Arteriovenous Fistula In Patients Research Articles

Effects of far infrared therapy in hemodialysis arterio-venous fistula maturation: A meta-analysis.

Hemodialysis patients rely on stable vascular access to perform effective hemodialysis and reach good dialysis quality. However, an obstructed or under-matured arteriovenous fistula (AVF) may increase infection rate and mortality in hemodialysis patients. Far infrared (FIR) therapy might help to promote AVF maturation and reduce obstruction rate. Therefore, this meta-analysis was conducted to evaluate the effect of FIR therapy on AVF obstruction rate and maturation. PubMed, Embase, the Cochrane Library, and other databases which provide publications in randomized controlled trials (RCTs) of FIR to improve AVF in patients with CKD (Chronic Kidney Disease) or HD (hemodialysis) were used to collect articles which published before February 2023. Two authors selected relevant articles independently based on pre-defined inclusion and exclusion criteria, and assessed the quality of the articles by using the Cochrane Handbook before performing a meta-analysis in Review Manager (RevMan) 5.4 software. Four RCTs with 475 patients were included. The results of the meta-analysis showed that the FIR therapy groups had better physiological maturation at 3 months (RR = 1.22; 95% CI = 1.07 to 1.39; p = .002) and clinical maturation at 12 months (RR = 1.35; 95% CI = 1.14 to 1.60; p < .001) than the control groups without FIR therapy. The obstruction rates within 12 months were much lower in the FIR therapy groups than in the control groups (RR = 0.24; 95% CI = 0.08 to 0.68; p = .007), also, there was no statistical heterogeneity. FIR could promote fistula maturation and reduce the incidence of AVF obstruction.

Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor Improves the Vascular Function of Arteriovenous Fistula in Rats with Hyperglycemia.

Few evidence-based medications to improve the primary patency of arteriovenous fistulas in patients with diabetes who require hemodialysis are available. We investigated whether proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) could improve arteriovenous fistula function through pleiotropic effects in a rat model of hyperglycemia. Ex vivo effects of PCSK9i on the aorta of Sprague-Dawley (SD) rats were investigated using an organ bath system. For in vivo experiments, an abdominal aortocaval (AC) fistula was generated in SD rats (200-250 g) after inducing hyperglycemia through streptozotocin administration (80 mg/kg, intraperitoneal). Alirocumab (50 mg/kg/week, subcutaneous) was administered on the day of fistula surgery and day 7. Echocardiography, blood flow through the aorta-limb, vasomotor reactivity, and serum biochemistry were examined on D14. Furthermore, enzyme-linked immunosorbent assay and immunoblotting were performed. PCSK9i induced aorta relaxation ex vivo through a potassium channel-associated mechanism. PCSK9i significantly improved blood flow and preserved endothelial function without changes in cardiac function and serum lipid levels in rats with hyperglycemia. The levels of lectin-like oxidized low-density lipoprotein receptor-1, superoxide dismutase, cyclooxygenase-2, caspase-1, and interleukin-1β were significantly reduced in the treatment group. PCSK9i decreased the ratio of phosphorylated to total p38 mitogen-activated protein kinase and extracellular signal-regulated kinase in the aorta of rats with hyperglycemia. Short-term treatment with PCSK9i preserved endothelial function, induced vascular dilatation, and increased blood flow in the AC fistula of rats with hyperglycemia. The pleiotropic mechanisms were associated with the suppression of oxidative stress and tissue inflammation during hyperglycemia.

Clinical Outcomes of Arteriovenous Fistula Treatment Using the Penumbra SMART COIL System: A Subgroup Analysis from the Multicenter SMART Registry

Endovascular embolization procedures are typically the primary treatment modality for arteriovenous fistula (AVF). The objective of this subset analysis was to evaluate the prospective long-term clinical outcomes of AVF patients treated with the SMART COIL System. Patients who had arteriovenous fistulas (AVF) and underwent endovascular coiling using the Penumbra SMART COIL system were part of a subset analysis within the SMART registry. The SMART registry is a post-market registry that is prospective, multicenter, and single-arm in design. After the treatment, these patients were monitored for a period of 12 ± 6 months. A total of 41 patients were included. No patients (0/41) had a procedural device-related serious adverse event (SAE). Re-access involving a guidewire due to catheter kickout was unnecessary for 85.4% (35/41) of the patients. Complete occlusion after the procedure was achieved in 87.8% (36/41) of patients. The periprocedural SAE rate was 2.4% (1/41), and no periprocedural deaths occurred (0/41). During the follow-up period, there were instances of re-treatment in 3.4% (1/29) of patients. At one year, the lesion occlusion was better or stable in 93.3% (28/30) of patients. The rate of serious adverse events (SAE) from 24 hours to 1 year (±6 months) following the procedure was 26.8% (11/41). The one-year all-cause mortality rate stood at 2.4% (1/ 41), and at the one-year follow-up, 90.9% (20/22) of patients had a modified Rankin Scale score within the range of 0 to 2. The coiling procedure for arteriovenous fistulas using the SMART COIL System proved to be safe and effective at the one-year follow-up.

