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Abstract The Arteriovenous Access Stage (AVAS) classification simplifies information about suitability of vessels for vascular access (VA). It’s been previously validated in a clinical study. Here, AVAS performance was tested against multiple ultrasound mapping measurements using machine learning. A prospective multicentre international study (NCT04796558) with patient recruitment from March 2021-July 2024. Demographics, risk factors, vessels parameters, types of predicted and created VA (pVA, cVA) were collected. We modelled pVA and cVA using the Random Forest algorithm. Model performance was estimated and compared using Bayesian generalized linear models. ROC AUC with 95% credible intervals was the performance metric. 1151 patients were included. ROC AUC for pVA prediction by AVAS was 0.79 (0.77;0.82) and by mapping was 0.85 (0.83;0.88). ROC AUC for cVA prediction by AVAS was 0.71 (0.69;0.74) and by mapping was 0.8 (0.78;0.83). Using AVAS with other parameters increased the ROC AUC to 0.87 for pVA (0.84;0.89) and 0.82 (0.79;0.84) for cVA. Using mapping with other parameters increased the ROC AUC to 0.88 for pVA (0.86;0.91) and 0.85 (0.83;0.88) for cVA. Multiple mapping measurements showed higher performance at VA prediction than AVAS. However, AVAS is simpler and quicker, so may be preferable for routine clinical practice.

Introduction: Hemodialysis nurses' cannulation technique, monitoring, and management methods can affect patients' vascular access longevity. An arteriovenous access assessment comprises a medical history and vascular assessment through physical examination and surveillance. However, further exploration is needed to fully understand hemodialysis nurses' knowledge, attitudes, and practices (KAP) in this area. Methods: Between June and July 2023, we recruited hemodialysis nurses from 21 cities in Guangdong Province using a convenience sampling method. Four questionnaires—the General Data Questionnaire, the KAP Scale of Arteriovenous Access Assessment among Hemodialysis Nurses, the Utrecht Work Engagement Scale, and the NASA Task Load Index—were utilized for data collection through the Questionnaire Star platform. Findings: Of the 530 hemodialysis nurses participating in the study, 458 (86.4%) had a valid response. The participants demonstrated moderate knowledge and practice levels regarding arteriovenous access assessment and exhibited positive attitudes. We identified several factors related to arteriovenous access assessment that predict KAP in hemodialysis nurses. These factors included years of experience as a hemodialysis nurse, whether a nurse's knowledge of physical examination was sufficient to meet clinical needs, whether a nurse had received training in performing physical examination, whether a nurse's department regularly checked the quality of physical examination, and nurses' levels of work engagement and mental workload. All factors explained 32.4% of the variance in participants' KAP regarding arteriovenous access assessment. Discussion: Improving hemodialysis nurses' assessment of arteriovenous access is crucial to ensure optimal patient care. Dialysis center managers and educators should prioritize understanding hemodialysis nurses' KAP of arteriovenous access assessment and any factors influencing these areas. [ABSTRACT FROM AUTHOR]

