Internal Arteriovenous Fistula Research Articles

#2431 Vascular access outcomes among patients on maintenance hemodialysis in Perpetual Succour Hospital: a 3-year cross-sectional analysis

Abstract Background and Aims Hemodialysis (HD) is the most widely used treatment modality worldwide in the care of patients with end stage renal disease (ESRD). The success of the therapy depends largely on the quality of the VA and its proper functioning, which has a bearing on the patient's quality of life. Vascular access dysfunction remains one of the leading causes of excessive morbidity, mortality, and healthcare costs in this group. A functional vascular access is mandatory to achieve good levels of dialytic efficiency, and it is considered the lifeline of patients on maintenance HD. The ideal vascular access should have specific characteristics among which the most important are the following: ease of placement; delivery of adequate blood flow for effective dialysis; good primary patency rates; low rates of complications and side effects; long-lasting life; and low economic costs. There are 3 types of vascular accesses (VAs): the internal arteriovenous fistula (IAVF); the central venous catheter, which can be tunneled (CVC-T) or not (CVC-nT); and the synthetic vascular graft. Internal arteriovenous fistula is considered the best option because it is safer, more durable, and less expensive. The catheter is essential for emergency onset in HD but is associated with a higher number of infections, higher mortality, and greater costs. Arteriovenous fistulae (AVF) have advantages over arteriovenous grafts (AVG) and central venous catheters (CVC), but whether AVF are associated independently with better survival is unclear. The aim of this study is to determine the vascular access outcomes of ESRD patients on maintenance hemodialysis. Specifically, this study (1) described the clinicodemographic profile of the patients in terms of age, sex, primary etiology of ESRD, employment status, comorbidities, hepatitis status and family history of the disease; (2) determined the vascular access used on the HD patients (AVF/AVG, CVC or IJ; (3) identified interventions performed to maintain vascular access for hemodialysis; (4) determined the categories of the vascular access site; (5) assessed the vascular access outcome; (6) determined the reason and number for vascular access change and the (7) clinical outcome of the HD patients. Method This is a single center, cross-sectional study of ESRD patients on maintenance hemodialysis enrolled in Perpetual Succour Hospital Hemodialysis Unit from April 1, 2021, to November 30, 2023. Results There were 260 hemodialysis patients included, with successful vascular access outcome (73.13%) and were younger (57.2 ± 14.1). Those who had failed vascular access were females (54.2%), unemployed (61.4%) and had diabetes mellitus (50.6%) as the primary etiology of their ESRD. Those with failed vascular access were hypertensive (86.7%), with history of CAD and MI (57.8%) and were having diabetes mellitus (56.6%). Proportion of those with failed and successful vascular access significantly differ among hypertensives $(p = .012)$, diabetics $(p = .039)$, with chronic glomerulonephritis $(p = .011)$, and among those with malignancy $(p = .003)$. Most of those who were alive had successful vascular access (76.8%), however, among those who had failed vascular access died (57.6%). And the association of clinical outcomes (death or not) and failure or success of vascular access is statistically significant, $(p = .001)$. Conclusion Our study showed that failed vascular access were more associated with female gender, diabetes mellitus as the primary etiology of ESRD and with other co-morbid conditions such as hypertension and CAD or MI. Successful vascular outcome were among those of younger age group compared to those whose vascular access failed, probably due to better vascular condition and fewer co-morbidities. As shown in Table 2, type of access, interventions performed, and vascular access site significantly differ among HD patients with failed vascular access outcome and with those who were successful $(p = .001)$Those with failure on the vascular access were changed to CVC (44.6%) while others had changed to IJ (22.9%). Eighty of those with failed vascular (96.4%) access has changed site due to no bruit (65.0%) and thrombosis (33.8%).

Efficacy of cutting balloon angioplasty versus high-pressure balloon angioplasty for the treatment of arteriovenous fistula stenoses in patients undergoing hemodialysis: Systematic review and meta-analysis.

