Radiocephalic Fistula Research Articles

Comparison of different anastomosis angles in radiocephalic fistula with modified functional end-to-side anastomosis

ObjectiveFunctional vein end to arterial side (ETS) anastomosis uses vein side to arterial side anastomosis with distal vein ligation, which is different from traditional ETS anastomosis. To date, there are no studies concerning different anastomotic angles of fistula with functional ETS anastomosis. The purpose of the study was to analyze the clinical outcomes concerning different anastomotic angles of functional ETS anastomosis in radiocephalic fistula.MethodsBetween January 2018 and December 2020, we performed a prospective cohort study concerning functional ETS anastomosis in radiocephalic fistula. According to vascular anatomy of patients, the anastomosis angles of fistula were designed at 30 ≤ angle ≤ 50°, 50 < angle ≤ 70°, and 135° smooth obtuse angle. The end points were the primary patency rate (PPR), the secondary patency rate (SPR) and the cumulative rate of reintervention (CRR) near anastomotic venous segment.Results124 patients with functional ETS anastomosiss were enrolled in this study. Pearson χ2 test showed that the group of 135°anastomosis angle had the maximum distance between arteries and veins, and the group of 30–50°anastomosis angle had the minimum distance between arteries and veins (P < 0.01). 30–50°anastomosis angle had the highest PPR at 12 months (P = 0.03) and the lowest CRR near anastomotic venous segment at 3 months (P = 0.04) and 12 months (P = 0.01). There were no significant differences among different anastomosis angles concerning the SPR within 12 months (P > 0.05). Kaplan–Meier and log-rank analysis showed that 30–50°anastomosis had the highest PPR (P = 0.03) and the lowest CRR near anastomotic venous segment (P = 0.01). A multivariable Cox model showed anastomotic angle was an independent factor predictive of the PPR (P = 0.04) and the CRR near anastomotic venous segment (P = 0.03). 50–70°anastomosis angle was a risk factor of decreasing PPR (P = 0.03). 50–70° (P = 0.01) and 135° (P = 0.03) anastomosis angle were both obvious risk factors of increasing CRR near anastomotic venous segment.Conclusion30–50°were the best anastomotic angles for functional ETS anastomosis, which had the highest PPR and lowest CRR near anastomotic venous segment.

Operative Technique of Autogenous Forearm Loop Fistula

Autogenous AV access are preferred in all CKD patients due to good patency rates and lower risks of infection. Radiocephalic fistulas (RCF) are the first preferred access, but most patients have diseased and small diameter radial arteries. We would like to describe a technique of creating a forearm loop fistula, utilising a good forearm vein in patients with diseased radial arteries and failed RCF.

The Importance of Perioperative Flow Evaluation and Prevention of Steal Syndrome in Arteriovenous Fistula Surgery Using Transit-Time Flow Measurement

Aim: Our aim is to evaluate the relationship between the survival time of arteriovenous (AV) fistula whose flows are measured with flow meter in patients with chronic renal failure who were operated for AV fistula (AVF) and present the results. Materials and Methods: In our clinic, we evaluated the flow meter measurement results with patency rates and usability after 6 months of AVF in 100 patients who underwent AVF operation due to chronic renal failure. Findings: In February 2012, transit-time flow measurement was put into use in our clinic. The last 50 consecutive patients with the same characteristics before this date constituted the control group (Group A) and the first 50 consecutive patients after this date constituted the study group. Radiocephalic fistula was made the most common (Group A, n = 50; Group B, n = 50). Nondominant upper extremity was selected when planning AVF for patients. First radiocephalic, then brachiocephalic AVF was performed. Fistulas flow was measured with an intraoperative flow meter. Those with bad flow were revised during the operation. Embolectomy was performed in one patient at the 2nd month due to fistula thrombosis, but it was not successful in one patient, and an AVF was opened with a graft. Results: While creating AVF, our aim is to use it effectively for a long time. By evaluating the fistula flows with the flow meter and make an intraoperative revision if necessary we ensure to extend the lifespan of a fistula.

