Abstract Arteriovenous Fistula Research Articles

The FACT : Use of a novel intermittent pneumatic compression device to promote pre-surgery arm vein dilation in patients with chronic renal failure.

Arteriovenous fistula (AVF) creation and maturation for hemodialysis is globally a topic of importance given the poor results and high costs associated with renal care. Successful AVF (surgical or endovascular) creation requires appropriate superficial veins and quality arteries. Many procedures fail due to initial small veins with limited blood flow capacity and distensibility. Intermittent pneumatic compression has previously shown success in trials to increase superficial veins in patients with end stage renal disease post AVF. The objective of this study is to investigate the role of an intermittent pneumatic device, the Fist Assist®, to dilate cephalic arm veins in patients with advanced chronic kidney disease (CKD) prior to AVF placement. Three centers enrolled subjects from June 2019 through July 2021. Baseline Doppler measurements of the cephalic vein in standard locations the forearm and upper arm with and without a blood pressure cuff were recorded. Patients were instructed and used Fist Assist® on their non-dominant arm for up to 4 h daily for 90 days. At approximately 3 months, Doppler measurements were repeated. The primary endpoint was cephalic vein enlargement with secondary endpoints based on percentage of veins approaching 2.5 mm in the forearm and 3.5 mm in the upper arm. Thirty-seven subjects with CKD (mean eGFR 13.8 mL/min) were enrolled and completed the trial. Paired-difference t-tests (one tail) for aggregate data showed significant venous dilation of the cephalic vein in both the forearm and upper arm after use with the Fist Assist® (p < 0.05). Mean differences in the forearm veins were approximately 0.6 and 1.1 mm in the upper arm cephalic vein after Fist Assist® application. There were no major complications reported by any subject during the trial. Fist Assist® use in patients with CKD is effective to enhance vein dilation. Forearm and upper arm cephalic veins increased on average 0.6 and 1.1 mm respectively after Fist Assist® application. This is the first trial to evaluate the effect of intermittent, focal pneumatic compression on pre-surgery vein diameter in patients with advanced CKD before AVF creation.

Covered Stent Placement for Subclavian Vein Stenosis Associated With Basilic Arteriovenous Fistula

Arteriovenous fistula (AVF) creation is used to palliate complex cyanotic heart diseases. We report an adult patient with AVF creation who subsequently developed severe left subclavian vein stenosis, causing significant left arm swelling. Covered stent placement successfully treated the venous stenosis, resulting in the normalization of his left arm swelling.

Tissue Ki67 proliferative index expression and pathological changes in hemodialysis arteriovenous fistulae: Preliminary single-center results.

Arteriovenous fistula (AVF) for hemodialysis integrates outward remodeling with vessel wall thickening in response to drastic hemodynamic changes. Aim of this study is to determine the role of Ki67, a well-established proliferative marker, related to AVF, and its relationship with time-dependent histological morphologic changes. All patients were enrolled in 1 year and stratified in two groups: (A) pre-dialysis patients submitted to first AVF and (B) patients submitted to revision of AVF. Morphological changes: neo-angiogenesis (NAG), myointimal thickening (MIT), inflammatory infiltrate (IT), and aneurysmatic fistula degeneration (AD). The time of AVF creation was recorded. A biopsy of native vein in Group A and of arterialized vein in Group B was submitted to histological and immunohistochemical (IHC) analysis. IHC for Ki67 was automatically performed in all specimens. Ki67 immunoreactivity was assessed as the mean number of positive cells on several high-power fields, counted in the hot spots. A total of 138 patients were enrolled, 69 (50.0%) Group A and 69 (50.0%) Group B. No NAG or MIT were found in Group A. Seven (10.1%) Group A veins showed a mild MIT. Analyzing the Group B, a moderate-to-severe MIT was present in 35 (50.7%), IT in 19 (27.5%), NAG in 37 (53.6%); AD was present in 10 (14.5%). All AVF of Group B with the exception of one (1.4%) showed a positivity for Ki67, with a mean of 12.31 ± 13.79 positive cells/hot spot (range 0-65). Ki67-immunoreactive cells had a subendothelial localization in 23 (33.3%) cases, a myointimal localization in SMC in 35 (50.7%) cases. The number of positive cells was significantly correlated with subendothelial localization of Ki67 (p = 0.001) and with NA (p = 0.001). Native veins do not contain cycling cells. In contrast, vascular cell proliferation starts immediately after AVF creation and persists independently of the time the fistula is set up. The amount of proliferating cells is significantly associated with MIT and subendothelial localization of Ki67-immunoreactive cells, thus suggesting a role of Ki-67 index in predicting AVF failure.

