Dialysis Access Research Articles

Single or dual antiplatelet therapy improves one-year arteriovenous graft patency and overall survival

IntroductionFollowing new dialysis access creation there is no consensus on the optimal use of anti-thrombotic therapy. Recent studies have suggested that single antiplatelet therapy may improve hospital mortality as well as patency. The aim of this study was to assess the role of different antiplatelet and anticoagulation therapies on outcomes following dialysis access creation. Material and MethodsA retrospective study was conducted utilizing patients from the Vascular Quality Initiative who underwent AV fistula (AVF) and AV graft (AVG) creation from 2011-2023. Patients who were antiplatelet and anticoagulation naive were separated into four cohorts: no antiplatelet (No APT), single antiplatelet (SAPT), dual antiplatelet (DAPT), and aspirin with anticoagulation (ASA + AC). Univariate Kaplan-Meier (KM) and multivariable regression analyses were conducted to assess overall survival, primary patency, and secondary patency. Results49,980 patients with AVF creation and 12,688 patients with AVG creation were identified. AVG patients had improved 1-year primary patency with SAPT compared to No APT (48% vs 44%, p = 0.03) on KM analysis. No difference on KM analysis was observed for AVF. Regression analysis showed decreased risk of loss of primary patency for AVF (HR 0.90, CI 0.83-0.97, p = 0.009). AVG with SAPT showed decreased risk of mortality (HR 0.80, CI 0.64 – 1.00, p = 0.05) and decreased risk of loss of primary patency (HR 0.80, CI 0.67-0.94, p = 0.009). DAPT also showed decreased risk of loss of primary patency for AVG (HR 0.64, CI 0.43-0.95, p = 0.028). Survival was worse for both AVF and AVG patients on ASA + AC on KM analysis. ConclusionsSingle antiplatelet therapy following access creation improves primary patency for both AVF and AVG, as well as overall survival for those with AVG. DAPT may further improve primary patency in those with AVG. The use of anticoagulation shows no clear benefit and may be harmful, however is more likely to reflect higher risk patients with other co-morbidities. These results suggest that following an AVF one should consider discharging patients on SAPT, and following an AVG one should consider SAPT or DAPT.

Correlation between pre-operative VE-cadherin and DLL4 and the maturation after primary arteriovenous fistula in uremic patients.

Uremic patients require dialysis to replace the declined kidney function, and arteriovenous fistula (AVF) is a commonly used dialysis access route. Our study aimed to explore vascular endothelial cells cadherin (VE-cadherin) and Delta-like ligand 4 (DLL4) expression in uremic patients undergoing primary AVF surgery and their correlation with AVF maturation. We conducted a prospective study that included n = 55 voluntary uremic patients receiving their initial AVF procedure for renal replacement therapy, subjects were divided into a mature group and a failure group based on whether the AVF matured within 3 months post-operatively. We analyzed the association of VE-cadherin and DLL4 with AVF maturation by examining their expression levels in serum and the endothelium of cephalic veins. Pre-operative serum VE-cadherin, in the mature group measured 125.07 (106.77-167.65) ng/L, and DLL4 was 92.78 (83.83-106.72) pg/mL, while the failure group had VE-cadherin at 95.40 (79.03-107.16) ng/L (P = 0.001), and DLL4 at 60.42 (43.98-80.15) pg/mL with a statistical significant; (P = 0.002), binary logistic regression analysis indicated a significant association between cephalic vein diameter, VE-cadherin, DLL4 levels, and AVF immaturity (P = 0.024, P = 0.014 respectively). Immunohistochemical staining showed slightly higher VE-cadherin levels in the mature group than in the failure group (P = 0.366). DLL4 was primarily located in the cell membrane and cytoplasm, concentrated in the inner membrane, with significantly higher levels in the mature group compared to the failure group (P = 0.027). The failure group exhibited lower levels of VE-cadherin and DLL4 in serum and vascular tissue, these results suggest that VE-cadherin and DLL4 might play pivotal regulatory roles in the onset and the progression of fistula immaturity, potentially serving as promising targets for future interventions.

