Brachiocephalic Arteriovenous Fistula Research Articles

Salvage of brachiocephalic aneurysmatic fistulas, using ePTFE graft with a minimally invasive approach.

In this study, we evaluated our surgical approach in requiring surgical treatment of brachiocephalic arteriovenous fistula (AVF) aneurysms for salvage of AVF. Between 2012 and 2022, 20 patients (16 men, 4 women; mean age 54.5 years) who were surgically treated for a brachiocephalic AVF aneurysm in our Cardiovascular Surgery Clinic were evaluated retrospectively. These 20 patients were operated on for aneurysm thrombosis and fistula failure in 16 patients, sudden rupture and severe bleeding in 3 patients, cosmetic reasons, and anxiety in 1 patient. These aneurysms were ligated and divided from distal and proximal cephalic veins. Then, a 6 mm dialysis graft was interposed between the well-developed cephalic vein distal and proximal to the aneurysm with small skin incisions. All patients were taken to dialysis via this dialysis graft 24 h after the procedure without any problem. All patients were discharged after dialysis. After surgery, no catheterization or any other additional procedure was required for hemodialysis. No complications, such as infection, hematoma, neurological damage, or ischemia, were observed after the surgical procedure. The mean postoperative follow-up was 12 months. In brachiocephalic AVF aneurysms requiring surgical treatment, hemodialysis can be continued with a graft placed in the same arm in this technique.

Hemodialysis Patients with High-Flow Arteriovenous Fistulas: An Evaluation of the Impact on Cardiac Function.

: Patients undergoing hemodialysis often experience changes in cardiac function when they have a high-flow arteriovenous fistula (AVF). This study aimed to assess the effect of high-flow AVFs on cardiac function in patients undergoing hemodialysis. : A longitudinal study was conducted on hemodialysis patients with high-flow AVFs. Echocardiographic parameters, such as left ventricular ejection fraction (LVEF), left atrial diameter (LAD), left ventricular end-diastolic dimension (LVEDD), right ventricular end-diastolic dimension (RVEDD), inferior vena cava diameter (IVCD), systolic blood pressure, and diastolic blood pressure, were measured and compared before and after AVF creation. : One hundred hemodialysis patients with high-flow AVFs (mean age: 55.95±13.39 years, mean body mass index: 24.71±3.43 kg/m²) were studied. LVEF significantly decreased (51.10%±5.39% to 47.50%±5.79%), while LAD, LVEDD, and IVCD significantly increased after AVF creation (P<0.05). Systolic (132.49±16.42 mmHg to 146.60±17.43 mmHg) and diastolic (79.98±8.40 mmHg to 83.33±9.68 mmHg) blood pressure substantially rose post-fistularization (P<0.001). Notably, LVEF reduction was more significant in brachio-cephalic AVFs (46.29%±4.24%) compared to distal radio-cephalic or snuffbox AVFs (49.17%±7.15%) (P=0.014). : High-flow AVFs can significantly affect echocardiographic parameters in hemodialysis patients, thereby increasing the risk of cardiac failure. Close cardiac monitoring may be necessary for early intervention. Distal AVFs may be preferable in patients with decreased cardiac function.

Preoperative mapping and multidisciplinary team are the key to success of arteriovenous access for hemodialysis