End Stage Renal Disease: AVF for Hemodialysys: Clinical Assessment with/without Ultrasound Doppler, Complications and Failure

Objective/Background: The objective of this study was to study the complications and failure rate after creating an arteriovenous fistula in patients suffering from end-stage renal disease (chronic renal failure). It was also intended to study the importance of preoperative Clinical assessment/physical examination of the patient; and if the vessels for anastomosis appeared to be of a doubtful size, then a doppler study was done to ensure that the vein is of adequate size for creation of a good fistula. Method: In this study 121 cases of end-stage renal disease (chronic renal failure) who needed vascular access for hemodialysis were taken. Ultrasound Doppler study was conducted in those patients whose vessels (for anastomosis) appeared to be of small size on Clinical examination. In the study, the arteriovenous fistulae were created under local anesthesia observing all aseptic precautions. Results: Most commonly, the difficulty encountered during surgery was when the caliber of the vein was small i.e. less than 2.5 mm. An arteriovenous fistula was created only when the size of the vein was at least 2.0 mm. When the size of the vein was small, then a longitudinal incision was given in the vein or Cheatlemanouvre was undertaken to perform the anastomosis. In 4 of the 121 cases when radiocephalic fistula was attempted, we had to convert to brachio-cephalic. No major complication was encountered during the surgery or post-operatively. Some patients (five) had redness and inflammation. Inflammation and redness subsided with antibiotics and it resulted in satisfactory recovery. The fistulas started well showing good thrill. After 30 days, 106 out of 121 AV fistulas created were functioning very well with a patency rate of 87.6%. Conclusion: There was no major complication after creating an arteriovenous fistula. It is important to do a thorough physical examination before surgery so that the vessel is assessed. In doubtful cases, an ultrasound doppler study should be done to know the size and patency of the vessel. We should also take relevant history especially of hypertension, diabetes, i/v canulation, etc.

Proximalization through one incision of a wrist arteriovenous fistula and distal revascularization with interval ligation.

In the setting of ischemic steal syndrome with tissue loss, patients with radiocephalic fistulas have limited options to preserve their conduit and treat their ischemic symptoms. To address this, we have proposed the technique of proximalization through one incision of a wrist arteriovenous fistula (POWR) with distal revascularization with interval ligation (DRIL) procedure. In the present retrospective, single-center, case series, we evaluated the outcomes of three patients with radiocephalic fistulas who had undergone POWR DRIL from 2017 to 2021. Their ischemic symptoms were monitored for regression. All three patients showed signs of regressing ischemia. The POWR DRIL represents an efficient procedure to address tissue loss and preserve the autogenous conduit.

Outflow Rescue of Elbow-Blockade Forearm Arteriovenous Fistulas: Outcomes of Open Surgical Techniques

Venous scarring at the elbow is a common problem that can cause early and late forearm arteriovenous fistula (AVF) dysfunction in hemodialysis patients. However, any effort to prolong the long-term patency of distal vascular accesses could benefit the patient's survival, maximizing the use of restricted venous patrimony. This study aims to report a single-center experience in the recovery of distal autologous AVF with venous outflow obstruction at the elbow using different surgical techniques. Retrospective observational study of all patients treated at a single vascular access center from January 2011 to March 2022, with dysfunctional forearm AVFs presenting with outflow stenosis or occlusions at the elbow treated by open surgery, using 3 different surgical techniques. Demographics and clinically relevant data were collected. Evaluated endpoints included primary, assisted primary, and secondary patency rates at 1 and 2years. Twenty-three patients with elbow-blocked outflow forearm AVFs have been treated with a mean age of 64±15years. The majority (96%) had a radiocephalic fistula. The median time from vascular access creation to intervention was 34.5months (12-216months). A total of 24 procedures have been performed using 3 different surgical techniques for bypassing the obstructed venous outflow at the elbow. Technical success was achieved in 96% of the surgically treated patients. Primary and secondary patency rates at 1year were 67.4% and 89.4%, respectively, and 52.9% and 82.0% at 2years, with a median follow-up of 19months (6-92months). AVFs outflow stenosis or occlusions at the elbow not amenable to endovascular therapy could lead to vascular access abandonment. Our study demonstrates multiple surgical solutions to avoid this adverse outcome. Elbow venous outflow surgical reconstruction seems effective for distal vascular access preservation. Close surveillance is essential for timely endovascular treatment of newly developed stenosis at the venous drainage.

