1
|
Bae M, Lee CW, Chung SW, Huh U, Kim J, Jeong H, Lee NH. Rejoining Veins for Forced Maturation of Small-Caliber Arteriovenous Fistula. Ann Vasc Surg 2024; 104:268-275. [PMID: 38583760 DOI: 10.1016/j.avsg.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND To evaluate the efficacy of rejoining mainstream and accessory veins for forced maturation of autogenous arteriovenous fistula (AVF). METHODS Twenty-three patients who underwent forced maturation through vein rejoining between January 2018 and September 2022 were included. In cases where AVF maturation failure due to the presence of accessory veins, rejoining was primarily considered when distinguishing the main branch becomes challenging. This difficulty typically occurs when the sizes of the 2 vessels are nearly equal and the combined diameters of these veins exceed 6 mm. RESULTS The mean age and follow-up duration were 57.39 ± 16.22 years and 965.65 ± 573.42 days, respectively. Rejoining of both arterial and venous cannulation sites was performed in 11 patients (47.8%), and rejoining of only the venous cannulation site or only the arterial cannulation site was performed in 11 patients (47.8%) and 1 patient (4.3%), respectively. The mean vein size was 0.35 ± 0.06 cm before rejoining and 0.69 ± 0.07 cm after surgery, indicating a significant increase in size (P < 0.01), whereas the flow did not change significantly following rejoining surgery. Maturation and cannulation success was 100%. The 1-year primary patency rate after surgery was 82.0%. During the follow-up period, 34.8% of the patients required additional percutaneous transluminal angioplasty to maintain patency, and 2 patients (11.8%) had stenosis in the rejoined section. CONCLUSIONS Rejoining surgery is an effective method for achieving AVF maturation in patients with accessory veins when identification of the mainstream vein is difficult, and this method may be considered when achieving maturation by sacrificing 1 vein is expected to be challenging.
Collapse
Affiliation(s)
- Miju Bae
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea; Department of Thoracic and Cardiovascular Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Chung Won Lee
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea; Department of Thoracic and Cardiovascular Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea.
| | - Sung Woon Chung
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea; Department of Thoracic and Cardiovascular Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Up Huh
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea; Department of Thoracic and Cardiovascular Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jongwon Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Hyuncheol Jeong
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Na Hyeon Lee
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| |
Collapse
|
2
|
Bae M, Kim J. Tongue patch angioplasty for small-caliber vein segments directly connected to juxta-anastomotic stenosis. J Vasc Access 2024:11297298241241345. [PMID: 38658822 DOI: 10.1177/11297298241241345] [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: 04/26/2024] Open
Abstract
This study introduces a surgical method to increase the size of small vessels in patients with juxta-anastomosis stenosis (JAS) requiring full-length dissection. The small-caliber segment that is adjacent to JAS is usually expanded using balloon angioplasty or surgically resected. After resection, if the cannulation site is sufficient, only the arterial anastomosis is moved proximally; otherwise, it is replaced with a prosthetic graft. Herein, we describe the cases of two 60- and 34-year-old men with left brachio-basilar and left radiocephalic fistulas, respectively. The first and second patients needed transposition and superficialization, respectively, both of which required full-length vessel dissection. Both patients developed JAS with a long, small-caliber segment, leaving no space for arterial needle cannulation. A tongue patch with a graft on the bottom and a native vein on the top was used to resolve the JAS and make the native vein the needle cannulation site. In our cases, this method was effective for more than 2 years without adverse events in the particular surgical area. Although this method had a complicated indication, it could help ensure a sufficiently long area of the native vein for cannulation.