Introduction and objectivesFunctional and durable vascular access is needed for adequate hemodialysis. Arteriovenous fistula is preferred over prosthetic grafts or central venous catheters, but it is associated with high rates of primary failure and maturation failure.Preoperative mapping of arm vessels with color Doppler ultrasound (CDU) has been shown to be helpful in achieving better short and long-term outcomes. Unfortunately, is more time-consuming than a physical examination and requires an experienced examiner and special equipment; some authors defend that CDU should not be part of the routine preoperative assessment.We reported our experience in preoperative vessel mapping using color Doppler ultrasound to purpose a vascular access to the surgical team, surveillance of vascular access, and evaluation of main outcomes (primary failure, maturation failure, and patency). MethodsThis is a single-center retrospective study that includes patients who attended a specific appointment for vascular access planning consultation between January 2019 and December 2021. A nephrologist performed the physical exam and vascular mapping and proposed to the vascular surgeon team a specific type and location of vascular access. Patients were followed until one month after the first hemodialysis through functioning vascular access. ResultsIn this study, 167 patients were evaluated (114 incident patients – chronic kidney disease stage 4 or 5 – and 53 prevalent patients – under hemodialysis through central venous catheter). The vascular accesses proposed by nephrologist were radial-cephalic arteriovenous fistula in 70 patients (41.9%), brachio-cephalic arteriovenous fistula in 50 patients (29.9%), brachio-basilic arteriovenous fistula in 34 patients (20.4%), arteriovenous graft in 8 patients (4.8%) and central venous catheter in 2 patients (1.2%).Vascular access was constructed in 141 patients: distal arteriovenous fistula in 57 patients (40.4%), brachio-cephalic arteriovenous fistula in 54 patients (38.3%), brachio-basilic AVF in 27 patients (19.1%), and arteriovenous graft in 3 patients (2.1%). The created access corresponds to the proposed access in 129 patients (91.5%).Twenty-two (15.6%) primary failures were registered. Distal arteriovenous fistulas and diabetes mellitus were associated with a higher risk of primary failure (OR=3.929 (1.485–10.392), p=0.004; OR=3.867 (1.235–12.113), p=0.014, respectively).The incidence of maturation failure at eight weeks was 4.8%.The primary patency at 6, 12 and 24 months was 76.3%, 70.4% and 49.2%. Primary assisted patency was 84.8% at 6 and 12 months and 81.3% at 24 months. ConclusionsThis study demonstrates that the study of the entire vascular territory performed with color Doppler ultrasound, within a multidisciplinary team of nephrologists and vascular surgeons, is associated with high rates of autologous access and very low rates of primary failure and maturation failure (almost unprecedented in the literature).

An unintended connection – Radial arteriovenous fistula after coronary angiogram

Abstract The following case is of a 44-year-old female undergoing maintenance hemodialysis (MHD) due to chronic interstitial nephritis, utilizing a left brachiocephalic (BC) arteriovenous fistula (AVF). Following presentation with retrosternal anginal pain, diagnosed as high lateral wall myocardial infarction, coronary angiogram revealed normal coronaries. Subsequently, dilated veins along the right forearm were noticed, attributed to a patent right radiocephalic AVF. Despite being asymptomatic, the patient underwent a Doppler ultrasound confirming a blood flow of 400 ml/min through the AVF. No further intervention was planned as the patient continued MHD through the left BC AVF.

Salvage Aneurysmorrhaphy as an Adaptable and Still Pertinent Technique in the Management of Challenging True Aneurysms of Arteriovenous Fistulas: A Case Series of Different Variations, With Illustrative Surgical Pictures

Salvage Aneurysmorrhaphy as an Adaptable and Still Pertinent Technique in the Management of Challenging True Aneurysms of Arteriovenous Fistulas: A Case Series of Different Variations, With Illustrative Surgical Pictures

Pathologic change of an arterialized giant venous aneurysm of a brachiocephalic arteriovenous fistula

Aneurysmal venous dilatation is a frequent complication of arterio venous fistulas (AVFs) created for hemodialysis. Venous aneurysm rupture can lead to lethal hemorrhage. A 49-year-old male patient presented with a giant aneurysmal dilatation of his AVF 10 years after its creation. The patient had complaints of pulsating pain and discomfort due to swelling of the left forearm. We performed an aneurysm resection and revised the overlying dermal lesion through a brachial plexus block. Here, we describe the pathological features of the arterialized venous aneurysm compared to simple venous aneurysms.

