Choice Of Vascular Access Research Articles

Management of some uncommon but significant complications of the tunneled cuffed catheter for hemodialysis.

Although use of the autogenous arteriovenous fistula is the first choice for vascular access for hemodialysis, the tunneled cuffed catheter (TCC) remains an important alternative method that is applied widely in maintenance hemodialysis for patients with end-stage renal disease. In addition to common complications, such as thrombosis, infection, formation of a fibrin sheath, or central vein stenosis, TCC dysfunction, such as kinks, cuff detachment, or mechanical destruction, can be easily overlooked. The reasons for these clinical problems are multifactorial and include the insertion handling, presence of diabetes mellitus, catheter type, malnutrition, and the patient's body habitus. This minireview describes our experience with TCC and the current literature on managing TCC dysfunction.

Factors Associated with the Initial Vascular Access Choice and Median Utilization Time in Hemodialysis Patients.

Factors Associated with the Initial Vascular Access Choice and Median Utilization Time in Hemodialysis Patients.

Comparative outcomes of surgical versus percutaneous arteriovenous fistulas: a prospective study.

For patients undergoing haemodialysis (HD), the choice of vascular access is pivotal in determining morbidity and mortality outcomes. Traditionally, native arteriovenous fistulas (AVFs) have been created through surgical procedures. However, percutaneous endovascular devices for AVF formation have been introduced into clinical practice, showing promising early results. This study aims to compare the outcomes of endovascular AVFs (endoAVFs) created using the WavelinQ EndoAVF System (BD, Franklin Lakes, NJ, USA) and surgically created radiocephalic (RC) AVFs in real-world settings. This prospective, single-centre, two-arm study included patients who underwent the creation of either an endoAVF using the WavelinQ EndoAVF System or an RC AVF at a university hospital between December 2021 and August 2023. A total of 20 patients who underwent an endoAVF and 40 who underwent a surgical AVF (SAVF) were included. Technical success was 100% in both groups. A total of 75% of the endoAVFs and 60% of the SAVFs met the criteria for physiological suitability. Among the AVFs that reached physiological suitability, the cannulation rate was 66% for the endoAVFs and 70.86% for the SAVFs. At the 6-month follow-up, the primary and cumulative patency rates were 65% and 75% in the endoAVF group and 57.5% and 60% in the SAVF group, respectively. At 12months, these rates were 50% and 70% in the endoAVF group and 50% and 60% in the SAVF group, respectively. No serious adverse events were observed. The reintervention rate was 0.25/patient/year in the endoAVF group and 0.1 in the SAVF group. The results of our study showed endoAVFs may be a safe and effective alternative to RC AVFs, showing high rates of technical success and patency with a low rate of reinterventions and complications.

Challenges to preserve vascular access functioning after surgical correction for arteriovenous access ischemic steal in hemodialysis patients: A single-center study.

Arteriovenous access ischemic steal (AVAIS) is a rare complication that causes morbidity and threatens hemodialysis access usability in patients with end-stage kidney disease (ESKD). This study aimed to determine the incidence of AVAIS over a 15-year period and assess the access usability after surgical correction. Access operations between January 2007 and August 2022 at Helsinki University Hospital were reviewed. Demographics, clinical, duplex, and contrast examinations with brachial artery volume flows, finger pressures, and delays to surgery were evaluated. Symptom relief, complications, access closures/re-interventions, primary, secondary, and functional patencies were assessed. Endpoints were permanent cessation of access use due to complication(s), transplantation, closure, definitive occlusion, or death. Among 2914 access-related operations, the overall incidence of AVAIS was 2.2%. At the first vascular consultation 52% had ulcer(s) or gangrene(s) resulting in 28 direct closures, and 30 corrections as follows: 20 proximalization of arterial inflow (PAI), 6 flow reduction procedures, 2 distal revascularization with interval ligation (DRIL), 1 distal radial artery ligation (DRAL), and 1 venous bypass. The median time from consultation to surgery was 18 days (range: 0-348 days) for direct closures and 43 days (0-170 days) for corrective surgery. The functional patencies after correction were 60% at 1 year and 55% at 2 years; the primary patencies were 45% and 28% and secondary patencies 61% and 57%, respectively. The functional patencies after PAI were 41% and 31%, respectively. In AVAIS, access preservation is challenging in ESKD patients with multiple diseases. Attention should be paid to the original choice of vascular access by considering each patient's risks. Delay to vascular consultation and intervention should be minimized. PAI should be reserved for selected patients when no other option is preferable.