Association of early failure of arteriovenous fistula with mortality in hemodialysis patients

Arteriovenous fistula (AVF) is prone to early dysfunction and relates to poor outcome. However, little is known about the role of early AVF dysfunction as an independent risk factor for death in hemodialysis patients. A retrospective cohort study was performed using data of patients who underwent initial AVF surgery at a single institution. Demographic, clinical, biochemistry and AVF parameters were extracted from the electronic records, and the association between these variables and mortality was analyzed by Cox proportional hazards model. A total of 501 patients on hemodialysis (63.4 ± 12.7 years, 57.3% male) were included, and the median observation period was 3.66 years. In multivariate analysis, early failure of AVF (hazard ratio (95% confidence interval): 1.54 (1.06–2.24); p = 0.023) was associated with overall mortality but not cardiovascular mortality. Other identified predictors of overall mortality included older age, peripheral artery disease (PAD), cardiomegaly, higher white blood cell (WBC) count and corrected calcium level, and lower total cholesterol level, while predictors of cardiovascular mortality included older age, coronary artery disease (CAD), PAD and lower hemoglobin level. In conclusion, patients with early AVF failure were associated with increased risk of overall mortality.

A real-time rule-based method of stenosis evaluation for arteriovenous fistula care by multiple sites blood flow measurement

Arteriovenous fistula (AVF) care is crucial for hemodialysis patients. Neglecting the care of patients on strict AVF care may cause stenosis and affect hemodialysis efficiency. Hence, AVF has been called a lifeline for these patients. Currently, in clinical care, angiography and ultrasound are used to evaluate the degree of stenosis (DOS) in AVF. However, these tools are expensive, time-consuming, and inappropriate for quick assessments before dialysis therapy or even at home care. This study proposed a real-time rule-based method of stenosis evaluation for AVF care by measuring the blood flow of multiple sites with Doppler ultrasound. The features of blood flow analyzed were the average flow rate (AFR) and the ratio of flow variation (RFV), which were measured in the fistula and arteriovenous anastomosis sites, respectively. In the clinical examinations of 60 patients, the results indicated that AFR would gradually decrease with DOS, and RFV reached the maximum at 30% to 50% stenosis and the lowest at 30%; this difference was statistically significant (p<0.05). Moreover, the classification results indicated that the proposed method achieved a high classification rate of 95% as well as a shorter processing time within 10 ms. This study also compared the results from a phantom experiment, which had three different DOS simulated vessel classes, and it showed the same trend. The proposed method was considered to be potentially suitable for real-time program design with a microsystem in wearable or small monitoring devices so as to provide a simple and fast rapid screening method for clinical AVF care.

Chronic leg ulcer as a complication of post-traumatic arteriovenous fistula: colour doppler evaluation

Arteriovenous fistula (AVF) can be either be iatrogenic, traumatic or congenital. Most femoral AVFs commonly developed secondary to penetrating injuries. This is a case of post traumatic femoral AVF in a 40 year old man who presented with chronic leg ulcer, is presented to illustrate the inherent danger in the delayed diagnosis and treatment of AVF and role of ultrasound in diagnosis. Review of the existing literature outlining the pathogenesis, clinical features and radiological therapeutic considerations as they relate to arteriovenous fistula.

Vision-Threatening Arteriovenous Fistula in the Upper Extremity

Arteriovenous fistulas (AVFs), which have low complication rates and can stay open for a long time, are preferentially used for hemodialysis in patients with end-stage renal disease (ESRD). Arteriovenous fistulas for hemodialysis frequently cause complications such as bleeding, thrombosis, ischemia of extremities, infection, edema, venous hypertension and venous aneurysm. These complications have negative effects on the quality of life and survival. In this report, a dialysis patient having severe edema in the left eye and arm for one year due to thrombosis in the AVF and experiencing a fast regression of edema after closure of the AVF will be presented. The present case emphasizes that thrombosis in the fistula, a frequent complication of AVF in patients with ESRD, can present with rare symptoms like periorbital edema which prevents unilateral vision in addition to its well-known symptoms.