Collapse
Affiliation(s)
- Miju Bae
- Department of Thoracic and Cardiovascular Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Jongwon Kim
- Department of Thoracic and Cardiovascular Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| |
Collapse
|
3
|
Xu S, Wang J, Tang L, Cao W, Liang L, Wei K, Wang Z, Kong X. The RADAR technique in reconstruction of failed autologous arteriovenous fistulas due to juxta-anastomotic stenosis is equivalent to that with traditional surgery in maintenance hemodialysis patients. J Vasc Access 2023:11297298231212225. [PMID: 37997036 DOI: 10.1177/11297298231212225] [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: 11/25/2023] Open
Abstract
OBJECTIVE Autologous arteriovenous fistula (AVF) is recommended as superior vascular access for hemodialysis but has a high rate of failure, and juxta-anastomotic stenosis (JAS) is one of the predominant causes of fistula failure. The aim of this study was to compare the primary patency in reconstruction of failed AVFs due to JAS between the radial artery deviation and reimplantation (RADAR) technique and traditional surgery (end-vein to side-artery neo-anastomosis) in maintenance hemodialysis (MHD) patients. METHODS A total of 1215 MHD patients with failed AVF were enrolled in this retrospective cohort study, and 614 patients with failed AVF received surgical intervention. Among these surgical interventions, 417 patients experienced AVF failure due to JAS. Finally, 25 patients who received the RADAR technique were enrolled. Controls of 50 patients received traditional surgery were randomly selected matched by age and sex. Clinical data such as age, sex, comorbidities, and blood biochemical indices were collected. Kaplan-Meier survival curves and Cox proportional hazards analyses were used to explore the difference between the RADAR group and the traditional group in reconstruction of failed AVFs. RESULTS The RADAR group and the traditional group shared common baseline characteristics. The primary patencies of the reconstructed AVFs were 88.8%, 79.0%, 72.2%, 57.4%, and 38.3% at 12, 24, 36, 48, and 60 months among the 75 patients, respectively. Kaplan-Meier survival curve analysis demonstrated similar primary patencies in the two groups (log-rank test, p = 0.73). Compared with the traditional group, the RADAR group had no difference in predicting AVF failure after adjusting for potential confounders, with an HR of 0.92 (95% CI, 0.18-4.63). CONCLUSIONS The primary patency of the RADAR technique and the traditional surgery in the reconstruction of failed AVFs due to JAS is almost equal in 5 years.
Collapse
Affiliation(s)
- Shuqi Xu
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, PR China
| | - Jie Wang
- Department of Blood Purification Center, Qufu People's Hospital, Qufu, Shandong, PR China
| | - Lijun Tang
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, PR China
- Nephrology Research Institute of Shandong Province, Jinan, Shandong, PR China
| | - Wei Cao
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, PR China
- Nephrology Research Institute of Shandong Province, Jinan, Shandong, PR China
| | - Liming Liang
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, PR China
- Nephrology Research Institute of Shandong Province, Jinan, Shandong, PR China
| | - Kai Wei
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, PR China
- Nephrology Research Institute of Shandong Province, Jinan, Shandong, PR China
| | - Zunsong Wang
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, PR China
- Nephrology Research Institute of Shandong Province, Jinan, Shandong, PR China
| | - Xianglei Kong
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, PR China
- Nephrology Research Institute of Shandong Province, Jinan, Shandong, PR China
| |
Collapse
|
4
|
Northrup H, He Y, Le H, Berceli SA, Cheung AK, Shiu YT. Differential hemodynamics between arteriovenous fistulas with or without intervention before successful use. Front Cardiovasc Med 2022; 9:1001267. [PMID: 36407418 PMCID: PMC9669082 DOI: 10.3389/fcvm.2022.1001267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/17/2022] [Indexed: 08/22/2023] Open
Abstract
A significant number of arteriovenous fistulas (AVFs) fail to maturate for dialysis. Although interventions promote maturation, functional primary patency loss is higher for AVFs with interventions (assisted maturation) than AVFs without interventions (un-assisted maturation). Although blood flow-associated hemodynamics have long been proposed to affect AVF remodeling, the optimal hemodynamic parameters for un-assisted maturation are unclear. Additionally, AVF maturation progress is generally not investigated until 6 weeks after AVF creation, and the examination is focused on the AVF's venous limb. In this exploratory study, patients (n = 6) underwent magnetic resonance imaging (MRI) at 1 day, 6 weeks, and 6 months after AVF creation surgery. Before successful use for hemodialysis, three AVFs required intervention and three did not. MRI of the AVFs were used to calculate lumen cross-sectional area (CSA) and perform computational fluid dynamics (CFD) to analyze hemodynamics, including velocity, wall shear stress (WSS), and vorticity. For the venous limb, the no-intervention group and intervention group had similar pre-surgery vein diameter and 1-day post-surgery venous CSA. However, the no-intervention group had statistically larger 1-day venous velocity (0.97 ± 0.67 m/s; mean ± SD), WSS (333 ± 336 dyne/cm2) and vorticity (1709 ± 1290 1/s) than the intervention group (velocity = 0.23 ± 0.10 m/s; WSS = 49 ± 40 dyne/cm2; vorticity = 493.1 ± 227 1/s) (P < 0.05). At 6 months, the no-intervention group had statistically larger venous CSA (43.5 ± 27.4 mm2) than the intervention group (15.1 ± 6.2 mm2) (P < 0.05). Regarding the arterial limb, no-intervention AVF arteries also had statistically larger 1-day velocity (1.17 ± 1.0 m/s), WSS (340 ± 423 dyne/cm2), vorticity (1787 ± 1694 1/s), and 6-month CSA (22.6 ± 22.7 mm2) than the intervention group (velocity = 0.64 ± 0.36 m/s; WSS = 104 ± 116 dyne/cm2, P < 0.05; vorticity = 867 ± 4551/s; CSA = 10.7 ± 6.0 mm2, P < 0.05). Larger venous velocity, WSS, and vorticity immediately after AVF creation surgery may be important for later lumen enlargement and AVF maturation, with the potential to be used as a tool to help diagnose poor AVF maturation earlier. However, future studies using a larger cohort are needed to validate this finding and determine cut off values, if any.