Abstract 4124084: Nitric Oxide Releasing Bionanomatrix Gel For Dialysis Arteriovenous Fistula Maturation

Introduction: About 600,000 patients in the US suffer from end-stage renal disease (ESRD); more than 75% of ESRD patients undergo dialysis. Vascular access dysfunction is a major cause of morbidity and hospitalization in dialysis patients. Arteriovenous fistulas (AVFs) are considered the gold standard of vascular access for dialysis. However, about 60% of AVFs fail to mature because of early venous neointimal development and poor vasodilation and vascular wall remodeling. Therefore, to promote AVF maturation, we propose the application of a nitric oxide (NO) releasing nanomatrix gel, or ‘NO gel’, on the created AVF. The NO gel is composed of peptide amphiphiles (PA), which contain a polylysine (KKKKK) group to form NO-donating residues. In this study, we test our hypothesis that the NO gel applied at AVF can promote AVF maturation by decreasing venous intimal hyperplasia, enhancing vasodilation and vascular outward remodeling in porcine model. Materials and Methods: PA containing with KKKKK was synthesized and charged with NO to produce NO gel. For in vivo studies, AVFs in porcine were created by connecting the jugular vein and carotid artery. The NO gel was applied perivascularly over the AVF anastomosis. And the pigs were sacrifice after 35 days. AVF hemodynamics were evaluated using MRI-based computed fluid dynamics analysis. Results: We found significant decrease in neointimal hyperplasia in porcine AVFs treated with NO gel compared to the control groups. Additionally, the percentage of open lumens was significantly higher in the NO gel-treated group. It is indicated that veins in NO treated group showed less fibrosis as an less type I collagen I produced in the NO treated group than control. Also, the NO gel significantly improved hemodynamics and vascular remodeling of porcine AVFs compared to the control. Conclusion: These results suggest that the NO gel plays a crucial role in AVF maturation by reducing intimal hyperplasia and stenosis following AVF creation in a pig model. When intimal hyperplasia is reduced and the vessel is dilated, less tensile force of blood flow is applied on the arterialized vein, directing the AVF to appropriate maturation.

Risk factors, management and outcomes for peritoneal dialysis access damage

Objectives: Peritoneal dialysis (PD) access damage is an uncommon complication of PD. This study aimed to describe the characteristics, management and outcomes of PD access damage. Methods: This retrospective study included patients who suffered from PD access damage between January 2018 and January 2024 at the PD Center of West China Hospital. Patient characteristics and access damage information were collected from medical records. Results: A total of 128 PD patients without PD access damage were included in the control group. A total of 45 patients (51% male; aged 58 ± 14 years) suffered from 49 cases of PD access damage. Multivariate logistic analysis revealed that previous peritonitis [odds ratio (OR) 3.93; 95% confidence interval (CI) 1.56 to 9.94] and assisted PD (OR 4.20; 95% CI 1.25 to 14.12) were risk factors, while catheter belt use (OR 0.16; 95% CI 0.06 to 0.44) and training frequency per year (0.34; 95% CI 0.19 to 0.64) were protective factors against PD access damage. Managements included cutting and repairing (N = 24), transfer set replacement (N = 11), catheter removal (N = 9) and catheter replacement (N = 4). Thirty-nine patients continued with PD after access repair and were followed up for a median of 35 months. The repaired access functioned well during follow-up. Conclusions: In conclusion, to avoid PD access damage, catheter belt and routine retraining are recommended. Once PD access damage is identified, patients should clamp the catheter, take prophylactic antibiotics and resort to the treatment team. The treatment team should evaluate PD access and handle it according to a clinical protocol.

The price of dialysis access: Implications of access type and patient-centric approaches to cost.