This systematic review and meta-analysis aimed to assess and compare the therapeutic outcomes of cutting balloon angioplasty and high-pressure balloon angioplasty for arteriovenous fistula stenosis in hemodialysis patients. All studies indexed in PubMed, Embase, and Cochrane Library Web of Science were retrieved. The retrieval deadline was July 15, 2023. Risk of bias 2.0 was used to evaluate the quality of the included studies. Revman 5.4 software was used for data analysis. This review included three studies and 180 patients, with 90 patients in the cutting balloon angioplasty group and 90 patients in the high-pressure balloon angioplasty group. The results of the meta-analysis suggested that compared with high-pressure balloon angioplasty, cutting balloon angioplasty can improve primary lesion patency rates of internal arteriovenous fistulas at 6 months (relative risk, 1.45; 95% confidence interval, 1.08-1.96; P = 0.01). However, there were no significant differences between the technical success rate (relative risk, 0.99; 95% confidence interval, 0.93-1.05; P = 0.72) and clinical success rate (relative risk, 1.01; 95% confidence interval, 0.95-1.07; P = 0.73). Therefore, cutting balloon angioplasty is likely to increase primary lesion patency rates at 6 months. However, more high-quality, large-sample, multicenter, randomized controlled trials are needed for further validation due to the limited number of included studies.

Effect of patient characteristics on vessel enhancement on arterio-venous fistula CT angiography in a retrospective cohort study.

To evaluate the effects of various patient characteristics on vessel enhancement on arterio-venous fistula (AVF) computed tomography (CT) angiography (AVF-CT angiography). A total of 127 patients with suspected or confirmed shunt stenosis and internal AVF complications were considered for inclusion in a retrospective cohort study. The tube voltage was 120 kVp, and the tube current was changed from 300 to 770 mA to maintain the image quality (noise index: 14) using automatic tube current modulation. To evaluate the effects of age, sex, body size, and scan delay on the CT number of the brachial artery or vein, we used correlation coefficients and multivariate regression analyses. There was a significant positive correlation between the CT number of the brachial artery or vein and age (R = 0.21 or 0.23, P < .01). The correlations were inverse with the height (r = -0.45 or -0.42), total body weight (r = -0.52 or -0.50), body mass index (r = -0.21 or -0.23), body surface area (body surface area [BSA]; r = -0.56 or -0.54), and lean body weight (r = -0.55 or -0.53) in linear regression analysis (P < .01 for all). There was a significant correlation between the CT number of the brachial artery or vein and scan delay (R = 0.19 or 01.9, P < .01). Only the BSA had significant effects on the CT number in multivariate regression analysis (P < .01). The BSA was significantly correlated with the CT number of the brachial artery or vein on AVF-CT angiography.

Plan, Do, Check, Act (PDCA) Cycle Nursing Model Reduces the Risk of Hemangioma in Hemodialysis Patients.

Background:We aimed to explore the effect of Plan, Do, Check, Act (PDCA) circulation nursing on the prevention of aneurysm after hemodialysis.Methods:A total of 139 hemodialysis patients from Oct 2018 to Jan 2020 in Nephrology Department of the First People’s Hospital of Lianyungang, China were enrolled. They were randomly divided into control group and PCDA group, including 58 patients in control group and 81 patients in PCDA group. Patients’ satisfaction, blood flow in arteriovenous internal fistula and the incidence of post-dialysis vascular-related complications were statistically investigated in the two groups.Results:The satisfaction of patients in PDCA group was significantly higher than that in control group (P<0.001). In addition, when there was no statistical difference in blood flow between the two groups, the probability of complications such as internal fistula obstruction, thrombosis, infection, secondary puncture and aneurysm was lower in patients in the PDCA group, none of which occurred aneurysm.Conclusion:PDCA circulation nursing can effectively improve the quality of care and medical effect of hemodialysis patients with internal arteriovenous fistula, improve patient satisfaction and reduce the incidence of complications.

