Vascular Access In Patients Research Articles

Clinical and Haemodynamic Effects of Arteriovenous Shunts in Patients with Heart Failure with Preserved Ejection Fraction.

The arteriovenous shunt (AVS) is the most commonly used vascular access in patients receiving regular haemodialysis. The AVS may have a significant haemodynamic impact on patients with heart failure. Many studies have sought to understand the effect of AVS creation or closure on heart structure and functions, most of which use non-invasive methods, such as echocardiography or cardiac MRI. Data are mainly focused on heart failure with reduced ejection fraction and there are limited data on heart failure with preserved ejection fraction. The presence of an AVS has a significant haemodynamic impact on the cardiovascular system and it is a common cause of high-output cardiac failure. Given that most studies to date use non-invasive methods, invasive assessment of the haemodynamic effects of the AVS using a right heart catheter may provide additional valuable information.

Comparison of Standard Technique, Ultrasonography, and Near-Infrared Light in Difficult Peripheral Vascular Access: A Randomized Controlled Trial

Successful placement of a peripheral intravenous catheter (PIVC) on the first attempt is an important outcome for difficult vascular access (DVA) patients. This study compared standard technique, ultrasonography (USG), and near-infrared light (NIR) in terms of success in the first attempt in patients with DVA. This was a prospective, randomized controlled study. The study was conducted in a tertiary care hospital. Emergency department patients who describe DVA history, have no visible or palpable veins, and were assessed by the nurse to have a difficult PIVC were included to study. The PIVC procedure was performed on patients by standard, USG, or NIR device techniques. For all approaches, the success of the first attempt was the primary aim. Total procedure time, the total number of attempts, and the need for rescue intervention were secondary aims. This study evaluated 270 patients. The first attempt success rates for USG, standard, and NIR methods were 78.9%, 62.2%, and 58.9%, respectively. The rate of first attempt success was higher in patients who underwent USG (USG versus standard, P = .014; USG versus NIR, P = .004; standard versus NIR, P = .648). The total median (IQR) procedure time for USG, standard, and NIR methods was 107 (69-228), 72 (47-134), and 82 (61-163) seconds, respectively. The total procedure time was longer in patients undergoing USG (standard versus USG, P <.001; NIR versus USG, P = .035; standard versus NIR, P = .055). The total median (IQR) number of attempts of USG, standard, and NIR methods were 1 (1-1), 1 (1-2), and 1 (1-2), respectively. A difference was found among the groups regarding the total number of attempts (USG versus NIR, P = .015; USG versus standard P = .108; standard versus NIR, P = .307). No difference was found among groups in terms of the need for rescue methods. It was found that USG increases the success of the first attempt compared with the standard method and NIR in patients with DVA.

Prediction of radial crossover in acute coronary syndromes: derivation and validation of the MATRIX score.

The radial artery is recommended by international guidelines as the default vascular access in patients with acute coronary syndromes (ACS) managed invasively. However, crossover from radial to femoral access is required in 4-10% of cases and has been associated with worse outcomes. No standardised algorithm exists to predict the risk of radial crossover. We sought to derive and externally validate a risk score to predict radial crossover in patients with ACS managed invasively. The derivation cohort consisted of 4,197 patients with ACS undergoing invasive management via the randomly allocated radial access from the MATRIX trial. Using logistic regression, we selected predictors of radial crossover and developed a numerical risk score. External validation was accomplished among 3,451 and 491 ACS patients managed invasively and randomised to radial access from the RIVAL and RIFLE-STEACS trials, respectively. The MATRIX score (age, height, smoking, renal failure, prior coronary artery bypass grafting, ST-segment elevation myocardial infarction, Killip class, radial expertise) showed a c-index for radial crossover of 0.71 (95% CI: 0.67-0.75) in the derivation cohort. Discrimination ability was modest in the RIVAL (c-index: 0.64; 95% CI: 0.59-0.67) and RIFLE-STEACS (c-index: 0.66; 95% CI: 0.57-0.75) cohorts. A cut-off of ≥41 points was selected to identify patients at high risk of radial crossover. The MATRIX score is a simple eight-item risk score which provides a standardised tool for the prediction of radial crossover among patients with ACS managed invasively. This tool can assist operators in anticipating and better addressing difficulties related to transradial procedures, potentially improving outcomes.