This study explores out-of-pocket (OOP) costs for patients and provider reimbursement for dialysis access creation. It aims to illustrate the financial characteristics of four dialysis access modalities to consider in decision-making for clinicians, patients, and payers. Retrospective data from the Merative™ MarketScan Commercial Claims and Encounters Databases from 2017 to 2022 was analyzed for patients who received an arteriovenous fistula (AVF), arteriovenous graft (AVG), peritoneal dialysis catheter (PDC), or percutaneous AVF (pAVF). ANOVA and Tukey HSD were used to assess cost differences among the four access modalities overall and in the context of insurance type and service site. Database extraction resulted in 20,863 unique procedures, comprising of 15,043 AVF, 4759 AVG, 896 PDC, and 165 pAVF. Mean age was 59.2 years (±14.19) and 60.53% of the cohort was male. EPO/PPO plans were the most represented (53.06%) and most procedures were performed in the hospital outpatient department (91.99%). There were significant differences found among OOP cost and reimbursement with respect to procedure type, insurance type, and service site. Overall, pAVF had both the highest cost and reimbursement. Patient OOP costs and provider reimbursement differ significantly based on procedure, insurance type, and service site. While pAVF creation is recognized with high reimbursements due to its complexity and the advanced technology required, it also has the highest OOP costs for patients. To help facilitate adoption of new technologies like pAVF, advocacy efforts should focus on encouraging payers to lower the OOP financial barriers for patients to receive these newer but costlier procedures.

Personalized decision-making for vascular access creation in hemodialysis.

Selecting the appropriate kidney replacement therapy (KRT) is crucial in order to secure optimal care for chronic kidney disease (CKD) patients with end-stage renal disease (ESRD). Next to renal transplantation, the choice of dialysis modality directly affects patient well-being, treatment effectiveness, and long-term outcomes.1 Therefore, clinical decision-making must take into account a range of factors to tailor decisions to each patient's unique needs. Previously, when the dialysis population was less diverse and resources more limited, straight-forward algorithms could be effectively implemented both for selection of KRT as well as for hemodialysis (HD) vascular access (VA). Recently, the growing ESRD population with more elderly being considered for dialysis care together with improved treatment opportunities have resulted in more challenging decision-making where on-size-fits-all strategies are being replaced by more tailored and personalized strategies aimed to ensure "the right dialysis access - to the right patient - at the right time - for the right reason." In this review, recent trends enforcing a more personalized approach in the selection of VA for HD are summarized and discussed, where these concerns have become especially relevant.

Sustainability of a “just in time” educational strategy to optimize opioid prescribing in outpatient dialysis access surgery

ObjectiveSurgeons continue to contribute to opioid overprescribing. Although many prior interventions have effectively addressed this problem, intervention sustainability remains an important aspect of combatting the opioid epidemic. In this study, we sought to determine the sustainability of a “just in time” educational strategy to optimize opioid prescribing in outpatient dialysis access surgery. MethodsWe distributed an informational handout with opioid prescribing recommendations to residents at the start of their vascular surgery rotations. We then reviewed patient charts from 4 years before and 2 years after the start of this intervention (January 1, 2018-December 1, 2023). We compared the percentage of patients prescribed opioids during the pre-intervention and intervention periods. To determine the role of possible confounders, we also performed logistic regression controlling for patient characteristics. For patients prescribed opioids, we compared the total oral morphine equivalents (OMEs) prescribed during the pre-intervention and intervention periods. We further assessed whether opioid prescribing or OMEs prescribed changed from the first to the second years of the intervention. ResultsDuring the 6-year study period, 368 patients underwent upper extremity dialysis access procedures. Significantly fewer patients received opioids during the intervention period, with 58% of patients (140 of 241) receiving a prescription in the pre-intervention period and 35% (44 of 127) receiving a prescription in the post-intervention period (P < .001). In a regression model controlling for patient characteristics, only the intervention and use of regional block were associated with decreased risk of being prescribed opioids (P < .001). Among patients who received opioid prescriptions, the median OMEs prescribed decreased from 90 in the pre-intervention period to 45 in the intervention period (P < .001). Opioid prescribing did not change significantly between the first and second years of the intervention, but there was an improvement in adherence to prescribing guidelines in the second year. ConclusionsWe identified that a simple, low-resource, email-based intervention was associated with a significant, sustained decrease in opioid prescriptions for patients undergoing dialysis access surgery. Other programs may consider adopting such an approach given its ease of implementation with few resources.