Survival of Vascular Accesses in Chronic Hemodialysis Patients

Background/Aims: Vascular access (VA) is the highest risk factor for blood infections, hospitalization, and mortality of patients undergoing hemodialysis (HD). The risk of mortality while using a catheter is greater than that while using grafts. The objective of this article is to know the survival rate in relation to the type of VA. Methods: A retrospective cohort of HD patients was studied. The data gathered included age, gender, first VA at the surrogate site, days between the first and second access, number of accesses, and anatomical site of VA placement. Mean differences were estimated using χ2 or Student’s t test. Survival was calculated using the Kaplan-Meier curves and included in tables. Statistical significance was established as p < 0.05. The statistical computer software package SPSSw v25 was used for the analysis. Results: A total of 896 patients were included with a mean age of 47.88 years (SD ± 16.52), the duration of the first VA was 398.81 days (±565.79), the mean number of VAs used was 2.26 (±1.15), and the median time undergoing HD was 728.73 days. The duration of catheter placement was 330.42 days, and 728.60 days for fistula use (p = 0.001). The mean number of days of renal replacement was 611.59 days for catheter and 1,495.25 days for internal arteriovenous fistula (IAVF) patients (p = 0.001). Conclusions: The survival of the initial VA is greater for the IAVF, followed by the tunneled catheters and the lowest by the non-tunneled catheters, which continue to be frequently used in our setting.

Bibliometric analysis on hemodialysis nursing research of China from 1997 to 2018

Objective To understand the research status, research hotspots and research fronts of domestic hemodialysis nursing by bibliometric analysis on literatures related to hemodialysis nursing research from 1997 to 2018 so as to provide a direction and thinking for further researches in the field. Methods We retrieved hemodialysis nursing related literatures published in China National Knowledge Infrastructure (CNKI) and WanFang data from 1st January 1997 to 18th July 2018. The BibExcel was used to de-duplication, and Excel was to set up a database to carry out statistical analysis including the number of papers, periodical distribution, fund, areas of literature studies, author institution, research hotspots and fronts. Results A total of 8 548 literatures were included. The annual number of papers had a tendency firstly increasing and then decreasing overall; fund projects were less; the number of core journals and papers was small; the research hotspots were focus on hemodialysis therapies, nursing intervention, uremia, complications and internal arteriovenous fistula; research fronts underwent three stages of development, and the future of them would fasten on high quality nursing, application effects and bundled care. Conclusions The number of literatures on domestic hemodialysis nursing is increasing with rich contents. However, the geographical distribution is narrow, and fund is less, and study quality and level need to be further enhanced. Scientific research should be devoted heavily to improve the guideline value of research findings for clinical practice in the field. Key words: Bibliometrics; Dialysis; Nursing; Research hotspots; Research fronts

Risk factors of thrombosis in internal arteriovenous fistula in maintenance hemodialysis patients