#1476 Impact of frailty on maturation of native arteriovenous fistula in patients with end-stage kidney disease

Abstract Background and Aims Morbimortality and quality of life in hemodialysis patients is directly related to the reliability and integrity of the vascular access. Current guidelines recommend a shift from a "fistula first" approach to a patient-centered approach due to the aging dialysis population. Frailty, defined as vulnerability to adverse health states due to impaired functional status, comorbidities and psychosocial factors, conditions a worse outcome of patients with end-stage kidney disease (ESKD) undergoing dialysis. Our aim was to assess frailty status before the performance of native arteriovenous fistulas (nAVF) as a predictor of failure to mature. Method Retrospective analysis of ESKD clinic patients who underwent a first nAVF between 2020-2022 and had undergone a frailty assessment before the surgery. The Frail-VIG index, evaluating frailty through deficit accumulation (scored from 0 to 1), vas employed. Patients were categorized as either non-frail (NF-ESKD: Frail-VIG &amp;lt; 0.2) or frail (F-ESKD: Frail-VIG ≥ 0.2). the study evaluated early nAVF and recorded the first ultrasound maturation values 4 weeks after surgery. Results Throughout the study period, 180 patients underwent a first nAVF, 57 (31.6%) having undergone a prior frailty assessment. 27 (47.4%) patients were classified as NF-ESKD, 30 (52.6%) as F-ESKD (23 mild, 6 moderate and 1 severe frailty). In the descriptive analysis, no differences in age, sex, toxic habits, CKD etiology or medical conditions were observed between the two groups (Table 1). Regarding surgical technique, there were no differences in nAVF location and laterality between the two groups (Table 1). F-ESKD patients had a higher primary fistula failure, defined as no flow prior to the first ultrasound evaluation (36.7% vs. 3.8%; p=0.002). In patients with an initial ultrasound evaluation, the F-ESKD group had lower arterial flow (1020.76 ± 589.42 vs. 1455.56 ± 679.78 ml/min; p=0.027) and smaller fistula diameter (4.52 ± 1.51 vs. 6.4 ± 1.61 mm; p=0.018). Maturation was assessed after the first ultrasound evaluation, defined as the presence of an arterial flow greater than 500 ml/min and a diameter greater than 4 mm. A higher proportion of frail patients (88.9% vs. 33.11%; p = 0.004), a lower capacity to perform instrumental activities measured by Lawton Brody index (4.63 ± 2.2 vs. 6.55 ± 2.2; p = 0.034) and a higher percentage of diabetic patients (88.89% vs. 48.48%; p = 0.033) were found in nAVF that had not reached ultrasound-guided maturity (Table 2). In a multivariate analysis adjusted for functional status, type of vascular access and comorbidities, the presence of frailty conferred a higher risk of fistula non-maturation (OR 11.42 95%CI 1.005 - 128.74; p = 0.049). Conclusion The prevalence of frailty is notable among in ESKD patients and contributes to a higher rate of failure in native nAVF. Within this population, adopting an individual approach to the selection of a definitive vascular access may prove both feasible and beneficial in ensuring optimal dialysis access.

Impact of stage-specific limb function exercises guided by a self-management education model on arteriovenous fistula maturation status.