Collapse
Affiliation(s)
- Hannah Northrup
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
| | - Yong He
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, United States
| | - Ha Le
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
| | - Scott A. Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, United States
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL, United States
| | - Alfred K. Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
- Veterans Affairs Medical Center, Salt Lake City, UT, United States
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
- Veterans Affairs Medical Center, Salt Lake City, UT, United States
| |
Collapse
|
5
|
Parker MH, Hashemi H, Grant C, Colpitts DK, Kfoury E, Mukherjee D, Neville R. A novel technique using long segment patch angioplasty maturation to increase the maturation rate of arteriovenous fistulas. J Vasc Surg 2021; 74:230-236. [PMID: 33348009 DOI: 10.1016/j.jvs.2020.12.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 12/05/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Given the superior patency of arteriovenous fistulas (AVFs) and the decreased risk of infection compared with arteriovenous grafts, the Kidney Disease Outcomes Quality Initiative guidelines have recommended the fistula-first approach. However, ∼20% to 60% of all fistulas will fail to mature. We have described our experience with a novel technique using bovine pericardial patch angioplasty to increase the rate of AVF maturation. METHODS We used 2-cm × 9-cm-long or 2.5-cm × 15-cm-long segment pericardial patch angioplasty to assist in the maturation of AVFs. A single-center, retrospective cohort study was conducted of all patients who had undergone patch angioplasty maturation (PAM) for AVFs that had failed to mature. The outcomes of interest were maturation status and patency, censored by the death and last known follow-up dates. RESULTS From March 2007 to October 2019, 139 patients had undergone PAM. Follow-up data were available for 137 of the 139 patients (98.6%), with 126 AVFs (92.0%) progressing to maturation. Of the 126 patients with AVFs that had progressed to maturity, the previous hemodialysis (HD) method was known for 88 patients (69.8%). Of these 88 patients, 70 (79.5%) had previously been receiving HD via an HD catheter. Using a Kaplan-Meier estimator censored for death and loss to follow-up, the assisted primary patency rates at 1, 2, and 3 years were 87.3%, 78.1%, and 68.0%, respectively. Of the 137 patients, 69 (54.8%) had required no additional interventions after patch angioplasty. The complications requiring intervention were stenosis (n = 45; 32.8%), thrombosis (n = 10; 7.3%), infection (n = 3; 2.2%), steal syndrome (n = 3; 2.2%), noninfected wound complications (n = 1; 0.8%), and pseudoaneurysm (n = 1; 0.8%). The average interval to intervention after patch angioplasty was 4.56 months. CONCLUSIONS Long-segment bovine pericardial PAM can be performed safely to treat nonmaturing AVFs, with a 92.0% successful maturation rate and patency rates comparable to those for AVFs. PAM should be a consideration for patients with nonmaturing AVFs.
Collapse
Affiliation(s)
- Michael H Parker
- Department of General Surgery, Inova Health System, Falls Church, Va.