Elevated Interleukin-6 Is Associated with an Increased Risk of Long-Term Arteriovenous Fistula Failure for Dialysis.

Background/Objectives: The autologous arteriovenous fistula (AVF) is the preferred choice for vascular access in patients with end-stage kidney disease (ESKD) undergoing maintenance hemodialysis. However, in the long term, the primary patency of AVF is suboptimal, with an AVF failure of approximately 30% in one year. The aim of this study is to examine how the pre-operative baseline levels of interleukin-6 (IL-6) affect long-term AVF failure. Methods: This retrospective, observational study involves ESKD patients admitted to the Vascular Surgery Clinic for AVF creation from January 2020 to December 2023. Ultimately, a total of 91 patients whose AVFs matured and began dialysis were enrolled. Prior to surgery, each patient underwent a thorough blood sample collection, with IL-6 levels assessed. The patients were categorized into two groups: those with functioning AVFs and those with dysfunctional AVFs. Their progress was monitored via a review of medical records, telephone interviews, or direct contact. Following the surgery, patients were observed for an average of 1.53 ± 0.94 years. Results: During the follow-up, patients who experienced AVF failure had a higher incidence of diabetes mellitus (p = 0.019) and active smoking (p = 0.012), as well as higher levels of IL-6 (p < 0.001). At ROC analysis, we found a strong association between IL-6 value and AVF failure (AUC: 0.814, p < 0.001), with an optimal cut-off value of 7.08 (76.5% Sensitivity and 79.7% Specificity). Furthermore, at the survival curve Kaplan-Meier analysis, we observed a higher occurrence of AVF failure in patients with baseline IL-6 values above the median (p = 0.004), in tertile 3 (p = 0.002), and above the optimal cut-off value (p < 0.001). At cox-regression analysis, elevated baseline IL-6 levels are associated with AVF Failure (HR: 2.23, p < 0.001). Conclusions: In the current study, we demonstrated that elevated IL-6 levels at baseline are associated with long-term AVF failure, independent of age, sex, and cardiovascular risk factors.

Comparison of the Symmetrik-Tip vs Split-Tip Tunneled Hemodialysis Catheter: A Retrospective Randomized Trial

ABSTRACT Background: Despite not being the primary choice for vascular access in hemodialysis patients, permanent tunneled catheters are commonly utilized but exhibit elevated rates of complications and dysfunction. This study retrospectively compares the dysfunction durations of symmetric and asymmetric-tipped permanent hemodialysis catheters. Materials and Methods: A total of 307 patients who underwent the placement of either symmetric or asymmetric-tipped permanent tunneled catheters at our interventional radiology clinic between 2021 and 2023 were included. The study aimed to examine the dysfunction rates associated with each type of catheter. Results: Among the included patients, 157 were male (51.1%), and 150 were female (48.9%), with an average age of 65.2±12.2 years. The catheters were predominantly placed in the right jugular in 242 patients (78.8%), followed by the left jugular in 59 patients (19.2%), and femoral placement in 6 patients (2%). Symmetric-tipped catheters were employed in 161 patients (52.4%), while asymmetric-tipped catheters were utilized in 146 patients (47.6%). During follow-up, the catheter dysfunction rate was significantly higher in split-tip catheters than in symmetrical-tip catheters (P&lt; 0.0001). Conclusion: The study revealed a statistically significant increase in catheter dysfunction for the asymmetric-tipped catheter type.

