Autogenous Arteriovenous Research Articles

Early Kidney Transplantation or Conversion to Peritoneal Dialysis after First-Time Arteriovenous Access Creation

After autogenous arteriovenous (AV) access creation for end-stage renal disease, a majority of patients will continue on hemodialysis (HD), a minority will receive definitive treatment with kidney transplantation, and a subset of patients will convert to peritoneal dialysis (PD). Our goal was to identify patient factors associated with early transition from HD to either kidney transplantation or PD. This is a case-control study of all patients with first-time AV access creation in the Vascular Quality Initiative (2011-2022) who had long-term follow-up. Patients who remained on HD after AV access creation were the control group while patients who received early kidney transplant or who converted to PD were the 2 case groups. Relationship among demographics, comorbidities, neighborhood social disadvantage, and functional status as they relate to renal replacement therapy modality was assessed. There were 19,782 patients included; the average age was 62±15years and 57% were male. During the follow-up period of a median 306 (71-403) days, 1.3% underwent a kidney transplantation and 2.3% underwent conversion to PD. On univariable analysis, rates of kidney transplantation or conversion to PD varied with race (P<0.001), insurance status (P<0.001), area deprivation index (ADI) quintile (P<0.001), and several medical comorbidities. On multivariable analysis, impaired ambulation, current smoking, Medicaid or Medicare insurance, Black race, heart failure, body mass index, and older age were associated with decreased transplantation rates. Conversion to PD was associated with ADI Q5, Q4, and Q3. Decreased conversion to PD was associated with impaired ambulation, Hispanic ethnicity, Black race, former smoking, medication-controlled diabetes, and older age. Decreased kidney transplantation was associated with Black race and noncommercial health insurance but not ADI quintile, suggesting disparities exist beyond community-level access to care. Early kidney transplantation conveyed a 3-year survival benefit compared with HD and PD, which had similar survival. Furthermore work is required to increase access to kidney transplantation and PD.

Improved Ultrasound-Guided Balloon-Assisted Maturation Angioplasty Using Drug-Eluting Balloons in the First Autogenous Arteriovenous Fistula Procedure: Early Experience.

In patients with end-stage renal failure requiring hemodialysis, autogenous arteriovenous fistula (AVF) is preferred over tunneled dialysis catheters due to lower complications and costs. However, AVF maturation failure remains a common issue due to small vein size, multiple venipunctures, and other factors. Guidelines recommend using vessels of >2 mm for forearm AVFs and >3 mm for upper arm AVFs. This study investigates the use of intraoperative Doppler ultrasound (DUS)-guided Balloon-Assisted Maturation (BAM) with drug-eluting balloons (DEB) during initial AVF creation. Data from 114 AVF procedures, of which 27.2% underwent BAM, were analyzed. BAM was performed in 25 distal radio-cephalic and 6 proximal brachio-cephalic AVFs. With DUS guidance, vein stenosis was identified and treated using DEB. Technical success was achieved in all cases, with no early mortality. Early BAM-related complications were minimal, and no AVF thrombosis occurred. AVF maturation time was 15 days (SD: 3), and no further complications were reported during a mean follow-up of 10.38 months. Using BAM with DEB during AVF creation led to successful maturation and dialysis use without the need for secondary procedures. This study emphasizes the importance of identifying AVF failure risk early and utilizing DUS-guided procedures to enhance AVF outcomes. A more liberal use of intraoperative BAM could limit reinterventions in patients undergoing AVFs.

The impact of neighborhood social disadvantage on presentation and management of first-time hemodialysis access surgery patients

