Radiocephalic Arteriovenous Fistula Research Articles

Coronary stent-graft use to salvage a juxta-anastomotic arterial rupture complicating a case of radio-cephalic fistuloplasty

BackgroundStenosis is a common complication of haemodialysis arteriovenous accesses. Endovascular approaches with percutaneous transluminal fistuloplasty have largely replaced open surgical approaches as first line treatment. Vessel rupture is an uncommon complication of fistuloplasty and most reports describe venous rupture. Stent-graft deployment can salvage this, however, its use requires careful assessment of the distal vasculature. Arterial rupture with fistuloplasty has rarely been described in the literature. This is a novel case describing the use of a BeGraft coronary stent-graft to manage juxta-anastomotic arterial rupture and pseudoaneurysm complicating fistuloplasty.Case presentationA 77 year old female with end stage renal failure secondary to systemic amyloid light chain type amyloidosis was referred for a suspected radio-cephalic arteriovenous fistula stenosis after difficulty cannulating with poor flow during dialysis and clinical reduction in the fistula thrill. Both Doppler ultrasound and intravenous fistulography confirmed a venous stenosis 2 cm distal to the anastomosis. The stenosis was treated by fistuloplasty, however, this was complicated by a rupture of the juxta-anastomotic arterial segment intraoperatively. Intermittent balloon tamponade was used to minimise extravasation although a pseudoaneurysm formed within the damaged arterial segment. The patient’s distal neurovascular status was assessed using the Barbeau test and we sonographically confirmed adequate retrograde arterial flow via a complete palmar arch directing blood from the ulnar artery. After discussion with the renal transplant team, a 4 mm BeGraft coronary stent-graft was deployed to control haemorrhage and bypass the pseudoaneurysm until adequate haemostasis and fistula flow was achieved. Follow-up 3 months post-procedure reported the patient continued with haemodialysis using the stented fistula with no further complications.ConclusionsTo our knowledge, this is the first case report describing the application of BeGraft coronary stent-grafts to salvage fistuloplasty of a radio-cephalic arteriovenous fistula stenosis complicated by juxta-anastomotic arterial rupture and pseudoaneurysm formation. We demonstrate the safety and short-term efficacy of this technology.

TH4.2 To do or not to do, Branch ligation of a non-maturing arterio-venous fistula for haemodialysis

Abstract Aim Up to 20% of arterio-venous fistulas (AVFs) may fail to mature to become usable for renal access in patients on Haemodialysis (HD). There is no consensus on benefit of branch ligation. This study aimed to assess the outcomes of branch ligation on maturation of these AVFs. Methods Electronic patient records and Renalware were accessed to obtain data of branch ligation procedures done at secondary care centre from 2016 till 2021. Results With a prevalent dialysis population of over 771 patients and incident dialysis population of 147 in 2021, we as a centre perform 250–300 access procedures annually. A total of 23 ligation procedure were done in the above-mentioned period. Less than 50% of patients had a large branch documented on Duplex scan report to be draining a significant and measurable flow away from the AVF. The other procedures were done based on clinical judgement. All procedures were done under Duplex guidance and under Local or Regional anaesthesia. About two thirds of the fistulas that required branch ligation were Radio-Cephalic AVFs, the rest Brachio-Cephalic AVFs. No complications were reported though one patient needed a fistuloplasty due to vein pinch. In 16 out of the 23(69.5%) patients there was clinical and sonological improvement in flow, and or vein diameter after the branch ligation making them usable for HD. Conclusion Branch ligation of non- maturing fistula in selected cases can help maturation and make these arteriovenous fistulas usable.

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.

Digital model of radiocephalic arteriovenous fistula for decision support and improvement of maturation

The native arteriovenous fistula (AVF) is the recommended first intention vascular access in dialysis patients. This non-physiological surgical construction implies many anatomical and hemodynamic parameters. Radio-cephalic AVFs are preferred due to a low rate of long-term complications. The early rates of thrombosis and failure of maturation of the distal AVFs remain high, between 20 and 50%. The aim of this work was to obtain a faithful digital model simulating the flow of a radiocephalic AVF to guide the surgeon in the choice and the technical realization of AFVs in order to improve maturation.

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.