Prevalence and Center Variability of Catheter-Based Hemodialysis in Vienna: Insights from the Vienna ACTS NOW Study.

Objectives: The choice of vascular access continues to be a critical component in the management of hemodialysis patients. Despite the international consensus favoring arteriovenous (AV) fistulas, the use of central venous catheters (CVCs) remains prevalent, with substantial variations across countries and even among dialysis centers within the same region. This study examines the prevalence of CVC use among chronic hemodialysis (CHD) patients in Vienna, Austria, and explores inter-center differences. Methods: A cross-sectional analysis was conducted on patients receiving CVC-based CHD in Vienna as of March 2023. Patient demographics, comorbidities and their hemodialysis history were collected. Additionally, a subset of the population underwent vascular access (VA) mapping to assess eligibility for AV fistula (AVF) or AV graft (AVG) creation. Results: A total of 335 patients received CVC-based hemodialysis, equaling a CVC proportion of 42.5%. 191 (57.0%) patients on CVC-based CHD gave their consent to record their clinical data and vascular access history. Of the 191 included patients, 61 gave their consent to receive VA mapping. Of the 61 patients who received VA mapping, 60 (98.4%) were eligible for an upper extremity AVF or AVG. There was no significant difference regarding patient demographics, dialysis vintage, history of previous AVF or AVG or Charlson Comorbidity Index between the mapping and non-mapping group. The odds ratio of having a CVC in the absence of in-house vascular surgery was 3.41 (95% CI: 2.31-5.02, p-value < 0.001) compared to patients with in-house vascular surgery. Conclusions: The majority of patients that consented to ultrasound VA mapping fulfilled vascular requirements for AVF or AVG creation. Our study highlights the potential to decrease the prevalence of CVC-based CHD in Vienna that could translate to a reduction in CVC-associated complications.

Comparative Study between One Year Patency of Brachio- Basilic Arteriovenous Fistula versus Brachial to Basilic Forearm Loop Graft in End Stage Renal Disease Patients

Abstract Background Autogenous arteriovenous fistula (AVF) is considered the first choice for vascular access. Transposed arteriovenous fistulas include transposed brachial-basilic arteriovenous fistulas and transposed brachial-brachial arteriovenous fistulas, both basilic vein and brachial vein are too deep to cannulate, so requires transposition to be accessible. Aim of the Work to compare the outcomes of patients treated with a Brachio-basilic arteriovenous fistula with those of patients treated with the polytetrafluorethylene (PTFE) brachial to basalic loop graft. Methods This prospective cohort observational study included 50 patients with end stage renal disease (ESRD) on regular hemodialysis who were divided into two equal groups; group A: included patients who underwent the Basilica forarm polyteterafloruracil arteriovenous graft (BBAVG) and group B: included patients who underwent Basilic vein transposition or basilic vein superficialization (BBAVF). Results There was no statistically significant difference between the two studied groups regarding age, gender, clinical characteristics, primary, assisted primary or secondary patency rates, functional maturity at 1, 3, and 6 months, early postoperative bleeding (p = 0.312), late postoperative bleeding (p = 1), early postoperative mortality (p = 1), thrombosis (p = 0.018), late postoperative thrombosis (p = 0.157), early postoperative mild Infection (p = 0.123), early postoperative sever infection (p = 1), late postoperative mild infection (p = 0.074) and late postoperative sever infection (p = 0.297). Conclusions Both BBAVF and PTFE brachial to basilic loop graft can be considered as viable options for vascular access in this patient population. The choice of procedure may depend on individual patient factors, as well as the risk of thrombosis, which should be carefully evaluated.