A rare case report: compartment syndrome after brachiocephalic arteriovenous fistula formation in a hemodialysis patient

Introduction: Acute compartment syndrome is a condition in which increased pressure in the tight fascia space reduces capillary perfusion below the level required for tissue viability. Very few cases of acute compartment syndrome associated with dialysis have been reported. It can lead to severe damage to the tissues of the arm. Case Illustration: A 47-year-old woman with end-stage renal failure presented to the emergency room with swelling and pain in the right upper extremity and has lasted for a day. Three days before admission, the patient underwent right brachiocephalic arteriovenous (AV) fistula surgery. Physical Examination showed a blackish bruise at the fossa cubiti, radial and ulnar artery were not palpable, but there is trill at AV fistula. Decreased motoric strength, reduced hand sensation and decreased capillary return in fingers. Oxygen blood saturation of the right fingers could not be read. Diagnosis of acute compartment syndrome was made. The patient was immediately taken to the operating room for decompression surgery. Emergency compartment fasciotomy was performed. After fasciotomy, necrotomy was performed. Furthermore, brachiocephalic AV fistula was ligated. Postoperative evaluation obtained good radial and ulnar artery. Six months after the surgery, the wound was fully healed and no sign of neuromuscular or vascular deficit. Conclusion: Compartment syndrome is a possible complication after AV fistula formation that can have disastrous consequences. However, it can be effectively treated if detected and treated early. Prognosis of compartment syndrome after fasciotomy depends on how quickly the condition is diagnosed and treated.

Effect of flow reduction surgery in a patient with high flow arteriovenous fistula with aortic dissection using 4D flow magnetic resonance imaging: A case report.

This study aimed to investigate cardiovascular function in a patient with high-flow arteriovenous fistula (AVF) who underwent aortic dissection (AD) using four-dimensional (4D) flow magnetic resonance imaging (MRI) as well as analyze the effect of flow reduction surgery on AD. On March 12, 2017, a 60-year-old woman underwent emergency surgery for AD. After that, she experienced acute kidney injury, and hemodialysis was initiated. On April 24, 2017, a left brachiocephalic arteriovenous fistula (AVF) was created to facilitate her dialysis. However, after 5 years, the patient presented with a high-flow AVF, and a flow reduction surgery was performed on March 11, 2022. To evaluate the procedure's effectiveness, we measured the changes in left ventricular (LV) function and blood flow in the aorta and vascular access before and after surgery using 4D flow MRI. Notable changes were observed in LV function, blood flow in the aorta before and after the surgery, and maximum velocity and flow volume after surgery. During the 6-month follow-up after the surgery, the maximum velocity and flow volume in the aorta and vascular access were reduced; also, indicators such as LV volume, cardiac output, cardiac index, and LV mass were improved. In patients with high-flow AVF, flow reduction surgery should be considered as it may improve LV function and reduce the risk of AD recurrence by lowering the flow volume of the aorta.

Dual outflow upper arm arteriovenous fistula: An effective technique to prevent cephalic arch stenosis.

Cephalic arch stenosis (CAS) is critical point to maintain functional arteriovenous fistula (AVF) in patients undergoing hemodialysis with brachio-cephalic AVFs. In this study, we aimed to determine the effectiveness of dual outflow (cephalic and basilic veins) as a surgical method to prevent CAS. Between July 2016 and December 2019, 369 patients underwent upper arm AVF creation. Among them the 251 patients were enrolled in this retrospective study. Two hundred seven underwent brachio-cephalic arteriovenous fistula (BCAVF) and 44 underwent brachio-cephalicbasilic arteriovenous fistula (BCBAVF). From the 251 patients, diabetes mellitus (66.7% vs 36.4%, P < .001) and hypertension (91.3% vs 75%, P = .002) were more common in the patient group who underwent BCAVF surgery; however, the difference in volume flow to the fistula did not differ between the 2 groups. CAS (30.4% vs 9.1%, P = .004) and fistula occlusion (15.9% vs 4.5%, P = .048) were likely to occur in the BCAVF group. The primary patency rates at 12 months were 74.3% and 86.4% for the BCAVFs and BCBAVFs, respectively (P = .075). The primary-assisted patency rates at 12 months were 87.0% for BCAVFs and 93.2% for BCBAVFs, respectively (P = .145). Secondary patency rates at 12 months were 92.2% for BCAVFs and 93.2% for BCBAVFs, respectively (P = .023). Compared to BCAVF, traditional upper arm AVF, upper arm AVF with cephalic and basilic vein dual drainage can be optimal surgical method to preventing CAS.

