AVF Maturation Research Articles

Bedside 3D ultrasound fistula maturation assessment by non-expert sonographers provides equivalent accuracy to formal duplex sonography: A prospective clinical trial.

EchoSure is an automated point-of-care 3D ultrasound (3DUS) designed to be used by dialysis technicians without advanced ultrasound training. The EchoMark/EchoSure System is a two-part system comprised of a bioresorbable implant, EchoMark, and a diagnostic ultrasound imaging platform, EchoSure. EchoSure was designed to enable any healthcare personnel in a dialysis clinic setting to obtain non-invasive, direct measurements of flow and vessel parameters that are critical quantifications used in the assessment of AVF maturation and readiness for hemodialysis cannulation. In this pilot feasibility study, we sought to explore whether use of an automated 3DUS could enable fistula assessment by non-experts and obtain measurement accuracy comparable to expert sonographer Duplex. This was a 20 subject prospective multicenter trial conducted at four sites in the United States. All subjects had an EchoMark implanted under their AVF during the fistula creation procedure. Subjects were evaluated at 2-weeks post-op with EchoSure and Duplex, followed by monthly assessments until either the 4-month visit or until radiographic maturation was achieved, whichever was longer. Beyond monthly ultrasound assessments, clinical follow-up continued every 6 months between months 6 and 24. Technical success of EchoMark implantation was demonstrated in 100% of subjects. Technical success of EchoSure was 99% across all scans. The mean percent difference in flow rate measurements between EchoSure and Duplex was -9.2% with a standard deviation of 38.1% compared to a mean percent difference of -15.7% with a standard deviation of 35.5% between Duplex measurements taken at the cannulation zone and brachial artery. Pearson correlation between EchoSure and Duplex was 0.708 versus 0.716 for the two Duplex measurements. Radiographic maturation was achieved in 70% of study subjects by 30 days and continued to rise to 90% through 90 days and 95% through 180 days after baseline. This study demonstrates the feasibility and accuracy of an automated 3D ultrasound system for assessment of maturation at the dialysis bedside by non sonographers.

#2491 Survival outcome of tunneled and non-tunneled hemodialysis catheters in incident hemodialysis requiring patients: a short term study

Abstract Background and Aims For long term hemodialysis, tunnel catheters are preferred over non –tunneled as vascular access. High cost and expertise in its catheterization are major limitations. It is unclear about the advantage of low cost non- tunneled catheter preference over costly tunnel catheters as short term access while awaiting AVF maturation. Method All consented incident End Stage Kidney Disease (ESKD) patients requiring hemodialysis from March’ 2021 to October’ 2023 were included. Less than 18 years of age, opting for peritoneal dialysis and patients initiating hemodialysis with AVF or AV Graft were excluded from the study. Subjects were randomized in two catheter groups (Tunneled and Non-tunneled). Under aseptic precautions, all catheters were inserted by ultrasound and C-arm guided following standard protocol. Mechanical, infective and catheter survival outcomes were recorded during dialysis initiation, at 2nd, 6th and 12th weeks. Blood culture samples were sent for those patients who were having fever with chills during dialysis. If the blood culture comes out to be positive for organism, all were treated for one week intravenous antibiotic depending upon the sensitivity or as per standard protocol. Catheter salvage in both the groups was tried till 6 weeks or till AVF maturation. If in any case, AVF is not matured, we continued dialysis with the same catheter. New catheter was inserted if patient do not respond antibiotics after one week of therapy, mechanical complications or due to inadequate flow. Adequacy of the dialysis and overall outcome of patients were monitored in both the groups of catheter. All demography data and survival analysis were analyzed. Results A total 133 patients were randomized into Tunneled-65 (48.87%) and non-tunneled-68 (51.12%). Average patient's age of tunneled and non-tunneled was 45.15 ± 15.89 and 40.39 ± 12.21 respectively. A total of 50 (37.3%) were males in tunneled and 54 (40.3%) males in non tunneled groups. A total 65 (54.2%) patients were complained fever with chills during dialysis, of them 31 (25.8%) in tunneled and 34 (28.3%) in non-tunneled group. Among the CRBSI group a total 3 catheters were removed in non-tunneled group whereas all patients in tunneled group were responded to antibiotic. There were total of 24 (18.2%) infections were reported and labelled as CRBSI. Of them 9 (6.7%) in tunneled and 15 (11.2%) in non-tunneled. Most common organism was Klebsiella and Coagulase negative Staphylococcus (Cons) in both the groups. There was only one mechanical complication in case of non- tunneled catheter. The estimated days for catheter survival is 66 for tunneled and 57 for non tunneled (p-0.001). However, in case of non tunneled catheter, 15 cases were reported in which two times catheter were inserted. A total of 14 (10.5%) patients were lost to follow up 8 (6%) in tunneled and 6 (4.5%) in non- tunneled. A total of 9 (5.8%) patients died, 5 (3.8%) in tunneled and 4 (3%) in non- tunneled within 12 weeks. Conclusion Although tunneled catheter showed longer catheter survival period, low cost and easy cannulation procedure in non-tunneled hemodialysis catheter is a better viable option for all incident ESKD patients while waiting for AVF maturation.