Comparison of primary patency of radiocephalic and brachiocephalic arteriovenous fistula in East Borneo, Indonesia

Background: There is still very limited study available for patency of arteriovenous fistulas (AVF) from developing country, specifically in East Borneo, Indonesia. The aim of this study is to compare the primary patency rate between radiocephalic (RC) and brachiocephalic (BC) AVF and to analyze the risk factors involved in the primary patency results of AVF RC and BC for hemodialysis. Methods: This study is a retrospective cohort study with a total of 154 patients underwent AVF from February 2017 until august 2018 and were monitored until august 2019. The patient’s primary patency of AVF was evaluated by the Kaplan-Meier survival curve. Each of the risk factors that were predicted to influence patency was analyzed for each AVF. Result: The mean age of 154 patients was 52.9 ± 9.5 years old. RC AVF was made in 130 patients (84.4%) and BC AVF was made in 24 patients (15.6%). There was no significant difference between the estimated primary patency for the RC group and BC AVF, the log-rank test (p=0.15). Risk factors for age, gender, hypertension, DM, and frequency of hemodialysis in both AVF showed statistically insignificant for primary patency. Conclusion: Our study showed there was no significant difference in the primary patency rate between the RC AVF and BC AVF group and other risk factors not significantly affecting primary patency in either type of AVF.

Patient-specific computational haemodynamics associated with the surgical creation of an arteriovenous fistula

Despite arteriovenous fistulae (AVF) being the preferred vascular access for haemodialysis, high primary failure rates (30-70%) and low one-year patency rates (40-70%) hamper their use. Furthermore, AVF creation has been associated with haemodynamic changes causing maladaptive cardiac remodelling leading to cardiovascular (CV) complications. In this study, we present a new workflow for characterising the haemodynamic profile prior to and following surgical creation of a successful left radiocephalic AVF in a 20-year-old end-stage kidney disease patient. The reconstructed vasculature was generated using multiple ferumoxytol-enhanced magnetic resonance angiography (FeMRA) datasets. Computational fluid dynamics (CFD) simulations utilising a scale-resolving turbulence model were completed to investigate the changes in the proximal haemodynamics following AVF creation, in addition to the post-AVF juxta-anastomosis flow patterns, which is impractical to obtain in-vivo. Following AVF creation, a significant 2-3-fold increase in blood flow rate was induced downstream of the left subclavian artery. This was validated through comparison with post-AVF patient-specific phase-contrast data. Proximal to the anastomosis, the increased flow rate yielded an increase in time-averaged wall shear stress (WSS), which is a key marker of adaptive vascular remodelling. In the juxta-anastomosis region, the success of the AVF was discussed with respect to the National Kidney Foundation's vascular access guidelines, where the patient-specific AVF met the flow rate and geometry criterion. The AVF venous diameter exceeded 6mm and the venous flow rate surpassed 600mL/min. This workflow may potentially be significant clinically when applied to multi-patient cohorts, with population-wide patient-specific conclusions being ascertained for the haemodynamic assessment of AVFs and improved surgical planning.

MO790: Arteriovenous Fistula Calcifications—Risk Factors and Impact on Arteriovenous Fistula Functionality

