Radiocephalic Arteriovenous Fistula Research Articles

Simplifying the Creation of the Ulnar Basilic Arteriovenous Fistula: The Royal Wave Position – A Case Series

ABSTRACT While the radio-cephalic arterio-venous fistula (RCAVF) remains the procedure of choice for hemodialysis, the value of the ulnar-basilic arterio-venous fistula (UBAVF) is perhaps underappreciated. The challenge of placing the forearm in a suitable and comfortable position for both the surgeon and the patient during the creation of the UBAVF may be an important factor inhibiting its use. We present a new method of hand positioning in the creation of the UBAVF that we have termed the “Royal Wave” position, which facilitates both patient comfort and surgical access intraoperatively. Patients suffering from chronic kidney disease stage -V were operated upon for the creation of UBAVF following the standardized protocol in the Royal Wave position. Patency (by Color Doppler) was recorded before discharge. Patients were clinically followed up for a period of 3 months. A total of five patients (four males) with the age range of 43–66 years were studied. The position was found to be comfortable for patients and suitable for surgeons. All five patients had successful creation of fistulas that remained patent, which was documented by Doppler report prior to discharge. The patients were followed up till 3 months post fistula creation. Thrombosis was not seen in any patient, and the basilic veins arterialized and were used for dialysis in all five patients. This innovation in positioning, the “Royal Wave” position improves the comfort of both the operator and the patient during surgery, and merits consideration when creating a UBAVF.

#741 Gender differences in vascular access for prevalent dialysis patients

Abstract Background Gender disparities of some aspects of vascular access (VA) for hemodialysis (HD) have been reported. Aim To analyze the VA profile of prevalent HD patients (pts) according to gender in Catalonia Method Data from the Catalan Renal Registry of end-stage kidney disease (ESKD) pts over 18 years of age treated by HD on 31 December were examined from 1997 to 2021. Results The total cumulative number of follow-ups registered for prevalent ESKD pts treated by HD was 95 575 out of 25 130 pts; we have VA information for most of the follow-ups (93.1%, 88 980/95 575). The number of prevalent HD pts increased from 3104 in 1997 to 4270 in 2021. The characteristics of prevalent HD pts in 2021 (n = 4270) were different for male (n = 2731) vs female (n = 1539) regarding mean age (69.1 ± 14.6 vs 70.9 ± 14.3 years), age bracket >74 years (42.4% vs 48.3%), median time on HD [24.0 (9.8−48.2) vs 27.6 (10.5−59.1) ], aetiology of ESKD as polycystic kidney disease (4.4% vs 7.2%), normal functional status (38.0% vs 28.4%), cardiovascular disease (76.3% vs 71.1%) and obesity rate (body mass index BMI>30 kg/m2: 17.4% vs 27.2%) (for all comparisons, p < 0.001). The distribution of the VA used for performing HD in 2021 was also different in men vs women: fistula AVF (58.1%, n = 1465 vs 45.6%, n = 657), graft (1.8%, n = 45 vs 3.5%, n = 51) and tunnelled catheter (35.8%, n = 903 vs 45.8%, n = 660) (for all comparisons, p < 0.001) ; there were no differences for non-tunnelled catheter (4.3%, n = 107 vs 5.0%, n = 72) (p = 0.15). In addition, the type of AVF was different in men vs women: radiocephalic AVF (53.9% vs 40.9%) and brachial artery-based AVF (46.1% vs 59.1%) (p < 0.001). The percentage of pts who required at least one hospital admission or outpatient procedure for any VA pathology in 2021 was similar when comparing men [7.3% (n = 180) and 19.6% (n = 456), respectively] and women [8.6% (n = 122) and 19.3% (260), respectively] (p = 0.34 and p = 0.38, respectively). Regarding the total cumulative number of VA used for HD, the percentage of pts who used only one VA was higher for men (50.4%, n = 1265) than women (47.1%, n = 663); however, this difference is reversed when the percentage of pts who used ≥4 VA was calculated: 11.5% (n = 289) vs 14.4% (n = 203) (for all comparisons, p = 0.001). The percentage of pts who have been dialyzed through AVF at some point over time was higher for men (69.2%, n = 1889) than women (62.6%, n = 964) (p < 0.001) The probability of performing HD through AVF in 2021was independently associated with male gender (odds ratio 1.58 [95% confidence interval: 1.36–1.82], p < 0.001) after adjusting for age, time on HD, primary kidney disease, cardiovascular disease, functional status and BMI (multivariate logistic regression analysis). The percentage of both men and women on HD through AVF decreased progressively from 1997 (89.1% and 81.3%, respectively) to 2021 (58.1% and 45.6%, respectively) (for both comparisons, p < 0.001). The percentage of prevalent men on HD with AVF was always higher over time than that of women from 1997 (89.1% vs 58.1%) to 2021 (81.3% vs 45.6%) (for both comparisons, p < 0.001). Conclusions 1) AVF was the main type of VA used for prevalent men on HD, but AVF and tunnelled catheter shared this ranking in women. 2) Male gender was an independent factor associated with a 58% greater probability of performing HD through AVF than female. 3) The percentage of prevalent HD pts dialyzed through AVF progressively decreased over time in both sexes but it was always higher in men than women. 4) The type of AVF mainly used was different depending on gender: radiocephalic AVF for men and brachial artery-based AVF for women.