Heart disease and chronic kidney disease are often comorbid conditions owing to shared risk factors, including diabetes and hypertension. However, the effect of congestive heart failure (CHF) on arteriovenous fistula (AVF) and AV graft (AVG) patency rates is poorly understood. We hypothesize preexisting HF may diminish blood flow to the developing AVF and worsen patency. We conducted a single-institution retrospective review of 412 patients with end-stage renal disease who underwent hemodialysis access creation from 2015 to 2021. Patients were stratified based on presence of preexisting CHF, defined as clinical symptoms plus evidence of reduced left ventricular ejection fraction (EF) (<50%) or diastolic dysfunction on preoperative echocardiography. Baseline demographics, preoperative measures of cardiac function, and dialysis access-related surgical history were collected. Kaplan-Meier time-to-event analyses were performed for primary patency, primary-assisted patency, and secondary patency using standard definitions for patency from the literature. We assessed differences in patency for patients with CHF vs patients without CHF, patients with a reduced vs a normal EF, and AVG vs AVF in patients with CHF. We included 204 patients (50%) with preexisting CHF with confirmatory echocardiography. Patients with CHF were more likely to be male and have comorbidities including, diabetes, chronic obstructive pulmonary disease, hypertension, and a history of cerebrovascular accident. The groups were not significantly different in terms of prior fistula history (P =.99), body mass index (P =.74), or type of hemodialysis access created (P =.54). There was no statistically significant difference in primary patency, primary-assisted patency, or secondary patency over time in the CHF vs non-CHF group (log-rank P >.05 for all three patency measures). When stratified by preoperative left ventricular EF, patients with an EF of <50% had lower primary (38% vs 51% at 1 year), primary-assisted (76% vs 82% at 1 year), and secondary patency (86% vs 93% at 1 year) rates than those with a normal EF. Difference reached significance for secondary patency only (log-rank P =.029). AVG patency was compared against AVF patency within the CHF subgroup, with significantly lower primary-assisted (39% vs 87% at 1 year) and secondary (62% vs 95%) patency rates for AVG (P <.0001 for both). In this 7-year experience of hemodialysis access creation, reduced EF is associated with lower secondary patency. Preoperative CHF (including HF with reduced EF and HF with preserved EF together) is not associated with significant differences in overall hemodialysis access patency rates over time, but patients with CHF who receive AVG have markedly worse patency than those who receive AVF. For patients with end-stage renal disease and CHF, the risks and benefits must be carefully weighed, particularly for those with low EF or lack of a suitable vein for fistula creation. [ABSTRACT FROM AUTHOR]

Physical examination (PE) of arteriovenous access remains of high clinical value and continues to be recommended by leading societies and guidelines. PE is easy to learn and perform. Once learned, examiners can provide a comprehensive arteriovenous (AV) access examination in 20 to 30 seconds. Therefore, we continue to advocate that AV access PE should be part of the training for all dialysis care providers. Similarly, ultrasound can provide important AV access evaluation and provide key information. It is relatively cheap and can be readily available at the bed side. Additionally, it is well accepted by patients, as it is not expected to be associated with pain or discomfort during the examination. We present in this review the key components of PE, signs and symptoms of AV access dysfunction, and the role of ultrasound in AV access evaluation as a complementary tool to PE.

Duplex ultrasound (DUS) is an essential tool for characterizing and monitoring arteriovenous (AV) access for hemodialysis. The aim of the work described here, requested by the French Society of Vascular Medicine in collaboration with the French-Speaking Vascular Access Society, is to propose a standardized methodology for performing and documenting DUS, taking into account the variety of AV access techniques and the problems routinely encountered. A steering committee reviewed the literature and selected the relevant references. A draft was prepared, and all items with missing or conflicting data were submitted to a Delphi consensus. The final document was discussed and approved by all participants. The principles of DUS evaluation of AV access consist of examination of the afferent artery, the anastomosis and the entire venous drainage system. DUS uses B-mode ultrasound, color flow, pulsed wave and power Doppler analysis. DUS can be used in a variety of clinical situations, which can directly influence the methodology of the examination and the interpretation of the results. Blood flow should be assessed as it correlates with the risk of thrombosis. The measurement should be adapted to the different anatomical and hemodynamic conditions encountered. Characterization of stenosis should take into account the residual diameter of the drainage vein and its hemodynamic consequences. Other complications can be assessed with a standardized DUS examination. When performed according to a rigorous methodology, DUS of the AV access allows a comprehensive assessment of its functionality and eliminates the need for further invasive diagnostic procedures. [ABSTRACT FROM AUTHOR]