The exercise of limb function is the most economical and safe method to promote the maturation of arteriovenous fistula (AVF). However, due to the lack of a unified exercise standard in China, many patients have insufficient awareness of the importance of AVF, leading to poor effectiveness of limb function exercise. The self-management education model can effectively promote patients to take proactive health-related actions. This study focuses on the characteristics of patients during the peri-AVF period and conducts a phased limb function exercise under the guidance of the self-management education model to observe changes in factors such as the maturity of AVF. To assess the impact of stage-specific limb function exercises, directed by a self-management education model, on the maturation status of AVFs. This study is a randomized controlled trial involving 74 patients with forearm AVFs from the Nephrology Department of a tertiary hospital in Sichuan Province, China. Patients were randomly divided into an observation group and a control group using a random number table method. The observation group underwent tailored stage-specific limb function exercises, informed by a self-management education model which took into account the unique features of AVF at various stages, in conjunction with routine care. Conversely, the control group was given standard limb function exercises along with routine care. The assessment involves the maturity of AVFs post-intervention, postoperative complications, and the self-management level of the fistula in both groups patients. Analyses were conducted using SPSS version 23.0. Count data were represented by frequency and percentage and subjected to chi-square test comparisons. Measurement data adhering to a normal distribution were presented as mean ± SD. The independent samples t-test was utilized for inter-group comparisons, while the paired t-test was used for intra-group comparisons. For measurement data not fitting a normal distribution, the median and interquartile range were presented and analyzed using the Wilcoxon rank sum test. At the 8-wk postoperative mark, the observation group demonstrated significantly higher scores in AVF symptom recognition, symptom prevention, and self-management compared to the control group (P < 0.05). However, the variance in symptom management scores between the observation and control groups lacked statistical significance (P > 0.05). At 4 wk after the operation, the observation group displayed a superior vessel diameter and depth from the skin of the drainage vessels in comparison to the control group (P < 0.05). While the observation group did manifest elevated blood flow rates in the drainage vessels relative to the control group, this distinction was not statistically significant (P > 0.05). By the 8-wk postoperative interval, the observation group outperformed the control group with notable enhancements in blood flow rates, vessel diameter, and depth from the skin of drainage vessels (P < 0.01). Seven days following the procedure, the observation group manifested significantly diminished limb swelling and an overall reduced complication rate in contrast to the control group (P < 0.05). The evaluation of infection, thrombosis, embolism, arterial aneurysm stenosis, and incision bleeding showed no notable differences between the two groups (P > 0.05). By the 4-wk postoperative juncture, complications between the observation and control groups were statistically indistinguishable (P > 0.05). Stage-specific limb function exercises, under the guidance of a self-management education model, amplify the capacity of AVF patients to discern and prevent symptoms. Additionally, they expedite AVF maturation and mitigate postoperative limb edema, underscoring their efficacy as a valuable method for the care and upkeep of AVF in hemodialysis patients.

Arteriovenous fistula for haemodialysis as a predictor of de novo heart failure in kidney transplant recipients.

The haemodynamic effects of a functioning haemodialysis arteriovenous fistula (AVF) can cause or exacerbate heart failure (HF). We investigated whether the presence of an AVF at the time of kidney transplant (KT) is associated with de novo HF. This was an observational cohort study including adult patients who received a KT in the West of Scotland between 2010 and 2020. We evaluated the risk and associations of pretransplant factors with de novo HF, alone and as a composite cardiovascular (CV) outcome (including non-fatal myocardial infarction, non-fatal stroke, de novo HF and CV death). Multivariable proportional hazards regression and sensitivity analyses were used to identify independent correlates of the outcomes. Among 1330 included patients, the incident rate of de novo HF after transplantation was 58/1000 person-years [95% confidence interval (CI) 50-67] in AVF patients (n=716) compared with 33/1000 person-years (95% CI 27-41) in non-AVF patients (n=614). De novo HF was associated with the presence of an AVF [adjusted hazard ratio (aHR) 2.14 (95% CI 1.40-3.26)], duration of dialysis [aHR 1.03/year increase (95% CI 1.01-1.04)], age at transplant [aHR 1.03/year increase (95% CI 1.02-1.05)], female sex [aHR 1.93 (95% CI 1.40-2.65)] and pretransplant diabetes [aHR 2.43 (95% CI 1.48-4.01)]. The presence of an AVF was also associated with the composite CV outcome [aHR 1.91 (95% CI 1.31-2.78)]. The presence of an AVF may be an underrecognized modifiable predictor of de novo HF posttransplantation.

Efficacy of cilostazol in promoting the maturation of newly created arteriovenous fistula in patients with end-stage renal disease: a systematic review and meta-analysis

BACKGROUND Arteriovenous fistula (AVF) is considered the gold standard for vascular access in hemodialysis. However, achieving the successful maturation of AVF remains a challenge. Cilostazol, a phosphodiesterase-3 inhibitor, has shown promise in enhancing AVF maturation. This study aimed to assess the clinical efficacy of cilostazol in promoting AVF maturation. METHODS This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive systematic literature search was performed using PubMed, ScienceDirect, Cochrane Library, ProQuest, and Google Scholar to identify studies investigating the efficacy of cilostazol on the maturation of newly created AVF in patients with end-stage renal disease and published up to August 2023. The intervention group received perioperative cilostazol therapy, while the control group did not receive cilostazol. The outcomes were the maturation rate of AVF and AVF-related complications. Meta-analysis was conducted using Review Manager software version 5.3. RESULTS 5 studies involving 549 patients were included. The intervention group comprised 228 patients, while the control group comprised 321 patients. In the pooled analysis, patients in the intervention group had a significantly higher rate of AVF maturation (odds ratio [OR] = 2.18, 95% confidence interval [CI]: 1.29–3.68, p = 0.003, I2 = 47%) and a lower rate of AVF-related complications (OR = 0.46, 95% CI: 0.28–0.77, p = 0.003, I2 = 27%) compared to the control. CONCLUSIONS Cilostazol was associated with a higher rate of AVF maturation and a lower rate of AVF-related complications.