Abstract BACKGROUND AND AIMS Vascular calcifications have been recognized as frequent findings in patients with end-stage renal disease (ESRD) and have intricate mechanisms, including chronic kidney disease—mineral and bone disorders (CKD-MBD), inflammation and advanced atherosclerosis. The pathogenesis of arteriovenous fistula (AVF) calcifications is not fully understood, since it involves many other factors related to haemodialysis (HD) such as haemodynamic variables or vessel wall shear stress. The current study aims to assess the risk factors related to AVF calcifications and the impact on AVF functionality. METHOD The study included 174 chronic HD patients, mean age 58 ± 12 years, 35% female, median AVF duration 44 ± 52 months, with 35.9% radio-cephalic AVF, 12.1% brachio-basilic AVF, 52% brachio-cephalic AVF. The same nephrologist performed Doppler and B-mode AVF US scans in order to record AVF calcifications (defined as areas of hyperechogenicity with or without posterior shadowing within the arterial wall), as well as other complications (stenosis, partial thrombosis, aneurysms). In the same month of the AVF ultrasound assessment, cardiac echocardiography was performed in order to assess valvular calcifications. Laboratory parameters were analysed in the same month (Hb, calcium, phosphorus, serum bicarbonate, iPTH, albumin, ferritin, CRP). Dialysis efficiency (mean eKt/V in the month of ultrasound assessment) was recorded. The AVF survival was followed for 1 year after the initial evaluation, or up to the patient's death/transplantation. Statistical analysis was performed using MedCalc 14.8.1.0. RESULTS In our group, we found that the prevalence of AVF calcifications was 38% (66/174). Significantly more radiocephalic AVFs (47%) had calcifications than brachio-cephalic (38%) or brachio-basilic AVFs (15%), P = 0.04. The presence of calcifications was associated with longer AVF duration (P &amp;lt; .001), the presence of concomitant AVF stenosis (P = .04) and lower Hb levels (P = .02). The presence of AVF calcifications was not significantly associated with age, cardiac calcifications, or the presence of diabetes mellitus. Moreover, there was no statistically significant difference between the eKT/v values obtained in the group with AVF calcifications versus without AVF calcifications. We used the Cox proportional hazards model adjusted for standardized predicted values to determine whether patients with AVF calcifications had an increased risk of AVF failure. We found that after 1 year, 18,1% AVFs with calcifications had failed (12/66) while only 4.6% AVFs without calcifications had failed (5/108) [P = 0.02, hazard ratio (HR) 3.5, 95% confidence interval (95% CI) 1–11.3]. CONCLUSION The prevalence of AVF calcifications was 38% and affects radio-cephalic AVFs the most. AVF calcifications detected through ultrasound represent a risk factor for AVF failure, but the mechanism might be different from the pathways engaged in other vascular calcifications associated with CKD. We found no correlation with concomitant cardiac calcifications or CKD-MBD related biochemical changes. We found that AVF calcifications rather associate with HD-related factors (longer AVF duration and the presence of AVF stenosis). We suggest that periodic screening via ultrasound may be an easy method to diagnose AVF calcifications.

MO777: The Impact of Morphological and Haemodynamic Characteristics of Blood Vessels on the Arteriovenous Maturation

Abstract BACKGROUND AND AIMS Doppler Ultrasound (DUS) is a superior tool for the assessment of arteriovenous fistula (AVF) functionality. The aim of the study was to determine the association between morphological and haemodynamic characteristics of the blood vessels with AVF maturation. METHOD The study was prospective that analysed 80 patients with chronic kidney disease (CKD) stage 4/5 and CKD stage 5 on haemodialysis (CKD5D) with newly created radio cephalic AVF. Haemodynamics and morphological evaluation of blood vessels by DUS was performed in all patients. The diameter of the cephalic vein, radial and brachial artery was measured: before creation, on the first day (24-h after creation) and at 4 weeks. The blood flow (BF) rate of AVF was calculated by DUS on day 1, at 4 and 8 weeks. The successful maturation of AVF was defined with BF ≥ 600 mL/min. RESULTS The mean age of the patients was 59.9 ± 13.5 years, of which 46 (57.50%) were males. Successful AVF maturation at 4 weeks was 43.75% and 62.5% at 8 weeks. The results of six adjusted models in multivariate analyses showed BF rate on day 1 was a predictor for AVF maturation at 4 (P &amp;lt;0.001) and 8 weeks (P &amp;lt;0.001). The receiver operating characteristic (ROC) analyses showed that the highest sum of sensitivity and specificity for the BF on day 1 was 395 mL/min (sensitivity 0.714 and specificity 0.889) for the outcome at 4 weeks; and 344 mL/min (sensitivity 0.860 and specificity 0.867) for the outcome measured at 8 weeks. The diameter of the blood vessel was AVF significantly larger in patients with mature AVF compared with patients with non-mature AVF. Male gender was significantly associated with AVF maturation of AVF at fourth week (P &amp;lt; 0.001) and at eighth week (P = 0.001) compared with the female gender. CONCLUSION Our study showed that BF rate of AVF on day 1 was a predictor for AVF maturation at 4 and 8 weeks. The diameter of blood vessels and male gender were statistically associated with AVF maturation.

