Access Failure Research Articles

Effects of hemodialysis access surveillance on reducing risk of hemodialysis access thrombosis: A meta-analysis of randomized studies.

Vascular access thrombosis remains the Achilles Heel for many a hemodialysis patient. We performed a systematic review and meta-analysis to assess the impact of monitoring vascular access blood flow on prediction and prevention of vascular access thrombosis. We hypothesized that monitoring vascular access blood flow has a pivotal role in lowering the risk of thrombosis and subsequent access failure. We conducted a systematic review in PubMed and EMBASE databases to identify randomized studies that have assessed the effect of hemodialysis access surveillance on the risk of thrombosis. A random-effects model was used for the meta-analysis. Subgroup analysis was performed among patients with arterio-venous fistula (AV-fistulas) and those with arterio-venous graft (AV-grafts). Ten randomized studies were included in the meta-analysis. The total number of patients included in the analysis was 1430. On performing the random-effects model among the included studies, hemodialysis access surveillance was associated with better outcomes (risk ratio = 0.73, 95% confidence interval ranges from 0.55 to 0.98). The analysis of the AV-fistula group showed an estimated overall risk ratio of 0.55 (95% confidence interval ranges from 0.33 to 0.89) favoring access surveillance. However, in the AV-grafts group, the estimated overall risk ratio was 0.92 (95% confidence interval ranges from 0.65 to 1.29) showing no additional benefit for access surveillance. Hemodialysis access surveillance using access blood flow monitoring can reduce the risk of access thrombosis for patients with AV-fistulas, but this is not the case with AV-grafts.

Invited Commentary Open Venous Bypass in the Era of Endovascular Therapy

Central venous disease and obstruction in dialysis patients is a common problem and a cause of upper extremity access failure. Endovascular therapy, angioplasty and stenting, is the first line of therapy nowadays in treating central venous disease. However high failure rates and need for re-intervention due to external compression at the thoracic outlet led many to perform other salvage procedures like clavicle or rib resection 1. Glass C. Maevsky V. Massey T. et al. Subclavian vein to right atrial appendage bypass without sternotomy to maintain arteriovenous access in patients with complete central vein occlusion, a new approach. Ann Vasc Surg. 2009; 23: 465-468 Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar and even more creative ideas like percutaneous bypass. 2. Chiung-Yu Chen M. Weng M.J. Percutaneous extraanatomic bypass for treatment of central venous occlusions in patients undergoing hemodialysis. AJR Am J Roentgenol. 2020; 214: 477-481 Crossref PubMed Scopus (2) Google Scholar Open central venous bypass should be considered in patients, particularly younger patients, as their life depends on a functioning upper extremity bypass. In addition, most of them have symptoms related to superior vena cava syndrome. The big questions are who should get it? What algorithm should we follow? What is the long-term patency? In the current paper, 3. Uceda P.V. Feldtman R.W. Ahn S.S. Long term results of bypass graft to the right atrium in the management superior vena cava syndrome in fialysis patients. Ann Vasc Surg. 2021; (accepted for publication) Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar the authors provide the readers with some answers to all these questions based on their experience. The authors present a mix of 5 patients (3 with fistulas, 1 with dialysis graft and 1 with dialysis catheter) treated with atrial bypass with no mortality. From the authors’ affiliation, two are vascular surgeons and one is a cardiac surgeon. Having a multidisciplinary approach, vascular and cardiac surgeons along with other interventionlists, would identify and increase the enthusiasm for this open and durable procedure and help some of the dialysis patients who need it the most.

