24%, P < 0.01), white, non-Hispanic race (51% vs. 22%, P < 0.01) and history of smoking (48% vs. 15%, P < 0.01) were statistically significant univariate predictors of 2-year mortality. Advanced age, white race and smoking were multivariate predictors with smoking having the largest impact (multivariate adjusted OR 11.8, P < 0.001).

CONCLUSIONS

History of tobacco smoking has a profoundly negative effect on two year survival in patients undergoing initial AV access. Absence of smoking history provides significant 2-year mortality protection and thorough attempt at autologous AVF creation should be made in these patients. Cardiac disease and advanced age continue to be lead predictors of mortality in ESRD patients.

Results of Prompt Surgical Intervention in Hemodialysis Radiocephalic Fistula Secondary Dysfunction

Radiocephalic fistula (RCF) dysfunction is a common problem due to low maturation and patency rates of these fistulas. The most common procedure in such cases is to place a temporary catheter for the dialysis. Temporary catheter placement and undergoing dialysis with this catheter cause complications, reduce the chance for fistula, and deteriorate the quality of life. The aim of this study was to demonstrate that immediate intervention in RCF dysfunctions can increase fistula success for the patient and can reduce the need for a catheter. Furthermore, the hemodialysis treatment can continue without affecting the quality of life. A total of 295 patients who were admitted for RCF dysfunction and who underwent early surgical intervention without any catheter placement were evaluated for postoperative complications, patency rates, and rates and durations of temporary catheter use over a mean time of 47 months of follow-up (range: 4–79 months). Of the patients, 77.2% (n = 228) underwent new proximal anastomosis (NEO; the radial artery and cephalic vein were reached with an incision created proximal to the previous anastomosis), 14.2% (n = 42) underwent brachiocephalic arteriovenous fistula (AVF), 8.4% (n = 25) underwent side-to-side brachiobasilic AVF + superficialization of the basilic vein. In 88.8% (n = 262) of the patients, successful cannulations were performed within the first 24 to 48 hours without any catheter requirement or complications. Temporary catheter was used for 15.1 ± 10.7 days in 11.2% (n = 33) of the patients. In RCF dysfunctions, early surgical interventions performed in the forearm and elbow provide early cannulation and thus decrease the catheter requirement, also prevent the complications of temporary catheters (infection, decreasing the fistula success, vascular injuries, etc.), increase the autogenous fistula success, and allow for the continuation of dialysis without disturbing the quality of life.

Thick PCL Fibers Improving Host Remodeling of PGS-PCL Composite Grafts Implanted in Rat Common Carotid Arteries

Vasculopathy and the consequential ischemia are major medical challenges. Grafting is an effective treatment to vascular occlusion. However, autologous grafting, despite scarcity, is the only choice for small diameter blood vessels. Synthetic grafts can fill the gap if they can work satisfactorily in arterial circulation. Electrospun polycaprolactone (PCL) sheathed porous poly(glycerol sebacate) (PGS) vascular grafts have good performances in arterial circulation in abdominal aortas and carotid arteries in rats. However, a major issue associated with the graft remodeling in vivo is limited neo-tissue formation inside PCL sheaths. Small pores of PCL sheaths inhibit cell infiltration and migration. To increase porosity of PCL sheaths of PGS-PCL composite grafts, diameters of electrospun PCL fibers are increased. The thick PCL fibers encourage cell migration and elicit a higher degree of CD206⁺ cells. In addition, some of the CD206⁺ cells co-express vascular cell markers in the thick-fiber grafts. The thick-fiber grafts also show improved mechanical properties and a higher elastin and collagen content. The data demonstrate the feasibility of improving graft vascular remodeling by increasing PCL fiber diameters and the critical role of CD206⁺ cells during graft vascular remodeling.

Challenges and novel therapies for vascular access in haemodialysis

Advances in standards of care have extended the life expectancy of patients with kidney failure. However, options for chronic vascular access for haemodialysis - an essential part of kidney replacement therapy - have remained unchanged for decades. The high morbidity and mortality associated with current vascular access complications highlights an unmet clinical need for novel techniques in vascular access and is driving innovation in vascular access care. The development of devices, biological approaches and novel access techniques has led to new approaches to controlling fistula geometry and manipulating the underlying cellular and molecular pathways of the vascular endothelium, and influencing fistula maturation and formation through the use of external mechanical methods. Innovations in arteriovenous graft materials range from small modifications to the graft lumen to the creation of completely novel bioengineered grafts. Steps have even been taken to create new devices for the treatment of patients with central vein stenosis. However, these emerging therapies face difficult hurdles, and truly creative approaches to vascular access need resources that include well-designed clinical trials, frequent interaction with regulators, interventionalist education and sufficient funding. In addition, the heterogeneity of patients with kidney failure suggests it is unlikely that a 'one-size-fits-all' approach for effective vascular access will be feasible in the current environment.

Comparison of Peritoneal Catheter Survival with Fistula Survival in Hemodialysis

Objective

To compare continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) with regard to long-term maintenance of access.

Design

Retrospective study of a four to six-year time period at one center.

Patients

One hundred and twenty-two CAPD patients between December 1988 and December 1992, and 172 HD patients between May 1986 and December 1992.

Main Outcome Measure

Cumulative survival rate of peritoneal catheters and arteriovenous fistulas (AVF) was the main outcome measure. Variables affecting the survival rate including sex, age, presence or absence of diabetes, and type of AVF (autogenous or prosthetic graft) were assessed. The causes of peritoneal catheter failures were analyzed.