| | - Homayoun Hashemi
- Department of General Surgery, Inova Health System, Falls Church, Va
| | - Courtney Grant
- Department of General Surgery, Inova Health System, Falls Church, Va
| | - Dayle K Colpitts
- Department of General Surgery, Inova Health System, Falls Church, Va
| | - Elias Kfoury
- Department of General Surgery, Inova Health System, Falls Church, Va
| | | | - Richard Neville
- Department of General Surgery, Inova Health System, Falls Church, Va
| |
Collapse
|
6
|
Beathard GA, Litchfield T, Jennings WC. Two-year cumulative patency of endovascular arteriovenous fistula. J Vasc Access 2020; 21:350-356. [PMID: 31566061 PMCID: PMC7222285 DOI: 10.1177/1129729819877780] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/30/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The recent advent of a device to create a proximal radial artery arteriovenous fistula using an endovascular approach to create the anastomosis represents a significant advance in dialysis access creation. This endovascular arteriovenous fistula offers the beneficial attributes of the proximal radial artery arteriovenous fistula while adding the advantages of avoiding a surgical procedure. The endovascular arteriovenous fistula can be created safely, functions well, has excellent patency, and has a high degree of patient satisfaction. The purpose of this study is to report the 2-year cumulative patency rate for a large multicenter cohort of endovascular arteriovenous fistula cases. DESIGN An endovascular arteriovenous fistula was created in 105 patients using either local or regional anesthesia and conscious sedation. Patient data were obtained from each program's electronic health record system. Data collection was truncated at 2 years postprocedure and used to calculate cumulative patency. Post-access creation patient satisfaction was assessed. RESULTS A physiologically mature arteriovenous fistula (blood flow ⩾500 mL/min and a target vein internal diameter ⩾4 mm) was obtained in 98%. A clinically functional arteriovenous fistula (supporting two-needle dialysis according to the patient's dialysis prescription) was demonstrated in 95%. Access failure resulting in the loss of access occurred in eight cases during the study period. The cumulative patency rate at 6, 12, 18, and 24 months was 97.1%, 93.9%, 93.9%, and 92.7%, respectively. The post-procedure patient evaluation emphasized a high level of patient satisfaction. CONCLUSION The proximal radial artery arteriovenous fistula created using an endovascular approach for the anastomosis is associated with excellent 2-year cumulative patency and is associated with a high level of patient satisfaction.
Collapse
Affiliation(s)
| | | | - William C Jennings
- Department of Surgery, School of Community Medicine, University of Oklahoma, Tulsa, OK, USA
| |
Collapse
|
7
|
Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 925] [Impact Index Per Article: 231.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
Collapse
|
8
|
Kong X, Tang L, Liang L, Cao W, Zhang L, Yong W, Ding N, Li W, Wang Z, Xu D. Clinical outcomes following the surgery of new autologous arteriovenous fistulas proximal to the failed ones in end-stage renal disease patients: a retrospective cohort study. Ren Fail 2019; 41:1036-1044. [PMID: 31814501 PMCID: PMC6913653 DOI: 10.1080/0886022x.2019.1696210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Most prior studies have explored surgery for the treatment of failed autologous arteriovenous fistulas (AVFs) with limited follow-up times and a lack of end point mortality. Accordingly, we conducted a retrospective cohort study to evaluate the clinical outcomes of the surgery of new AVF proximal to the failed forearm AVF. Methods: In this study, 538 end-stage renal disease patients (group A, 418 with primary AVF; and group B, 120 with failed AVF) were consecutively enrolled between January 2013 and June 2016, with a median follow-up time of 41 months. Primary and secondary patency, all-cause mortality, and risk factors associated with AVF failure were explored by the Kaplan–Meier method or Cox proportional hazards model. Results: In group A (n = 418), the primary and secondary patencies of AVF were 85.6% vs. 96.8%, 79.7% vs. 95.0%, 75.1% vs.93.9%, 73.2% vs. 93.6% and 73.2% vs. 93.6% at 12, 24, 36, 48 and 60 months, respectively. The primary patencies of AVF in group B were 95.0%, 91.7%, 89.2%, 88.3% and 88.3% at 12, 24, 36, 48 and 60 months, respectively. After adjusting for potential confounders, age, angiotensin-converting inhibitors or angiotensin-receptor blockers (anti-RAAS) drugs and D-dimer were independent predictors of AVF failure. However, there were no differences between functional and failed AVF regarding all-cause mortality. Conclusions: The study revealed that the primary and secondary patiencies of the surgery of new AVF proximal to the failed ones were ideal operations to restore failed forearm AVF.