Objective To investigate the risk factors and improvement measures of thrombosis in internal arteriovenous fistula in maintenance hemodialysis patients. Methods Case control studies were performed in this study. Totals of 100 maintenance hemodialysis patients with thrombosis in internal arteriovenous fistula from January 2009 to June 2015 in Lishui Central Hospital were included in observation group, while another 100 patients with maintenance hemodialysis who did not have thrombosis in internal arteriovenous fistula were involved as control group. The related clinical and nursing data were collected, and the correlation between the thrombosis in internal arteriovenous fistula and related factors were analyzed to improve targeted nursing. Results Prevalence of diabetes, puncture failure rate, hematoma occurrence rate, high intensity in site-directed oppression, tightly binding after hemodialysis rate, oppression time longer than 30 min after hemodialysis rate, ultrafiltration rate, hemoglobin, high-sensitivity C-reactive protein, fasting blood glucose, total cholesterol, low density lipoprotein cholesterol, calcium-phosphorus product and D-dimer in observation group were higher than those in control group. The differences were statistically significant (P<0.05). There were statistically significant differences in the systolic pressure and low molecular weight heparin usage between two groups (P<0.05). The multi-factor logistic regression analysis showed that the diabetes[OR=1.417, 95%CI (1.196-1.803), P=0.001], puncture failure[OR=1.393, 95%CI (1.185-1.638), P=0.000], tightly binding after hemodialysis[OR=1.249, 95%CI (1.101-1.416), P=0.001], oppression time longer than 30 min after hemodialysis[OR=8.369, 95%CI (1.725-40.596), P=0.008], systolic pressure[OR=1.031, 95%CI (1.001-1.061), P=0.040], ultrafiltration rate[OR=1.490, 95%CI (1.146-1.937), P=0.003], high-sensitivity C-reactive protein[OR=1.594, 95%CI(1.085-2.342), P=0.017], low-density lipoprotein cholesterol[OR=9.456, 95%CI (2.534-55.040), P=0.007] and D-dimer[OR=11.711, 95%CI (5.310-69.231), P=0.005] were independent risk factors for thrombosis in internal arteriovenous fistula in maintenance hemodialysis patients. Usage of low molecular weight heparin[OR=0.101, 95%CI (0.017-0.590), P=0.011] was protective factor. Conclusions Thrombosis in internal arteriovenous fistula in patients with maintenance hemodialysis is not only related to metabolic factors, but also related to nursing factors. We should strictly control the ultrafiltration rate, improve puncture success rate, strengthen the health education and nursing observation post operation so as to early spot and prevent the thrombosis in internal arteriovenous fistula. Key words: Internal arteriovenous fistula; Thrombosis; Influencing factors

Barriers to primary prophylaxis in haemophilic children: the issue of the venous access.

Modem treatment for hemophilic children is based on prophylaxis and immune tolerance induction (ITI). Both treatment regimens are based on frequent infusions at early ages, therefore an adequate venous access is essential. Peripheral veins represent the best option, however, different solutions, as central venous access devices (CVADs) and arteriovenous fistulae (AVFs), can be adopted if needed. CVADs have been used in hemophiliacs, however their survival is affected by infectious complications. Among CVADs, fully implantable devices are usually preferred to external lines due to a lower infectious risk. The limited survival of CVADs may have a relevant impact on treatment outcome, especially in case of ITI where treatment interruptions are counterproductive. To overcome such drawbacks, internal AVF has been considered as an alternative option owing to a lower rate of infectious complications. Moreover, AVF is easy to use in the home setting and well accepted by children. Possible complications not preventing AVF use are postoperative hematoma and transient symptoms of distal ischemia; one case of symptomatic thrombosis has been reported so far. Long-term complications include loss of patency, aneurysmatic dilatation and, rarely, limb dysmetria and a regular follow-up is mandatory to allow early remedial intervention. Surgical dismantlement of AVF is recommended as soon as transition to peripheral veins is possible.

Risk factors for pulmonary hypertension in patients receiving maintenance peritoneal dialysis.

We investigated the risk factors for pulmonary hypertension (PH) in patients receiving maintenance peritoneal dialysis (MPD). A group of 180 end-stage renal disease patients (124 men and 56 women; mean age: 56.43±8.36) were enrolled in our study, which was conducted between January 2009 and June 2014. All of the patients received MPD treatment in the Dialysis Center of the Second Affiliated Hospital of Soochow University. Clinical data, laboratory indices, and echocardiographic data from these patients were collected, and follow-ups were scheduled bi-monthly. The incidence and relevant risk factors of PH were analyzed. The differences in measurement data were compared by t-test and enumeration data were compared with the χ2 test. Among the 180 patients receiving MPD, 60 were diagnosed with PH. The remaining 120 were regarded as the non-PH group. Significant differences were observed in the clinical data, laboratory indices, and echocardiographic data between the PH and non-PH patients (all P<0.05). Furthermore, hypertensive nephropathy patients on MPD showed a significantly higher incidence of PH compared with non-hypertensive nephropathy patients (P<0.05). Logistic regression analysis showed that the proportion of internal arteriovenous fistula, C-reactive protein levels, and ejection fraction were the highest risk factors for PH in patients receiving MPD. Our study shows that there is a high incidence of PH in patients receiving MPD and hypertensive nephropathy patients have an increased susceptibility to PH.