#1487 Preoperative ultrasound vascular mapping as a predictor of arteriovenous fistula survival: a prospective cohort study

Abstract Background and Aims The morbidity and mortality of hemodialysis (HD) patients is directly related to the vascular access (VA) type. The arteriovenous fistula (AVF) is considered the VA of choice. When compared to the use of catheter, the use of AVF encompasses a lower infectious complications rate and a higher survival rate. The use of catheter has been independently associated with an increased risk of morbidity and mortality, especially during the first year of treatment. It is essential that HD programs maintain a high incidence and prevalence of AVF as a VA. For that reason, a multidisciplinary management is mandatory, with the collaboration of nephrologists, vascular surgeons, radiologists, and nurses. All patients who have an indication of AVF should have a prior ultrasound vascular mapping performed by the nephrologist to determine the most appropriate type of AVF. According to guidelines, there are several factors that increase the risk of AVF failure including advanced age, history of smoking, diabetes mellitus and peripheral vascular disease, among others. Therefore, the aim of this study is to determine the benefits of performing a preoperative ultrasound vascular mapping in terms of AVF survival. The secondary objective is to associate some risk factors to a higher rate of AVF failure. Method We conducted a prospective cohort study between January 2020 and December 2023. The viability of AVF was compared between AVF resulting from a preoperative ultrasound vascular mapping and those AVF without previous mapping. A multivariate analysis was performed with the entire population to determine the factors related to AVF survival. Results This study analyzed a total of 136 AVF, both native and prosthetic. Our population included 106 patients, mostly men (69.79%), with a median age of 68 years old (IR: 56-76), and history of smoking in a 39.10%, of diabetes in a 42.43%, and of peripheral vascular disease in a 17.54%. A preoperative ultrasound vascular mapping was previously performed in 107 AVF (78.7%). A total of 93 AVF were functional (68.4%). Regarding the analyzed risk factors of AVF failure (including advanced age and history of smoking, diabetes mellitus and peripheral vascular disease, and elbow/wrist AVF), we observed that advanced age and elbow AVF were related to higher survival of the AVF (p = 0.048 and p = 0.01 respectively). In the multivariate analysis we observed that advanced age and elbow AVF were independent predictors of AVF survival (p = 0.038 and p = 0.001, respectively). When comparing the cohorts, in the AVFs were the preoperative vascular ultrasound was performed, 78 AVF were functional (72.9%). In the AVFs were no mapping was performed, 15 AVF were functional (51.7%). This difference was statistically significant (p = 0.03). This implies a 21.2% increase in the probability of AVF survival when performing our AVF mapping. Conclusions The performance of a preoperative ultrasound vascular mapping by the nephrologist in our population has been associated to a significant increase in AVF survival. For that reason, we consider that it is an indispensable tool for the creation and monitoring of VA. When analyzing risk factors classically associated to AVF failure, we found that advanced age and elbow AVF were independent predictors of higher AVF survival. Other risk factors, such as history of diabetes mellitus, smoking, and peripheral arterial disease, were not significantly related to AVF failure in our population.

#3055 Replacement of tunneled cuffed hemodialysis catheters on coated guidewire: a strategic approach to treat CVC-related infections

Abstract Background and Aims Infections of tunneled hemodialysis central venous catheters (CVCs) are a serious problem, and the outcome of dialysis patients strongly depends on their clinical management. Several specialists are involved in choosing the appropriate technical and clinical strategy but often there is no consensus among them on the proper management. We believe that the role of nephrologists must be pivotal in this setting throughout the entire process, from the choice of vascular access to the management of complications. Here, we present our experience using an approach to replace CVCs that was conceived to minimize the rate of infections. Method We propose a CVC replacement technique to minimize the risk of contamination by using a guidewire coating that allow no contact between the old and new CVC. We carried out a retrospective observational study of tunneled CVCs replacement with this technique performed at the Nephrology Unit of the "A. Gemelli Polyclinic" between January 2020 and June 2023. The following parameters were analyzed: age, sex, infection-supporting pathogen, CVC age, and dialysis age. Results During the reporting period, we carried out a total of 87 CVC guidewire replacement procedures for HD tunneled catheters defined “access to be preserved” using our technique. Among the patients (median age 70,6) undergoing this procedure, n=5 (5.75%) presented with endocarditis (n=4 by Staphylococcus aureus, n=1 by Pseudomonas aeruginosa). The follow-up ranged from 6 months to 3 years. During this time only one patient, with endocarditis, had a recurrent infection caused by Pseudomonas aeruginosa after 3 months from the CVC replacement whereas 12 patients presented a de novo CVC infection caused by a different pathogen (n=4 by Staphylococcus aureus, n=1 by Pseudomonas Aeruginosa. Conclusion Overall, our data are encouraging as the lower rate of recurrent infections in our cohort suggests that our CVC replacement technique can be potentially used even in case of dangerous pathogens.