ObjectivesThe impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) arteriovenous (AV) access creation have not been well-characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members living within a community. Our goal was to examine the effect of ADI on health outcomes for first-time AV access patients. MethodsWe identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between July 2011 to May 2022. Patient zip codes were correlated with an ADI quintile, defined as quintile 1 (Q1) to quintile 5 (Q5) from least to most disadvantaged. Patients without ADI were excluded. Preoperative, perioperative, and postoperative outcomes considering ADI were analyzed. ResultsThere were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 34% were of Black race, 10% were of Hispanic ethnicity, and 85% received autogenous AV access. Patient distribution by ADI quintile was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with lower rates of autogenous AV access creation (OR, 0.82; 95% confidence interval [CI], 0.74-0.90; P < .001), preoperative vein mapping (OR, 0.57; 95% CI, 0.45-0.71; P < .001), access maturation (OR, 0.82; 95% CI, 0.71-0.95; P = .007), and 1-year survival (OR, 0.81; 95% CI, 0.71-0.91; P = .001) compared with Q1. Q5 was associated with higher 1-year intervention rates than Q1 on univariable analysis, but not on multivariable analysis. ConclusionsThe patients undergoing AV access creation who were most socially disadvantaged (Q5) were more likely to experience lower rates of autogenous access creation, obtaining vein mapping, access maturation, and 1-year survival compared with the most socially advantaged (Q1). Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population.

The Impact of Neighborhood Social Disadvantage on Presentation and Management of Hemodialysis Access Surgery Patients

The impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) access surgery have not been well characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members within a community. Herein, we examined the effect of ADI on health outcomes for first-time HD access patients. We identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between August 2011 and May 2022. Patient zip codes were correlated with an ADI quintile (Q1-Q5, least to most disadvantaged). Patients without ADI were excluded. Perioperative and long-term outcomes considering ADI were analyzed. There were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 10% were of Hispanic ethnicity, and 85% received autogenous arteriovenous (AV) access. Patient distribution by ADI quintile (Q) was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with decreased autogenous access creations (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.77-0.94; P = .002), fewer preoperative vein imaging (OR, 0.62; 95% CI, 0.50-0.77; P < .001), lower access maturation (OR, 0.82; 95% CI, 0.71-0.94; P = .005), and lower 1-year survival (OR, 0.80; 95% CI, 0.71-0.90; P < .001) compared to Q1. Q5 was not associated with significantly higher 1-year intervention rates (Table). The most socially disadvantaged (Q5) AV access creation patients were more likely to experience disparities at the time of preoperative AV access creation, access type, as well as well as at 1-year outcomes. Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population.TableUnivariate and multivariable analysis of outcomes of interest stratified by Area Deprivation Index (ADI) quintileADIAV fistulaVein imaging obtainedAccess matured at last follow-up1-Year intervention1-Year survivalUniMultiUniMultiUniMultiUniMultiUniMultiQ16138 (87)(ref)2413 (91)(ref)2695 (86)(ref)798 (31)(ref)6483 (92)(ref)Q26771 (85)0.84 [0.75-0.93]2254 (91)1.01 [0.80-1.26]2840 (83)0.83 [0.72-0.97]961 (32)0.98 [0.86-1.11]7121 (89)0.82 [0.72-0.93]Q37717 (85)0.81 [0.73-0.89]2575 (94)1.50 [1.18-1.90]3253 (83)0.82 [0.71-0.95]1089 (31)0.93 [0.82-1.05]8122 (89)0.80 [0.71-0.90]Q48211 (84)0.76 [0.69-0.84]2619 (91)0.96 [0.78-1.19]3529 (84)0.91 [0.78-1.05]1268 (32)0.94 [0.83-1.06]8844 (90)0.88 [0.79-0.99]Q57838 (84)0.85- [0.77-0.94]2018 (88)0.62 [0.50-0.77]3694 (82)0.82 [0.71-0.94]1433 (34)0.99 [0.88-1.12]8370 (90)0.80 [0.71-0.90]P value<.001-<.001-<.001-.047-<.001-Multi, multivariable analysis; Uni, univariate analysis.Univariate results represented as number (%). Multivariable results represented as adjusted odds ratio. Brackets in multivariable analysis indicated the 95% confidence interval. Bold indicated statistically significant results. Of patients with long-term follow-up data, the average length of last long-term follow-up data was 383 ± 240 days. Open table in a new tab

Preliminary Experience of Intraoperative Ultrasound-guided Balloon-Assisted Maturation Angioplasty of Autogenous Arteriovenous Fistula with Drug-Eluting Balloons

Preliminary Experience of Intraoperative Ultrasound-guided Balloon-Assisted Maturation Angioplasty of Autogenous Arteriovenous Fistula with Drug-Eluting Balloons

Clinical Observation of Safflower Wine Wet Dressing to Improve the Function of Autogenous Arteriovenous Fistula in Hemodialysis Patients