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.

Predictors of Arteriovenous Fistula Maturation among Patients with Severe Obesity

There is an increasing prevalence of obesity among patients who develop end-stage renal disease and require dialysis. While referrals for arteriovenous fistulas (AVFs) among patients with class 2-3 obesity (i.e., body mass index [BMI] ≥ 35) are increasing, it is unclear what type of autogenous access is most likely to mature in this patient population. This study was designed to evaluate factors that impact maturation of AVF among patients with class ≥2 obesity. We retrospectively reviewed AVFs created at a single center from 2016 to 2019 for patients who had undergone dialysis within the same healthcare system. Ultrasound studies were used to evaluate factors that defined functional maturation, including diameter, depth, and volume flow rates through the fistula. Logistic regression models were used to evaluate the risk-adjusted association between class ≥2 obesity and functional maturation. A total of 202 AVFs [radiocephalic (24%), brachiocephalic (43%), and transposed brachiobasilic (33%)] were created during the study period, of which 53 (26%) patients had a BMI >35. Functional maturation was significantly lower among patients with class ≥2 obesity undergoing brachiocephalic (58% obese versus 82% normal-overweight; P=0.017), but not radiocephalic or brachiobasilic AVFs. This was primarily a result of excessive AVF depth in severely obese patients (9.6±4.0mm obese versus 6.0±2.7mm normal-overweight; P<0.001), whereas there was no significant difference found in average volume flow or AVF diameter between groups. In risk-adjusted models, a BMI ≥35 was associated with a significantly lower likelihood of achieving AVF functional maturation (odds ratio: 0.38; 95% confidence interval: 0.18-0.78; P=0.009) after controlling for age, sex, socioeconomic status, and fistula type. Patients with a BMI >35 are less likely to mature AVFs after creation. This principally affects brachiocephalic AVFs and occurs because of increased fistula depth as opposed to diameter or volume flow parameters. These data can help guide decision-making when planning AVF placement in severely obese patients.

Preoperative mapping and multidisciplinary team are the key to success of arteriovenous access for hemodialysis

Introduction and objectivesFunctional and durable vascular access is needed for adequate hemodialysis. Arteriovenous fistula is preferred over prosthetic grafts or central venous catheters, but it is associated with high rates of primary failure and maturation failure.Preoperative mapping of arm vessels with color Doppler ultrasound (CDU) has been shown to be helpful in achieving better short and long-term outcomes. Unfortunately, is more time-consuming than a physical examination and requires an experienced examiner and special equipment; some authors defend that CDU should not be part of the routine preoperative assessment.We reported our experience in preoperative vessel mapping using color Doppler ultrasound to purpose a vascular access to the surgical team, surveillance of vascular access, and evaluation of main outcomes (primary failure, maturation failure, and patency). MethodsThis is a single-center retrospective study that includes patients who attended a specific appointment for vascular access planning consultation between January 2019 and December 2021. A nephrologist performed the physical exam and vascular mapping and proposed to the vascular surgeon team a specific type and location of vascular access. Patients were followed until one month after the first hemodialysis through functioning vascular access. ResultsIn this study, 167 patients were evaluated (114 incident patients – chronic kidney disease stage 4 or 5 – and 53 prevalent patients – under hemodialysis through central venous catheter). The vascular accesses proposed by nephrologist were radial-cephalic arteriovenous fistula in 70 patients (41.9%), brachio-cephalic arteriovenous fistula in 50 patients (29.9%), brachio-basilic arteriovenous fistula in 34 patients (20.4%), arteriovenous graft in 8 patients (4.8%) and central venous catheter in 2 patients (1.2%).Vascular access was constructed in 141 patients: distal arteriovenous fistula in 57 patients (40.4%), brachio-cephalic arteriovenous fistula in 54 patients (38.3%), brachio-basilic AVF in 27 patients (19.1%), and arteriovenous graft in 3 patients (2.1%). The created access corresponds to the proposed access in 129 patients (91.5%).Twenty-two (15.6%) primary failures were registered. Distal arteriovenous fistulas and diabetes mellitus were associated with a higher risk of primary failure (OR=3.929 (1.485–10.392), p=0.004; OR=3.867 (1.235–12.113), p=0.014, respectively).The incidence of maturation failure at eight weeks was 4.8%.The primary patency at 6, 12 and 24 months was 76.3%, 70.4% and 49.2%. Primary assisted patency was 84.8% at 6 and 12 months and 81.3% at 24 months. ConclusionsThis study demonstrates that the study of the entire vascular territory performed with color Doppler ultrasound, within a multidisciplinary team of nephrologists and vascular surgeons, is associated with high rates of autologous access and very low rates of primary failure and maturation failure (almost unprecedented in the literature).