Disturbed flow in the juxta-anastomotic area of an arteriovenous fistula correlates with endothelial loss, acute thrombus formation, and neointimal hyperplasia.

Clinical failure of arteriovenous neointimal hyperplasia (NIH) fistulae (AVF) is frequently due to juxta-anastomotic NIH (JANIH). Although the mouse AVF model recapitulates human AVF maturation, previous studies focused on the outflow vein distal to the anastomosis. We hypothesized that the juxta-anastomotic area (JAA) has increased NIH compared with the outflow vein. AVF was created in C57BL/6 mice without or with chronic kidney disease (CKD). Temporal and spatial changes of the JAA were examined using histology and immunofluorescence. Computational techniques were used to model the AVF. RNA-seq and bioinformatic analyses were performed to compare the JAA with the outflow vein. The jugular vein to carotid artery AVF model was created in Wistar rats. The neointima in the JAA shows increased volume compared with the outflow vein. Computational modeling shows an increased volume of disturbed flow at the JAA compared with the outflow vein. Endothelial cells are immediately lost from the wall contralateral to the fistula exit, followed by thrombus formation and JANIH. Gene Ontology (GO) enrichment analysis of the 1,862 differentially expressed genes (DEG) between the JANIH and the outflow vein identified 525 overexpressed genes. The rat jugular vein to carotid artery AVF showed changes similar to the mouse AVF. Disturbed flow through the JAA correlates with rapid endothelial cell loss, thrombus formation, and JANIH; late endothelialization of the JAA channel correlates with late AVF patency. Early thrombus formation in the JAA may influence the later development of JANIH.NEW & NOTEWORTHY Disturbed flow and focal endothelial cell loss in the juxta-anastomotic area of the mouse AVF colocalizes with acute thrombus formation followed by late neointimal hyperplasia. Differential flow patterns between the juxta-anastomotic area and the outflow vein correlate with differential expression of genes regulating coagulation, proliferation, collagen metabolism, and the immune response. The rat jugular vein to carotid artery AVF model shows changes similar to the mouse AVF model.

Pull-through technique through antegrade radial artery puncture without sheath insertion in balloon-assisted radiocephalic arteriovenous fistulas maturation

PurposeThe aim of this study was to investigate the effectiveness and safety of the pull-through technique through antegrade radial artery puncture without sheath insertion in balloon-assisted radiocephalic AVF maturation.MethodsWe retrospective studied a total of 62 patients with immature radiocephalic AVF, who received balloon-assisted maturation in our hospital. 15 patients received pull-through technique through radial artery without sheath insertion and 47 patients received treatment through a regular venous approach.ResultsThe success rate of pull-through technique group and control group was 86.7% (13 out of 15), 89.1% (41 out of 46) respectively. There was no significant difference between two groups (P > 0.05). In our study, there were 2 patients in the pull-through technique group and 3 patients in the control group, which had hematoma in the vein puncture site (P = 0.59). There were also no differences in the primary patency rate between two groups at 6 months and 12 months (76.9% vs 70.7%, 38.4% vs 41.5%, respectively, P > 0.05).ConclusionThe pull-through technique through antegrade radial artery without sheath insertion in promoting radiocephalic AVF maturation is effective and safe.