Results

The cumulative survival rate of all peritoneal catheters was significantly longer than the AVF survival rate (84% vs 74% at one year; 73% vs 61% at two years; and 63% vs 48% at three years) (p = 0.029). There were no differences in peritoneal catheter survival according to sex, age, or diabetes. Compared with A VF survival, peritoneal catheter survival was significantly longer in male (p = 0.0492), elderly (p = 0.0082), and diabetic (p = 0.0022) patients. Prosthetic graft and old age were risk factors for AVF survival. Of all peritoneal catheter failures, infectious complications were responsible for 75% (33/44) and mechanical complications for 25% (11/44). Peritonitis was the leading infectious complication (21/33) and outflow obstruction was the leading mechanical complication (9/11).

Conclusion

In terms of long-term maintenance of access, CAPD is superior to HD, especially in the elderly or diabetics. Prevention and proper management of peritonitis may prolong the peritoneal catheter survival.

Predictors of Primary Functional Maturation of Autogenous Radiocephalic Arteriovenous Fistula in a Cohort of Asian Patients

BACKGROUND

The aim of this study was to investigate the predictors of autogenous radiocephalic arteriovenous fistula (RCAVF) maturation.

METHODS

This was a retrospective analysis of patients undergoing RCAVF creation from June 2013 to December 2018 at a single medical center. Comparison of the variables between the matured and nonmatured group was performed.

RESULTS

A total of 277 patients (men, 173; 62.5%) with a mean age of 56.6 ± 16.9 years underwent primary RCAVF creation during the study period. The mean diameter of the cephalic vein and radial artery were 2.4 ± 0.6 mm (range 1.5 to 4.3 mm) and 2.3 ± 0.5 mm (range 1.5 to 4.0 mm), respectively. Primary functional maturation was achieved in 236 patients (236/277, 85%). There was no statistical significance between the matured and nonmatured group in terms of age (56.4 ± 14.8 vs. 58.1 ± 15.1, respectively; P = 0.498), coronary arterial disease (12% vs. 17%, respectively; P = 0.449), diabetes mellitus (42% vs. 39%, respectively; P = 0.864), smoking (26% vs. 22%, respectively; P = 0.699), or antiplatelet therapy (23% vs. 24%, respectively; P = 0.844). However, female gender (35% vs. 54%, respectively; P = 0.024), peripheral arterial disease (9% vs. 22%, respectively; P = 0.025), and small vein (2.4 ± 0.5 mm vs. 2.0 ± 0.5 mm, respectively; P < 0.01) and artery (2.4 ± 0.5 vs. 2.1 ± 0.4, respectively; P < 0.01) diameter were associated with the failure of maturation. The best cutoff diameter for the cephalic vein and radial artery was 1.85 mm and 2.05 mm, respectively.

CONCLUSIONS

In this cohort of patients undergoing RCAVF creation, vein and artery diameter on preoperative ultrasound mapping was the predictor of functional maturation. Female gender and presence of peripheral arterial disease were associated with failure of maturation.

A Meta-analysis of Preoperative Duplex Ultrasound Vessel Diameters for Successful Radiocephalic Fistula Placement

Background

The Kidney Dialysis Outcomes Quality Initiative (K/DOQI) guidelines for vascular access recommend the use of radiocephalic wrist arteriovenous fistulas (RCAVFs) as the initial option for dialysis access. The survival rate of a successfully placed fistula is excellent. However, 10–24% of RCAVFs fail to reach functional status as the result of early thrombosis or maturation failure. Many authors have investigated the utility of preoperative vascular mapping by Duplex ultrasound to predict adequate vessel size for successful fistula placement. This meta-analysis is the first in which preoperative radial arterial (RAD) and cephalic venous diameters (CVD) required for favorable fistula outcomes are reviewed.

Methods

A literature search was performed by use of the MEDLINE electronic base for “arteriovenous, fistula, ultrasound, and hemodialysis.” The analysis yielded 166 studies, of which 20 studies included preoperative duplex data. Meta-analysis was performed by applying the statistical test of comparing two proportions, assuming equal variances.

Results

A total of 433 patients were duplexed for preoperative evaluation of the RAD and 386 for CVD. The total number of subjects ranged from 21 to 91, mean age 58.7 years. The subjects were 55.5% male, 39.0% with diabetes mellitus. Meta-analysis yielded 2.0 mm for RAD and 2.0 mm for CVD as designated cutoff vessel diameters. Our study showed the mean fistula success rate was significantly different between RAD >2.0 mm (59%) and RAD >2.0 mm (40%). The mean fistula success rate was also significantly different between CVD > 2.0 mm (71%) and >2.0 mm (29%). Successful fistula placement was defined as a functional fistula at least 4–6 weeks after creation.

Conclusion

On the basis of our study, the use of Duplex ultrasound is important in determining preoperative vessel diameter size, and subsequent functional success rate of fistula placement.

Functional Patency of Autogenous AV Fistulas for Hemodialysis

Background

Although AV fistulas are the preferred access for hemodialysis and have low complication rates, failure to function remains high and time to first dialysis may be several months.

Methods

Data from a Computerized Patient Record System of patients undergoing AV fistula from October 2000 to March 2006 were reviewed for type of fistula, interval from AV fistula construction to first hemodialysis, patency period, and complication rate.

Results

129 patients were identified who underwent 155 autogenous AV fistula constructions. The average age was 62.1 (range 40–84) years old. 114 radiocephalic and 41 brachiocephalic fistulas were performed. 57 (50%) radiocephalic fistulas allowed successful hemodialysis after an average length of 13±5 weeks with a primary patency of 13±4 months. 24 (42%) fistulas subsequently thrombosed, 7 (12%) developed fistula stenosis, and 2 (4%) developed steal syndrome. 28 (68%) brachiocephalic fistulas reached successful hemodialysis after 6±2 weeks with a primary patency of 16±7 months. Eleven (42%) of the brachiocephalic fistulas that reached hemodialysis remained patent while four (15%) thrombosed. Two (8%) brachiocephalic fistulas thrombosed before reaching hemodialysis. There were two incidences (5%) of steal syndrome in the brachiocephalic group with one case being severe leading to tissue loss in the hand.