Analysis on factors relevant to operation success rate of internal arteriovenous fistula used in pediatric patients with end stage renal disease

To analyze the factors relevant to success rate of arteriovenous fistula (AVF) plasty in children who need maintenance hemodialysis and to provide predictor of the success of operation. Totally 62 patients who had arteriovenous fistula plasty operation for maintenance of hemodialysis in our hospital treated during June 2007 to April 2014 were enrolled into this study, 41 were male, and 21 female, median age of surgery was 11 years and 9 months (age range was 5 y 8 m to 16 y 2 m). The proportions of primary diseases were: chronic glomerulonephritis 29% (18), kidney abnormality and dysplasia 27% (17). These 62 cases were divided into 2 groups: the success group and the failure group according to whether there were tremble and vascular murmur on the surgery site 1 week after the surgery. Factors like sex, choice of operation side, choice of operation vessel, anesthesia, urine protein, model of vascular suture line, age of surgery, inner diameter of anastomotic stoma, hemoglobin (Hb), platelet (Plt), hematocrit (Hct), coagulation function (prothrombin time, PT, fibrinogen, Fib, activated partial thromboplastin time, APTT), creatinine (Scr), Ca²⁺, left ventricular ejection fraction (LVEF), blood pressure (before, during and after surgery) were collected retrospectively. Student's t test and chi-square tests were used to analyze the differences of the factors between 2 groups. Those factors which were statistically significant in t test and chi-square test were taken into multi factor logistic regression analysis. (1) Average time interval from final diagnosis of ESRD to surgery was 30.8 days. (2) Relevant factors of operation success rate: anesthesia (χ² = 5.531, P=0.026), preoperative serum cholesterol (CHO) (t=-2.069, P=0.043), mean systolic blood pressure in the afternoon before operation (t=2.154, P=0.042), systolic blood pressure when the operation was finished (t=2.199, P=0.032) were related to the success rate of AVF operation in the t test and chi-square test. Multi factors logistic regression analysis showed systolic blood pressure measured when the operation was finished was a dependent protective factor of the surgery (OR=0.962, P=0.040, 95% CI=0.926-0.998). When the systolic blood pressure at the end of operation elevated 1 mmHg (1 mmHg=0.133 kPa), the failure rate of the surgery would be 0.962 times. The time interval from final diagnosis of ESRD to surgery was 30.8 days, it was much shorter than 6-12 months which was suggested by 2006 NKF-KDOQI vascular access guideline. As dependent protective factor of success rate, the systolic blood pressure at the end of operation was suggested to be the predictor of successful operation. And the higher systolic blood pressure at the end of operation may increase the success rate of operation.

Effects of perioperative rehabilitation for patients with self-forearm internal arteriovenous fistula

Objective To evaluate the effects of perioperative rehabilitation for patients with self-forearm internal arteriovenous fistula. Methods Divided 124 patients with end-stage renal disease into the functional training group (65 cases, A group)and the control group(59 cases,B group) randomly, and then compared certain related indexes between the two groups. Results In the A group , the artery diameter was obvious widen before functional training without operation, and the vein diameter was obvious widen before functional training without operation too,P <0.05. After operation, the A group Anastomotic unobstructed was obviously better than B group in one-stage,P <0.05. A group with thrombosis cases significantly less postoperative than B group,P <0.05. A group with edema of hands was significantly shorter than B group , P <0.01. Postoperative fistula time to maturity in the A group was (43.76 ± 2.21) days, which was significantly shorter than that of in the B group , (49.69 ± 5.85) days,P <0.01. Conclusion Systematic strengthening of perioperative functional exercises can significantly improve preoperative vascular conditions, improve the success rate of operation, reduce risk of thrombosis cases, shorten the time of hand edema and the time of fistula in mature. Key words: Internal arteriovenous fistula; Perioperative period; Rehabilitation