#1335 Distal radio-cephalic arteriovenous fistula survival: comorbid conditions and long-term surveillance in hemodialysis

Abstract Background and Aims With a low incidence of infection and distal ischemia, the distal radio-cephalic arteriovenous fistula (dRCF) is the reference access for hemodialysis (HD). Smaller venous diameter and obesity have been associated with poor distal arteriovenous fistula (AVF) outcomes in some studies. On the other hand, HD patients often suffer from multiple co-morbidities, resulting in an increased number of complications. The impact of all these factors on vascular access survival has not been entirely characterized. We evaluated long-term follow-up demographic and clinical data from a cohort of patients in relation to primary and secondary dRCF survival. Method The study included prevalent patients who had been receiving hemodialysis for at least 6 months at the same reference hospital. From 2008 to 2023, we retrospectively collected dRCF for HD performed by a single reference surgical team. All dRCF could be confirmed to be clinically useful for dialysis (i.e., functional patency). Socio-demographic data were collected. Our medical team (nephrologist and radiologist) periodically performs a physical examination and duplex ultrasound to identify physical signs of possible complications, understand the underlying cause and plan treatment in advance. The time to first repair is termed primary AVF survival, while secondary survival is the time after first repair. Primary and secondary survival analysis was performed using the Kaplan-Meier method. Results Of 253 prevalent patients receiving HD, 82.2% had an AVF. The mean HD vintage was 61 ± 50 months. HD was started on a planned basis in 61.4% of cases, with AVF being the initial access in 71.7% of cases. We included 145 dRCFs for HD. dRCF was the unique AVF that was placed in 74.5% of the patients. Mean age 69.5 ± 14.5 (years), women 31%, mean BMI 27.3 ± 6.08 kg/m2, non-smokers 46.9%, obesity 37.9%, diabetes mellitus 44.8%, ischemic cardiopathy 20%, peripheric vasculopathy 15.9%. Diabetic nephropathy was the most common cause of chronic kidney disease in our population, accounting for 44.8% of cases. dRCF primary failure was 11.11%, 40% of these patients were over 80 years of age. The dRCF was left-sided in 82.2%. dRCF median survival was 64.5 ± 50.4 months; survival rates at 12, 36 and 60 months were 92%, 67% and 41%, respectively. Primary and secondary dRCF median survival was 33 ± 39 months and 50 ± 45 months, respectively. Primary and secondary survival rates at 12, 36 and 60 months were 60%, 32% and 17% and 84%, 53% and 33%, respectively. With a median survival of 62 ± 44 months, 29.7% of the dRCF did not undergo repair either before or during dialysis. The dRCF requiring percutaneous intervention and/or surgical reanastomosis before dialysis was 16.7%. Factors identified as being associated with lower primary survival were obesity and peripheral vasculopathy (p=0.01 and p=0.001, respectively), as shown in Figs. 1 and 2. The percentage of salvage procedures (percutaneous, surgical or both) in obese was 78,2%; 76,7% involved surgical repair, most of which were lipectomies, superficializations with or without transposition. Although not statistically significant (p=0.056), dRCF secondary survival is decreased in diabetic patients (Fig. 3). No statistical impact was found between age, sex, smoking, or ischemic cardiopathy and either primary or secondary survival. Conclusion Our obese patients on HD are a special population with an increased need for surgical reintervention of dRCF, which impacts primary but not secondary survival. Primary dRCF survival is lower in patients with peripheral vascular disease compared to other comorbidities; however, this vasculopathy is not associated with worse secondary dRCF survival with active follow-up. It is likely that individualized and careful long-term active surveillance was a key aspect in improving the functional patency of dRCF in our patients with multiple comorbidities. Undoubtedly, these issues deserve further prospective investigation.