Surgical Approaches to Symptomatic Arteriovenous Fistula Aneurysms: a Single-Center Experience

Arteriovenous fistulas (AVFs) created for hemodialysis accesses are prone to aneurysmal degeneration. Arteriovenous fistula aneurysms may lead to pain, aesthetic problems, infection, bleeding, and fistula thrombosis. The aim of this study is to report our surgical approaches and outcomes of AVF aneurysms. Medical records of a total of 21 patients (9 males, 12 females) with an AVF aneurysm who underwent surgery at Karabuk Training and Research Hospital, Department of Cardiovascular Surgery between January 2013 and March 2015 were retrospectively analyzed. The mean age was 59.7±13.5 years. Aneurysmectomy was performed on eight patients, while partial aneurysmectomy and polytetrafluoroethylene graft interposition were carried out in four patients. Three patients underwent aneurysmorrhaphy, whereas six patients underwent thrombectomy + aneurysmorrhaphy to the aneurysmatic segment. All patients were discharged without any event at the postoperative second day. They were scheduled for follow-up visits and assessed by Doppler ultrasound. Currently, surgical repair is the gold standard in the treatment of AVF aneurysms. Based on our experience, we recommend surgical interventions for selected patients to maintain AVF continuation.

Bloodstream infection among patients on hemodialysis by arteriovenous fistula and graft

Arteriovenous (AV) graft or fistula is the major risk factor for bacteremia in hemodialysis (HD) patients. The present study was designed to evaluate the prevalence of risk factors for bloodstream infections (BSIs) among patients with AV graft or fistula for HD and to identify the microorganisms isolated from the bloodstream of patients. From May 2010 to May 2013, this retrospective study was performed. A questionnaire that included demographic and medical data was completed for each case. Also laboratory data, including catheter blood culture and peripheral blood cultures were collected for each case. The collected data were analyzed using SPSS software. A p value < 0.05 was considered significant. Overall, 106 cases received AV fistula and graft for HD in this study. Regarding the type of vascular access, 68 % had AV fistulas, 32 % had AV graft. A total of 49 episodes of BSIs were found in this study. These BSIs detected represent an incidence rate of 0.64/1,000 catheter days (0.65/1,000 catheter days in AV fistula and 0.64/1,000 catheter days in AV graft) and 2.56/1,000 dialysis sessions (2.49/1,000 dialysis sessions in AV fistula and 2.71/1,000 dialysis sessions in AV graft). Staphylococcus aureus was common pathogenic organism in BSIs. In the multivariable logistic regression model presence of diabetes mellitus, older age, low serum albumin level, and poor patient hygiene were all independently associated with occurrence of a BSI. Our data suggest that improved nutrition and hygiene and diabetes management in HD patients may decrease the incidence of bacteremia.

Predicting dialysis vascular access blood flow and diameter: too much, too little, or just right

Arteriovenous fistula (AVF) maturation continues to cause significant morbidity and mortality. Despite the magnitude of the clinical problem, however, there are no effective clinical or biological predictors of AVF success or failure. Caroli et al. describe an innovative technology that may be successful in predicting AVF flow and diameter using standard-of-care preoperative inputs. Pending additional longer-term validation, the use of this technology could help us get the right access into the right patient at the right time.

Thrombosed hemodialysis access as an unusual source of emboli in the upper extremity of a kidney transplant recipient

Arteriovenous fistula (AVF) is no longer used in kidney transplant recipients. However, there is no consensus regarding whether or not to ligate a well-functioning AVF after successful kidney transplantation, particularly in patients with well and stably functioning kidney transplants. Most AVFs without complications are left in situ and more than one-third of native AVFs close spontaneously. The currently accepted policy toward thrombosed AVFs is retention within the patient's extremity without treatment. These thrombosed AVFs seldom cause serious problems. However, when combined with aneurysmal dilatation of the proximal vein adjacent to the arterial anastomotic area, the AVF could act as the source of distal arterial emboli. This is very similar clinical scenario to that observed in embolization from a peripheral arterial aneurysm. Here we describe a case report of upper extremity ischemia following massage of a thrombosed aneurysmal AVF. The patient was successfully treated with a combination of catheter-directed thromboaspiration, thrombolysis, and surgical repair of the thrombosed AVF. To the best of our knowledge, this is the first report of upper extremity embolism after massage of a thrombosed aneurysmal AVF involving this combined treatment.

Carotid-Jugular Fistula Diagnosed by Transesophageal Echocardiography

Arteriovenous fistulas (AVFs) in the neck are rare, and are most frequently caused by internal jugular catheter placement or penetrating trauma. Diagnosis can be missed when pathognomonic physical exam findings are absent, and heart failure can develop late when AVFs go unrepaired. We present what we believe to be the first reported case of common carotid-internal jugular fistula diagnosed during transesophageal echocardiography. Causes, physical exam findings, complications, diagnostic imaging, and treatment are discussed.

