Access Surgeon Research Articles

One-Stage Posterior Only Corpectomy AndFusionInTheTreatment Of Metastatic Spinal Disease WithoutNeurologic Deficit: A Case Presentation

Introduction The treatment of lumbar metastatic burst fractures without neurologic deficit can be approached using a one-stageposterior-only corpectomy and fusion technique. This technique involves the removal of the af ected vertebral bodyand its replacement with an expandable titanium cage to provide stability and promote fusion. Case Report We describe our initial experience with the case of a 36-year-old female who presented with spinal nervecompression symptoms with radiological features of a solitary metastatic disease of the second lumbar vertebraewith a background history of missed unilateral breast tumour. She had a one-staged L2 posterior corpectomy, insertion of an expandable cage and stabilization with pedicle screws and rods. She subsequently did well withnoneurological deficit. Subsequently, she had a full assessment for breast cancer which revealed a left breast malignant tumour and had a radical mastectomy done and followed up with chemotherapy. Discussion Lumber corpectomy combines a posterior approach for instrumentation with an anterior approach for corpectomy and reconstruction of the anterior column. This combined approach is usually associated with high morbidity, long operative time, more blood loss, long hospital stay, protracted rehabilitation period and an access surgeon. In our case, a single approach was done to achieve posterior rigid stabilization, 360° neural decompression, and anterior column reconstruction without exposing the patient to the morbidity associated with the combined approach or the possible vascular complication of an anterior surgery. Conclusion This case shows that a one-stage posterior only corpectomy and fusion can be done safely with good outcome in a poor resource setting

An Update in Complication Rates Associated With Anterior Lumbar Surgery: A Systematic Review and Meta-Analysis.

Systematic Review and meta-analysis. To conduct an updated systematic review and meta-analysis of complications associated with different anterior fusion techniques/approaches and adjuvant resources (i.e., computed tomography angiography (CTA), rhBMP-2, and access surgeons). A systematic review was conducted from 1/1/2014-4/1/2024 for studies evaluating the incidence of complications associated with anterior lumbar procedures. Comparisons of complications were made between surgical approach, use of CTA, rhBMP-2, and access surgeons. Meta-analyses were conducted using a generalized linear mixed model. 54 studies were included in the final analysis with 8066 patients and an average follow-up of 31.2 months. The overall complication rate associated with anterior lumbar surgery was 13.1%, including an intraoperative complication rate of 3.8%, postoperative complication rate of 7.4%, infection rate of 1.5%, and reoperation rate of 1.7%. Forest plot analysis showed no significant difference in overall complication rates between open and mini-open techniques, although mini-open techniques were associated with lower overall reoperation rates. The use of CTA was associated with an increase in intraoperative and overall complications, and the use of an access surgeon was associated with a decreased risk of reoperation. The use of rhBMP-2 was not associated with overall complication risk. While anterior lumbar surgery provides numerous benefits, surgeons and patients alike should be aware of the complication and safety profile prior to surgery. High quality studies are warranted to help elucidate the true benefit of certain techniques and adjuvant resources in reducing complications.

Minimally Invasive Transpedicular Approach with Stereotactic Navigation for Evacuation and Fusion of Thoracic Ventral Epidural Abscess of Thoracic Spine: an illustrative case

Background: Surgical treatment of ventral thoracic pathologies can be challenging due to anatomical restrictions limiting corridor access, need for extensive spinal cord manipulation and limited experience for most spine surgeons’ due rarity of ventral thoracic pathologies. There is growing evidence that creation of a ventrolateral operative corridor through minimal invasive (MIS) transpedicular approach is safe and effective for accessing and treating of ventral thoracic spinal lesions [ 1-6] However, poor visualization with difficulty of spinal cord manipulation due to tubular retractor restriction remains changeling for MIS transpedicular approach. Objective: The authors illustrate a case of concurrent utilization of MIS tubular approach and stereotactic navigation to ensures safe and effective removal of epidural abscess and subsequent fusion. Conclusion: Addressing any lesion located anteriorly to the dentate ligament can be challenging and often necessitates either an antero-lateral or an anterior approach. This choice may depend on various factors, including the availability of an access surgeon. Utilization of stereotactic navigation with MIS transpedicular approach for ventral thoracic lesions, allows for real time intraoperation localization and visualization increasing lesion targeting accuracy and less cord manipulation. It also provides immediate post instrumentation checks and less radiation exposure for operating personals.