Abstract Background Treatment of end-stage kidney disease (ESKD) with hemodialysis requires surgical creation of an arteriovenous (AV) vascular access—fistula (AVF) or graft (AVG)—to avoid (or limit) the use of a central venous catheter (CVC). AVFs have long been considered the first-line vascular access option, with AVGs as second best. Recent studies have suggested that, in older adults, AVGs may be a better strategy than AVFs. Lacking evidence from well-powered randomized clinical trials, integration of these results into clinical decision making is challenging. The main objective of the AV Access Study is to compare, between the two types of AV access, clinical outcomes that are important to patients, physicians, and policy makers. Methods This is a prospective, multicenter, randomized controlled trial in adults ≥ 60 years old receiving chronic hemodialysis via a CVC. Eligible participants must have co-existing cardiovascular disease, peripheral arterial disease, and/or diabetes mellitus; and vascular anatomy suitable for placement of either type of AV access. Participants are randomized, in a 1:1 ratio, to a strategy of AVG or AVF creation. An estimated 262 participants will be recruited across 7 healthcare systems, with average follow-up of 2 years. Questionnaires will be administered at baseline and semi-annually. The primary outcome is the rate of CVC-free days per 100 patient-days. The primary safety outcome is the cumulative incidence of vascular access (CVC or AV access)-related severe infections—defined as access infections that lead to hospitalization or death. Secondary outcomes include access-related healthcare costs and patients’ experiences with vascular access care between the two treatment groups. Discussion In the absence of studies using robust and unbiased research methodology to address vascular access care for hemodialysis patients, clinical decisions are limited to inferences from observational studies. The goal of the AV Access Study is to generate evidence to optimize vascular access care, based on objective, age-specific criteria, while incorporating goals of care and patient preference for vascular access type in clinical decision-making. Trial registration : This study is being conducted in accordance with the tenets of the Helsinki Declaration, and has been approved by the central institutional review board (IRB) of Wake Forest University Health Sciences (approval number: 00069593) and local IRB of each participating clinical center; and was registered on Nov 27, 2020, at ClinicalTrials.gov (NCT04646226).

Digital hypoperfusion ischaemic syndrome (DHIS), also known as steal syndrome, is a well recognised serious complication of haemodialysis (HD) access creation. The clinical presentation varies from cyanosis to tissue loss due to necrosis or gangrene. In this article, we present a case of painless digital ulceration due to DHIS and provide a review of the literature. A 40-year-old-female presented with multiple painless digital ulcerations of the left hand. Her medical profile included atherosclerotic disease, hypertension, hyperparathyroidism and type I diabetes causing retinopathy, peripheral neuropathy, gastroparesis and end-stage renal disease (ESRD). Her ESRD required HD with the construction of a left-arm basilic vein transposition arteriovenous fistula (AVF). A year later, she developed intermittent, painless ulcerations of the left hand. A Doppler ultrasound confirmed the diagnosis of DHIS. The patient was treated with AVF ligation surgery. At six months postoperatively, she had near complete re-epithelialisation of her ulcers. This case is unique in that the patient did not have preceding pain, likely due to her underlying diabetic neuropathy. While DHIS in haemodialysis patients with AVF is well documented in literature, digital ulceration in this context is an advanced form of this condition. Early recognition of digital ulceration as a complication of DHIS may enable early intervention and prevent permanent damage. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to describe an efficacious method using Cleaner XT rotational thrombectomy with catheter-directed thrombolysis and drug-eluting balloon angioplasty for the salvage of thrombosed arteriovenous fistulae and grafts. Materials and Methods: Retrospective analysis of all patients with thrombosed hemodialysis accesses who underwent endovascular salvage using the Cleaner XT rotational thrombectomy system at a single institution between June 2019 and September 2020 was performed. Patency was presented as Kaplan-Meier survival curves, and regression analysis was performed to examine predictors of postintervention primary patency and assisted primary patency based on Cox proportional-hazards model. Results: Thirty-four patients with thrombosed accesses underwent Cleaner XT rotational thrombectomy between June 2019 and September 2020. Technical and clinical success were both 100%. Mean procedure time was 62 ± 20 minutes. Mean postintervention primary patency time was 152 ± 51 days; 30, 90, 180, and 365 day postintervention primary patency rates were 89%, 80%, 68%, and 56%, respectively. Mean postintervention-assisted primary patency time was 157 ± 59 days; 30, 90, 180, and 365 day postintervention-assisted primary patency rates were 91%, 82%, 71%, and 59%, and 180 and 365 day secondary patency rates were 97.2% and 94.4%, respectively. Conclusion: The Cleaner XT rotational thrombectomy device demonstrates excellent clinical and technical success rates, with good patency results at all time points up to 12 months postintervention. [ABSTRACT FROM AUTHOR]

