Early Fistula Research Articles

Clival dural reconstruction via transnasal approaches: fat graft fixation technique.

CSF fistulas are the weak spots of transnasal endoscopic and microsurgical skull base approaches. An autologous fat graft is considered the best substrate for clival dural reconstruction via transnasal approaches. However, potential gravitational displacement of the graft may result in CSF leakage. The authors have developed and described herein the fat graft fixation (FGF) technique to secure the fat graft against dislocation after transclival resection of chordomas invading the dura. Seventy-five patients with cranial chordomas underwent surgical treatment at the authors' institution from September 2006 through June 2023. Of these, the authors collected demographic, clinical, radiological, surgical, and outcome data from 34 patients who underwent an endoscope-assisted microsurgical transclival approach via a transnasal, sublabial, or sublabial transmaxillary extended corridor. The FGF reconstruction technique was progressively implemented to improve clival reconstruction, with a focus on the results. With a custom-made 8-mm 3/8 round atraumatic surgical suture needle, a 4/0 Vicryl stitch was placed through the adjacent dural borders. An abdominal autologous fat graft was then placed over the dural defect. One triple knot was tied to secure the graft and prevent its delayed gravitational displacement. The primary outcome was to determine if the FGF group had a higher rate of early or late oronasal CSF fistula compared to the unlocked free graft group. Secondary outcomes included tension pneumocephalus, surgical site infection, and meningitis. The fat graft was not used in 8 (23.5%) of the 34 patients because the dura was intraoperatively intact. The unlocked free graft and FGF techniques were used in 20 (58.8%) and 6 (17.6%) patients, respectively. Of the 34 patients, no fistulas were observed in the group treated with the FGF technique, while 4 fistulas were found in the unlocked free graft group (p < 0.05), with 2 of these cases involving meningitis. Patients with a CSF fistula underwent a total of 7 surgical procedures: 3 revision surgical procedures, 2 lumboperitoneal shunts, and 2 ventriculoperitoneal shunts. In the authors' preliminary experience, the FGF technique has shown promise in eliminating the risk of CSF fistula and other related complications after the transclival approach for clival chordomas involving the dura.

Predictive ability of systemic coagulation-inflammation index on early fistula failure after radiocephalic arteriovenous fistula creation.

To the best of our knowledge, a possible predictive relationship between the systemic coagulation-inflammation index (SCI) and arteriovenous fistula (AVF) failure following AVF creation has not yet been examined. We therefore designed this study to examine the predictive ability of SCI on postoperative early AVF failure in patients undergoing primary radiocephalic AVF operation. A total of 189 patients who underwent primary radiocephalic AVF operation for hemodialysis access were included in this retrospective observational cohort study, and then divided into two groups according to whether AVF failure occurred within the first 3 months after the operation; as failed AVF group (n = 44) and non-failed AVF group (n = 145). The patients' baseline clinical characteristics and laboratory parameters were recorded and then compared between the groups. Patients in failed AVF group were significantly older and had higher smoking rate than those in non-failed AF group. The median values of fibrinogen, platelet-to-lymphocyte ratio and SCI were significantly higher in failed AVF group than in non-failed AVF group. With regards to other clinical characteristics and laboratory parameters, no significant differences were detected between the groups in the univariate analyses. Only age and SCI maintained their significances in the multivariate logistic regression analysis, and were therefore considered as the independent predictors of AVF failure. ROC curve analysis revealed that SCI of 37.9 constituted the optimum cut-off value with 97.7% sensitivity and 94.5% specificity rates for predicting AVF failure. The present study demonstrated for the first time in the literature that SCI significantly and independently predicted early AVF failure following radiocephalic AVF creation.