Stent-Graft Repair of Peroneal Arteriovenous Fistula

Arteriovenous fistulas (AVFs) are infrequently seen in the civilian health-care system; traditionally, these lesions have been treated with ligation, or direct surgical repair with concomitant revascularization. We describe a rare case of a peroneal AVF treated with a stent-graft.

Influence of Autologous Arteriovenous Fistula on the Blood Supply to the Hand in Very Elderly Hemodialyzed Patients

Arteriovenous fistula (AVF) creation for hemodialysis (HD) could predispose to local arterial insufficiency of the hand (steal syndrome). Patients with diabetes mellitus, peripheral arterial disease and elderly patients tend to have a higher risk of hand ischemia. To estimate the influence of AVF on the blood supply to the hands in the elderly population and to identify steal syndrome cases by non-invasive diagnostics (finger photoplethysmography (PPG), pulse volume recording (PVR), Doppler analysis and pulseoxymetry). The evaluation was carried out in 25 random patients (10 females, 15 males) >75 yrs of age (79.6 +/- 3.87 yrs), whose functioning autologous AVFs had been placed at least 1 month previously. Mean PPG and PVR amplitudes did not differ in statistical analysis (p > 0.05) between hands with and without an AVF. One patient (4%) with end-to-side anastomosis was diagnosed with steal syndrome (typical manifestation confirmed in PPG, Doppler and pulseoxymetry). Two other patients with high brachio-cephalic anastomosis presented subclinical steal syndrome (only low PPG and PVR). Even in the very elderly, AVF creation should be considered due to a lesser influence on the blood supply to the hands. Non-invasive diagnostics used by us seemed to be useful in identifying steal syndrome after AVF creation.

The Clinical Utility of Doppler Ultrasound Prior to Arteriovenous Fistula Creation

Arteriovenous fistula (AVF) is the preferred access for long-term hemodialysis, with superior long-term patency rates; however, early failure rates are significant. Recent evidence has brought into question the preferred site of AVF creation in many patient groups. A preoperative test that could reliably predict the outcome of a proposed AVF would be of great benefit. Doppler ultrasound has been the most extensively studied and widely used test to guide access creation. Accurate and validated measurements of internal vessel diameter, both arterial and venous, and blood flow in the upper extremity are obtainable by Doppler ultrasound. Studies evaluating the utility of Doppler ultrasound prior to AVF creation suggest that vessel size and blood flow are predictive of AVF outcome. An AVF created using a cephalic vein and/or radial artery smaller than 1.5-2.0 mm is likely to fail; such preoperative data may indicate that an upper arm AVF should be the primary access attempted. Further prospective studies are needed to evaluate the utility of Doppler ultrasound.

Pulse oximeter analysis of peripheral cyanosis distal to an AV fistula

Arteriovenous (AV) fistulas are routinely constructed for hemodialysis in patients with renal failure. The case of a hemodialysis patient with cyanosis of the hand distal to an AV fistula is described. Pulse oximeter analysis found a saturation of 72% in the cyanotic hand with a normal saturation of 97% in the opposing hand. Evaluation of 11 additional patients with AV fistulas and no cyanosis or symptoms found no difference in oxygen saturation between extremities. Pulse oximetry was found to be useful for evaluating the oxygenation status distal to an AV fistula, and in asymptomatic patients with an AV fistula, the oxygenation status distal to the fistula should be no different from that of the opposing extremity.

Arteriovenous Fistula Masquerading as Valvular Heart Disease

ARTERIOVENOUS (AV) fistula in a patient after laminectomy is a well-recognized cause of congestive heart failure. 1,2 In most patients with this surgical complication, the clinical syndrome of high-output heart failure is recognized and the diagnosis made without difficulty. We recently cared for a woman with this condition in whom the diagnosis of AV fistula was not made despite examination by numerous physicians. The patient had a loud systolic murmur, which misled her physicians into thinking that severe, acute mitral regurgitation was the cause of her heart failure. Report of a Case A 54-year-old woman with no history of cardiac problems reported having seven months of dyspnea on exertion, ankle swelling, and weight gain. The patient had undergone a lumbar laminectomy at the L5-S1 level six years previously. On physical examination, blood pressure was 150/55 mm Hg; there was no jugular venous distention. The point of maximal impulse was in