Subclavian Vein Access Research Articles

RF catheter ablation of AVNRT in a patient with interrupted inferior vena cava anomaly with hemiazygos continuity with persistent left superior vena cava

Intrahepatic interruption of the inferior vena cava (IVC) with continued hemizygous is a very rare abnormality and sometimes it may be accompanied by other cardiovascular abnormalities. Continuation of the hemizygous vein draining into the right atrium through the left superior vena cava (LSVC) is much rarer. In this paper, we have presented a patient who had simultaneous IVC interrupted with persistent LSVC and suffered from Atrioventricular nodal reentrant tachycardia (AVNRT). Finally, radiofrequencies (RF) catheter ablation for AVNRT was successfully performed through a left subclavian vein access.

Use of a Novel Three-Dimensional Model to Teach Ultrasound-guided Subclavian Vein Cannulation.

Central venous cannulation is an essential skill in perioperative and critical care medicine. Ultrasound guidance is the standard of care for femoral and internal jugular vein access, with the subclavian vein being perceived to be less amenable to ultrasound-guided (UG) insertion, resulting in a lack of procedural competency and low cannulation rate. There is a paucity of resources and a lack of experience among staff physicians to effectively instruct trainees. Simulation-based medical education has the potential to help maintain high-stakes, infrequently performed skills and counteract possible unrecognized skill decline. We aimed to create a novel, low-cost, high-fidelity three-dimensional (3D) model for UG subclavian vein (UG-SCV) access with an accompanying curriculum to improve this important skill. A curriculum was created consisting of preparatory material reviewing UG-SCV access, followed by an in-person didactic lecture focusing on ultrasound use and management of complications and a deliberate practice session scanning volunteers and practicing UG vascular puncture on a 3D model. A qualitative usability test design was used to assess the validity of the curriculum in trainees with advanced vascular access skills (anesthesiologists). Participants were second-year anesthesia residents, anesthesia fellows, and staff physicians. Focus groups conducted after each session explored the face validity of the model and curriculum. By applying a usability design, the curriculum was optimized and finalized. Between September 2020 and February 2021, 28 participants tested the curriculum. The focus groups ensured that the curriculum achieved its objective, with iterative changes made after each session in a quality improvement framework Plan-Do-Study-Act approach. After the third cycle, minimal changes were suggested, and the curriculum and 3D model were finalized. An additional group of participants was used to ensure that no new input would help improve the curriculum further. A focused curriculum for enhancing skills in UG-SCV cannulation usinga novel 3D model was successfully implemented and validated through a usabilitytest design. This curriculum is better targeted for practitioners experienced incentral venous access to master a subclavian approach and maintain their skill level.

Left Bundle Branch Pacing in a Child Who Survived Cardiac Arrest with Congenital Complete Heart Block and Recurrent Torsades de Pointes

A 2-year-old girl was referred to the Harapan Kita National Heart Center due to the return of spontaneous circulation after cardiac arrest, bradyarrhythmia and repeated seizures with loss of consciousness. She had been treated with an epilepsy drug for 1 year. Electrocardiography during one epilepsy episode showed complete heart block with junctional escape rhythm and QT interval prolongation, which then progressed to torsades de pointes. Echocardiography revealed left atrium and left ventricle dilatation with reduced ejection fraction. Left bundle branch permanent pacemaker was successfully implanted through left subclavian vein access. During the 3-week follow-up, there were no recurrent seizures and echocardiography revealed improvement of left ventricle ejection fraction.

P255 A GOOD PERSPECTIVE NEEDS TWO POINT OF VIEW: TRANSVENOUS CRT–D LEAD EXTRACTION COMPLICATED BY INTRAOSSEUS COURSE OF THE CORONARY SINUS LEAD

Abstract A 66 year old woman with dilated cardiomyopathy, carrier of CRT–D device in secondary prevention since 2013 and a mitralic mechanical prosthesis, suffered of CIED infection, confirmed by PET imaging exam. She was scheduled in our Hospital Unit for transvenous lead extraction. The procedure was performed by the subclavian approach, and the transvenous lead extraction was staged using mechanical telescopic sheats. After the extraction of the atrial and ventricular leads, the advance of the sheats was hampered by tenacious adherences along the site of vascular subclavian access of the coronary sinus lead. Firstly the portion of the lead running inside the coronary sinus was retracted with a pigtail by femoral vein approach. The inability to pass over the tenacious adherences at the point of the subclavian vein access were overcome expanding the surgical field with the help of the Vascular Surgeon, finding out that the adherence was determined by the presence of an osteophyte embracing the lead to the clavicle. The osteophyte was then surgically removed and the lead was finally extracted by jugular vein access. In this case the CIED leads were implanted using a intrathoracic subclavian venous access, where the vein lies behind the medial region of the clavicle. This approach could rarely lead to a periosteal penetration during needle advance that can generate osteophytes between the lead and the bone. In those circumstances the transvenous lead extraction could become extremely complicated, whatever technique is used.