Venous distensibility may be an indicator of early arteriovenous fistula failure, a retrospective single-centre cohort study

Background Arteriovenous-fistula (AVF) are crucial for hemodialysis access, yet they frequently experience early failure. While studies have identified potential patient and clinical risk factors, these findings remain inconsistent. This inconsistency might be attributed to the varying definitions of “early failure”. Our retrospective cohort study aimed to evaluate how common risk factors predict four frequently early-failure criteria: thrombosis/stenosis, <500 ml/min blood flow, <5 mm vein diameter, and ≥6 mm deep vein. We also assessed how well these risk factors predict early failure defined as meeting at least one of these criteria. Additionally, we examined the predictive ability of vein-distensibility, a previously overlooked factor in AVF failure. Methods Consecutive patients with first-time AVF employing standard minimum preoperative artery- and vein-diameters (1.8–2.0 mm) who underwent first Doppler-ultrasound (DUS) at ≤4 months in 2016–2022 were identified. Early AVF failure was defined as the presence of at least one of the following conditions on the first DUS: poor blood flow (Qa), poor vein diameter, poor vein depth, and thrombosis/stenosis. Factors associated with early AVF failure were explored with multivariate analyses. Results 105 patients were eligible and 63 (60%) had an early AVF failure. The only strong predictor of early failure was low vein-distensibility (Odds ratio = 0.57, 95% confidence intervals [CIs] = 0.38–0.83, p = 0.005). Female sex only predicted too-deep veins (Odds ratio = 14.29, 95% CIs = 2.00–100, p = 0.024). Conclusions venous distensibility may be a useful early-failure determinant when minimum preoperative vessel-diameter limits are met. Moreover, the female sex is associated with too-deep AVF veins.

The Effect of Main Bronchus Stump Closure Method on the Incidence of Stump Failure during Pneumonectomy for Tuberculosis

The objective: to evaluate the effectiveness of various methods for the main bronchus stump closure when performing pneumonectomy for destructive pulmonary tuberculosis.Subjects and Methods. Treatment results of 1211 tuberculosis patients from 1958 to 2022 were studied. The patients were treated in three clinical phthisiopulmonary centers. All of them underwent pneumonectomy with closure of the main bronchus stump by different methods.Results. We studied results of using different methods for suturing the main bronchus during pneumonectomy. For this purpose, the incidence of early fistulae of the bronchial stump and mortality from bronchopleural complications were assessed. The worst result was observed when using a mechanical suture (21.7% and 8.3%, respectively), the combination of polyspast-circular ligature with mechanical suture improved the effectiveness (2.3% and 4.6%, respectively), and the best result was demonstrated by the stump-free method of bronchus closure offered by D.B. Giller et al. (0.3% and 0.1%, respectively).

Transanal circumferential pouch advancement for treatment of pouch vaginal fistulae

BackgroundIleal pouch anal anastomosis (IPAA) circumferential pouch advancement (CPA) involves full-thickness transanal 180–360° dissection of the distal pouch, allowing the advancement of healthy bowel to cover the internal opening of a vaginal fistula. We aimed to describe the long-term outcomes of this rare procedure.MethodsPatients with IPAA who underwent transanal pouch advancement for any indication between 2009 and 2021 were included. Demographics, operative details, and outcomes were reviewed. An early fistula was defined as occurring within 1 year of IPAA construction. Clinical success was defined as resolution of symptoms necessitating CPA, pouch retention, and no stoma at the time of follow-up. Figures represent the median (interquartile range) or frequency (%).ResultsOver a 12-year period, nine patients were identified; the median age at CPA was 41 (36–44) years. Four patients developed early fistula after index IPAA, and five developed late fistulae. The median number of fistula repair procedures prior to CPA was 2 (1–2). All patients were diagnosed with ulcerative colitis at the time of IPAA and all late patients were re-diagnosed with Crohn’s disease. Four (44.4%) patients had ileostomies present at the time of surgery, three (33.3%) had one constructed during surgery, and two (22.2%) never had a stoma. The median follow-up time was 11 (6–24) months. Clinical success was achieved in four of the nine (44.4%) patients at the time of the last follow-up.ConclusionsTransanal circumferential pouch advancement was an effective treatment for refractory pouch vaginal fistulas and may be offered to patients who have had previous attempts at repair.