Anchor versus parachute suturing technique in arteriovenous fistula creation for hemodialysis.

Chronic kidney disease (CKD) affects 13% of the global population and requires renal replacement therapy due to ESRD. Hemodialysis (HD) is the most common dialysis modality for ESRD patients, but establishing vascular access is challenging due to high morbidity and mortality rates. Arteriovenous fistulas (AVFs) are the gold standard for vascular access, but many fail due to anastomotic hemodynamics, vein diameter, and anastomatic suture technique. A prospective study was conducted to evaluate the impact of two continuous suturing techniques, the anchor technique and the parachute technique, on AVFs' initial outcomes. This randomized, controlled study involved adult patients who presented for AVF creation at our center. We divided the patients into two groups: anchors and parachutes. Four skilled vascular access surgeons performed the procedures. The primary goal was functional maturation of the AVF, defined as an AVF fistula ready to be cannulated with a cannulating vein length of at least 10cm, a diameter of more than 6mm, a depth of less than 6mm, and a flow rate of 600mL/min. Secondary goals included patency and complications such as bleeding, infection, steal syndrome, and aneurysmal dilatation at the anastomosis site. AVFs were evaluated immediately after surgery and during follow-up visits at the outpatient clinic. A duplex scan was performed to measure flow at various intervals. All patients provided appropriate written consent. The study involved 186 patients, with 86 excluded. 100 were randomized, with 5 cases losing follow-up and 3 deaths within 12months. The follow-up continued until January 2024, with a mean of 8.6months. The Parachute technique shows higher technical success (p value = 0.046) and primary patency at 30days (p value = 0.014) compared to Anchor, but there is no statistical significance between both groups regarding functional maturation at 6 weeks (p value = 0.352). The parachute technique has a higher hematoma rate than the anchor technique (p value = 0.025), while other complications like intra-operative bleeding, postoperative bleeding, pseudoaneurysm formation, thrombosis, steal syndrome, and seroma formation show no significant differences. Nine patients, five of whom were diabetic and underwent conservative management, exhibited mild to moderate steal syndrome. This suggests an increased risk of steal syndrome among diabetic patients. The parachute technique for AVF creation offers better technical success and short-term primary patency outcomes, while both parachute and anchor techniques are equally effective for long-term functional maturation and overall complication rates.

Retrospective analysis of medium-term outcomes following anterior lumbar interbody fusion surgery performed in a tertiary spinal surgical centre.

Anterior lumbar interbody fusion (ALIF) can treat spondylolisthesis, degenerative disc disease and pseudoarthrosis. This approach facilitates complete discectomy, disc space distraction, indirect decompression of neural foramina and placement of large interbody devices. Several intra- and postoperative complications can be attributed to the anterior approach: vascular/visceral injury, hypogastric plexus injury and urogenital consequences. Spine-specific complications include implant migration, graft failure, pseudoarthrosis and persistent symptomology. This retrospective study reviewed patient demographics, medium-term outcomes and complication rates following ALIF surgery performed over a 5-year period. A total of 110 consecutive patients had undergone ALIF surgery at a single tertiary spinal centre. The database was reviewed with a primary outcome of identifying postoperative 90-day complications and whether a revision anterior operation was required after primary ALIF. No patients required revision anterior operation after their primary ALIF surgery by final follow-up. Out of 110 patients, 11 (10%) recorded a complication attributed to the anterior stage of their operation within 90 days. Our 90-day complication rate of 10% lies within the 2.6% acute complication and 40% overall complications rates described in previous literature. The risk of vascular/visceral injury is significant (3%) and we recommend that ALIF be performed as a dual surgeon procedure with a vascular-trained access surgeon accompanying the spinal surgeon. ALIF is a valid revision surgical option for failed posterior approaches leading to complications such as pseudoarthrosis. In our sample, 89% of patients were managed with posterior fixation to augment the anterior fusion as, biomechanically, this is a proven construct.

