Vascular Access In Patients Research Articles

Peculiarities of Arteriovenous Prosthesis Functioning in Patients on Hemodialysis

Long-term and proper functioning of vascular access is necessary for renal replacement therapy in patients with chronic kidney disease (CKD). If it is impossible to form an arteriovenous fistula due to a pathologically changed structure of the vascular wall of peripheral arteries and veins, an arteriovenous prosthesis of various locations is implanted to form a permanent vascular access. However, the problem of long-term use of arteriovenous prostheses remains relevant, in particular, due to the prevalence of hemodynamic disorders, such as thrombosis, stenoses, and pseudoaneurysms.
 The aim of the study was a retrospective analysis of hemodynamic disorders and peculiarities of the use of arteriovenous prostheses as permanent vascular access in patients undergoing hemodialysis therapy.
 There were analyzed 586 medical records of inpatients and 103 discharge epicrisis of outpatients of the intensive nephrology department. Out of the 467 primary permanent vascular accesses formed for renal replacement therapy, 391 (83.72%) ones – were native arteriovenous fistulas (AVF) and 76 (16.27%) – were arteriovenous prostheses (AVP).
 It was found that the increase in the frequency of initial uncorrected and corrected primary loss of vascular access for AVF is the greatest during the first year of use and amounts to 35.53% and 26.32% of cases, respectively. Instead, the greatest increase in secondary loss of patency is observed during the first six months of using prostheses, which corresponds to 10.53% of patients. It is worth paying attention to the problem of concomitant pathology, in particular diabetes mellitus, arterial hypertension, calcification disease, which directly affect the state of the vascular wall and the functioning effectiveness of the vascular access. The obtained results indicate the necessity to review and supplement the existing methods of prevention of hemodynamic disorders of AVF during the first 6-12 months of their use in order to improve the quality of patients’ lives.

Percutaneous Placement and Management of High-flow Catheter for Hemodialysis: The Case for DualCath, Two-tunneled, Single-lumen Silicone Catheters

Abstract Introduction: Tunneled central venous catheters (CVCs) are often regarded as the final choice for vascular access in patients needing extracorporeal renal replacement therapy due to their higher morbidity, lower performance, and increased cost. The inherent limitations of tunneled CVCs have been recognized and extensively analyzed in numerous studies. Materials and Methods: The objective is to offer a comprehensive technical note on the percutaneous placement and management of high-flow DualCath (DC) for hemodialysis, involving the simultaneous insertion of two tunneled single-lumen silicone catheters through a single skin incision and vein puncture. In addition, we aim to summarize the results derived from our extensive clinical experience. Results: This 20-year study involved the placement of 1035 DC devices. The main indications were end-stage kidney disease in 859 cases, acute kidney injury in 50 cases, and miscellaneous purposes in 30 cases. Most of the insertions were in the internal jugular vein, with varying dwell times averaging 213 ± 335 days. In total, the DC devices were used for 594 patient-years. Conclusion: DC can be placed using a minimally invasive percutaneous method in both chronic and acute settings, showcasing its exceptional versatility. The design and geometry of the two silicone cannulas are precisely tailored to meet the needs of clinicians, focusing on achieving optimal flow performance, and ensuring adequate dialysis.

Outcomes of a Comprehensive Ultrasound Guided Peripheral IV Insertion (USGPIV) Training Program in a Pediatric Emergency Department