Heterogeneous gene expression during early arteriovenous fistula remodeling suggests that downregulation of metabolism predicts adaptive venous remodeling

Clinical outcomes of arteriovenous fistulae (AVF) for hemodialysis remain inadequate since biological mechanisms of AVF maturation and failure are still poorly understood. Aortocaval fistula creation (AVF group) or a sham operation (sham group) was performed in C57BL/6 mice. Venous limbs were collected on postoperative day 7 and total RNA was extracted for high throughput RNA sequencing and bioinformatic analysis. Genes in metabolic pathways were significantly downregulated in the AVF, whereas significant sex differences were not detected. Since gene expression patterns among the AVF group were heterogenous, the AVF group was divided into a ‘normal’ AVF (nAVF) group and an ‘outliers’ (OUT) group. The gene expression patterns of the nAVF and OUT groups were consistent with previously published data showing venous adaptive remodeling, whereas enrichment analyses showed significant upregulation of metabolism, inflammation and coagulation in the OUT group compared to the nAVF group, suggesting the heterogeneity during venous remodeling reflects early gene expression changes that may correlate with AVF maturation or failure. Early detection of these processes may be a translational strategy to predict fistula failure and reduce patient morbidity.

Pathohistomorphometric and Immuno-Histologic Changes in Early Arteriovenous Fistula Failure in Patients with Chronic Kidney Disease.

Hemodialysis is a prevalent treatment for the end-stage chronic kidney disease (CKD) worldwide. The primary arteriovenous fistula (AVF), widely considered the optimal hemodialysis access method, fails to mature in up to two-thirds of the cases. The etiology of the early AVF failure, defined as thrombosis or inability to use within three months post-creation remains less understood, and is influenced by various factors including patient demographics, surgical techniques, and genetic predispositions. Neointimal hyperplasia is a primary histological finding in stenotic lesions leading to the AVF failure. However, there are insufficient data on the cellular phenotypes and the impact of the preexisting CKD-related factors. This study aims to investigate the histological, morphometric, and immunohistochemical alterations in the fistula vein, pre-, peri-, and post-early failure. Eighty-nine stage 4-5 CKD patients underwent standard preoperative assessment, including the Doppler ultrasound, before a typical radio-cephalic AVF creation. Post-failure, a new AVF was created proximally. The vein specimens were collected during the surgery, processed, and analyzed for morphometric analyses and various cellular markers, including Vimentin, TGF, and Ki 67. The study enrolled 89 CKD patients, analyzing various aspects of their condition and AVF failures. The histomorphometric analysis revealed substantial venous luminal stenosis and varied endothelial changes. The immunohistologic analysis showed differential marker expressions pre- and post-AVF creation. This study highlights the complexity of the early AVF failures in CKD patients. The medial hypertrophy emerged as a significant preexisting lesion, while the postoperative analyses indicated a shift towards neointimal hyperplasia. The research underscores the nuanced interplay of vascular remodeling, endothelial damage, and cellular proliferation in the AVF outcomes.

Thirty-day prevalence and clinical impact of fluid collections at the resection margin after distal pancreatectomy: Follow-up of a multicentric randomized controlled trial

