Vascular Access Problems Research Articles

Ultrasound Guided Vascular Access Practical Issues (Pictorial Essay)

Ultrasound-guided vascular access is rapidly becoming a more critical topic as critical care medicine systems struggle with an increasing number of patients with vascular access problems. Depending on the situation up to 50% of the patients may have no peripheral vascular access sites or access is very difficult to obtain, which can lead to many complications such as bleeding, pneumothorax or prolonged procedure.

Very high power- short duration radiofrequency ablation in patients with congenital heart disease and atrial fibrillation: safety and outcome

Abstract Funding Acknowledgements Type of funding sources: None. Background It has been shown recently that ablation of paroxysmal and persistent atrial fibrillation (AF) using very high-power-short duration (vHPSD) ablation protocol is safe and effective. Data for vHPSD ablation protocol in adult patients with congenital heart disease (ACHD) are lacking. We searched our database for ACHD patients undergoing AF ablation using vHPSD ablation regarding periprocedural safety and outcome. Methods The data of 62 consecutive ACHD patients with mild (n=43; 69.4%), moderate (n=15; 24.2%) or complex (n= 4; 6.4%) CHD were analysed (Table 1 ). Mean age was 60,43 ± 12,7 years ( 46% male) with a Cha2ds2-VASc2 Score median of 2. Patients were diagnosed with paroxysmal AF (n= 24; 38%) or persistent AF (n= 38; 61%). In 6 patients (9,6 %), a previous conventional pulmonary vein isolation (PVI) had been performed. Settings used for vHPSD ablation were 70 W/5-7 s or 60 W/7-10 s using irrigated-tip catheters. Circumferential PVI was performed in all 62 patients; in 30 patients (48%) additional substrate ablation was performed. The 30-day incidence of adverse events was analyzed and patients followed-up in regular visits at our outpatient clinic using repetitive 7 days Holter ECGs every 3 months. Results No adverse events such as cardiac tamponade, pericardial effusion >10mm, transient ischemic attack/stroke, atrio-esophageal fistula, cardiac arrest or death occurred. Vascular access complications were detected in 7/62 patients (11%), including 4 patients with a need of intervention (surgical n=2, thrombin injection n=2). Complete PVI was performed in all patients (mean procedure time 129 ± 42min, mean fluoroscopy time 9,09 ± 5.44 min. Radiofrequency (RF) time was 127.27 ± 7,25 min (111,43 ± 27,83 min PVI only, 148,76 ± 46,07 min PVI + substrate ablation). After a mean follow up of 249 days, freedom of any atrial arrhythmia off antiarrhythmic drugs (AAD) after a single ablation procedure was present in 26/47 patients (55.3%). Success rate was significantly higher in patients with paroxysmal AF (n=16/18; 88%) compared to patients with persistent AF (n=10/29; 34.5%; p< 0.001; Figure 1) Conclusion: In this first study using vHPSD in ACHD patients of variable complexity with paroxysmal or persistent AF, the technique was safe and effective. Major periprocedural complications were rare and limited to vascular access problems. No vHPSD ablation modality-related complications occurred. vHPSD was fast in all patintes regardless of CHD complexity. Results in the paroxysmal CHD group were excellent and encouraging for persistent AF.

Cuffed-tunneled catheters in hemodialysis patients: problems and solution methods: A single-center retrospective cohort study

Background/Aim: Cuffed-tunneled catheter patients encounter various problems during their catheterization period. Early detection and resolution of these problems prolong the life of the catheter. The purpose of the present study was to investigate the problems and solution methods of cuffed-tunneled catheters in hemodialysis patients during their use in light of our experience and literature. Methods: The study was designed as a retrospective cohort study. Twenty-four months of patient data who had a diagnosis of renal failure and who received cuffed-tunneled hemodialysis catheters between January 2013 and June 21 in the Department of Cardiovascular Surgery of Adiyaman University Faculty of Medicine were analyzed electronically based on the hospital data recording system. The demographic characteristics, localization of the inserted catheter, and duration of catheter use were determined. Primary and secondary patency ratios were calculated and recorded along with the complications in the patients and our treatment approaches to these complications. Finally, the collected data were discussed with reference to the literature data. Results: The data from 322 cuffed-tunneled catheters were collected in a total of 228 patients during the observation period. It was found that no revision procedure was applied to 73 patients (catheter) during the 24-month period, and a total of 204 revision procedures were applied to 155 patients. The revision procedure consisted of 110 thrombolytic treatments, 64 vein exchanges, 18 tunnel changes, and 12 catheter changes. Primary and secondary patency ratios at 6, 12, 18, and 24 months were calculated as 90.79%, 63.60%, 40.11%, and 32.02% and 96.05%, 89.91%, 72.37%, and 58.33%, respectively. The most common factors that affected primary and secondary patency ratios were determined to be gender (P<0.001 and P=0.056, respectively), body mass index (P<0.001 and P<0.001, respectively) and diabetes mellitus (P=0.018 and P=0.690, respectively). Conclusion: Thrombolytic treatment is an effective and safe method in catheter thrombosis, which is one of the most important factors rendering the cuffed-tunneled hemodialysis catheters dysfunctional. Also, in tunnel infections, tunnel replacement is a salvage procedure in patients with vascular access problems.

