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Li D, Hao M, Sheng H, Ge H, Zhu Y. Lumen diameter is associated with the patency after percutaneous angioplasty of arteriovenous fistulas. J Vasc Access 2022:11297298221112531. [PMID: 36573705 DOI: 10.1177/11297298221112531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
AIM To assess the value of lumen diameter after percutaneous angioplasty (PTA) to predict functional dialysis use (FDU) of arteriovenous fistulas (AVF). METHODS We performed a retrospective study of all patients who underwent first PTA because of AVF stenosis between March 2019 and March 2021. The outcome was FDU of AVF at 6 months follow up. Independent factors of FDU were identified using multivariate regression analyses. Receiver operating characteristic (ROC) curve was performed to investigate the predictive ability of lumen diameter for FDU. RESULTS A total 68 patients were included into this study and the AVF of 53 cases (77.9%) were good for FDU after 6 months. The AVF age was younger in failure group than that in success group (16.1 ± 9.1 months vs 28.3 ± 20.0 months, p = 0.026). Compared with failure group, the post-PTA minimum luminal diameter (MLD) was bigger in success group (4.5 [4.0-4.5 mm] vs 5.5 mm [4.5-5.5 mm], p < 0.001). Meanwhile, the gain of lumen diameter in success group was also bigger than that in failure group (2.5 mm [2.0-3.0 mm] in failure group vs 3.0 mm [2.75-3.5 mm] in success group, p = 0.012). The residual stenosis was higher in failure group than that in success group (30% [10%-40%] vs 10% [0%-20%], p = 0.003). Logistic regression showed that AVF age and post-PTA MLD were independent predictors of FDU. ROC analysis showed that the gain of lumen diameter, post-PTA MLD and improvement of stenosis were comparable to predict FDU. For post-PTA MLD, the area under ROC curve was 0.804 (95% CI, 0.681-0.927, p < 0.001). The best cutoff is 4.75 mm, with the sensitivity and specificity was 71.7% and 80.0%, respectively. CONCLUSIONS AVF age and post-PTA MLD were independently predictors for FDU of AVF after PTA. To get the best performance, a minimum vein diameter of 4.75 mm should be obtained after angioplasty.
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Affiliation(s)
- Dandan Li
- Department of Vascular Surgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu Province, China
| | - Ming Hao
- Department of Vascular Surgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu Province, China
| | - Haijun Sheng
- Department of Vascular Surgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu Province, China
| | - Hongwei Ge
- Department of Vascular Surgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu Province, China
| | - Yongbin Zhu
- Department of Vascular Surgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu Province, China
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Northrup H, Somarathna M, Corless S, Falzon I, Totenhagen J, Lee T, Shiu YT. Analysis of Geometric and Hemodynamic Profiles in Rat Arteriovenous Fistula Following PDE5A Inhibition. Front Bioeng Biotechnol 2021; 9:779043. [PMID: 34926425 PMCID: PMC8675087 DOI: 10.3389/fbioe.2021.779043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
Arteriovenous fistula (AVF) is essential for chronic kidney disease (CKD) patients on hemodialysis, but treatment for AVF maturation failure remains an unmet clinical need. Successful AVF remodeling occurs through sufficient lumen expansion to increase AVF blood flow and lumen area. Aberrant blood flow is thought to impair AVF remodeling, but previous literature has largely focused on hemodynamics averaged over the entire AVF or at a single location. We hypothesized that hemodynamics is heterogeneous, and thus any treatment's effect size is heterogeneous in the AVF. To test our hypothesis, we used the PDE5A inhibitor sildenafil to treat AVFs in a rat model and performed magnetic resonance imaging (MRI) based computational fluid dynamics (CFD) to generate a detailed spatial profile of hemodynamics in AVFs. 90 mg/kg of sildenafil was administered to rats in their drinking water for 14 days. On day 14 femoral AVFs were created in rats and sildenafil treatment continued for another 21 days. 21 days post-AVF creation, rats underwent non-contrast MRI for CFD and geometrical analysis. Lumen cross-sectional area (CSA) and flow rate were used to quantify AVF remodeling. Parameters used to describe aberrant blood flow include velocity magnitude, wall shear stress (WSS), oscillatory shear index (OSI), and vorticity. Geometrical parameters include arterial-venous (A-V) distance, anastomosis angle, tortuosity, and nonplanarity angle magnitude. When averaged across the entire AVF, sildenafil treated rats had significantly higher CSA, flow rate, velocity, WSS, OSI, and vorticity than control rats. To analyze heterogeneity, the vein was separated into zones: 0-5, 5-10, 10-15, and 15-20 mm from the anastomosis. In both groups: 1) CSA increased from the 0-5 to 15-20 zone; 2) velocity, WSS, and vorticity were highest in the 0-5 zone and dropped significantly thereafter; and 3) OSI increased at the 5-10 zone and then decreased gradually. Thus, the effect size of sildenafil on AVF remodeling and the relationship between hemodynamics and AVF remodeling depend on location. There was no significant difference between control and sildenafil groups for the other geometric parameters. Rats tolerated sildenafil treatment well, and our results suggest that sildenafil may be a safe and effective therapy for AVF maturation.
