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de Winter EP, Wilschut D, Plasmans K, Eefting D, van der Steenhoven T, Putter H, Rotmans J, van der Bogt K. Intraoperative transit time flow measurement predicts maturation of radiocephalic arteriovenous fistulas. J Vasc Surg 2024; 80:232-239. [PMID: 38432488 DOI: 10.1016/j.jvs.2024.02.028] [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: 10/17/2023] [Revised: 02/18/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE The arteriovenous fistula (AVF) is the first choice for gaining vascular access for hemodialysis. However, 20% to 50% of AVFs fail within 4 months after creation. Although demographic risk factors have been described, there is little evidence on the intraoperative predictors of AVF maturation failure. The aim of this study was to assess the predictive value of intraoperative transit time flow measurements (TTFMs) on AVF maturation failure. METHODS In this retrospective cohort study, intraoperative blood flow, measured using TTFM, was compared with AVF maturation after 6 weeks in 55 patients. Owing to its significantly higher prevalence and risk of nonmaturation, the radiocephalic AVF (RCAVF) was the main focus of this study. A recommended cutoff point for high vs low intraoperative blood flow was determined for RCAVFs, using a receiver operating characteristic curve. RESULTS The average intraoperative blood flow in RCAVFs was 156 mL/min. Patients with an intraoperative blood flow equal or lower than the determined cutoff point of 160 mL/min, showed a 3.03 times increased risk of AVF maturation failure after 6 weeks, compared with patients with a higher intraoperative blood flow (P < .001). CONCLUSIONS The intraoperative blood flow in RCAVFs measured by TTFM provides an adequate means of predicting AVF nonmaturation 6 weeks after surgery. For RCAVFs, a cutoff point for intraoperative blood flow of 160 mL/min is recommended for maximum sensitivity and specificity to predict AVF maturation failure after 6 weeks.
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Affiliation(s)
- Eduard Pierre de Winter
- Haaglanden Medical Centre, the Hague, the Netherlands; Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Kim Plasmans
- Haaglanden Medical Centre, the Hague, the Netherlands
| | - Daniel Eefting
- Haaglanden Medical Centre, the Hague, the Netherlands; Leiden University Medical Centre, Leiden, the Netherlands; University Vascular Center West, Leiden, The Hague, and Delft, the Netherlands
| | - Tim van der Steenhoven
- Haaglanden Medical Centre, the Hague, the Netherlands; University Vascular Center West, Leiden, The Hague, and Delft, the Netherlands
| | - Hein Putter
- Leiden University Medical Centre, Leiden, the Netherlands
| | - Joris Rotmans
- Leiden University Medical Centre, Leiden, the Netherlands
| | - Koen van der Bogt
- Haaglanden Medical Centre, the Hague, the Netherlands; Leiden University Medical Centre, Leiden, the Netherlands; University Vascular Center West, Leiden, The Hague, and Delft, the Netherlands.
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Kim MJ, Ko H, Kim SM. Predicting factors for early failure of vascular access in hemodialysis patients. Ann Surg Treat Res 2024; 106:255-262. [PMID: 38725806 PMCID: PMC11076948 DOI: 10.4174/astr.2024.106.5.255] [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] [Received: 01/15/2024] [Revised: 02/25/2024] [Accepted: 03/04/2024] [Indexed: 05/12/2024] Open
Abstract
Purpose This study aimed to investigate the incidence of early failure of vascular access for hemodialysis, and determine which factors measured in duplex ultrasound study could predict early failure. Methods We performed a retrospective review of patients who underwent arteriovenous fistula (AVF) or arteriovenous graft (AVG) creation for hemodialysis between September 2019 and January 2023. Early failure was defined as any event that required surgical or endovascular intervention within 6 months following AVF or AVG creation. Results A total of 189 patients were included. Early failure occurred in 36 patients (19.0%), which included 22 AVFs and 14 AVGs. In the patients who underwent AVF, the preoperative venous diameter, postoperative venous and arterial diameters, and flow volume of AVF all were significantly smaller in the early failure group compared to the patent group. In AVG, the preoperative venous diameter was the only parameter that differed between the 2 groups. A sonographic score was defined based on these factors. In a multivariable analysis, male sex, a previous history of AVF or AVG creation, and sonographic score were found to be significantly associated with early failure. The postoperative venous diameter in AVF and the preoperative venous diameter in AVG were highly predictive of early failure (areas under the curves 0.92 and 0.82, respectively). Conclusion Venous diameter measured 6 weeks following AVF operation and preoperative venous diameter in AVG were highly predictive of early failure among the duplex ultrasound parameters. Surveillance strategies in the early phase following vascular access creation can be based on these factors.