Placing a Hemodialysis Catheter in Patients With Multiple Access Failure and Exhausted Usual Approachable Veins: Egyptian Single Center Experience

Highlights Abstract Background: End-stage renal disease (ESRD) is a growing global health hazard. Most patients are maintained on dialysis rather than transplantation. Adequate vascular access for hemodialysis is crucial to achieve an optimal dialysis dose and to reduce morbidity and mortality. Patients with multiple access failure are in desperate need for lifesaving access, especially in the absence of alternatives (transplantation or peritoneal dialysis). Objective: Patients with multiple vascular access failure and exhausted approachable veins are being referred to an interventional nephrology or radiology centers. The aim of this work is to evaluate a single center’s experience of sophisticated venous approaches to provide access for hemodialysis. Methods: This study was performed at the Interventional Nephrology Center at Kasr Al-Ainy University Hospitals. Epidemiological data of patients, e.g., age, gender, as well as the number of previously cannulated central veins, were documented. Results: Data of 188 patients with multiple dialysis venous access failure (117 females and 71 males, aged 17–56 years) were collected. Successful innominate (brachiocephalic) venous cannulation was achieved in 149 patients (79%). Eighteen patients had successful external iliac venous approach (9%). Successful transhepatic venous approach was placed as permanent access in 7 patients (4%). The rest of the patients (n = 14, 7%) were referred to other centers due to failure. Conclusions: Sophisticated central venous approaches, mainly brachiocephalic, as described in this study, may play as alternatives for placing either temporary or tunneled hemodialysis catheters in patients with multiple vascular access failure and stenosed or thrombosed central veins.

An Active Handoff Algorithm based on The Retention Time of Complementary Nodes

Due to the frequent joining and quitting of nodes in P2P network, it often leads to the failure of accessing nodes, and the decrease of system availability. Some of the existing methods are to switch a node’s service to its backup node after it is found to exit, and the backup node will continue to provide services. But the actual results are not ideal. The reason is that the service request of the node is always not responded from the time when the node exits the network to the time when the service switches to the backup node. This paper proposes an active handoff algorithm based on the retention time characteristics of complementary nodes. By predicting the exit time of the node, it finds the node complementary to the node in time as the backup node, and actively switches to the backup node before the node exits the network, so as to realize the service continuity. Experimental results show that the algorithm reduces the access failure and improves the system availability.

Microservice Monitoring and Handoff Algorithm Based on Dual-node Hot Standby

The service provider nodes in distributed microservice architecture often exit, join the network or have faults, which will affect the availability of the system. One of the main causes of the problem is the “bump” of service nodes. In this paper, a monitoring and switching algorithm based on dual-node hot backup is adopted, which makes the probability of bumping lower than the traditional single machine and switching method. Moreover, with the gradual increase of system scale, the performance of dual-node hot backup algorithm is still stable. Experimental results show that this method can effectively reduce the occurrence of service consumption node access failure events and improve the availability of the system.

Access-site hematoma in distal and conventional transradial access: a randomized trial.

Distal transradial access (dTRA) has been recently proposed as an innovative access for coronary procedures and a valuable alternative to conventional transradial access (cTRA). The aim of this study was to assess the safety of dTRA versus cTRA in patients undergoing percutaneous coronary angiography and intervention. In this single-center randomized trial, consecutive patients admitted for stable cardiac condition or acute coronary syndrome (ACS) were assigned to dTRA or cTRA. The primary endpoint was an early discharge after transradial stenting of coronary arteries (EASY) grade ≥II access-site hematoma (ASH). Vascular access failure, radial artery occlusion (RAO) at hospital discharge, 30-day rates of death, myocardial infarction, stroke and bleeding not related to coronary artery bypass grafting were considered as secondary endpoints. A total of 204 patients were included and randomized to dTRA (N.=100) or cTRA (N.=104). The two populations were similar, except for a higher percentage of ACS in the dTRA than in the cTRA group (38% versus 24%, P=0.022). The rate of EASY grade ≥II ASH was lower in dTRA than in cTRA patients, but the difference was not statistically significant (4% versus 8.4%, respectively, P=0.25). Vascular access failure was more frequent in dTRA patients than in cTRA patients (34% versus 8.7%, P<0.0001). We detected no case of RAO at hospital discharge and similar rates of 30-day adverse events in both groups. DTRA is safe and feasible. When compared to cTRA, dTRA is technically more demanding and limited by more frequent crossover to an alternative vascular access.