Complications of femoral access for hemodialysis: A surgical perspective

Background: Vascular access, especially arteriovenous fistula (AVF), is critical for patients requiring haemodialysis. Due to delayed diagnosis, late referral, poverty and limited availability of competent access surgeons, many patients commence haemodialysis without an AVF, hence the frequent use of venous catheters. Objectives: To assess the pattern of complications associated with repeated femoral punctures for haemodialysis. Materials and Methods: This is a multicentre prospective study conducted at the Cardiovascular units of the University of Port Harcourt Teaching Hospital, Port Harcourt and Federal Medical Centre, Umuahia between January 2017 and December 2022. 66 patients were recruited for the study. Data obtained were patients’ demography, complications of femoral access, surgical approach and outcome. Results: 15 patients presented with severe lower limb pains and inability to walk, 10 with fibrosis/ hardening of the skin of both groins, 8 with skin infection at the repeated puncture sites, 12 had Pseudoaneurysm of the superficial femoral artery (SFA), 6 had iatrogenic femoro-femoral Arteriovenous Fistula (AVF) of the SFA and superficial femoral vein (SFV), 5 had groin abscess. All the patients had internal jugular venous catheters inserted. Some patients had Fogarty catheter thrombectomies and interposition Great Saphenous Vein (GSV) graft repairs, while some others had successful takedown of the AVF, Fogarty thrombectomy and direct prolene 6/0 repair of the vein & arterial wall defects. All those that underwent surgical treatment had successful recovery. Conclusion: Femoral vein cannulation, apparently easy to perform, should not be used as the vascular access of choice for chronic haemodialysis.

Cranial sutures.

Cranial sutures are not of great concern to the modern neurosurgeon, except when abnormalities interfere with the skull's shape and its ability to expand during childhood. It is a commonplace that a craniotomy may cross a variety of sutures without providing any extra difficulty to the operator. The sagittal suture does remain useful as a definition of the midline of the cranium and as an indicator of the underlying sinus. Galen for reasons that are far from clear, "observed" relationships between the sutures, the meninges and the pericranium which led him to advise avoidance of any surgical proximity to the sutures. The result of this proscription was a severe limit of the access surgeons considered was appropriate and thus limited their ability to care for their patients.

Successful Implantation of a Ventricular Shunt With Termination in the Iliac Bone in the Adult Patient With Obstructive Hydrocephalus

BACKGROUND AND IMPORTANCE: With the exception of the 3 classic shunt placement options (ventriculoperitoneal, ventriculopleural, and ventriculoatrial), surgically feasible alternative sites for distal catheter placement remain limited and often require the assistance of an access surgeon. Tubbs et al suggested the possibility of intraosseous cerebrospinal fluid diversion in the ilium, noting that ilium infusion in cadaveric specimens was possible without the development of body edema or fluid overflow. Since this publication, limited case reports have been published on the success of ventriculo-ilium (VI) shunt placement. Here, we describe the technique used for successful VI shunt placement in 2 adult patients. CLINICAL PRESENTATION: Here, we describe 2 patients with differing etiologies of hydrocephalus (obstructive and nonobstructive) and complex medical and surgical problems precluding traditional distal shunt termini. Both patients underwent successful placement of a VI shunt with distal catheter placement into the right iliac crest using a small right-angle connector and small cranial fixation plate to prevent backout of the catheter. DISCUSSION AND CONCLUSION: We report the first demonstration of successful placement of a VI shunt in 2 adult patients with evidence of shunt functionality and improved neurological outcome. We propose that the placement of a VI shunt is an easy and viable option when more traditional shunt methods are not available for use.