Radiocephalic Fistula Recovery Using the Forearm Basilic Vein: A Case Report

Dysfunction of the arteriovenous fistula for hemodialysis is a challenge for the nephrologist and the vascular surgeon. Although experience is limited, the use of the forearm basilic vein as outflow of the radiocephalic fistula has been considered. We report the case of a 60-year-old male, with cardiovascular comorbidities and a history of ischemic complications induced by the hemodialysis access. Drainage problems were present in the radiocephalic fistula and the forearm basilic vein was used in the vascular access repair. The procedure was successful, and the patient maintains a functional fistula, with secondary patency of 32 months, with no cardiac complications or hand access-induced distal ischaemia syndrome.

Does the balloon-assisted maturation procedure offer comparable results for AVF created with a smaller vein?

Traditionally, a venous diameter of less than 3 mm was not considered for creation of AVF. Some studies have reported smaller venous size could be used for operation. AVF created with a smaller vein may have a lower maturation rate. Currently, percutaneous angioplasty is also used to enhance the maturation of AVF. This study aimed to establish whether the BAM procedure could offer comparable results for AVF created with a smaller vein. From January 2016 to July 2021, 290 patients who received native AVF operation were enrolled in this study. All of the preoperative venous sizes were measured by Duplex ultrasonography under tourniquet enhancement. The study cohort was categorized into two groups based on the pre-operative venous diameter: smaller vein group (SVG, 2.5 < size < 3 mm, 53.1%) and normal vein group (NVG, size ⩾ 3 mm, 46.9%). The mean age was 64 ± 12.9 years, and 58.6% of patients were male. Hypertension and DM were the most common comorbidities. Most patients underwent operation of radio-cephalic fistula (71.4%). The overall primary maturation rate was 79%. The primary maturation rate was significantly higher in the NVG (86% vs 72.7%, p = 0.009). However, after the BAM procedure, the secondary maturation rate was similar in both groups (94.1% vs 90.3%, p = 0.319). According to our study, the BAM procedure can significantly increase the maturation rate, and the secondary maturation rate was similar in both groups. Thus, more patients can be given the opportunity to undergo creation of an AVF for long-term hemodialysis.

Radiocephalic Fistula Recovery Using the Forearm Basilic Vein: A Case Report

Dysfunction of the arteriovenous fistula for hemodialysis is a challenge for the nephrologist and the vascular surgeon. Although experience is limited, the use of the forearm basilic vein as outflow of the radiocephalic fistula has been considered. We report the case of a 60-year-old male, with cardiovascular comorbidities and a history of ischemic complications induced by the hemodialysis access. Drainage problems were present in the radiocephalic fistula and the forearm basilic vein was used in the vascular access repair. The procedure was successful, and the patient maintains a functional fistula, with secondary patency of 32 months, with no cardiac complications or hand access-induced distal ischaemia syndrome.

Relationship Between Quick of Blood with Arteriovenous Radiocephalic And Brachiocephalic Fistula to Blood Urea Nitrogen (BUN), Creatinine Serum, Neutrophil to Lymphocyte Ratio (NLR), And Hemoglobin in Patients Hemodialysis

Chronic kidney disease (CKD) is a chronic disease with a high prevalence worldwide. In 2017, an estimated 1.2 million people died from CKD globally. There are 713,783 CKD sufferers (0.38%) in Indonesia aged 15 years who have been registered nationally. Hemodialysis (HD) is one of three renal replacement therapies for managing CKD. Adequate vascular access is required in patients undergoing HD. Vascular access is ideal if it causes minor complications when used for hemodialysis. Arteriovenous fistula (AVF) is a common vascular access used during HD. The main options for AVF are radiocephalic (RC) and brachiocephalic (BC) fistula, with their respective advantages and disadvantages. This cross-sectional study compares QB in patients with RC and BC fistula and with hematological parameters pre and post-HD. There were 18 RC subjects and 18 BC subjects involved in this study. Subjects were then examined for hematological parameters and QB before and after HD. The results of this study showed that QB in the RC group was not significantly different from the BC group (p=0.126). The mean comparative test showed that the levels of Hb, BUN, and SC were significantly different before and after HD both in the RC group (p=0.005; p=&lt;0.001; p=&lt;0.001) and BC (p=0.001; p =&lt;0.001; p=&lt;0.001). The correlation test results showed that QB only correlated with SC pre-HD levels (p=0.030; r=0.361). Multivariate tests showed that the decrease in BUN levels with AV fistula BC was higher than with RC (p=0.015). This study proves that QB is unrelated to the type of AV fistula used, but QB is positively correlated with serum creatinine levels in patients undergoing HD. BC fistula were also found to lower BUN levels better than RC fistula.