Conclusion

Brachiocephalic fistulas were superior to radiocephalic in both time to maturity, primary patency, and functional primary patency. Brachiocephalic fistulas had a higher maturation rate and were less likely to fail once hemodialysis began. Vascular surgeons should develop better patient selection to predict which fistulas will function successfully rather than risk complications of prolonged central catheters.

Polytetrafluoroethylene and Bovine Mesenterial Vein Grafts for Hemodialysis Access: A Comparative Study

Purpose

This study aimed to evaluate the safety and patency rate of bovine mesenterial vein grafts (BMVG) for vascular access (VA) in hemodialysis patients (HDP), compared to expanded polytetrafluorethylene (ePTFE grafts) over a mid- to long-term period.

Methods

Patency and complication rate of 23 consecutive HDP with BMVG for VA were compared to a control group consisting of 23 similar HDP with ePTFE grafts. In both groups, the graft was placed preferably in a forearm loop configuration. The same surgeon performed all procedures. All patients were followed over a period of 4 yrs.

Results

Graft placement was successful in all patients. Patency rates did not differ significantly in both groups. However, there were less severe complications in the BMVG group.

Conclusion

The BMVG is a viable alternative for HD access in patients where autologous construction is not possible, and should be given priority in patients with a failed ePTFE graft or high risk for infection.

Role of Preoperative Duplex Ultrasonography to Predict Functional Maturation of Wrist Radiocephalic Arteriovenous Fistula: A Study on Indian Population

Radiocephalic arteriovenous fistula (RCAVF) is the first choice for native arteriovenous fistula (AVF). Preoperative vessel assessment with ultrasonography (USG) has been reported to enhance the outcome of native AVF, but data regarding its predictive value for functional maturation of RCAVF are scanty. We aimed to determine the role of preoperative duplex USG (DUS) for prediction of functional maturity of radiocephalic fistula in the wrist. The data from 173 patients were analyzed prospectively. The estimated duplex variable included size, patency, and continuity of cephalic vein and size, peak systolic velocity, and wall calcifications in radial artery at the wrist. The subjects underwent RCAVF creation and were reviewed 6-8 weeks post procedure for adequacy of maturation. Doppler variables between successful and failed maturation groups were compared. Successful functional fistula maturation was noted in 138 (80.9%) patients. Values of radial artery diameter, cephalic vein diameter, and peak systolic velocity were >2 mm, 2.2 mm, and 32.8 cm/s, respectively, for successful maturation of RCAVF in more than 90% of cases. Vascular calcifications were detected preoperatively in 15 diabetic patients and 9 (60%) of them had fistula failure. Preoperative DUS can provide a good prediction on functional maturation of RCAVF. Vascular calcifications were associated with high risk of maturation failure in diabetics.

The Effect of Age on Radiocephalic Fistula Patency

Background

Inferior patency rates for radiocephalic fistulae in the elderly have been reported and may explain the increasing use of prosthetic grafts for vascular access. The aim of this study was to assess whether the patency rates of primary radiocephalic fistulae are affected by age.

Methods

A retrospective casenote review of 53 consecutive patients undergoing primary fistula formation between 1995 and 1998 under the care of a single consultant vascular surgeon. The setting was a specialist vascular surgical unit where the protocol is to offer all new patients a radiocephalic fistula. Fistula patency was defined as successful use for dialysis.

Results

Cumulative patency rates at 2 years were 60% in patients over 60 years (n=27), and 53% in patients under 60 years (n=26). The higher patency rates in the older age group were not significant on log rank testing (p=0.39).

Conclusion

Age over 60 years did not influence patency rates of primary radiocephalic fistulae, which should remain the haemodialysis access procedure of choice at all ages.

Vascular Screening Prior to Placement of Tunnelled and Cuffed Hemodialysis Catheters

Purpose

To demonstrate the importance of venous vascular screening before the placement of tunneled and cuffed hemodialysis catheters in patients requiring hemodialysis prior to placement and/or maturation of an arteriovenous fistula (AVF) or graft (AVG).

Methods

Between October 1998 and March 2000, all patients requiring hemodialysis access placement were prospectively evaluated with duplex ultrasound for status of upper extremity vessels and central veins prior to selection of a permanent access site. When interim tunneled and cuffed hemodialysis catheters were required, they were placed on the side contralateral to proposed AVF/AVG placement. No catheters were placed without initial vascular screening. The study group was compared to historical controls during a similar period (April 1997 through September 1998) when no vascular screening was performed.

Results

During the study period, 234 screening duplex ultrasound examinations were performed in 244 patients. Ten patients required no screening prior to access site placement. Overall, 353 catheters were placed, 243 (69%) on the right side and 110 (31%) on the left side. During the control period, 394 catheters were placed in 255 patients, 306 (78%) right-sided and 88 (22%) left-sided. The increase in left-sided catheters with ultrasound screening and careful planning for future access sites was significant (p<0.01).

Conclusion

Vascular-screening-directed catheter placement significantly alters the side of catheter placement when compared to a management protocol without prior screening. Such screening helps identify the side of permanent access placement, while directing interim catheters to the contralateral side such that central veins may be preserved for permanent access.

Arteriovenous Grafts: Much Maligned But in Need of Reconsideration?

There are substantial variations in arteriovenous fistula (AVF) use among hemodialysis patients in different countries, in different regions of the U.S., and even in different hemodialysis units within a single metropolitan area. These variations persist after adjustment for patient demographics and comorbidities, suggesting that practice patterns play a major role in determining the frequency of AVF use. These observations led to vascular access guidelines urging nephrologists and surgeons to increase AVF creation in patients with chronic kidney disease. Over the past 20 years, as clinicians have adopted these guidelines, the prevalence of AVF use in hemodialysis patients has increased substantially. At the same time, clinicians have recognized important limitations of an unwavering "Fistula First" approach. First, a substantial proportion of AVFs fail to mature even when routine preoperative vascular mapping is used, leading to prolonged catheter dependence. Second, certain patient subgroups are at high risk for AVF nonmaturation. Third, nonmaturing AVFs frequently require interventions to promote their maturation. Fourth, AVFs that require such interventions have shortened cumulative patency. Fifth, arteriovenous grafts (AVG) have several advantages over AVFs, including lower primary failure rates, fewer interventions prior to successful cannulation, and shorter duration of catheter dependence with its associated risk of bacteremia. All these observations have led nephrologists to propose an individualized approach to vascular access, with AVG being preferred in patients who initiate hemodialysis with a catheter, particularly if they are at high risk for AVF nonmaturation and have a relatively short life expectancy.

