Vascular Access Options Research Articles

Prospective Analysis of Arteriovenous Fistula Performance in the Context of Competing Risks.

Many patients with newly created arteriovenous fistulas (AVF) may die before the AVF is needed for hemodialysis. However, formal competing risks frameworks are rarely used to report AVF patency, which may lead to biased estimates. We sought to identify the proportion of newly created AVF experiencing primary non-function and to describe long-term patency using a competing risk framework. We did a prospective observational study in 257 adults with newly created AVF in Alberta, Canada. The primary outcome was primary non-function. Secondary outcomes included loss of primary-patency, loss of assisted primary-patency, and loss of secondary functional-patency. Results were presented using icon-array plots to form the basis for future decision aids. Participants were 63.0% male with mean age 62.3 years and median follow-up of 18.5 months (range 0.02-180 months). Of 257 participants, 50 could not be assessed for function or primary non-function, usually due to death. Of the remaining 207, 102 (49.3%) had primary non-function, and function was ultimately established for 142 (68.6%). Thus, only 142 of the 257 participants (55.3%) ultimately used the AVF for hemodialysis. High rates of competing risks led to biased results from Kaplan-Meier analyses of lost patency. When accounting for competing risks, loss of primary-patency among AVF with established function was 36.6%, 65.5% and 66.2%, at 1y, 3y and 5y respectively. Only 55% of fistulas were ultimately used for hemodialysis when accounting for competing risks and primary non-function. These results and the icon-array plots may inform discussions surrounding vascular access options for patients.

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.

A perspective on integrated dialysis access management: in advance of integrated care plan

(To read the full article, in English or French, click on the pdf logo on the right). We would like to draw attention to the critical issue of dialysis access management and vascular access (VA) options in patients transitioning to chronic renal replacement therapy and from peritoneal dialysis (PD) to hemodialysis (HD). We advocate for the establishment of dedicated consultation services for integrated dialysis access management to optimize patient outcomes. We highlight specific cases where a tailored approach to VA selection is essential, emphasizing the importance of risk stratification and timely access preparation. The preferred use of arteriovenous fistula in HD patients and the challenges surrounding its maturation are discussed. We also explore circumstances necessitating urgent versus planned transitions to HD, incorporating considerations for patient-centered care and education. Sonography’s role in managing PD-related infections and the potential benefits of home HD in the transition process are also examined. We suggest the development of scoring systems to predict patient transitions and emphasize the need for an integrated approach to dialysis access management. Overall, we advocate for proactive measures to prevent vascular access failure and ensure a safe and effective transition process for patients with chronic kidney disease.

Pivotal Role of Duplex Ultrasonography on Arteriovenous Fistula for Hemodialysis Access

The global incidence of end-stage renal disease (ESRD) is rising, amounting to more than 800 million individuals are suffered, in line with the rise of the number of patients undergoing hemodialysis as treatment modalities. Hemodialysis requires vascular access, and the arteriovenous fistula (AVF) access is considered the most ideal vascular access option due to its long-term patency and low complication rate compared to other access options. However, up to one-third of hospital admissions for ESRD patients are caused by AVF dysfunction, which is also one of the main causes of morbidity and mortality in ESRD patients. AVF creation requires careful pre- and post-operative evaluation to ensure the vascular access maturation and patency. While the latest guidelines have not explicitly emphasized the role of vascular mapping and surveillance, routine duplex ultrasonography before and after AVF creation procedures holds great potential advantages to ensure the success of AV access for hemodialysis.

Vascular Access Considerations in Home Hemodialysis.

There is a global interest in expanding home dialysis utilization among patients with ESKD. Home hemodialysis (HHD) is an appealing KRT option for this population because of its multiple clinical and quality of life benefits. Central to successful HHD is the establishment and maintenance of a functioning vascular access that serves as a patient's lifeline while on therapy. While the selection of a vascular access type is influenced by individual patient circumstances, the arteriovenous fistula is generally the preferred access method. Training patients to use their dialysis access requires attention to safety, risk management, and monitoring for complications to minimize adverse events and technique failure. Policies incorporating systematic frameworks for quality improvement and assurance, in conjunction with the measurement of metrics relating to vascular access, are tools that should be used by HHD programs to enhance the value of care delivered. In this perspective, we aim to describe what is currently known about the various vascular access options in HHD and to elucidate what needs to be taken into consideration in the selection and care of this access.