Application of a supporting catheter in surgery for forearm arteriovenous fistula construction.

This study explored the feasibility of a supporting catheter combined with modified end-to-side anastomosis in the operation of radio-cephalic arteriovenous fistula (RC-AVF) and evaluated the clinical application value of this technique. Sixty patients underwent RC-AVF operations in our hospital from January 2022 to June 2022. All the patients were treated with modified end-to-side AVF anastomosis and divided into the control group or the test group depending on whether a supporting catheter was applied. The clinical data of 60 cases were analysed retrospectively. Intraoperative related indices, the first time the fistula was used, the success rate of first puncture, the blood flow of first dialysis, the maturity condition of fistula, the size of anastomosis, the diameter of radial artery and drainage vein, the blood flow of brachial artery 8 weeks after operation and the incidence of complications within 6 months after operation were compared between the two groups. Compared with that in the control group, the time spent on the vascular anastomosis in the test group was significantly shortened (p<0.05). The blood flow of the first dialysis, the size of the anastomosis, the diameter of the drainage vein, the blood flow of the brachial artery 8 weeks after the operation and the incidence of complications within 6 months after operation were significantly different between the two groups (p<0.05). In the RC-AVF operation, using a supporting catheter can not only increase operation efficiency by reducing surgical injury and difficulty of vascular anastomosis, but also improve postoperative prognosis. RC-AVF is worth promoting in clinical practice.

Assessment of volume flow rate in arteriovenous fistulas with a novel ultrasound Doppler device (earlybird): Trend analysis, comparison of methods, and inter- and intra-rater reliability.

An accessible tool is required to analyze volume flow trends in arteriovenous fistulas for hemodialysis. Earlybird, an easy-to-place ultrasound Doppler device, has shown comparable accuracy to duplex ultrasound. In this study, we compared volume flow measurements obtained with duplex ultrasound and the dilution technique to an enhanced earlybird device, featuring a dual Doppler probe system, eliminating the requirement for a known insonation angle. Nine patients with a distal radiocephalic arteriovenous fistula were monitored for 12 months with regular volume flow measurements. Correlation and inter- and intra-class reliability analyses were conducted. An overall moderate correlation was observed between earlybird and duplex ultrasound or dilution technique (intraclass correlation coefficient = 0.606 (95% confidence interval 0.064, 0.721) and 0.581 (0.039, 0.739), respectively). Duplex ultrasound compared to dilution measurements, demonstrated an overall moderate correlation (0.725 (0.219, 0.843)). Correlation between earlybird and duplex ultrasound was stronger for the arteriovenous fistula (0.778 (0.016, 0.901)) than the brachial artery (0.381 (-0.062, 0.461)). For earlybird, inter-rater reliability was excellent for the arteriovenous fistula (0.907 (0.423, 0.930)) and poor for the brachial artery (0.430 (0.241, 0.716)). Duplex ultrasound showed a good inter-rater reliability (arteriovenous fistula: 0.843 (0.610, 0.871), brachial artery: 0.819 (0.477, 0.864)). The overall intra-rater reliability was good for duplex ultrasound (rater A: 0.893 (0.727, 0.911); rater B: 0.853 (0.710, 0.891)), while excellent for earlybird (rater A: 0.905 (0.819, 0.928); rater B: 0.921 (0.632, 0.969)). We observed a weaker correlation in the measurements of volume flow rates in arteriovenous fistulas when obtained using earlybird compared to dilution technique, unlike the comparison between duplex ultrasound and the dilution technique. However, inter-rater reliability for the arteriovenous fistula was excellent with earlybird and good with duplex ultrasound, indicating the potential of earlybird as a tool for frequent measurements, enabling trend surveillance and predicting adverse outcomes.