Spatial Based Pilot Allocation (SBPA) in Crowded Massive MIMO Systems

In this study, a new approach of random access and pilot allocation in crowded scenarios of massive multi-input multi-output (MIMO) systems is proposed. When the number of users in a cell is more than number of orthogonal pilots, random access to pilots (RAP) is a promising solution to solve the massive access problem of users; though the collision of pilots is a by-product of this method. There are several methods for pilot collision resolution such as strongest user collision resolution (SUCR), but they have one major limitation; i.e. they cannot serve users more than the number of orthogonal pilots simultaneously in coherent transmission mode. In this paper, angle of arrival (AOA) and angular spread (AS) of the received pilots in a compressed sensing approach are examined by applying sparsity of massive MIMO channels in angular domain. That allows to allocate same orthogonal pilot to non-overlapped users in spatial domain for coherent data transmission. By applying this approach in newly proposed protocol (SBPA), the limitation in number of adopted simultaneous users in crowded scenarios of a massive MIMO system would be resolved. Numerical results show improvement in access failures rate compared to SUCR in crowded massive MIMO systems.

Arteriovenous Fistula Versus Graft Access Strategy in Older Adults Receiving Hemodialysis: A Pilot Randomized Trial

BackgroundIt is unclear whether surgical placement of an arteriovenous (AV) fistula (AVF) confers substantial clinical benefits over an AV graft (AVG) in older adults with end-stage kidney disease (ESKD). We report vascular access outcomes of a pilot clinical trial.Study DesignPilot randomized parallel-group open-label trial.Setting & ParticipantsPatients 65 years and older with ESKD and no prior AV access receiving maintenance hemodialysis through a tunneled central venous catheter referred for AV access placement by their treating nephrologist.InterventionParticipants were randomly assigned in a 1:1 ratio to surgical placement of an AVG or AVF.OutcomesIndex AV access primary failure, successful cannulation, adjuvant interventions and infections.ResultsOf 122 older adults receiving hemodialysis and no prior AV access surgery, 24% died before (n = 18) or were too sick for (n = 11) referral for a permanent AV access. Of 46 eligible patients, 36 (78%) consented and were randomly assigned to AVG (n = 18) and AVF (n = 18) placement, of whom 13 (72%) and 16 (89%) underwent index AV access surgical placement, respectively. At a median follow-up of 321.0 days, primary AV access failure was noted in 31% in each group. The proportion of patients with successful cannulation was 62% (8 of 13) in the AVG and 50% (8 of 16) in the AVF group; median times to successful cannulation were 75.0 and 113.5 days, respectively. Endovascular procedures were recorded in 38% and 44%, and surgical reinterventions, in 23% and 25%, respectively. AV access infection was seen in 3 (23%) and 2 (13%) patients, respectively.LimitationsSmall sample size precludes statistical inference.ConclusionsAlmost one-quarter of older adults with incident ESKD and a central venous catheter as primary access were not referred for AV access placement due to medical reasons. Based on these limited results, there is little reason to favor either an AVF or AVG in this population until results from a larger randomized clinical trial become available.FundingGovernment funding to an author (Dr Murea is supported by National Institutes of Health∖National Institute on Aging grant 1R03 AG060178-01).Trial RegistrationNCT03545113.

Valiant NAVION stent graft system application: First Asian case-series analysis.