Does catheter material affect functional performance of intravenous ports via the superior vena cava?

IntroductionThe catheter is the only intravascular portion of an implanted port and plays a crucial role in catheter related complications. Both polyurethane and silicone are biocompatible materials which are utilized for catheter manufacturing, but their correlation to complications remains controversial. The aim of this study was to try to analyze the relationship between catheter materials and complications.Materials and methodsA total of 3144 patients who underwent intravenous port implantation between March 2012 and December 2018 at Chang Gung Memorial Hospital, Linkou, Taiwan were recruited. Of these, 1226 patients received silicone catheter port implantation and 1679 received polyurethane catheter ports. Case matching was done prior to analysis and catheter related complications and cumulative complication incidence for each group were compared.ResultsIntergroup differences were identified in entry vessel (p = 0.0441), operation year (p < 0.0001), operation method (p = 0.0095), functional period (p < 0.0001), patient follow up status (p < 0.0001), operating time for vessel cutdown (p < 0.0001) and wire assisted approach (p = 0.0008). Stratified by specific entry vessel, no statistical difference was found in complication rate or incidence between the silicone and polyurethane groups. We further compared the cumulative complication incidence of the silicone and polyurethane groups, and also found no statistical difference (p = 0.4451).ConclusionAs long as external stress forces generated by surrounding structures and focused on potential weak points are avoided, both silicone and polyurethane materials provide sufficient structural stability to serve as reliable vascular access for patients.

HeRO® graft: technical application and clinical experience in 73cases

Zunehmendes Alter, Komorbiditäten und die Dauer der chronischen Dialysepflichtigkeit erschweren die Anlage und den Erhalt eines funktionierenden Gefäßzugangs bei Patienten mit terminaler Niereninsuffizienz. Dabei steigt durch zentralvenöse Katheter und kardiologische bzw. onkologische Eingriffe das Risiko einer zentralen Stenose bzw. Okklusion. Die Implantation des Hemodialysis-Reliable-Outflow(HeRO®)-Grafts (Merit Medical Systems Inc., South Jordan, UT, USA) ist ein inzwischen etabliertes kombiniert chirurgisch/interventionelles Verfahren zur Wiederherstellung des stenosierten oder okkludierten venösen Abstroms. Hierdurch kann der Gefäßzugang an der oberen Extremität erhalten bleiben und die wichtige Gefäßressource der unteren Extremität geschont werden. In unserem Zentrum wurden seit 2013 insgesamt 73 Grafts erfolgreich mit steigendem Bedarf implantiert. Der operative Eingriff ist bei uns ein etabliertes und risikoarmes Verfahren geworden. Nach der Implantation ist bei akuter Thrombosierung jedoch 2‑ bis 3‑mal jährlich eine Reintervention erforderlich. Entsprechende Erfahrung vorausgesetzt, sind diese Revisionseingriffe technisch einfach durchzuführen. Bei vollständiger Okklusion der zentralvenösen Strombahn im Bereich der V. cava superior, die nicht durch den HeRO®-Graft passiert werden kann, ist ein Kombinationseingriff mit dem Surfacer®-Sytem (Inside-out-Verfahren) möglich und sinnvoll. Der HeRO®-Graft kann bei Bedarf an eine früh punktierbare Prothese angeschlossen werden. Hierdurch können passagere Dialysekatheter vollständig umgangen werden. Trotz steigender Zahl der HeRO®-Graft-Implantationen bleibt diese Option in unserem Zentrum ein Reserveverfahren. Die interventionellen Verfahren ohne Implantation von Fremdmaterial sollten zunächst ausgeschöpft und etablierte gefäßchirurgische Alternativen (wie beispielsweise der V.-jugularis-Anschluss) vorrangig durchgeführt werden.