Background: Treatment of end-stage kidney disease (ESKD) with hemodialysis requires surgical creation of an arteriovenous (AV) vascular access—fistula (AVF) or graft (AVG)—to avoid (or limit) the use of a central venous catheter (CVC). AVFs have long been considered the first-line vascular access option, with AVGs as second best. Recent studies have suggested that, in older adults, AVGs may be a better strategy than AVFs. Lacking evidence from well-powered randomized clinical trials, integration of these results into clinical decision making is challenging. The main objective of the AV Access Study is to compare, between the two types of AV access, clinical outcomes that are important to patients, physicians, and policy makers. Methods: This is a prospective, multicenter, randomized controlled trial in adults ≥ 60 years old receiving chronic hemodialysis via a CVC. Eligible participants must have co-existing cardiovascular disease, peripheral arterial disease, and/or diabetes mellitus; and vascular anatomy suitable for placement of either type of AV access. Participants are randomized, in a 1:1 ratio, to a strategy of AVG or AVF creation. An estimated 262 participants will be recruited across 7 healthcare systems, with average follow-up of 2 years. Questionnaires will be administered at baseline and semi-annually. The primary outcome is the rate of CVC-free days per 100 patient-days. The primary safety outcome is the cumulative incidence of vascular access (CVC or AV access)-related severe infections—defined as access infections that lead to hospitalization or death. Secondary outcomes include access-related healthcare costs and patients' experiences with vascular access care between the two treatment groups. Discussion: In the absence of studies using robust and unbiased research methodology to address vascular access care for hemodialysis patients, clinical decisions are limited to inferences from observational studies. The goal of the AV Access Study is to generate evidence to optimize vascular access care, based on objective, age-specific criteria, while incorporating goals of care and patient preference for vascular access type in clinical decision-making. Trial registration: : This study is being conducted in accordance with the tenets of the Helsinki Declaration, and has been approved by the central institutional review board (IRB) of Wake Forest University Health Sciences (approval number: 00069593) and local IRB of each participating clinical center; and was registered on Nov 27, 2020, at ClinicalTrials.gov (NCT04646226). [ABSTRACT FROM AUTHOR]

This study aimed to determine the cost-effectiveness of drug-coated balloon (DCB) angioplasty compared with conventional balloon angioplasty (cPTA) in patients with arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) dysfunction from a Singapore healthcare perspective. Existing cost-effectiveness studies comparing DCB and cPTA have not incorporated AVF/AVG abandonment costs. This Markov model-based economic evaluation incorporated AVF/AVG creation and maturation costs on top of routine intervention costs to model a hypothetical cohort of 60-year-old AVF/AVG flow dysfunction patients. Effectiveness was measured in quality-adjusted life-years. Cost-effectiveness was assessed using incremental net monetary benefit (NMB) at a Singapore willingness-to-pay threshold of Singapore dollar (S$)87 000. Deterministic and probabilistic sensitivity analyses were performed to examine parameter uncertainty. To test hypotheses regarding cost-effectiveness, intervention counts per patient, cumulative incidence functions of AVF/AVG abandonment, and survival curves of death were compared between DCB and cPTA. DCB was not cost-effective at 3-year horizon (NMB = −S$1424), but was cost-effective at 1- and 6-year horizons (NMB = S$356 and S$3738, respectively). At 3 years, there was a 34.5% probability of DCB being cost-effective, but at 1- and 6-year horizons there was, respectively, 58.6% and 59.9% probability of DCB being cost-effective. DCB had graphically less AVF/AVG-abandonments, but this was not statistically significant (P =.21). Differences in other parameters were neither graphically nor statistically significant. With AVF/AVG abandonment considered, DCB may be weakly cost-effective compared with cPTA in treating AVF/AVG flow dysfunction. AV access creation and maturation costs could have important explanatory value in assessing DCB cost-effectiveness. [ABSTRACT FROM AUTHOR]