#2192 Aging dialysis population and late referral: two factors influencing the choice of vascular access

Abstract Background and Aims The decision on the type of vascular access for hemodialysis is based on several factors including the timing of renal replacement therapy initiation and certain patients’ clinical and demographic features. We hypothesized that the increasing age of patients on hemodialysis and the issue of "late referral" can be relevant in this context and favor the use of central venous catheter (CVC) over arteriovenous fistula (AVF), with a surge in catheter-related complications. Method We carried out a retrospective observational study of vascular access procedures (AVF creation and long-term CVCs placement) performed at the Nephrology Unit of the “Fondazione Policlinico Universitario Agostino Gemelli” between January 2020 and December 2023. Results A total of 415 procedures for AVF creation (median age 63.5, IQR 55.5 - 71.5 years), of which 59 (14,2%) in “late referral” patients (median age 61, IQR 47.5 - 72.5 years), were performed. During the same period, 343 CVCs were placed, of which 151 (44%) in patients with planned admission as previously evaluated by a nephrologist (median age 69, IQR 60 - 79 years). The remaining 192 CVC placements (56%) involved patients after an emergency admission (median age 69, IQR 57 - 80 years). In 56 (29%) of these patients an AVF was created concurrently or within 60 days from the emergency procedure. Such patients were significantly younger (median age 66, IQR 57 - 73 years) than those who underwent a CVC placement after a planned admission (p=0.01) or others with emergency admission (p=0.03). In a multivariate analysis (logistic regression) the use of CVC over AVF was significantly and independently correlated with both late referral and age. Conclusion These data suggest that the increasing use of CVCs in hemodialysis may be due to the age of incident patients and remark the importance of early evaluation in order to choose the most appropriate vascular access.

Patients, healthcare providers, and general population preferences for hemodialysis vascular access: a discrete choice experiment.

A patient-centered dialysis treatment option requires an understanding of patient preferences for alternative vascular accesses and nephrologists often face difficulties when recommending vascular access to end-stage kidney disease (ESKD) patients. We aimed to quantify the relative importance of various vascular access characteristics to patients, healthcare providers and general population, and how they affect acceptability for patients and healthcare providers. In a discrete choice experiment, patients with maintenance hemodialysis (MHD), healthcare providers, and individuals from the general population were invited to respond to a series of hypothetical vascular access scenarios that differed in five attributes: cumulative patency, infection rate, thrombosis rate, cost, and time to maturation. We estimated the respondents' preference heterogeneity and relative importance of the attributes with a mixed logit model (MXL) and predicted the willingness to pay (WTP) of respondents via a multinomial logit model (MNL). Healthcare providers (n = 316) and the general population (n = 268) exhibited a favorable inclination toward longer cumulative patency, lower access infection rate and lower access thrombosis rate. In contrast, the patients (n = 253) showed a preference for a 3-year cumulative patency, 8% access infection rate, 35% access thrombosis rate and 1.5 access maturity time, with only the 3-year cumulative patency reaching statistical significance. Among the three respondent groups, the general population found cumulative patency less important than healthcare providers and patients did. Patients demonstrated the highest WTP for cumulative patency, indicating a willingness to pay an extra RMB$24,720(US$3,708) for each additional year of patency time. Patients and healthcare providers had a strong preference for vascular access with superior patency. While the general population preferred vascular access with lower thrombosis rates. These results indicate that most patients prefer autogenous arteriovenous fistula (AVF) as an appropriate choice for vascular access due to its superior patency and lower complications than other vascular access types.