Ішемічні порушення кінцівки при АВФ для хронічного гемодіалізу

Ischemic steal syndrome (ISS) develops from 2 to 20% of cases in patients on chronic hemodialysis with arteriovenous fistula (AVF) or arteriovenous prosthesis (AVP). Moreover, there is a different frequency of ISS development in patients with distal (radiocephalic) AVF and proximal AVF. For radiocephalic fistulas, this index is about 2%. With proximal fistulas, ISO can reach up to 20-25%. The purpose of the study: To conduct an analysis of the clinical course of ischemic syndrome distal to permanent vascular access for people suffering from Stage 5 of Chronic kidney disease with efferent renal replacement therapy. Research materials and methods. The terms of the development of ischemic disorders after the formation of permanent vascular access (PVA) in patients with AVF are from an hour to a week ("acute"), but can appear after a month or more ("chronic") and even after several years. Despite the fact that the severity of "chronic" ischemia is usually moderate, long-term complaints of hypoperfusion can lead to trophic disorders, up to necrosis and gangrene (about 1% of patients). It is also noted that up to 25% of patients have temporary ischemic complications after the formation of AVF and AVP. There is currently no generally accepted ISS classification. In the foreign literature, there are several attempts by different researchers to develop a classification that would be of practical importance for the diagnosis and treatment of ISS. Research results and their discussion. Most of the authors base their practice primarily on the clinical diagnosis of ISS. Instrumental diagnostics has a clarifying character. Taking an anamnesis can reveal risk factors for the development of ISS. To identify complaints, some authors proposed a questionnaire based on the visual analog scale (VAS), in which points are obtained by multiplying the subjective severity of symptoms (from 0 to 10) by their frequency of occurrence (0 – never, 10 – always). A decrease in tactile and temperature sensitivity may be detected during a neurological examination. One of the most severe variants of acute ischemic syndrome is the development of so-called unilateral ischemic neuropathy. Trophic disorders occurring on the limbs containing arteriovenous access (AVA) can also be the result of venous hypertension, which is accompanied by edema. NKF/DOQI 2006 recommendations require the immediate elimination of access when an UIN is detected. However, even in cases where this complication is detected in the shortest possible time, and the fistula is ligated, full regression of symptoms does not occur in all patients. Delay in surgical tactics significantly worsens the prognosis. Conclusions. The most serious complaint that complicates full-fledged hemodialysis is pain due to ischemia of all three nerves of the forearm, which appears or worsens during the replacement therapy procedure. Weakening of the pulse distal to the AVF is characteristic of most patients, both with proximal and distal AVF.

Evaluating national guideline concordance of recurrent interventions after radiocephalic arteriovenous fistula creation