BackgroundPrior studies have suggested that arteriovenous fistula (AVF) or graft (AVG) creation may be associated with slowing of estimated glomerular filtration rate (eGFR) decline. It is unclear if this is attributable to the physiological benefits of a mature access on systemic circulation versus confounding factors.MethodsWe examined a nationwide cohort of 3026 US veterans with advanced chronic kidney disease (CKD) transitioning to dialysis between 2007 and 2011 who had a pre-dialysis AVF/AVG and had at least three outpatient eGFR measurements both before and after AVF/AVG creation. Slopes of eGFR were estimated using mixed-effects models adjusted for fixed and time-dependent confounders, and compared separately for the pre- and post-AVF/AVG period overall and in patients stratified by AVF/AVG maturation. In all, 3514 patients without AVF/AVG who started dialysis with a catheter served as comparators, using an arbitrary 6-month index date before dialysis initiation to assess change in eGFR slopes.ResultsOf the 3026 patients with AVF/AVG (mean age 67 years, 98% male, 75% diabetic), 71% had a mature AVF/AVG at dialysis initiation. eGFR decline accelerated in the last 6 months prior to dialysis in patients with a catheter (median, from -6.0 to -16.3 mL/min/1.73 m2/year, P < 0.001), while a significant deceleration of eGFR decline was seen after vascular access creation in those with AVF/AVG (median, from -5.6 to -4.1 mL/min/1.73 m2/year, P < 0.001). Findings were independent of AVF/AVG maturation status and were robust in adjusted models.ConclusionsThe creation of pre-dialysis AVF/AVG appears to be associated with eGFR slope deceleration and, consequently, may delay the onset of dialysis initiation in advanced CKD patients.

Autologous arteriovenous fistulas in the arm have been shown to be superior to all other types of arteriovenous access and should be placed as far distally as possible. The aim of the present study was to delineate the advantages of snuffbox fistulas (SBFs). From January 2007 through April 2017, first time or new arteriovenous fistula surgery was performed in 375 patients. If feasible, an SBF was chosen. The observation period ended in December 2019. The focus of the present study was on the patency rates, redo surgery, complications, and mortality rates. SBFs were created in 236 patients (92 women and 144 men; mean age, 67 years; 46% with diabetes). Within the first 6 weeks, 11% of the fistulas had failed. The primary patency rates were 75%, 69%, 64%, 61%, 60%, and 58% after 1, 2, 3, 5, 7, and 9 years, respectively. The secondary patency rates were 86%, 83%, 80%, and 77% after 1, 2, 3, and 5 years, respectively. Age, sex, and the presence of diabetes mellitus had no effect on the primary patency rates. Patients with a right-sided SBF had significantly worse primary patency. Of the 236 patients, 154 (65%) had died during the observation period. The incidence of surgical site infection within the first 30 days and access-related ischemia during the observation period was <1%. The results from the present study have shown that with suitable anatomic conditions, a SBF is a good choice for the creation of dialysis access. The patency rates were encouraging, and it offers the longest puncturable segment of the cephalic vein. Also, the rate of perioperative complications was low. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to analyze and evaluate the possible factors in the long-term patency of arteriovenous (AV) access for hemodialysis (HD). Materials and Methods: This was a cross-sectional study recruiting patients from January 2019 to December 2019. All patients who have a working HD vascular access, either AV fistula (AVF) or AV graft which has been working for at least 2 years were included and collected demographic data along with other parameters such as timing of creation, interventions, dialysis sessions, and antiplatelet therapy among others. Results: We included 81 patients with AV access patent more than 2 years; 22.5% were aged >65 years, 39.6% were diabetic, 68.5% were hypertensive, and 26.1% had vascular disease. Analysis revealed that the patient factors such as current tobacco usage and side of creation and technical factors such as maturation time, number of dialysis sessions, and single-center dialysis have a significant effect on the patency of the AV access, while the factors such as past tobacco usage, diabetes, hypertension, use of jugular catheter before access creation, and cannulation technique could not establish any statistical effect on the patency of AV access. Conclusion: There is a complex interaction of factors that may affect the patency of an individual AV access. These need to be carefully considered when selecting surgical site or technique, adjuvant treatments, and follow-up protocols for AVFs.