BackgroundPostoperative fluid collections at the resection margin of the pancreatic stump are frequent after distal pancreatectomy, yet their clinical impact is unclear. The aim of this study was to assess the 30-day prevalence of postoperative fluid collections after distal pancreatectomy and the factors associated with a clinically relevant condition. MethodsPatients enrolled in a randomized controlled trial of parenchymal transection with either reinforced, triple-row staple, or ultrasonic dissector underwent routine magnetic resonance 30 days postoperatively. Postoperative fluid collection was defined as a cyst-like lesion of at least 1 cm at the pancreatic resection margin. Postoperative fluid collections requiring any therapy were defined as clinically relevant. ResultsA total of 133 patients were analyzed; 69 were in the triple-row staple transection arm, and 64 were in the ultrasonic dissector transection arm. The overall 30-day prevalence of postoperative fluid collections was 68% (n = 90), without any significant difference between the two trial arms. Postoperative serum hyperamylasemia was more frequent in patients with postoperative fluid collections than those without (31% vs 7%, P = .001). Among the postoperative fluid collection population, an early postoperative pancreatic fistula (odds ratio 14.9, P = .002), post pancreatectomy acute pancreatitis (odds ratio 12.7, P = .036), and postoperative fluid collection size larger than 50 mm (odds ratio 6.6, P = .046) were independently associated with a clinically relevant postoperative fluid collection. ConclusionPostoperative fluid collections at the resection margin are common after distal pancreatectomy and can be predicted by early assessment of postoperative serum hyperamylasemia. A preceding pancreatectomy acute pancreatitis and/or postoperative pancreatic fistula and large collections (>50 mm) were associated with a clinically relevant postoperative fluid collection, representing targets for closer follow-up or earlier therapeutic interventions.

P402 Early diagnosis of Crohn’s disease with perianal lesions as first clinical symptom: Development and validation of a new MR imaging-based model disease

Abstract Background Early diagnosis is crucial for the treatment and prognosis of Crohn's disease. Perianal fistulae or abscesses may present as the initial manifestation of Crohn's disease (CD) in patients. Despite magnetic resonance imaging (MRI) is the gold standard for the clinical assessment of perianal fistulae, there is shortage of MRI properties for clinical use in early perianal fistula diagnosis in CD. Methods Data from patients with a definitive diagnosis of PFCD and cryptoglandular disease (CGD) between September 2013 and December 2020 were examined retrospectively. The data was splited into training and test sets at a 7:3 ratio. The MRI characteristics were reviewed by two gastroenterology radiologists in consensus. The characteristics were then used to train a random forest classification model to predict a diagnosis of PFCD. The validity of the model was assessed using the area under the receiver operating characteristic curve (AUROC) and confusion matrix. Predictor importance was determined using the Shapley additive explanation (SHAP) framework. Results A total of 144 patients diagnosed with PFCD and 406 patients diagnosed with CGD were included. Utilizing the Boruta algorithm, 12 significant features which confirmed important for the diagnosis of PFCD, and a random forest classification model was developed. The model demonstrated an area under the receiver operating characteristic curve (AUROC) of 0.9294 (95% CI: 0.8706-0.9882), an accuracy of 0.9515 (95% CI: 0.9067-0.9788) and a kappa of 0.8779. SHAP values was utilized to estimate the variable importance, and the top five features were ulceration in rectal wall, thickened rectal wall, T2 hyperintensity, submucosal fistula and age. The model for predicting PFCD diagnosis based on MRI was dynamically visualised using a web display approach (https://doctoryang1971.shinyapps.io/forceplot/). Conclusion We have developed a multi-modal visual dynamic prediction model that can be effectively used to guide the early diagnosis of patients with Crohn's disease who present with perianal fistula at their first clinical visit. PFCD is likely to originate as transmural ulcers leading to submucosal inflammation or fistulae before penetrating the anal sphincter and developing into complex perianal fistulae.

Study on the Correlation between Blood Pressure Variability and Early Arteriovenous Fistula Failure and Recanalization in End-Stage Renal Disease

Study on the Correlation between Blood Pressure Variability and Early Arteriovenous Fistula Failure and Recanalization in End-Stage Renal Disease

ARTERIO-VENOUS FISTULA CREATION FOR HEMODIALYSIS. WHAT IS HAPPENING IN BULGARIA?