Cerebral dural arteriovenous fistulas in patients with PTEN-related hamartoma tumor syndrome.

Central nervous system (CNS) dural arteriovenous fistulas (DAVF) have been reported in PTEN-related hamartoma tumor syndrome (PHTS). However, PHTS-associated DAVF remain an underexplored field of the PHTS clinical landscape. Here, we studied cases with a PTEN pathogenic variant identified between 2007 and 2020 in our laboratory (n = 58), and for whom brain imaging was available. Two patients had DAVF (2/58, 3.4%), both presenting at advanced stages: a 34-year-old man with a left lateral sinus DAVF at immediate risk of hemorrhage, and a 21-year-old woman with acute intracranial hypertension due to a torcular DAVF. Interestingly, not all patients had 3D TOF/MRA, the optimal sequences to detect DAVF. Early diagnosis of DAVF can be lifesaving, and is easier to treat compared to developed, proliferative, or complex lesions. As a result, one should consider brain MRI with 3D TOF/MRA in PHTS patients at genetic diagnosis, with subsequent surveillance on a case-by-case basis.

Delayed Pulsatile Tinnitus by an Ascending Pharyngeal Artery-Internal Jugular Vein Fistula Caused by Blunt Trauma: A Case Report and Review of the Literature.

Head and neck trauma-induced pulsatile tinnitus (PT) should be approached with caution, as it can rarely be attributed to an arteriovenous fistula (AVF). We present a 26-year-old male with a history of blunt trauma who presented delayed PT with direct AVF between the ascending pharyngeal artery (APA) and the internal jugular vein (IJV). The patient underwent occlusion of the fistula with transarterial embolization using coils and PT was completely resolved, confirming successful treatment. The delayed manifestation of PT in the APA-IJV fistula is probably due to the gradual formation of a pseudoaneurysm and subsequent AVF. This case highlights the importance of investigating PT in head trauma patients, as it can be a sign of AVF and possible complications. Overall, this case contributes to understanding delayed PT with AVF and emphasizes the importance of prompt diagnosis and treatment of AVF in patients with head and neck trauma.

Educational video for self-care with arteriovenous fistula in renal patients: randomized clinical trial.

to evaluate the effect of an educational video on the knowledge, attitude, and practice of self-care with arteriovenous fistula in patients undergoing hemodialysis treatment. randomized controlled clinical trial, with two arms and single-blind. The intervention used an educational video on arteriovenous fistula self-care. The Fistula Self-Care Knowledge, Attitude, and Practice Scale was applied to 27 renal patients on hemodialysis in the control group and 28 in the intervention group at baseline, after seven and fourteen days. The data was analyzed using the Statistical Package for the Social Sciences software, using the chi-square test, Student's t-test, Mann-Whitney test, and Friedman's test with post-hoc analysis for multiple comparisons. there were statistically significant differences in the knowledge and practice of self-care with the fistula at 0, 7 and, 14 days in the intervention (p= 0.004 and p<0.001, respectively) and control groups (p<0.001 for knowledge and practice). Attitude showed a significant difference at follow-up (p<0.001), but the post-hoc analysis did not confirm the significance obtained. patients' knowledge and practice showed significant increases at follow-up in the control and intervention groups, while the increase in attitude was not significant in either group. Clinical trial, registration number: U1111-1241-6730.

Is there correlation between flow volume and Kt/V ratio in upper arm arteriovenous fistula in patients end stage renal failure?