Preoperative and postoperative vascular characteristics in AVF creation surgery

Background: Early postoperative vascular ultrasound can predict the maturity of arteriovenous fistulas as well as detect complications.
 Objective: To present the characteristics of upper extremity vessels on ultrasound prior to AVF surgery and to analyze the changes in vessel size and flow rate postoperatively.
 Subjects and methods: We prospectively describe 80 cases of AVF formation at Dong Nai General Hospital from April 2022 to April 2023. Vascular ultrasound evaluations were conducted preoperatively and at 1 day, 2 weeks and 6 weeks postoperatively to evaluate the diameter and the blood flow of vessels used to create AVFs.
 Results: Eighty patients underwent AVF surgery. In forearm AVFs, the median diameter of the feeding artery and the draining vein were 2.12 (1.83 – 2.5) mm and 3.38 (2.9 – 3.80) mm, respectively. In upper-arm AVFs, the median diameter of the feeding artery and the draining vein were 3.67 (3.45 – 3.99) mm and 4.0 (3.64 – 4.05) mm, respectively. The draining vein flow rate showed a strong correlation with the brachial artery flow rate (R2 = 0.94, correlation coefficient = 0.88). The diameter and flow rate of the draining vein at 6 weeks post-surgery displayed significant correlations with their respective values at 2 weeks post-surgery, with correlation coefficients of 0.92 (R2 = 0.66) and 1.04 (R2 = 0.86), respectively. After 6 weeks post-surgery, non-diabetic patients exhibited larger draining vein diameters and higher flow rates compared with diabetic patients.
 Conclusions: The study highlighted the predictive potential of vascular ultrasound at the 2-week postoperative mark for AVF maturation The brachial artery flow rate can serve as a reliable indicator of AVF flow rate. Given the tendency for diabetic patients to exhibit smaller draining vein diameter and lower AVF flow rate than non-diabetic patients, particular caution is recommended when performing preoperative ultrasound mapping in this patient population.

Vein Compliance is Superior to Vein Diameter for Predicting Unassisted AVF Maturation

Vein Compliance is Superior to Vein Diameter for Predicting Unassisted AVF Maturation

Intimal CD31-Positive Relative Surfaces Are Associated with Systemic Inflammatory Markers and Maturation of Arteriovenous Fistula in Dialysis Patients.

Arteriovenous fistula dysfunction is a widely disputed subject in the scientific literature on end-stage kidney disease (ESKD). The main cause of mortality and morbidity in these patients is the non-maturation or dysfunction of the arteriovenous fistula. Despite the many complications, the native arteriovenous fistula remains the gold standard in the treatment of these patients requiring renal replacement. This study aims to discuss the predictive role of some systemic inflammatory biomarkers (NLR, PLR, SII, IL-6), intimal hyperplasia, and neoangiogenesis (characterized by intimal-media CD31-positive relative surface) in arteriovenous fistula maturation failure. The present study was designed as an observational, analytical, and prospective study which included patients diagnosed with ESKD with indications of radio-cephalic arteriovenous fistula (RCAVF). Demographic data, comorbidities, preoperative laboratory data and histological/digital morphometry analysis results were processed. The patients included were divided into two groups based on their AVF maturation status at 8 weeks: "Maturation" (Group 1) and "Failed Maturation" (Group 2). There was no difference in the demographic data. In terms of comorbidities, the second group had a greater incidence of heart failure (p = 0.03), diabetes (p = 0.04), peripheral artery disease (p = 0.002), and obesity (p = 0.01). Additionally, regarding the laboratory findings, these patients had higher levels of serum uric acid (p = 0.0005), phosphates (p < 0.0001), and creatinine (p = 0.02), as well as lower levels of total calcium (p = 0.0002), monocytes (p = 0.008), and lymphocytes (p < 0.0001). Moreover, all inflammatory markers (p = 0.001; p < 0.0001; p = 0.006, and p = 0.03) and Ca-P product (p < 0.0001) had higher baseline values in Group 2. Upon immunohistochemical analysis, regarding the density of neoformed vessels, there was a higher incidence of CD31-positive surfaces (p = 0.006) and CD31-positive relative surfaces (p = 0.001); the NLR (r = 0.323; p = 0.03), PLR (r = 0.381; p = 0.04), SII (r = 0.376; p = 0.03), and IL-6 (r = 0.611; p < 0.001) are all significantly correlated with vascular density, as evidenced by CD31. Heart failure, peripheral artery disease, obesity, and diabetes, as well as the systemic inflammatory markers (NLR, PLR, SII, IL-6), intimal hyperplasia, and CD31-positive relative surfaces are predictors of arteriovenous fistula maturation failures.