The Valiant NavionTM stent graft system is a third-generation low profile thoracic endograft designed for thoracic endovascular aortic repair. In this population analysis, we report on the first Asian all-comers experience and outcomes who underwent thoracic endovascular aortic repair with the use of this new stent graft system. Between May 2019 and October 2020, 21 patients with different aortic pathologies were prospectively recruited and retrospectively analyzed. Important clinical and device-related outcomes were evaluated. The endpoints included short-term survival, technical success, access failures, major vascular and clinical complications, endoleaks, and hospital stay. The commonest indication of stenting was penetrating aortic ulcers (28.6%) and six (28.6%) patients had emergency stenting performed for aortic transection or rupture. 30 days of survival postprocedure was recorded and complete. There were no major vascular complications. Deployment accuracy was 100%, and the technical success rate was 94.7% (18/19) with one patient having a Type 2 endoleak on follow-up imaging. No neurological complications were noted. The mean operative time was 95 ± 73.6 min and the mean fluoroscopy time was 16.2 ± 10.8 min. Mean hospital stay for elective zone 2, 3, and 4 stenting was 5.3 ± 3.8 days, and only one patient postzone 1 thoracic endovascular aortic repair required a brief (0.5 days) ICU stay. All procedures were performed via the percutaneous transfemoral route with 100% success in percutaneous closure. This first reported Asian case series demonstrated versatility, safety, and efficacy of the Valiant NavionTM stent in Asian patients with different aortic pathologies.

Early experience with a novel 088 long sheath in transradial neurointerventions

BackgroundTransradial access (TRA) for neuroendovascular procedures has several clear benefits compared to transfemoral access. In this study, we report our initial experience with neuroendovascular procedures performed via transradial access using the novel Ballast 088 long sheath. MethodsWe conducted a retrospective analysis and identified 91 consecutive patients who underwent neuroendovascular procedures via TRA using the Ballast 088 long sheath. Data collection was performed on indication for procedure, number of vessels selectively catheterized, fluoroscopy time, procedure duration, radiation exposure, failure of radial access and conversion to transfemoral access, periprocedural complications, and procedural outcomes. ResultsAmongst 91 patients, the average age was 65.5 years ± 14.2 with 45 (49.5 %) female patients. 25 (27.5 %) patients underwent aneurysm treatment, 2 (2.2 %) AVM/AVF embolization, 28 (30.8 %) intracranial or extracranial stenting, 31 (34.1 %) stroke treatment, and 5 (5.5 %) underwent diagnostic angiogram. The mean number of target vessels catheterized was 1.07 ± 0.25, the mean procedure duration (minutes) was 96.5 ± 57.2, mean fluoroscopy time (minutes) was 21.9 ± 14.2, mean contrast dose (ml) was 112.7 ± 66.7, and mean radiation exposure (Gycm2) was 54.82 ± 41.37. The success rate of target vessel catheterization was 100 %. There were no complications resulting in long term sequelae. Access complications occurred in 1 (1.1 %) patients. Transfemoral conversion was required in 3 (3.3 %) patients. ConclusionsThe Ballast 088 long sheath is safe and effective for TRA in neuroendovascular procedures with a low rate of complications and conversion.

Incremental Massive Random Access Exploiting the Nested Reed-Muller Sequences

Massive machine-type communication (mMTC) is expected to provide reliable and low-latency connectivity for an enormous number of devices, which turn active sporadically or frequently. In this highly dynamic situation, it is crucial to design efficient random access (RA) procedures to cope both with the flood of simultaneous access requests and with the potential access failures. In this article, by exploiting the large sequence space, the excellent correlation property and especially the elegant nested structure of Reed-Muller (RM) sequences, we propose a new RA scheme, which facilitates both instantaneous access for newly active users and incremental access for the existing users who suffer from detection failures. In particular, when a failure occurs, the user continues accessing the channel employing an expanded RM sequence, which is combined with the previously received ones at the access point (AP) to form a longer sequence so as to attain potentially better detection probability. Furthermore, a recursive detection algorithm is designed for jointly detecting the resultant RM sequences and the channel coefficients of both the newly active users and the existing ones. The performance of the proposed algorithm is analyzed in detail. Our simulation results validate the analysis and show the scheme’s superior access probability, access latency and computational complexity.

The Impact of Clinical Presentation on Survival in Patients Requiring Hemodialysis Catheters for Acute and Unplanned Dialysis: A Prospective Observational Study.