Introduction: Chronic kidney disease is irreversible and may result in end-stage renal failure (ESRF). The kidney replacement program is determined by calculating Kt/V ratios, one of the dialysis efficiency indicators in treatment planning in routine dialysis applications in ESRF patients. We aimed to investigate whether there is a correlation between flow rate and Kt/V ratio. Methods: All patients were evaluated by B-mode ultrasonography (US) and color doppler ultrasonography (CDUS). The anastomosis line diameter was measured in the B-mode US. The fistula flow rate was calculated in a spectral examination at the anatomical location where the fistulized flow was best obtained at the anastomosis level. Patients with a fistula flow rate above 300 mL/min in CDUS examinations were considered reasonable flow rates. The fistula flow rate in these patients was compared with the Kt/V ratios. Spearman’s rank correlation coefficient was calculated since the normal distribution condition was not met to determine the relationship between variables. Results: The results of this study showed a high level (r=0.72, P=0.001) of positive and statistically significant correlation between flow rate and Kt/V ratio in upper arm arteriovenous fistula in patients with end stage renal failure. Conclusion: We found a highly positive and statistically significant correlation between fistula flow rate and Kt/V ratio. Low Kt/V ratios have different causes. Low fistula flow should be considered first in low Kt/V values.

Impact of monthly arteriovenous fistula flow surveillance on hemodialysis access thrombosis and loss

Arteriovenous fistula flow dysfunction is the leading cause of vascular access thrombosis and loss in patients undergoing hemodialysis. However, data regarding the influence of access flow rate measurements on the long-term outcomes of access are limited. This study aims to identify accesses at a high risk of thrombosis and loss among patients undergoing hemodialysis by measuring the access flow rate and exploring an optimal threshold value for predicting future access thrombosis. We enrolled 220 patients with arteriovenous fistula undergoing hemodialysis. The primary outcome was the occurrence of access thrombosis. Access flow rates were measured monthly using the ultrasound dilution method and were averaged using all measurements from patients with patent access. In patients experienced access thrombosis, those immediately before the thrombosis were selected. Using these data, we calculated the access flow rate threshold for thrombosis occurrence by analyzing the receiver operating characteristic curve, and the patients were divided into two groups according to whether access flow rates were higher or lower than 400 mL/min. During a median follow-up period of 3.1 years, 4,510 access flows were measured (median measurements per patient, 33 times; interquartile range, 11-54). A total of 65 access thromboses and 19 abandonments were observed. Access thrombosis and loss were higher in the lowflow group than in the high-flow group. This study revealed that low access flow rates are strongly associated with access thrombosis occurrence and subsequent loss of arteriovenous fistulas in patients undergoing hemodialysis.

Standardization of Pre-operative Evaluation to Improve the Outcome of Arteriovenous Fistula for Vascular Access of Hemodialysis: A Review of 700 Cases.

Background With the advent of COVID-19, mortality rates of end-stage kidney disease (ESKD) rose by 37% which makes its treatment an important part of healthcare. Arteriovenous fistula (AVF) is linked to higher patient survival rates. Cimino-Brescia fistula is the most effective vascular access technique, but it has a high rate of primary failure (PF) and a several-week maturation period before it can be used. The current study aims to verify the preoperative evaluation in improving survival among AVF patients. Methodology The current study is a retrospective analysis of the hospital database from Jan 2022 to July 2023, with patients of a mean age of 60.2 years. The sample size was around 700, including the patients indicated for long-term hemodialysis (HD) with an estimated GFR of less than 20 mm/min/1.73m². Following AVF surgery, post-operative outcomes, PF, and maturation time were considered. Results Among the 757 AVF procedures, 588 (82%) were new cases, and 112 (16%) had prior AVF history on the same side. PF was observed in 126 (18%) AVFs, while 574 (84%) achieved maturation. Age at surgery did not correlate with PF. Male sex and brachiocephalic AVF (BCAVF) had lower PF rates, while female gender, non-BCAVF, and vascular chronic kidney disease (CKD) were independent predictors. Proximal fistulas had a higher failure risk (32%). During surgery, the PF occurred six times more frequently in patients with veins and arteries under 2 mm and without a bruit. Conclusion AVF maturation aims to achieve a functional AVF for easy dialysis, requiring meticulous vein selection, doppler vascular mapping, and a standardized process to reduce PF rates. Factors determining PF include thrill and bruit, flow rates, and comorbidities. These findings can help clinicians make informed decisions and improve outcomes for patients undergoing fistula surgery.

Arteriovenous fistula, pulmonary hypertension, and tricuspid dysfunction in renal transplant recipients. A possible solution

Introduction: Cardiovascular dysfunction is the first cause of death in patients with chronic kidney disease. Methods: Observational, longitudinal and prospective study, which included 58 patients with functioning renal transplant who were studied different echocardiographic variables, before and six months after the closure of the arteriovenous fistula. Results: The average age was 46.62 years and the most frequent was male 30 (51.72%). The flow of angioaccesses at the wrist level was demonstrated in 28 patients (45.9%) with evidence of regression of mean pulmonary artery pressure from 25.56 to 19.58 mmHg (p=0.002), more connoted for those of intermediate flow; 14. Also, the area of tricuspid insufficiency was greater for that group; from 3.15 to 1.96 cm2 (p=0.001). The pattern of mild dysfunction was observed in 38 patients (62.3%) prior to closure. Subsequent to this 27; (51.9%), exhibited minimal valvular insufficiency and 9 individuals (14.9%) did not show any degree of valvular dysfunction. Conclusions: Closure of the arteriovenous fistula in patients with functioning renal transplantation contributed to decrease the risk of pulmonary hypertension and progression of tricuspid valve dysfunction.