Malnutrition: A risk factor for vascular access problems.

Vascular access problems are leading causes of morbidity, hospitalization, and impaired quality of life in chronic hemodialysis patients. Native arteriovenous fistula is the gold standard of vascular access. Geriatric nutritional risk index (GNRI), has recently been shown to be an easy and objective instrument for assessing nutritional status in these patient groups. Considering the association between arteria-venous fistula patency and inflammation, as well as the fact that inflammation is a component of malnutrition, the objective of this study was to determine the relation of malnutrition identified by GNRI with fistula patency. This is a single-center, retrospective, observational study. Hemodialysis patients with AVF were included in the research. Preoperative and postoperative GNRI values were computed and laboratory data were recorded. The patients were analyzed in two groups as the ones without thrombosis history (Group 1) and with thrombosis history (Group 2). According to GNRI, patients were investigated in four groups: G0 (non-risk group, >98), G1 (low risk, 92-98), G2 (moderate risk, 82-91), and G3 (high risk, 82). Of the 331 patients, 60.1% (199) were male and the average age was 55 ± 15 years. Preoperative GNRI levels were significantly higher in group 1. In correlation analysis, patency time was positively correlated with preoperative GNRI values. Among the preoperative GNRI groups, the G3 group had a patency duration of 6 months (4.9-7.04), whereas the G0 group had a patency length of 37.59 (35.5-39.65) months. By linear regression analysis, preoperative GNRI and postoperative albumin level were determined to be the significant indicators of patency time. GNRI a new tool for detecting malnutrition was strongly associated with fistula patency in hemodialysis patients. Detection of malnutrition before fistula operation may be helpful for the future follow up of the patients in terms of fistula patency.

Social Risk Screening Changes Medical Decision-Making in a Complex Outpatient Pediatric Antibiotic Therapy Program.

Complex outpatient antibiotic therapy (COpAT) programs facilitate the treatment of serious infections at home, shorten inpatient stays, and improve patient satisfaction when compared to inpatient care [1]. However, COpAT delivery can be complicated by antibiotic side effects and vascular access problems, the management of which can become particularly difficult when attempted in the context of high social risk in the home and community [2]. The use of standardized social risk screening for optimizing infectious disease (ID) discharge plans is largely unexplored. We tested the feasibility and implementation of a novel social risk screening tool for COpAT and described alterations in care plans generated based on social risk information. A COpAT social risk screening tool was created by adapting publicly available social determinants of health screening toolkits [3, 4] to focus on social risks previously identified as prevalent in our patient population and relevant to our COpAT delivery system [5, 6] (Figure 1). From March to October 2019, the COpAT physician assistant assessed social risks for 29 of 40 (73%) consecutively eligible parents/caregivers. Results of social risk screening and COpAT modifications were documented in the patient’s EMR as a progress note. To assess changes made as a result of screening, we retrospectively compared the original COpAT plan by the inpatient consulting ID team to the final COpAT plan. We tabulated changes in COpAT plans using six predefined, a priori categories of change: (1) antibiotic use; (2) caregiver education; (3) COpAT follow-up plans; (4) social work referral; (5) new inpatient consultation; and (6) hospital length of stay. The study was deemed quality improvement and IRB oversight was waived.

Effects and safety of Ophiocordyceps sinensis preparation in the adjuvant treatment for dialysis patients: A protocol for systematic review and meta-analysis.