Clinical Observation of Safflower Wine Wet Dressing to Improve the Function of Autogenous Arteriovenous Fistula in Hemodialysis Patients

Repeated failure of arterio-venous haemodialysis access

Background: The subsequent development of vascular access techniques and devices now permits patients to be maintained on dialysis for decades. Aim of study: To evaluate the most possible causes behind repeated arteriovenous (AV) access failure in ESRD patients and finding the relationship between those causes and the timing of access failure, and putting the possible solutions in the form of interventions and guidelines for those patients. Patients and methods: This retrospective non-randomized study was conducted in department of vascular surgery, Al-Azhar University Hospitals – Cairo (Al-Hussein and Sayed Glal Hospitals). This study was conducted on 100 ESRD patients on regular hemodialysis and with repeated AV access failure; at least two failed accesses for each patient. The total number of failed accesses was 245 where 230 accesses were autogenous AV fistulae and 15 were synthetic bridge grafts in upper limb. Results: Among the cases of access thrombosis 25.5% were associated with access stenosis, 10.5% with hypotension, and 2.5% with external compression. Among the cases of failure of maturation 16% were due to small vein diameter (less than 2.5 mm), 9% associated with hypotension, and 7% with hypotension together with central venous stenosis.

Comparison of autogenous basilic vein, polytetrafluoroethylene and polycarbonate grafts for haemodialysis access

This study aims to present data obtained by comparing the results of three different kinds of arterio-venous fistula (AVF) in hemodialysis patients. One hundred twenty (120) patients were operated with autogenous brachiobasilic (BBF) AVF, upper arm polytetrafluoroethylene (PTFE) or polycarbonate-urethane (PCU) graft AVF in our centre between January 2015 and January 2018. They were enrolled for a retrospective study into three groups; BBF Group (n=54), PTFE Graft Group (n=36), PCU Graft Group (n=30). Their data was analyzed, primary and secondary patency rates, complications and cannulation time were calculated. Primary patency rates of the 1st, 2nd and 3rd years were recorded to be respectively 81.4%, 72.2% and 59.2% in the Autogenous Arteriovenous Fistula (BBF) Group; 61.1%, 55.5% and 44.4% in the PTFE Group and 63.3%, 60% and 46.6% in the PCU Group. Infections occurred in 3.7% of BBF patients, in 8.3% of PTFE patients and 10% of PCU patients. First cannulation times were: 69± 17 (day) in BBF Group, 20 ± 5 (day) in PTFE Group and 10± 3(day) in PCU Group. BBF was observed to perform better than AVG in terms of primary and secondary patency and to result in low infection rates. On the other hand, first cannulation was performed earlier in both graft AVFs. There was no significant difference between PTFE and PCU in terms of our outcomes.

Ultrasound-Guided Cradle-Like Infiltrative Anesthesia for Percutaneous Transluminal Angioplasty of Stenotic Autogenous Arteriovenous Hemodialysis Access

Percutaneous transluminal angioplasty (PTA) is an effective treatment for autogenous arteriovenous hemodialysis access (AAVA) stenosis; however, it causes pain in most cases. Therefore, safe and effective anesthesia for PTA is required. We introduced a method of ultrasound-guided cradle-like infiltration anesthesia (UCIA) to administer analgesia during PTA. Using ultrasound guidance, 1% lidocaine was injected into the bilateral and inferior perivascular spaces of the stenosis to form a cradle-like region. In this study, 100 consecutive patients were divided into two groups, and the analgesic effect of UCIA was evaluated using a numerical rating scale with non-ultrasound-guided infiltration anesthesia as a control. Meanwhile, we compared the effect of PTA between the two groups with the postoperative internal diameter of the stenosis. The numerical rating scale score was 4.6 ± 1.9 and 2.0 ± 1.6 (P < 0.001) in UCIA group and non-ultrasound-guided infiltration anesthesia group, respectively. The postoperative internal diameter of stenosis was 3.9 ± 0.6 mm and 4.1 ± 0.7 mm (P=0.113); the postoperative AAVA flow volume was 627 ± 176 mL/min and 644 ± 145 mL/min (P=0.600). This study preliminarily showed that UCIA is effective and safe for the analgesia of AAVA PTA.