Transradial access for balloon-assisted maturation of arteriovenous fistulas.

Balloon-assisted maturation (BAM) of arteriovenous fistulas has conventionally been performed via direct fistula access. The transradial approach has not been well described for BAM, although its use has been reported throughout the cardiology literature. The purpose of the present study was to assess the outcomes of transradial access for its use with BAM. A retrospective review of 205 patients with transradial access for BAM was performed. One sheath was inserted into the radial artery distal to the anastomosis. We have described the procedural details, complications, and outcomes. The procedure was considered technically successful if transradial access had been established and the AVF had been ballooned with at least one balloon without major complications. The procedure was considered clinically successful if no further interventions had been required for AVF maturation. The average time for BAM via transradial access was 35± 20minutes, with 31± 17mL of contrast used. No access-related perioperative complications, including access site hematoma, symptomatic radial artery occlusion, or fistula thrombosis, had occurred. The technical success rate was 100%, and the rate of clinical success was 78%, with 45 patients requiring additional procedures to achieve maturation. Transradial access is an efficient alternative to trans-fistula access for BAM. It is technically easier and allows for better visualization of the anastomosis.

Role of Color Doppler Ultrasonography in evaluation of hemodialysis AV fistula

Background: A significant percentage of the Egyptian population is affected by end-stage kidney disease, which requires long-term hemodialysis. For patients receiving regular hemodialysis, the arteriovenous fistula is now the method most frequently employed to provide vascular access. Objective: The current study's objective was to assess the role and utility of CDUS in assessing vascular access and identifying shunt complications for hemodialysis. Patients and methods: This prospective, randomized controlled trial investigation has been carried out at the Health Insurance Hospital Nasr City's radio-diagnosis department. We included a sample size of thirty patients who needed an arteriovenous fistula in the upper limb for hemodialysis. Patients ranged in age from 8 to 70 and were both male and female. Results: The majority of patients had normal vessel diameters. 6 patients (20%) have a BB fistula, 8 patients (26.7%) have an RC fistula, and 15 patients (50%) have a BC fistula. The study showed a mean age of AVF maturation occurs 2.17 ± 0.379 weeks after its 1st creation. 3 patients had an uncomplicated 10% and 27 patients had shunt complications of 90%. The investigation revealed a significant percentage of venous thrombosis (12 patients, 40%), stenosis (9 patients, 30%), aneurysmal dilatation (6 patients, 20%), pseudoaneurysmal formation (3 patients, 10%), and finally steal syndrome (3.3%, 1 patient). Conclusion: Early identification and repair of a failing hemodialysis fistula can improve the quality of hemodialysis treatment. For patients having AV dysfunction, the CDUS results from this series were useful in determining further treatment care.