Background:Most studies addressing hemodialysis initiation with a dialysis catheter focus on patients entering maintenance dialysis programs and exclude other patients, such as those with acute kidney injury (AKI), making interpretation and application of the results difficult for clinicians managing patients at the time of dialysis commencement.Objective:To compare the survival of all patients requiring a catheter for hemodialysis access according to the nature of clinical presentation.Design:Prospective observational.Setting:An Australian tertiary renal unit.Patients:All patients requiring a central venous catheter (CVC) for hemodialysis access between 2005 and 2015.Measurements:Baseline comorbidities, demographics, and nature of clinical presentation. Data regarding each episode of dialysis access insufficiency and each CVC were collected. The primary outcome was all-cause mortality.Methods:Patients were classified into 1 of 3 groups based on physician assessment at the time of presentation: patients believed to have AKI with expected renal recovery (AKI), patients considered to be entering the maintenance dialysis program without a functioning dialysis access (Maintenance Dialysis), patients unable to perform peritoneal dialysis, or use their existing hemodialysis access (Access Failure). Time-split multivariable Cox regression analyses were used to compare survival between groups.Results:A total of 557 eligible patients had complete prospective data regarding CVC use and were included in the analyses. The majority of patients were in the AKI (246/557, 44%) and Maintenance Dialysis groups (182/557, 33%) compared with the Access Failure group (129/557, 23%). During a median follow-up of 3 years, 302 (54%) of the 557 patients died. Following adjustment, risk of all-cause mortality was higher in the AKI group (hazard ratio [HR]: 2.01, 95% confidence interval [CI]: 1.31-3.60, P = .001) during the first 2 years after catheter insertion and lower in years 2 to 4 (HR: 0.42, 95% CI: 0.20-0.88, P = .02) than in the reference Maintenance Dialysis group. No difference in mortality risk between the Access Failure and reference group was found.Limitations:Single-center study. Possible residual confounding owing to the observational study design.Conclusions:Patients requiring acute or unplanned hemodialysis experience high mortality, and the nature of clinical presentation does influence outcomes. Most notable is the greater early mortality experienced by patients with AKI compared to other patient groups. Prospective definition of the nature of unplanned dialysis initiation is important to accurately measure and improve outcomes in this high-risk patient population.Human Research Ethics Committee Approval NumberCH62/6/2017-042.

Intraoperative vascular Doppler ultrasound blood flow and peak systolic velocity predict early patency in hemodialysis arteriovenous fistula.

BackgroundChronic kidney disease is a major public health problem. Hemodialysis is the most common renal replacement therapy. Arteriovenous fistulas (AVF) are a possible access option, but early failure rates remain high.Objectivesto investigate the value of intraoperative vascular Doppler ultrasound for predicting early AVF patency.MethodsProspective observational study. Consecutive patients undergoing AVF were assessed with vascular Doppler ultrasonography intraoperatively and on days 1, 7, 30, and 60. Patients were divided into groups according to presence or absence of primary and secondary patency. Blood flow (BF) and peak systolic velocity (PSV) were compared. ROC curves were plotted and used to define the PSV and BF values that yielded greatest sensitivity (Sens) and specificity (Spec).Results47 patients met the inclusion criteria and were analyzed. Higher intraoperative PSV and BF values were observed in patients who had primary and secondary patency than in patients with access failure. The values with greatest sensitivity and specificity for predicting 30-day primary patency were 106 cm/s for venous PSV (Sens: 75% and Spec: 71.4%) and 290.5 ml/min for arterial blood flow (Sens: 80.6% and Spec 85.7%). Values for 30-day secondary patency were 106 cm/s for arterial PSV (Sens: 72.7%, Spec: 100%) and 230 ml/min for venous blood flow (Sens: 86.4%, Spec100%). Values for 60-day primary patency were 106 cm/s for venous PSV (Sens: 74.4%, Spec: 62.5%) and 290.5 ml/min for arterial blood flow (Sens: 80%, Spec: 75%).ConclusionsPeak systolic velocity and blood flow measured using intraoperative vascular Doppler ultrasound can predict early patency of hemodialysis arteriovenous fistulas.