Vascular Access Stenosis Caused by Membranous Structure in Patients on Hemodialysis.

A membranous structure (MS) may be seen on ultrasound at a site of vascular access (VA) stenosis in patients on hemodialysis. It can also be encountered during percutaneous transluminal angioplasty (PTA) and be impassable from one side but easily passed from the other. This study aimed to examine the characteristics of MS cases and how to treat them. Percutaneous transluminal angioplasty performed at our hospital for arteriovenous fistula-vascular access stenosis between July 2021 and June 2022 were identified. They were divided into two groups: membranous structure and nonmembranous structure. Data of patients such as age, history of dialysis and vascular access use, number of percutaneous transluminal angioplastys performed for vascular access, and diabetes status were collected. Membranous structure cases were examined in terms of puncture direction. A total of 72 percutaneous transluminal angioplasty were performed in 37 patients. Membranous structure was identified in nine percutaneous transluminal angioplastys. Patients with membranous structure were older than those without membranous structure (mean age 75.3 ± 7.54 vs. 70.0 ± 10.8 years, P = 0.21) and tended to have a history of vascular access use (57.6 ± 106 vs. 48.4 ± 59.8 months, P = 0.28), a history of dialysis (152 ± 95.6 vs. 91.2 ± 116 months, P = 0.02), fewer percutaneous transluminal angioplasty procedures (1.44 ± 0.726 vs. 3.24 ± 2.69, P = 0.02), and lower incidence of diabetes (1 vs. 38 cases). In the nonmembranous structure group, all percutaneous transluminal angioplastys performed were successful. In the membranous structure group, six percutaneous transluminal angioplastys were successful, two were impassable, and one was acutely occluded. The successful cases and the acute obstruction case were passed by centrally directed puncture. Impassable cases involved peripheral directional puncture. Vascular access stenosis can be caused by membranous structure and successfully treated by bidirectional puncture.

Long-Term Outcomes of Subcutaneous Versus Transvenous Implantable Cardioverter Defibrillator Use Among Patients on Maintenance Dialysis

Despite an elevated risk of sudden cardiac death among dialysis patients, implantable cardioverter defibrillators (ICDs) have not been shown to improve mortality and are associated with high complication rates. Subcutaneous (S-)ICDs may reduce the risk of complications for eligible dialysis patients, but safety and benefits versus transvenous (TV-)ICDs are unknown. To compare long-term outcomes between dialysis patients receiving S-ICD versus TV-ICDs. We performed a retrospective analysis of ICD implants among Fee-For-Service Medicare beneficiary dialysis patients in the National Cardiovascular Data Registry ICD Registry. Outcomes were ascertained from Medicare claims data. We compared survival outcomes, hospital admissions, and ICD- associated and dialysis vascular access-associated complications, between eligible S-ICD and single chamber TV-ICD recipients using stabilized inverse probability of treatment weighting. We identified 529 dialysis patients receiving S-ICDs and 842 receiving single chamber TV-ICDs who met the inclusion criteria. S-ICD recipients were younger, more often Black, and had a higher burden of cardiac disease and prior dialysis access interventions. After propensity weighting, there was no difference in the risk of death (HR 1.12, 95% CI 0.96-1.30), hospital admission (HR 1.01, 95% CI 0.88-1.16), bacteremia/sepsis (HR 1.01, 95% CI 0.80-1.26), device reoperation (HR 1.06, 95%CI 0.59-1.89) and subsequent dialysis access interventions (HR 1.12, 95% CI 0.86-1.46). In this representative longitudinal cohort study of dialysis patients, compared with TV-ICD, S-ICD was not associated with decreased risks of death, hospitalization, device complications, and dialysis access interventions.

