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Introduction: Creation of an arteriovenous fistula (AVF) in patients with advanced atherosclerotic changes of the artery is often a challenge for the physician due to difficulties in suturing the vein to the side of the frangible artery. The sleeve technique relies on advancing the end of the artery into the lumen of the vein and protecting the anastomosis by adventitial sutures., Material and Methods: The sleeve technique was performed in 23 patients with chronic kidney disease stage IV and V and included hemodialysis patients. Their mean age was 60.8 ± 14.8 years and hemodialysis treatment time 49.8 ± 40.2 months. The most frequent causes of chronic kidney disease are ischemic nephropathy (43%, n = 10) and type l diabetes (21%, n = 5). Only patients with extremely advanced atherosclerotic were recruited and analyzed., Results: The primary patency rate was 67%, 59%, 44% and 28% at 6, 12, 24, and 36 months, respectively. The secondary patency rate was 67%, 61%, 50% and 37% at 6, 12, 24, and 36 months, respectively. In three patients the AVF failed directly after the operation. Delayed fistula failure occurred in seven patients. The overall success in the creation of a functioning fistula was achieved in 15 of the 23 patients (65%). No serious complications were observed., Conclusions: In patients with calcified atherosclerotic plaques, which constitute a barrier or make it difficult to suture the vein to the side of the artery, the sleeve method may be considered as an alternative before abandoning the creation of a fistula on the forearm. The technique is much simpler than the standard end-to-side or side-to-side anastomosis.

Introduction: Severe, life-threating, complications might occur on dialysis catheter removal., Methods: We present a useful technique that may prevent vascular air embolism and severe bleeding., Results: The suture is placed around the catheter and tied over previous tract just after device removal., Conclusions: Applying a compressing suture to the tract left after removal of a tunnelled haemodialysis catheter is a simple manoeuvre that could prevent severe complication.

Background: A profound knowledge of vascular anatomy and an understanding of vascular access functionality with respect to possible complications are critical in selecting the site for arteriovenous anastomosis., Methods: Outline of vasculature variations of the upper limb with prevalence reported in literature of at least 1%, which may affect access creation, is depicted in this review., Results: Over a dozen arterial anatomical anomalies of the upper limb, the most common is "high origin" of the radial artery (12-20%). Superficial positions of brachial, ulnar and radial artery as well as accessory brachial are another possible anatomic variants (0.5-7%). The most variable venous layout on the upper arm is seen in the anatomy of the brachial vein and the basilic vein forming the axillary vein. Three types of basilic vein course on upper arm have been described., Conclusions: The mapping technique to assess vascular variants facilitate site selection for AVF creation even in cases with previously attempted failed access (misdiagnosed vascular variant could force to secondary options). Thus, a thorough understanding and evaluation of anatomy, taking into consideration the possible vascular variations of the forearm and upper arm, are necessary in the planning of AVF creation and increase the success of AVF procedures.

Purpose: The standard approach in patients with a clotted arteriovenous fistula (AVF) on the forearm is the creation of another vascular access on the arm using the patient's own vessels or a prosthetic graft. Here we propose another option as secondary angioaccess for chronic hemodialysis (HD): superficialization of the radial artery., Methods: Indications for the procedure were 1) long-standing forearm AVF that has irreversibly clotted and/or central vein stenosis resistant to angioplasty; 2) patients who have no other prospect for forearm or even brachial AVF. The procedure was undertaken in 7 chronic HD patients dialyzed by forearm AVF for 27±26 months., Results: In one case the superficialization was abandoned intra-operatively due to small diameter of the artery (<4 mm). Five of 6 elevated arteries were patent and the follow-up period ranges from 11 to 15 (median 12) months. In 1 male patient with prothrombin G20210A mutation the artery clotted after 13 months of usage., Conclusions: Superficialized radial artery was successfully used for hemodialysis over one year. The only prerequisite for safe repeated puncture is a patent and enlarged radial artery. Due to avoidance of arteriovenous shunt this access type may be particularly suitable for patients with cardiac failure.