Computer assisted Doppler waveform analysis and ultrasound derived turbulence intensity ratios can predict early hyperplasia development in newly created vascular access fistula: Pilot study, methodology and analysis.

ObjectivesFollowing surgical creation of arterio-venous fistulae (AVF), the desired outward remodeling is often accompanied by the development of neointimal hyperplasia (NIH), which can stymie maturation and may lead to thrombosis and access failure. The aim of this study was to investigate the feasibility of using a non-invasive test, to detect and quantify the turbulent flow patterns believed to be associated with NIH development.DesignThis was a prospective, observational study. Ultrasound derived turbulence intensity ratios (USTIR) were calculated from spectral Doppler waveforms, recorded from newly formed AVF, and were compared with haemodynamic and structural changes observed during the initial maturation period.SettingMeasurements were obtained by accredited Clinical Vascular Scientists, at the Royal Free Hospital, London.ParticipantsPatients with newly created AVF were invited to participate in the study. A total of 30 patients were initially recruited with 19 participants completing the 10 week study protocol.Outcome measuresThe primary outcome measure was the development of NIH resulting in a haemodynamically significant lesion.The secondary outcome was successful maturation of the AVF at 10 weeks.ResultsElevated USTIR in the efferent vein 2 weeks post surgery corresponded to the development of NIH formation (P = 0.02). A cut off of 6.39% predicted NIH development with a sensitivity of 87.5% and a specificity of 80%.ConclusionAnalysis of Doppler waveforms can successfully identify deleterious flow patterns and predict inward luminal remodelling in maturing AVF. We propose a longitudinal follow up study to assess the viability of this technique as a surveillance tool.

Retrograde intrarenal surgery for renal stones in children

Introduction:There are very few studies in the literature describing retrograde intrarenal surgery (RIRS) in preschool children. We have evaluated the feasibility, stone-free rate, and complications of RIRS in children <5 years of age.Methods:All children <5 years of age and stone size <2 cm (renal/proximal ureteric), who underwent RIRS at our hospital from February 2010 to May 2020 were included in this retrospective study. All children were prestented for the passive dilatation of ureter. A 7.5 Fr flexible ureterorenoscope was introduced over the ureteral access sheath (UAS) or over a guidewire. At 2 weeks, the stent was removed and at 2 months the child was evaluated for residual stones.Results:A total of 62 children with 67 renal units met the inclusion criteria. The mean age was 42.11 months (4–60 months). Mean weight was 13.31 kg (6–16.3 kg). Mean stone size was 11.9 mm (7.3–18.2 mm). Majority of the stones were in pelvis (37.8%). UAS 9.5/11.5 Fr was placed in 40 (63.5%) children. Mean operative time was 55.2 min; mean hospitalization was 61 h. Four out of the 67 renal units (5.9%) required conversion to minipercutaneous nephrolithotomy in the same sitting, due to access failure. Two cases who developed post-operative fever required a change of antibiotics. Two cases required ureteroscopy for steinstrasse postoperatively. Stone-free rate at 2 months for stones size ≤2 mm was 76.3%.Conclusion:Pediatric RIRS is a promising option in young children as it offers acceptable stone-free rates and a low incidence of high-grade complications. However, it requires expertise and should be offered in tertiary care centres.

Predictors of Radial to Femoral Artery Crossover During Primary Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

Radial access for primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infarction (STEMI) is associated with reduced mortality and bleeding, when compared to femoral access. However, radial access failure may be associated with an increased door-to-balloon time.