Improved AV Fistula Usability with Fewer Interventions Leads to Reduced Annualized Cost of AV Fistula Patients: A Propensity Score-Matched Comparative Prospective Study

A vascular external support for arteriovenous fistula (AVF) creation (VasQ, Laminate Medical, Tel Aviv, Israel) has improved functional success in multiple European studies. Herein is the first complete report of the U.S. Pivotal Comparative Study results with a cost analysis is presented for VasQ over a 24-month period. The U.S. Pivotal study prospectively enrolled 144 patients (90% brachiocephalic and 10% radiocephalic) at 15 sites. A group of 782 patients treated by the same surgeons from the study immediately prior to the VasQ trial enrollment period was developed from the Medicare claims database as a comparative group. Demographic, procedural and postprocedural data were collected for up to 24 months after surgery. To emulate randomized studies, a propensity score weighting method (inverse probability treatment weighting using average treatment effect) was applied to the claims data. Statistical comparisons of primary patency (freedom from intervention), functional success (continuous use for dialysis over a minimum of 30 days), and post-creation intervention rates were made against the matched comparator group as well as calculating payer cost. Descriptive comparisons were made for primary failure rate (abandonment before first use by 6-month follow-up) and 24-month cumulative patency (freedom from abandonment) rates against published meta-analyses. The median diameter of vessels at the VasQ AVF creation site was 4.25 mm (range, 2.0-6.6 mm) arterial and 3.95 mm (range, 2.3-7.8 mm) venous. Incidence of steal (4.2%), infection (0.7%), and (pseudo)aneurysm (0.7%) at 24 months compared favorably with standard AVF creations. Demographic data for the VasQ and Medicare control groups before and after weighting were typical of a U.S. population (Table I). VasQ AVFs demonstrated superior primary patency, functional success and intervention rates compared against the matched cohort (Table II). Primary failure of 7.9% for VasQ AVF patients compared favorably to the 22.0% to 32.2% reported in contemporary U.S. meta-analyses. Cumulative patency of 76.7% (95% confidence interval, 67.7%-83.4%) at 24 months for VasQ was superior to contemporary meta-analyses reporting 53.7% to 63.0% for standard AVFs. No difference in cumulative patency was observed between patients requiring interventions and those that did not, demonstrating VasQ did not inhibit the ability of physicians to maintain patency. The nearly 50% reduction in access interventions with VasQ at 6 months resulted in an annualized cost reduction of $7764.19 per patient-year. The VasQ vascular external support device delivered more functional fistula success, with earlier usability and fewer interventions, reducing overall costs of fistula creation.Table IMatched demographicsCharacteristicsVasQUnmatched controlUnmatched SMDMatched controlMatched SMDMale61.1% (88/144)56.3% (440/782)9.964.9%−7.9Black35.4% (51/144)47.4% (364/768)−24.531.5%8.3White53.5% (77/144)43.1% (331/768)20.957.9%−9.0Other11.1% (16/144)9.5% (73/768)5.310.6%1.8Mean age58.9 ± 11.460.8 ± 12.7−15.758.7 ± 5.63.0Obesity52.1% (75/144)51.2% (400/782)1.948.3%7.6Active dialysis66.0% (95/144)65.3% (511/782)1.365.7%0.6Diabetic69.4% (100/144)79.0% (618/782)−22.069.4%0.1Congestive heart failure21.5% (31/144)41.6% (325/782)−44.122.8%−3.0SMD, Standard mean difference.Values are (proportion) and [range]. Boldface entries indicate statistical significance. Open table in a new tab Table IIVasQ patient outcomes relative to a matched Medicare comparatorEndpoint (n)VasQ vs controlOdds ratioMatched P valuePrimary patency at 6 months64.2% vs 35.5%3.27[2.15-5.17]<.0001Continuous AVF use at 3 months43.4% vs 26.7%2.15[1.32-4.47].0069Continuous AVF use at 6 months72.5% vs 56.3%2.05[1.23-3.75].0059Intervention rate at 6 months0.97 vs 1.91NA<.0001Values are 95% confidence intervals. Boldface entries indicate statistical significance. Open table in a new tab