IntroductionTimely and reliable peripheral intravenous cannulation is an imperative skill in a pediatric emergency department. Utilization of point-of-care ultrasound guidance has proven to significantly improve first-attempt peripheral intravenous cannulation insertion rates in pediatric patients. We sought to develop, implement, and evaluate an ultrasound-guided peripheral intravenous training program for emergency nurses in a tertiary care pediatric center. MethodsTwelve emergency nurses underwent a training program that consisted of an interactive asynchronous learning module followed by 8 hours of training by a vascular access clinical instructor. Data was collected on each ultrasound-guided peripheral intravenous insertion via survey methodology. ResultsComplete data for a total of 210 ultrasound-guided peripheral intravenous were recorded over the 9-month period. A total of 65.2% (137/210) of patients who received an ultrasound-guided peripheral intravenous had known difficult intravenous access on history. A total of 89.5% (188/210) of patients had a difficult intravenous access of ≥4. The mean difficult intravenous access score for the patients in which ultrasound-guided peripheral intravenous insertions were attempted was 4.78 (95% confidence interval, 4.55-5.01). A total of 193 of 210 (91.9%) of ultrasound-guided peripheral intravenous were attained successfully. On the first attempt, 86.5% (167/193) ultrasound-guided peripheral intravenous were attained, and 98.96% (191/193) were attained within the first 2 attempts. ConclusionWe found that implementing a comprehensive ultrasound-guided peripheral intravenous training program for emergency nurses in a pediatric tertiary care center led to a high first-pass success rate in attaining peripheral intravenous cannulations. It also facilitates vascular access in patients with known difficult intravenous access. Consideration should be made to implementing point-of-care ultrasound intravenous training programs to improve pediatric vascular access in the emergency department, particularly in patients with known difficult intravenous access.

Epidemiological study of vascular access in patients undergoing hemodialysis in Attica

Introduction: Hemodialysis is the most common therapy for final stage of the chronic kidney failure. Vascular access is the link between the patient and the machine and the dialyzer so that hemodialysis can be applied effectively. Although huge technological advances have been made, vascular access is still the weak link in treatment. Aim: The determination of the percentages and the type of vascular access carried by patients undergoing hemodialysis in Attica in a statistically significant examined population. Correlation of quality of life, levels of physical activity, the effect of early referral of patients to a nephrologist. Methods: A non-experimental synchronous study was performed where initially the studied population was selected and then the information regarding the determinant and the disease at a specific time was obtained and conducted in hemodialysis units of the public and private sector of Attica. Questionnaires were used for data collection: a) measuring quality of life, b) measuring fatigue c) measuring restless legs syndrome. The statistical program SPSS 22.0 was used for the analysis. Results: In 63.4% of the examined population, vascular access was created with arteriovenous anastomosis (AFA). More than half of the patients visited early a nephrologist before initial hemodialysis session with a rate of 66.2%. Most of those who had AFA visited a nephrologist early. There was a significant difference in the fatigue score depending on the type of vascular access. In the analysis of the dimensions of the quality-of-life scale, it was found that the type of vascular access and previous vascular accesses are related to dimensions of quality of life. Conclusion: It seems that patients who visited a nephrologist in time before initial hemodialysis session had increased rates of AFA and a better score in terms of quality of life. Fatigue was associated with the type of vascular access. The need for National registry system of vascular access seems to help the scientific community in extracting useful scientific data.

Balloon-Targeted Extra-Anatomic Sharp Recanalization Technique to Re-establish Supraclavicular Vascular Access

A balloon-targeted extra-anatomic sharp recanalization (BEST) technique was investigated to re-establish supraclavicular vascular access in patients with central venous occlusion. Query of the authors’ institution’s database yielded 130 patients who underwent central venous recanalization. Of these, a retrospective review of 5 patients with concurrent thoracic central venous and bilateral internal jugular vein occlusions who underwent sharp recanalization using the BEST technique from May 2018 to August 2022 was performed. Technical success was achieved in all cases without major adverse events. Four (80%) of the 5 patients underwent hemodialysis reliable outflow (HeRO) graft placement using the newly established supraclavicular vascular access.

