Assessment of Long-Term Vasoplegia Induced by Brachial Plexus Block: A Favorable Effect for Hemodialysis Angioaccess Surgery?

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

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

General, regional or local anesthesia for successful radial cephalic arteriovenous fistula

Autogenous fistulas and in particular radiocephalic fistulas are recommended as the first vascular access for hemodialysis. Unfortunately, the rates of early failure and non-maturation are very high. For more than a decade, brachial plexus block has been proposed as the anesthesia of choice for fistula creation due to its beneficial sympathectomy-like effect, causing vasodilation and attenuation of spasm. Until recently, there was not a single randomized clinical study supporting this proposition. Because performing regional anesthesia is time-consuming and requires expertise, many surgeons prefer local or general anesthesia for vascular access surgery. However, in August 2016 a randomized clinical trial was published showing that regional anesthesia significantly reduces early failure and improves primary and functional patency at 3 months compared to local anesthesia. The aging of the dialysis population, with their attendant morbidity and increased risk for general anesthesia, makes it clear that regional anesthesia is the recommended approach for fistula creation. The excess time required for this approach will decrease with increasing expertise along the learning curve, and will be compensated by a reduction in time that would otherwise be needed for new access construction due to failure of fistulas constructed under local anesthesia.

The Utility of Peripheral Nerve Blocks in Interventional Radiology

OBJECTIVE

The aim of this article is to provide an overview of peripheral nerve blocks, the use of peripheral nerve block within and outside interventional radiology, and the complications of peripheral nerve block.

CONCLUSION

Interventional radiologists are often responsible for sedation and pain management in the majority of interventional radiology procedures. Peripheral nerve block is increasingly being used in interventional radiology.

Anesthesia for Vascular access Surgery

The type of anesthesia chosen is an integral part of the decision-making process for arteriovenous access construction. We discuss the different types of anesthesia used, with emphasis on brachial plexus block, which is potentially safer than general anesthesia in this fragile patient population with end-stage renal disease. Brachial plexus block is superior to local anesthesia and enables the use of a tourniquet to minimize potential damage to the blood vessels during anastomosis using microsurgery techniques, and does not lead to the vasospasm that may be seen with local anesthesia. Regional anesthesia has a beneficial sympathectomy-like effect that causes vasodilation with increased blood flow during surgery and in the fistula postoperatively that may prevent early thrombosis and potentially improve outcome.

Tips and Tricks in Creation of Forearm Arteriovenous Fistulae

Forearm arteriovenous fistula (AVF) is a direct anastomosis between the radial artery and the cephalic vein or the ulnar artery and the basilic vein, which are small-caliber vessels. The surgical technique must be precise to avoid postoperative stenosis of the anastomosis which may result in early thrombosis or nonmaturation. In our experience, microsurgery and preventive hemostasis are two major contributions to creation of forearm AVF. Using these techniques, construction of a radial-cephalic fistula was possible in 78% of children in our hospital, with 60% secondary patency rates at 4 years. In a personal unpublished series, 69% of the first arteriovenous angioaccess of adult patients were forearm fistulae, with 63% and 91% primary and secondary 1-year patency rates, respectively. Finally, 68% primary patency and 96% secondary patency rates at 1 year were reported by Pirozzi et al. in adults with an internal diameter of <1.6 mm in the radial artery.

Preventive Hemostasis for Hemodialysis Vascular Access Surgical Reinterventions

Surgical reinterventions for treatment of complications or ligation of haemodialysis vascular access (VA), when performed in or below the mid/lower part of the upper arm, could benefit from the use of preventive haemostasis with an inflatable tourniquet. This technique offers several advantages, such as the reduced risk of bleeding and the increased accuracy of dissection allowing for a minimally invasive approach. The use of preventive haemostasis is safe, economical and time-saving. All the secondary procedures on VA that could benefit from its use are reviewed.