ObjectiveRadiocephalic arteriovenous fistulas have been historically perceived as requiring multiple follow-up procedural interventions to achieve maturation and maintain patency. Recent clinical practice guidelines from the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) emphasize a patient-centered hemodialysis access strategy with new maximum targets for intervention rates, potentially conflicting with concomitant recommendations to prioritize autogenous forearm hemodialysis access creation. The present descriptive study seeks to assess whether radiocephalic fistulas can meet the KDOQI guideline benchmarks for interventions following access creation, and to elucidate clinical and anatomic characteristics associated with the timing and frequency of interventions following radiocephalic arteriovenous fistula creation. MethodsProspective patient-level data from the multicenter PATENCY-1 and PATENCY-2 randomized trials, which enrolled patients undergoing new radiocephalic arteriovenous fistula creation, was analyzed (ClinicalTrials.govNCT02110901 and NCT02414841). The primary outcome was the rate of interventions at 1 year postoperatively. Incidence rates were calculated, and time to surgical or endovascular intervention following fistula creation was modeled using recurrent event extensions of the Cox proportional hazards model. Confidence intervals at the 95% level were calculated using nonparametric bootstrapping. ResultsThe cohort consisted of 914 patients; mean age was 57 years (standard deviation, 13 years), and 22% were female. Median follow-up was 707 days (interquartile range, 447-1066 days). The incidence of interventions per person-year was 1.04 (95% confidence interval [CI], 0.95-1.13) overall; 1.10 (95% CI, 0.98-1.21) before fistula use, and 0.96 (95% CI, 0.82-1.11) after fistula use. The most common interventions overall were balloon angioplasty (54.9% of all interventions), venous side-branch ligation (16.4%), and open revisions (eg, proximalization from snuffbox to wrist, 16.4%). The locations requiring balloon angioplasty included the juxta-anastomotic segment (51.7% of angioplasties), the outflow vein (29.2%), the inflow artery (14.8%), the central veins (3.8%), and the cephalic arch (0.5%). Common indications were to restore or maintain patency (75.6% of all interventions), assist maturation (14.9%), improve depth (4.4%), or improve augmentation (3.0%). In the multivariable regression analysis, female sex (adjusted hazard ratio [HR], 1.21; 95% CI, 1.05-1.45), diabetes (HR, 1.21; 95% CI, 1.01-1.46), and intraoperative vein diameter <3.0 mm (vs ≥4.0 mm: HR, 1.33; 95% CI, 1.02-1.66) were associated with earlier and more frequent interventions. Patients not on hemodialysis at the time of fistula creation underwent less frequent interventions (HR, 0.69; 95% CI, 0.59-0.81). ConclusionsPatients with radiocephalic arteriovenous fistulas can expect to undergo one intervention, on average, in the first year after creation, which aligns with current KDOQI guidelines. Patients already requiring hemodialysis, female patients, patients with diabetes, and patients with intraoperative vein diameters <3.0 mm were at increased risk for repeated intervention. No subgroup exceeded guideline-suggested maximum thresholds for recurrent interventions. Overall, the results demonstrate that creation of radiocephalic arteriovenous fistula remains a guideline-concordant strategy when part of an end-stage kidney disease life-plan in appropriately selected patients.

Hemodialysis Access Outcomes for Patients with Unstable Housing.

End-stage renal disease has traditionally been noted to disproportionately affect patients with fewer resources. Our goal was to assess practice patterns and outcomes in patients with unstable housing undergoing permanent hemodialysis access creation. A retrospective, single-center review of patients with unstable housing was conducted. Perioperative and long-term outcomes were assessed. Univariable and multivariable analysis as well as Kaplan-Meier analysis were performed. There were 144 patients (63% male) identified with a mean age of 57 years. Thirty-three percent of patients had no current permanent residence, and 81% had at least 3 addresses the year before operation. Access type included brachiocephalic (48%), brachiobasilic (19%), radiocephalic fistulas (11%), and prosthetic grafts (19%). Thirty-day readmission was seen in 27.8% of patients. Kaplan-Meier analysis showed that 1-year and 4-year patient survival were 94.4% and 80.6%, respectively. Multivariable analysis demonstrated that newly formed access (odds ratio [OR] 3.66, 95% CI 1.02 to 13.16, p = 0.05), absence of a permanent residence (OR 2.92, 95% CI 1.15 to 7.44, p = 0.03), and female gender (OR 2.86, 95% CI, 1.18 to 7.14, p = 0.02) were associated with 90-day readmission. Multivariable analysis of mortality revealed that previous stroke (hazard ratio [HR] 7.15, 95% CI 1.93 to 26.5, p = 0.003), history of alcohol use disorder (HR 4.55, 95% CI 1.22 to 16.99, p = 0.024), and age (HR 1.10, 95% CI, 1.02 to 1.18, p = 0.017) were associated with 4-year mortality; housing instability was not associated with decreased survival. Preoperative tunneled dialysis catheter (HR 1.63, 95% CI 1.02 to 2.61, p = 0.04) was associated with 4-year reintervention and frequent address change (HR 0.47, 95% CI 0.27 to 0.81, p = 0.01) was found to be a protective factor against long-term reintervention. Poor outcomes in patients with unstable housing were primarily driven by comorbidities. Lack of permanent residence was significantly associated with readmission.