Comparing the Utility of Landmark-Palpation Guided to Ultrasound-Guided Teaching Methodologies for Subclavian Central Venous Access Using a Formalin-Embalmed Cadaver Model.

Low-risk and realistic simulation strategies are needed to train clinical learners to perform hands-on invasive procedures. This follow-up study compares the utility of landmark-guided palpation-based to ultrasound-guided teaching techniques for subclavian central venous access using formalin-embalmed cadavers. The subclavian veins of 3 cadavers were imaged with ultrasound to evaluate vein patency before palpation-based venous access was attempted. Twenty-three first-year medical students were trained to access the subclavian vein using palpation-based techniques. Training involved ten minutes of didactic orientation and ten minutes of hands-on practical instruction using cadavers. Participant confidence was measured using a 10-point Likert scale on pre- and post-training questionnaires. Objective skills testing for each participant included quantifying the number of skin punctures and recording the time elapsed from first skin puncture to fluid flashback into the syringe. Data was analyzed using a generalized linear model (GLM) approach. Participant confidence significantly increased following training in both ultrasound and palpation training groups across all questionnaire items (P<0.001). The ultrasound group had fewer skin punctures (P<0.001) and fewer failures (1) than the palpation group (6). Participants in the ultrasound group were more confident than those in the palpation group in their ability to locate the vein and select the optimal site for needle access (P<0.05). Formalin-embalmed cadavers provide a safe, stress-free, and effective means by which to train students in subclavian vein access using both palpation and ultrasound-based techniques. Repeated practice accessing and aspirating fluid from a cadaveric subclavian vein significantly increases trainee confidence, an essential factor in physician performance that may lead to fewer complications. Introducing this type of low-risk and hands-on practice may be beneficial for trainees before they attempt subclavian vein access on live patients.

Feasibility and outcomes with subclavian vein access for crescent jugular dual lumen catheter for venovenous extracorporeal membrane oxygenation in COVID-19 related acute respiratory distress syndrome.

Femoral-femoral Veno-Venous ExtraCorporeal Life Support (V-V ECLS) has been associated with higher infections rates, vascular site bleeding complications, and restricted patient mobility. Jugular or bicaval dual lumen V-V ECLS conceptually overcomes some of these adverse factors, but experience has shown that jugular vein cannulation still limits mobility and has increased bleeding complications. Technique and outcomes of subclavian vein single-cannulation with Crescent jugular dual-lumen V-V ECLS is described. five patients with COVID-19 related acute respiratory distress syndrome (ARDS) underwent right subclavian vein V-V ECLS placement with the Crescent 32 French jugular dual-lumen V-V ECLS catheter. A standardized percutaneous technique was developed that allowed efficient insertion without need for any specialized imaging (i.e. transesophageal echocardiogram) and outcomes assessed. Mean age of the five patients was 41.2years, all obese with an average basal mass index of 45.2kg/m2 and mean days to decannulation of 24.2days. Outcomes discovered included; improved patient mobility allowing physical rehabilitation, no vascular access site related complications requiring surgery or endovascular intervention, and none had evidence of superior vena cava syndrome. One patient had subclavian/axillary vein thrombosis with resolution after 3months of direct-acting oral anticoagulants, and one patient had blood cultures positive at day 37, nearing decannulation. Subclavian vein access for crescent jugular dual lumen V-V ECLS catheter appears to be safe and feasible with added benefits of decreased bleeding and increased mobility over jugular or femoral-femoral access site for long term V-V ECLS support in COVID-19 related ARDS patients.