Transradial versus transfemoral access for diagnostic cerebral angiography: frequency of acute MRI findings in 500 consecutive patients at a single center

BackgroundThe frequency of clinically symptomatic and asymptomatic diffusion-weighted imaging (DWI) hyperintense lesions and their correlation with the transradial artery (TRA) approach is unclear.ObjectiveTo assess the frequency of abnormal diffusion restriction...

A modeling study of position and orientation of hemodialysis needles and the impact on vascular access

Patients with chronic kidney disease (CKD) need renal replacement therapy (RRT) and the favored method is hemodialysis (HD). An arteriovenous fistula is the preferred choice of vascular access, with two metal needles used to transfer the blood with waste to the dialysis machine and return the blood without waste from the dialysis machine to the patient’s body. However, wounds on the veins can cause blood clots which if left untreated could be life threatening. The hemodialysis needles can cause vascular wall abnormalities. The position and orientation of these needles might cause intimal hyperplasia (IH) and finally lead to blood clots. This study aims to analyze the hemodynamic effects on the vascular endothelium in AVF vascular access. A 15G needle was placed inside a vein at angles of 20°, 40°, and 90° with normal insertion and flipped needle in an idealized cephalic vein with the bore of the needle centrally located, conforming to standard cannulation practice. The 3D model created by SolidWorks consists of shaft, back eye, bevel, and vein only; the vein and 15G needle were assembled together. The mathematical model of blood rheology in this paper used Carreau’s law in the fluid domain. It was imported into Ansys CFX for calculation, a finite volume based software, which was implemented to solve the governing equations of the blood flow. The result showed that if the venous needle was not towards the venous return, a vortex appeared at the vein both upstream and downstream due to the venous needle, resulting in wall shear stress at the vein increasing significantly, and the flipped bevel seems to cause higher wall shear stress. For antegrade positioning of the vein vascular access return in the model when normally inserted, it was found that only 1% of the flow out of the back eye and vortex occurred downstream of the vein. Needles placed at a higher angle can increase wall shear stress and pressure on the vein. The flipped bevel is not significant in terms of either pressure or wall shear stress. However, when the needle is placed at a greater angle, wall shear stress and pressure on the vein were also increased. The flipped bevel caused higher wall shear stress and pressure when increasing the needle angle. Jetting from the venous needle causing intimal hyperplasia (IH) leads to blood clots, pain on the vein, and ultimately arm pain. Thus, the best cannulation procedure is for the venous needle to be toward the venous return, at a lower angle, and with the tip of the needle on the middle of the vein. Furthermore, the back eye should not be used for the venous needle but should be used for the arterial needle.

Diagnostic performance and inter-reviewer agreement of colour Doppler ultrasound in haemodialysis fistula and graft complications: a multicentre prospective study.