#2543 NEPHROFLOW FOR ESTIMATION OF VASCULAR ACCESS FLOW FOR HEMODIALYSIS: WHEN TO MEASURE?

Abstract Background and Aims Current guidelines emphasize the need for surveillance of vascular access (VA) for hemodialysis (HD), especially arteriovenous fistulas (AVF). Detecting a reduction in VA flow is auseful tool to anticipate the complications of VA as thrombosis. The DMed NephroFlow(NIPRO®) system, based on ultrasound dilution (UD) methods, has been shown tobe comparable to the classic Transonic® measurement system for estimating VA flow and canbe applied for VA surveillance. Our objetctive is to determine if there are significant differences when performing flow measurements with NephroFlow® between the first hour and the second hour of the HD session, as well as between any of the three days in which the patient attends HD. Method For two consecutive weeks, patients with AVF or graft (gAVF) on HD in our unit underwent VA flow measurements using the NephroFlow® system at the first and second hour of HD, on the 3 days that they attended HD sessions. Interspersing the first hour with the second each week to avoid significant loss in HD quality. For the study, we proceeded according to the usual recommendations of stable flow at 250 ml/min, corresponding ultrafiltration rate, needles in the same vein, without change in dry weight, with the same nurse staff, and transferring all patients to conventional HD. Results Twenty-one patients have been included, 13 male and 8 female, mean age 68±12.3 years. The mean time on HD was 36±23 months. The type of VA was: 10 patients presented a radiocephalic AVF, 5 brachiocephalic AVF, 2 patients a brachiobasilic AVF, and 4 patients a gAVF. The estimated mean flow obtained by NephroFlow ® in the first hour of all sessions and in the second hour was 1056 ± 754 and 1130.16 ± 769 ml/min, respectively; intraclass correlation index was 0.737 and K-W Test H 0.349 (p≤0.05). The mean flow on the first day was 1129±794.5ml/min, ICC = 0.662; second day 1027.5±729ml/min, ICC = 0.812; third day 1121.5±±ml/min, ICC = 0.774. In all cases p&amp;lt;0.05. Conclusion No significant differences have been observed in the VA flow estimated with the NephroFlow® ultrasound dilution system, neither at measurement time (the first or the second hour of HD session) nor day of performance (first, second or third day of HD session of the week). NephroFlow® UD system may be a useful tool for VA surveillance and could be applied when is necessary.