Ophiocordyceps sinensis(O. sinensis), a genus of ascomycete fungi, has been intensively studied in various disease models, which is a rich source of various bioactive compounds and used in the treatment for end-stage renal disease patients. This systematic review highlights the therapeutic roles of O. sinensis as adjuvant treatment for dialysis patients with clinical evidence. The systematic review will be performed according to the Cochrane Handbook for Systematic Reviews of Interventions. The protocol is being reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols Statement. An literature search strategy will be developed and adapted for 9 databases. Searches will be run from the database inception until the date of the search implementation and be updated before the review is completed. Randomized controlled trials that investigate the effects of O. sinensis for dialysis patients (peritoneal dialysis and hemodialysis) will be included. We will focus on outcomes recommended by the core outcome measures in effectiveness trials, including mortality, cardiovascular disease, infection, vascular access problems, dialysis adequacy, hyperkalaemia, life participation. Two researchers will independently screen the studies, extract data and evaluate study quality using the Risk of Bias 2 tool. Subgroup analysis will be performed according to peritoneal dialysis and hemodialysis. Sensitivity analyses will be conducted based on the Leave-1-Out Method. The Grading of Recommendations Assessment, Development, and Evaluation approach will be used to rate the quality of the evidence. Meta analysis will be performed using Review Manager 5.3 and R packages. Studies have reported positive results of O. sinensis as adjuvant treatment for patients with dialysis. This review will synthesis current evidence on how O. sinensis can improve dialysis. Thus, it is expected that robust and conclusive evidence of the effects of O. sinensis during or after treatment can be obtained. These findings can inform future research and the selection of O. sinensis to promote quality of life for people with dialysis.

Proximal venous outflow obstructions and transfemoral approach in patients with arteriovenous fistula

Congratulations to the authors for their effort [1]. Endovascular treatment for central venous occlusions, which cause many vascular access problems among hemodialysis patients, has increased in recent years. Although most of these procedures have been applied via forearm vessels, there were studies reporting the use of the transfemoral approach in complicated cases [2,3]. In the publication, the authors reported that they applied a fistulogram by using a 6 Fr sheath from forearm veins and diagnosed the occlusion site. After the fistulogram, the authors used transfemoral access for other invasive procedures not to injure forearm vessels. We conclude that the invasive endovascular procedures for treating the occluded segment could be completed via the same access point, and the transfemoral approach must not be a routine route for access and reserved for more complicated cases or when the forearm is unavailable.

Barriers to Home Haemodialysis

Introduction: Significant variation exists in the prevalence of home haemodialysis (HHD) among UK renal centres. Our centre has a HHD prevalence of 2%, and we aimed to study how many patients who chose HHD as their preferred mode of renal replacement therapy (RRT) went on to receive this treatment and the barriers to starting this treatment. Methods: A retrospective single-centre analysis of electronic medical records for all patients who chose HHD at the time of RRT education was performed, and data were collected on patient demographics, comorbidity, frailty, RRT events, and barriers to HHD. Results: 116 patients chose HHD as their preferred mode of RRT between 2006 and 2018. Of these patients, 93 required RRT, but only 28 patients ever received HHD. No statistical difference was identified between those patients who only received unit haemodialysis (UHD) and those who went onto receive HHD with respect to age, gender, comorbidity, frailty, and socioeconomic deprivation. Patient choice, change in clinical condition, transplantation, home environment, vascular access problems, and training delays were identified as reasons patients did not start HHD. No documented reason could be found in 9 patients with a breakdown of communication between clinics and peripheral dialysis units attributed as a significant contributor in some of these patients. Of the 26 patients who started HHD after UHD, 19 did so within 1 year of starting UHD. Conclusion: Most patients who choose HHD do not receive HHD. Many patients never start HHD because of potentially reversible barriers including inadequate communication among clinicians about patient choices, patients changing their minds once in a dialysis unit, and inadequate timely training support.

COMPLICATIONS DEVELOPED IN PATIENTS WITH CONTINUOUS RENAL REPLACEMENT THERAPY IN THE INTENSIVE CARE UNIT AND NURSING INTERVENTIONS

This study is to determine the complications developing in patients undergoing continuous renal replacement therapy in an intensive care unit and nursing interventions to prevent these complications. Along with the socio-demographic and clinical characteristic of the patients, complication development status and nursing interventions for developing complications were determined. Data were evaluated with mean, standard deviation and frequency. In this descriptive study, a total of 48 CRRTs were applied to 27 patients hospitalized in the general intensive care units of a university hospital between 02 January 2019 and 02 January 2020. The average age of the patients is 62.92+20.13, APACHE II 25.92+5.33, the duration of stay in intensive care is 23.73+23.67 days. Common first three complications in patients undergoing CRRT; 75.0% hypotension, 47.9% vascular access problem, 43.8% system clotting. Nursing interventions related to common complications have been defined as giving the patient an appropriate position, checking the pressure indicators of the hemofiltration device, checking the arterial and venous pressures and ultrafiltration rate on the indicators of the device, hourly fluid inlet and outlet was followed, vital signs were monitored hourly. It was found that many complications developed in patients undergoing CRRT and nurses in the intensive care unit applied basic nursing interventions. There were not sufficient.