Distal Forearm Arteriovenous Fistula Maturation in Diabetic Hemodialysis Patients.

Atherosclerotic disease of the forearm arteries can impede the maturation of distal fistulas in diabetic patients. The goal of this study was to look at the maturity of diabetic hemodialysis patients' distal forearm (radiocephalic snuffbox or distal forearm) arteriovenous fistulas. Patients with chronic renal failure who were candidates for distal forearm radiocephalic arteriovenous fistula implantation were evaluated in this cross-sectional study. Patients' demographic details, underlying disorders, laboratory measurements, vital signs, and information on their surgery were all noted. Patients were checked for fistula development 1 week, 1 month, 2months, and then monthly until 6 months after surgery. Arteriovenous fistula maturation characterized by optimal blood flow, vessel dilation, and structural adaptations. Among 343 patients (56% male, 44% female, mean age: 57.32 ± 12.48years), hypertension prevailed (81.9%), followed by hyperlipidemia (42.3%) and coronary artery disease history (25.9%). AVFs achieved 58.3% maturation in 64.98 ± 11.05days; higher BP during creation correlated with successful maturation (17.02 ± 1.46mmHg vs 13.90 ± 1.93mmHg, P < .05). No significant statistical difference found in distal forearm arteriovenous fistula maturation between males (57.8%) and females (58.9%) (P > .005). However, 41.7% of AVFs failed in 18.83 ± 17.89days. Failed AVFs exhibited lower BP during operation and failure (11.75 ± 1.86mmHg). Kaplan-Meier analysis depicted maturation probabilities over 90 days post-surgery. Diabetes and patient sex did not affect the maturation time of distal forearm AVFs in hemodialysis patients. Increased blood pressure during and after surgery correlated with shorter maturation time.

Snuffbox Versus Wrist Radiocephalic Arteriovenous Fistulas: 10 Years Experience.

Background The wrist radiocephalic arteriovenous fistula (RCAVF) is the initial suggested procedure for establishing hemodialysis vascular access (HVA) in the most distal site of the upper limb. The anatomical snuffbox arteriovenous fistula (SBAVF) is barely utilised, despite its remote location. In this study, we aimed to analyse and compare the results of SBAVF and RCAVF in terms of their maturity, patency, and failure rates. Methodology This descriptive, retrospective study compared outcomes between SBAVF and RCAVF in terms of maturation, patency, and failure. All patients with chronic kidney disease who attended and underwent either procedure at Betsi Cadwaladr University Health Board between 2013 and 2023 were studied. Results In a period of 10 years, 179 patients were included. Overall, 102 (57%) were male and 77 (43%) were female, with a male-to-female ratio of 1.3:1. Wrist radiocephalic fistula was the dominant type of surgery done in 76% (n = 136), while the snuffbox radiocephalic fistula was done in fewer than 24% (n = 43) of patients. Most patients underwent a successful arteriovenous (AV) fistula (n = 105, 58.7%), in contrast to 67 patients whose fistulas failed. There was a significant relationship between fistula failure and complications (p = 0.000). There was no significant effect of the fistula site, hypertension, diabetes, cardiac diseases, smoking, peripheral vascular disease, or central vein stenosis on the failure of the AV fistula (p = 0.127, 0.534, 0.510, 0.397, 0.017, 0.68, and 0.371, respectively). Conclusions The snuffbox AV fistula is a suitable and feasible first choice for patients on hemodynamic therapy.

Computational fluid-structure interaction analysis of the end-to-side radio-cephalic arteriovenous fistula

Background and ObjectiveIn the current work, we present a descriptive fluid-structure interaction computational study of the end-to-side radio-cephalic arteriovenous fistula. This allows us to account for the different thicknesses and elastic properties of the radial artery and cephalic vein. MethodsThe core of the work consists in simulating different arteriovenous fistula configurations obtained by virtually varying the anastomosis angle, i.e. the angle between the end of the cephalic vein and the side of the radial artery. Since the aim of the work is to understand the blood dynamics in the very first days after the surgical intervention, the radial artery is considered stiffer and thicker than the cephalic vein. ResultsOur results demonstrate that both the diameter of the cephalic vein and the anastomosis angle play a crucial role to obtain a blood dynamics without re-circulation regions that could prevent fistula failure. ConclusionsWhen an anastomosis angle close to the perpendicular direction with respect to the radial artery is combined with a large diameter of the cephalic vein, the recirculation regions and the low Wall Shear Stress (WSS) zones are reduced. Conversely, from a structural point of view, a low anastomosis angle with a large diameter of the cephalic vein reduces the mechanical stress acting on the vessel walls.