Performance of peripheral catheters inserted with ultrasound guidance versus landmark technique after a simulation-based mastery learning intervention.

Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is an effective method to gain vascular access in patients with difficult intravenous access (DIVA). While USGPIV success rates are reported to be high, some studies have reported a concerning incidence of USGPIV premature failures. The purpose of this study was to compare differences in USGPIV and landmark peripheral intravenous catheter (PIV) utilization and failure following a hospital-wide USGPIV training program for nurses. The authors performed a retrospective, electronic medical record review of all USGPIVs and PIVs inserted at a tertiary, urban, academic medical center from September 1, 2018, through September 30, 2019. The primary outcome was differences between USGPIV and PIV time to failure. A total of 43,470 short peripheral intravenous catheters (PIVCs) were inserted in 23,713 patients. Of these, 7972 (16.8%) were USGPIV. At 30 days of follow-up, for PIVCs with an indication for removal documented, USGPIVs had higher Kaplan-Meier survival probabilities than PIVs (p < 0.001). The use of simulation-based mastery associated with USGPIVs, demonstrated lower failure rates than standard PIVs after 2 days and USGPIVs exhibited improved survival rates in patients with DIVA. These findings suggest that rigorous simulation-based insertion training demonstrates improved USGPIV survival when compared to traditional PIVCs. SBML is an extremely useful tool to ensure appropriately trained clinicians acquire the necessary knowledge and skillset to improve USGPIV outcomes.

Are continued policies of prioritizing native vascular access in patients on hemodialysis programs useful?

The guidelines recommend establishing native vascular access as opposed to prosthetic or catheter-based access despite information relating to its effectiveness being scarce from a patient-orientated perspective. We analyzed the effectiveness of a continued policy of native vascular access (CPNVA) in patients undergoing hemodialysis. A retrospective, observational study, including 150 patients undergoing hemodialysis between 2006 and 2012 at our center, and who underwent a CPNVA. Statistical analysis was based on treatment intention. In 138 patients (92%), the first useful access (FUA) was native, and in 12 patients (8%), it was prosthetic. In 50 patients (33.3%), more than one procedure had to be carried out in to order to achieve FUA. The probability of dialysis occurring via a FUA was 67.1% and 45.3% at 1 and 5 years respectively. Over the follow-up period (mean time=30 months), 84 patients (56%) required repairs or new access, extending the effectiveness of the CPNVA to 88.3% and 73.2% at 1 and 5 years respectively. The effectiveness of the CPNVA was reduced if the patient: required a catheter initially (HR: 3.6, p=0.007); in cases of initially elevated glomerular filtration rate (HR: 1.1, p=0.040); in cases of history of previous access failure before FUA (HR: 3.9, p=0.001); and in female patients (HR: 2.4, p=0.031). The long-term effectiveness of a CPNVA is high. However, the percentage of patients requiring diverse procedures in order to achieve FUA and the need for re-interventions yield the necessity to optimize preoperative evaluation and postoperative follow-up.

Rapid Assessment of Vascular Exit Site and Tunneling Options (RAVESTO): A new decision tool in the management of the complex vascular access patients.

In the last decade, different standardized protocols have been developed for a systematic ultrasound venous assessment before central venous catheterization: RaCeVA (Rapid Central Vein Assessment), RaPeVA (Rapid Peripheral Vein Assessment), and RaFeVA (Rapid Femoral Vein Assessment). Such protocols were designed to locate the ideal puncture site to minimize insertion-related complications. Recently, subcutaneous tunneling of non-cuffed central venous access devices at bedside has also grown in acceptance. The main rationale for tunneling is to relocate the exit site based on patient factors and concerns for dislodgement. The tool we describe (RAVESTO-Rapid Assessment of Vascular Exit Site and Tunneling Options) defines the different options of subcutaneous tunneling and their indications in different clinical situations in patients with complex vascular access.