Evaluation of a Point-of-care ultrasound (POCUS) workshop for peripheral intravenous cannulation

BackgroundPoint-of-care ultrasound (POCUS) is increasingly used as a non-invasive vascular access assessment method by clinicians from multiple disciplines worldwide, prior and during vascular access cannulations. While POCUS is a relatively new method to establish a vascular access in patients with complex vascular conditions, it is also essential to train and educate individuals who are novices in the techniques of cannulation so that they become proficient in performing this task subsequently on patients safely and successfully. A simulated environment may be a helpful tool to help healthcare providers establish skills in using POCUS safely and may also help them to successfully establish vascular access in patients. With this project, we sought to determine if participants of a simulated POCUS workshop for vascular access can use this technique successfully in their individual clinical environment after their attendance of a half-day workshop.MethodsA mixed-methods longitudinal study design was chosen to evaluate a point-of-care ultrasound workshop for peripheral intravenous cannula insertion. The workshops used simulation models for cannulation in combination with multiple ultrasound devices from various manufacturers to expose participants to a broader variety of POCUS devices as they may also vary in different clinical areas. Participants self-assessed their cannulation skills using questionnaires on a 10-point rating scale prior to and directly after the workshop.ResultsA total of 85 Individuals participated in eleven half-day workshops through 2021 and 2022. Workshop participants claimed that attending the workshop had significantly enhanced their clinical skill of using ultrasound for the purpose of cannulating a venous vessel. The level of confidence in using this technique had increased in all participants directly after conclusion of the workshop.ConclusionsGlobally, clinicians are increasingly using POCUS to establish vascular access in patients, and it is necessary that they receive sufficient and adequately structured and formal training to successfully apply this technique in their clinical practice. Offering a workshop which uses simulation models in combination with various POCUS devices to demonstrate this technique in a hands-on approach has proven to be useful to establish this newly learned skill in clinicians.

#3226 DEVELOPMENT AND USABILITY ASSESSMENT OF AN AI-ENHANCED DASHBOARD SUPPORTING AVF MANAGEMENT IN CLINICAL PRACTICE

Abstract Background and Aims Despite the rise in publications reporting Artificial Intelligence (AI) solutions in healthcare, their usage in clinical practice remains limited. Prominent barriers for their implementation in clinical practice are the lack of integration of AI-based tools in the hospital health information system and clinical workflows. We previously developed an AVF Failure risk score to assess the expected incidence of AVF failures within 3 months based on routinely collected dialysis data. The risk score showed high accuracy (AUC = 0.81) and calibration. Based on this risk score, we developed an AI-enhanced dashboard supporting the management of AVF in hemodialysis patients. The usability and usefulness of the AI-enhanced AVF management dashboard was evaluated in a pilot quality improvement program. Method A quality improvement framework was used to evaluate the usability of an AI-enhanced dashboard for AVF management (Fig. 1A). First, healthcare professionals (HCP) were involved to provide inputs for model design, endpoint definition, and potential predictors through various qualitative interview techniques such as brainstorming sessions and focus groups (Phase I). A machine learning model was then developed to assess the expected incidence of AVF failure within 3 months. The model used routinely collected clinical data to minimize additional burden on clinical workflow. (Phase II). After developing and validating the model, a model error analysis was conducted using case studies methodology to improve model performance (Phase III). Once the model reached a good accuracy, think-aloud interview was used to abstract HCP needs and to design a user interface for model output. A user-friendly dashboard was developed to display the risk of AVF failure within 3-months and patient's vascular access history (Phase IV). This solution was integrated in the health record system and updated monthly with the latest risk score and medical information. A pilot quality improvement program was conducted in 15 clinics across 4 countries (IT, CZ, SK, SG) from May to December 2022. HCP were asked to evaluate their agreement with the risk score using a 5-point Likert scale (completely disagree to agree) and assess the usefulness of the dashboard in clinical decision making. At this stage the dashboard is not used for medical decision making (Phase V). The evaluation results were compiled into a monthly report and shared with all the HCP involved in the project to promote awareness and engagement. After 3 months of usage, a round-table discussion was held with all participants to gather their feedback and discuss clinical cases (Phase VI). Results Access to the AI-enhanced dashboard increased during the evaluation period. In the first two months of the pilot quality improvement program, the AI-enhanced dashboard was evaluated for 20% patients with an AVF, a proportion that doubled by the end of the program (Fig. 1B). HCP reported 90% agreement with risk model rating (Fig. 1C), suggesting that the model capture relevant physiological status of the patient and its output is understandable by the healthcare staff. Qualitative analysis of round-table discussions showed that the dashboard is perceived as useful and clear. HCP suggested few changes in the user interface to enhance actionability and improve clinical workflow integration. Conclusion Our results support the usefulness and intelligibility of the AI-enhanced AVF management dashboard. The advance of AI-models highlighted the importance to develop new strategies for their integration and evaluation in clinical practice. The engagement of HCP in the early phases of AI-model design and development grants a continuous feedback loop bringing clinical and AI world together. A clinical perspective in dashboard design reflects the needs of healthcare professionals and enhance consideration of patient medical needs. The synergy between theoretical and clinical perspective is crucial to improve model performance, usability, and implementation in clinical practice.