Effectiveness of a native vein arteriovenous fistula tracking system.

This study aims to evaluate the effectiveness of a tracking program on the functional maturation rate of arteriovenous fistula (AVF). Two major clinical outcomes (commencement of cannulation and functional maturation) of created AVFs were compared between two cohorts. (i) Cohort 1: historical cohort; (ii) Cohort 2: AVFs created after implementation of the tracking project. Multivariable Cox regression models were used to assess the association between cohort allocation and the two major clinical outcomes. Data of 114 and 141 patients were analyzed respectively from Cohorts 1 (historical data) and 2 (with AVF tracking). After adjustment of covariates in the multivariable analysis, the AVFs created in Cohort 2 were more likely to be cannulated earlier (adjusted HR: 2.82; 95% CI: 1.97-4.05; p < 0.001), compared to those in Cohort 1. Similarly, the AVFs of Cohort 2 patients had significantly higher probability of functional maturation (adjusted HR: 1.81; 95% CI: 1.31-2.48; p < 0.001) than fistulas in Cohort 1. Cannulation was commenced for half of the AVFs by 4.1 months post-creation in the historical cohort (Cohort 1), whereas in the post-tracking cohort, 50% of the AVFs were cannulated by 2.3 months after creation (p < 0.001). It took 5.5 and 4.3 months for 50% of the AVFs created in Cohort 1 and Cohort 2 patients to achieve catheter-free functional maturation, respectively (p = 0.06). An AVF tracking program with maturation target for the access surgeons, together with a standardized tracking, feedback, and clinical strategy adjustment system is able to improve the AVF functional maturation rate.

Implications of COVID-19 Infection on Arteriovenous Fistula Thrombosis.

Objective: This study aims to identify and analyze implications of COVID-19 positivity on AVF occlusion, subsequent treatment patterns, and ESRD patient outcomes. Our aim is to provide a quantitative context for vascular access surgeons in order to optimize surgical decision making and minimize patient morbidity. Methods: The de-identified national TriNetX database was queried to extracted all adult patients who had a known AVF between January 1, 2020 and December 31, 2021. From this cohort individuals who also were diagnosed with COVID-19 prior to creation of their AVF were identified. Cohorts were propensity score matched according to age at AVF surgery, gender, ethnicity, diabetes mellitus, nicotine dependence, tobacco use, use of anticoagulant medications, and use of platelet aggregation inhibitors, hypertensive diseases, hyperlipidemia, and prothrombotic states. Results: After propensity score matching there were 5170 patients; 2585 patients in each group. The total patient population had 3023 (58.5%) males and 2147 (41.5%) females. The overall rate of thrombosis of AV fistulas was 300 (11.6%) in the cohort with COVID-19 and 256 (9.9%) in the control group (OR 1.199, CI 1.005-1.43, P =.0453). Open revisions of AVF with thrombectomy were significantly higher in the COVID-19 cohort compared to the non-COVID-19 group (1.5% vs .5% P = .0002, OR 3.199, CI 1.668-6.136). Regarding the time from AVF creation to intervention, the median days for open thrombectomy in COVID-19 patients was 72 vs 105 days in controls. For endovascular thrombectomy, the median was 175 vs 168 days for the COVID-19 and control cohorts respectively. Conclusion: As for this study, there were significant differences in rates of thrombosis and open revisions of recent created AVF, however endovascular interventions remained remarkably low. As noted in this study, the persistent prothrombotic state of patients with a history of COVID-19 may persist beyond the acute infectious period of the disease.

Lateral approach to the lumbar spine: The utility of an access surgeon.