Collapse
Affiliation(s)
- Xianglei Kong
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Lijun Tang
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Liming Liang
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Wei Cao
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Lei Zhang
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Wei Yong
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Nannan Ding
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Wenbin Li
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Zunsong Wang
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Dongmei Xu
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Shandong Provincial Key Laboratory for Rheumatic Disease and Translational Medicine, Jinan, China.,Nephrology Research Institute of Shandong Province, Jinan, China
| |
Collapse
|
9
|
Affiliation(s)
- Charmaine E Lok
- Division of Nephrology, Department of Medicine, University Health Network-Toronto General Hospital and The University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Gallieni M, Hollenbeck M, Inston N, Kumwenda M, Powell S, Tordoir J, Al Shakarchi J, Berger P, Bolignano D, Cassidy D, Chan TY, Dhondt A, Drechsler C, Ecder T, Finocchiaro P, Haller M, Hanko J, Heye S, Ibeas J, Jemcov T, Kershaw S, Khawaja A, Labriola L, Lomonte C, Malovrh M, Marti I Monros A, Matthew S, McGrogan D, Meyer T, Mikros S, Nistor I, Planken N, Roca-Tey R, Ross R, Troxler M, van der Veer S, Vanholder R, Vermassen F, Welander G, Wilmink T, Koobasi M, Fox J, Van Biesen W, Nagler E. Clinical practice guideline on peri- and postoperative care of arteriovenous fistulas and grafts for haemodialysis in adults. Nephrol Dial Transplant 2019; 34:ii1-ii42. [PMID: 31192372 DOI: 10.1093/ndt/gfz072] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Indexed: 01/02/2023] Open
Affiliation(s)
| | | | | | | | | | - Jan Tordoir
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Davide Bolignano
- Institute of Clinical Physiology of the Italian National Council of Research, Reggio Calabria, Italy.,ERBP, guideline development body of ERA-EDTA, London, UK
| | | | | | | | - Christiane Drechsler
- ERBP, guideline development body of ERA-EDTA, London, UK.,University of Würzburg, Würzburg, Germany
| | - Tevfik Ecder
- Istanbul Bilim University School of Medicine, Istanbul, Turkey
| | | | - Maria Haller
- ERBP, guideline development body of ERA-EDTA, London, UK.,Ordensklinikum Linz Elisabethinen, Linz, Austria
| | | | - Sam Heye
- Jessa Hospital, Hasselt, Belgium
| | - Jose Ibeas
- Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Aurangzaib Khawaja
- Queen Elisabeth Hospital, University Hospitals Birmingham, West Midlands Deanery, Birmingham, UK
| | | | - Carlo Lomonte
- Miulli General Hospital, Acquaviva delle Fonti, Italy
| | | | | | | | | | | | | | - Ionut Nistor
- ERBP, guideline development body of ERA-EDTA, London, UK.,University of Medicine and Pharmacy, Iasi, Romania
| | - Nils Planken
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ramon Roca-Tey
- Hospital de Mollet, Fundació Sanitària Mollet, Barcelona, Spain
| | - Rose Ross
- Ninewells Hospital Scotland, Dundee, UK
| | | | | | | | | | | | - Teun Wilmink
- Heart of England NHS foundation Trust, Birmingham, UK
| | - Muguet Koobasi
- ERBP, guideline development body of ERA-EDTA, London, UK
| | - Jonathan Fox
- ERBP, guideline development body of ERA-EDTA, London, UK.,University of Glasgow, UK
| | - Wim Van Biesen
- ERBP, guideline development body of ERA-EDTA, London, UK.,Ghent University Hospital, Ghent, Belgium
| | - Evi Nagler
- ERBP, guideline development body of ERA-EDTA, London, UK.,Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
11
|
Spanish Clinical Guidelines on Vascular Access for Haemodialysis. Nefrologia 2018; 37 Suppl 1:1-191. [PMID: 29248052 DOI: 10.1016/j.nefro.2017.11.004] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/21/2017] [Indexed: 12/26/2022] Open
Abstract
Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.
Collapse
|
12
|
Beathard GA, Lok CE, Glickman MH, Al-Jaishi AA, Bednarski D, Cull DL, Lawson JH, Lee TC, Niyyar VD, Syracuse D, Trerotola SO, Roy-Chaudhury P, Shenoy S, Underwood M, Wasse H, Woo K, Yuo TH, Huber TS. Definitions and End Points for Interventional Studies for Arteriovenous Dialysis Access. Clin J Am Soc Nephrol 2018; 13:501-512. [PMID: 28729383 PMCID: PMC5967683 DOI: 10.2215/cjn.11531116] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This paper is part of the Clinical Trial Endpoints for Dialysis Vascular Access Project of the American Society of Nephrology Kidney Health Initiative. The purpose of this project is to promote research in vascular access by clarifying trial end points which would be best suited to inform decisions in those situations in which supportive clinical data are required. The focus of a portion of the project is directed toward arteriovenous access. There is a potential for interventional studies to be directed toward any of the events that may be associated with an arteriovenous access' evolution throughout its life cycle, which has been divided into five distinct phases. Each one of these has the potential for relatively unique problems. The first three of these correspond to three distinct stages of arteriovenous access development, each one of which has been characterized by objective direct and/or indirect criteria. These are characterized as: stage 1-patent arteriovenous access, stage 2-physiologically mature arteriovenous access, and stage 3-clinically functional arteriovenous access. Once the requirements of a stage 3-clinically functional arteriovenous access have been met, the fourth phase of its life cycle begins. This is the phase of sustained clinical use from which the arteriovenous access may move back and forth between it and the fifth phase, dysfunction. From this phase of its life cycle, the arteriovenous access requires a maintenance procedure to preserve or restore sustained clinical use. Using these definitions, clinical trial end points appropriate to the various phases that characterize the evolution of the arteriovenous access life cycle have been identified. It is anticipated that by using these definitions and potential end points, clinical trials can be designed that more closely correlate with the goals of the intervention and provide appropriate supportive data for clinical, regulatory, and coverage decisions.
