Vascular Access Construction Research Articles

Outcomes of two different polytetrafluoroethylene graft sizes in patients undergoing maintenance hemodialysis

Arteriovenous access creation is mandatory for maintenance hemodialysis. If native fistula placement was not possible or failed, a prosthetic conduit would be the best substitute. The purpose of this prospective study was to compare outcomes of two different sizes of polytetrafluoroethylene (PTFE) grafts, in hemodialysis patients, at the Mustafa Khomeini Hospital in Iran. The study population consisted of 586 end-stage renal disease referrals for vascular access construction (January 2003 to January 2007) of which eventually 102 subjects were candidates for PTFE graft who were followed for one year. Data were collected by a questionnaire and analyzed using the SPSS, life table, Kaplan- Meier and Log-Rank tests. Out of 102 PTFE implantation candidates (mean value of age 51.7 ± 17.06 yrs), 56% were male and 44% female. PTFE grafts of 8 mm and 6 mm sizes were randomly placed in 57 and 45 subjects, with distribution of 83%, 12% and 5% in arm, forearm and thigh. The most underlying diseases were hypertension and diabetes. There was a significant difference in complication rates between patients with and without underlying diseases [42% vs. 10% (P = 0.03)]. One-year patency rates were 42.2% and 36.5% for 6 mm and 8 mm grafts and 28.2% vs. 52% in patients with and without underlying diseases respectively. Despite more complication frequency in 8 mm grafts, the patency and complication rates of two graft groups did not significantly differ. Hypertension and diabetes could have contributory roles in graft complication rate, which may be preventable. Non-tapered grafts of 6 mm and 8 mm sizes have not significant different outcomes. Further research is recommended with larger sample size and longer duration.

Axillary loop grafts for hemodialysis access: Midterm results from a single-center study

This study reports our midterm results with arteriovenous axillary loop grafts (AVALG) and evaluates their role in construction of vascular access for patients on chronic hemodialysis. The clinical data of 27 patients who underwent construction of an AVALG for hemodialysis access at our institution between July 2002 and December 2006 were analyzed retrospectively. Outcome measures included graft patency, the complication rate, and the frequency and morbidity of secondary procedures after AVALG creation. The Kaplan-Meier method was used to calculate the primary and secondary patency curves. AVALG was constructed as the first access procedure in eight patients: five patients with no suitable vein to construct an adequate angioaccess on the upper limbs, and three patients with elbow and forearm arteritis. The 19 other patients had all had two to five failed prior vascular accesses leading to exhaustion of venous access sites on the upper extremities (18 cases), or a steal syndrome (one case). No postoperative death occurred, but four patients died of causes unrelated to the intervention between the second and the tenth postoperative months. The mean follow-up was 15 months (range, 2-48 months). The primary patency rate at 12 months and the secondary patency rate at 18 months were 51% and 80%, respectively. Infection (three cases), thrombosis (seven cases), and stenosis of the outflow vein (two cases) were the main complications, occurring in 10 of the 27 patients (41%). Twelve secondary procedures were performed in these 10 patients with little additional morbidity. Five of the 27 patients developed irreversible AVALG occlusion leading to access loss: two patients with concomitant graft infection and three patients with a history of subclavian vein catheterization. AVALG may represent a supplementary option for chronic hemodialysis patients with vascular steal or inadequate upper extremity venous access sites.

Mid-thigh Arteriovenous Graft in Lower Extremity Vascular Access Construction for Hemodialysis Patients

Patients who receive dialysis rely on vascular access. With advances in hemodialysis technique and dialysis service, the lifespan of patients has increased, but the sites of arteriovenous access in the upper extremities are exhausted after long-term use. In this situation, lower extremity arteriovenous graft is a popular choice by using the common femoral artery over the groin area. Unfortunately, the long-term patency rate is not satisfactory in lower extremity loop graft and there is a high infection rate. We investigated the feasibility of constructing arteriovenous access at the mid-thigh level when the upper extremity vessels are exhausted. [ Hong Kong J Nephrol 2007;9(2):86–8]

2005 Japanese Society for Dialysis Therapy Guidelines for Vascular Access Construction and Repair for Chronic Hemodialysis

The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Dr Ohira, has published an original Japanese guideline, 'Guidelines for Vascular Access Construction and Repair for Chronic Hemodialysis'. The guideline was created mainly because of the existence of numerous factors characteristic of Japanese hemodialysis therapy, which are described in this report, and because we recognized the necessity for standardization in vascular access-related surgeries. This guideline consists of 10 chapters, each of which includes guidelines, explanations or comments and references. The first chapter discusses informed consent of vascular access (VA)-related surgeries, which often resulted in trouble between dialysis staff and patients. The second chapter describes the fundamentals of VA construction and timing of the introduction of hemodialysis with emphasis on the avoidance of catheter indwelling if at all possible. In the third chapter, arteriovenous fistula (AVF) construction and management are discussed from the viewpoint of the most preferable type of VA. The fourth chapter deals with arteriovenous grafts (AVG) which has recently increased in clinical applications. The factors which improve the AVG patency rate are discussed and postoperative management methods are emphasized to avoid possible complications. The fifth chapter deals with short and long-term vascular catheters. It is emphasized that these methods are definitely effective but, at the same time, are apt to be associated with several serious complications and might result in vascular damage. In the sixth chapter, superficialization of an artery is explained. This was originally for emergency use or backup but has been used permanently in 2-3% of Japanese hemodialysis patients. In the seventh chapter, methods for the use of VA are described and the buttonhole method is referred to as one of the options for patients who complain of intense pain at every cannulation. In the eighth chapter, the importance of continuous monitoring is stressed for maintaining appropriate function of VA. As a rule, the internal shunt type VA (AVF, AVG) places a burden on cardiac function. Thus, in the ninth chapter, it is stressed that VA construction, maintenance and repair should always be carried out with consideration of cardiac function which is not constant but variable. The 10th chapter forms one of the cores of this guideline and deals with repair and timing of VA. It is shown how to select a surgical or interventional repair method. In the final 11th chapter, VA types and resultant morbidity and mortality of hemodialysis patients are reviewed.