Lateral lumbar interbody fusions (LLIFs) utilize a retroperitoneal approach that avoids the intraperitoneal organs and manipulation of the anterior vasculature encountered in anterior approaches to the lumbar spine. The approach was championed by spinal surgeons; however, general/vasculature surgeons may be more comfortable with the approach. The objective of this study was to compare short-term outcomes following LLIF procedures based on whether a spine surgeon or access surgeon performed the approach. We retrospectively identified all one- to two-level LLIFs at a tertiary care center from 2011 to 2021 for degenerative spine disease. Patients were divided into groups based on whether a spine surgeon or general surgeon performed the surgical approach. The electronic medical record was reviewed for hospital readmissions and complication rates. We identified 239 patients; of which 177 had approaches performed by spine surgeons and 62 by general surgeons. The spine surgeon group had fewer levels with posterior instrumentation (1.40 vs. 2.00; P < 0.001) and decompressed (0.94 vs. 1.25, P = 0.046); however, the two groups had a similar amount of two-level LLIFs (29.9% vs. 27.4%, P = 0.831). This spine surgeon approach group was found to have shorter surgeries (281 vs. 328 min, P = 0.002) and shorter hospital stays Length of Stay (LOS) (3.1 vs. 3.6 days, P = 0.019); however, these differences were largely attributed to the shorter posterior fusion construct. On regression analysis, there was no statistical difference in postoperative complication rates whether or not an access surgeon was utilized (P = 0.226). Similar outcomes may be seen regardless of whether a spine or access surgeon performs the approach for an LLIF.

263 Minimally Invasive Non-Radical Nephrectomy for Benign Renal Disease: A Single Centre Experience Comparing Two Surgical Approaches

Abstract In our high-volume tertiary centre for renal disease, we perform in excess of 150 nephrectomies for benign or malignant disease per annum. In this study we compare outcomes between laparoscopic and retroperitoneoscopic minimally invasive (MI) approaches. We retrospectively reviewed our database of all patients who underwent MI non-radical nephrectomy over a 3-year period. Indication for surgery, conversion rate, operative time, blood loss, length of stay and post-operative complications were examined. A total of 61 MI nephrectomies were performed by three experienced minimal access surgeons. Indications for surgery included chronic infection, stone disease, tuberculosis, and obstruction associated with pain. Mean age was 51 years (range 22–89), 72% were female. The approach was laparoscopic in 62% and retroperitoneoscopic in 38%. Median operative time 137 minutes. The overall conversion rate was 3% (2 patients). Median blood loss 50ml's with 1.5% transfusion rate. Median length of stay was 2 days (1–69). There was no significant change in the renal function (P=0.32). Four patients developed Clavien-Dindo grade 3 complication. There was no recorded mortality in our series. We acknowledge this is a retrospective study that may be subject to selection bias, however our experience of this procedure in high volume centre with experienced operators shows that both laparoscopic and retroperitoneoscopic approaches are safe in performing MI non-radical nephrectomy with very low conversion rate.

Racial Disparities in Arteriovenous Fistula Use Among Hemodialysis Patients: The Role of Surgeon Supply

IntroductionFactors contributing to racial disparities in arteriovenous fistula (AVF) use among hemodialysis (HD) patients remain poorly defined. We evaluated whether the Black/White race disparity in AVF use is affected by vascular access surgeon supply.MethodsUsing Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb) and Medicare claims data from the US Renal Data System (USRDS), competing risk analyses of all US patients initiating HD with a central venous catheter (CVC) from 2016 to 2017 (n = 100,227) were performed. The likelihood of successful AVF use was compared between Black and White patients after adjusting for vascular access surgeon supply.ResultsCompared with the first (lowest) quartile of surgeon supply, higher supply levels were associated with modestly increased adjusted likelihoods of overall AVF use: 4% (95% CI 1.4%–7.2%), 4% (95% CI 1.4%–7.1%), and 3% (0.0%–6.1%) for second, third, and fourth quartiles, respectively. Although areas with lower surgeon supply had a higher proportion of Black patients, residing in areas with a greater surgeon supply was not significantly associated with a mitigation in racial disparity. Specifically, compared with White patients, Black patients were 10% (95% CI 7%–13%) and 8% (95% CI 5%–11%) less likely to have successful AVF use in lower and higher surgeon supply areas, respectively.ConclusionRegions with lower surgeon supply had a higher proportion of Black dialysis patients. However, racial disparities in AVF use among patients initiating HD with a CVC were similar in regions with a high and low surgeon supply. Other patient, provider, and practice factors should be evaluated toward mitigating lower rates of AVF use among Black HD patients.