MO779: Benefits of a Nefrovascular Ultrasound Consultation: Results of 2 Years of Follow-Up

Abstract BACKGROUND AND AIMS The main vascular access for haemodialysis patients is the arteriovenous fistula (AVF). There is a high rate of early primary failure and loss of primary patency, therefore, vascular access monitoring is essential for the early diagnosis of complications and prolonging their survival. Our objective is to analyse the results of a consultation for the review and follow-up of AVFs using colour-Doppler ultrasound, performed by the nephrologist. METHOD Retrospective descriptive study of vascular ultrasounds performed from January 2019 to January 2021. Including clinical and demographic variables of the patients, as well as ultrasound parameters. Data from the Review group were compared; ultrasounds performed 3–4 weeks after performing vascular access; versus Dysfunction group; whose patients were referred from the advanced chronic kidney disease (ACKD) consultations or from the different dialysis centres upon detecting any data of suspected vascular access dysfunction. RESULTS A total of 166 vascular ultrasounds were performed: 106 (64%) in the Review group and 60 (36%) in the Dysfunction of the AVF group. A higher proportion of women was found in the Dysfunction group and upper mean age, close to the significance, P = 0.06 and P = 0.059 respectively. No significant differences were found with respect to other demographic characteristics in both groups (hypertension, diabetes, anticoagulant treatment and aetiology of kidney disease). Regarding the type of vascular access, a lower proportion of radiocephalic AVFs was observed in the Revision group (65% versus 50%) and a greater number of elbow AVFs (humero cephalic, humero basilic and humero median) in the Dysfunction group (35% versus 50%) with differences close to significance, P = 0.057. In the Review group, in 70.8% the findings were normal, in 24.5% lack of development was found, thrombosis in 9.4%, stenosis 6.6%, aneurysm 6%, oedema 17% and haematoma 6.6%. A 43% of the patients did not require to implement measures, in 42% exercise was recommended, in 6% repose of the AVF and 6 patients were requested fistulography and 3 were referred to cardiovascular surgery (CCV). In the Access Dysfunction group, the ultrasound diagnosis was normal in 28%, thrombosis was objective in 25%, stenosis 37%, aneurysm 42%, oedema 17%, haematoma 22%. 37% were referred for fistulography and 15% for revision by CCV. Regarding the ultrasound parameters, significant differences (P &amp;gt; 0.05) were found in terms of AVF flow, proximal and distal resistance index and vein calibre, but not in terms of vein depth and anastomosis diameter. A total of 28 fistulograms were performed, finding 86% agreement with the ultrasound findings. And in 93% the intervention was successful. Only 24% of the patients referred to the consultation required some type of intervention, and up to 65% were able to save the AVF, avoiding the realization of a new vascular access. CONCLUSION The systematic review after performing the vascular access made it possible to diagnose complications early and allow early intervention. It might be necessary to establish predictive criteria for vascular access dysfunction to individualize the follow-up for each patient, such as age, sex, or type of vascular access. Systematized vascular ultrasound by the nephrologist is very useful to preserve the functionality of the vascular access. On the other hand, the Vascular Nephrodiagnosis Consultation can avoid performing invasive and unnecessary procedures for the patient.

Incidence of Anastomotic Pseudoaneurysm of Arteriovenous Fistula in Hemodialysis Patients Having Non-Cuffed Catheters as Vascular Access – Association or Causation?