Single-Institution Learning Curve for Management of Mega-Fistulae Revision

Mega-fistulae are generalized aneurysmal dilations of a high flow (1500-4000 mL/min) autogenous arteriovenous (AV) access which may result in hemorrhage and/or high-output cardiac failure. Current treatments include ligation, ligation with prosthetic jump graft, and imbrication; however, these may not be suitable for advanced disease, or may result in loss of functioning access, poor cosmesis, or recurrence. We describe our early experience with a technique of complete mega-fistula resection and replacement with an early use prosthetic graft that both maintains existing AV access and eliminates the need for long-term catheter (LTC) placement; including lessons learned. A single-center, retrospective review of medical records was conducted fromMarch 2018-February 2021. Outcomes were technical success, LTC use, time to cannulation, and complications. Mega-fistulae were completely resected from the proximal to distal aneurysmal segment, including all pseudoaneurysms, followed by tunneling a prosthetic graft (Propaten later converted to Acuseal; W.L. Gore Assoc.) with an end-to-end anastomosis to the remaining arterial and venous ends of the previous AV access. We had 100% immediate technical success (n=12). Pre-operative long-term catheters were placed in all eight Propaten patients; one was already placed in an Acuseal patient. Average time to cannulation was six weeks with Propaten and 4.5 days with Acuseal. At 30 days, three Propaten patients developed complications including one instance of skin necrosis, one seroma, and one hematoma. Two Acuseal patients developed complications including one central venous occlusion (CVO) and one graft infection. Of the six patients with long-term follow-up, five continue to use their access, however, two required thrombectomies and central venous angioplasties. One patient required a new contralateral access due to CVO. Complete mega-fistula resection and replacement with Acuseal graft maintains existing AV access and may eliminate the need for long-term catheter placement. Our early experience with this technique is encouraging, but further follow-up is required to determine the durability of this approach.

Preoperative Vein Mapping is Not Associated With Arteriovenous Access Type Created But is Associated With Improved Patency

Autogenous arteriovenous (AV) fistulas are preferred for hemodialysis access, with AV grafts (AVGs) reserved for when a suitable vein is unavailable. Preoperative vein mapping can be used to identify usable veins for autogenous access. We evaluated whether vein mapping is associated with access type and outcomes. We queried the Vascular Quality Initiative database for patients who had undergone initial AV access creation from 2011 to 2019. We evaluated the associations of preoperative vein ultrasound/venogram mapping with patient characteristics, access type, and 30-day and 1-year patency. Of 20,461 patients receiving an initial AV access, 92% had undergone preoperative vein mapping. The patients who had undergone vein mapping were more likely to be women (43.1% vs 39.8%; P = .01), outpatients (84.1% vs 81.2%; P = .002), obese (43.3% vs 39.2%; P = .002), and diabetic (62.6% vs 59.8%; P = .03). They were also more likely to have concomitant coronary artery disease (21.8% vs 18.9%; P = .008), congestive heart failure (31.3% vs 25.9%; P < .001), and concurrent tunneled dialysis catheters (43.7% vs 35%; P < .001) and to already require dialysis (55.8% vs 52%; P = .004). We found no significant difference in AVG creation between the patients who had and had not undergone vein mapping (14.2% vs 13.6%; P = .5). Furthermore, no significant correlation was found between the proportions of preoperative vein mapping and AVG creation at the center and regional levels (P = .14 and P = .1; and P = .4 and P = .11, respectively). Preoperative vein mapping was associated with higher 30-day patency (94.7% vs 90%; P = .001) and 1-year patency (90% vs 82%; P < .001) for autogenous access. On multivariable analysis, concurrent tunneled dialysis catheter use, congestive heart failure, coronary artery disease, obesity, female sex, and outpatient status were independently associated with increased preoperative vein mapping use (P < .05 for all). Preoperative vein mapping was not independently associated with AVG creation likelihood (odds ratio, 0.98; 95% confidence interval [CI], 0.81-1.17; P = .8) but was independently associated with increased 30-day patency (odds ratio, 2.23; 95% CI, 1.44-3.45; P < .001) and 1-year patency (hazard ratio, 1.56; 95% CI, 1.19-2.04; P = .001). Preoperative vein mapping was more likely to be performed in patients presenting with cardiovascular comorbidities and potential technical concerns. Vein mapping did not appear to minimize AVG creation; however, it was associated with improved autogenous access patency. Although most patients received preoperative vein mapping, increasing its use might further improve access outcomes.