Multiple single cannulation technique of arteriovenous fistula: A randomized controlled trial

IntroductionDespite the impact needling has had on vascular access survival and patient outcome, there is no universal or standardized method proposed for proper cannulation. Rigorous studies are needed, examining cannulation practices, and challenges to achieving complication‐free cannulation.MethodsThis randomized, open‐label trial was conducted at 18 dialysis units owned by a large private dialysis provider operating in Portugal. Eligible patients were adults on chronic hemodialysis, with a new arteriovenous fistula (AVF); cannulated for at least 4 weeks complication‐free. Patients were randomly assigned in a 1:1 ratio to one of three cannulation techniques (CT): Multiple Single cannulation Technique (MuST), rope‐ladder (RLC), and buttonhole (BHC). The primary endpoint was AVF primary patency at 1 year.FindingsOne hundred seventy‐two patients were enrolled between March 2014 and March 2017. Fifty‐nine patients were allocated to MuST, 56 to RLC, and 57 to BHC.MuST and RLC were associated with a better AVF primary patency than BHC. Primary patency at 12 months was 76.3% in MuST, 59.6% in BHC, and 76.8% in RLC group. Mean AVF survival times were 10.5 months (95% CI = 9.6, 11.3) in the MuST group, 10.4 months (95% CI = 9.5, 11.2) in RLC, and 9.5 months (95% CI = 8.6, 10.4) in BHC. BHC was a significant risk predictor for AVF survival with 2.13 times more events than the other two CT (HR 2.13; 95% CI = 1.07, 4.21; p = 0.03).DiscussionMuST was easy to implement without a diagram and there is no need to use blunt needles. This study showed MuST was efficacious and safe in maintaining the longevity of AVF in dialysis patients.

Oversized balloon angioplasty for endovascular maturation of arteriovenous fistulae to accelerate cannulation and to decrease the duration of catheter use.

The functional autologous arteriovenous fistula is considered the best vascular access for patients on hemodialysis. Some fistulae exhibit maturation problems after creation and do not reach adequate vessel diameter and flow in dialysis. The aim of this study was to describe our technique of oversized balloon angioplasty for assisted maturation of arteriovenous fistulae to accelerate the cannulation and to decrease the time of catheter use and its outcome. A retrospective analysis of balloon-assisted procedures for maturation failure was performed in a single center between October 2011 and January 2019. Patients underwent imaging procedures to identify stenosis, followed by angioplasty using oversized high-pressure balloons from the anastomosis to the deep venous outflow tract. The flow volume, time interval of use of the fistula and removal of the catheter, patency rates, and complications rates were evaluated. Seventy-eight patients underwent 124 balloon angioplasty procedures. Technical and clinical success was achieved in 91% of the cases. In patients in whom maturation was successful, the fistula was cannulated in a mean time of 5 days after the procedure (range, 1-20 days). On average, catheter removal was performed 14 days (range, 5-33 days) after the maturation procedure. The mean flow volume in the fistula before the procedure was 276 ml/min (range, 122-488 ml/min) and 24 h after the maturation was 1014 ml/min (range, 760-1800 ml/min).The primary patency rate at 3, 6, and 12 months was 87.3%, 66.2%, and 50.7%, respectively. Assisted primary patency was 100% at 3 months, 92.9% at 6 months, and 90.0% at 12 months. Minor complications occurred in 18% of cases, and major complications in 4.8%. The oversized balloon-assisted arteriovenous fistula maturation technique is safe and effective, allowing the cannulation of the fistulae a few hours or days after the procedure and decreasing the time of catheter use.

Appropriate vascular access for patients with cancer

Questions as to how best to meet vascular access needs and safety requirements when caring for patients with cancer occur daily in clinical practice, yet evidence for which methods are optimal is poor. In cancer, use of vascular devices such as peripherally inserted central catheters (PICCs), Hickman-type tunnelled catheters (eg, Hickman), or totally implanted ports (PORTs) is common. Collectively, these are referred to as central venous access devices (CVADs). Hickman and PICCs are catheters with an external segment, in contrast to PORTs, which are totally implanted under the skin. CVADs are rightly referred to as a lifeline for patients with cancer. In addition to chemotherapy, they are used to administer blood products, hydration, parenteral nutrition, antibiotics, and phlebotomy. The devices also improve patients' quality of life by reducing the need for venepunctures. Central venous access devices for the delivery of systemic anticancer therapy (CAVA): a randomised controlled trialFor most patients receiving SACT, PORTs are more effective and safer than both Hickman and PICCs. Our findings suggest that most patients receiving SACT for solid tumours should receive a PORT within the UK National Health Service. Full-Text PDF

A triple tunnel from the mid-calf to the femoral vein in patient with severe dementia.