Audit of Vascular Access Surgery in A Tertiary Care Hospital

Objective: to analyze the outcomes of arteriovenous fistula (AVF) constructed in our setup.&#x0D; Study Design: Retrospective observational study.&#x0D; Place and Duration of Study: Combined Military Hospital, Lahore, from Mar 2019 to Mar 2020.&#x0D; Methodology: Our study included all the patients who had their arteriovenous fistula (AVF) made during the study period. Data was collected via telephone calls, to inquire about the status of AV fistula after one year of AV fistula construction surgery.&#x0D; Results: Out of 130 study participants, 97 were successfully contacted. Mean age of patients was 54 .39 ± 12.75 years. Majority were male patients (71.1%) and had their first dialysis via temporary dialysis access catheter. Most of the patients (74.7%) had functional AVF. 35 (36.1%) patients were not alive at the time of contact. In 9 (9.2%) patients, AV fistula failed with the most common cause being thrombosis (77.7%).&#x0D; Conclusion: Current study is one of the pioneer in Pakistan where we have started to audit our performance as the dedicated access surgeons. It is high time for us to evaluate our performance so that better outcome can be offered to the dialysis dependent patients.

Infectious complications during the initial 225 cases of standard PCNL: A single center experience

Introduction: Percutaneous nephrolithotomy(PCNL) has emerged as the treatment of choice for medium to large urinary stones. Infection is a life threatening complication and is the most common cause of death following PCNL. This study aimed to examine different predictors of infective complications in PCNL. Methods: This retrospective study was done on patients who underwent PCNL between 2016 and 2020 at a tertiary level medical college hospital. Medical records were reviewed for study variables. Results: Two hundred and twenty five cases were included out of which 121 were male. A total of 151 complications were recorded among which 27(17.88%) were major complications. Infectious complications were seen in 67 (29.77%) patients among which 39 cases (17.33%) were febrile urinary tract infections. Urosepsis developed in four patients and one patient died due to urosepsis related complication. Female (p=0.003), Diabetes mellitus (p=0.002), positive urine culture (p=0.0001), stone location (p=0.01), degree of hydronephrosis (p=0.001), duration of surgery (p=0.001), number of access tracts (p=0.0001), and initial 100 cases (p=0.001) were associated with post PCNL infections. Conclusion: Female, Diabetes mellitus, preoperative urine culture positivity, stone location, degree of hydronephrosis, duration of the operation, number of access tracts and surgeon experience are risk factors for post PCNL infections. Surgeons should be extra vigilant during their initial period. Urinary tract infection should be treated and extra care should be taken when operating in female patients giving ample attention to preoperative investigations.

Review of advanced energy devices for the minimal access gynaecologist

Key content Contemporary energy devices utilise advanced bipolar, ultrasound, hybrid technology, plasma beam and laser energy. Each energy modality has specific characteristics influencing its particular benefits and disadvantages. Gynaecologists must be aware of the available energy modalities to select the optimum device. Minimal access surgeons must demonstrate a comprehensive understanding of their instruments to ensure surgical success and safety. Learning objectives To understand the biophysics of advanced energy devices and their practical applications. To review advantages, disadvantages and safety issues associated with each modality and offer practical tips and problem‐solving for commonly available devices. To enable surgeons to select the optimal device for their surgical tasks. Ethical issues Trainee minimal access surgeons should have solid theoretical knowledge of energy devices before performing hands‐on surgery. Consideration of the safety aspects of energy devices will enable surgeons to minimise harm to their patients. Potentially high investment costs necessitate consideration of the anticipated benefits of energy devices to ensure value for money.