Clinical Utility of a New Predicting Score for Radiocephalic Arteriovenous Fistula Survival

BACKGROUND

Radiocephalic arteriovenous fistula (RC-AVF) is the recommended first choice for vascular access (VA). The CAVeA₂T₂ scoring system was recently published (ipsilateral central venous catheter access, age >73 years, vein <2.2 mm, lower limb angioplasty, and absent intraoperative thrill). The aim of the present study was to assess the clinical utility of the CAVeA₂T₂ scoring system for predicting RC-AVFs survival in our center and its subsequent application in VA management.

MATERIAL AND METHODS

In this single-center retrospective study, all RC-AVFs performed from January 2010 to July 2014 were included. The CAVeA₂T₂ was applied. Primary, assisted primary, and secondary patency rates were measured.

RESULTS

Sixty RC-AVFs were analyzed. Mean age was 64.3 ± 14.7 years. Mean CAVeA₂T₂ score was 1.23 ± 1.2. The median fistula secondary patency was 13.7 ± 1.6 months. Secondary patency was at 6 weeks and at 6, 12, and 24 months: 88.3%, 66.7%, 55%, and 31.7%, respectively. Increasing score (≥2) was associated with a decrease in primary (log-rank, χ² = 16.7, dif = 1, P = 0.0001) and secondary patency rate survival (log-rank, χ² = 5.4, dif = 1, P = 0.0001). In addition, stratification of the CAVeA₂T₂ score into 3 groups (scores 0-1, 2, and 3+) retained its significance for primary (log-rank, χ² = 19.4, dif = 2, P = 0.0001) and secondary patency rate survival (log-rank, χ² = 5.5, dif = 2, P = 0.046) at the end of the study.

CONCLUSIONS

In the present study, the CAVeA₂T₂ scoring system has proved to be a useful, easy to apply tool that is highly predictive of RC-AVF survival. Based on our results, we should avoid perform RC-AVFs, in those patients with CAVeA₂T₂ score ≥2 and late nephrology referral. Prospective studies should be designed to establish the management of patients with a higher CAVeA₂T₂ score.

Complications of the Arteriovenous Fistula: A Systematic Review

The implementation of patient-centered care requires an individualized approach to hemodialysis vascular access, on the basis of each patient's unique balance of risks and benefits. This systematic review aimed to summarize current literature on fistula risks, including rates of complications, to assist with patient-centered decision making. We searched Medline from 2000 to 2014 for English-language studies with prospectively captured data on ≥100 fistulas. We assessed study quality and extracted data on study design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion criteria (61 unique cohorts; n>11,374 fistulas). Median complication rates per 1000 patient days were as follows: 0.04 aneurysms (14 unique cohorts; n=1827 fistulas), 0.11 infections (16 cohorts; n>6439 fistulas), 0.05 steal events (15 cohorts; n>2543 fistulas), 0.24 thrombotic events (26 cohorts; n=4232 fistulas), and 0.03 venous hypertensive events (1 cohort; n=350 fistulas). Risk of bias was high in many studies and event rates were variable, thus we could not present pooled results. Studies generally did not report variables associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an urgent need to standardize reporting of methods and definitions of vascular access complications in future clinical studies to better inform patient and provider decision making.

Subcutaneous Transposition of Arterialized Upper Arm Veins for Hemodialysis Angioaccess: Optimal Alternative to Grafts

The authors report 42 subcutaneous transpositions of arterialized deep upper arm veins for hemodialysis angioaccess: 37 basilic (BaF) and 5 brachial (BrF) fistulas, done in 38 patients, 18 of them diabetics, with local anesthesia. Indications for BaF and BrF creation were surgically exhausted forearm veins and/or severe arteriosclerotic changes of distal arteries. No neurologic or circulatory complications were seen. Cumulative patency rates for all fistulas was 100% at the first month and 82% one year after surgery. BaF and BrF are optimal autogenous alternatives to synthetic grafts.

Primary Vascular Access for Chronic Hemodialysis: A Comparison of Arteriovenous Fistulae with PTFE Grafts

The purpose of this study was to compare patency rates of arteriovenous fistula (AVF) and polytetrafluoroethylene grafts (PTFE) for hemodialysis and the complications associated with each. All new permanent vascular access procedures for hemodialysis performed at one institution between January 1989 and December 1993 were reviewed with follow-up to December 1995. Patient demographics, secondary operations, complications, and length of stay were compared between the two types of access strategies. Seventy-seven PTFE and 89 AVF were performed in 166 patients. Age, sex, and frequency of diabetes were similar between the two groups. Primary patency rate at 36 months for AVF was 53%, compared with 16% for PTFE (p<0.01). Secondary patency rate at 36 months was 70% for AVF and 50% for PTFE (p<0.02). PTFE was associated with more hospital days per patient per year (26 vs 6.9), more infections (12 vs one during secondary patency interval), and a higher initial failure rate (19 vs eight) as compared with AVE. Patient survival rate at 4 years was higher for those with AVF (65% vs 52%). We conclude that an AVF as the primary access procedure for new renal dialysis patients is preferable to PTFE whenever possible.

Polyurethane Grafts: A Viable Alternative for Dialysis Arteriovenous Access?