Haemodialysis provides various options for vascular access, including native arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs), and central intravenous catheters. However, the use of catheters should be avoided due to their association with greater risks when opposed to AVFs or AVGs. AVFs have garnered strong endorsement as the favoured vascular access choice for extended haemodialysis. A total of 200 patients initially diagnosed with AVF/AVG dysfunction were referred to the radiology department across 3 different institutions. The inclusion criteria involved patients who encountered repeated difficulties with access cannulation during dialysis. Conversely, the exclusion criteria comprised cases that had been solely assessed using colour Doppler ultrasound (CDUS), those exclusively evaluated with digital subtraction angiography (DSA), situations where DSA was not feasible, instances requiring immediate intervention due to acute access failure, and cases in which patients refused participation. Inter-observer agreement regarding complications of AVF/AVG was very good for the identification of thrombus (κ = 1.0), seroma (κ = 0.953), aneurysm (κ = 0.851), and pseudoaneurysm (κ = 0.851). It was considered good for the detection of juxta-anastomosis stenosis (κ = 0.751) and feeding artery stenosis (κ = 0.638). However, he agreement was fair for identifying draining vein stenosis (κ = 0.380) and distal arterial steal syndrome (κ = 0.210). The overall diagnostic performance of CDUS exhibited 86% sensitivity in identifying stenosis, with a specificity of 99.1%, a positive predictive value (PPV) of 96.5%, a negative predictive value (NPV) of 97%, and an accuracy of 94.3%. CDUS is a noninvasive diagnostic approach for the prompt picking of AVF complications. It serves as a suitable first-line imaging modality for nonfunctional AVF due to its cost-effectiveness and accessibility. Additionally, we provide evidence of reproducibility, encouraging the diligent use of CDUS in AVF and AVG evaluation for early complication detection and management guidance.

Vascular Access Blood Purification Treatments in Chronic Renal Failure: Impact on Quality of Life

Objective: To observe the effects of blood purification treatment and assess the prognostic impact of different vascular pathways on patients with chronic renal failure (CRF). Methods: A retrospective analysis of clinical data was conducted on 68 CRF cases, categorizing them based on their choice of blood purification vascular access. Group A received an autologous arteriovenous fistula, Group B received an internal jugular vein tunneled polyester sleeve catheter, and Group C received a polytetrafluoroethylene graft vascular fistula. Clinically relevant observation indicators, complication rates, and quality of life scores among the three groups were compared. Results: No significant differences were found between the three groups regarding observed values of clinically relevant indicators and quality of life scores (P &gt; 0.05). When comparing thromboembolism rates Group A had the highest rate, followed by Group C and Group B; for infection rate comparison, Group C had the highest rate, followed by Group B and Group A (P &lt; 0.05). Conclusion: In comparison with the other two vascular access methods, although autologous arteriovenous fistula poses a higher risk of thromboembolism, it exhibits a lower infection rate. Therefore, it is recommended as the preferred vascular access form for blood purification in patients with CRF. If this approach is unavailable, careful consideration should be given. The use of an internal jugular vein with a tunneled polyester sleeve catheter is suggested to better ensure the effectiveness and safety of the patient’s treatment.

Right Access at the Right Time: Choice and Timing of Predialysis Vascular Access.

Right Access at the Right Time: Choice and Timing of Predialysis Vascular Access.

Risk factors for arteriovenous fistula dysfunction in hemodialysis patients: a retrospective study

Arteriovenous fistula (AVF) is the first choice of vascular access in hemodialysis (HD) patients. However, the correlations between patient factors and the arteriovenous fistula patency remain unclear. Therefore, our study investigates the risk factors associated with AVF dysfunction in HD patients. A total of 233 end-stage renal disease (ESDR) patients who met the study inclusion criteria in the Nephrology Department of Hunan Provincial People’s Hospital between December 2020 and June 2022 were included in this study. The baseline demographic, clinical and laboratory parameters were collected at the time of AVF creation and analyzed. Of the 233 ESRD patients, 146 (62.7%) were male and the mean age was 56.11 ± 12.14 (21–82) years. The patients were followed for a median time of 14 months. Kaplan–Meier analysis showed a 6-, 12- and 24-month post-placement survival of 87.1%, 82.8% and 80.7%, respectively. Univariate Cox regression analysis revealed weight (HR, 1.03; P = 0.03) as a predictor for the loss of vascular access functionality. In addition, multivariate Cox regression analysis further demonstrated that sex (HR, 3.41; P = 0.03), weight (HR 1.08; P < 0.01) and phosphorus level (HR: 3.03; P = 0.01) are independent risk factors for AVF dysfunction. AVF dysfunction is highly associated with several risk factors including weight, phosphorus level, and sex. Positive intervention strategies targeting these potential factors, such as weight loss or oral phosphate binders could improve the long-term success of AVF.