Purpose. The arterio-venous anastomosis (AVA) continues to be the "gold standard" for vascular access in patients undergoing haemodialysis. This retrospective study aims to analyze the causes that led to End Stage Renal Disease (ESRD), the type of native AVA, their localization, and their patency. Material and Methods. The study included the last 100 consecutive and random AVAs constructed in our clinic. 68 men of average age 62.3 (+/-10.8) years and 32 women of average age 59.9 (+/-15.8) years were operated. The main causes that led to ESRD were: Glomerulonephritis - 33%, Hypertension- 24% and Diabetes- 20%. The overweight patients were 33% and the smokers - 30%. Results. AVA has been successfully constructed in 82% of the patients on the left hand and in 18% on the right hand. A distal latero-terminal radio-cephalic fistula (DLTRC) was constructed on only 8% of the patients. The most common type of anastomosis was an L.T. radio-cephalic in the forearm - 58%, followed by an L.T. brachio-cephalic fistula - 19% and latero-lateral, radio-cephalic in the forearm - 14% of the patients. The early fistula patency was - 80%, one-year cumulative patency was 94%. Conclusion. The analysis of our results shows that the relative share of the overweight and diabetes population is increasing today. In practice, solutions for the construction of primary forearm anastomosis are increasingly common.

Early arteriovenous fistula failure associated with mortality and major adverse cardiovascular events in patients undergoing incident hemodialysis.

Arteriovenous fistula (AVF) patency is important for patients undergoing hemodialysis. The association between early AVF failure and the prognosis, including all-cause mortality and major adverse cardiovascular events (MACE), has not been fully investigated. The present study was performed to investigate the association between early AVF failure and 3-year mortality, cardiovascular disease (CVD) mortality, and MACE. We analyzed 358 patients who started hemodialysis in our institution from October 2008 to February 2020. We defined early AVF failure as cases requiring percutaneous transluminal angioplasty or reoperation within 1 year after AVF surgery. The patients were divided into two groups according to the presence or absence of early AVF failure, and the prognosis of each group was examined. The association between early AVF failure and outcomes (3-year all-cause mortality, CVD mortality, and MACE) was determined using Cox proportional hazards regression analysis. During the 3-year follow-up, 75 (20.9%) patients died (cardiovascular death: n = 39) and 145 patients developed MACE. According to the multivariable analysis, the early AVF failure group had a significantly higher risk of 3-year all-cause mortality (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.09-1.83; p = 0.009), CVD mortality (HR, 1.54; 95% CI, 1.29-2.08; p < 0.001), and MACE (HR, 1.68; 95% CI, 1.25-2.26; p < 0.001). When the patients were stratified by age, early AVF failure was associated with 3-year all-cause mortality in all groups except for the younger group (<65 years of age). Early AVF failure was associated with an increased risk of 3-year all-cause mortality, CVD mortality, and MACE.

Arteriovenöz Fistül Cerrahisinde Rejyonal ve Lokal Anestezi Karşılaştırması: Tek Merkezli Bir Araştırma

Background: This retrospective study aimed to compare the outcomes of regional anesthesia and local anesthesia techniques in arteriovenous fistula operations, focusing on early patency rates, operation time, and postoperative pain. Methods: A total of 77 arteriovenous fistula and arteriovenous graft operations performed between April 2020 and April 2023 on adult patients with chronic renal failure were analyzed. The patients were divided into two groups based on the anesthesia technique: Group-1 (n=49) received local anesthesia, while Group-2 (n=28) received regional anesthesia. Results: The majority of operations in the local anesthesia group involved radio-cephalic arteriovenous fistula, while brachio-cephalic, brachio-basilic arteriovenous fistula, and arteriovenous grafts were predominantly performed in the regional anesthesia group. There was no significant difference in operation time between the two groups. However, the regional anesthesia group had a significantly lower need for pain relief within the first 24 hours postoperatively. There were no significant differences in early postoperative fistula failure or bleeding/hematoma between the groups. One case of local wound infection was observed in each group during post-discharge follow-up. Conclusion: This retrospective analysis suggests that regional anesthesia provides superior pain control in the first 24 hours following arteriovenous fistula surgery compared to local anesthesia. Regional anesthesia is a safe and effective technique and may be preferred for more sophisticated arteriovenous fistula procedures.