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Affiliation(s)
- Hannah Northrup
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States.,Division of Nephrology and Hypertension, University of Utah Department of Internal Medicine, Salt Lake City, UT, United States
| | - Maheshika Somarathna
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Savanna Corless
- Division of Nephrology and Hypertension, University of Utah Department of Internal Medicine, Salt Lake City, UT, United States
| | - Isabelle Falzon
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States.,Division of Nephrology and Hypertension, University of Utah Department of Internal Medicine, Salt Lake City, UT, United States
| | - John Totenhagen
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States.,Veterans Affairs Medical Center, Birmingham, AL, United States
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah Department of Internal Medicine, Salt Lake City, UT, United States.,Veterans Affairs Medical Center, Salt Lake City, UT, United States
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Meola M, Marciello A, Di Salle G, Petrucci I. Ultrasound evaluation of access complications: Thrombosis, aneurysms, pseudoaneurysms and infections. J Vasc Access 2021; 22:71-83. [PMID: 34313154 PMCID: PMC8607320 DOI: 10.1177/11297298211018062] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Arteriovenous fistula (AVF) complications are classified based on fistula outcomes. This review aims to update colour Doppler (CD) and pulse wave Doppler (PWD) roles in managing early and late complications of the native and prosthetic AVF. Vascular access (VA) failure occurs because inflow or outflow stenosis activates Wirchow's triad inducing thrombosis. Therefore, the diagnosis of the tributary artery and outgoing vein stenosis will be the first topic considered. Post-implantation complications occur from the inability to achieve AVF maturation and dialysis suitability due to inflow/outflow stenosis. Late stenosis is usually a sequence of early defects repaired to maintain patency. Less frequently, in the mature AVF or graft, complications are acquired 'de novo'. They derive either from incorrect management of vascular access (haematoma, pseudoaneurysm, prosthesis infection) or wall pathologies (aneurysm, myxoid valve degeneration, kinking, coiling, abnormal dilation from defects of elastic structures). High-resolution transducers (10-20 MHz) allow the characterization of the wall damage, haemodynamic dysfunctions, early and late complications even if phlebography remains the gold standard for the diagnosis for its sensitivity and specificity.
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Affiliation(s)
- Mario Meola
- Institute of Life Sciences-Sant'Anna School of Advanced Studies; Department of Internal Medicine University of Pisa- Pisa, Italy
| | - Antonio Marciello
- Nephrology and Dialysis Unit ASL-TO3 Collegno, Pinerolo-Torino, Italy
| | - Gianfranco Di Salle
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Ilaria Petrucci
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
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He Y, Northrup H, Roy-Chaudhury P, Cheung AK, Berceli SA, Shiu YT. Analyses of hemodialysis arteriovenous fistula geometric configuration and its associations with maturation and reintervention. J Vasc Surg 2020; 73:1778-1786.e1. [PMID: 33091518 DOI: 10.1016/j.jvs.2020.09.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/22/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE An arteriovenous fistula (AVF) is the preferred vascular access for chronic hemodialysis; however, the rates of AVF maturation failure and reintervention remain high. We investigated the AVF geometric parameters and their associations with AVF physiologic maturation and reintervention in a prospective multicenter study. METHODS From 2011 to 2016, patients undergoing vein end-to-artery side upper extremity AVF creation surgery were recruited. Contrast-free dark blood and phase-contrast magnetic resonance imaging (MRI) scans were performed using 3.0T scanners to obtain the AVF lumen geometry and flow rates, respectively, at postoperative day 1, week 6, and month 6. The arteriovenous anastomosis angle, nonplanarity, and tortuosity of the fistula were calculated according to the lumen centerlines. AVFs were considered physiologically matured if, using the week 6 MRI data, the flow rate was ≥500 mL/min and the minimum vein lumen diameter was ≥5 mm. The associations of these geometric parameters with AVF maturation and reintervention due to perianastomotic and mid-vein stenosis within 1 year were assessed. RESULTS A total of 111 patients had a usable day 1 MRI scan, with most having upper arm AVFs (n = 73). Compared with the forearm AVFs, upper arm AVFs had greater anastomosis angles (P < .001), larger deviations from a plane (nonplanarity; P = .002), and more prominent tortuosity (P = .038) at day 1. These parameters significantly increased between day 1 and week 6 in upper arm AVFs. In contrast, significant changes in these parameters in forearm AVFs were not observed. The rate of maturation was 54% and 86% for forearm and upper arm AVFs, respectively. None of the geometric parameters at day 1 were associated with AVF maturation in either location. The rate of reintervention was 24% and 30% for forearm and upper arm AVFs, respectively, with a larger nonplanarity angle at day 1 associated with less reintervention (30° ± 15° vs 21° ± 10°; P = .034) in upper arm AVFs only. This relationship was unchanged after adjusting for age, sex, race, dialysis status, or diabetes. CONCLUSIONS In our study, upper arm fistulas had a larger anastomosis angle, were more nonplanar, and had more tortuous veins than forearm fistulas. For upper arm fistulas, a larger nonplanarity angle is associated with a lower rate of reintervention within 1 year. Once confirmed, vascular surgeons could consider increasing the nonplanarity angle by incorporating a tension-free gentle curvature in the proximal segment of the mobilized vein to reduce reinterventions when creating an upper arm fistula.