Purpose: This retrospective study aimed to compare the clinical outcomes between hybrid surgical thrombectomy (ST) and AngioJet pharmacomechanical thrombectomy (PMT) for thrombotic occlusion of arteriovenous graft. Materials and Methods : : This study enrolled patients who underwent either hybrid ST or AngioJet PMT in Presbyterian Medical Center from July 2018 to December 2018. We primarily compared the technical and clinical success rates between the two groups immediately after the procedures. Subsequently, the postprocedure clinical outcomes, including the primary and secondary patency rates and complications, were also compared. Results : : The hybrid ST group had a significantly higher bleeding amount than the AngioJet PMT group (P=0.02). The technical and clinical success rates were 96.7% and 93.3% in the AngioJet PMT group and 100% and 100% in the hybrid ST group, respectively. There was no significant difference in complications between the groups. The primary and secondary patencies at 12 months were not statistically different between the groups. Conclusion : : Comparable clinical outcomes were observed between the AngioJet PMT and hybrid ST groups, highlighting an equivalent efficacy of these two methods. Although the cost is more expensive, AngioJet PMT lowered the bleeding amount. Therefore, it can be considered in selected patients who are at risk of bleeding or reluctant to surgery.

Abstract Background There are limited data focusing specifically on the types of arteriovenous (AV) access used and outcomes of AV access among cancer patients as a consequence of cancer. We aimed to describe outcomes of AV access among cancer patients requiring chronic haemodialysis, and also to compare outcomes between patients with and without cancer. Methods In this single-centre, retrospective, observational cohort study, 84 patients diagnosed with cancer before AV access placement were included; we analysed outcomes of AV access among these patients and compared these outcomes with our previous results. The study endpoints were AV access patency and early failure, defined as AV access abandonment within 12 months after AV access placement. Results Various cancer types, stages, and treatments were identified in our analysis. Autologous arteriovenous fistulas (AVFs) were used for 92.9% of this study population. Using our previous results for comparison, we found no significant difference in death-censored primary (P = 0.546) and secondary (P = 0.266) patency of AV access between patients with and without cancer; however, the rate of early AVF failure was statistically significantly higher among cancer patients (25.6% vs 13.9%; P = 0.008), and the most common cause of AVF failure was patient death. The rate of early failure was significantly higher among patients with advanced-stage cancer (59.1%) than among those with early-stage cancer (12.9%) (P

Purpose: To assess 6-month safety and efficacy of a self-expanding stent graft placement to treat stenotic or thrombosed synthetic arteriovenous access graft at the venous anastomoses., Material and Methods: This prospective, multicenter, post-market surveillance study assessed the GORE ® VIABAHN ® Endoprosthesis (stent graft) in Japanese patients with stenotic or thrombosed vascular access grafts. Key efficacy and safety outcomes were primary patency (PP) and secondary patency (SP) of the target lesion and the vascular access circuit, repeat interventions, technical and clinical success, incidence of adverse and serious adverse events, and device deficiencies through 6 months., Results: The 103 enrolled patients (mean age 71.8 years; 57.3% female) had stent grafts placed in the venous anastomosis of arteriovenous access grafts (on-label). The majority of lesions were stenotic (77.1%) and located in the upper arm (91.4%). Mean lesion length was 42.9 ± 23.6 mm and diameter was 6.7 ± 1.9 mm; 28 patients (27.2%) had elephant trunk placements. Technical and clinical success rates were 100%. At 6 months, Kaplan-Meier estimates of target lesion and circuit PP were 75.1% (95% CI: 65.2, 82.6) and 66.8% (95% CI: 56.4, 75.3), and SP rates were 93.8% (95% CI: 86.7, 97.2) and 93.8% (95% CI: 86.7, 97.2), respectively. Mean cumulative number of reinterventions (0.36; 95% CI: 0.20, 0.51) and incidence of device- or procedure-related adverse events were low (⩽3%). No device deficiencies were reported., Conclusions: The 6-month outcomes of the self-expanding stent graft to treat thrombosed venous anastomoses of synthetic hemodialysis vascular access grafts with stenosis demonstrated safety and effectiveness., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: H. Haruguchi, M. Fukasawa, K. Ikeda, K. Suemitsu, T. Sato, J. Nakamura, T. Noguchi, D. Eguchi, T. Kamimura, and K. Aikawa have no industry relationships to disclose. M. Miyamoto declares: Honorarium from W. L. Gore & Associates, G.K., Medtronic Japan, Boston Scientific Japan, KANAKA Medical Products, Medicon Inc., and Filips Japan. M. Murakami declares: Honoraria for presentations from Boston Scientific, Kaneka Medix, W. L. Gore & Associates, and Medtronic.