Collapse
Affiliation(s)
- Gerald A Beathard
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Tordoir JH, Zonnebeld N, van Loon MM, Gallieni M, Hollenbeck M. Surgical and Endovascular Intervention for Dialysis Access Maturation Failure During and After Arteriovenous Fistula Surgery: Review of the Evidence. Eur J Vasc Endovasc Surg 2018; 55:240-248. [DOI: 10.1016/j.ejvs.2017.12.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 12/03/2017] [Indexed: 01/01/2023]
|
14
|
Ferral H, Alonzo MJ. Transjugular venous approach for endovascular intervention in upper-extremity dialysis access fistulae and grafts. Semin Vasc Surg 2017; 29:206-211. [PMID: 28779788 DOI: 10.1053/j.semvascsurg.2017.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A transjugular venous access is an alternative approach for endovascular intervention in upper-extremity dialysis arteriovenous fistulae and grafts. The transjugular access is recommended for patients who have an unfavorable anatomy for the direct arm access approach. Ultrasound evaluation of the arteriovenous access is essential before intervention and includes evaluation of the inflow artery and outflow vein diameters, arteriovenous anastomosis, and the entire outflow vein, specifically looking into potential problem areas. Patency of the ipsilateral internal jugular vein needs to be assessed. If patency of the ipsilateral internal jugular vein is confirmed, it can be used for access. Retrograde access into the outflow vein is obtained with a reverse-curve catheter and a Glidewire. In some cases, puncture of the outflow vein is necessary along with the use of snares to direct the catheter system into the outflow vein. The techniques for intervention are described. Successful access into the outflow vein is possible in >95% of cases. The technique is useful for fistula maturation, declotting procedure, and arteriovenous fistula and graft maintenance. If intervention is unsuccessful, the transjugular access offers the possibility of placement of a dialysis catheter for temporary or long-term dialysis.
Collapse
Affiliation(s)
- Hector Ferral
- Section of Interventional Radiology, Department of Radiology, NorthShore University Health System, 2650 Ridge Avenue, Evanston, IL 60201.
| | - Marc J Alonzo
- Section of Interventional Radiology, Department of Radiology, NorthShore University Health System, 2650 Ridge Avenue, Evanston, IL 60201
| |
Collapse
|
15
|
Beathard GA, Urbanes A, Litchfield T. Changes in the Profile of Endovascular Procedures Performed in Freestanding Dialysis Access Centers over 15 Years. Clin J Am Soc Nephrol 2017; 12:779-786. [PMID: 28420654 PMCID: PMC5477215 DOI: 10.2215/cjn.09730916] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 02/10/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVES Marked changes occurred in the vascular access profile of patients receiving hemodialysis in the United States over the 15-year period of 2001-2015. This study was undertaken to evaluate how these changes have affected dialysis access maintenance and salvage procedures performed in freestanding dialysis access centers and to examine the effectiveness, efficiency, and safety of these procedures in this setting. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were collected from freestanding, dedicated dialysis access centers operating under a common system of management. Data were available on 689,676 dialysis access procedures. Data relating to case mix, procedure outcome, procedural time, and intraprocedural and immediate postprocedural complications were analyzed. RESULTS The arteriovenous procedure profile changed from one characterized by approximately equal numbers of angioplasties and thrombectomies performed on arteriovenous grafts (AVGs) to one characterized primarily by angioplasties performed on arteriovenous fistulas. The percentage of angioplasties performed throughout the study was significantly greater than thrombectomies, with a mean of 67.9% versus 32.1% (P<0.001). Interventional procedures did not decrease with increasing arteriovenous fistula utilization in prevalent patients receiving dialysis. The incidence roughly paralleled the increasing prevalence of this type of access. A decreasing percentage of AVG utilization resulted in a progressive, roughly parallel, but disproportionately higher, decrease in the percentage of AVG procedures (P<0.001). A progressive improvement in procedure outcomes and a decrease in complication rates and procedure times were observed (P<0.001 for each). A progressive decrease in tunneled dialysis catheter placement was also observed. CONCLUSIONS The procedure profile treated in freestanding, dedicated dialysis access centers changed significantly over 15 years, reflecting the changes that have occurred in the vascular access profile of the dialysis population.