Patient Perspectives on Arteriovenous Fistula Placement, Maturation, and Use: A Qualitative Study

Rationale & ObjectiveArteriovenous fistula (AVF) use among U.S. hemodialysis (HD) patients is suboptimal, especially among Black patients. We interviewed a group of predominantly Black HD patients to probe experiences and perspectives surrounding steps along the AVF care continuum, which includes placement, maturation, and use of AVFs. Study DesignIndividual semi-structured interviews. Setting & ParticipantsPatients with kidney failure receiving HD in Birmingham, Alabama. Analytical ApproachTranscripts were coded and thematically analyzed. ResultsWe interviewed 53 Black and 6 White patients at different steps of the AVF care continuum: 29 were dialyzing with a central venous catheter (15 had not undergone AVF placement, 9 had a maturing AVF, and 5 had a non-functional AVF) and 30 were dialyzing with an AVF. We coded transcripts using qualitative thematic analysis. Three themes emerged: (1) the circumstances of dialysis initiation sometimes altered the timeline of AV access placement; (2) patients had variable levels of knowledge of steps along the AVF continuum; and (3) the life impacts of dialysis access were a significant factor in patients’ experience of dialysis. LimitationsSingle-institution study; low number of non-Black participants limited comparison of patient experiences by race. ConclusionsAmong a group of predominantly Black HD patients, perspectives surrounding the AVF care continuum included consideration of the circumstances of dialysis initiation, patient knowledge, and the life impacts of dialysis access. These findings may inform targeted interventions aimed at optimizing dialysis access use and addressing disparities across the AVF continuum.

Nano-based perivascular intervention sustains a nine-month long-term suppression of intimal hyperplasia in vein grafts

Open vascular reconstructions (OVR), including bypass grafts and dialysis access, are standard treatments for cardiovascular and renal diseases. Unfortunately, OVR often fail largely due to intimal hyperplasia (IH), and there are no clinical methods to prevent this complication. Perivascular drug administration during OVR presents a promising strategy for IH suppression. However, durations of drug release from carriers are generally short whereas sustained efficacy is essential for clinical success. This raises a critical question in clinical translation: can IH suppression be realistically maintained long-term (e.g., over 6 months) with short-term perivascular interventions? To address this question, we modified a rat vein-graft model to prolong IH progression. We then applied Pericelle, a nanoparticle/hydrogel hybrid system that we developed for perivascular delivery of rapamycin, an established IH-inhibitory drug. Surprisingly, despite short (∼3-month) drug release, Pericelle demonstrated IH suppression throughout 3, 6, and 9 months with IH reduced from 115.58 ± 27.89 to 40.34 ± 5.18 at 9 months (P < 0.05, n = 6 rats), as indicated by morphometric analysis. Live animal ultrasonography showed the same trend. Consistently, histone-3 lysine-27 trimethylation, an epigenetic mark associated with IH progression, was decreased at 6 months after Pericelle treatment. Moreover, Pericelle exhibited promising efficacy in mitigating IH in a porcine model of arteriovenous fistula that mimics dialysis access. These results suggest that Pericelle-mediated suppression of IH in rat vein-grafts extends much beyond drug release, offering potential solutions to longstanding translational challenges in reducing OVR failure.