Treatment of Ischemic Steal Syndrome in a Patient With Aberrant Arterial Anatomy Following Dialysis Access Surgery

Symptomatic ischemic steal syndrome (ISS) is a complex complication that develops in a small number of patients who have undergone a dialysis access procedure. This report describes the case of a 44-year-old female with aberrant upper extremity arterial anatomy who developed ISS following a radio-cephalic fistula. Ultrasound evaluation revealed abnormal blood flow in the radial artery and identified a communication between the radial and ulnar arteries distal to the anastomosis of the arteriovenous fistula. These findings assisted with the development of a surgical plan to ligate the intervening radial artery which resulted in resolution of the ISS symptoms.

Methods for reducing the incidence of complications in distal arteriovenous fistula formation

The OBJECTIVE was to improve the results of surgical treatment and to reduce the incidence of postoperative vascular complications in patients after distal radial-cephalic arteriovenous fistula formation using a new method of vascular anastomosis application and cilostazol medication.MATERIALS AND METHODS. We studied 69 patients. The comparison group included 32 patients who underwent standard treatment with distal radiocephalic fistula formation according to the generally accepted method without additional conservative treatment. The main group consisted of 37 patients in whom the fistula formation was carried out according to the proposed method, and in the postoperative period, cilostazol medication was used at a dosage of 100 mg mg twice a day for more than 2 months.RESULTS. The main group showed smaller number of vascular complications: 12 (32.4 %) patients versus 15 (46.8 %) patients in the comparison group.CONCLUSION. The use of the proposed surgical method for arteriovenous fistula formation in combination with the use of cilostazol in the postoperative period leads to a decrease in the incidence of vascular complications, in particular, to a decrease in the frequency of thrombosis and disorders of the arteriovenous fistula formation.

Impact of Isometric Exercise in Adolescents With End Stage Kidney Disease and Unsuitable Vessels For An Autologous Arteriovenous Fistula.

Despite the lack of calcification, to perform a native Arteriovenous Fistula (AVF) in young patients may pose a challenge due to small vessel diameter. We report a case series with no options of AVF in which vessel caliber improvement after isometric exercise allowed for radiocephalic fistula creation in all of them. Since 2017 to 2019, four patients were referred to our unit to create an AVF. Following a first assessment with physical examination and doppler ultrasound, none of them were eligible for AVF performance due to small vessel caliber. Once they were considered unsuitable for it, they started an isometric exercise program. Age ranged from 13 to 19years. There were three males and one female. Two were in predialysis and two in hemodialysis program. Initial diameters of the forearm cephalic vein and the radial artery respectively were: case A < 1.5/2.3mm, case B 1.5/1.6mm, case C < 1.5/1.6mm and case D 2.1/1.3mm. Median duration of exercise program was 13weeks (range 5-23). Post-exercise vessel diameters were: case A 2.7/2.3mm, case B 2.5/2mm, case C 2.8/1.8mm and case D 2.7/2mm. Radiocephalic AVF were performed in the four cases. After a median follow up of 19 months (range 9-30months), 75% of patients required further interventions but all of them had a functional AVF. In these four cases isometric preoperative exercise allowed the creation of AVF. Without the improvement in vessel diameter observed afterwards, all of them would have been rejected for AVF performance. Despite the high rate of adjunctive interventions needed, given the safety of the program and the potential risks of Central Venous Catheters, we consider it a valuable option.

Early and midterm patency of arteriovenous fistula for hemodialysis access using different techniques and their advantages and disadvantages.

This descriptive retrospective study was done to observe the different techniques of arteriovenous fistula creation for advantages and disadvantages, complications, and early and midterm patency. Fifty-three arteriovenous fistulas were created from September 2018 to August 2020 using four different techniques. Radio-cephalic arteriovenous fistula was usually the first option. Other techniques like brachio-cephalic arteriovenous fistula, radio-basilic arteriovenous fistula, and brachio-basilic arteriovenous fistula were used when the radio-cephalic fistula had thrombosed or could not be constructed due to small-sized cephalic vein in the forearm. The majority of patients (41 (77.35%)) underwent radio-cephalic fistula creation. Early patency was 38 (92.7%) in the radio-cephalic technique whereas it was 12 (100%) in the radio-basilic, brachio-cephalic, and brachio-basilic techniques combined. The midterm patency was 32 (78%) in the radio-cephalic technique, 5 (83%) in the brachio-cephalic technique, 3 (75%) in the radio-basilic technique, and 1 (50%) in the brachio-basilic technique. Radio-basilic and brachio-cephalic are alternative techniques for fistula creation after radio-cephalic depending upon the size of the basilic vein in the forearm or cephalic vein in the cubital fossa or arm. The radio-basilic technique may have advantages over the brachio-cephalic technique which need to be further evaluated. Proximal fistulas like brachio-basilic and brachio-cephalic are more commonly associated with limb edema.