Guidelines of vascular access construction and repair for chronic hemodialysis 1

Guidelines of vascular access construction and repair for chronic hemodialysis 1

Guidelines of vascular access construction and repair for chronic hemodialysis 4

Guidelines of vascular access construction and repair for chronic hemodialysis 4

Guidelines of vascular access construction and repair for chronic hemodialysis 3

Guidelines of vascular access construction and repair for chronic hemodialysis 3

Guidelines of vascular access construction and repair for chronic hemodialysis 2

Guidelines of vascular access construction and repair for chronic hemodialysis 2

Guidelines of vascular access construction and repair for chronic hemodialysis 5

Guidelines of vascular access construction and repair for chronic hemodialysis 5

Guidelines of vascular access construction and repair for chronic hemodialysis 6

Guidelines of vascular access construction and repair for chronic hemodialysis 6

Cost of renal replacement therapy in Turkey.

By the end 2000, 22224 patients were on renal replacement therapy (RRT) in Turkey. We investigated the cost of RRT in three medical faculties and one private dialysis centre. Yearly expenses were US dollars 22759 for haemodialysis (HD), US dollars 22350 for continuous ambulatory peritoneal dialysis (CAPD), and US dollars 23393 and US dollars 10028, respectively, for the first and second years of transplantation (Tx). In the first year, renal Tx was significantly more expensive than CAPD. However, after the first year of renal transplantation, Tx became significantly more economical than both CAPD and HD. The sum of all yearly RRT expenses for the country was US dollars 488958709, which corresponds to nearly 5.5% of Turkey's total health expenditure. Measures such as early construction of vascular access, promoting home dialysis and the reuse of the dialysers, strict control of the use of some expensive drugs like erythropoietin and active vitamin D, and also increasing the number of transplantations, especially if pre-emptive transplantation is possible, should be taken into account in order to reduce these expenses.

Superficialization of the wrist native arteriovenous fistula for effective hemodialysis vascular access construction

It is commonly known that the best type of vascular access for chronic hemodialysis, defined as the one with the lowest number of complications and longest use, is the primary (Brescia-Cimino) radiocephalic fistula. One reason for the impossibility of its creation is that the vein vessel on the forearm is located too deeply, which is primarily caused by the patients' obesity. In 24 obese patients the superficialization procedure of the venous part of fistula under the skin was performed. In 23 patients of this group, an easy and uncomplicated fistula puncturing was achieved. One patient had the complication of fistula clotting. Subcutaneous transposition of the arterialized median antebrachial vein is a simple and effective method of an adequate distal native fistula creation in patients with deeply located forearm veins.

The utility of the VCS clip for creation of vascular access for hemodialysis: long-term results and intraoperative benefits

The purpose of this study was to compare the effectiveness of the VCS ® vascular clip approximating system for the creation of hemodialysis access fistulas. 173 new vascular accesses were created, 92 prosthetic grafts and 81 autologous fistulas over a 40-month period. 50 sutured and 42 clipped fistulas comprised the prosthetic graft series, and 33 sutured and 48 clipped cases the autologous series. Risk factors associated with access patency were correlated and the primary patencies compared in the suture versus clipped group. A significant improvement in primary patency was noted for the clipped prosthetic group at all time points studied, with a positive trend also noted for clipped autologous fistulae. Conclusions: The vascular clipping system (the VCS system) provides both long-term and immediate advantages for vascular access construction. Clips have been used successfully to treat seven consecutive patients with upper extremity arterial steal syndrome without the technical difficulties associated with traditional methods of repair.

Clinical experience with the expanded polytetrafluoroethylene vascular prosthesis.

Expanded polytetrafluoroethylene grafts were used in 44 patients in the last 18 months. In 13 patients the graft was used for various types of peripheral vascular reconstructive procedures, as a substitute of the autogenous saphenous veins. In 31 patients the prosthesis was used for the construction of vascular access for hemodialysis. Results of the use of this new vascular prosthesis are comparable to those achieved with the autogenous saphenous vein when used for the same purposes. A much longer period of observation is necessary before a definitive verdict can be reached on the safety and clinical applicability of any new vascular prosthetic material. But preliminary clinical results with the PTFE vascular prosthesis are encouraging and seem to justify continued cautious application of this vascular substitute.