An evaluation of distal radiocephalic side-to-side anastomosis performed for hemodialysis in patients with end-stage chronic renal failure

Aim: In our study we evaluate the early and late term patency ratio, time to maturation and fistula associated complication rates in cases with an arteriovenous fistula (AVF) created via a distal radiocephalic side-to-side anastomosis without ligation of distal cephalic vein in patients with end-stage renal failure (ESRF) and suggest that the fistulae complications can be diagnosed and treated with simpler and minimally-invasive methods. 
 Methods: The demographic data, outpatient clinic follow-up records on day 1, week 1, month 1 and year 1, fistula-related complications and treatments given for complications of patients were evaluated.
 Results: Of the 50 operated patients, five(10%) developed fistula thrombosis on postoperative day 1 and underwent thrombectomy with a Fogarty catheter inserted via the distal cephalic vein; the fistula remained active after thrombectomy in two patients. Of the 47 patients followed at Month 1, 37 had a functional fistula and two had a functional fistula following thrombectomy. The early-term primary and secondary patency ratio was 78.7% and 82.9%, respectively. Of the 45 patients who attended the 1-year follow-up, 33(76.7%) had a non-intervened fistula, and with the addition of the two patients who underwent early-term thrombectomy, 35(81.3%) patients in total had fully functional fistulae. The one-year primary and secondary patency ratio was 76.7% and 81.3%, respectively. None of the patients developed such complications as venous hypertension or distal ischemia.
 Conclusions: Arteriovenous fistula created via distal radiocephalic side-to-side anastomosis without ligation of distal cephalic vein can be successfully used as a vascular access in patients with ESRF.

Tunnelled central venous catheters for incident haemodialysis patients: a Victorian survey exploring reasons for use.

Tunnelled central venous catheters (T-CVCs) are used globally as vascular access for patients on haemodialysis (HD) but are associated with increased sepsis, mortality, cost and length of hospitalisation compared with more permanent HD vascular access. The reasons for using T-CVC are varied and poorly understood. A significant and increasing proportion of incident HD patients in Victoria, Australia, have required T-CVC over the last decade. To explore reasons for a significant and increasing proportion of incident HD patients in Victoria, Australia, having required T-CVC over the last decade. With rates of starting HD with definitive vascular access consistently below a Victorian quality indicator target of 70%, an online survey was developed to explore reasons why the rate remained lower than desired and to help inform future decisions about this quality indicator. The survey was completed by dialysis access coordinators over an 8-month period and involved all public nephrology services in Victoria. Of the 125 surveys completed, 101 incident HD patients had no attempt at permanent vascular access prior to T-CVC insertion. For almost half of these (48 patients), there was no active medical decision not to create permanent vascular access prior to commencing dialysis. Reasons for insertion of the T-CVC included deterioration of kidney function faster than anticipated, surgical referral being overlooked, complications related to peritoneal dialysis requiring a change in dialysis modality and changes to initial decisions regarding dialysis modality for kidney failure. These survey results provide an opportunity for quality improvement initiatives with respect to dialysis access planning and care.

Case Studies.