Implantación de la técnica del “ojal” o “buttonhole” en una unidad de hemodiálisis hospitalaria: satisfacción del paciente

Por los profesionales del campo de la Nefrología y la Diálisis es conocida la vital importancia de contar con un acceso vascular óptimo desde que en 1945 se realizase el primer tratamiento renal sustitutivo con hemodiálisis. Esto es debido a que la calidad del acceso vascular (AV) condiciona la eficiencia y efectividad de dicha técnica, así como la morbilidad y calidad de vida de los pacientes sometidos a esta terapia1. Para que un AV sea considerado óptimo debe reunir varias características: permitir el abordaje seguro y continuado al sistema vascular, proporcionar flujos suficientes que permitan suministrar la dosis de diálisis requerida y carecer de complicaciones. Sin embargo, a pesar de que, en la actualidad, este tipo de AV no existe, el que más se acerca a estos requisitos es la fístula arteriovenosa interna (FAVI)1. Por ello, se considera el acceso vascular de elección en los pacientes con insuficiencia renal crónica terminal que requieren hemodiálisis. La evidencia científica coincide en la importancia de los cuidados enfermeros efectivos de la FAVI y de una técnica de punción adecuada para conseguir el correcto desarrollo y permeabilidad, prolongar su supervivencia y minimizar las complicaciones relacionadas con la disfunción (estenosis, aneurismas, trombosis, infección...). El correcto uso y mantenimiento de este acceso vascular (AV) va a ser la piedra angular relacionada con el aspecto técnico de la hemodiálisis en el que la enfermería puede incidir. Se ha comprobado que la técnica de punción de la FAVI es motivo de ansiedad y disconfort para el paciente y, secundariamente para el personal del enfermería2. Además de influir en la supervivencia de la FAVI, dado que las punciones repetidas acaban alterando la morfología y características del vaso sanguíneo3, como ya enunció Kronung en 1984 con su análisis de las consecuencias de las múltiples punciones, y la mejor técnica para evitar su daño4, debido a la elongación de la pared frontal del vaso provocada por el desplazamiento del tejido y al posterior llenado con un trombo del hueco generado tras la retirada de la aguja.

Effect of puncture-related pain on the quality of life in patients undergoing maintenance hemodialysis through internal arteriovenous fistula

To investigate the effect of puncture-related pain on the quality of life in patients undergoing maintenance hemodialysis through internal arteriovenous fi stula. A total of 180 hemodialysis patients with the arteriovenous fistula were surveyed by the kidney disease quality of life short form(KDQOL-SF1.3), demographic data questionnaire, visual analogue scale and pain self-efficacy questionnaire. The median score of puncture-related pain was 5 and the score of pain self-efficacy was (31.42±14.59). The quality of life in the patients undergoing maintenance hemodialysis is poor. KDQOL-SF1.3 was (69.45±24.19), SF-36 was (49.82±19.17) and ESRD-targeted was (55.46±18.37). Multivariate analysis demonstrated that the quality of life was positively correlated with the patient gender (β=0.152, P< 0.05, OR=1.638, 95% CI 1.241-1.954), working position (β=0.307, P< 0.05, OR=2.069, 95% CI 1.206--3.148), using time of arteriovenous fistula (β=-0.815, P< 0.05, OR=0.223, 95% CI 0.095-0.741), the score of pain (β=-0.017, P< 0.05, OR=1.004, 95% CI 0.886-1.431) and pain self-efficacy (β=-0.409, P< 0.05, OR=0.803, 95% CI 0.710-0.984). There existed negative correlation between the quality of life score and the puncture-related pain score in these patients (r=-0.472, -0.465, -0.381, P< 0.01), positive correlation between the quality of life score and the score of pain self-efficacy (r=0.647, 0.203, 0.518, P< 0.05), and negative correlation between the puncture-related pain score and the score of pain self-efficacy(r=-0.745, P< 0.01). Puncture-related pain is a crucial influential factor on the quality of life in the patients undergoing maintenance hemodialysis through internal arteriovenous fistula.