THE RETURN OF SUBCLAVIAN CANNULATION IN THE CRITICAL CARE SETTING: A WESTERN CRITICAL CARE EXPERIENCE

THE RETURN OF SUBCLAVIAN CANNULATION IN THE CRITICAL CARE SETTING: A WESTERN CRITICAL CARE EXPERIENCE

How to perform extrathoracic venous access for cardiac implantable electronic device placement: Detailed description of techniques

Venous access is needed for implantation of cardiac implantable electronic devices (CIEDs) with endocardial leads. Extrathoracic venous access in the prepectoral region has become the standard of care for CIED implantation because of lower risks for pneumothorax and likely less lead malfunction due to subclavian crush syndrome. The most common extrathoracic venous access sites in the pectoral region are extrathoracic subclavian vein access, axillary vein access, and cephalic vein access. This review provides a detailed description of the anatomy, technical considerations, and relative advantages and disadvantages of each of these extrathoracic venous access sites.

Subclavian venous catheterization: focused on the procedure

Central venous catheterization is a typical technique performed in the emergency department and intensive care unit. Most subclavian vein access may be inserted without help, using anatomic landmarks alone. This study aimed to present the precise procedure of central venous catheterization via the subclavian vein and endovascular techniques using a simulation video clip.

PO-707-08 ANTIDROMIC LEFT PERICARDIOPHRENIC VEIN ACCESS FOR DEPLOYMENT OF A PHRENIC NERVE STIMULATOR: LESSONS LEARNED FROM COMPLEX CORONARY SINUS LEAD IMPLANTATION

Left pericardiophrenic vein (PPV) access is required to deploy over-the-wire phrenic nerve stimulator leads for implantable sleep apnea therapy devices. Coursing along the left lateral aspect of the pericardium, the left PPV is accompanied by the left phrenic nerve and terminates superiorly at the left brachiocephalic vein (BCV) and inferiorly at the left inferior phrenic vein. A superior approach may be complicated by congenital atresia, tortuous anatomy, or iatrogenic dissection. We report a novel approach to PPV access using retrograde wire externalization and antidromic lead placement derived from complex coronary sinus (CS) access techniques. Recognize techniques for complex vascular access for phrenic nerve stimulators and cardiac implantable electronic devices (CIED). The right chest was prepared for subclavian vein access and pre-pectoral generator implant. A 7 French (Fr) delivery sheath and inner 5 Fr Merit CS vertebral vein selector were used to engage the left BCV. Contrast angiography and a 0.014 mm angioplasty wire were used to identify the PPV. Repeated attempts to engage the tortuous vein were associated with proximal dissection. An alternative approach with inferior PPV access was selected. The sheath and vein selector were positioned within the left hepatic vein and the left phrenic vein for angiography. The angioplasty wire was advanced retrogradely into the PPV and left subclavian vein followed by an additional support wire. A separate 7 Fr sheath was placed in the right subclavian vein and a 4 Fr snare was used to secure and externalize the distal angioplasty wire. The wire was used as a rail to advance the phrenic nerve stimulator anterogradely into the PPV. Lead deployment was successful and phrenic nerve stimulation thresholds were satisfactory. Antidromic posterolateral cardiac vein access has been well described for complex coronary sinus lead implantation. The technique may be applied to extracardiac vascular anatomy for challenging PPV lead implantation. This case highlights the technical expertise and anatomical familiarity needed to optimize cardiac implantable electronic device implantation.

Advancing Point-of-Care Ultrasound Training in Medical Schools: Ultrasound-Guided Subclavian Vein Access Training Using Formalin-Embalmed Cadavers.

OBJECTIVES:This brief report examines the feasibility of using formalin-embalmed cadavers in training medical students to use ultrasound guidance to access the subclavian. This novel educational approach is discussed in the context of the ongoing integration of point-of-care ultrasound training into medical education. Additionally, this report explores how cadavers can provide practical, effective, and hands-on skills training opportunities for medical students to learn to perform common clinical procedures under ultrasound guidance.DESIGN:This report presents subjective and objective data evaluating the utility of teaching medical students to perform ultrasound-guided subclavian vein access on formalin-embalmed cadavers.SETTING:Rocky Vista University College of Osteopathic Medicine in Ivins, UT.SUBJECTS:Twenty-five first-year medical students at Rocky Vista University.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Pre and posttraining questionnaires were administered to assess each participant’s self-confidence in using ultrasonography to access the subclavian vein of a cadaver. A statistically significant increase in participant self-confidence was observed across all questionnaire items from pre to posttraining. Objective evaluation consisted of a supervised skills test. Participants were evaluated on their ability to visualize the subclavian vein with ultrasound and achieve flashback of blood/embalming fluid into a syringe. During skills testing, the number of needle sticks and the time taken to achieve flashback were recorded for each participant. Twenty-three of the 25 participants were able to successfully complete the skills testing assessment.CONCLUSIONS:The formalin-embalmed cadaver can be a readily available and effective learning tool for medical education programs seeking to provide training opportunities in ultrasound-guided clinical procedures. The use of cadavers allows learners to train in a low stress and anatomically authentic environment without risk of patient discomfort.