#5863 A NOVEL SELF-SEALING DIALYSIS PORT EVALUATION

Abstract Background and Aims There are several complications associated with hemodialytic vascular that arise from the incorrect cannulation, including aneurysms, infection, vessel damage, and uncontrolled bleeding. These risks severely limit treatment opportunities for self-cannulation by patients, which is necessary step for home hemodialysis. To improve quality of life and reduce complications, we developed a novel access port, called Safe Entry Port for AV fistuLae (SEAL), that integrates with fistulae, guides cannulation, and uses an internal colinear valve to prevent aneurysms with minimal risk of back-bleeding and infections (Figure 1A-C). Method The device was additively manufactured using direct metal laser sintering of FDA-approved Ti-6Al-4V. It was then polished and coated with silver-doped titanium nitride (TiN/Ag). The operation of the valve was tested in a mock circulation system using a peristaltic pump and Tyvek tubing to produce a pulsatile hydrostatic pressure gradient. The antimicrobial properties of the valve coating were evaluated in vitro against biofilm formation using standard assays for bacterial spreading area and turbidity. A custom computer-controlled robotic cannulation system was created to fatigue test the port as well as to determine the needle force required to open the valve. Finally, the device was implanted subdermally on a mature brachiocephalic arteriovenous fistula of an adult sheep and cannulated biweekly for six weeks. Device integration and host tissue reaction were evaluated using standard histopathological methods and micro-CT scanning. Results SEAL is engineered to integrate directly over a fistula via a Ti matrix (a mesh of small holes covering the sides of the device for interaction with host tissue). No fluid leaked through the valve during in vitro testing even under physiologically high circulatory pressure. In repeated cannulations of the device during ex vivo simulations with 14G dialysis needles, the peak force required to engage the valve recorded in our dialysis fatigue cycling simulation was 160.5 $ \pm $ 0.02 mN (Figure 1D, E). The device withstood cannulation cycles equivalent to 14 years of dialysis. Furthermore, the colinear valve smoothly opened for continuous flow through the needle guide (Figure 1F-I) and closed automatically under the tensile force similar to that of subcutaneous tissue. Antimicrobial TiN/Ag coating showed significant reduction in bacterial growth in both biofilm assays (Figure 1J,K). In preclinical trials, no signs of infection or backbleeding were observed during the continuous six-week cannulation period; vascular access was continuous with no resistance or complications. Conclusion We show that SEAL nearly eliminates backbleeding risk both in vitro and in vivo. The TiN/Ag coating of the colinear valve significantly limits bacterial biofilm formation ex vivo. Preclinical studies in the sheep model show that the device implanted on a mature fistula can easily be cannulated twice a week without any infection, cannulation complications, or backbleeding for an extensive period. SEAL has the potential to change the future of dialysis treatments, improve the quality of life for patients due the reduction of complications, and allow improved access to home hemodialysis.

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.

Brachiocephalic Arteriovenous Fistula Creation Below the Elbow Demonstrates Similar Patency Rates to Above-Elbow Anastomoses

Brachiocephalic Arteriovenous Fistula Creation Below the Elbow Demonstrates Similar Patency Rates to Above-Elbow Anastomoses

3D printed hemodialysis access and subcutaneous volume model as a guide for cannulation: A proof of concept training tool.

A 54-year-old underwent brachiocephalic arteriovenous fistula placement. Following maturation of the access, consistent cannulation for routine hemodialysis was challenging for clinical specialists. A three-dimensional intraluminal access model was generated, but clinical specialists adept at cannulation had difficulty orienting the model to the patient's anatomy without repeat supervision. When provided the model prima facie, 50% (4/8) clinical specialists were not able to spatially orient the model appropriately in the x-axis with respect to the coronal plane (2/8) or in the z-axis with respect to the transverse plane (2/8). Spatial renderings of the subcutaneous volume available for cannulation were then printed and physically applied to the vascular access model resulting in appropriate spatial orientation among all clinical specialists (n = 12) that were presented the models for the first time. Mean Kt/V increased during the 3-month period directly following model introduction. This case demonstrates the potential utility of 3D-modeling to readily visualize the subcutaneous volume of a hemodialysis vascular access and reduce cannulation error.

Brachiocephalic arteriovenous fistula maturity in end stage renal disease: The role of intraoperative brachial artery blood flow rate and peak systolic velocity.