Variables Leading to Usage of Alteplase Versus Heparin Lock in Patients With Tunneled Catheters in Hemodialysis Care Project Centers, Saudi Arabia.

A hemodialysis tunneledcatheter is one option for vascular access used with hemodialysis patients; however, catheter complications such as thrombosis are still inevitable. To prevent thrombosis formation, a catheter-locking solution is instilled between dialysis sessions. Heparin is used as a default locking solution in our Hemodialysis Care Project centers, while arecombinant tissue plasminogen activator (rt-PA) such as alteplase is used to treat suspected catheter thrombosis. This study aimed to identify the clinical factors, catheter brands, and hemodialysis variables that influence the choice of use for alteplase versus heparin, for those patients with tunneled catheters, and reduce overprescribing of high-alert medication alteplase. A retrospective medical chart review study was conducted involving 230 patients with tunneled catheters; the first group of 133 patients used alteplase regularly three times a week, while the second group of 97 patients completed at least one year using the same catheter access with heparin lock only. Multivariate logistic regression and logistic regression analysis showed a significant association (p < 0.05) between different variables. Results suggest that overweight and hyperlipidemia patients are more likely to use alteplase. Patients using brand-name catheters such as Hemostar/Vas-cath (BD, Franklin Lakes, NJ) are less likely to use heparin than those using Medcompcatheters (Medcomp, Yuma, AZ). In addition, patients having a history of angioplasty would be less likely to have heparin than no angioplasty. Moreover, if the patient's fluid removal were equal to or less than 2 kg, they would be more likely to use heparin and vice versa. The study postulates that identified variables affect whether alteplase or heparin is used in hemodialysis tunneled catheters, and may be useful to increase awareness, improve practices, or judiciously control the use of alteplase within Saudi Arabia and globally.

Off-the-Shelf Synthetic Biodegradable Grafts Transform In Situ into a Living Arteriovenous Fistula in a Large Animal Model.

Current vascular access options require frequent interventions. In situ tissue engineering (TE) may overcome these limitations by combining the initial success of synthetic grafts with long-term advantages of autologous vessels by using biodegradable grafts that transform into autologous vascular tissue at the site of implantation. Scaffolds (6 mm-Ø) made of supramolecular polycarbonate-bisurea (PC-BU), with a polycaprolactone (PCL) anti-kinking-coil, are implanted between the carotid artery and jugular vein in goats. A subset is bio-functionalized using bisurea-modified-Stromal cell-derived factor-1α (SDF1α) derived peptides and ePTFE grafts as controls. Grafts are explanted after 1 and 3 months, and evaluated for material degradation, tissue formation, compliance, and patency. At 3 months, the scaffold is resorbed and replaced by vascular neo-tissue, including elastin, contractile markers, and endothelial lining. No dilations, ruptures, or aneurysms are observed and grafts are successfully cannulated at termination. SDF-1α-peptide-biofunctionalization does not influence outcomes. Patency is lower in TE grafts (50%) compared to controls (100% patency), predominantly caused by intimal hyperplasia. Rapid remodeling of a synthetic, biodegradable vascular scaffold into a living, compliant arteriovenous fistula is demonstrated in a large animal model. Despite lower patency compared to ePTFE, transformation into autologous and compliant living tissue with self-healing capacity may have long-term advantages.

Vascular access for haemodialysis

David Mantle discusses the various vascular access options for patients undergoing haemodialysis

Alternative dialysis access strategies: A case report of a patient with transrenal hemodialysis catheter due to exhausted traditional routes and review of literature.