Distal positioning of the skin paddle of pectoralis major myocutaneous flap in head and neck reconstruction.

To assess outcomes of pectoralis major myocutaneous flap (PMF) wherein the skin paddle (SP) was positioned with its distal portion extending beyond the lower border of pectoralis major by ≥2 cm (PMF-d). Consecutive head and neck reconstructions with PMF-d (n = 110). SP dimensions l2 (distal extent below the lower border of pectoralis major), l1 (proximal extent above lower border of pectoralis major), and b (breadth) were recorded. Endpoints were SP necrosis, recipient dehiscence, early fistula, and persistent fistula. Median values of l2 , l1 , and b were 3.0, 6.0, and 6.0 cm, respectively. When l2 = 2.0-3.0 cm, SP necrosis occurred in only one (1%) subject (with obesity). When l2 was ≥3.5 cm, necrosis occurred in four (16%) subjects, three of whom also had l1 /l2 < 2.0 (proximal SP < 67% of entire SP). Statistically, increased l2 was the only risk factor for necrosis (p = 0.001). Overall, incidence of recipient dehiscence, early fistula, and persistent fistula were 32 (29%), 20 (20%), and 3 (3%), respectively. Persistent fistula occurred only in the setting of SP necrosis and/or re-irradiation. Careful patient selection, adequate proximal SP, and l2 = 2.0-3.0 cm is associated with a negligible risk of necrosis. The enhanced reach and laxity and additional skin surface area and soft tissue volume conferred with PMF-d facilitate recipient wound healing.

Redo ileal pouch-anal anastomosis for early versus late sepsis-related pouch failure

BackgroundPouch failure after restorative proctocolectomy with ileal pouch–anal anastomosis occurs in 5% to 15% of cases, mostly due to septic complications. We aimed to determine if the timing of pouch failure impacted long-term outcomes for redo ileal pouch–anal anastomosis after sepsis-related complications. MethodWe retrospectively analyzed our prospectively collected institutional pouch database. Patients who underwent redo ileal pouch–anal anastomosis for septic complications between 1988 and 2020 were divided into an early (pouch failure within 6 months of stoma closure after index operation, or stoma never closed) and a late failure group (pouch failure after 6 months of stoma closure). The primary endpoint was pouch survival. ResultsIn total, 335 patients were included: 241 (72%) in the early and 94 (28%) in the late failure group. The most common indication for failure was an anastomotic leak in the early failure group (163, 68%) and fistula in the late failure group (59, 63%), P < .001. Pouch survival at 3, 5, and 10 years was 77%, 75%, and 72% for the early and 79%, 75%, and 68% for the late failure group (P = .94). The most common reason for redo pouch failure was fistula in both groups. Quality of life was similar in both groups. In multivariate analysis, the only factor associated with pouch failure was the final diagnosis of Crohn's disease. ConclusionOutcomes after redo ileal pouch–anal anastomosis were comparable between patients with early and late sepsis-related index pouch failure, with acceptable rates of long-term pouch survival and good quality of life.

Drug-coated balloon for early recurrent arteriovenous fistula dysfunction.