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Affiliation(s)
- Yong He
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Hannah Northrup
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Prabir Roy-Chaudhury
- Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC; Department of Medicine, W. G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, NC
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah; Renal Section, Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla; Vascular Surgery Section, Malcom Randall Veterans Affairs Medical Center, Gainesville, Fla
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah; Renal Section, Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah.
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Lawson JH, Niklason LE, Roy-Chaudhury P. Challenges and novel therapies for vascular access in haemodialysis. Nat Rev Nephrol 2020; 16:586-602. [PMID: 32839580 PMCID: PMC8108319 DOI: 10.1038/s41581-020-0333-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Jeffrey H Lawson
- Department of Surgery, Duke University, Durham, NC, USA.
- Humacyte, Inc., Durham, NC, USA.
| | - Laura E Niklason
- Humacyte, Inc., Durham, NC, USA
- School of Engineering & Applied Science, Yale University, New Haven, CT, USA
| | - Prabir Roy-Chaudhury
- University of North Carolina Kidney Center, Chapel Hill, NC, USA
- WG (Bill) Hefner VA Medical Center, Salisbury, NC, USA
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Falzon I, Northrup H, Guo L, Totenhagen J, Lee T, Shiu YT. The geometry of arteriovenous fistulas using endothelial nitric oxide synthase mouse models. KIDNEY360 2020; 1:925-935. [PMID: 33117991 PMCID: PMC7591147 DOI: 10.34067/kid.0001832020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/30/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Arteriovenous fistula (AVF) maturation failure is a significant clinical problem in the hemodialysis population. Geometric parameters of human AVFs were associated with AVF development, but causative studies are lacking. We characterized mouse AVF geometry using endothelial nitric oxide synthase (NOS3) mouse models. METHODS Carotid-jugular AVFs were created in NOS3 overexpression (OE), knockout (KO), and wild type (WT) mice. At 7 and 21 days postcreation, black-blood magnetic resonance images of AVFs were acquired and used to build three-dimensional reconstructions of AVF lumens. We used these reconstructions to calculate the lumen area, lumen centerline, and centerline-derived parameters: anastomosis angle, tortuosity, nonplanarity angle, and location of maximal distance between the feeding artery and AVF vein. Inter- and intrauser variabilities were also determined. RESULTS When all mice were considered, increased minimum AVF venous lumen area was accompanied by increased venous tortuosity and increased distance between the artery and vein, with both remaining in-plane with the anastomosis. At day 7, the lumen area of AVFs from all strains was 1.5- to 2.5-fold larger than native veins. Furthermore, at day 21, AVF lumen in NOS3 OE (4.04±1.43 mm2) was significantly larger than KO (2.74±1.34 mm2) (P<0.001) and WT (2.94±1.30 mm2) mice (p<0.001). At day 21, the location of maximal artery-vein distance on the vein was further away from the anastomosis in OE (4.49±0.66 mm) than KO (2.87±0.38 mm) (p=0.001). Other geometric parameters were not significantly different between mouse strains or time points. Inter- and intrauser variabilities were small, indicating the reliability and reproducibility of our protocol. CONCLUSIONS Our study presents a detailed characterization of mouse AVF geometry, and a robust protocol for future mechanistic studies to investigate the role of molecular pathways in AVF geometry. Identifying a geometry related to desired AVF remodeling can help inform surgery to enhance AVF maturation.
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Affiliation(s)
- Isabelle Falzon
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Hannah Northrup
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Lingling Guo
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - John Totenhagen
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Veterans Affairs Medical Center, Birmingham, Alabama
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Veterans Affairs Medical Center, Salt Lake City, Utah
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Dardik A, Gloviczki P, Lawrence PF. Vascular science: A glimpse into the future. J Vasc Surg 2018; 68:1S-2S. [PMID: 30470354 DOI: 10.1016/j.jvs.2018.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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