P2. FAT GRAFT PULMONARY EMBOLISM: IN FAVOUR OF A LYMPHATIC ROUTE

PURPOSE: Fat Pulmonary Embolism Syndrome (F-PES) complicates high-volume fat grafting. Adipocyte disruption generates triglyceride (TGC) oil dispersed in lipoaspirate (lipocrit). TGC plasma concentration ([TGC]p) was compared with lipocrit during liposuction-lipografting procedures. 1 buttock grafting case suffered a F-PES that required ICU support. METHODS: n=27 (19 breast, 8 buttocks) lipocrit recorded and ([TGC]p) measured in peripheral blood samples preoperatively, intra and 24h postoperatively. F-PES patient underwent right subclavian vein access (SVC) and Inferior Vena Cava (IVC) at ICU admission RESULTS: Lipocrit (200-600 cc graft volume) ranged 19-27%.Peripheral [TGC]p pre-, intra- post- and at 24h displayed no significant differences for all cases. In the F-PES case, SVC drawn [TGC]p was 7-fold higher than that from simultaneously drawn IVC or peripheral samples and returned to normal peripheral levels 48 h later. These unexpected data prompted measurement of:Critical Micelle Concentration (CMC) of fat graft oil when mixed in either lymphatic (chylous, CMCc) or plasmatic (CMCp) fluids. CMCp was consistently higher than CMCc (CMCc=110 mg/dL, CMCp=320 mg/dL, n=17, P<0.001).Interstitial Pressures (IP) both intramuscular (im) and subcutaneous (sc) at recipient sites. IPsc raised to pressures below 50 mmHg and returned to baseline within 24 h. IPim raised above 50 mmHg and persisted CONCLUSION: F-PES appears associated to increased [TGC]p detectable at the SVC only. TGC micelle formation is thermodynamically adverse in plasma versus chyle, suggesting a preferential lymphatic uptake of grafted oil at the recipient site. This lymphatic uptake could be favored when graft oil is implanted im, where IP-im reach pressures that prevent venous drainage.

EP News: Case Reports

Left bundle branch area pacing is a promising new approach to physiological pacing. As electrophysiology procedures are trending toward less fluoroscopy dependence, there is a need to explore approaches to perform this form of pacing without fluoroscopy guidance. Coluccia et al (https://doi.org/10.1016/j.hrcr.2021.12.019) shared a case of an 84-year-old man with symptomatic paroxysmal atrioventricular block. Subclavian vein access was performed without fluoroscopic and ultrasound guidance. A steerable decapolar diagnostic catheter was introduced to create anatomies of the caval vessels, right atrium and ventricle, and coronary sinus.

Pacemaker implantation using electroanatomical mapping system Carto 3: technical protocol, single centre experience