Outcomes of AV fistula formation for dialysis patients using interrupted sutures one-year single center study

Objectives: To document the Outcomes of AV fistula formation for dialysis patients using interrupted sutures.&#x0D; Methods: In this Cross-sectional study conducted at PNS Shifa Karachi, from June 2022 to June 2023, patients above 18 years of age, male or female, with ESRD/CKD were included. After clinical screening and ultrasound doppler, the distal most part of wrist was considered as a site for radio cephalic AVF. Operation was performed under surgical loupe with 4.5x magnification. Standard incision of about 4-5 cm oblique proximal to the wrist crease was given at the volar surface on the radial side of Distal forearm, extending till the lateral side up to the snuffbox. Subcutaneous tissue was incised and dissection was done to identify the cephalic vein and radial artery. Distal most end of the cephalic vein was ligated using vicryl 4-0 suture and cephalic vein dissected free from the underling tissue to mobilize it up to the radial artery.&#x0D; Results: During the study N=35 patients who required AVF creation visited the department. The mean age of the study participants was 59.34±15.48. If thrill at the site of AVF and backflow at cut end of cephalic vein were present the surgeons were satisfied, higher satisfaction among the surgeon was achieved in the AVF created at brachiocephalic artery while the diameter of vessels didn’t contribute in surgeon satisfaction.&#x0D; Conclusion: Presence of thrill at the site of AVF and backflow at cut end of cephalic vein have strong association with good prognosis of AVF.&#x0D; doi: https://doi.org/10.12669/pjms.40.5.8990&#x0D; How to cite this: Naz F, Javaid RH, Noor S, Katpar H. Outcomes of AV fistula formation for dialysis patients using interrupted sutures one-year single center study. Pak J Med Sci. 2024;40(5):---------. doi: https://doi.org/10.12669/pjms.40.5.8990&#x0D; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Does Piggyback Straight Line On-lay Technique Have Better Maturation for Radiocephalic Arteriovenous Fistula Than a Traditional Method? A Head-to-head Comparison of Two Surgeries

Does Piggyback Straight Line On-lay Technique Have Better Maturation for Radiocephalic Arteriovenous Fistula Than a Traditional Method? A Head-to-head Comparison of Two Surgeries

Pull-through technique through antegrade radial artery puncture without sheath insertion in balloon-assisted radiocephalic arteriovenous fistulas maturation

PurposeThe aim of this study was to investigate the effectiveness and safety of the pull-through technique through antegrade radial artery puncture without sheath insertion in balloon-assisted radiocephalic AVF maturation.MethodsWe retrospective studied a total of 62 patients with immature radiocephalic AVF, who received balloon-assisted maturation in our hospital. 15 patients received pull-through technique through radial artery without sheath insertion and 47 patients received treatment through a regular venous approach.ResultsThe success rate of pull-through technique group and control group was 86.7% (13 out of 15), 89.1% (41 out of 46) respectively. There was no significant difference between two groups (P > 0.05). In our study, there were 2 patients in the pull-through technique group and 3 patients in the control group, which had hematoma in the vein puncture site (P = 0.59). There were also no differences in the primary patency rate between two groups at 6 months and 12 months (76.9% vs 70.7%, 38.4% vs 41.5%, respectively, P > 0.05).ConclusionThe pull-through technique through antegrade radial artery without sheath insertion in promoting radiocephalic AVF maturation is effective and safe.

Hemodialysis Patients with High-Flow Arteriovenous Fistulas: An Evaluation of the Impact on Cardiac Function.