Collapse
Affiliation(s)
- Gerald A. Beathard
- Lifeline Vascular Access a division of DaVita Healthcare, Denver, Colorado; and
- Department of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Aris Urbanes
- Lifeline Vascular Access a division of DaVita Healthcare, Denver, Colorado; and
| | - Terry Litchfield
- Lifeline Vascular Access a division of DaVita Healthcare, Denver, Colorado; and
| |
Collapse
|
16
|
Impaired maturation of distal radio-cephalic fistula for haemodialysis: a review of treatment options. J Nephrol 2016; 30:45-51. [DOI: 10.1007/s40620-016-0332-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/28/2016] [Indexed: 11/26/2022]
|
17
|
Surgical Options in the Problematic Arteriovenous Haemodialysis Access. Cardiovasc Intervent Radiol 2015; 38:1405-15. [DOI: 10.1007/s00270-015-1155-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/30/2015] [Indexed: 11/27/2022]
|
18
|
Kwon H, Choi JY, Ko HK, Kim MJ, Kim H, Park H, Han Y, Ko GY, Kwon TW, Cho YP. Comparison of Surgical and Endovascular Salvage Procedures for Juxta-anastomotic Stenosis in Autogenous Wrist Radiocephalic Arteriovenous Fistula. Ann Vasc Surg 2014; 28:1840-6. [DOI: 10.1016/j.avsg.2014.06.060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/25/2014] [Accepted: 06/21/2014] [Indexed: 11/30/2022]
|
19
|
Beathard GA. How is arteriovenous fistula longevity best prolonged?: The role of optimal fistula placement. Semin Dial 2014; 28:20-4. [PMID: 25256400 DOI: 10.1111/sdi.12304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Gerald A Beathard
- University of Texas Medical Branch and Lifeline Vascular Access, Houston, Texas
| |
Collapse
|
20
|
Azevedo PN, Turmel-Rodrigues L. Never Too Old For an Autogenous Dialysis Fistula? Results of Endovascular Interventions in Nonagenarians. Semin Dial 2014; 28:E1-6. [DOI: 10.1111/sdi.12257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Pedro N. Azevedo
- Radiologie Vasculaire Diagnostique & Interventionnelle; Clinique St-Gatien; Tours France
- Department of Nephrology and Renal Transplantation; Centro Hospitalar Do Porto-Hospital de Santo António (CHP-HSA); Porto Portugal
| | - Luc Turmel-Rodrigues
- Radiologie Vasculaire Diagnostique & Interventionnelle; Clinique St-Gatien; Tours France
| |
Collapse
|
21
|
Strategies for planning the optimal dialysis access for an individual patient. Curr Opin Nephrol Hypertens 2014; 23:314-20. [DOI: 10.1097/01.mnh.0000444815.49755.d9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Abstract
A native arteriovenous fistula (AVF) should be systematically evaluated at 4 to 6 weeks after creation. Any clinical indications of nonmaturation should be promptly followed up and confirmed by detailed duplex ultrasonography looking for a deep vein or inadequate access flow due to stenoses. Once vein depth has been ruled out, a significant stenosis is invariably identified and should therefore be operated on or dilated. Predilation angiography should be performed preferably through the brachial artery. Arterial lesions are frequent causes of nonmaturation of forearm AVFs and should therefore be dilated. The best results are obtained when the juxta-anastomotic vein and the feeding artery are dilated with 6 and 4 mm dilation balloons, respectively. Our opinion is that there is no or only the very rare indication for ligation or embolization of collaterals. Rupture of the weak venous or arterial wall is common (15% of cases), the majority of which can be managed with prolonged balloon tamponade. Nonmaturing AVFs are ideally needled only 7 to 14 days after successful dilation to allow hematomas caused by cannulation and local anesthesia to resorb. Including initial failures, 1-year primary and secondary patency rates reported by interventional radiologists range from 34% to 39% and 68% to 79%, respectively. Results after dilation of diseased radial arteries feeding normal veins are even better, with primary patency rates ranging for 65% to 83%, and secondary patency rates of over 90%. Using an aggressive and multidisciplinary treatment strategy, nonmaturing dialysis fistulas can be identified, evaluated and salvaged with angioplasty.