Background: Anastomotic pseudoaneurysm affecting arteriovenous fistula created for hemodialysis is an unusual and catastrophic complication. There is lack of clinical data in literature about its incidence and management. Aims and Objectives: To study the incidence and understand the aetiology of anastomotic pseudoaneurysm of arteriovenous fistula (PA-AVF) occurring in first six months after surgery. Materials and Methods: Cohort study based on retrospective analysis of three-year data of case-series of PA-AVF occurring in first six months after AV fistula creation for hemodialysis. Results: Among the 283 AV fistula surgeries (215 distal forearm radio-cephalic AVF and 68 brachial artery or cubital region AVF), 7 patients (2.4%) developed PA-AVF within 1 to 8 weeks after AV fistula surgery. Over-extended dependence on non-cuffed hemodialysis (HD) catheter was a common factor among patients developing this complication. All the patients had a prolonged stay (34 to 75 days) of non-cuffed HD catheters before development of PA-AVF. Diagnosis of HD catheter-related blood stream infection (HD-CRBSI), which overlapped with development of PA-AVF, was proven in 4 patients, two of which also had surgical site infection. One patient had traumatic PA-AVF and in two patients the cause could not be established although features consistent with CRBSI were present. Excision of pseudoaneurysm and ligation of radial artery was done in all cases. Conclusion: Infection is the most common cause of anastomotic pseudoaneurysm of AV fistula. Our study points towards extended use of non-cuffed hemodialysis catehters as a risk factor for development of PA-AVF. Prevention and early aggressive management of CRBSI and surgical site infections along with a limited use of non-cuffed HD catheters for the minimum required duration is the key to reduce the incidence of this complication

Clinical Characteristics and Outcome of Arteriovenous Fistula among Patients Undergoing Haemodialysis with end Stage Renal Disease

Objective: To determine the clinical characteristics and failure rate of arteriovenous fistula (AVF) among patients undergoing haemodialysis with end stage renal disease. Methodology: This was a cross-sectional study, done at department of urology at Bilawal Medical College for Boys, Liaquat University of Medial and Health Sciences Jamshoro Pakistan, with time duration of eleven months from April 2021 to February 2022. All the patients with age of more than 20 years, both genders, end stage renal disease and undergoing haemodialysis were included. The optimal site for fistula development was determined after taking blood pressure and completing the Allen test. Vascular diameter, intravascular thrombosis, arterial wall atherosclerosis, and the opening of arterial inflow and venous outflow access were all assessed during the procedure. End- to- side and side-to-side arteriovenous fistula were established if there were no contraindication. The patients were discharged after establishing the fistula's patency and experiencing the thrill. The patient's fistula patency and hemodialysis performance were assessed till six weeks. All the information was documented in the self-made proforma. SPSS version 26 was used for the data analysis. Results: A total of 100 cases were studied, most of the cases (49.0%) were more than 50 years old and males were most common 71.0%. Out of all, 59(59.0%) cases were diabetics and hypertensive. According to the site of arteriovenous fistulae (AVF), Left radio cephalic AVF was31.0%, left brachio cephalic AVF was 40.0%, left brachio basilic AVF 24.0%, right radio cephalic AVF 03.0%, right Brachio cephalic AVF 1.0% and right brachio basilic AVF 1.0%. At 6th week follow-up arteriovenous fistula was observed successfully functional in 91.0% cases, while 5.0% arteriovenous fistula were burst and in 3.0% it was failed, while one patient was died during this six-weeks follow-up. Conclusion: For haemodialysis, the arteriovenous fistula was observed to be the best and preferable option with higher functioning rate, noninvasive and lower complicated. Keywords: Renal failure, AVF, function, failure

Feasibility and safety of guidewire-balloon entrapment technique for recanalization of thoracic central vein occlusion in hemodialysis patients.

To explore the feasibility and safety of Guidewire-Balloon Entrapment Technique (GBET) for the recanalization of thoracic central vein occlusions (TCVOs) in hemodialysis patients. A retrospective observational study was conducted using data from 28 patients who required the establishment or maintenance of hemodialysis access and were treated with GBET for the recanalization of right-sided TCVOs from January 2017 to April 2021. Of the patients, 27 required tunneled cuffed catheter (TCC) placement or exchange, and 1 had an outflow tract occlusion of the Brescia-Cimino radio cephalic arteriovenous fistula (AVF). A total of 26 patients successfully underwent TCC exchange and placement using GBET; 1 patient underwent successful recanalization of an occlusion of the outflow tract of the right Brescia-Cimino AVF; and 1 patient underwent successful TCC placement in the left internal jugular vein (LIJV) after the failure of TCC placement in the right internal jugular vein (RIJV). The success rate for GBET was 27/28 (96.43%), and there were no major complications. GBET is a safe and effective method for the recanalization of right-sided TCVOs, especially for TCC exchange and placement, and can be used as a safe and easy approach for TCVO recanalization.