: Patients undergoing hemodialysis often experience changes in cardiac function when they have a high-flow arteriovenous fistula (AVF). This study aimed to assess the effect of high-flow AVFs on cardiac function in patients undergoing hemodialysis. : A longitudinal study was conducted on hemodialysis patients with high-flow AVFs. Echocardiographic parameters, such as left ventricular ejection fraction (LVEF), left atrial diameter (LAD), left ventricular end-diastolic dimension (LVEDD), right ventricular end-diastolic dimension (RVEDD), inferior vena cava diameter (IVCD), systolic blood pressure, and diastolic blood pressure, were measured and compared before and after AVF creation. : One hundred hemodialysis patients with high-flow AVFs (mean age: 55.95±13.39 years, mean body mass index: 24.71±3.43 kg/m²) were studied. LVEF significantly decreased (51.10%±5.39% to 47.50%±5.79%), while LAD, LVEDD, and IVCD significantly increased after AVF creation (P<0.05). Systolic (132.49±16.42 mmHg to 146.60±17.43 mmHg) and diastolic (79.98±8.40 mmHg to 83.33±9.68 mmHg) blood pressure substantially rose post-fistularization (P<0.001). Notably, LVEF reduction was more significant in brachio-cephalic AVFs (46.29%±4.24%) compared to distal radio-cephalic or snuffbox AVFs (49.17%±7.15%) (P=0.014). : High-flow AVFs can significantly affect echocardiographic parameters in hemodialysis patients, thereby increasing the risk of cardiac failure. Close cardiac monitoring may be necessary for early intervention. Distal AVFs may be preferable in patients with decreased cardiac function.

Intraoperative transit time flow measurement predicts maturation of radiocephalic arteriovenous fistulas

ObjectiveThe arteriovenous fistula (AVF) is the first choice for gaining vascular access for hemodialysis. However, 20% to 50% of AVFs fail within 4 months after creation. Although demographic risk factors have been described, there is little evidence on the intraoperative predictors of AVF maturation failure. The aim of this study was to assess the predictive value of intraoperative transit time flow measurements (TTFMs) on AVF maturation failure. MethodsIn this retrospective cohort study, intraoperative blood flow, measured using TTFM, was compared with AVF maturation after 6 weeks in 55 patients. Owing to its significantly higher prevalence and risk of nonmaturation, the radiocephalic AVF (RCAVF) was the main focus of this study. A recommended cutoff point for high vs low intraoperative blood flow was determined for RCAVFs, using a receiver operating characteristic curve. ResultsThe average intraoperative blood flow in RCAVFs was 156 mL/min. Patients with an intraoperative blood flow equal or lower than the determined cutoff point of 160 mL/min, showed a 3.03 times increased risk of AVF maturation failure after 6 weeks, compared with patients with a higher intraoperative blood flow (P < .001). ConclusionsThe intraoperative blood flow in RCAVFs measured by TTFM provides an adequate means of predicting AVF nonmaturation 6 weeks after surgery. For RCAVFs, a cutoff point for intraoperative blood flow of 160 mL/min is recommended for maximum sensitivity and specificity to predict AVF maturation failure after 6 weeks.

Association of radiocephalic arteriovenous anatomical markers with post-angioplasty blood flow volume.

Doppler ultrasound (DUS) blood volume flow (VF) calculation is the most reliable method for demonstrating the success of endovascular treatment of dysfunctional radiocephalic arteriovenous fistula (AVF). Due to the difficulty of this method for the interventionalist, VF-correlated markers are required during the procedure. To investigate the relationship between intraprocedural anatomical markers (AMs) and changes in VF induced by percutaneous transluminal angioplasty (PTA). The study included 56 patients with dysfunctional radiocephalic AVF who underwent PTA between September 2020 and 2022. The VF of all patients was measured using DUS before and 1 h after PTA. AMs were determined from 10 images, five before and five after balloon angioplasty. The mean post-PTA VF was 637 ± 277 mL/min compared to baseline (151 ± 107 mL/min). Before and after balloon angioplasty, vein diameter (VD), artery diameter (AD), stenosis minimum luminal diameter (MLD), stenosis percentage (SP), and VF values were statistically significant (P = 0.001). Spearman's correlation analysis showed a positive strong linear relationship between VF and MLD (rs = 0.850, P <0.001), and a negative strong linear relationship between VF and SP (rs = 0.815). Receiver operating characteristic curve analysis showed that the sensitivity and specificity for VF ≥400 mL/min at cutoffs of SP <50% and MLD >2.5 mm were 81% and 82%, and 81% and 90%, respectively. Among the AMs readily available during PTA, first MLD and then SP provided satisfactory results in predicting VF.