Achieving the ideal exit site is the new philosophy for complicated vascular access patients. Recent publications have described multiple venous access solutions such as tunneling to the scapular region, the chest to the arm, and from the femoral vein to the abdominal and patellar region. In the patients afflicted with delirium, dementia, or confusion even these sites may not be sufficient. The following case study illustrates a triple tunneled femoral catheter on a non-cooperative patient with inoperable endocarditis to be discharged and treated with long term antibiotics.

Arteriovenous fistulas for hemodialysis: Brief review and current problems.

The number of people worldwide living with end-stage renal disease is increasing. Arteriovenous fistulas are the preferred method of vascular access in patients who will require hemodialysis. As the number of patients with arteriovenous fistulas grows, the role of physicians who intervene who maintain and salvage these fistulas will grow in importance. This review aims to familiarize practitioners with the rationale for arteriovenous fistula creation, the detection of fistula dysfunction, and the state of the art on fistula maintenance and preservation. Current controversies are briefly reviewed.

Current State of Vascular Access in Patients on Hemodialysis in Bahrain

Current State of Vascular Access in Patients on Hemodialysis in Bahrain

To PICC or not to PICC? A cross-sectional survey of vascular access practices in the ICU.

Vascular access patterns in the intensive care unit (ICU) have shifted from non-tunneled central venous catheters (CVCs) towards peripherally inserted central catheters (PICCs). We evaluated perceptions of critical care practitioners regarding these devices and variation in evidence-based practice. A 35-question survey on ICU vascular access was deployed in 13 Michigan hospitals. Descriptive statistics summarized responses. Differences in utilization, perceptions and evidence-based practices between PICCs and CVCs, by participant and site-level characteristics, were assessed. 314 of 621 eligible providers responded to the survey (response rate 51%). 15% of providers reported not routinely using ultrasound when placing CVCs. Respondents whom were trainees, from larger hospitals, and from closed ICUs were more likely to use ultrasound (p<0.001). Additionally, 21% of respondents stated they did not specify number of CVC lumens, while 46% did not specify number of PICC lumens (p<0.001). The likelihood of specifying PICC lumens increased when vascular access protocols were in place (p=0.001). 2/3 of respondents (n=173, 66%) stated more research on ICU vascular access was needed. Variation in guideline-based vascular access practices exists in the ICU. Defined local protocols may improve guideline adherence. Studies evaluating vascular access decisions and patient safety in the ICU appear necessary.

Mid-term results of tunneled brachial venous hemodialysis catheter placement: Our single-center experience with 21 patients.

Background This study aims to analyze the safety and efficacy of permanent hemodialysis catheter insertion via the brachial vein in unsuitable patients for catheter insertion from other vascular access sites. Methods A total of 21 patients (6 males, 18 females; mean age: 54.4±11.3 years; range, 48 to 77 years) who underwent permanent hemodialysis catheter insertion via the brachial vein between February 2019 and February 2020 were retrospectively analyzed. All patients underwent brachial venous tunneled catheter insertion under the ultrasound guidance and under local anesthesia. Transthoracic echocardiography was performed before and six months after catheter insertion. The primary patency rate of the catheter at six months of follow-up, potential associated complications of a permanent hemodialysis catheter including catheter thrombosis and catheter infections, and all-cause mortality rates were recorded. Results Catheter removal was required in eight patients (catheter thrombosis, n=5; catheter infection, n=2; and extensive hematoma, n=1). The catheters were patent in the remaining 13 (62%) patients at six months. Mortality occurred in one patient due to bacterial pneumonia. No life-threatening complications including hemothorax or pneumothorax and neurological injury was observed in any of the patients. Conclusion Our study results show that brachial venous tunneled catheter placement for hemodialysis can be a safe and valid alternative to catheter insertion from the jugular or subclavian veins for vascular access in patients with end-stage renal disease.