Arteriovenous fistula (AVF) is the preferred vascular access option due to its lower risk of complications and better long-term outcomes. However, AVF maturation failure is still quite high. Achieving an adequate blood flow rate (BFR) through the AVF is essential for maintaining hemodialysis adequacy. This study aims to investigate brachial artery intraoperative BFR and peak systolic velocity (PSV) increase as a predictor of brachiocephalic AVF maturation. A multicenter retrospective cohort study was conducted on patients with end stage renal disease undergoing brachiocephalic AVF creation from July 2019 to February 2022 from five hospitals. Doppler ultrasound examinations of BFR and PSV were collected. BFR and PSV increases were calculated by comparing pre-operative and intraoperative results. Maturity was determined at 6 weeks postoperatively. This study included 83 patients, with 50 patients (60.24%) achieving maturity at 6 weeks. Brachial artery BFR difference has an excellent diagnostic value to predict brachiocephalic AVF maturation with an area under the curve (AUC) of 97%. BFR increase of 184.58 ml/min predicts brachiocephalic AVF maturity with a sensitivity of 100%, specificity of 84.8%, and accuracy of 93.98%. Meanwhile, brachial artery PSV increase has a low diagnostic value to predict brachiocephalic AVF with an AUC of 71.2%. PSV increase of 8.97 cm/s predicts brachiocephalic AVF maturity with a sensitivity of 82%, specificity of 51.5%, and accuracy of 69.9%. The increase in intraoperative brachial artery BFR and PSV in brachiocephalic AVF can be used as a useful parameter to predict AVF maturation.

The Importance of Perioperative Flow Evaluation and Prevention of Steal Syndrome in Arteriovenous Fistula Surgery Using Transit-Time Flow Measurement

Aim: Our aim is to evaluate the relationship between the survival time of arteriovenous (AV) fistula whose flows are measured with flow meter in patients with chronic renal failure who were operated for AV fistula (AVF) and present the results. Materials and Methods: In our clinic, we evaluated the flow meter measurement results with patency rates and usability after 6 months of AVF in 100 patients who underwent AVF operation due to chronic renal failure. Findings: In February 2012, transit-time flow measurement was put into use in our clinic. The last 50 consecutive patients with the same characteristics before this date constituted the control group (Group A) and the first 50 consecutive patients after this date constituted the study group. Radiocephalic fistula was made the most common (Group A, n = 50; Group B, n = 50). Nondominant upper extremity was selected when planning AVF for patients. First radiocephalic, then brachiocephalic AVF was performed. Fistulas flow was measured with an intraoperative flow meter. Those with bad flow were revised during the operation. Embolectomy was performed in one patient at the 2nd month due to fistula thrombosis, but it was not successful in one patient, and an AVF was opened with a graft. Results: While creating AVF, our aim is to use it effectively for a long time. By evaluating the fistula flows with the flow meter and make an intraoperative revision if necessary we ensure to extend the lifespan of a fistula.

Rupture infected pseudoaneurysm on brachiocephalic AV-fistula: emergency and definitive management

Background: Vascular access bleeding is a rare event that can be fatal in hemodialysis patients. It requires emergency and surgical management to reduce the risk of ischemic events in the patient’s forearm and reduce mortality risk. Objective: To describe the clinical presentation, emergency and surgical intervention, and outcome of rupture-infected anastomotic pseudo aneurysm of the brachiocephalic arteriovenous fistula that underwent a definitive surgical procedure. Case Description: A 55-year-old man presented with bleeding on the AV-fistula surgery site, accompanied with pain and swelling on his forearm that occurred 3 hours before admission to the hospital. The Patient had a history of brachiocephalic AV-fistula surgery 3 weeks earlier. On physical examination, It was found that the surgical site wound looked wet and swollen, with lots of necrotic tissue and pus and lost stitches. In Emergency Departments, the patient was administered intravenous normal saline fluids, bleeding inhibitors and pressure bandages to reduce ongoing bleeding. Then the patient had planned for immediate vascular reconstruction surgery. The brachial artery is repaired using great saphenous vein patch plasty. Results: The patient’s postoperative 30-days follow-up went well, and there was no sign of complication, such as pain, infection, paresthesia, bleeding at the surgical site or ischemia in the distal forearm. Conclusion: Vascular access bleeding can be fatal to hemodialysis patients. Optimal treatment for the patient's life and hemodialysis access is a top priority. A good assessment of the condition of AVF and the choice of subsequent therapy greatly affect the patient's prognosis.