Intravascular lithotripsy: A new way to treat calcified radial arteries in non-functioning peripheral fistulas for dialysis

Background and Aims : Patients with advanced chronic kidney disease receiving hemodialysis (CKD-5D) have extensive arterial calcifications that may prevent the normal function of radio-cephalic fistulas (RCF, Fig 1) utilized as dialysis access. While radial artery angioplasty has given fair results, there is a risk of restenosis. Intravascular shockwave lithotripsy (IVSW) is a new technique to treat heavily calcified peripheral arteries. We describe the first 3 cases of radial artery IVSW (RA-IVSW) therapy in CKD-5D patients.

Age-based comparison of vascular access outcomes in maintenance hemodialysis population.

The hemodialysis population is aging, worldwide. In Israel, more than half of the dialysis population is older than 68 years. The policy for vascular access among this population is still a matter of debate, with several studies demonstrating conflicting results. This study compared vascular access outcomes across age groups (<65, 65-75, >75 years) in a single hemodialysis center in Israel. This was a retrospective, single center analysis of all vascular accesses created in adult hemodialysis patients in our institution, from January 1, 2006, through December 31, 2012. Patient characteristics, primary and secondary access failure, and complications were collected from electronic medical records. Follow-up was until death or up to 5 years. A total of 612 vascular accesses created among maintenance hemodialysis patients were included, of which 196 were in patients >75 years, 184 in patients 65-75 years, and 232 in patients <65 years. Mean age of the >75 years group was 80.5 ± 4.3 years and 60.7% were men. Vascular access site was the most important predicator for primary access failure (odds ratio for primary failure of radiocephalic arteriovenous fistula was 3.5 (95% CI 2.1-6), whereas age did not affect the primary failure rate (odds ratio 1.5, p = 0.648). Radiocephalic fistulas were more prone to secondary failure than other vascular access sites were. Complications were slightly more common in the oldest group. Eight percent of the patients >75 years died before access was used. In our cohort, age did not affect vascular outcomes, whereas VA site seemed to be the most important parameter in primary and secondary VA failures. Our results support considering VA on an individual basis and supply valuable information regarding complication and failure rates of VA among patients >75 years.

Snuff-Box Versus Wrist Radiocephalic Arteriovenous Fistulas for Hemodialysis: Maturation Tend and its Affecting Factors

Thanks to its well proved long-term patency rates, native radiocephalic arteriovenous fistula remains the most commonly used vascular access type. Many articles had approached the criteria leading to a mature fistula. The aims of this work are to evaluate variables that may affect the maturation of distal fistulas and to determine if wrist fistulas have less risk of maturation failure than the snuff-box fistulas. We recorded all distal radiocephalic fistulas that had been created from January 2018 to February 2021. Epidemiological and clinical profile of patients, characteristics of performed fistulas and per and post-operative data were recorded and analyzed. From January 2018 to February 2021, 165 upper limb vascular accesses for hemodialysis had been created including 47 (28.5%) distal radiocephalic fistulas. Among the latter, 39 (83%) fistulas were performed at the wrist and 8 (17%) at snuff-box area. There were 34 men (72.3%). Mean age was 67years (37-87). Both types of fistulas had approximately an identic frequency of primary maturation failure (50% for radiocephalic versus 47.2% for snuff-box fistulas). Secondary maturation had been achieved in 9 fistulas. Patients with medical history of dyslipidemia, peripheral arterial disease (PAD), central catheter placement, and bad quality of vessels tend to develop an immature fistula. No significant differences in maturation tend between snuff-box and wrist fistulas had been demonstrated. Thus, it seems reasonable to privilege the creation of the most distal fistulas allowing preservation of wrist fistulas as a second option in case of snuff-box fistulas maturation failure. However, selection of the most suitable cases for snuff-box fistulas creation, based on clinical and duplex ultrasound data, remains primordial.