British Journal of NursingVol. 32, No. Sup7 Case StudiesCase StudiesGema Munoz-Mozas, Colin Fairhurst, Simon ClareGema Munoz-MozasVascular Access Advanced Nurse Practitioner and Lead Vascular Access Nurse, Royal Marsden NHS Foundation TrustSearch for more papers by this author, Colin FairhurstVascular Access Advanced Clinical Practitioner, University Hospitals Plymouth NHS TrustSearch for more papers by this author, Simon ClareResearch and Practice Development Director, the Association for Safe Aseptic PracticeSearch for more papers by this authorGema Munoz-Mozas; Colin Fairhurst; Simon ClarePublished Online:10 Apr 2023https://doi.org/10.12968/bjon.2023.32.Sup7.S11AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Akhtar N, Lee L. Utilization and complications of central venous access devices in oncology patients. 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Cost effectiveness of ultrasound-guided long peripheral catheters in difficult vascular access patients.

Peripheral intravenous catheter (PIVC) placement is a routinely performed invasive procedure in hospital settings with an unacceptably high failure rate that can result in significant costs. This investigation aimed to determine the cost-effectiveness of using long peripheral catheters (LPC) versus standard short peripheral catheters (SPC) in the difficult vascular access (DVA) population. A secondary analysis was performed of a randomized control trial that compared a 20-gauge 4.78 cm SPC to a 20-gauge 6.35 cm SPC for the endpoint of survival. This study assessed cost-effectiveness of the comparative interventions. Costs associated with increased hospitalization length of stay due to PIVC failure, including labor, materials, equipment, and treatment delays were estimated by utilizing healthcare resource utilization data. Cost-effectiveness of the LPC was analyzed through the incremental cost-effectiveness ratio, the cost-effectiveness acceptability curve, and the incremental net benefit. A sensitivity analysis was conducted to evaluate the robustness of the results during the time interval of PIVC insertion. Among the 257 patients, the average total cost for therapy was lower in the LPC group compared to the SPC group ($400 vs $521; mean difference -$121, 95% bootstrapped CI -$461 to $225). A marginally significant absolute difference of complication averted was found for LPC versus SPC (10.8%, p = 0.07). The estimated incremental cost-effectiveness ratio (ICER) for LPC as compared with SPC was -$1123 (95% bootstrapped CI -$8652 to $5964) per complication averted. In a willingness to pay (WTP) analysis, as WTP = $0, the incremental net benefit (INB) $121 was positive, indicating LPC was less costly. Analysis of PIVCs that survived ⩽48 h (n = 134) demonstrated a lower average total cost for therapy among the LPC group ($418 vs $531; mean difference -$113, 95% bootstrapped CI -$507 to $282). Forty-seven of 66 (71.2%) LPCs did not experience a complication, compared with 37 of 68 (54.4%) SPCs, resulting in a significant absolute difference of complication adverted of 16.8% (p = 0.04). In addition, with a positive slope, the INB $113 was positive as WTP = $0, indicating LPC was estimated to be cost-effective. When using ultrasound guidance for vascular access, LPCs are potentially a cost-effective strategy for reducing PIVC complications in DVA patients compared to SPCs. Given this finding, ultrasound-guided LPCs should be routinely considered as first-line among the DVA population in order to improve their overall care and wellbeing.

Epinephrine administration in adults with out-of-hospital cardiac arrest: A comparison between intraosseous and intravenous route