Effect of the mean platelet volume/platelet count ratio on arteriovenous fistula function in chronic hemodialysis patients

ObjectiveThe aim was to study the effect of increased mean platelet volume/platelet count (MPV/PL count) on arteriovenous fistula (AVF) function in chronic hemodialysis (HD) patients.BackgroundVascular access failure substantially contributes to morbidity and hospitalization in HD patients.Patients and methodsA case–control study was conducted on 50 HD patients on regular HD for more than 6 months in Shebin El-Koom Teaching Hospital, Menoufia, Egypt. The patients were divided into two groups: 25 patients with functioning AVF as group 1 and 25 patients with nonfunctioning AVF as group 2. Patients were subjected to full history taking, clinical examination, laboratory workup, and radiology by Duplex ultrasound.ResultsThere was no significant effect of age, sex, BMI, diabetes mellitus, hypertension, smoking, or type of anastomosis on AVF in HD patients. There was a significant effect of intradialysis hypotension on AVF in HD patients. There was a highly significant effect of fistula function on Kt/V in HD patients. There was a highly significant increase of MPV/PL count ratio in HD patients with failure of AVF. MPV/PL count at a cut-off level of 53.7 can accurately predict failure of AVF in the studied HD patients with 100% sensitivity and 84% specificity.ConclusionAssessment of MPV/PC ratio could adequately predict the failure of the function of AVF in the studied patients.

Patency of trans-lumbar and intra-atrial catheters in patients with end stage renal disease and end stage vascular access failure

Patency of trans-lumbar and intra-atrial catheters in patients with end stage renal disease and end stage vascular access failure

Bilateral Tortuous Upper Limb Arterial Tree and Their Clinical Significance

The detailed knowledge about the possible anatomical variations of upper limb arteries is vital for the reparative surgery of the region. Brachial artery is the main artery of upper limb; it is a continuation of axillary artery from the lower border of teres major muscle. During routine cadaveric dissection, we found bilateral tortuous brachial artery which was superficial as well as tortuous throughout its course. It is called superficial as it was superficial to the median nerve. At the neck of radius, it was divided into two terminal branches radial and ulnar arteries which were also tortuous. Tortuosity of the radial artery was more near the flexor retinaculum. When observed, the continuation of ulnar artery as superficial palmar arch also showed tortuosity throughout, including its branches. Being superficial such brachial artery can be more prone to trauma. Tortuous radial artery is one of the causes of access failure in trans-radial approach of coronary interventions. To the best of our knowledge, this is the first case where entire post axillary upper limb arterial system is tortuous bilaterally. So knowledge of such tortuous upper limb arterial tree is important for cardiologist, radiologist, plastic surgeons and orthopedic surgeons

Transcarotid versus transfemoral access in patients undergoing transcatheter aortic valve replacement with complex aortofemoral anatomy.

While major vascular complications (MVC) remains an issue after Transfemoral (TF) transcatheter aortic valve replacement (TAVR), we compared outcomes in TF versus transcarotid (TC) approaches in patients with complex vascular anatomy. Among patients undergoing TAVR in our center between 2015 and 2018, we evaluated patients with complex vascular anatomy defined on CT scan as: (a) iliofemoral diameter between 5.5 and 6 mm or <6.5 mm with severe calcifications or tortuosity AND/OR (b) abdominal aorta pathology. The primary endpoint included access failure, mortality, MVC, major bleeding and stroke at 1-month. Among 483 patients, 131 (31.2%) with complex vascular anatomy underwent TF (n= 51;39.2%) or TC (n= 80;60.8%) TAVR. The mean age was 81.7± 6.9. TC group had higher STS score (p= .01), higher incidence of coronary artery disease (p= .04) and lower left ventricular ejection fraction (p< .001). In TC group, primary endpoint occurred twice less without reaching significance compared to TF group (n= 8; 10.0% vs. n= 10; 19.6% respectively; p= .1). Incidence of MVC was higher in TF group (11.8 vs. 1.3% in the TC group; p= .01) with similar incidence of stroke between groups (p= .8). Despite higher patient risk profile, TC approach in complex aortofemoral anatomy provides similar favorable outcomes with less MVC compared to TF approach.