Maintaining Continuous Arteriovenous Access in Mega-Fistula Repair: Surgical Technique and Outcomes

Mega-fistulae of autogenous arteriovenous (AV) access could result in arterial steal, high-output cardiac failure, or rupture with resulting hemorrhage. Current treatment options, which include ligation with or without jump prosthetic graft or imbrication, are suboptimal, leaving possible need for new accesses to be placed, cosmetically unappealing results, or future recurrent dilations. We describe a technique that allows for a complete resection of the mega-fistula while allowing continuous use of the AV access.

Autogenous Arteriovenous Bundle Implantation Maintains Viability Without Increased Immune Response in Large Porcine Bone Allotransplants

BackgroundTransplantation of living allogeneic bone segments may permit reconstruction of large defects, particularly if viability is maintained without immunosuppression. Development of a new autogenous osseous blood supply accomplishes this goal in rodent experimental models. This study evaluates potential systemic and local inflammatory responses to this angiogenesis in a large-animal model. MethodsVascularized allogeneic tibia segments were transplanted orthotopically into matched tibial defects in Yucatan minipigs. Microvascular anastomoses of bone nutrient artery and vein were supplemented by intramedullary placement of an autogenous arteriovenous (AV) bundle in group 1. Group 2 served as a no-angiogenesis control. A 3-drug immunosuppression regimen was withdrawn after 2 weeks. During the 20-week survival period, periodic leukocyte counts and inflammatory cytokine levels were measured. Thereafter, osteocyte survival was quantified and transplant rejection graded by histologic examination and quantitative real-time polymerase chain reaction of immunologic markers. ResultsBoth groups developed an initial systemic response, which resolved after 4 to 6 weeks. No differences were seen in blood cytokine levels. Interleukin 2 expression was diminished in group 1 tibiae. As expected, nutrient pedicles had thrombosed without sustained immunosuppression, occluded by intimal hyperplasia. In group 1, angiogenesis from the autogenous AV bundle resulted in significantly less osteonecrosis (P = .04) and fibrosis (P = .02) than group 2 allotransplants. ConclusionsSystemic immune responses to large-bone allotransplants were not increased by generation of an autogenous osseous blood supply within porcine tibial bone allotransplants. Implanted AV bundles diminished inflammation and fibrosis and improved bone viability when compared to no-angiogenesis controls.

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Assessment of the Hemodynamics of Autogenous Arteriovenous Fistulas With 4D Phase Contrast-Based Flow Quantification MRI in Dialysis Patients.

Regular monitoring of autogenous arteriovenous fistulas (AVFs) for hemodialysis patients has importance. Hence, 4D flow MRI may be an alternative for assessing the hemodynamics of AVFs. To compare the hemodynamics of AVFs using Doppler ultrasound (DUS) and 4D-MRI in renal dialysis patients. Case-control study from October 2017 to April 2018. Fifty patients (age [range] = 59.52 [39-71] years) with AVFs were included. Black-blood MRI and 4D flow MRI at 3.0T and AVF ultrasonography were also performed. The hemodynamics acquired from 4D flow MRI and ultrasonography by two radiologists were compared. The AVF anatomy was described through an examination of the black-blood MRI. The consistency of AVF anatomy and hemodynamics and the consistency of the hemodynamics of AVFs from 4D flow MRI and ultrasound were analyzed by paired t-tests. The morphological parameters of AVFs acquired from black-blood MRI were used for a Pearson correlation analysis with the hemodynamic parameters obtained from 4D flow MRI data. The consistency of the morphological and hemodynamic parameters measured from MRI by the two radiologists was good (all P < 0.01). The velocities and flow volumes from the 4D flow MRI and vascular ultrasound of AVFs were in moderate agreement (all P < 0.05, r = 0.292-0.569), except for the peak flow velocity at the anastomosis (P = 0.366, r = -0.078). The flow volume and WSS near the anastomotic site were closely related to the morphology of the AVFs (all P < 0.05). The hemodynamics of the complications group were significantly different from those of patients without any complications (normal patients group) (all P < 0.01). Compared with ultrasonography, 4D flow MRI is a promising technique to noninvasively estimate the AVF hemodynamics of renal dialysis patients. 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:1272-1280.