Polyurethane grafts, promoted for their self-sealing properties and low complication rates, were recently introduced for hemodialysis access. We review our experience with this graft material to determine its complication and patency rates. Between January 1995 and December 1999, 118 patients, 75 female and 43 male, with a mean age of 51 years, had a total of 163 polyurethane arteriovenous grafts inserted. The grafts were mostly 6 mm in diameter (69.3%), placed in a loop configuration (91.4%) in the forearm (49.7%). The median follow-up period was 12 months. The grafts were first cannulated for hemodialysis at a median time of 19 days after implantation, with 12% used within 3 days. Thrombosis and infection were the most common complications at rates of 32.7% and 30.0%, respectively. Infection was the most common cause of graft loss (61.5%). These complications were amenable to salvage intervention. The 1-year primary and secondary patency rates were 73% and 86%, respectively; the 3-year secondary patency rate, 72%. The 1-year serviceability rate was 64%. With satisfactory patency rates and the advantage of its self-sealing properties permitting early cannulation, polyurethane grafts provide a viable alternative for hemodialysis access. Early recognition and appropriate management of complications can prolong graft survival.

Balloon Angioplasty for Arteriovenous Graft Stenosis

Purpose:

To retrospectively review the long-term outcome as well as the cost effectiveness of thrombolytic therapy and balloon angioplasty (TBA) versus surgical thrombectomy and balloon angioplasty (SBA) in the treatment of prosthetic dialysis access grafts.

Methods:

Between February 1996 and February 1999, 63 hemodialysis patients (35 women; mean age 62.2 years) were treated for 105 thromboses in 6-mm polytetrafluoroethylene straight or loop bridge arteriovenous grafts. Choice of treatment was at the discretion of the surgeon or interventional radiologist: either Fogarty balloon thrombectomy followed by balloon dilation of the venous anastomotic stenosis or urokinase thrombolysis followed by angioplasty.

Results:

Forty-eight SBAs and 55 TBAs were performed in 63 patients without complications. The primary patency rates in the entire cohort were 34%, 29%, and 17% at 1, 2, and 3 months, respectively. Primary patency after TBA was 29%, 18%, and 11%, and that for SBA, 45%, 45%, and 33% over the same time intervals. The mean graft survival was 10 days for TBA versus 31 days for SBA. Repeat angioplasty performed in 23 grafts produced secondary patency rates of 52% at 1 month, 34% at 3 months, and 5% at 5 months. The Medicare reimbursement for both treatments was identical ($1638 for TBA and $1670 for SBA).

Conclusions:

The poor patency rate and high cost of TBA and SBA suggests that these procedures should not be routinely used for salvage of thrombosed arteriovenous grafts with outflow stenosis. Patch angioplasty or creation of simultaneous temporary and new permanent accesses may be a more cost-effective approach in these patients.

Interventions for Failed Wrist Fistulae: Is it Worthwhile?

A well-functioning forearm fistula is considered as the most suitable access for dialysis. It is easy to construct, has the fewest number of complications and lasts for a long time. Many patients fail to enjoy this benefit due to the high rates of thrombosis and the failure to mature associated with this procedure. Attempts to salvage failed and failing fistula suggest that there is a group of patients where interventions can help provide this benefit. This article provides a brief review of current experience using surgical and interventional techniques to salvage failing forearm fistulae. It attempts to classify modes of presentation of access failure and different modalities used to salvage them. It also suggests an algorithm that can be used to identify patients who may benefit from these interventions and a guide to make the decisions related to selection of a treatment modality. Successful salvage of a failing forearm fistula provides the patient with an opportunity to enjoy all the benefits of this access.

Retrospective review of arteriovenous fistula success rate in a multi-ethnic Asian population

BACKGROUND

Native vein arteriovenous fistulas (AVFs) are the recommended first-line vascular access in hemodialysis patients. Despite this, AVFs are plagued with unfavorable maturation rates. We conducted a retrospective cohort study to assess the AVF success rate and to identify any significant associating factors.

METHODOLOGY

Demographic and clinical data of all AVFs created from January 2011 to June 2013 at a single center with a multi-ethnic Asian population, were reviewed. The primary outcome was AVF successfully used for hemodialysis (FUSH) at 6 months. Secondary endpoints were the overall FUSH and actual maturation time of the AVFs. Univariate and multivariate analyses were performed to identify factors associated with AVF success.

RESULTS

A total of 375 fistulas were created during the study period (110 radiocephalic, 176 brachiocephalic, 89 brachiobasilic). The mean age was 59.4 ± 12.6 years and 42.9% were females. Seventy-one percent of patients had diabetes, 32.5% had ischemic heart disease and 10.7% had peripheral vascular disease. 246/375 (65.6%) AVFs FUSH by 6 months, and the average AVF maturation time was 16.1 ± 10.7 weeks. Of the 246 AVFs, 11% required secondary procedure to assist their success. Univariate analysis showed that gender (p = 0.035), age (p = 0.018), vein size on pre-operative vein mapping (p = 0.004) and operating surgeon (p = 0.021) were significant factors associated with AVF success. On multivariate analysis, age, pre-operative vein size and operating surgeon were significantly associated with fistula success.

CONCLUSIONS

Reasonable FUSH rates can be achieved in the study patients. Patient age, pre-operative vein mapping size and operating surgeon were shown to influence AVF success rate.

Preoperative vascular access evaluation for haemodialysis patients

BACKGROUND

Haemodialysis treatment requires reliable vascular access. Optimal access is provided via functional arteriovenous fistula (fistula), which compared with other forms of vascular access, provides superior long-term patency, requires few interventions, has low thrombosis and infection rates and cost. However, it has been estimated that between 20% and 60% of fistulas never mature sufficiently to enable haemodialysis treatment. Mapping blood vessels using imaging technologies before surgery may identify vessels that are most suitable for fistula creation.