MO166: The Longitudinal Evolution of Covid-19 Outcomes Among Hemodialysis Patients: A Nationwide Multicentre Controlled Study

Abstract BACKGROUND AND AIMS Haemodialysis (HD) patients are at increased risk for adverse short-term consequences of COVID-19. In this study, we investigated the characteristics of chronic HD patients in the post-COVID-19 period and compared them with the control group. METHOD We conducted a national multicentre observational study involving adult chronic HD patients recovering from COVID-19. The control HD group was selected from patients with similar characteristics who did not have COVID-19 in the same center. SARS-CoV-2 RT-PCR negative patients and patients in the active period of COVID-19 were not included. RESULTS A total of 1223 patients (635 COVID-19 groups, 588 control groups) were included in the study from the data collected from 47 centres between 21 April 2021 and 11 June 2021. The patients' baseline demographics, comorbidities, medications, HD characteristics and basic laboratory tests were quite similar between the groups (Table 1). 28th-day mortality and between 28th day and 90th day mortality were higher in the COVID-19 group than in the control group [19 (3.0%) patients and 0 (0%) patients; 15 (2.4%) patients and 4 (0.7%) patients, respectively]. Presence of respiratory symptoms, rehospitalization, need for home oxygen therapy, lower respiratory tract infection and A-V fistula thrombosis were significantly higher in the COVID-19 group in the first 28 days of illness and between 28 and 90 days. Mortality was significantly associated with preexisting COVID-19, age, current smoking, use of tunneled HD catheter, persistence of respiratory symptoms, rehospitalization, need for home oxygen support, presence of lower respiratory tract infection within 28 days and persistence of respiratory symptoms. CONCLUSION In the post-COVID-19 period, mortality, rehospitalization, respiratory problems and vascular access problems are higher in maintenance HD patients who have had COVID-19 compared to control HD patients. Table 2. Comparative presentation of patients data on the 28th day and between 28 and 90 day COVID-19 groupN = 635 Control groupN = 588 28th-day results, n(%) Death* 19(3.0) 0(0) Any respiratory symptoms* 152(23.9) 11(1.9) Rehospitalization for any reason* 52(8.2) 24(4.1) Need for home oxygen support * 26(4.1) 2(0.3) Lower respiratory tract infection* 65(10.2) 8(1.4) AV fistula thrombosis* 13(2.0) 2(0.3) Other thromboembolic events * 15(2.4) 4(0.7) Need for HD catheter placement* 21(3.3) 9(1.5) 28th day-90. day resultsa n(%) N:616 N:588 Death* 15(2.4) 4(0.7) Any respiratory symptoms* 45(7.3) 10(1.7) Rehospitalization for any reason* 44(7.1) 18(3.1) Need for home oxygen support* 12(1.9) 2(0.3) AV fistula thrombosis* 9(1.5) 1(0.2) Other thromboembolic events* 9(1.5) 2(0.3) Need for HD catheter placement 13(2.1) 10(1.7) HD: haemodialysis, AV: arteriovenous. *P < .05. a Patients who died before 28 days were not included.

The Longitudinal Evolution of Post–COVID-19 Outcomes Among Hemodialysis Patients in Turkey