Vascular access is the primary lifeline for patients with end-stage renal disease. While arteriovenous fistulas and grafts are the conventionally favored methods for dialysis therapy, certain patients may deplete these traditional vascular access options due to various reasons. In the quest for alternatives, unconventional vascular pathways could be considered, including transhepatic, trans-lumbar and trans-renal approaches. We present a case of a 61-year-old male who exhausted all the traditional vascular access options, therefore trans-renal hemodialysis catheter placement was performed. Overall, this case highlights the challenges of securing a reliable vascular access to perform dialysis therapy and implementing unconventional methods whenever regular means are exhausted.

Fatal superior vena cava rupture complicating dialysis catheter exchange.

Central vein stenosis (CVS) is a common and challenging complication in hemodialysis patients with chronic central venous catheters (CVCs). CVS often remains asymptomatic and is discovered incidentally during follow-up imaging. CVS symptoms include arm swelling, venous hypertension, impaired dialysis flow rates, and development of collateral veins. However, these symptoms can be nonspecific and overlap with other conditions, making the diagnosis challenging. Timely recognition and appropriate intervention are crucial to prevent complications and optimize patient outcomes. Diagnostic tools commonly used include duplex ultrasonography and venography to assess the degree and location of stenosis. Management strategies for CVS encompass a multidisciplinary approach involving nephrologists, interventional radiologists, and vascular surgeons. Initial conservative measures may include anticoagulation therapy, along with pharmacological interventions such as antiplatelet agents and thrombolytics. The endovascular approach is the first line for managing CVS by using balloon angioplasty either alone or in combination with stent placement, but CVS typically recurs frequently, requiring repeated interventions with an increased risk of complications. Additionally, alternative vascular access options such as arteriovenous fistulas or grafts may be considered. In this report, we describe a case of a 25-year-old woman who presented with an extensive history of multiple dialysis access failure for left internal jugular vein central venous tunneled catheter exchange. The procedure was complicated by a fatal superior vena cava rupture likely related to the dislodgment of the guidewire causing perforation into the pericardium space with subsequent cardiopulmonary collapse. The post-mortem autopsy showed severe organized stenosis of SVC and transmural defect above the SVC/atrial junction.

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.

Superficialization of the Basilic Vein in Brachiobasilic Arteriovenous Fistula: An Alternative Vascular Access for Hemodialysis- A Single Center Experience

Introduction: The use of basilic vein to create brachiobasilic arteriovenous fistula (BBAVF) is the vascular access option of choice for hemodialysis when cephalic veins are not available. To create BBAVF, the basilic vein should be superficialized and lateralized. The study aims to highlight the outcome and morbidity of BBAVF at the tertiary referral center and aims to improve the results of the procedure in patients with chronic renal failure.Materials and Methods: This is prospective, descriptive study conducted at College of Medical Sciences Teaching Hospital from January 2019 to December 2022.The demographic data, morbidities, results were analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0 (SPSS).Results: We evaluated outcome of total forty patients who underwent BBAVF with transposition of basilic vein. The mean age of patients was 61 ± 10.85 years and male:female ratio was 2.07:1. The mean size of basilic vein was 3.05 ± 0.84mm and brachial artery was 4.11 ± 0.99mm. The most common co-morbidities in this study was Diabetes Mellitus and hypertension both was present in 52.5% of patients, only hypertension in 27.5%, only Diabetes Mellitus in 5%, HTN with PVD in 2.5% and HTN, Diabetes Mellitus with PVD in 2.5% of patients. The postoperative complications were bleeding in 25% (10), infection 10% (4), primary failure 7.5% (3), pseudoaneurysm 5% (2), and oedema 7.5% (3).Total 82.5% (33) of cases were able to start dialysis in 45 days. The failure rate was 12.5% (5) due to thrombosis and pseudoaneurysm.Conclusion: BBAVF is a suitable option for vascular access in patients with failed previous AVF or patients with small cephalic vein. Relocation of basilic vein for AVF is feasible, safe and with good patency and complication rates are acceptable.