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Affiliation(s)
- Min Jun Kim
- Department of Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyunmin Ko
- Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Suh Min Kim
- Department of Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
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Kanchanasuttirak P, Pitaksantayothin W, Kanchanasuttirak W. Accuracy of physical examination versus Doppler ultrasonography for determining maturity in postoperative arteriovenous fistula formation. Asian J Surg 2024:S1015-9584(24)00603-1. [PMID: 38609821 DOI: 10.1016/j.asjsur.2024.03.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Differentiating between arteriovenous fistula (AVF) maturation and failure can help determine which AVF will undergo successful canulation and which ones will require immediate rescue. METHODS A prospective observational study was conducted at Vajira Hospital in Bangkok, Thailand, between October 2020-November 2022. A single vascular surgeon performed a physical examination on patients with chronic kidney disease undergoing AVF placement, and a radiologist conducted Doppler ultrasonography during the second and sixth postoperative weeks. Dialysis nurses determined AVF maturity by performing cannulation. The study compared the accuracy of physical examination and Doppler ultrasonography. A model was developed to predict the success of AVF use. RESULTS Out Of the 125 recruited patients, 81% demonstrate unassisted maturation of their AVF. The male sex and brachiocephalic type are associated with AVF maturation. The physical examination findings of palpable thrill and the absence of a strong pulse at the 6th week show an area under the receiver operating curve (AUC) value of 0.79. Similarly, arterial end-diastolic velocity on ultrasonography at the 6th week also demonstrates a comparable predictive value with an AUC of 0.82 (p = 0.697). Meanwhile, the model that combined end-diastolic velocity and venous volume flow yields the best results for predicting AVF maturation, with an AUC of 0.92. These models provide more accurate predictions compared to physical examination alone (AUC: 0.92 vs. 0.79; p < 0.01). CONCLUSION Although a prudent physician predicts AVF maturation through a thorough physical examination, Doppler ultrasonography is preferred in anticipating the success of postoperative AVF placement.
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Affiliation(s)
- Pong Kanchanasuttirak
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Dusit, Bangkok, Thailand.
| | - Wacharaphong Pitaksantayothin
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Dusit, Bangkok, Thailand
| | - Wiraporn Kanchanasuttirak
- Department of Radiology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Dusit, Bangkok, Thailand
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Gasparin C, Lima HDN, Regueira A, Marques AGB, Erzinger G. Predictors of arteriovenous fistula maturation in hemodialysis patients: a prospective cohort from an ambulatory surgical center in Joinville, Brazil. J Bras Nefrol 2023; 45:287-293. [PMID: 36511850 PMCID: PMC10697164 DOI: 10.1590/2175-8239-jbn-2022-0120en] [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: 07/20/2022] [Accepted: 10/10/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The high rate of arteriovenous fistula maturation failure is a concern in a scenario of growing numbers of patients on hemodialysis. Non-vascular factors tied to maturation success have not been fully discussed. METHODS This prospective observational cohort study included patients with CKD on dialysis or pre-dialysis prescribed arteriovenous fistula creation for the first time in an ambulatory surgical center in Joinville, Brazil, from January 2021 to July 2021. Anthropometric aspects, sociodemographic characteristics, comorbidities, and vascular parameters observed in Doppler ultrasound were analyzed. Variables associated with maturation were analyzed in multivariate models by logistic regression. RESULTS Eighty-eight of 145 participants (60.1%) were males. Included patients had a median age of 59 years. Successful arteriovenous fistula maturation occurred in 113 (77.9%) patients. Factors such as increased BMI, hematocrit, arm circumference, and skinfold thickness were associated with lower chances of arteriovenous fistula maturation in univariate analysis. On the other hand, larger vein and artery diameter and fistulas in the more proximal portion of the arm were associated with higher maturation success. In multivariate analysis, smoking and larger skinfold and arm circumference were associated with lower chances of successful maturation. Increased systolic blood pressure and vein diameter were associated with greater chance of success. CONCLUSION In addition to the vascular parameters assessed in Doppler ultrasonography, factors related to obesity and/or nutritional aspects may influence arteriovenous fistula maturation.