Collapse
|
23
|
Wasse H, Huang R, Long Q, Zhao Y, Singapuri S, McKinnon W, Skardasis G, Tangpricha V. Very high-dose cholecalciferol and arteriovenous fistula maturation in ESRD: a randomized, double-blind, placebo-controlled pilot study. J Vasc Access 2014; 15:88-94. [PMID: 24101420 PMCID: PMC3979512 DOI: 10.5301/jva.5000187] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2013] [Indexed: 12/26/2022] Open
Abstract
PURPOSE While vitamin D is critical for optimal skeletal health, it also appears to play a significant role in vascular homeostasis. This pilot study compared arteriovenous (AV) access outcomes following cholecalciferol supplementation compared to placebo in end-stage renal disease patients preparing to undergo AV access creation. METHODS A total of 52 adult hemodialysis patients preparing for arteriovenous fistula (AVF) creation were randomized to receive perioperative high-dose cholecalciferol versus placebo in this double-blind, randomized, placebo-controlled pilot study. The primary outcome was mean response to high-dose oral cholecalciferol versus placebo, and secondary outcome AV access maturation at 6 months. Logistic regression was used to assess the association between AV access maturation and baseline, posttreatment and overall change in vitamin D concentration. RESULTS A total of 45% of cholecalciferol-treated and 54% of placebo-treated patients were successfully using their AVF or arteriovenous graft (AVG) at 6 months (p=0.8). Baseline serum concentrations of 25(OH)D and 1,25(OH)2D did not differ between those who experienced AVF or AVG maturation and those who did not (p=0.22 and 0.59, respectively). Similarly, there was no relationship between AVF or AVG maturation and posttreatment serum 25(OH)D and 1,25(OH)2D concentration (p=0.24 and 0.51, respectively). CONCLUSIONS Perioperative high-dose vitamin D3 therapy does correct 25(OH)D level but does not appear to have an association with AV access maturation rates. Future research may include extended preoperative vitamin D3 therapy in a larger population or in certain subpopulations at high risk for AVF failure.
Collapse
Affiliation(s)
| | - Rong Huang
- Emory University, Division of Nephrology, Atlanta, GA
| | - Qi Long
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Yize Zhao
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - William McKinnon
- Peachtree Vascular Associates, Emory University Hospital Midtown, Atlanta GA
| | - George Skardasis
- Peachtree Vascular Associates, Emory University Hospital Midtown, Atlanta GA
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Atlanta, GA and Staff Physician, Atlanta VA Medical Center, Atlanta, GA
| |
Collapse
|
24
|
Natural history of venous morphologic changes in dialysis access stenosis. J Vasc Access 2014; 15:298-305. [PMID: 24500849 DOI: 10.5301/jva.5000212] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2013] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Venous stenosis secondary to neointimal hyperplasia is a major etiology of early arteriovenous fistula (AVF) failure. The natural history of AVF failure is likely influenced by progressive vascular insults to the vein prior to and after AVF creation. The main objectives of this study were to (1) provide a histologic and morphometric description of non-chronic kidney disease (CKD), upper extremity vein specimens and (2) perform a morphometric analysis to study venous histology from non-CKD upper extremity veins, veins collected at the time of new vascular access surgery and veins collected from failed stenotic AVFs. METHODS Vein samples from 11 non-CKD deceased donors, 29 subjects receiving new vascular access creation and 20 subjects with stenotic failed AVFs were collected for histologic and morphometric analysis. RESULTS The mean values of average intima/media thickness ± S.E. from veins collected from non-CKD subjects, subjects receiving new vascular access and subjects with stenotic AVFs were 0.16±0.02, 0.43±0.07 and 3.84±0.55, respectively (p<0.0001). Among donor, non-CKD, vein samples, only diabetes (p=0.0007) was associated with increased average intima/media thickness. CONCLUSIONS Our results demonstrate a progressively increasing venous neointimal hyperplasia development from the non-CKD period through the period of AVF creation and failure. Vascular injuries from complications of progressive CKD prior to access placement and vascular injuries after vascular access placement may play important roles in these progressive vascular changes, and need to be further elucidated.
Collapse
|
25
|
|