Accesos venosos para hemodiálisis: abordaje yugular

It is not an uncommon event that patients with stabilized kidney failure or healthy individuals develop a sudden deterioration in their kidney function requiring dialysis, while lacking an adequate vascular access. In these situations, the implant of a double-lumen tunneled catheter within the internal jugular vein should be considered the best option to start hemodialysis.The vascular approach must be practiced preferentially on the right side, under ultrasound control and fluoroscopy guidance to verify the correct location of the tip of the catheter in the right atrium. Catheters with outer caliber between 13.5 and 15.5Fr can provide adequate blood flow for hemodialysis.As the use of different types of anticoagulants and antiplatelet drugs is so widely extended, it is necessary, before implanting the catheter, to check the coagulation parameters and platelet count; and, when required, the establishment of specific corrective actions to prevent hemorrhagic complications during the implant of the catheter should be undertaken.Gaining vascular access may involve complications. Infection or sepsis is not a rarity, and its prevention requires carrying out the procedure with strict adherence to the rules for an aseptic insertion of the implant, and performing an adequate care and cleaning after every use of the catheter. Anti-microbial solutions for sealing the lumen are also effective in this context, but if an infection develops, the catheter must be removed and an appropriate antibiotic regimen must be established. Other situations that may involve removal of the catheter are: malfunction, breaking, venous thrombosis and central venous stenosis or occlusion. However, there are cases of venous thrombosis in which, before removing the catheter, direct fibrinolysis may be tried. Similarly, in selected cases of central venous stenosis or occlusion, pneumatic dilatation with balloon catheter (angioplasty, APT) may be tried (once or more) to restore the venous caliber. Finally, in very infrequent situations in which APT fails, it is possible to implant a stent to resolve the stenosis; however, as it is frequently not effective in the medium term, it should only be considered as a last resort.In conclusion, jugular access for dialysis in patients without a competent internal arterio-venous fistula is an optimum choice. Although it presents a wide range of complications, if being expected, an effective and appropriate treatment may be safely established. As complications involving complex instrumentation, such as APT or stenting, show a low frequency (below 3%), jugular access can be considered a safe, comfortable and effective access for dialysis procedures.

Issues related to vascular access in pediatric blood purification

This article makes a summary on the vascular access issues related to pediatric blood purification and progress, especially in view of the characteristics, principles of selection, maintenance and development direction of various vascular access in application of children patients. Key words: Blood purification; Vascular access; Child; Internal arteriovenous fistula

Endovascular repair of a ruptured subclavian artery aneurysm in a patient with Ehlers–Danlos syndrome using a sandwich technique

We present the case of a type IV Ehlers-Danlos syndrome patient with a ruptured right subclavian artery aneurysm and associated arteriovenous fistula who underwent successful endovascular repair requiring simultaneous stent graft repair of the innominate artery using a sandwich technique. A 17-year-old man with known type IV Ehlers-Danlos syndrome developed right neck and shoulder swelling. CTA study demonstrated a 17 × 13-cm ruptured subclavian artery aneurysm with an associated internal jugular vein arteriovenous fistula. In the hybrid suite, a 7 mm × 15-cm stent graft (Viabahn, WL Gore & Associates, Flagstaff, AZ) was advanced from the right brachial approach into the innominate artery. A separate wire was placed into the right carotid artery via the right femoral approach (7 Fr), and a 7 mm × 10-cm stent graft (Viabahn) was advanced into the innominate artery. An additional 8 mm × 10-cm stent graft (Viabahn) was placed from the right brachial approach to obtain a distal-landing zone in the axillary artery. Complex vascular anatomy, in which graft seal creation may be challenging, does not exclude endovascular approaches as the sandwich technique can be utilized as a suitable alternative to open repair.

During the pre-dialysis stage of chronic kidney disease, which treatment is associated with better survival in dialysis?