Correlation Between Preoperative Vein Distensibility With Radiocephalic Arteriovenous Fistula Maturation in Patients With End Stage Renal Disease

Introduction: Patients with end stage renal disease require hemodialysis. Radiocephalic arteriovenous fistula is the main choice of vascular access in patients who undergo hemodialysis procedure. Physiological vein distensibility is an important aspect in forming a mature arteriovenous fistula. This study aims to analyze the correlation between preoperative distensibility and arteriovenous fistula maturation. Method: Data are collected from end stage renal disease patients in Hasan Sadikin Hospital and RA Habibie Hospitals that will go through radiocephalic arteriovenous fistula procedure during the period of October 2018 to February 2019. Vein distension procedure is performed before the operation and maturation is evaluated four to six weeks after the operation. The comparison of preoperative venous distensibility in two different groups of arteriovenous fistula maturation category is analyzed using chi square test model. Result: This study found that preoperative venous distensibility value affects arteriovenous fistula maturation with a statistical significance (p-value = 0.007), yielding a contingency coefficient of 0.553, and a very strong relation value of 0.782. Conclusion: Preoperative vein distensibility of more than 30% is predictive of successful arteriovenous maturation.

Accidental Carotid Artery Cannulation During Internal Jugular Vein Access for Hemodialysis

Temporary central venous catheters are frequently used for vascular access in patients who require renal replacement therapy. The right internal jugular vein is the preferred central vein in such occasions. Accidental cannulation of the carotid artery is a potential complication of catheter placement in the internal jugular vein. This can lead to serious consequences such as stroke, life threatening hemorrhage and airway obstruction. Surgical removal is the management option of choice if a catheter is inadvertently placed in the carotid artery.

Comparison of distal radiocephalic fistula vs proximal radiocephalic fistula.

Background:Distal radiocephalic fistula (DRCF) at wrist is the first option of vascular access in patients undergoing hemodialysis. In patients with a failed DRCF or unsuitable for DRCF the current recommendation is to perform a brachiocephalic fistula. Proximal forearm radiocephalic fistulas (PRCF) are created less frequently. The aim of the present study was to evaluate the outcomes of PRCF and DRCF.Material and Methods:A longitudinal study was conducted in the department of MKCG Medical College from January 2018 to July 2019. Data was collected and entered in Microsoft excel. The analysis was done by R version 3.6.1. Quantitative data were presented in the form of Mean and SD and were tested by unpaired t-test. Categorical data were presented as count and proportion and was tested by Chi-square test or if applicable Fischer's exact test. Comparison between two procedures was done by Kaplan-Meier method and evaluated by the log-rank test. With the 95% of Level of significance, P value <0.05 was consider statistically significant during analysis.Results:The demographic data of the two patient groups were similar except that those with PRCF were more likely to have had a previous access and caliber of distal vessel was less. Early failure was lower for PRCF than DRCF (6.06% vs 15%). Primary patency rate at one year was 87.87% in PRCF vs 70% in DRCF.Conclusion:A PRCF can be a suitable alternative to a brachiocephalic fistula in patients who cannot receive a DRCF.

Multifrequency Bioimpedance Phase Angle as a Tool to Predict Maturation Failure of Native Fistulae for Hemodialysis

Background and objectives: An arteriovenous fistula is considered to be an ideal vascular access for patients receiving hemodialysis, its main limitation is its high failure rate to achieve maturation and long-term functionality loss. Multiple strategies have attempted to identify patients at risk. Bioelectrical impedance has shown to be a valuable resource in the determination of the hydration status, and the measurement of the phase angle through this method has demonstrated to be a good indicator of the nutritional state and it’s related as a general marker of survival. The objective of this study is to analyze the role of plasma albumin and phase angle measured through bioelectrical impedance as tools useful for predicting failure of arteriovenous fistulas.