Objective: To evaluate the application of percutaneous right atrial puncture and tunneled cuffed catheter insertion and the establishment of peripheral arteriovenous (AV) access in hemodialysis patients with superior vena cava occlusion (SVCO), and to provide evidence-based support for the re-establishment of vascular access in patients with limited vascular resources., Methods: Patients with SVCO were enrolled. Then, either right neck percutaneous puncture catheterization or peripheral AV access construction was performed on the patients according to their personal preference. The patients were divided into the catheter group and the AV access group accordingly. Under the guidance of double C-arm digital subtraction angiography, a puncture was made in the right brachiocephalic vein or the stump of superior vena cava. Portal venous shunt instrument RUPS100 was then inserted through the guide wire, and the hard end of the guide wire was used to puncture the right atrium to achieve sharp recanalization of the occlusive superior vena cava. Afterwards, balloon expansion of the obstructive superior vena cava lesion and the subsequent implantation of the tunneled-cuffed catheter were performed. In AV access group, after evaluating the collateral veins by venougraphy and the peripheral vessel by ultrasound, autologous AV fistula or graft was established according to the vascular conditions of the patient and their personal preferences. The demographic information and clinical outcomes, such primary and primary assisted patency of access, were documented and the incidence of complications was monitored. With the duration of patent access defined as the survival time, Kaplan-Meier survival analysis was performed to compare the patency rates of the two groups., Results: A total of 45 SVCO patients were enrolled and underwent re-establishment of vascular access. Among them, 21 cases were in the catheter group and 24 cases were in the AV access group. All patients had their vascular access successfully constructed and received hemodialysis, and no relevant complications or deaths occurred during the procedure. Over the mean follow-up period of (471.22±125.94) days, the primary patency rates in the catheter group 95.2% and 85.7% at 6 and 12 months, respectively, and the primary assisted patency rates were 100% and 95.2%, respectively. The primary patency rates of the AV access group were 79.2% and 62.5% at 6 and 12 months, and the primary assisted patency rates were 95.8% and 87.5%, respectively. No significant difference was observed between the two groups. Kaplan-Meier survival analysis showed that the median survival time (defined as the duration of patent access) was 670.00 (468.99, 871.01) days in the catheter group and 450.00 (339.24, 560.76) days in the AV access group, with the catheter group outperforming the AV access group. The primary patency rate of the catheter group was better than that of the AV access group ( P =0.049). On the other hand, no significant difference was observed in the primary assisted patency rates of the two groups., Conclusions: Long-term vascular access can be established for SVCO patients by either percutaneous catheterization through the right atrium of superior vena cava stump or the establishment of peripheral AV access. The comprehensive plan, which includes the establishment of AV access first and the subsequent catheterization, is expected to improve the total duration of long-term vascular access and prolong the overall survival of dialysis patients, which provides new ideas for re-establishing dialysis access in patients with exhausted central venous resources., Competing Interests: 利益冲突　所有作者均声明不存在利益冲突, (© 2024《四川大学学报（医学版）》编辑部 版权所有Copyright ©2024 Editorial Office of Journal of Sichuan University (Medical Sciences).)