Hemodiyaliz Damar Erişim Yolları ve Bakımı

Hemodialysis remains the most widely used method for treating renal failure. Life expectancy and quality in hemodialysis are directly proportional to the quality of dialysis, and this quality depends on the reliability and integrity of the patient’s vascular access route. The ideal vascular access route provides reliable, uncomplicated access to dialysis and is also suitable for the patient’s needs. Hemodialysis vascular access options have not changed substantially over the past six decades, and arteriovenous fistula (AVF) remains the access of choice. Although AVF is a vascular intervention recommended and preferred in clinical practice guidelines for hemodialysis, it can develop into serious complications such as thrombosis, hematoma, edema, peripheral ischemia, bleeding, and infection. To prevent these complications, it is extremely important to educate patients about AVF care. This review has been prepared as a guide for healthcare professionals who care for hemodialysis patients.

Comparative study between 1-year patency of brachiobasilic arteriovenous fistula versus brachial to basilic forearm loop graft in patients with end-stage renal disease

Background The most preferred method of vascular access is the autogenous arteriovenous fistula (AVF). When ready for dialysis, autogenous AVF outperforms arteriovenous grafts (AVG) in terms of patency and survival. An alternate method of vascular access for such individuals is the transposed AVF or AVG. Aim The goal of this trial is to evaluate and contrast the results of those who were treated with a brachiobasilic (BB) AVF to those who were treated with a polytetrafluoroethylene brachial to basilic forearm loop graft. Primary endpoints Assisted primary patency, primary patency also secondary patency. Secondary endpoints: postoperative complications (wound infection, bleeding, steal syndrome, and procedure-related mortality), functional maturity. Patients and methods This is a prospective cohort observational trial performed at the Vascular Surgery Department, Faculty of Medicine, Ain Shams University. Data about patients who had forearm loop grafts or BB AVFs during the period from January 2021 to January 2022 were collected according to the study inclusion criteria. There was a total of 50 individuals included (25 patients in each group). The first group included cases who had BB AVF with basilic vein transposition (BB tAVF) whereas the second group included patients who had brachial-basilic forearm loop graft (BB AVG). Results Regarding age and sex distribution or risks of cardiovascular events, there was not a statistically significant distinction among the two study groups. The fistula group required statistically significant longer time to achieve functional maturity mean±SD (BB tAVF=9.64±2.29 vs .BB AVG=6.6±2 assisted and secondary patencies at 3, 6, 12, and 18 months). No statistically significant variation existed among groups regarding postoperative bleeding, infection, and procedure-related mortality. Conclusion Both BB AVF and polytetrafluoroethylene brachial to basilic forearm 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, possible risks of prolonged central venous catheter (CVC) use, as well as the risks of infection and thrombosis, which should be carefully evaluated.

Potential prosthetic arterio-venous graft dissection: A rare case

Arterio-venous fistulas (AVF) are recommended as the first line vascular access option in patients requiring haemodialysis in end stage renal disease (ESRD). Prosthetic grafts have been used successfully as an alternative in cases where AVF is not feasible. We present a rare case of dissection of the prosthetic graft. Knowledge and recognition of this complication is important in making correct diagnosis and deciding appropriate treatment.

Identification of small diameter nerve fiber damage in hemodialysis patients' hands using the cutaneous silent period

BackgroundThe arteriovenous fistula is the most effective vascular access option for hemodialysis patients. An important and largely unreported concern detected at follow-up is the complaints of tingling or numbness in the hands of those patients. Furthermore, the cutaneous silent period qualifies as a straightforward evaluation of small nerve fiber function. This study aims to evaluate the function of small-diameter nerve fibers in the hands of patients undergoing continuous hemodialysis (HD) on the side with the arteriovenous fistula (AVF) and on the contralateral side.ResultsA cross-sectional study of 40 randomly chosen patients with chronic kidney disease on regular hemodialysis three times weekly the cutaneous silent period (CSP) was recorded on the hand with and without AV fistula. The cutaneous silent period (CSP) CSP was elicited by electrical square pulse stimulation using standard bipolar electrodes. The average cutaneous silent period onset and end latencies demonstrated significant prolongation in the hemodialysis patient group (arteriovenous fistula and non-arteriovenous fistula) compared with the control group. Correlation between cutaneous silent period with hemodialysis duration and adequacy of hemodialysis (KT\\V). There was a statistically negative correlation observed between cutaneous silent period onset latency on the arteriovenous side and a positive correlation with KT\\V on non-arteriovenous fistula. side.ConclusionsHemodialysis patients recommended to undergo regular neurophysiological testing to check for small nerve fiber affection. In particular, measuring the cutaneous Silent period that provides a quick and noninvasive way to rule out small A-delta nerve malfunction. In addition, less nerve injury results from hemodialysis's increased efficiency.