Brachiocephalic and Radiocephalic Arteriovenous Fistulas in Patients with Tunneled Dialysis Catheters Have Similar Outcomes

Patients with tunneled dialysis catheters (TDCs) have a time-sensitive need for afunctional permanent access due to high risk of catheter-associated morbidity. Brachiocephalic arteriovenous fistulas (BCF) have been reported to have higher maturation and patency compared to radiocephalic arteriovenous fistulas (RCF), although more distal creation is encouraged when possible. However, this may lead to a delay in establishing permanent vascular access and, ultimately, TDC removal. Our goal was to assess short-term outcomes after BCF and RCF creation for patients with concurrent TDCs to see if these patients would potentially benefit more from an initial brachiocephalic access to minimize TDC dependence. The Vascular Quality Initiative hemodialysis registry was analyzed from 2011 to2018. Patient demographics, comorbidities, access type, and short-term outcomes including occlusion, reinterventions, and access being used for dialysis, were assessed. There were 2,359 patients with TDC, of whom 1,389 (58.9%) underwent BCF creation and 970 (41.1%) underwent RCF creation. Average patient age was 59years, and 62.8% were male. Compared with RCF, those with BCF were more often older, of female sex, obese, nonindependently ambulatory, have commercial insurance, diabetes, coronary artery disease, chronic obstructive pulmonary disease, be on anticoagulation, and have a cephalic vein diameter of ≥3mm (all P<0.05). Kaplan-Meier analysis for 1-year outcomes for BCF and RCF, respectively, showed that primary patency was 45% vs. 41.3% (P=0.88), primary assisted patency was 86.7% vs. 86.9% (P=0.64), freedom from reintervention was 51.1% vs. 46.3% (P=0.44), and survival was 81.3% vs. 84.9% (P=0.02). Multivariable analysis showed that BCF was comparable to RCF with respect to primary patency loss (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.91-1.36, P=0.316), primary assisted patency loss (HR 1.11, 95% CI 0.72-1.29, P=0.66), and reintervention (HR 1.01, 95% CI 0.81-1.27, P=0.92). Access being used at 3months was similar but trending towards RCF being used more often (odds ratio 0.7, 95% CI 0.49-1, P=0.05). BCFs do not have superior fistula maturation and patency compared to RCFs in patients with concurrent TDCs. Creation of radial access, when possible, does not prolong TDC dependence.

Development of hemodynamically relevant acquired arterio-venous fistulae in patients with venous malformations.

Venous malformations tend to retain their slow-flow behavior, even in progressive disease or regression following therapy. The aim of this study is to analyze the development of acquired hemodynamic relevant arterio-venous fistulae in patients with slow-flow malformations. This study is a retrospective analysis based on a consecutive local registry at a tertiary care Interdisciplinary Center for Vascular Anomalies. Patients with venous malformations and development of secondary arterio-venous fistulae were included. Indications for therapy of the vascular malformation were based on patients' symptoms and complications. The following endpoints were of clinical interest and were assessed: origin of development of arteriovenous fistula, development of secondary comorbidities as a result of the vascular malformation. For analysis we focused on descriptive statistics. Out of 1213 consecutive patients with vascular malformations, in 6 patients perfusion changed from slow flow to arterio-venous fast-flow patterns. Four patients developed the fistula after local trauma in the area of the malformation, the other 2 patients developed the fistula due to progression of the disease and recurrent thrombophlebitis. These 2 patients had no trauma or interventions at the time of arterio-venous fistula development. Acquired arterio-venous fast-flow fistula in patients with slow flow vascular malformation is very rare and might be a result of local trauma or the progression of the disease with recurrent thrombophlebitis. Specific evidence-based treatment options for these patients do not exist.

Long-term arteriovenous fistula prognosis for maintenance hemodialysis patients who accepted PIRRT by using arteriovenous fistula.