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Affiliation(s)
- Claudete Gasparin
- Universidade da Região de Joinville, Programa de Pós-Graduação em
Saúde e Meio Ambiente, Joinville, SC, Brazil
- Fundação Pró-Rim, Joinville, SC, Brazil
| | - Helbert do Nascimento Lima
- Universidade da Região de Joinville, Programa de Pós-Graduação em
Saúde e Meio Ambiente, Joinville, SC, Brazil
| | | | | | - Gilmar Erzinger
- Universidade da Região de Joinville, Programa de Pós-Graduação em
Saúde e Meio Ambiente, Joinville, SC, Brazil
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Subhi Y, Windfeld-Mathiasen J, Horwitz A, Horwitz H. Risk of Central Serous Chorioretinopathy in Male Androgen Abusers. Ophthalmol Ther 2023; 12:1073-1080. [PMID: 36692812 PMCID: PMC10011293 DOI: 10.1007/s40123-023-00658-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/13/2023] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Male gender is an important risk factor of central serous chorioretinopathy (CSC), and studies have explored the pathophysiological role of androgens in CSC with conflicting results. In this study, we shed light on this hot topic by exploring the risk of CSC in a large cohort of male androgen abusers. METHODS This study included male androgen abusers identified through a nationwide anti-doping test program across Danish fitness centers from January 3 2006 to March 1 2018. For each case, we randomly sampled ten male controls using Danish nationwide registries. These controls were matched in age and date. Cases and controls were followed until May 16 2018. Data on diagnoses were extracted using the Danish National Registry of Patients using ICD-10 codes to identify cases with CSC. RESULTS We included 1189 cases and 11,890 controls. Mean age at the time of doping sentence was 27.4 ± 6.9 years, and mean length of follow-up was 15.8 ± 3.6 years. We identified no cases of CSC in androgen abusers, and five cases of CSC in the control cohort. The difference between groups was not statistically significant (P = 1.0). CONCLUSIONS Male androgen abusers were not at increased risk of CSC. Considering the lack of any signal in this large study, we speculate that if male androgen plays any direct role in the pathophysiology of CSC, its role may be subtle at best.
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Affiliation(s)
- Yousif Subhi
- Department of Ophthalmology, Rigshospitalet, Valdemar Hansens Vej 3, 2600, Glostrup, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | | | - Anna Horwitz
- Department of Ophthalmology, Rigshospitalet, Valdemar Hansens Vej 3, 2600, Glostrup, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Horwitz
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Gasparin C, Lima HDN, Regueira Filho A, Marques AGB, Erzinger G. Preditores da maturação de fístula arteriovenosa de pacientes em hemodiálise: coorte prospectiva de um centro cirúrgico ambulatorial, Joinville, Brasil. J Bras Nefrol 2022. [DOI: 10.1590/2175-8239-jbn-2022-0120pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Resumo Introdução: A alta taxa de falha na maturação da fístula arteriovenosa é motivo de preocupação para o crescente número de pacientes em hemodiálise. Os fatores não vasculares não foram totalmente estudados em relação ao sucesso da maturação. Métodos: Estudo de coorte prospectivo, observacional de pacientes com DRC diálise ou pré-diálise encaminhados para a primeira criação de fístula arteriovenosa em um centro cirúrgico ambulatorial de Joinville, Brasil, de janeiro de 2021 a julho de 2021. Aspectos antropométricos, características sociodemográficas, comorbidades, além de fatores vasculares verificados pelo ultrassom Doppler. As variáveis associadas à maturação foram analisadas em modelos multivariados por regressão logística. Resultados: Dos 145 pacientes participantes, 88 (60,1%) eram homens, com idade mediana de 59 anos. Houve sucesso na maturação da fístula arteriovenosa em 113 (77,9%) pacientes. Fatores como aumento do IMC, hematócrito, circunferência do braço e valor das dobras cutâneas foram associados a menor chance de maturação da fístula arteriovenosa na análise univariada. Por outro lado, o maior diâmetro da veia e da artéria e fístulas na porção mais proximal do membro superior foram associados a maior sucesso de maturação. Na análise multivariada, tabagismo, maior dobra cutânea e circunferência do braço foram associados a menor chance de sucesso da maturação. O aumento da pressão arterial sistólica e o do diâmetro da veia foram associados a maior chance de sucesso. Conclusão: Além dos aspectos vasculares avaliados pela ultrassonografia Doppler, fatores relacionados à obesidade e/ou a aspectos nutricionais podem influenciar a maturação da fístula arteriovenosa.
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Affiliation(s)
- Claudete Gasparin
- Universidade da Região de Joinville, Brazil; Fundação Pró-Rim, Brazil
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Brinks J, van Dijk EHC, Meijer OC, Schlingemann RO, Boon CJF. Choroidal arteriovenous anastomoses: a hypothesis for the pathogenesis of central serous chorioretinopathy and other pachychoroid disease spectrum abnormalities. Acta Ophthalmol 2022; 100:946-959. [PMID: 35179828 PMCID: PMC9790326 DOI: 10.1111/aos.15112] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 12/30/2022]
Abstract
The pachychoroid disease spectrum (PDS) includes several chorioretinal diseases that share specific choroidal abnormalities. Although their pathophysiological basis is poorly understood, diseases that are part of the PDS have been hypothesized to be the result of venous congestion. Within the PDS, central serous chorioretinopathy is the most common condition associated with vision loss, due to an accumulation of subretinal fluid in the macula. Central serous chorioretinopathy is characterized by distinct risk factors, most notably a high prevalence in males and exposure to corticosteroids. Interestingly, sex differences and corticosteroids are also strongly associated with specific types of arteriovenous anastomoses in the human body, including dural arteriovenous fistula and surgically created arteriovenous shunts. In this manuscript, we assess the potential of such arteriovenous anastomoses in the choroid as a causal mechanism of the PDS. We propose how this may provide a novel unifying concept on the pathophysiological basis of the PDS, and present cases in which this mechanism may play a role.