To report the efficacy and safety of a drug-coated balloon (Ranger, Boston Scientific) in patients with dysfunctional autogenous arteriovenous fistula. In this investigator-initiated, prospective observational cohort study, 25 participants with dysfunctional arteriovenous fistula were enrolled from January 2018 to June 2019. The drug-coated balloon was applied after successful vessel preparation by high-pressure balloon angioplasty. The primary endpoint was the target lesion primary patency rate at 6 months. The secondary outcome included anatomical and clinical success rate, postoperative major adverse events within 30 days, and the target lesion primary patency rate at 12 months. Statistical analysis of the data was performed. The χ test or Fisher's exact test was used for analyzing categorical variables, and continuous variables were analyzed using Student's t-test. Also, Kaplan-Meier analysis was used to evaluate the target lesion primary patency days with the log-rank test. At 6 months, the target lesion primary patency rate was 68% in the drug-coated balloon treatment group. The anatomical and clinical success rates were 100%. One patient had thrombosed access 10 days after the index procedure, and two died of cardiovascular events 4 months after the operation. Subgroup analysis showed that the early recurrent stenosis group had non-inferior mean drug-coated balloon primary patency days (less than 90 days after prior percutaneous angioplasty, n = 10) compared with the late recurrence group (prior PTA patency days more than 90 days, n = 10), 179.3 ± 102.9 versus 257.1 ± 71 days (p = 0.153). DCB angioplasty had significant improvement in primary patency days for early recurrent stenosis (67.7 ± 19.3 vs 179.3 ± 102.9, p < 0.001). The results demonstrated the appliance of Ranger DCB in stenotic AVFs is a safe and effective treatment modality, especially for early recurrent AVF stenosis.

Catheter-Related Blood Stream Infections and Associated Factors Among Hemodialysis Patients in a Tertiary Care Hospital.

Non-tunneled central venous catheter remains the preferred vascular access at hemodialysis initiation in developing countries despite a high burden of infection complications. The goal of this study was to determine the burden, risk factors, and microbiological spectrum of catheter-related bloodstream infections at a tertiary care center in Ethiopia. A retrospective cross-sectional study design was applied among patients who underwent central venous catheter insertion for hemodialysis between January 2016 and June 2022 with no native arteriovenous fistula and stayed more than 48 hours. Data were collected from the patient's registration book, patient charts, and microbiology registry and analyzed using SPSS 21. Binary logistic regression was applied to assess the relationship between the independent and outcome variables. P-values less than 0.05 with AOR and 95% CI were used as statistically significant variables. In this study, 353 patients were included. The mean age was 39±17.9 years and the average duration of catheter stay was 58 ±95 days. A hundred thirty-five (38.2%) CRBSIs were documented with an incidence rate of 7.74 episodes per 1000 catheter days. The causative microorganism was predominantly gram-negatives (57.6%). Duration of a catheter (AOR: 0.3; P < 0.001), previous CVC infection (AOR: 11.9; P < 0.001), high white blood cell count (AOR: 0.31; P<0.001), urban residence (AOR: 1.92; P<0.05), and low hemoglobin levels (AOR: 2.78; P < 0.05) were independently associated with catheter-related bloodstream infections. In conclusion, the incidence of catheter-related bloodstream infection among patients on hemodialysis was high with gram-negative predominance. Early fistula must be planned to reduce the duration of temporary vascular access.

Outflow Rescue of Elbow-Blockade Forearm Arteriovenous Fistulas: Outcomes of Open Surgical Techniques

Venous scarring at the elbow is a common problem that can cause early and late forearm arteriovenous fistula (AVF) dysfunction in hemodialysis patients. However, any effort to prolong the long-term patency of distal vascular accesses could benefit the patient's survival, maximizing the use of restricted venous patrimony. This study aims to report a single-center experience in the recovery of distal autologous AVF with venous outflow obstruction at the elbow using different surgical techniques. Retrospective observational study of all patients treated at a single vascular access center from January 2011 to March 2022, with dysfunctional forearm AVFs presenting with outflow stenosis or occlusions at the elbow treated by open surgery, using 3 different surgical techniques. Demographics and clinically relevant data were collected. Evaluated endpoints included primary, assisted primary, and secondary patency rates at 1 and 2years. Twenty-three patients with elbow-blocked outflow forearm AVFs have been treated with a mean age of 64±15years. The majority (96%) had a radiocephalic fistula. The median time from vascular access creation to intervention was 34.5months (12-216months). A total of 24 procedures have been performed using 3 different surgical techniques for bypassing the obstructed venous outflow at the elbow. Technical success was achieved in 96% of the surgically treated patients. Primary and secondary patency rates at 1year were 67.4% and 89.4%, respectively, and 52.9% and 82.0% at 2years, with a median follow-up of 19months (6-92months). AVFs outflow stenosis or occlusions at the elbow not amenable to endovascular therapy could lead to vascular access abandonment. Our study demonstrates multiple surgical solutions to avoid this adverse outcome. Elbow venous outflow surgical reconstruction seems effective for distal vascular access preservation. Close surveillance is essential for timely endovascular treatment of newly developed stenosis at the venous drainage.