OBJECTIVES

We compared the effect of conducting routine radiological imaging evaluation for vascular access creation preoperatively with standard care without routine preoperative vessel imaging on fistula creation and use.

SEARCH METHODS

We searched Cochrane Kidney and Transplant's Specialised Register to 14 April 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled adult participants (aged ≥ 18 years) with chronic or end-stage kidney disease (ESKD) who needed fistulas (both before dialysis and after dialysis initiation) that compared fistula maturation rates relating to use of imaging technologies to map blood vessels before fistula surgery with standard care (no imaging).

DATA COLLECTION AND ANALYSIS

Two authors assessed study quality and extracted data. Dichotomous outcomes, including fistula creation, maturation and need for catheters at dialysis initiation, were expressed as risk ratios (RR) with 95% confidence intervals (CI). Continuous outcomes, such as numbers of interventions required to maintain patency, were expressed as mean differences (MD). We used the random-effects model to measure mean effects.

MAIN RESULTS

Four studies enrolling 450 participants met our inclusion criteria. Overall risk of bias was judged to be low in one study, unclear in two, and high in one.There was no significant differences in the number of fistulas that were successfully created (4 studies, 433 patients: RR 1.06, 95% CI 0.95 to 1.28; I² = 76%); the number of fistulas that matured at six months (3 studies, 356 participants: RR 1.11, 95% CI 0.98 to 1.25; I² = 0%); number of fistulas that were used successfully for dialysis (2 studies, 286 participants: RR 1.12, 95% CI 0.99 to 1.28; I² = 0%); the number of patients initiating dialysis with a catheter (1 study, 214 patients: RR 0.66, 95% CI 0.42 to 1.04); and in the rate of interventions required to maintain patency (1 study, 70 patients: MD 14.70 interventions/1000 patient-days, 95% CI -7.51 to 36.91) between the use of preoperative imaging technologies compared with standard care (no imaging).

AUTHORS' CONCLUSIONS

Based on four small studies, preoperative vessel imaging did not improve fistula outcomes compared with standard care. Adequately powered prospective studies are required to fully answer this question.

An Outcomes Comparison of Native Arteriovenous Fistulae, Polytetrafluorethylene Grafts, and Cryopreserved Vein Allografts

BACKGROUND

Despite almost 2 decades of experience with cadaveric vein, there remains a paucity of available data regarding the role of cadaveric vein in hemodialysis, specifically with regard to outcomes and patency. Observations from our own experience have suggested that cadaveric vein grafts (CVGs) provide good outcomes, particularly in patients with recurrent access failure. Accordingly, this study aims to comparatively examine patency, access-related outcomes, and survival in patients undergoing placement of arteriovenous fistulae (AVF), polytetrafluorethylene (PTFE) grafts, and CVGs.

METHODS

This is a single institution 11-year retrospective case series evaluating the outcomes of 210 patients who underwent creation of AVF, PTFE grafts, and CVGs for hemodialysis access. Patients in the AVF (n = 70) and arteriovenous graft (AVG; n = 70) groups were matched to the CVG (n = 70) group by age, gender, and access location. Postoperative end points for all groups included primary and assisted patency, cause of access abandonment, and survival.

RESULTS

Patients were matched for age (P = 0.8707), gender (P = 0.6958), and access location and no significant differences existed between groups. AVF showed superior primary patency at 30 days, 1 year (64.3%, P < 0.0001) and 2 years (54.3%, P = 0.0091) in comparison to both AVG and CVG. AVG had reduced patency at 30 days (84.3%, P = 0.0009), 1 year (50.0%, P < 0.0001), and 2 years (32.9%, P = 0.0001) in comparison to AVF and CVG groups. Overall, AVF had the highest patency at all-time points followed, respectively by CVG and AVG. No significant difference existed between AVF and CVG groups with regard to secondary patency at 30 days (98.6% vs. 97.1%, P = 1.0000), 1 year (81.4% vs. 78.6%, P = 0.6749), and 2 years (68.6% vs. 51.4%, P = 0.0573). AVG patients had decreased survival (years) after access creation in comparison to AVF and CVG groups (P = 0.0003).

CONCLUSIONS

Our findings lend further support to the use of cadaveric vein for hemodialysis access surgery. As demonstrated through this comparative study, CVGs are capable of providing favorable results with regard to patency, access longevity, and patient survival. These current outcomes indicate that cadaveric vein is a sustainable alternative to PTFE for hemodialysis access surgery and should be accordingly considered for difficult access patients.

Current Outcomes and Indications for Cryopreserved Vein Allografts in Hemodialysis Access Surgery

Introduction

Cryopreserved vein allografts (cadaveric vein) have emerged as an option for arteriovenous graft reconstruction; however, indications for their use in hemodialysis access remains to be clearly defined. Observations from our own experience have suggested that cadaveric vein grafts (CVGs) provide good outcomes, particularly in patients with a history of infection, recurrent access failure and advanced age.

Methods

This is a 10-year retrospective study. Primary outcomes were ( 1 ) to identify characteristics specific to this patient population and ( 2 ) to better define indications for use of cadaveric vein in hemodialysis access creation.

Results

Indications for creation of CVGs included patient history of either active or recent infection (41.5%), recurrent access failure (43.4%) or surgeon preference secondary to patients’ advanced age (9.4%). Observed primary patency rates were 84.9% (30 days), 22.6% (1 year) and 16.0% (2 years). Secondary patency was 93.4% (30 days), 66.0% (1 year) and 52.8% (2 years). Patient death was the highest cause of graft abandonment (52.9%) followed by thrombosis (19.1%), infection (11.7%) and rupture (11.7%). CVG patency at the time of patient death was 83.7%.

Conclusions

The rates of both primary and secondary patency in CVGs are highly comparable to the reported patency rates of polytetrafluoroethylene (PTFE) grafts and allow for lifelong maintenance of dialysis access. Our observed outcome suggests that CVGs should be considered for patients needing vascular access in the presence of infection. CVGs may likewise be viable alternatives to PTFE grafts in the elderly and patients with limited access options.