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Affiliation(s)
- Joost Brinks
- Department of OphthalmologyLeiden University Medical CentreLeidenThe Netherlands
| | - Elon H. C. van Dijk
- Department of OphthalmologyLeiden University Medical CentreLeidenThe Netherlands
| | - Onno C. Meijer
- Department of Medicine, Division of Endocrinology and MetabolismLeiden University Medical CentreLeidenThe Netherlands
| | - Reinier O. Schlingemann
- Department of Ophthalmology, Amsterdam University Medical CentresUniversity of AmsterdamAmsterdamThe Netherlands,Department of OphthalmologyUniversity of Lausanne, Jules‐Gonin Eye Hospital, Fondation Asile des AveuglesLausanneSwitzerland
| | - Camiel J. F. Boon
- Department of OphthalmologyLeiden University Medical CentreLeidenThe Netherlands,Department of Ophthalmology, Amsterdam University Medical CentresUniversity of AmsterdamAmsterdamThe Netherlands
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The AIUM Practice Parameter for the Performance of Ultrasound Vessel Mapping Prior to Dialysis Access Creation. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:E16-E20. [PMID: 34792211 DOI: 10.1002/jum.15876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 06/13/2023]
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Abstract
Vascular access is absolutely essential for haemodialysis due to its relationship with quality of dialysis and associated morbidity. Therefore, it must be monitored and continuously surveilled from the moment it is created to prevent failure in maturation and thrombosis. Multidisciplinary collaboration is necessary when the main aim is to achieve the adequate vascular access flow with the fewest possible complications. The starting point, and probably the main one, is vascular access planning. This planning requires both a deep understanding of the anatomy of the upper limb and enough skill to examine it by Doppler ultrasound. The aim of this article is to review the anatomical and haemodynamical concepts of the arterial and venous vascular tree and explain how to perform ultrasound mapping, optimising the technical resources provided by this tool. Likewise, adequate access creation criteria that minimise the risk of failure and associated complications will be discussed.
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Affiliation(s)
- Joaquim Vallespin
- Department of Vascular Surgery, Parc Taulí University Hospital, Parc Taulí Research and Innovation Institute (I3PT), Autonomous University of Barcelona, Barcelona, Spain
| | - Mario Meola
- Department of Internal Medicine, Sant'Anna of Advanced Studies - Life Sciences Institute, University of Pisa, Pisa, Italy
| | - Jose Ibeas
- Department of Nephrology, Parc Taulí University Hospital, Parc Taulí Research and Innovation Institute (I3PT), Autonomous University of Barcelona, Barcelona, Spain
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Murea M, Woo K. New Frontiers in Vascular Access Practice: From Standardized to Patient-tailored Care and Shared Decision Making. KIDNEY360 2021; 2:1380-1389. [PMID: 35369664 PMCID: PMC8676387 DOI: 10.34067/kid.0002882021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/07/2021] [Indexed: 02/04/2023]
Abstract
Vascular access planning is critical in the management of patients with advanced kidney disease who elect for hemodialysis for RRT. Policies put in place more than two decades ago attempted to standardize vascular access care around the model of optimal, namely arteriovenous fistula, and least preferred, namely central venous catheter, type of access. This homogenized approach to vascular access care emerged ineffective in the increasingly heterogeneous and complex dialysis population. The most recent vascular access guidelines acknowledge the limitations of standardized care and encourage tailoring vascular access care on the basis of patient and disease characteristics. In this article, we discuss available literature in support of patient-tailored access care on the basis of differences in vascular access outcomes by biologic and social factors-age, sex, and race. Further, we draw attention to the overlooked dimension of patient-reported preferences and shared decision making in the practice of vascular access planning. We discuss milestones to overcome as requisite steps to implement effective shared decision making in vascular access care. Finally, we take into consideration local practice cofactors as major players in vascular access fate. We conclude that a personalized approach to hemodialysis vascular access will require dynamic care specifically relevant to the individual on the basis of biologic factors, fluctuating clinical needs, values, and preferences.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Karen Woo
- Department of Surgery, University of California Los Angeles, Los Angeles, California
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