Streamlining Preoperative Evaluation for Dialysis Access: A Pilot Study

Outpatient in-person clinic evaluation is the standard consultation practice for an initial referral for hemodialysis (HD) access. However, most factors predicting the complexity of first-time access surgery can be determined from history rather than physical exam. This study compares the outcomes of patients undergoing first-time arteriovenous fistula creation screened with a standardized preoperative phone interview and no preoperative clinic visit (SPEEDY group) to those opting for a standard in-person clinic visit. From September 2021 to August 2022, all patients scheduled in our vascular surgery clinic for first-time dialysis access were interviewed via telephone using a standardized history questionnaire. Those meeting criteria and expressing desire to bypass the initial clinic visit were scheduled for surgery without an in-person preoperative evaluation (SPEEDY group). The comparison group included patients who were study-eligible but desired to meet with the surgeon preoperatively. Time from referral to fistula creation, overall fistula patency rates, and the incidence of access-specific complications were compared between the 2 groups. Of the 107 patients contacted, 43 (40%) were study eligible. Of these eligible patients, 21 (49%) were scheduled for surgery without a preoperative visit, of whom 19 (90%) underwent surgery. Compared to eligible controls, SPEEDY patients had a younger median age (49.3years vs. 58.9, P=0.056) but similar median duration of HD prior to fistula creation. SPEEDY patients had a significantly shorter median time from initial referral to surgery than eligible controls (48days vs. 82, P=0.01). Incidence of complications did not differ between the groups. At a median follow up time of 18.3months (IQR 11.4-20.9) there was no difference in overall access patency between SPEEDY participants and eligible controls (P=0.83). A standardized telephone questionnaire can effectively be used to identify patients who can safely undergo first time dialysis access surgery without an in-person clinic evaluation, significantly reducing time from initial referral to surgery without increasing complications or compromising patency rates.

Beyond Appearances: A Case Report of Mistaken Identity in Dialysis Access

Beyond Appearances: A Case Report of Mistaken Identity in Dialysis Access

Outcomes of Extra-Anatomic Surgical Bypass in Treatment of Central Venous Occlusive Disease in Pediatric Chronic Hemodialysis Patients: One-Year Follow-Up

Abstract Background Maintenance of hemodialysis vascular access patency in pediatric patients remains a key issue. Venous hypertension due to proximal central venous outflow obstruction is a major impediment to long-term arteriovenous access. Prior ipsilateral insertion of central venous catheters is a common risk factor. Management of Central venous occlusive disease (CVOD) in an attempt to avert sacrificing the fistula and improving symptoms of venous hypertension. Surgical bypass has the advantage of being a bale out technique for management of CVOD with maintaining the existing dialysis access and providing prolonged patency and satisfactory outcome specially with the scarce data about the role of endovascular intervention in management of CVOD in pediatric population. Objectives The aim of our prospective, observational study is to evaluate the efficacy and outcome of the surgical management of hemodialysis-related central venous occlusive disease in pediatric patients. Patients and Methods This study was conducted on (15) Pediatric patients with end stage renal disease on regular hemodialysis via upper extremity access who underwent extra-anatomic surgical bypass to treat symptomatic venous hypertension due to central venous occlusive disease. Bypass take-off was from subclavian vein, cephalic vein, or axillary vein of the affected side according to site of obstruction and outflow including contralateral subclavian vein, internal jugular vein or ipsilateral femoral vein. The study period started from June 2021 until May 2022. Patients included in the study were essentially attending the Vascular Outpatient Clinic at Ain Shams University Hospitals and Nasser Institute for Search &amp; Treatment at Cairo. Results Regarding the type of bypass used in the studied patients, the most frequent type used is Lt Axillary to Rt Subclavian bypass and Lt Subclavian to Rt Subclavian bypass 3 (20%) followed by Rt Axillary to Lt Subclavian bypass, Rt Cephalic to Lt Subclavian bypass and Rt Axillary to Rt femoral bypass 2 (13.33%). Technical success was achieved in the 15 (100%) cases while functional success occurred in 13 (86.6%) cases; patients had performed their 4 hours hemodialysis sessions via their preexisting access within 24 h post-procedurally. No in-hospital morbidity or death was recorded. Primary patency rates at 1, 3, 6, and 12 months were 93.3, 86.6, 73.3, and 66.6%, respectively. Secondary patency rates at 1, 3, 6, and 12 months were 100, 93.3, 80, and 73.3%, respectively. Conclusion Extra-anatomic surgical bypass is safe and effective method for management of Central venous occlusive disease and has the advantage of being a bail out technique for maintaining the existing dialysis access and also providing symptomatic relief of venous hypertension, prolonged patency and satisfactory outcome.