Temporal regulation of notch activation improves arteriovenous fistula maturation

BackgroundArteriovenous fistula (AVF) maturation is a process involving remodeling of venous arm of the AVFs. It is a challenge to balance adaptive AVF remodeling and neointima formation. In this study we temporally controlled Notch activation to promote AVF maturation while avoiding neointima formation.MethodsTemporal Notch activation was controlled by regulating the expression of Notch transcription factor, RBP-Jκ, or dnMAML1 (dominant negative MAML2) in vascular smooth muscle cells (VSMCs). AVF mouse model was created and VSMC phenotype dynamic changes during AVF remodeling were determined.ResultsActivated Notch was found in the nuclei of neointimal VSMCs in AVFs from uremic mice. We found that the VSMCs near the anastomosis became dedifferentiated and activated after AVF creation. These dedifferentiated VSMCs regained smooth muscle contractile markers later during AVF remodeling. However, global or VSMC-specific KO of RBP-Jκ at early stage (before or 1 week after AVF surgery) blocked VSMC differentiation and neointima formation in AVFs. These un-matured AVFs showed less intact endothelium and increased infiltration of inflammatory cells. Consequently, the VSMC fate in the neointima was completely shut down, leading to an un-arterialized AVF. In contrast, KO of RBP-Jκ at late stage (3 weeks after AVF surgery), it could not block neointima formation and vascular stenosis. Inhibition of Notch activation at week 1 or 2, could maintain VSMC contractile markers expression and facilitate AVF maturation.ConclusionsThis work uncovers the molecular and cellular events in each segment of AVF remodeling and found that neither sustained increasing nor blocking of Notch signaling improves AVF maturation. It highlights a novel strategy to improve AVF patency: temporally controlled Notch activation can achieve a balance between adaptive AVF remodeling and neointima formation to improve AVF maturation.Translational perspectiveAdaptive vascular remodeling is required for AVF maturation. The balance of wall thickening of the vein and neointima formation in AVF determines the fate of AVF function. Sustained activation of Notch signaling in VSMCs promotes neointima formation, while deficiency of Notch signaling at early stage during AVF remodeling prevents VSMC accumulation and differentiation from forming a functional AVFs. These responses also delay EC regeneration and impair EC barrier function with increased inflammation leading to failed vascular remodeling of AVFs. Thus, a strategy to temporal regulate Notch activation will improve AVF maturation.

Von Willebrand Factor: A Central Regulator of Arteriovenous Fistula Maturation Through Smooth Muscle Cell Proliferation and Outward Remodeling.

BackgroundArteriovenous fistula (AVF) maturation failure is a main limitation of vascular access. Maturation is determined by the intricate balance between outward remodeling and intimal hyperplasia, whereby endothelial cell dysfunction, platelet aggregation, and vascular smooth muscle cell (VSMC) proliferation play a crucial role. von Willebrand Factor (vWF) is an endothelial cell–derived protein involved in platelet aggregation and VSMC proliferation. We investigated AVF vascular remodeling in vWF‐deficient mice and vWF expression in failed and matured human AVFs.Methods and ResultsJugular‐carotid AVFs were created in wild‐type and vWF−/− mice. AVF flow was determined longitudinally using ultrasonography, whereupon AVFs were harvested 14 days after surgery. VSMCs were isolated from vena cavae to study the effect of vWF on VSMC proliferation. Patient‐matched samples of the basilic vein were obtained before brachio‐basilic AVF construction and during superficialization or salvage procedure 6 weeks after AVF creation. vWF deficiency reduced VSMC proliferation and macrophage infiltration in the intimal hyperplasia. vWF−/− mice showed reduced outward remodeling (1.5‐fold, P=0.002) and intimal hyperplasia (10.2‐fold, P<0.0001). AVF flow in wild‐type mice was incremental over 2 weeks, whereas flow in vWF−/− mice did not increase, resulting in a two‐fold lower flow at 14 days compared with wild‐type mice (P=0.016). Outward remodeling in matured patient AVFs coincided with increased local vWF expression in the media of the venous outflow tract. Absence of vWF in the intimal layer correlated with an increase in the intima‐media ratio.ConclusionsvWF enhances AVF maturation because its positive effect on outward remodeling outweighs its stimulating effect on intimal hyperplasia.