Outcomes of Vascularized Bone Allotransplantation with Surgically Induced Autogenous Angiogenesis in a Large Animal Model: Bone Healing, Remodeling, and Material Properties.

Bone vascularized composite allotransplantation (VCA) is a possible alternative for the treatment of large bone defects. Clinical application of VCAs is limited by the need for life-long immunosuppression (IS). We report an alternative method to maintain bone allotransplant viability in a large animal model without the need for life-long IS by using autogenous vessel implantation. Fourteen bone only VCAs were transplanted in a porcine tibia defect model with short-term IS. Two groups were used to evaluate the effect of the implantation of an autogenous arteriovenous (AV)-bundle, therefore the only difference between the groups was the patency of the AV-bundle. We radiographically evaluated bone healing and allogenic pedicle patency. AV-bundle patency and union were evaluated with micro-CT. Bone remodeling was assessed with histomorphometry and material properties were evaluated with axial compression testing and cyclic reference point indentation. Two subjects did not reach the final time point. Twelve tibiae healed proximally, and nine at the distal transplant-bone interface. Bone allotransplants showed their viability in the first 4 to 6 weeks by significant periosteal bridging arising from the transplant and maintained pedicle patency. Bone material properties were not affected by the implantation of an AV-bundle when compared with ligated AV-bundle controls, but diminished compared with normal bone. Significantly higher bone formation rates resulted from the implantation of a patent AV-bundle. New periosteal bone formation and subsequent bone healing result from blood flow through the microsurgically repaired nutrient blood supply, demonstrated by maintained allogenic pedicle patency. The implantation of a patent autogenous AV-bundle has no adverse effect on material properties, but a positive effect on bone remodeling of endosteal surfaces despite thrombosis of the allogenic pedicle. Bone material properties change after transplantation compared with normal bone, although 20-weeks survival time is relatively short for the final evaluation of bone material properties.

A national study of autogenous arteriovenous access use and patency in a contemporary hemodialysis population

ObjectiveThe predicted outcomes of autogenous arteriovenous (AV) hemodialysis access creation are predominantly based on historical data; however, both the hemodialysis population and clinical practices have changed significantly during the last decade. This study examined contemporary AV access clinical use and patencies. MethodsA multicenter observational cohort study was performed of all new AV accesses created in Scotland in 2015. The primary end point was efficacy assessed by successful AV access use for a minimum of 30 days and primary, primary assisted, and secondary patency at 1 year. Data obtained included all interventions to maintain or to restore patency. Predictors of patency loss including demographics, comorbid conditions, dialysis status, AV access location, duplex ultrasound surveillance, procedures, prior access, and antiplatelets were assessed. Kaplan-Meier and competing risks analyses were performed to estimate the probability of AV access failure. All patients were followed up for at least 1 year or had a censoring event. ResultsA total of 582 AV accesses were created in 537 patients (mean age, 60 [standard deviation, 14] years; 60% men; 42% with diabetes) in nine adult renal centers. Mean follow-up was 11.8 (standard deviation, 7.6) months. By the end of the follow-up, 322 (55.3%) AV accesses were successfully used for dialysis. At 1 year, 48% (95% confidence interval [CI], 44-52) of AV accesses had primary patency, (95% CI, 63-71) had primary assisted patency, and 69% (95% CI, 65-73) had secondary patency. The leading cause of primary patency loss was primary failure (30%). An average of 0.48 intervention per patient-year was required to maintain patency. On multivariable analysis, patency was better for an upper arm than for a forearm AV access (1-year secondary patency of upper arm vs forearm AV accesses, 74% vs 58%). The cumulative hazard and incident functions for AV access failure were 31% (95% CI, 27-35) and 23% (95% CI, 20-27) at 1 year, respectively. ConclusionsDespite advances in recent years with preoperative vessel assessment and surveillance, patency rates have not improved, with primary failure remaining the major obstacle. Competing events should be taken into consideration; otherwise, biases may occur with overestimation of the probability of AV access failure.