IntroductionThe benefits and risks of the intraosseous (IO) route for vascular access in patients with out-of-hospital cardiac arrest (OHCA) remain controversial. This study compares the success rates of establishing the access route, epinephrine administration rates, and time-to-epinephrine between adult patients with OHCA with IO access and those with intravenous (IV) access established by paramedics in the prehospital setting. MethodsThis was a retrospective study conducted by the San-Min station of Taoyuan Fire Department. Data for IV access were collected between January 1, 2020, and December 31, 2020. Data for IO access were collected between January 1, 2021, and March 10, 2021. Inclusion criteria were adult patients with OHCA who received on-scene resuscitation attempts and in whom either IV or IO route access was established by paramedics. Exclusion criteria were missing data, return of spontaneous circulation before establishing vascular access, cardiac arrest en route to hospital, patients not resuscitated, and OHCA unidentified by the dispatcher. Exposure was defined as IV route vs. IO route (EZ-IO®). The outcome measurements were per-patient based success rates of route establishment (successes/attempts), administration rates of epinephrine (epinephrine administered per case/enrolled OHCAs), and odds ratios of IV versus IO on epinephrine administration. We used nonparametric Mann-Whitney rank sum tests for the analysis in continuous variables and Fisher's exact tests for the analysis of categorical variables and the outcomes. Firth logistic regression method was used for sparse data. Factors associated with epinephrine administration other than vascular access were also analyzed. Time-to-epinephrine (defined as time from paramedic arrival to epinephrine injection) was reviewed and calculated by two independent observers and the Kaplan-Meier method was used to compare the two access routes. ResultsA total of 112 adult patients were enrolled in the analysis, including 71 men and 41 women, with an average age of 67 years. There were 90 IV access cases and 22 IO access cases. The groups were compared for median success rates of route establishment (33% vs. 100%, P < 0.001) and administration rates of epinephrine (52% vs. 100%, P < 0.001). The adjusted odds ratio of IO versus IV was 32.445, 95% confidence interval (CI) of 1.844–570.861. Time-to-epinephrine was significantly shorter in the cumulative time-event analysis by the Kaplan-Meier method (P < 0.001). ConclusionThe IO route was significantly associated with higher success rates of route establishment, epinephrine administration, and shorter time-to-epinephrine in the prehospital resuscitation of adult patients with OHCA.

Vascular Access in Patients With Peripheral Arterial Disease Undergoing TAVR: The Hostile Registry

BackgroundThe optimal access route in patients with severe peripheral artery disease (PAD) undergoing transcatheter aortic valve replacement (TAVR) remains undetermined. ObjectivesThis study sought to compare clinical outcomes with transfemoral access (TFA), transthoracic access (TTA), and nonthoracic transalternative access (TAA) in TAVR patients with severe PAD. MethodsPatients with PAD and hostile femoral access (TFA impossible, or possible only after percutaneous treatment) undergoing TAVR at 28 international centers were included in this registry. The primary endpoint was the propensity-adjusted risk of 30-day major adverse events (MAE) defined as the composite of all-cause mortality, stroke/transient ischemic attack (TIA), or main access site–related Valve Academic Research Consortium 3 major vascular complications. Outcomes were also stratified according to the severity of PAD using a novel risk score (Hostile score). ResultsAmong the 1,707 patients included in the registry, 518 (30.3%) underwent TAVR with TFA after percutaneous treatment, 642 (37.6%) with TTA, and 547 (32.0%) with TAA (mostly transaxillary). Compared with TTA, both TFA (adjusted HR: 0.58; 95% CI: 0.45-0.75) and TAA (adjusted HR: 0.60; 95% CI: 0.47-0.78) were associated with lower 30-day rates of MAE, driven by fewer access site–related complications. Composite risks at 1 year were also lower with TFA and TAA compared with TTA. TFA compared with TAA was associated with lower 1-year risk of stroke/TIA (adjusted HR: 0.49; 95% CI: 0.24-0.98), a finding confined to patients with low Hostile scores (Pinteraction = 0.049). ConclusionsAmong patients with PAD undergoing TAVR, both TFA and TAA were associated with lower 30-day and 1-year rates of MAE compared with TTA, but 1-year stroke/TIA rates were higher with TAA compared with TFA.