IntroductionHemodialysis (HD) patients have increased risk for short-term adverse outcomes of COVID-19. However, complications and survival at the post–COVID-19 period have not been published extensively.MethodsWe conducted a national, multicenter observational study that included adult maintenance HD patients recovered from confirmed COVID-19. A control HD group without COVID-19 was selected from patients in the same center. We investigated the characteristics and outcomes in the follow-up of HD patients and compare them with the non–COVID-19 group.ResultsA total of 1223 patients (635 patients in COVID-19 group, 588 patients in non–COVID-19 group) from 47 centers were included in the study. The patients' baseline and HD characteristics were almost similar. The 28th-day mortality and mortality between 28th day and 90th day were higher in the COVID-19 group than non–COVID-19 group (19 [3.0%] patients vs. none [0%]; 15 [2.4%] patients vs. 4 [0.7%] patients, respectively). The presence of respiratory symptoms, rehospitalization, need for home oxygen therapy, lower respiratory tract infection, and arteriovenous (AV) fistula thrombosis was significantly higher in the COVID-19 group in both the first 28 days and between 28 and 90 days. In the multivariable analysis, age (odds ratio [OR] [95% CI]: 1.029 [1.004–1.056]), group (COVID-19 group vs. non–COVID-19 group) (OR [95% CI]: 7.258 [2.538–20.751]), and vascular access type (tunneled catheter/AV fistula) (OR [95% CI]: 2.512 [1.249–5.051]) were found as independent parameters related to 90-day mortality.ConclusionIn the post–COVID-19 period, maintenance HD patients who have had COVID-19 have increased rehospitalization, respiratory problems, vascular access problems, and high mortality compared with the non–COVID-19 HD patients.

Acute kidney injury due to deposition disease

Acute kidney injury presenting without obvious cause is a diagnostic dilemma. One condition to be considered is monoclonal gammopathy. A case of light chain deposition disease was detected as a cause, involving kidney and extra renal site. It is a part of monoclonal immunoglobulin deposition disease, and may or may not be related to multiple myeloma. Delayed diagnosis can lead to end stage kidney disease, requiring long term dialysis, with its vascular access problems, preventing the treatment by autologous stem cell transplant. The case is presented with review of literature.

Chest-to-arm tunneling: A novel technique for medium/long term venous access devices.

Chest-to-arm (CTA) tunneling has been described recently as a technique that allows an optimal exit site at mid-arm even in chronically ill patients with complex clinical issues and challenging problems of vascular access. We adopted CTA tunneling in oncologic and in non-oncologic patients, in totally implanted and in external devices, for both medium and long-term intravenous treatments. We report our experience with 60 cases of CTA tunneling: 19 patients requiring a totally implantable device, who had bilateral contraindication to venous access at the arm and bilateral contraindication to placement of the pocket in the infra-clavicular area; 41 patients requiring an external central venous catheter, who had bilateral contraindication to insertion of peripherally inserted central catheters or femoral catheters, as well as contraindication to an exit site in the infraclavicular area. All venous access devices were inserted with ultrasound guidance and tip location by intracavitary electrocardiography, under local anesthesia. There were no immediate or early complications. Patients with CTA-ports had no late complications. In patients with CTA-tunneled external catheters, there were two dislodgments, four episodes of central line associated blood stream infections, and one local infection. There were no episodes of venous thrombosis or catheter malfunction. Our experience suggests that CTA tunneling is a safe maneuver, with very low risk of complications, and should be considered as an option in patients with complex venous access.

"Interventional Radiologist: Role in Managing Vascular Access Problems in Patients with Chronic Kidney Disease (CKD)"

Priyanka Gupta, Pankaj Sharma* and Udit Chauhan Author Affiliations Department of Radiodiagnosis, AIIMS Rishikesh, India Received: June 07, 2021 | Published: June 16, 2021 Corresponding author: Dr Pankaj Sharma, Associate Professor Radiodiagnosis, AIIMS Rishikesh, India DOI: 10.26717/BJSTR.2021.36.005872