Long Term patency of Tunneled catheters in End Stage Renal Disease patients for vascular access- A single center study

Aim: To look for the success and survival rate of tunneled catheters in hemodialysis patients. Design: Prospective study Duration &amp; place of study: Department of Nephrology, Shaikh Zayed Hospital, Lahore from January 2017 to January 2018. Methodology: This study comprised of 71 consecutive subjects in whom tunneled catheters were inserted. The ESRD patients requiring permanent access for hemodialysis because of AVF failure, cardiomyopathy, waiting time for AVF maturation or renal transplantation were selected, those with previous permanent catheter insertions were excluded. The catheter was inserted in right internal jugular vein with doppler ultrasound. Result: The study included 71 patients; average age was 41±13 years, of them 43 were males. The success rate to insert catheter in an ideal location was observed in 73.2% and in non-ideal place in 26.8%patients. It was removed in67.6% and remained in situ till end of study in 32.4% patients. Functional AV fistula, renal transplantation and resolving AKI were elective reasons to remove catheters in 40%, 29% and 2% patients. The mean time of duration where tunneled catheter continued to serve as a vascular access and removed electively without catheter related problems was significantly different with Conclusion: The success rate of permanent catheter insertion was 99.2 % in our study. The catheter insertion under doppler ultrasound vision by a nephrologist offers a long lasting, safe and reliable alternative to restore a vascular access. Keywords: End Stage Renal Disease, Tunneled Catheter, Hemodialysis

A longitudinal study of the arterio-venous fistula maturation of a single patient over 15 weeks

Arterio-venous fistula creation is the preferred vascular access for haemodialysis, but has a large failure rate in the maturation period. Previous research, considering the remodelling mechanisms for failure-to-mature patients, has been limited by obtaining the patient-specific boundary conditions at only a few points in the patient history. Here, a non-invasive imaging system was used to reconstruct the three-dimensional vasculature, and computational fluid dynamics was used to analyse the haemodynamics for one patient over 15 weeks. The analysis suggested evidence of a control mechanism, which adjusts the lumen diameter to keep the wall shear stress near constant in the proximal regions of the vein and artery. Additionally, the vein and artery were shown to remodel at different growth rates, and the blood flow rate also saw the largest increase within the first week. Wall shear stress at time of creation may be a useful indicator for successful AVF maturation.

Factors Affecting Arteriovenous Fistula (AVF) Maturation

AVF requires postoperative maturation before cannulation to initiate hemodialysis treatment. AVF maturation usually takes about six weeks and depends on the development of vascular remodeling. However, AVF surgery is not always followed by successful maturation. Recent studies have shown that the rate of maturation failure in patients with chronic kidney disease undergoing AVF-type vascular access establishment is very high, ranging from 20% to 60%. The source search was carried out on the online portal of journal publications as many as 12 sources from Medscape, Google Scholar, National Center for Biotechnology Information (NCBI) with the keywords chronic kidney disease, hemodialysis, AVF, and maturation. Many factors are involved in the functional maturation of AVF, including age, sex, coagulation factors, lipid profile, hypoalbumin, venous diameter, diabetes, hypertension, peripheral vascular disease, smoking, obesity, and dialysis. Failure of AVF maturation results in insufficient blood flow to allow cannulation and initiation of hemodialysis.

Evaluation of Factors Affecting Wrist Radio-Cephalic Arteriovenous Fistula Maturation: A Single Institutional Observational Study