‘It's about what I'm able to do’: Using the capabilities approach to understand the relationship between quality of life and vascular access in patients with end-stage kidney failure

Prevalence rates of End-Stage Kidney Failure (ESKF) have risen in across the world in recent years, making it one of the most common chronic illnesses. The main treatment for ESKF is haemodialysis, where one is ‘connected’ to a dialysis machine to clean and filter the blood via a surgically-created portal, also known as ‘vascular access’. Without functioning vascular access, dialysis is impossible. People with ESKF have different experiences with their access modalities, but universally describe their access point as a ‘lifeline’. Previous research has emphasised the impact it can have on wellbeing (Kalloo et al., 2016; Casey et al., 2014; Quinn et al., 2008), and specifically on short- and long-term outcomes.Capturing Quality of Life (QoL) within ESKF populations has traditionally focused upon assessing wellbeing from an objective, normative, top-down stance, rather than appreciating the nuanced effect vascular access can have as experienced by those living with kidney failure. In this article, we argue current QoL measures used with ESKF groups are insufficient at capturing the impact of vascular access on wellbeing. Using the accounts of twenty-four haemodialysis patients, we share insights into the direct and indirect influences vascular access has upon QoL, using Nussbaum's Capabilities Approach as an analytical lens. By prioritising and privileging the voices of those directly affected, the Vascular Access Specific Quality of Life (VA Specific-QOL) model provides a starting point for a more representative way to assess wellbeing in this group.

Midline catheters: A 3-year experience at a veterans administration medical center

Midline catheters are recommended over peripherally inserted central catheters as short-term vascular access device for peripherally compatible infusates. We assessed the effectiveness and safety of midline catheters. Data from midline catheter placements from June 2016 to May 2019 at a tertiary-care Veterans Administration medical center were retrospectively collected. Patients were followed until catheter removal or death, whichever occurred first. The primary outcome was completion of intended therapy; secondary outcomes were catheter-related complications, including major (eg, catheter-related bloodstream infections [CRBSI] or venous thromboembolism [VTE]) and minor (eg, catheter occlusion, kinking, dislodgement) events. Of 115 midlines, 62 (53.9%) were for antibiotic infusion and 49 (32.6%) for difficult access. The median dwell time was 11 days (interquartile range, 5.5-19.5 days). Midline catheters lasted through completion of therapy in 93 patients (80.9%). Catheter-related complications occurred in 27 patients (23.5%), including catheter dislodgement in 10 patients (8.7%), catheter kinking in 8 (7.0%), and catheter occlusion in 3 (2.6%). Only 1 patient experienced a major complication, a deep venous thrombosis (0.9%). Midlines appear to be effective and safe for short-term vascular access in patients requiring peripherally compatible infusates. While the rate of major complications is low, minor complications that necessitate device removal are common.

Arteriovenous fistula: an interesting alternative to central venous catheters in patients not undergoing dialysis

Native arteriovenous fistula (AVF) is the recommended first line vascular access in patients undergoing hemodialysis. For other chronic pathologies requiring a long-term vascular access, central venous catheters are used the most. The aim of this study was to evaluate the mid-term results of arteriovenous fistulas used as chronic vascular accesses in patients not undergoing dialysis.

Vascular access in emergency hemodialysis patients in remote areas

The goal of this study was to identify vascular access in patients undergoing emergency hemodialysis in outlying areas at RSU NTB. This study, which was conducted concurrently from secondary data of patients with chronic kidney disease (CKD) who needed emergency hemodialysis through a temporary non-tunnel double-lumen vascular catheter access at the West Nusa Tenggara Regional General Hospital from May 2019 to May 2022, is a quantitative descriptive study using a cross-sectional approach. by including 331 research participants, the majority of them were between the ages of 46 and 55 (n=31.4%), with a male to female ratio of 54.4% to 45.6%. According to this study, hypertension, which affected 158 individuals (n=47.7%) of the research subjects, was the most prevalent ailment. As many as 122 patients (n=36.9%) with chronic kidney disease (CKD) who have hemodialysis grounds report shortness of breath as their primary complaint. Emergency hemodialysis, which involved 295 patients (n=89.1%) of patients with chronic kidney disease, was the most common reason for hemodialysis, followed by chronic or regular hemodialysis, which involved 30 patients (n=9.1%). In conclusion, comorbidities and clinical symptoms were taken into account when deciding the type of hemodialysis that will be administered.

Use of ultrasound to confirm guidewire position in hemodialysis catheter implantation.