MO859TRANSITIONS BETWEEN THE DIFFERENT DIALYSIS MODALITIES AND THEIR EFFECT ON SURVIVALS: A SINGLE-CENTER STUDY

Abstract Background and Aims An integrated care approach available today, which implies that most patients will use different modalities at different time points of their disease, creates a need to accumulate data on patient outcomes and survival when switching from one treatment modality to another. The aim was to compare survival after the transition from hemodialysis (HD) to continuous ambulatory peritoneal dialysis (CAPD) and after the transfer from CAPD to HD. Method A single-center retrospective trial included 20 (18.9%) from 106 initiating CAPD between January 2016 and December 2020 patients, who were transferred from CAPD to HD or from HD to CAPD through a follow-up period until December 2020. 2 groups of patients were identified: the 1st group included CAPD-to-HD transition patients, the 2d group - HD-to-CAPD transition patients. At the end of a follow-up, the transfer's causes, outcomes, and cohort life expectancy (CLE) on the new treatment modality were evaluated. Results A summary of patients' characteristics are shown in the table below. The patient's number in the 1st group was 13, in the 2d - 7. Transfer causes in the 1st group were peritonitis (76.9%), leakage (15.4%), in the 2d group - vascular access problems (57.1%), poor hemodialysis tolerance (28.6%). In both groups in 1 case transfer cause was the patient's preference (7.7% and 14.3% respectively). In the 1st group CAPD duration was 29 [13;50] months, transfer outcomes included death in 7 cases (53.8%), renal transplantation (RT) in 2 cases (15.4%), in 2 cases (15.4%) patients were alive and were on HD, in 2 cases (15.4%) patients later were transferred back to CAPD. In the 2d group HD duration was 23 [3;30] months, transfer outcomes included death in 2 cases (28.6%), RT in 2 cases (28.6%), in 3 cases (42.8%) patients were alive and on CAPD. In the 1st group in 6 from 7 cases (85.7%) patients died in the intensive care unit (ICU), the main causes of death included cardiovascular accidents - 42.8% (cardiac arrest, acute heart failure, stroke), sepsis - 28.6% (due to gallbladder empyema and diabetic foot sepsis), bleeding - 28.6% (due to essential thrombocythemia, undiagnosed peptic ulcer). In the 2d group all patients died at home, causes of death involved congestive heart failure - 50% and uremia - 50.0%. In the 1st group CLE was 3.4 months, in the 2d - 20.5 months. Conclusion Post-transfer mortality is higher in the CAPD-HD transition group. In most cases, such patients die faster and in more severe condition and almost always in the ICU. Almost half of the CAPD-to-HD transfer patients died due to cardiovascular complications. Therefore, when transferring a patient to HD, it is necessary to take into account the load exerted on the heart and blood vessels, as well as the risks of bleeding and sepsis.

Persons With Hemophilia of Generation Y and Their Relatives Attitudes and Expectations From Treatment.

This multicenter cohort study aimed to determine the attitudes and expectations of persons with hemophilia of Generation Y (PwH-Y) toward hemophilia and its treatment comparatively with the opinions of their non-hemophiliac relatives. The study was representative regarding quota-control variables of hemophiliacs registered to the provincial representatives of the Hemophilia Society of Turkey in 4 geographic regions and Istanbul. Sixty-four PwH-Y (62 males) and their 56 first-degree relatives (17 males; Generation X/baby boomers) were interviewed face-to-face using mixed data collection method. “Focus Group Study” method was used for qualitative data. Treatment adherence, requirements, and social activities were questioned with a semi-structured form. Treatment adherence rate of the PwH-Y (46.2%) was lower than that perceived by their relatives (71.4%) (p ≤ 0.05). Vascular access problems were the most common reasons for non-adherence (60% in PwH-Y and 25% in relatives). Among the components the hemophiliacs and their relatives needed most, support for accessibility of drugs/treatment ranked first (41.1% and 45%, respectively), followed by emotional support (26.1% and 32.5%, respectively). For increasing treatment success in PwH-Y, treatment should be personalized and shaped based on personal requirements.

Complications of permanent vascular access for haemodialysis

Permanent vascular access is the basis of renal replacement therapy by the method of programmed haemodialysis, on whose stable functioning depends the life of patients with end-stage renal disease. At the present time, there is significant deficit of scientific and methodological Russian-language literature on this problem, with no Russian consensus documents concerned. This article is a review of the contemporary world literature dedicated to the problem of permanent vascular access, including currently in force European (2018) and North American (2019) guidelines for good clinical practice, also discussing the problems of strategy and tactics of creating a permanent vascular access, monitoring its dysfunction, pathophysiology of functioning of arteriovenous fistulas. Presented herein are unified approaches to diagnosis and treatment of thrombolytic and haemorrhagic complications associated with the access, as well as local infectious and non-infectious complications. Special attention is paid to indications for the operation and rational therapeutic decision-making.