Risk Factors and Utility of Intraoperative Arteriovenous Fistula Blood Flow Level as a Surrogate Marker of Arteriovenous Fistula Failure in Patients with End-stage Renal Disease.

An arteriovenous fistula (AVF) can fail for different reasons at each stage after its creation. The study aimed to analyze the associations of the clinical and laboratory parameters, including the intraoperative AVF blood flow, with AVF failure at different periods (3 weeks and 3, 6, 9, 12, 24, and 36 months) after the AVF's creation and to evaluate the usefulness of the intraoperative AVF blood flow as a surrogate marker of AVF failure in patients with end-stage renal disease (ESRD). This was a single-center, retrospective cohort study that included 130 patients with ESRD who underwent the creation of new radiocephalic AVFs. The associations of the preoperative clinical and laboratory parameters and intraoperative flow with AVF failure in the different observation periods were investigated. Intraoperative AVF blood flow was significantly associated with AVF failure from 3 weeks to 24 months (P <0.05). Hemoglobin level and the size of the anastomosis were significantly associated with AVF failure at 6 months (P <0.05). In the analysis of the receiver operating characteristic curve, intraoperative AVF blood flow was significant from 3 weeks to 24 months (P <0.05). The intraoperative blood flow with the greatest sensitivity and specificity was 205-225 mL/min. Intraoperative blood flow was independently associated with AVF failure from 3 weeks to 24 months after the AVF's creation. An intraoperative AVF blood flow of >225 mL/min is crucial for long-term AVF patency. The intraoperative AVF blood flow level could be a surrogate marker of AVF failure in ESRD patients.

Creating Radio-cephalic Arteriovenous Fistula in the Forearm with a Modified No-Touch Technique.

Autologous arteriovenous fistula (AVF) is the primary and best option to obtain vascular access for hemodialysis treatment; other options are arteriovenous graft (AVG) and central venous catheterization (CVC). The implementation of radio-cephalic autologous arteriovenous fistula (RC-AVF) in the forearm was preferred among patients with superior vascular conditions. However, there is a high rate of early fistula failure. The chosen surgical method is understood to have an effect on the maturation of the fistula. New surgical procedures such as radial artery deviation and reimplantation (RADAR) have been significantly improved for juxta-anastomotic stenosis. Nevertheless, new problems such as stenosis of arteries and narrowing of surgical indication were also found. In this report, we presented a modified no-touch technique (MNTT) to create an RC-AVF, in which the venous and arterial wall avoid devascularization and the radial artery does not sever.

Creating Radio-cephalic Arteriovenous Fistula in the Forearm with a Modified No-Touch Technique

Creating Radio-cephalic Arteriovenous Fistula in the Forearm with a Modified No-Touch Technique

PATENCY RATE OF BRACHIOCEPHALIC VS RADIOCEPHALIC AVF IN CHRONIC KIDNEY DISEASE PATIENTS IN POPULATION OF D.I.KHAN DIVISION, PAKISTAN

Background: All patients with chronic renal failure need vascular access for hemodialysis that is possible with CVP line but it can be retained for only 02-03weeks due to infection. The most suitable and effective vascular access on long term basis is the creation of arteriovenous fistula (AVF). The objective of this study was to compare the patency rate of Radiocephalic vs Brachiocephalic AVFs in population of D.I.Khan division, Pakistan. Materials &amp; Methods: This randomized controlled trail was conducted in the surgical unit at District Headquarter Teaching Hospital D.I.Khan, Pakistan from January 2017 to January 2020. Two hundred and sixty six patients were randomly allocated by toss method into two groups, one for Brachiocephalic AVF (BCAVF) and second for Radiocephalic AVF (RCAVF). Sex &amp; patency rates were our nominal while age grouping was our ordinal variable. The data for the sample was described by count &amp; percentages &amp; was analyzed for the population as confidence interval at 80% confidence level. McNemar chi-square test was used to test hypothesis to compare the patency rate of Brachiocephalic AVF vs. Radiocephalic AVF at alpha 0.05 with Yates continuity correction using online statistical calculator. Results: The patency was present in 129 (97%, 80% CI 94.45-98.39%) cases &amp; absent in 4 (3%, 80% CI 1.61-5.55%) cases in Brachiocephalic AVF group while it was present in 107 (80.5%, 80% CI 76.04-84.86%) cases &amp; absent in 26 (19.5%, 80% CI 15.52-24.32%) cases in Radiocephalic AVF group. McNemar chi-square test showed p-value of &lt;.0001 (less than alpha). So, the null hypothesis was rejected, showing significant difference between two groups. Conclusion: Brachiocephalic AVF creation is more ideal in terms of patency and maturation as compare to Radiocephalic AVF because of increased vessel diameter and increased arterial pressure at proximal site below elbow joint.