Expandable Cage Technology-Transforaminal, Anterior, and Lateral Lumbar Interbody Fusion.

This review of the literature will focus on the indications, surgical techniques, and outcomes for expandable transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and lateral lumbar interbody fusion (LLIF) operations. The expandable TLIF cage has become a workhorse for common degenerative pathology, whereas expandable ALIF cages carry the promise of greater lordotic correction while evading the diseased posterior elements. Expandable LLIF cages call upon minimally invasive techniques for a retroperitoneal, transpsoas approach to the disc space, obviating the need for an access surgeon and decreasing risk of injury to the critical neurovascular structures. Nuances between expandable and static cages for all 3 TLIF, ALIF, and LLIF operations are discussed in this review.

The Feasibility of Anterior Spinal Access: The Vascular Corridor at the L5-S1 Level for Anterior Lumbar Interbody Fusion.

Cross-sectional study. To analyze the feasibility of anterior spinal access to the vascular corridor at the L5-S1 junction, by evaluating three crucial anatomical landmarks. This provides a framework for risk-stratification for the clinician during preoperative evaluation. The anterior lumbar interbody fusion (ALIF) offers many advantages for fusion at the L5-S1 junction. However, the variant iliac vasculature may preclude safe anterior access. Five hundred magnetic resonance imaging (MRI) images of the L5-S1 level were identified, with 379 meeting inclusion criteria. We graded the anterior access into three grades, namely, easy, advanced, or difficult by looking at three important anatomical landmarks-the vascular corridor (narrow if ≤25 mm, medium if 25-35 mm [inclusive], and wide if >35 mm), the left common iliac vein (LCIV) location (grades A-D based on the relative position of the LCIV to the L5-S1 disc space), and the presence or absence of a fat plane. Our results showed that 43.27% of the patients had wide corridor for the anterior access, 19.26% of patients had no fat plane, and 7.65% had a LCIV that extended past the midline of the disc (Grade C, D: >50%). By combining these three factors, 37.20% would have easy anterior access, while a minority (1.85%) would have a difficult anterior access. The ALIF at L5-S1 offers significant benefits to the patient. The surgeon should be aware of the dangers in an anterior access by looking at three crucial factors to determine whether the access is easy, advanced, or difficult. Patients with a difficult access should be attempted by experts, vascular access surgeons, or consider an alternative approach to L5-S1.Level of Evidence: 3.

258. Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: a retrospective cohort study

258. Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: a retrospective cohort study

Quality indicators of vascular access procedures for hemodialysis

Improved quality of surgical procedures can minimize complications, the morbidity and mortality of patients, and in addition decrease costs. Quality indicators in angioaccess surgery are, however, not clearly defined. The aim of this review article is therefore to find the most important factors affecting quality in vascular access procedures. Even though autogenous arteriovenous fistula has been recognized as the best vascular access for hemodialysis, the high percentage of unsuccessful attempts associated with it raises the question about quality assessment in angioaccess procedures. Unfortunately, quality indicators in vascular access surgery are difficult to define and measure. Among those that can be obtained are: the time between the presentation of patients to a vascular access surgeon and the construction of a fistula, the percentage of autogenous fistulas, the percentage of functional fistulas in prevalent and incident hemodialysis patients, the percentage of creation of a functional fistula in the first attempt, and durability of an access. Organizational improvement and educational programs are also necessary at institutions with inferior quality indicators of vascular access care, as even small increase in quality may mean the survival of an individual patient. Quality indicators in angioaccess surgery can also serve as a helpful tool in choosing the best vascular access surgeon or vascular access center. The choice can consequently reflect on increased survival and quality of life in patients needing hemodialysis.