Purpose: Although catheter use exposes the patient to several complications, tunneled cuffed catheters are widely applied for temporary or long-term vascular access. The aim of the study was to establish the rate of tunneled dialysis catheter damage and report our experience with breakage repair., Methods: All 363 cuffed tunneled hemodialysis catheters inserted into 309 patients from May 2000 to December 2008 were followed up. When connector damage was encountered, repair with a two-piece adaptor for peritoneal dialysis was attempted., Results: Mechanical breakage occurred in 33 (9.1%) of catheters with an incidence of 0.36/1000 catheter-days. The most frequent was connector damage, found in 25 cases (67.6%). Catheter repair using a peritoneal dialysis Luer adaptor was performed with good early and long-term outcome., Conclusions: Tunneled catheter breakage is a relatively rare complication. Catheter repair using the adaptor for peritoneal dialysis is easy to perform, safe, and cost-effective.

Purpose: Management of failing tunneled hemodialysis catheters, sometimes the only vascular access for hemodialysis, presents a difficult problem. In spite of various techniques having been developed, no consensus has been reached about the preferred technique, associated with the longest catheter patency., Methods: We report disruption of the fibrin sheath covering dysfunctional tunneled hemodialysis catheter by means of angioplasty, followed by over guidewire catheter exchange., Results: Following the procedure, the catheter placed in the recovered lumen of the vessel presented correct function., Conclusions: The described procedure allowed maintenance of vascular access in our patient. Additionally, dilatation of the concomitant central vein stenosis opens an option for another attempt for arteriovenous fistula creation.

Purpose: Conventional brachiobasilic fistula creation consists of the mobilization and preparation of the brachial part of the basilic vein along its whole length, the vein transposition on the anterior surface of the arm and anastomosis using the brachial artery. In case of late thrombosis, the reparation of such a fistula is almost impossible., Methods: To avoid total vein clotting in the case of thrombosis we decided to prepare only a short part of the vein in our method and not to mobilize the other part of the vein. The brachiobasilic fistula with our modification was performed as a two-stage procedure in 18 patients (8 females and 10 males), aged from 37-78 yrs (60 +/- 13.6 yrs)., Results: In two patients early thrombosis occurred. The reparation procedure was not performed in two patients (the first patient died due to pneumonia; the second patient did not give his permission for further intervention). In 16 patients brachiobasilic fistula creation was successful. Late thrombotic complications occurred in three patients (in the 3rd, 8th and 12th months). A new successful fistula, a few centimeters proximally to the original one, was per-formed in 2 patients 24hr and in 1 patient 48 hr after fistula clotting. On the following day after the procedure the fistula was ready to be used. The primary, assisted primary and cumulative secondary patency rates after 12 months of follow-up were 74, 89 and 100%, respectively., Conclusion: In comparison with standard brachiobasilic techniques our method offers the possibility of a reparation procedure in the case of late thrombosis, which could improve the long-term patency of brachiobasilic fistulas. However, a prospective controlled study is necessary to establish if this new technique is superior to the traditional surgical procedure.

Introduction: Arteriovenous fistula (AVF) creation for hemodialysis (HD) could predispose to local arterial insufficiency of the hand (steal syndrome). Patients with diabetes mellitus, peripheral arterial disease and elderly patients tend to have a higher risk of hand ischemia., Purpose and Methods: To estimate the influence of AVF on the blood supply to the hands in the elderly population and to identify steal syndrome cases by non-invasive diagnostics (finger photoplethysmography (PPG), pulse volume recording (PVR), Doppler analysis and pulseoxymetry). The evaluation was carried out in 25 random patients (10 females, 15 males) >75 yrs of age (79.6 +/- 3.87 yrs), whose functioning autologous AVFs had been placed at least 1 month previously., Results: Mean PPG and PVR amplitudes did not differ in statistical analysis (p > 0.05) between hands with and without an AVF. One patient (4%) with end-to-side anastomosis was diagnosed with steal syndrome (typical manifestation confirmed in PPG, Doppler and pulseoxymetry). Two other patients with high brachio-cephalic anastomosis presented subclinical steal syndrome (only low PPG and PVR)., Conclusions: Even in the very elderly, AVF creation should be considered due to a lesser influence on the blood supply to the hands. Non-invasive diagnostics used by us seemed to be useful in identifying steal syndrome after AVF creation.