Increased use of brachiocephalic arteriovenous fistulas improves functional primary patency

OBJECTIVE

As vascular surgeons strive to meet the Fistula First Initiative, some authors have observed a decrease in arteriovenous fistula (AVF) maturation rates in association with an increase in AVF creation. In May 2012, we adopted a practice change in an attempt to maintain the same high level of AVF creation while leading to a decrease in fistula failures.

METHODS

A retrospective study was conducted of all dialysis access procedures performed by a single vascular surgeon before (period 1; before May 1, 2012) and after (period 2; after May 1, 2012) the change in practice pattern. The adopted change included favoring the brachiocephalic location unless the patient was an ideal anatomic candidate for a radiocephalic AVF, creating a larger and standardized arteriotomy, and using a large venous footplate whenever possible. The main outcome measure was primary functional patency at 1 year. Secondary outcome measures included primary patency at 1 year, time to maturation, type of fistula created, steal syndrome, and tunneled hemodialysis catheter infections.

RESULTS

Of 213 vascular access procedures performed, 191 (90%) were AVFs. There was no difference in use of AVFs between period 1 (93% AVFs) and period 2 (88% AVFs; P = .2). Use of brachiocephalic AVFs increased from 38% in period 1 to 56% in period 2 (P = .01), with a corresponding trend toward a decrease in radiocephalic AVFs in period 2 (36% in period 1 to 27% in period 2; P = .2). Primary functional patency at 1 year was 47% in period 1 and 63% in period 2 (P = .03). Primary patency at 1 year was 51% in period 1 and 70% in period 2 (P = .001). Time to reach functional maturation was decreased in period 2 (median, 76 vs 82.5 days; P = .046). There was no difference in steal syndrome (P = 1.0), and the incidence of hemodialysis catheter infections was lower in period 2 (0 vs 7 [7%]; P = .006).

CONCLUSIONS

Increasing brachiocephalic AVF creation and reducing our reliance on radiocephalic AVFs resulted in a significant increase in primary functional patency at 1 year. This was achieved while maintaining the same high percentage of fistulas, a lower rate of central catheter infections, and the same low incidence of steal syndrome.

A comparison between one-stage and two-stage procedures for the creation of brachiobasilic arteriovenous fistulas

INTRODUCTION

Vascular access is essential to end-stage renal failure patients requiring haemodialysis. Many patients require multiple fistula formation attempts in order to gain good access, making secondary and tertiary fistula options vital. Brachiobasilic fistulas are well established, but there is little evidence to compare the different surgical techniques in creating them. This study aimed to determine the patency and complication rates associated with these procedures.

METHODS

Retrospective data was collected by reviewing case notes to determine fistula survival time and surgical setting. Patency, complications and required interventions were recorded for each group at three time intervals. The Kaplan-Meier method was used to calculate survival for each cohort.

RESULTS

37 brachiobasilic arteriovenous fistulas were created in 35 patients. 17 fistulas were one-stage procedures; 20 fistulas were made in two stages. Survival proportions were measured as 70.6%, 58.8% and 51.5% for the one-stage procedure and 95%, 90% and 78% for the two-stage procedure at 1 month, 1 year and 2 years respectively with p = 0.0385.

DISCUSSION

Native brachiobasilic fistulas have advantages over prosthetic grafts. There are technical aspects which make the two-staged procedure preferable, including being more amenable to a day case surgery setting. Despite this, there is a lack of relative outcome differences in the literature, thus necessitating further work.

CONCLUSION

Our data suggests creation of brachiobasilic fistulas using a two-staged procedure may result in improved patency rates. Complication rates were found to be statistically equivocal, with fistuloplasties and embolectomy shown to be effective in fistula salvage.

Outbreak of Hemodialysis Vascular Access Site Infections Related to Malfunctioning Permanent Tunneled Catheters: Making the Case for Active Infection Surveillance

Objective:

To describe an outbreak of infections with permanent cuffed hemodialysis catheters recognized through ongoing surveillance and related to a specific malfunctioning permanent catheter.

Design:

The outbreak was suspected from the results of prospective infection surveillance and confirmed by a retrospective cohort study using medical records for patients receiving dialysis between April 1,1999, and March 31, 2000.

Setting:

Integrated network of six outpatient hemodialysis facilities in southern Idaho and eastern Oregon.

Patients:

Outpatients receiving long-term hemodialysis.

Results:

During the 18 months prior to the outbreak, the overall infection rate was 4.1 infections per 1,000 dialysis sessions with a catheter rate of 8.9 per 1,000 dialysis sessions. During the 7 months of the outbreak, the overall rate increased to 5.8 per 1,000 dialysis sessions, whereas the catheter rate increased to 18.1 per 1,000 dialysis sessions. Reports of malfunctioning “Brand A” catheters prompted discontinuation of their placement. A manufacturer recall occurred in April 2000. During the 14 months after the outbreak, the overall infection rate decreased to 3.3 per 1,000 dialysis sessions and the catheter rate to 10.8 per 1,000 dialysis sessions. A 12-month retrospective cohort study recognized 96 patients with an identifiable catheter brand and 48 infections. Of these, 27 (56%) occurred in patients with Brand A catheters. The relative risk for infection when compared with other catheter brands was 1.96 (95% confidence interval, 1.32 to 2.92; P < .001).

Conclusions:

Ongoing infection surveillance in hemodialysis facilities can identify specific device-related outbreaks of infections and promote interventions to reduce infectious complications and promote patient safety. Surveillance for vascular access site infections is recommended as a routine activity in hemodialysis facilities.