Background: Chronic renal failure is the most common indication for which arterio-venous (AV) fistula creation surgery is being performed. Various studies have found that native arteriovenous fistulas are the best in long-term patency with lower complications. We conducted this study to find out the role of preprocedural duplex ultrasound (DUS) in predicting outcomes of radio-cephalic fistula in the wrist in the North-Karnataka population. Methods: This prospective study was conducted from May 2019 to July 2020 on 50 patients who were hemodialysis-dependent and underwent AV fistula creation with age from 20 to 70 years. All the patients underwent preoperative DUS and were followed up post-operatively after one, two, and six weeks. Hemodialysis was initiated through the constructed fistula once it was mature, and the maximum blood flow through the fistula was measured. SPSS version 20.0 was used for statistical analysis. Results: Among 50 subjects, the overall cumulative success of AVF maturation was 86% (43), and failure to mature rate was 14% (7). Logistic regression of maturation outcome in the wrist autologous arteriovenous fistula for individual factors showed statistically significant results (P &lt; 0.05) for the diameter of the radial artery &gt; 1.6 mm and the distensibility of the cephalic vein &gt; 0.4 mm. Conclusions: Vein distensibility and radial artery diameter are key factors in predicting successful AVF maturation. The use of intraoperative papaverine instillation directly on vessels can improve arteriovenous fistula outcomes.

Effect of Radiocephalic Anastomotic Length on the Maturation of Arteriovenous Fistula

A radiocephalic arteriovenous fistula (RCAVF) is associated with better long-term patency and fewer complications. However, RCAVF have lower maturation rate for hemodialysis compared with upper AVF or arteriovenous graft. We performed this study to determine the effect of the radiocephalic (RC) anastomotic length on the AVF maturation. We reviewed the patients who underwent RCAVF creation with a side-to-end manner from March 2015 to December 2018. AVF maturation was defined as successful hemodialysis (HD) in at least two consecutive sessions. We compared the possible factors including the RC anastomotic length between the initial HD success group and initial HD failure group. A total of 114 patients underwent RCAVF creation: 72 males and 42 females (63.2% and 36.8%, respectively). The mean preoperative arteriotomy length of the AVF was 14.1 mm (range 11.0-16.0 mm). Out of 114 patients, initial HD was executed successfully in 83 patients (72.8%). Among the 31 patients with initial HD failure (27.2%) balloon angioplasty was successfully performed in 17 patients, failed in 4 patients, and not performed in 10 patients. The secondary success rate after balloon angioplasty was 87.7%. After factor analysis, pre-emptive AVF (P=0.01), vein diameter (P < 0.001), and flow rate (P < 0.001) were revealed significant factors for initial HD success, but not RC anastomotic length of AVF (P=0.55). The length of the radiocephalic anastomosis does not affect the RCAVF maturation rate statistically. However, lengthening of arteriotomy on the radial artery may increase the initial success rate of HD.

The effect of preprocedural serum albumin to fibrinogen ratio on arteriovenous fistula maturation

Background/Aim: Inflammation and inflammatory parameters are known to have unfavorable effects both on the surgical success and survival. The reference point of the present study are the results of an investigation of the effects of blood proteins such as albumin and fibrinogen, which affect blood viscosity, and other hematological parameters, on the success of arteriovenous fistula operations. Methods: This retrospective cohort study includes the data of 135 patients who underwent arteriovenous fistula surgery by the same surgeon in the same center. The patients were divided into two groups, as those with an active fistula 8–12 weeks after surgery and those with a dysfunctional fistula. After applying the exclusion criteria, the remaining data were compared using appropriate statistical methods to evaluate the influence on fistula maturation rates. Results: A statistical analysis performed after the evaluation of the fitness of the data to a normal distribution revealed fistula maturation to be associated with fibrinogen (P<0.001), albumin (P<0.001), fibrinogen-to-albumin ratio (FAR) (P<0.001) and neutrophil-to-lymphocyte ratio (NLR) (P=0.002). It was further noted that C-reactive protein (CRP) (P<0.001), CRP-to-albumin ratio (CAR) (P<0.001), neutrophil count (P=0.003) and lymphocyte count (P=0.03) all played a role in this process. A receiver operating characteristic (ROC) curve analysis revealed the cut-off values for fibrinogen (P<0.001, AUC: 0.930), CRP (P<0.001, AUC: 0.892), FAR (P<0.001, AUC: 0.988), CAR (P<0.001, AUC: 0.916), neutrophil count (P=0.011, AUC: 0.661) and albumin (P<0.001, AUC: 0.946) in terms of fistula maturation. Conclusion: The present study reveals that low albumin and high fibrinogen levels negatively affect AVF maturation. As reported previously in literature, and supported by the present study, high CRP levels may be associated with early AVF dysfunction.