Abstract Funding Acknowledgements Type of funding sources: None. Background / Purpose: Three-dimensional electro-anatomical mapping systems (EAM) reduce fluoroscopy exposure during ablation procedures. The aim of this study is to evaluate the security and feasibility of performing pacemaker implantation with EAM routinely on a more regular basis (without fluoroscopy) and to draft a technical protocol to perform these implants. Methods Eight non-selected patients with pacemaker indication that had been referred to the electrophysiology unit of our institution underwent a dual chamber pacemaker implantation with EAM system Carto 3 (Biosense Webster, Irvine, CA, USA). All implants were performed by the same operator and, in all cases, the same lead model was employed. All difficulties that arose during the implantations were solved applying the actions contained in the protocol described below. First - Creation of three anatomical maps with Carto 3: venous access, right atrium and right ventricle. Annotate the end of the venous sheath. Second- For right ventricle lead positioning, connect the pacemaker lead to the Carto 3 system as an external catheter. Place the right ventricle lead, fix it and perform measurements. Third - Fuse the three maps with the "anatomical merge" tool. Fourth - Using the "design line" tool, draw a line from the tip of the lead to the end of the venous sheath following the expected trajectory of the lead in its correct position. Measure that distance. Calculate (substrate) the theoretically remaining lead. Fifth - With a ruler, measure the portion of the lead remaining out of the sheath. Sixth - Reposition the lead, if necessary. Seventh - Repeat the same procedure for the atrial lead and complete the implant procedure. Finally - Verify leads position with fluoroscopy (optional). Results : Eight patients received a dual chamber pacemaker, 75% male with a mean age 82,88 ±4,97 years. The most frequent indication was AV block (75%). The implant was performed through cephalic vein access (37,5%), subclavian vein access (50%). Mean procedure time (skin to skin) was 94 ±15 minutes. There were no complications related to the implant nor was it necessary to replace the lead. Conclusions : Pacemaker implantation with Carto 3 is a safe and reliable. The learning curve is not steep and the operator should be confident enough only after a few procedures. The protocol developed facilitates the implant procedure. Fluoroscopy timeCase12345678Fluoroscopy time (s)474786246060Dose area product (Gy*cm2)4,270,3710,0290,0630,0630,020,1230,018Abstract Figure. Carto image: dual chamber pacemaker.

Preferential central venous catheter access with concurrent IVC filter use.

In our aging population, there is an increased incidence of concurrent IVC filter and central venous catheter use. One of the risks of concurrent use is filter embolization, which almost always occurs due to the J-tipped guidewire. In this case, we describe the successful placement of a central venous catheter in the femoral vein in a patient with an IVC filter. Some guidelines exist concerning CVC placement in patients with IVC filters, and this case highlights the benefits of placing a CVC in the femoral vein. While little research exists regarding higher rates of IVC filter embolization in internal jugular and subclavian vein access sites, we hypothesize it is due to the conical shape of IVC filters.

Technical factors and outcomes in pediatric central venous port placement

Purpose While central venous port placement is common, there remains variation in placement technique and rates of technical complications. The aim of this study was to assess variability in techniques and identify predictors of complications for children undergoing port placement.Methods We retrospectively reviewed all 331 patients who underwent venous port placement at a single tertiary children's hospital from May 2018 to June 2020. The primary outcome was early revision or replacement (R/R) for complications occurring within 30 days. Secondary outcomes included radiation exposure and rate of intraoperative conversion to a secondary site.Results The median age was 7 years (Interquartile Range 3–13 years) and the most common diagnoses were leukemia (30.2%), solid tumors (27.8%), and brain tumors (16.9%). Initial approach for port placement was ultrasound-guided internal jugular (IJV) in 255 (147 by surgery and 108 by interventional radiology [IR]) and landmark subclavian vein (SCV) in 76 (all by surgery). Early R/R occurred in 5.1%, including 9.0% of patients with leukemia but 1.1% with solid tumors. Individual proceduralist volume ranged from 2 to 98 cases and was inversely correlated with early R/R (r = -0.12, p = 0.30). In univariate analysis, ports placed by IR had an increased rate of early R/R (9.3%, n = 10) compared to those placed by surgery (3.2%, n = 7, p = 0.036) but this was not significant in multivariable regression controlling for diagnosis and age (Hazard Ratio 2.04; p = 0.19). Mean fluoroscopy time was significantly longer for ports placed by IR (59.9 s) compared to those placed by surgery (15.1 s, p < 0.001). Initial SCV access was associated with an increased (14.5 vs 0.4%) rate of conversion to a secondary site.Conclusions Though venous port placement is a largely safe procedure in children, a substantial minority of patients, particularly those with leukemia, require early R/R. Proceduralist volume and training may influence early R/R, fluoroscopy exposure, and anatomic site preferences.

Intermittent Pacemaker Malfunction Caused by Continuous Compression of the Lead by the Clavicle (Subclavian Crush Syndrome).

Subclavian vein access is still one of the most favoured access options for cardiac implantable electronic device (CIED) implantation. For the physician, the technique is reasonably familiar and easy to carry out. However, this has several potential complications. In this case, we present a late complication of subclavian access. The patient presented with intermittent loss of pacemaker output, which caused him to experience several syncopal events. In the acute setting, we changed the lead polarity and achieved a good outcome. Further management of this situation consisted of removal and replacement of the damaged lead.LEARNING POINTSSubclavian vein access is still one of the most favoured access options for cardiac device implantation.Intermittent loss of output can be a sign of pacemaker malfunction due to subclavian crush syndrome.Damaged lead extraction may be difficult to perform.