Anesthetic effect of ultrasound-guided block of the musculocutaneous nerve during endovascular treatment of dysfunctional radiocephalic arteriovenous fistulas.

Delivering requisite and minimal anesthesia for endovascular treatment (EVT) of dysfunctional arteriovenous fistulas (AVFs) under the target nerve block can achieve reasonable analgesia. We evaluated the anesthetic efficacy of ultrasound (US)-guided selective block of the musculocutaneous nerve (MCN) during the EVT of runoff venous strictures in the forearm through the radiocephalic (RC)-AVF at the wrist or the anatomical snuff box and analyzed the factors inhibiting the analgesia achieved under the MCN block. We enrolled 30 adult patients undergoing hemodialysis who had received 78 EVT sessions in an outpatient clinic mainly for long and/or multiple outflow-venous strictures in the forearm under US-guided blocks of the MCN, which provides sensory innervation to the anterolateral forearm where the cephalic vein courses. We assessed patients' pain during balloon dilations using the Wong-Baker FACES® Pain Rating Scale (WBFRS) and evaluated the factors increasing the pain (WBFRS score ⩾4), including patient characteristics, dilated strictures, additional nerve blocks, and types of balloon catheters. In 25 EVT sessions (32.1%) out of 78 sessions, patients complained of stronger pain (WBFRS score ⩾4), while in the other 53 sessions (67.9%), presented with no pain and slight pain (WBFRS score = 0 or 2). Univariate analysis clarified that dilation of the AVF anastomosis, presence of dilated stenosis >4 cm, and a single block of the MCN or its sensory terminal significantly triggered more pain (p < 0.05). Consequently, multivariate analysis of all the factors with p < 0.1 in the univariate analysis, including multiple dilated stenosis sites, demonstrated that dilation of the AVF anastomosis significantly caused severe pain despite the anesthesia of the MCN block (p < 0.05). US-guided selective block of the MCN could be a leading anesthetic option for EVT for multiple long stenoses of the cephalic vein draining through the RC-AVF in the wrist or anatomical snuff box.

Intractable arteriovenous access-related pain relieved after a single, pain-free hemodialysis session under selective block of the sensory nerves in the upper limb: A psychosocial factorial case.

Intractable arteriovenous access (AVA)-related pain can not only lead to abandonment of a well-functioning AVA, but can also cause hemodialysis (HD) patients to be unwilling to accept, interrupt, or withdraw from HD. Such pain primarily derives from nociceptive and neuropathic factors caused by mechanical stimulation of needle cannulation; however, this might be related to psychosocial factors making it difficult for patients to accept their dependency on HD. Furthermore, the pain can be complicated by the interaction of biological and psychosocial factors, which hampers appropriate pain management and treatment. However, there have been few investigations pertaining to this matter. Herein, we describe the case of an HD patient who experienced chronic refractory AVA-related pain during a 32-month period of HD sessions, which occasionally caused treatment interruption. After clinical inquiry, physical evaluation, and ultrasonographic assessment of the blood circulation and cutaneous nerves in the ipsilateral upper limb to the radiocephalic arteriovenous fistula in the anatomical snuffbox, we diagnosed the patient with primarily psychosocially driven pain in consultation with an experienced pain clinician. A single, pain-free HD session under ultrasound-guided sensory nerve blocks in the upper limb markedly relieved her pain, followed by HD sessions with subtle but acceptable pain. This report provides insights into the mechanism underlying the vicious cycle of AVA-related pain, including the psychosocial aspects that might trigger such pain, as well as into the importance of treating such pain to improve the patient's quality of life, and underscores the need for cooperation of experts engaged in HD and pain management.