An unintended connection – Radial arteriovenous fistula after coronary angiogram

Abstract The following case is of a 44-year-old female undergoing maintenance hemodialysis (MHD) due to chronic interstitial nephritis, utilizing a left brachiocephalic (BC) arteriovenous fistula (AVF). Following presentation with retrosternal anginal pain, diagnosed as high lateral wall myocardial infarction, coronary angiogram revealed normal coronaries. Subsequently, dilated veins along the right forearm were noticed, attributed to a patent right radiocephalic AVF. Despite being asymptomatic, the patient underwent a Doppler ultrasound confirming a blood flow of 400 ml/min through the AVF. No further intervention was planned as the patient continued MHD through the left BC AVF.

Predicting recurrent interventions after radiocephalic arteriovenous fistula creation with machine learning and the PREDICT-AVF web app.

Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines discourage ongoing access salvage attempts after two interventions prior to successful use or more than three interventions per year overall. The goal was to develop a tool for prediction of radiocephalic arteriovenous fistula (AVF) intervention requirements to help guide shared decision-making about access appropriateness. Prospective cohort study of 914 adult patients in the United States and Canada undergoing radiocephalic AVF creation at one of the 39 centers participating in the PATENCY-1 or -2 trials. Clinical data, including demographics, comorbidities, access history, anatomic features, and post-operative ultrasound measurements at 4-6 and 12 weeks were used to predict recurrent interventions required at 1 year postoperatively. Cox proportional hazards, random survival forest, pooled logistic, and elastic net recurrent event survival prediction models were built using a combination of baseline characteristics and post-operative ultrasound measurements. A web application was created, which generates patient-specific predictions contextualized with the KDOQI guidelines. Patients underwent an estimated 1.04 (95% CI 0.94-1.13) interventions in the first year. Mean (SD) age was 57 (13) years; 22% were female. Radiocephalic AVFs were created at the snuffbox (2%), wrist (74%), or proximal forearm (24%). Using baseline characteristics, the random survival forest model performed best, with an area under the receiver operating characteristic curve (AUROC) of 0.75 (95% CI 0.67-0.82) at 1 year. The addition of ultrasound information to baseline characteristics did not substantially improve performance; however, Cox models using either 4-6- or 12-week post-operative ultrasound information alone had the best discrimination performance, with AUROCs of 0.77 (0.70-0.85) and 0.76 (0.70-0.83) at 1 year. The interactive web application is deployed at https://predict-avf.com. The PREDICT-AVF web application can guide patient counseling and guideline-concordant shared decision-making as part of a patient-centered end-stage kidney disease life plan.

Dialysis Access-Associated Steal Syndrome in High-Risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review and Meta-Analysis of Preventive Operative Techniques.

This systematic review and meta-analysis examine preventive operative techniques in high-risk patients undergoing surgery for hemodialysis access to mitigate the risk of Dialysis Access-Associated Steal Syndrome (DASS). Chronic kidney disease often leads to end-stage renal disease (ESRD), necessitating dialysis. Successful vascular access is crucial for efficient dialysis, but complications, such as DASS, pose significant challenges. DASS redirects arterial blood flow, affecting populations undergoing arteriovenous access surgery. This study aims to assess preventive strategies, including distal revascularization with interval ligation (DRIL) and extension techniques. A systematic search of PubMed, Cochrane Library, EMBASE, and Web of Science until 2022 identified 11 relevant studies. The inclusion criteria comprised non-pediatric hemodialysis patients reporting outcomes related to patency and complications. The data were analyzed using Review Manager 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen). Meta-analysis indicated a significant association between DASS and arteriovenous fistula (AVF) or arteriovenous graft (AVG) procedures. Radiocephalic AVF (RC-AVF) and distal endovascular AVF procedures were favored. Various interventions addressed venous narrowing, including simple plication and loop interposition. The Modified by Inserted Latex Link for Endovascular Repair (MILLER) technique, DRIL, Extension Technique, and Proximalization of Arterial Inflow (PAI) were assessed for arterial bypass graft and blood supply preservation. This study underscores the importance of individualized strategies in preventing DASS during hemodialysis access surgery. Prophylactic measures, such as the extension technique, show promise, while DRIL remains effective in treatment. Ongoing research is imperative for optimizing outcomes in this complex patient population.