Use of Basilic vein in arteriovenous fistulas construction for hemodialysis access. Is it a good option alternative to prosthetic arteriovenous grafts?

For patients with a failed forearm autogenous fistula (AF) and an exhausted cephalic vein, there is controversy about whether a brachial basilic AF with transposition or an arteriovenous prosthetic bridging graft (BG) must be the second vascular access option. This work measured and compared these two modalities according to patency rates, complications, and revisions. A retrospective study of 104 cases that had either a brachial basilic AF (72) or an Arteriovenous BG (32). Technical success, operative complications, procedurerelated mortality, maturation time, functional primary, secondary, and overall patency rates were all assessed. Technical success was obtained in all participants. No procedure-linked mortality. Maturation time for BGs was significantly shorter than AFs. The complication rate was significantly higher in BGs than in AFs. The most prevalent complication was access thrombosis. The functional primary patency rate was significantly higher in AF than in BG at 12-month followup: 77.7% vs 53.1% (p < 0.012). secondary patency rate was higher in AF than in BG at 1-year follow-up 62.5% vs 42.8% (p = 0.063), respectively. In addition, BGs required more interventions to preserve patency. AF had higher primary, secondary and overall functional patency rates and needed fewer procedures to keep patency than BGs. Cases that need early vascular access as a result of central venous catheter complications or who have a reduced life expectancy may benefit from BGs.

#6898 CATHETER RELATED BLOODSTREAM INFECTION IN NON-TUNNELED HEMODIALYSIS CATHETERS IN A RESOURCE-LIMITED HOSPITAL IN MERIDA, YUCATAN, MEXICO

Abstract Background and Aims There is scarcity in epidemiological data regarding chronic kidney (CKD) disease in low- and medium-income countries, and information about vascular access infectious complications is limited. In Mexico, access to renal replacement therapy (RRT) is burdensome for the uninsured patients. The General Hospital Agustin O'Horán, is a secondary care level unit in Yucatan, which receives uninsured patients from southeast Mexico. In our hospital, patients who are not candidates for peritoneal dialysis start hemodialysis with non-tunneled hemodialysis central venous catheters (NTHC), mainly due to the late nephrology referral and the shortage of vascular access specialists in our unit which prevents for the timely creation of an arteriovenous fistula or the placement of a tunneled hemodialysis catheter (THC). Permanence of NTHC is the main risk factor for catheter related bloodstream infection (CRBI) and according to the literature, Gram positive microorganisms are the most common isolated microbes. The aim of our study was to describe the incidence and risk factors for CRBSI in our hospital, from January to December 2022. Method We conducted a prospective and observational study in patients older than 18 years with CKD who were candidates to start hemodialysis and who had a NTHC inserted in our hospital from January to December 2022. We evaluated the incidence, organisms and risk factors related to CRBSI. Results During the study period, 94 NTHC were placed, 63.8% of them were inserted in women. Median age of the population was 49.4 years, and the most frequent comorbidities were diabetes mellitus (63.8%), hypertension (86.2%) and renal lithiasis (27.7%). 73.4% of the NTHC were Mahurkar® catheters and most of the insertions (73.4%) were not ultrasound guided. The right jugular vein was the most common insertion site (72.3%), followed by the left jugular vein. Mean catheter use duration was 71 ± 66 days. 27 patients had evidence of CRBI, the incidence rate was 0.78 per 1000 catheters-day. CRBI was more frequent in patients with prolonged catheter use (more than 30 days) (p&amp;lt;0.001) (Table 1). In respect to blood cultures reports, 51.83% were Gram positive organisms and 48.12% were Gram negative (Table 2). Conclusion Vascular access survival without infectious complications is of paramount importance in hemodialysis patients. The prolonged used of NTHC with the associated risk for developing CRBI negatively impacts the health outcomes in our population. In accordance to previously published literature, the main isolated microbes in our hospital comprise Gram positive bacteria. One of the biggest challenges in our country is to provide our CKD population with better vascular access options like THC or arteriovenous fistula to improve the outcomes and reduce infectious complications.