Initial vascular access type in patients with a failed renal transplant

BACKGROUND AND OBJECTIVES

Permanent hemodialysis vascular access is crucial for RRT in ESRD patients and patients with failed renal transplants, because central venous catheters are associated with greater risk of infection and mortality than arteriovenous fistulae or arteriovenous grafts. The objective of this study was to determine the types of vascular access used by patients initiating hemodialysis after a failed renal transplant.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data from the US Renal Data System database on 16,728 patients with a failed renal transplant and 509,643 patients with native kidney failure who initiated dialysis between January 1, 2006, and September 30, 2011 were examined.

RESULTS

At initiation of dialysis, of patients with a failed transplant, 27.7% (n=4636) used an arteriovenous fistula, 6.9% (n=1146) used an arteriovenous graft, and 65.4% (n=10,946) used a central venous catheter. Conversely, 80.8% (n=411,997) of patients with native kidney failure initiated dialysis with a central venous catheter (P<0.001). Among patients with a failed transplant, predictors of central venous catheter use included women (adjusted odds ratio, 1.75; 95% confidence interval, 1.63 to 1.87), lack of referral to a nephrologist (odds ratio, 2.00; 95% confidence interval, 1.72 to 2.33), diabetes (odds ratio, 1.14; 95% confidence interval, 1.06 to 1.22), peripheral vascular disease (odds ratio, 1.31; 95% confidence interval, 1.16 to 1.48), and being institutionalized (odds ratio, 1.53; 95% confidence interval, 1.23 to 1.89). Factors associated with lower odds of central venous catheter use included older age (odds ratio, 0.85 per 10 years; 95% confidence interval, 0.83 to 0.87), public insurance (odds ratio, 0.74; 95% confidence interval, 0.68 to 0.80), and current employment (odds ratio, 0.87; 95% confidence interval, 0.80 to 0.95).

CONCLUSIONS

Central venous catheters are used in nearly two thirds of failed renal transplant patients. These patients are usually followed closely by transplant physicians before developing ESRD after a failed transplant, but the relatively low prevalence of arteriovenous fistulae/arteriovenous grafts in this group at initiation of dialysis needs to be investigated more thoroughly.

The comparison of the complications of axillobrachial and femorofemoral arteriovenous shunt prostheses in hemodialysis, a 3 year study in Alzahra general hospital

BACKGROUND

This study was performed to compare the outcome and complications of axillobrachial and femorofemoral graft as upper and lower limb arteriovenous shunt prostheses.

MATERIALS AND METHODS

In a prospective cohort study, we observed and followed-up all cases with a new insertion of ePTFE between February 2006 and February 2009. Assessment of patency and the complication rates of their prostheses were the essential parts of this observation.

METHODS

In a prospective cohort study, we observed and followed-up all cases with a new insertion of ePTFE between February 2006 and February 2009. Assessment of patency and the complication rates of their prostheses were the essential parts of this observation.

RESULTS

A total of 69 grafts were performed. Forty-nine of them were successfully followed-up (18 femorofemoral and 31 axillobrachial grafts). Immediate primary patency was 100%. For axillobrachial type, primary patency at 1, 3, and 6 months, respectively, was 86%, 60%, and 47%. Secondary patency at 1, 3, and 6 months was 86%, 75%, and 50%, respectively. For femorofemoral type, primary patency at 1, 3, and 6 months, respectively, was 88%, 40%, and 34%. Secondary patency at 1, 3, and 6 months was 94%, 47%, and 41%, respectively. (P > 0.05) Complications included a puncture-site hematoma, thrombosis, infection, venous hypertension, need of an excision and pseudoaneurysm formation. Pseudoaneurysm rate difference between the two groups was interestingly significant, while others were relatively similar; however, the rates were different.

CONCLUSION

The significant difference of aneurysm rate among our two groups, besides the insignificant difference of other complications and also the similar primary and secondary patency rates, manifest a brilliant guidance chart for the surgeons in order to choose the most compatible site for inserting ePTFE grafts (Gore-tex) as arteriovenous shunt prostheses for HD accessing.

Radiocephalic fistula: review and update

Since initially described in 1966, radiocephalic fistula or Brescia-Cimino fistula is one of the most commonly performed fistulas in the world of arteriovenous access. The indications for insertion include, but are not limited to, hemodialysis. Although this is a frequently performed procedure, the primary and secondary patency rates and predictors of failure are not well defined. The review of this topic is difficult because of the diversity in reporting and the absence of consensus between series. Following the current published recommendations by the Society of Vascular Surgery regarding standardization of terminology to facilitate meaningful comparison between the diversity of published data, this review is an attempt to summarize and highlight the relevant information with regard to primary patency, secondary patency, and predictors of failure of radiocephalic fistula using the available English literature.

Evaluation of arteriovenous fistulas made with the diamond-shaped anastomosis technique

Background

Obtaining vascular access suitable for long-term use in hemodialysis patients is of utmost importance. In these patients, autogenous methods are generally used for access. There are various techniques for obtaining autogenous access in hemodialysis patients.

Material/Methods

Our objective was to evaluate the outcomes of the “diamond-shaped anastomosis” technique used as a surgical technique during the creation of arteriovenous fistulas in patients with chronic renal failure. We randomly selected and retrospectively examined 67 patients on whom the “diamond-shaped anastomosis” technique had been performed.

Results

We found an 89% patency rate in the 67 randomly selected patients on whom we applied this technique in the early stage (first 6 months).

Conclusions

Maintaining fistula patency in the early postoperative period is important in fistula functioning. The diamond-shaped anastomosis is a simple technique with proven efficiency. This method can be applied in all situations and contributes to postoperative early stage latency.

Dialysis access

Although hemodialysis access procedures are considered the most common vascular procedures performed by either general or vascular surgeons, there is a paucity of level-one evidence in the literature. Randomized controlled trials are limited, and most of these studies have small sample sizes compared with other areas of vascular surgery, that is, carotid or aneurysm studies. We summarize the results of the world's literature for arteriovenous access in table format as a tool for those specialists managing patients with arteriovenous access procedures.