Creating hemodialysis autogenous access in children and adolescents

ObjectiveEnd-stage renal disease (ESRD) in childhood and adolescence is rare, with relatively few published reports of pediatric ESRD vascular access. This study analyzes a 10-year experience creating arteriovenous fistulas (AVFs) in children and adolescents. Our goal is to review our strategy for creating functional autogenous vascular access in younger patients and report our results. MethodsWe retrospectively reviewed data and outcomes for consecutive vascular access patients aged ≤19 years during a 10-year period. Each patient had preoperative vascular ultrasound mapping by the operating surgeon in addition to physical examination. A distal forearm radiocephalic AVF was the first access choice when feasible, and a proximal radial artery inflow AVF was the next option. Demographic data, inflow artery, venous outflow target, and required transposition vs direct AVFs were variables included in the analysis. Primary and cumulative patency were calculated by Kaplan-Meier analysis. ResultsThirty-seven AVFs were created in 35 patients. No grafts were used. Ages were 6 to 19 years (mean, 15 years), and 20 were male. Causes of ESRD included glomerular disease (n = 18) and urinary obstruction or reflux (n = 7), among others. Three had previous AVFs, and 10 were obese. The proximal radial artery supplied AVF inflow in 25 patients and the brachial artery in only seven. Eleven individuals required a transposition and one a vein translocation to the contralateral arm. No patients developed hand ischemia, although two later required banding procedures for high flow. Eleven patients had successful transplants. A single patient died, unrelated to the vascular access. Five AVFs failed. Of these, two had new successful AVFs created, two regained renal function, one was transplanted, and one declined other procedures. Primary and cumulative patency rates were 75% and 85% at 12 months, 70% and 85% at 24 months, and 51% and 85% at 36 months, respectively. Median follow-up was 16 months. ConclusionsCreating an AVF for hemodialysis is a successful vascular access strategy for pediatric and adolescent patients. Proximal radial artery AVFs provided safe and functional access when a distal AVF was not feasible. Cumulative AVF patency was 85% at 36 months.

Clinical characteristics and preoperative ultrasound parameters related to low patency in radio-cephalic arteriovenous fistulas.

Our objective is to describe the clinical characteristics and preoperative ultrasound mapping parameters associated with primary and secondary patency of radio-cephalic arteriovenous fistulas (RCF). A retrospective, single-center, descriptive study, including patients undergoing a RCF creation between 2015 and 2019. Socio-demographic data and ultrasound parameters were collected and an analysis of primary and secondary patency was performed. Eighty-four patients were included in this study. Mean age was 65.6 (±13.9) years; 76.6% were male. Mean preoperative ultrasound parameters: forearm cephalic vein diameter was 2.8 (±0.57) mm, radial artery diameter was 2.6 (±0.42) mm, radial artery systolic peak velocity was 68 (±14.3) cm/s radial artery resistance index was 0.76 (±0.9). At the end of the 4 years the follow-up, the mean primary and secondary patency were 47.2% and 80% respectively. Only female sex was significantly associated with a decrease in both primary patency (p = 0.043, HR = 0.48) and secondary patency (p = 0.021, HR = 0.023). Furthermore, radial artery systolic peak velocity (p = 0.007, HR = 2.6) showed a significant association with decreased primary patency and forearm cephalic vein diameter showed a borderline significant association with decreased secondary patency (p = 0.046, HR = 8.2). A standardized evaluation by a vascular surgeon or nephrologist represent a key in the preoperative assessment of AVF candidates. Based on our results, we will consider to avoid distal vascular access in both female patients with lower radial artery systolic peak velocity (less than 68 cm/s) and borderline forearm cephalic vein diameter (less than 2.8 mm) after initial assessment in our clinical practice. Our results could encourage new studies in order to stablish the potential role of these parameters in the RCFs patency rates.

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

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