Cephalic vein approach for the implantable central venous access: A retrospective review of the single institution's experiences; Cohort Study.

Long-term venous access is usually required in patients receiving chemotherapy. We hypothesized that, out of the various central line approach techniques, the cephalic vein cut-down technique can be a safe and simple alternative in terms of surgical safety, feasibility, cost-effectiveness, and functional outcomes.We retrospectively reviewed the medical records of 569 patients who underwent implantable central venous access between January 2012 and December 2014 at our hospital.We classified our cohort according to access routes, as follows: 230 patients underwent subclavian vein access, 134 patients underwent internal jugular vein access, 25 patients underwent external jugular vein access, and 119 patients underwent cephalic vein access. The cephalic vein group had a significantly longer operation time than the subclavian group (P < .01); however, there was no difference in operation time between the internal jugular vein and cephalic vein groups (P = .59). The procedure-related complications and functional outcomes of the implanted venous port during chemotherapy were comparable between the cephalic group and other groups. Additionally, body mass index, operation time, and age did not correlate with catheter dysfunction in the multivariate logistic regression analysis (P = .53; P = .66; P = .19, respectively).We suggest that a cut-down central venous catheter insertion through the cephalic vein can be performed easily and safely with no differences in surgical and clinical outcomes compared to those of conventional percutaneous approaches. Moreover, the cephalic vein approach requires no specialized equipment, including percutaneous vascular kits, tunneling instruments, and intraoperative ultrasonography. Therefore, this technique might incur less medical expenses than conventional approaches and would be helpful for both patients and surgeons.

Creating arteriovenous fistulas for children in Guatemala

ObjectiveThe Guatemalan Foundation for Children with Kidney Diseases was established in 2003 as the first and only comprehensive pediatric nephrology program and hemodialysis unit in Guatemala. Bridge of Life (BOL) is a not-for-profit charitable organization focused on chronic kidney disease and supplied equipment, training and support during formation of the hemodialysis unit. Pediatric permanent vascular access (VA) expertise had not been established and noncuffed dialysis catheters provided almost all VA, many through subclavian vein access sites. BOL assistance was requested for establishing a VA surgical program, resulting in recurring BOL surgical missions to create arteriovenous fistulas (AVF) in these children. This study analyzes the BOL pediatric VA missions to Guatemala. MethodsThree surgical pediatric VA missions were conducted in Guatemala from 2015 to 2017. Each mission was led by two or three surgeons. All supplies and equipment (including ultrasound units) were taken as part of each mission. The BOL surgical VA mission teams work with local pediatric surgeons, pediatric nephrologists, and dialysis nurses to establish collegial relationships and foster teaching interactions. We retrospectively reviewed the patient demographic data, procedures, and outcomes for these missions. ResultsAVFs were created in 54 new pediatric patients. Ages were 8 to 19 years (13.4 ± 2.8 years) and 29 patients (54%) were male. Patient weights were 28 to 50 kg (30.8 ± 8.3 kg) with body mass indexes of 12 to 25 kg/m2 (17.9 ± 2.9 kg/m2). Radiocephalic AVFs were created in 21 children (39%), proximal radial artery AVFs in 12 (22%). and brachial artery inflow AVFs in 5 (9%). Sixteen patients (30%) required transpositions and one a translocation; two of these were femoral procedures. Primary and cumulative patency rates were 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. The median follow-up was 17 months. Interventions with fistulagram and balloon angioplasty options were not available for AVF dysfunction or access salvage during the study period. However, six patients underwent an AVF revision and salvage during subsequent missions or by one of the Guatemalan surgeons (R.S.). Four individuals underwent successful transplantation during the study period. There were no operative deaths or major complications. ConclusionsPediatric VA missions to Guatemala created safe and functional AVFs in concert with local pediatric surgeons and pediatric nephrologists. Three surgical missions included access operations in 54 new patients. Cumulative AVF patency was 85% at 36 months.

AIUM Practice Parameter for the Use of Ultrasound to Guide Vascular Access Procedures.

AIUM Practice Parameter for the Use of Ultrasound to Guide Vascular Access Procedures.