Hemodialysis is the most used dialysis modality in Brazil for the treatment of end-stage chronic kidney disease and severe acute kidney injury. Non-tunneled, short-term, double-lumen catheters allow immediate vascular access in patients without a definitive vascular access for dialysis treatment. Implantation is performed using the Seldinger technique, traditionally based on anatomical landmarks or with puncture under direct visualization by ultrasonography. Confirmation of the placement of the catheter is usually made with a chest X-ray after the end of the procedure. To describe the use of ultrasonography to confirm the proper positioning of the guidewire during catheter implantation in real time, ensuring the desired path. We used the Seldinger technique for catheter implantation. The confirmation of the position of the guidewire occurred after the introduction of 50cm of this wire, as described in the aforementioned technique. A convex transducer was placed longitudinally below the xiphoid process to visualize the guidewire in the inferior vena cava, or transversely at the same location to visualize it in the cavoatrial junction or right ventricle, using the two-dimensional mode of the ultrasound device. After viewing the guidewire, the catheter implantation proceeded. The technique was performed in 1549 patients, and regarded 2596 catheter implantations over a period of 5 years and 9 months. The only complication observed was local hematoma, occurring in 0.1% of cases. Confirmation of guidewire position with ultrasonography during catheter implantation is recommended because it is safe, low cost and ensures correct catheter direction.

Hemodialysis vascular access in elderly patients: A comprehensive review.

The number of elderly patients initiating hemodialysis (HD) increased considerably over the past decade. Arteriovenous fistulas (AVFs) are the preferred vascular access (VA) type in most HD patients. Choice of VA for older hemodialysis patients presents a challenge. The higher incidence of comorbidities, longer AVF maturation times, risk of primary failure, risk of patency loss, and shorter life expectancy are important factors to consider. In this review we provide a comprehensive analysis on maturation rates, primary failure, patency, and mortality regarding vascular access in patients older than 75 years of age.

Trans-radial approach versus trans-femoral approach in patients with acute coronary syndrome undergoing percutaneous coronary intervention: An updated meta-analysis of randomized controlled trials.

IntroductionTrans-radial approach (TRA) is recommended over trans-femoral approach (TFA) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). We intended to study the effect of access on all-cause mortality.Methods and resultsWe searched PubMed and EMBASE for randomized studies on patients with ACS undergoing PCI. The primary outcome was all-cause mortality at 30-days. The secondary outcomes included in-hospital mortality, major adverse cardiac or cerebrovascular event (MACE) as defined by the study, net adverse clinical event (NACE), non-fatal myocardial infarction, non-fatal stroke, stent thrombosis, study-defined major bleeding, and minor bleeding, vascular complications, hematoma, pseudoaneurysm, non-access site bleeding, need for transfusion, access site cross-over, contrast volume, procedure duration, and hospital stay duration. We studied 20,122 ACS patients, including 10,037 and 10,085 patients undergoing trans-radial and trans-femoral approaches, respectively. We found mortality benefit in patients with ACS for the trans-radial approach [(1.7% vs. 2.3%; RR: 0.75; 95% CI: 0.62–0.91; P = 0.004; I2 = 0%). Out of 10,465 patients with STEMI, 5,189 patients had TRA and 5,276 had TFA procedures. A similar benefit was observed in patients with STEMI alone [(2.3% vs. 3.3%; RR: 0.71; 95% CI: 0.56–0.90; P = 0.004; I2 = 0%). We observed reduced MACE, NACE, major bleeding, vascular complications, and pseudoaneurysms. No difference in re-infarction, stroke, and serious bleeding requiring blood transfusions were noted. We noticed a small decrease in contrast volume(ml) {mean difference (95% CI): −4.6 [−8.5 to −0.7]}, small but significantly increase in procedural time {mean difference (95% CI) 1.2 [0.1 to 2.3]}and fluoroscopy time {mean difference (95% CI) 0.8 [0.3 to1.4] min} in the trans-radial group.ConclusionTRA has significantly reduced 30-day all-cause mortality among patients undergoing PCI for ACS. TRA should be the preferred vascular access in patients with ACS.