Specialised care of patients in advanced stages of chronic kidney disease (CKD) is associated with better survival in dialysis, but it is not known which treatments specifically favour this outcome. To analyse normal treatment in advanced stages of CKD and establish which treatments are associated with better survival in dialysis as well as their relationship with causes of death. Cohort, prospective observational study of 591 patients who started dialysis (491 haemodialysis and 100 peritoneal dialysis), who had previously been monitored in the CKD clinic. The treatments analysed were: antihypertensive treatments, statins, antiplatelet drugs, xanthine oxidase inhibitors, correction of metabolic acidosis, treatment with (calcium or non-calcium) phosphate binders, vitamin D (calcitriol or paricalcitol), erythropoietin and the availability of an internal arteriovenous fistula (IAVF). The independent association of each of these treatments with mortality in dialysis was analysed using Cox regression models adjusted for age, sex, pre-dialysis monitoring time, renal function at the start of dialysis, comorbidity, serum albumin and C-reactive protein, and with stratification of the type of dialysis. With a median follow-up period of 28 months, the total number of patients who died was 191 (32%). In the multivariate models, we observed that, in addition to age, the comorbidity index, serum albumin, pre-dialysis treatment with angiotensin-converting-enzyme inhibitors and/or angiotensin receptor blockers, correction of acidosis with sodium bicarbonate and IAVF at the start of haemodialysis were significantly associated with better survival in dialysis. We did not observe differences in causes of death between the different treatments analysed. These results suggest a potential delayed benefit of some treatments in pre-dialysis stages on the outcome of dialysis. Furthermore, beginning dialysis without an IAVF, resulting in the need for intravenous catheters, worsens prognosis in these patients.

Angiosarcoma in vascular access after transplantation.

The most frequent complications that occur after the completion of an internal arteriovenous fistula are thrombotic. Other complications, such as infection, cardiac decompensation, aneurysm/pseudoaneurysm or median nerve injury, are less common. Nonetheless, after transplantation, adjuvant immunosuppression has long-term side effects, such as the development of malignancies. Here, we report the case of a patient subjected to renal transplantation who developed an angiosarcoma located in an internal arteriovenous fistula.

Internal mammary arteriovenous fistula found late after aortic root replacement

A 37-year-old male patient with Marfan syndrome was referred for a routine check-up at our department. At the age of 17, he was operated due to aortic root dilatation and severe aortic valve regurgitation. A composite graft was placed in the aortic position and the coronary arteries were re-implanted. He had been seen elsewhere on a regular basis since the operation. Despite successful outcome and treatment with heart failure medication the ejection fraction remained <30%. Upon examination, the patient was uncongested; however, in NYHA III. …

Application of improved wet sensors in the early warning of internal fistula needles prolapse

Objective To explore the warning effect of the improved wet sensor in the oozing and bleeding of internal fistula puncture site,so as to prevent the phenomenon of fistula needle slippage.Methods From January 2012 to June 2012,to select the 60 patients who accepted hemodialysis treatment by arteriovenous fistula needle,then to monitor the blood oozing and bleeding of fistula needle point with the improved wet sensors.Results The saline induction alarm sensitivity between the wet sensors with resistance value of 1.2 MΩ and 2.2 MΩ and the wet sensors with value of 2 000 Ω,significant differences were found (t =19.91,20.13 ; P ＜0.01).While no significant difference was found in saline induction alarm sensitivity between the wet sensors with resistance value of 1.2 MΩand of 2.2 MΩ (t =1.43,P ＞ 0.05).The sensitivity of wet sensors with resistance value of 1.2 MΩ and 2.2 MΩ was higher.when the oozing amount reached (1.21 ± 0.49) ml and (1.12 ± 0.50) ml,they were alerted.While there was no significant difference was found between them (t =0.73,P ＞ 0.05).Conclusions The wet sensor can effectively monitor and early warning the oozing and bleeding during the operation of internal fistula puncture point,and can effectively prevent the phenomenon of fistula needle slippage and avoid the harm of dialysis accident. Key words: Diffusion of innovation; Internal arteriovenous fistula; Wet sensor; Early warning; Puncture needle prolapse