Arterial Diameter and Percentage of Monocytes are Sex-Dependent Predictors of Early Arteriovenous Fistula Maturation

Arteriovenous fistulae mature less frequently in women than in men, leading to inferior patency and decreased fistula utilization in women. We hypothesized that both anatomic and physiologic sex differences explain reduced maturation. The electronic medical records of patients who had a primary arteriovenous fistula created from 2016 to 2021 at a single center were reviewed; sample size was determined using a power calculation. Postoperative ultrasound and laboratory tests were obtained at least 4weeks after fistula creation. Primary unassisted fistula maturation was determined up to 4years postprocedure. A total of 28 women and 28 men with a brachial-cephalic fistula were analyzed. The inflow brachial artery diameter was smaller in women than in men, both preoperatively (4.2±0.9 vs. 4.9±1.0mm, P=0.008) and postoperatively (4.8±0.8 vs. 5.3±0.9mm, P=0.039). Despite similar preoperative brachial artery peak systolic velocity, women had significantly lower postoperative arterial velocity (P=0.027). Fistula flow was reduced in women, particularly in the midhumerus (747.0±570.4 vs. 1,117.1±471.3cc/min, P=0.003). Percentages of neutrophils and lymphocytes were similar among women and men 6weeks after fistula creation. However, women had reduced monocytes (8.5±2.0 vs. 10.0±2.6%, P=0.0168). Among 28 men, 24 of 28 (85.7%) achieved unassisted maturation, whereas only 15 of 28 (53.6%) women had fistulae that matured without intervention. Secondary analysis using logistic regression suggested that postoperative arterial diameter was associated with maturation in men, while postoperative monocyte percentage was associated with maturation in women. Sex differences during arteriovenous fistula maturation are present in arterial diameter and velocity, suggesting that both anatomic and physiologic differences in arterial inflow contribute to sex differences in fistula maturation. In men, postoperative arterial diameter is correlated with maturation, whereas in women, the significantly lower proportion of circulating monocytes suggests a role for the immune response in fistula maturation.

Uterovesical fistulas as obstetric complications: Diagnosis, management and prognosis (Review).

Urogenital fistulas are abnormal communications between the female genital and urinary tract; while such fistulas, which are the most commonly encountered, are located between the vagina and urinary bladder and are caused by the local extension of a tumoral process. Another frequently encountered cause is represented by the obstetric one, leading to the development of uterovesical fistulas. However, many questions regarding the diagnosis and management of uterovesical fistulas remain unanswered. Therefore, the aim of this article was to review the existent data so far, with special attention being focused on the pathogenic mechanisms leading to this complication, on the modalities of diagnosis, and on the possible therapeutic strategies. Therefore, according to the time of diagnosis, uterovesical fistulas can be classified as early fistulas, diagnosed in the first months postoperatively and late fistulas, diagnosed within several years from the initial surgical procedure. For early fistulas, a conservative therapeutic strategy can be taken in consideration, while in cases diagnosed after a longer period of time, a surgical approach should be taken into consideration. Meanwhile, although a surgical approach can cure most of the cases, attention should be given towards preventive strategies such as provision of quality obstetric care with improvements of surgical skills.