Accuracy Of Spiral Laminar Flow, Spectral Broadening And Murmur / Thrill As Av-Shunt Maturuty Predictors In Dr. Mohammad Hoesin Hospital Palembang

Background : Hemodialysis is a therapy for end-stage cornic kidney disease (ESRD) which is most often used as renal replacement therapy. Vascular access for hemodialysis is essential in the management of patients with chronic kidney disease. One type of vascular access is av fistula. A well-matured AVF is needed in order to function optimally during the hemodialysis process. The study of Srivastava et al. In India examined a predictor parameter of the maturation of AVF using Doppler ultrasound. The parameters studied were Spiral Laminar Flow (SLF), Spectral Broadening and Murmur / thrill. The results of this study state that SLF is the most important and early predictor of AVF maturation.5 Research on the accuracy of spiral laminar flow, spectral broadening and murmur / thrill as predictors of av-shunt maturity has never been carried out in Indonesia. This encourages this research to be carried out.&#x0D; Method : This type of research is the prognostic test. The study was conducted in the vascular and endovascular subdivisions from July - September 2020 or until the number of research samples is met.&#x0D; Result : There were 30 samples in this study, Murmur / thrill had high sensitivity and specificity values ​​on day 21 while SLF and spectral broadening had very high sensitivity and specificity values ​​in predicting AVF maturase from day 7th and 21th, also had a significant association with AVF maturase (p &lt; 0.001).&#x0D; Conclusion : Murmur / thrill on 21th day can be a perdictor for maturity of AVF

Activation of EphrinB2 Signaling Promotes Adaptive Venous Remodeling in Murine Arteriovenous Fistulae

BackgroundArteriovenous fistulae (AVF) are the preferred mode of vascular access for hemodialysis. Before use, AVF remodel by thickening and dilating to achieve a functional conduit via an adaptive process characterized by expression of molecular markers characteristic of both venous and arterial identity. Although signaling via EphB4, a determinant of venous identity, mediates AVF maturation, the role of its counterpart EphrinB2, a determinant of arterial identity, remains unclear. We hypothesize that EphrinB2 signaling is active during AVF maturation and may be a mechanism of venous remodeling. MethodsAortocaval fistulae were created or sham laparotomy was performed in C57Bl/6 mice, and specimens were examined on Days 7 or 21. EphrinB2 reverse signaling was activated with EphB4-Fc applied periadventitially in vivo and in endothelial cell culture medium in vitro. Downstream signaling was assessed using immunoblotting and immunofluorescence. ResultsVenous remodeling during AVF maturation was characterized by increased expression of EphrinB2 as well as Akt1, extracellular signal-regulated kinases 1/2 (ERK1/2), and p38. Activation of EphrinB2 with EphB4-Fc increased phosphorylation of EphrinB2, endothelial nitric oxide synthase, Akt1, ERK1/2, and p38 and was associated with increased diameter and wall thickness in the AVF. Both mouse and human endothelial cells treated with EphB4-Fc increased phosphorylation of EphrinB2, endothelial nitric oxide synthase, Akt1, ERK1/2, and p38 and increased endothelial cell tube formation and migration. ConclusionsActivation of EphrinB2 signaling by EphB4-Fc was associated with adaptive venous remodeling in vivo while activating endothelial cell function in vitro. Regulation of EphrinB2 signaling may be a new strategy to improve AVF maturation and patency.

The Predictive Factors of Arteriovenous Fistula Maturation in Patients with End-Stage Renal Disease

Highlights Arterial diameter above 2 mm had an almost 5 times better AVF maturation outcome. Average age of ESRD patients who underwent the AVF procedure was above 50 years. Percentage of AVF maturation was higher in men. Hypertension was the most common comorbid factor in ESRD patients.