#6597 THE EFFECT OF PATHOGEN ON THE OUTCOME OF HEMODIALYSIS CATHETER-RELATED BLOODSTREAM INFECTIONS IN HOSPITALIZED PATIENTS: A SINGLE CENTER ANNUAL RECORD

Abstract Background and Aims Tunneled double-lumen catheters are increasingly used as permanent vascular access in hemodialysis patients, particularly in those with limited vascular access options. Catheter-related bloodstream infection (CRBSI) is a major cause of hospitalization with increased mortality and cost. The purpose is to study the effect of the pathogen on the clinical course of the hemodialysis patients with CRBSI. Method Patients hospitalized in our department from 11/2021 to 12/2022 with established CRBSI were retrospectively studied. Their demographics, duration of hospitalization, microbiological data, central venous catheter management and hospital outcome were recorded. Results A total of 27 patients with median age (SD) 68,03 (16,93) years were treated, 12 (44.4%) were men. The following pathogens were isolated from the blood cultures: Staphylococcus aureus in 7 (25.9%) patients, coagulase-negative Staphylococcus in 10 (37%) patients, Gram-positive bacteria in 4 (14.8%) patients, Gram-negative bacteria in 3 (11.1%) patients, candida in one (3.7%) patient, while 2 (7.4%) patients had negative cultures. Mean (SD) duration of hospitalization was 16,85 (13,15) days for all patients. Patients in whom Staphylococcus aureus and Candida were isolated had longer hospital stay than other infections with a mean (SD) 29 (18) days and 41 days respectively (p = 0.014). Metastatic infections occurred in 4 (14,8%) patients, of whom 2 had endocarditis, one endocarditis and pulmonary abscess, and one endocarditis, lung abscess and brain abscess. All 4 patients isolated Staphylococcus aureus in blood culture out of a total of 7 (57,1%) patients with this pathogen (p = 0.02). 3 of 7 (42,8%) patients with Staphylococcus aureus, 1 of 10 (10%) with coagulase-negative Staphylococcus, and 1 of 3 (33,3%) with Gram-negative bacteria died (p = 0.385). In 26 of the 27 patients (96.3%) central venous catheter was removed. Conclusion The majority of patients in the present sample required central venous catheter removal. The type of pathogen seems to play an important role both in the duration of hospitalization and in the occurrence of metastatic infections.

Persistent median artery on computed tomographic arteriovenous fistulograms in patients on haemodialysis.

Cadaveric studies suggest an increasing prevalence of the persistent median artery (PMA) over a prolonged timeframe. The aim of this retrospective cross-sectional study was to evaluate the PMA prevalence in haemodialysis patients who had computed tomographic fistulograms (CTFs), and if present, their calibres and origins. All consecutive adult patients referred for an upper limb CTFs for assessment of arteriovenous fistula (AVF) dysfunction from 2006 to 2021 were included. Patients whose CTF did not include the forearm were excluded. PMA was identified as an artery running alongside the median nerve between flexor digitorum superficialis and flexor digitorum profundus. Patient demographics, presence of PMA including size and origin were recorded. A PMA was found in 91/170 (53.5%) CTFs (7:3 male-to-female ratio, mean age 71-years). When stratified by age, prevalence increased with decreasing age; 51% in >70-year-olds, 54% in 50-70-year-olds and 67% in <50-year-olds. The average PMA diameter was 2.2 mm proximally and 1.8 mm distally. No stenosis was observed in the PMAs. The PMA prevalence appears to increase with decreasing age and is a frequently encountered anatomical variant. Radiologists assessing forearm vasculature need to be aware of this anatomical variant and potentially include it in their future reports. Further research into the PMA may make its potential use as arterial conduits for AVF, potential donor grafts for coronary artery bypass surgery or additional vascular access options possible. Whether the reducing prevalence with age reflects an overall increasing prevalence is yet to be determined.