Complications according to intrathoracic versus extrathoracic venous access for cardiac device implantation: results from the PLACE (Planning Lead Access for Cardiac Electrostimulation) study

Abstract Background and Aims The choice of the vascular access for cardiac pacing devices (CIED) implant may impact on patients outcome. Recent studies and consensus documents encourage the use of an extra-thoracic access to prevent adverse events. In this large, multicenter, retrospective study we report the impact of leads access on post-procedural outcome. Methods Consecutive patients receiving a CIED from 2008 to 2019 in 4 high-volume Italian hospitals were enrolled. Short- and long-term complications (i.e. pneumothorax, cardiac tamponade, pocket decubitus, pocket hematoma, lead dislodgement, lead failure) were collected and their relationship with the type of vascular access (extra- vs intra-thoracic, i.e. cephalic vein/extra-thoracic axillary vein vs subclavian vein puncture) was analyzed. Primary endpoint was the occurrence of at least one complication during follow-up. Results A total of 4,443 patients were enrolled; 3,374 (75.9%) received a pacemaker (PM) and 1,069 (24.1%) an implantable cardioverter defibrillator (ICD). Mean follow-up was 1,630±1,010 days. At least one complication occurred in 7.6% of patients. At multivariate Cox regression analysis, adjusted for baseline confounders, the presence of structural heart disease (HR 1.59, 95%CI 1.21-2.10; p=0.001), anticoagulant therapy at implantation [HR 1.31, 95%CI 1.0004-1.71; p=0.05) and female gender (HR 0.78, 95%CI 0.63-0.98; p=0.03) were associated with the primary outcome measure. Extra-thoracic access did not reduce the risk of complications compared to intra-thoracic access (HR 0.97, 95%CI 0.76-1.25 p=0.81). The use of both accesses in the same patient conferred a significant increase in the risk of complications (HR vs single approach:1.95, 95%CI 1.41-2.69; p &amp;lt;0.001). Conclusions The choice of a different vascular access (intra- vs extra-thoracic) does not impact on post-procedural complications in patients receiving CIED. In particular, the intra-thoracic subclavian vein puncture by experienced operators is not related to a poorer outcome. The need for both types of access in the same patient (i.e. increased procedure complexity) increases the risk of post-procedural complications.Graphical abstract

Percutaneous Placement and Management of High-flow Catheter for Hemodialysis: The Case for DualCath, Two-tunneled, Single-lumen Silicone Catheters

Abstract Introduction: Tunneled central venous catheters (CVCs) are often regarded as the final choice for vascular access in patients needing extracorporeal renal replacement therapy due to their higher morbidity, lower performance, and increased cost. The inherent limitations of tunneled CVCs have been recognized and extensively analyzed in numerous studies. Materials and Methods: The objective is to offer a comprehensive technical note on the percutaneous placement and management of high-flow DualCath (DC) for hemodialysis, involving the simultaneous insertion of two tunneled single-lumen silicone catheters through a single skin incision and vein puncture. In addition, we aim to summarize the results derived from our extensive clinical experience. Results: This 20-year study involved the placement of 1035 DC devices. The main indications were end-stage kidney disease in 859 cases, acute kidney injury in 50 cases, and miscellaneous purposes in 30 cases. Most of the insertions were in the internal jugular vein, with varying dwell times averaging 213 ± 335 days. In total, the DC devices were used for 594 patient-years. Conclusion: DC can be placed using a minimally invasive percutaneous method in both chronic and acute settings, showcasing its exceptional versatility. The design and geometry of the two silicone cannulas are precisely tailored to meet the needs of clinicians, focusing on achieving optimal flow performance, and ensuring adequate dialysis.