Maintenance hemodialysis (MHD) patients are often admitted to the hospital for severe morbidities. Prolonged intermittent renal replacement therapy (PIRRT) is required during the hospital staying. There are controversial opinions on the use of arteriovenous fistula (AVF) as vascular access for PIRRT in MHD patients. Patients with AVF who accepted PIRRT in our center between January 2014 and June 2021 were retrospectively screened. AVF dysfunction and patient mortality were assessed as endpoints. Univariate and multivariate regression models were employed to identify the risk factors of AVF dysfunction. About 162 patients were included in our present study. Twenty-six experienced AVF dysfunction, of whom 53.8%, 19.2%, and 27.0% had percutaneous transluminal balloon angioplasty, surgical revision, and AVF reconstruction, respectively. The accumulated AVF dysfunction rates were 11.8%, 16.2%, and 21.0% in 1, 2, and 3 years, respectively. Multivariate analysis revealed that smoking (HR 2.750, 95% CI 1.181-6.402, p = 0.019), higher platelet (PLT, HR 1.009, 95% CI 1.000-1.017, p = 0.047), higher prothrombin activity (PTA, HR 1.039, 95% CI 1.012-1.066, p = 0.004), and lower diastolic blood pressure (DBP, HR 0.963, 95% CI 0.932-0.996, p = 0.026) were independent risk factors for AVF dysfunction. During the follow-up period, 37 patients died. Overall, the use of AVF for PIRRT might not dramatically increase the incidence of AVF dysfunction. And, Smoking, lower DBP, higher PLT, and higher PTA were associated with increased AVF dysfunction.

End Stage Renal Disease: AVF for Hemodialysys: Clinical Assessment with/without Ultrasound Doppler, Complications and Failure

Objective/Background: The objective of this study was to study the complications and failure rate after creating an arteriovenous fistula in patients suffering from end-stage renal disease (chronic renal failure). It was also intended to study the importance of preoperative Clinical assessment/physical examination of the patient; and if the vessels for anastomosis appeared to be of a doubtful size, then a doppler study was done to ensure that the vein is of adequate size for creation of a good fistula. Method: In this study 121 cases of end-stage renal disease (chronic renal failure) who needed vascular access for hemodialysis were taken. Ultrasound Doppler study was conducted in those patients whose vessels (for anastomosis) appeared to be of small size on Clinical examination. In the study, the arteriovenous fistulae were created under local anesthesia observing all aseptic precautions. Results: Most commonly, the difficulty encountered during surgery was when the caliber of the vein was small i.e. less than 2.5 mm. An arteriovenous fistula was created only when the size of the vein was at least 2.0 mm. When the size of the vein was small, then a longitudinal incision was given in the vein or Cheatlemanouvre was undertaken to perform the anastomosis. In 4 of the 121 cases when radiocephalic fistula was attempted, we had to convert to brachio-cephalic. No major complication was encountered during the surgery or post-operatively. Some patients (five) had redness and inflammation. Inflammation and redness subsided with antibiotics and it resulted in satisfactory recovery. The fistulas started well showing good thrill. After 30 days, 106 out of 121 AV fistulas created were functioning very well with a patency rate of 87.6%. Conclusion: There was no major complication after creating an arteriovenous fistula. It is important to do a thorough physical examination before surgery so that the vessel is assessed. In doubtful cases, an ultrasound doppler study should be done to know the size and patency of the vessel. We should also take relevant history especially of hypertension, diabetes, i/v canulation, etc.

Systematic review and meta-analysis of preoperative interventions to support the maturation of arteriovenous fistulae in patients with advanced kidney disease.

There is great potential to improve outcomes of arteriovenous fistulas (AVFs) by focusing more on the preoperative period of AVF creation. We aim to systematically review the evidence on safety and efficacy of various preoperative interventions that have been tried to improve AVF maturation and success rate. We searched five databases: PubMed, Embase, CINAHL, Cochrane Library and King's Fund Library. Experimental studies that investigated the effect of various preoperative interventions to improve AVF outcomes among advanced chronic kidney disease (CKD) patients were searched. The effect size for primary outcome was calculated as the weighted mean difference in the final vessel calibre, rate of AVF maturation or primary failure between the intervention and control arm. We also assessed adverse effects and dropout rates. This review was preregistered in the International Prospective Register of Systematic Reviews (CRD42020193257). Eight eligible studies were identified involving three types of intervention: hand exercise (n=6), cholecalciferol supplementation (n=1) and pneumatic compression of the arm using a Fist Assist device (n=1). The overall effect size of hand exercise on distal cephalic vein calibre was 0.24mm [95% confidence interval (CI) 0.03-0.45] on meta-analysis of hand exercise studies. On restricting analysis to two randomized controlled trials (RCTs) that had independent control groups, the effect size was higher, at 0.29mm (95% CI 0.11-0.47). Hand exercise was a well-tolerated intervention, especially when confined to the first 4weeks. Hand exercise is the predominant intervention tried in the preoperative period of AVF creation, although there is methodological heterogeneity. Intermittent pneumatic compression using a Fist Assist device is a novel intervention that has shown some promise. Well-designed prospective RCTs are needed on preoperative interventions among advanced CKD patients, aimed at improving AVF outcomes.