Closure of an Endovascular Arteriovenous Fistula Initially Created for Dialysis Access by Placement of Radial Artery Covered Stent

Closure of an Endovascular Arteriovenous Fistula Initially Created for Dialysis Access by Placement of Radial Artery Covered Stent

The carbon footprint of the vascular surgery operating room

ObjectiveClimate change is the single greatest threat to global human health, contributing to changes in disease patterns, water and food insecurity, vulnerability in shelter and human settlements, climatic volatility, and population growth and migration. Health care generates between 8% and 10% of all greenhouse gas emissions. Surgical care accounts for a significant proportion owing to equipment and drug use, sterility requirements, and life support systems. There are currently minimal data describing this carbon consumption. The purpose of this study was to determine the carbon use of common vascular interventions and to identify variables associated with increased carbon use. MethodsWe conducted an observational study of all elective and urgent vascular surgery procedures performed at our institution over a 2-month period in 2023. All waste generated was weighed and cataloged per hospital waste practices. Additional characteristics of the procedures were also collected. Carbon use was determined by applying DEFRA greenhouse gas life-cycle conversion factors to the mean waste produced. These factors take into account greenhouse gas emissions generated in the initial production and eventual disposal. Variables associated with increased carbon production were evaluated by linear regression models with log-transformed outcomes. ResultsFifty-nine procedures were included. Complex endovascular aortic procedures were the most carbon intensive (69.35 kg CO2), equivalent to driving a medium-sized vehicle 369 km. Dialysis access procedures (11.5 kg CO2) and minor amputations (10.6 kg CO2) were the least carbon intensive. Open surgical bypasses (28.4 kg CO2) and cerebrovascular procedures (20.3 kg CO2) produced a moderate amount of carbon. Endovascular interventions were 50% more carbon intensive than open interventions (95% confidence interval, 28%-77%; P < .01). Aortic interventions were 63% more carbon intensive than nonaortic interventions (95% confidence interval, 28%-109%; P < .01). In both models, there was nearly a one-half percent increase in carbon generated for each minute of additional operating time (P < .01). Blood loss was not consistently associated with carbon use. ConclusionsClimate change is a major threat to human health. The environmental impact of day-to-day surgery is rarely considered but clearly significant. Larger procedures are associated with increased carbon use, particularly if they are endovascular or aortic. The duration of the case is also associated with increased use. Further work should be done to identify additional variables and opportunities for carbon reduction.

Measuring perianastomotic pressure to identify patients at high risk for dialysis-associated steal syndrome

ObjectiveDialysis access-associated steal syndrome (DASS) is one of the most serious complications of hemoaccess surgery. Treatment algorithms involve significant morbidity; a tool to reliably identify patients at risk who could benefit from interventions at time of operation would be useful. We present a strategy of using perianastomotic pressure (PAP) measurement to identify patients who may be at high risk of developing DASS. MethodsPatients who underwent dialysis access creation between January 1, 2018, and September 30, 2022, at our institution were reviewed. Beginning in October 2019, we developed a strategy of measuring systolic pressure at the arterial anastomosis intraoperatively. A ratio of this value compared with the systemic systolic pressure was calculated. In patients believed to be at high risk for developing DASS based on clinical findings, selective banding of the access was performed intraoperatively to augment distal perfusion. ResultsOf 857 total patients, 36 (4.2%) developed clinically significant DASS, defined as requiring operative treatment, either intraoperatively or during follow-up (mean, 76 days; range, 0-602 days). DASS was more common for femoral-based accesses (6/12 [46.2%]) compared with upper extremity accesses (30/840 [3.6%]; P < .001). No patients who underwent radiocephalic arteriovenous fistula or infraclavicular axillary arteriovenous graft construction developed DASS. There was no difference in DASS for upper extremity arteriovenous fistulas (20/576, 3.47%) vs AV grafts (10/264, 3.79%; P = .82). There were 216 patients who had PAP measured intraoperatively. Fourteen (6.5%) of these 216 patients developed DASS requiring intervention in follow-up. The mean PAP ratio of these 14 patients was 0.395 vs 0.557 for the 202 patients who did not (95% confidence interval, 0.07-0.25; P = .001). Seventeen patients who had a low PAP ratio with poor distal perfusion underwent intraoperative banding, which improved the mean PAP ratios from a mean of 0.33 to 0.58. Despite banding, 3 of these 17 patients (17.6%) in this high-risk subgroup went on to develop DASS postoperatively. The calculated mean PAP ratio in patients who either developed DASS postoperatively or underwent prophylactic banding intraoperatively was 0.37, which was significantly lower than the mean ratio of 0.57 in the control group (P = .001). ConclusionsLow PAP ratios (<0.50) identified patients at increased risk for DASS, but prophylactic banding did not always prevent the occurrence of DASS in select patients. Because steal is a dynamic phenomenon, intraoperative conditions are not always going to reflect later adaptation. Nonetheless, PAP measurement may identify a subgroup of patients warranting procedural modification or closer postoperative physiological monitoring.