Safety, Efficiency and Treatment Satisfaction in Children with Primary Immunodeficiency Receiving Subcutaneous Immunoglobulin Treatment

OBJECTIVEPatients with Inborn Errors of Immunity, also known as Primary Immunodeficiency (PID), are prone to recurrent bacterial infections and these patients often require lifelong IgG replacement therapy. The aim of this presentation is to evaluate the efficacy, safety, and patient satisfaction in PID patients receiving subcutaneous immunoglobulin (SCIG) treatment and to share our expe-riences.METHODSTwenty-one patients who were followed up with the diagnosis of PID by our Pediatric Allergy and Immunology Clinic and received regular intravenous immunoglobulin therapy (IVIG) befo-re starting SCIG treatment were included in the study.RESULTSA total of 21 patients were included in the study. 10 of the patients (47.6%) were female, 11 (52.4%) were male, and the mean age was 8.8±4.42 years. Five of the patients were Syrian patients living in the refugee camp. Threshold IgG levels of the patients were evaluated every 3 months. IgG levels were significantly higher than baseline IVIG levels at weeks 3, 6, and 12 of SCIG treatment, respectively. There was no significant difference between 3rd, 6th and 12th months of SCIG treatment. A statistically significant decrease was observed in the frequency of infections in patients who received SCIG treatment (p=0.003). During SCIG treatment, the total infection rate was 4.1/person/year. According to the TSQM-9 satisfaction questionnaire, the annual hospitalization rate was 0.9/patient/year for IVIG and 0.4/patient/year for SCIG (p>0.005), and 61.9% of patients were moderately satisfied, 14.2%. 19% were very satisfied and 4.7% were not satisfied with the treatment. When the satisfaction criteria were evaluated, it was observed that the patients mostly (71%) were satisfied with the absence of vascular access prob-lems and the comfort of self-application at home.CONCLUSIONSCIG therapy causes high serum IgG levels and a reduced frequency of infections and can be a safe, effective, and well-tolerated treatment alternative in patients with PID with high patient satisfaction.

A rare complication following internal jugular vein catheterization to malposition: acute Budd Chiari syndrome

BackgroundTunneled catheters can be used as an alternative vascular access in patients with limited health expectancy,vascular access problems and several comorbidities. We aimed to present a patient with venous stenosis related- reversible acute Budd-Chiari syndrome after catheter malposition.Case presentationAfter changing of tunneled catheter insertion, 36-year old man was admitted to our hospital with sudden onset of nausea, fever, chills and worsening general condition In computed tomography (CT) imaging, a hypodense thrombus was observed in which the distal end of the catheter is at the level of drainage of the hepatic veins in the inferior vena cava and that blocked hepatic vein drainage around the catheter. The catheter was removed and a new catheter was inserted in the same session. Because patient’s general condition was good and without fever, he was discharged with advices on the 9th day of hospitalization.ConclusionAlthough catheter malposition and thrombosis are not a common complication, clinicians should be alert of these complications.

Persons with Hemophilia of Generation Y and Their Relatives Attitudes and Expectations from Treatment

Background: A “generation” is defined as a cohort of people born within a particular span of time and shaped by similar events, trends, or developments. Generation Y includes the people born between 1981 and 1999. This study aimed to determine the attitudes and behaviors of persons with hemophilia of Generation Y (PwH-Y) towards hemophilia and its treatment and their suggestions for the solutions regarding treatment problems comparatively with the opinions of their non-hemophiliac first-degree relatives and thus to provide information for healthcare workers about these problems. Methods: This multicenter cohort study included 64 PwH-Y and their 56 first-degree relatives. A face-to-face interview was performed using a mixed data collection technique. Findings: The rate of adherence to treatment reported by the PwH-Y (46·2%) was significantly lower than that perceived by their relatives (71·4%) (p≤0·05). Vascular access problems ranked first among the reasons for non-adherence to treatment (60% in the PwH-Y and 25% in their relatives). Among the components that the hemophiliacs and their relatives need most, support for accessibility of drugs and treatment ranked first and followed by emotional support both in the PwH-Y (41·1% and 26·1%, respectively) and in their relatives (45% and 32·5%, respectively). Interpretation: Hemophiliacs and their relatives should be supported according to their requirements to maximize hemophilia treatment success. The most comprehensive step would be enabling “Hemophilia Treatment Centers”, where a multidisciplinary team that would be in close contact with PwH-Y and their relatives, provides care, and works under the leadership of an experienced hematologist. Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Declaration of Interests: Bulent Zulfikar has acted in advisory board and/or provided consultancy for Pfizer, Shire, Novo Nordisk, Roche, Sobi, Bayer, and BioMarin and reports personal fees outside the submitted work. The other authors declare that there is no conflict of interest. Ethics Approval Statement: The study was approved by the Ethics Committee of Istanbul Arel University (decision number: 2017/02, date: 24/3/2017). All patients and their relatives provided informed consent for participation in the study.