First Choice Of Vascular Access Research Articles

To use intraosseous access or not to use intraosseous access: determinants of traineesʼ decision in paediatric emergencies

We aim to determine whether the duration of paediatric training and previous real life intraosseous (IO) insertion experience influence a trainee paediatrician's decision on emergency vascular access choices. A survey was conducted using a predesigned proforma to collect data on paediatric trainees' previous paediatric experience including IO training, and their first choice of vascular access in three hypothetical cases modified from real life scenarios. Of the 105 trainees contacted, 98 participated in the survey, all of which were Advanced Paediatric Life Support Course trained, and 65 had previous real life IO needle insertion experience. Experienced trainees (i.e. with more than 6 years paediatric experience) were more likely to have previous real life experience in IO insertion (odds ratio: 5.94, 95% confidence interval: 2.25-15.72). Despite resuscitation councils' clear recommendation to use IO access in the arrested infant, only 51 participants (52%) chose IO as their first vascular access choice in this situation. Previous real life IO insertion experience significantly increased trainees' willingness to use IO as their first emergency vascular access choice (P<0.0001, Fisher's exact test; odds ratio: 10.13, 95% confidence interval: 3.62-28.35). Nothing helps more than previous real life IO needle insertion experience to reduce trainee paediatricians' reluctance in using IO access in an emergency, but this experience was only found more frequently among the more experienced trainees. IO access-specific workshops may provide useful supplemental training to traditional resuscitation courses, and may reduce trainees' reluctance in its use.

Creating Radiocephalic Arteriovenous Fistulas: Technical and Functional Success

The radiocephalic arteriovenous fistula (RC-AVF) at the wrist is the recommended first choice for hemodialysis access. Several authors have reported early thrombosis or failure of RC-AVFs to mature in up to 20% to 57% of patients. We report a consecutive series of individuals in whom physical and ultrasonography (US) examinations predicted success with RC-AVFs. Records of all patients who underwent vascular access operations by the communicating author from June 2003 through June 2008 were reviewed to identify those individuals with RC-AVF procedures. Physical examination and US screening criteria for creating a RC-AVF included a continuous and uninterrupted outflow vein diameter > or = 2.5 mm and a normal radial artery inflow examination with vessel diameter > or = 2.0 mm. A venous branching point at the wrist was identified to create a broad patch for the RC-AVF anastomosis. We reviewed 796 consecutive vascular access operations, identifying 75 RC-AVFs created in 74 patients. Patient ages were 20 to 82 years (mean 57 years). Eighteen were women and 42 were diabetic. Mean followup was 14.5 months. Primary, primary-assisted, and cumulative (secondary) patency were 58.3%, 96.2%, and 100%, respectively, at 12 months and 48.1%, 91.5%, and 95.7%, respectively, at 24 months. RC-AVF at the wrist remains our first choice for vascular access in the subset of patients meeting specific preoperative criteria by physical and United States examinations. Cumulative patency was 100% at 12 months and 95.7% at 24 months. Although RC-AVF construction technique is important, careful patient selection is believed to be the critical element in creating functional and durable RC-AVFs.

Difficult Vascular Access in Patients With End-Stage Renal Failure

Background/aim End-stage renal failure patients requiring long-term hemodialysis need a durable vascular access. The arteriovenous fistula (AVF) with its long patency rate and low complication profile is usually the first choice for vascular access creation. However, when superficial veins are not suitable for AVF creation or all have been exhausted as a result of repeated AVF procedures, arteriovenous grafts (AVGs) using expanded polytetraflouroethylene (ePTFE) is an alternative. This study reviewed our experience in using PTFE AVGs for vascular access in patients requiring chronic hemodialysis. Materials and methods In a prospective study, from September 2002 to October 2004, 21 PTFE AVGs were placed in 21 patients. We evaluated the complications and patency. Results There were 12 female and nine male patients of mean age 58 ± 8.7 years (range = 45 to 76 years). Nine patients (43%) had hypertensive nephrosclerosis, 6 (29%) diabetic, 2 (10%) glomerulonephritis, 3 (14%) systemic lupus erythematosis requiring long-term steroids, and 1 (4.7%) unknown cause. The patency rate at 24 months was 85.7%. Complications included graft thrombosis (three; 14.3%), wound infection (three; 14.3%) and graft infection (one; 4.8%). Conclusion ePTFE AVGs offer reasonable patency and serviceability rates as a vascular access modality, but in view of their complication profile, the native vein arteriovenous fistula should continue to be the first choice for vascular access for patients requiring chronic hemodialysis.

Evaluation of primary failure in native AV‐fistulae (early fistula failure)

The most preferable method of vascular access (VA) in maintenance hemodialysis is a native arteriovenous fistula (AVF). Advanced age as well as the rapid increase in underlying diseases such as diabetic nephropathy and nephrosclerosis in these patients also means that the veins and arteries used to establish the AVF have undergone vascular damage, making construction of an AVF more difficult compared with earlier construction. Although there are various conditions under which arterial superficialization or AV graft must be chosen, it remains the rule that the first choice for VA should be AVF whenever possible. To improve postoperative results, it is necessary to reduce malfunctions immediately following surgery. We conducted a survey of 23 dialysis facilities throughout Japan and analyzed data from the past 3 years regarding the functionality of the AVF at initial puncture following construction of 5007 examples of newly constructed AVFs. Upon initial puncture, primary failure (PF) is defined as those cases in which thrombosis or inadequate blood flow occur. Primary failure occurred in 7.6% of the cases in this series, but there was a wide distribution of PF, 0.8% to 23.6%, because of differences in quality among facilities. This difference in PF is probably affected by technical aspects, the main factor being the characteristics of the patient. Survey responses included: (1) vascular damage of the veins and arteries used in creating the AVF and (2) the suitability of the location chosen for construction. In the data collected, many methods were used to repair those primary AFVs in which PF occurred. The salvage rate was 70%. Currently, the most preferable form of VA is AVF adhering to the principle that the proper timing of the choice and construction of AVF should consider the maturation period. To accomplish this, it is vital that vascular mapping be performed preoperatively to construct the AVF. If PF does occur, the cause should be thoroughly investigated and repairs made effectively.

Factors and complications affecting catheter and technique survival with permanent single-lumen dialysis catheters.

This long-term study on the outcome of permanent silicone single-lumen dialysis catheters consisted of 43 surgically inserted catheters in 33 patients. All catheters were attached to a pressure-pressure single-cannula dialysis system. Technique and catheter survival were 80 and 59% at 1 year, and 63 and 50% at the 3rd year respectively. These parameters were not different in older patients (> or = 70 years, n = 12). Factors corresponding to a less successful outcome were placement in the left jugular vein (3-month actuarial survival of 44%) and absence of distal side holes (1-year actuarial survival of 44%). Insertion in both subclavian veins was not different to the classical right jugular vein. Infectious complications (incidence of 0.72 per 1000 catheter days) often caused simultaneous catheter and technique failure (14 versus 15%), whereas inadequate flow (incidence of 2 per 1000 catheter days) caused catheter rather than technique failure (30 versus 12%). The incidence of both complications declined significantly with time after insertion during the follow-up period. The first 3 months after insertion were more predisposed to the occurrence of inadequate flow than catheter-related infections. The general performance of these permanent single-lumen catheter devices justifies their long-term application in haemodialysis, even as a first choice of vascular access, especially in the elderly. Insertion in the left jugular vein and use of catheters without side holes should be avoided, providing a better catheter survival.