Effectiveness of autologous interposition saphenous graft in the creation of proximal arteriovenous fistula: Our initial experience

Abstract: For the individuals with end-stage renal disease, maintenance hemodialysis is a common treatment. When we compare to dialysis catheters or prosthetic grafts, arteriovenous fistula (AVF) is associated with a greater maturation period but a smaller incidence of infections, central venous stenosis, hospitalizations, and mortality. Fistulas mature by a dynamic process which is known as venous arterialization, where the breakdown of elastin and release of nitric oxide promote the functional and structural remodeling of the venous wall, permitting the expansion of venous outflow. Veins made them exposed to the arterial environment at the time of venous grafts and AVFs creation. Successful adaptation of the vein to the arterial flow is the most demanding part for long-term success, identified by venous dilation followed by wall thickening. Arteriovenous fistulas (AVF) and grafts (AV graft) are the commonest form of vascular access used for maintenance of hemodialysis. In general AVF is superior than AV graft in terms of its durability, patency, complication rate and overall survival of patients. But when the calibre of the vein is not satisfactory or length is not adequate to make tension free anastomosis, interposition graft is used. Most commonly used bridging material is polytetrafluoroethylene (PTFE) polymer. In this case, we used an interposition graft of the saphenous vein for making dialysis access on a 38 year old male patient having renal insufficiency and evaluated its efficacy in maintaining flow.

Assessing Permanent Dialysis Access in Underserved Patients with Advanced Kidney Disease in Austin, Texas

Assessing Permanent Dialysis Access in Underserved Patients with Advanced Kidney Disease in Austin, Texas

The Role of Healthcare Administration and Policy in Improving Access to Dialysis for ESRD Patients in CKD: Challenges and Solutions

End-Stage Renal Disease (ESRD) presents a critical challenge within the spectrum of Chronic Kidney Disease (CKD) and represents the final stage of CKD, necessitating timely and consistent access to dialysis for patient survival. However, access to dialysis remains significantly constrained in many regions due to a combination of systemic, financial, and infrastructural barriers. This article explores the pivotal role that healthcare administration and policy play in overcoming these challenges to enhance dialysis accessibility for ESRD patients. Multifaceted barriers are there regarding access to dialysis, including the economic burden of treatment, limited availability of dialysis centers, and disparities in healthcare delivery. The analysis then shifts to the policy landscape, discussing existing healthcare policies aimed at expanding dialysis services, as well as gaps that persist in current frameworks. The role of healthcare administration is also scrutinized, particularly in terms of resource allocation, service delivery optimization, and patient education. Through case studies and comparative analysis, it was identified that successful strategies from various regions that have effectively improved access to dialysis. These include public-private partnerships, subsidies, and advancements in telemedicine. The article concludes by offering policy recommendations and administrative strategies tailored to address the unique challenges faced by ESRD patients, emphasizing the need for a collaborative, patient-centered approach in healthcare planning and implementation. By highlighting these key areas, this article aims to provide actionable insights for policymakers, healthcare administrators, and other stakeholders committed to improving dialysis access and, ultimately, patient outcomes for those suffering from ESRD.