Background: Arteriovenous (AV) access practice and its outcomes vary internationally. To provide a better understanding of the patterns and outcomes of AV access creation, we investigated the patency and risk factors of arteriovenous fistulas (AVFs) and grafts (AVGs) as initial AV access in the Korean adult population using data from the last 10 years., Methods: The National Health Insurance Service database was queried retrospectively to identify patients undergoing hemodialysis with AVFs and AVGs as well as their clinical characteristics and outcomes from 2008 to 2019. AV access patency and its associated risk factors were evaluated., Results: During the study period, 64,179 AVFs and 21,857 AVGs were placed. The mean patient age was 62.6 ± 13.6 years (21.5% were ⩾75 years old), and 39.3% patients were women. More than half of the patients underwent AV access creation at tertiary care hospitals. At 1 year, the primary, primary assisted, and secondary patency rates were 62.2%, 80.7%, and 94.2% for AVFs, and 46.0%, 68.4%, and 86.8% for AVGs, respectively. AVG, older age, female sex, diabetes, and creation at general hospitals (vs tertiary hospitals) were associated with decreased patency outcomes (all, p  < 0.05)., Conclusion: This study using national data showed that three quarters of patients with AV access had AVF and AVF showed superior performance to AVG and identified several patient and center factors related to AV access patency in Korea., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Thrombosis of the vascular access in patients with end-stage renal disease requiring hemodialysis are common and require timely interventional procedures to restore patency. The aim of the current study was to identify factors having a significant effect on patency rates after access thrombosis. Our hypothesis was the length of time between the initial clotting of the access and the subsequent percutaneous declotting impacts the patency rates of the vascular access., Methods: In this retrospective cohort study, patients with a clotted arteriovenous access between Jan 1, 2011, and Jan 1, 2016, were included. Demographics, access history, and associated details of the access procedure were reviewed from the electronic medical record. Statistical analysis was done using t -test and chi-square or fisher exact tests to compare arteriovenous fistulae (AVF) and arteriovenous grafts (AVG). Primary patency, defined as the time from index procedure to endpoint, was analyzed using the Kaplan-Meier method and log rank test., Results: There were 883 percutaneous declotting procedures reviewed. About 351 procedures were performed in patients with an AVF and 532 with an AVG. The mean time from thrombosis to declotting was 1.71 ± 2.29 days. The overall median primary patency for both AVF and AVG was 43 days with no difference in patency between patients with AVF (39 days) versus AVG (42 days; p  = 0.385). The time period from access thrombosis to declotting did not affect patency rates for either AVG or AVF ( p  = 0.385). On multivariable analysis, prior intervention (HR: 1.32, 95% CI: 1.14-1.53, p  < 0.001) and cardiovascular disease (HR: 1.19, 95% CI: 1.03-1.37, p  = 0.016) were independently associated with access patency., Conclusions: Time from thrombosis to declotting did not affect patency rates however once there was a thrombotic event, recurrent thrombosis requiring intervention was common with patency significantly decreased. Future prospective studies to validate our results and study pathogenic mechanisms of recurrent thrombosis are warranted., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: This prospective, observational first in human study evaluated the safety and effectiveness of WRAPSODYTM Cell-impermeable Endoprosthesis (Merit Medical Systems, Inc.) in the treatment of arteriovenous fistula and arteriovenous graft access circuit stenosis. Materials and Methods: Investigators conducted a prospective analysis of 46 patients with access circuit stenosis from three centres. Treatment sites included the peripheral outflow veins (e.g. cephalic arch, basilic vein swing point; 16 fistula and 10 graft patients); the graft-vein anastomosis (9 patients); and the central veins (up to, but not including the SVC; 11 patients). Primary outcome measures included 30-day freedom from access circuit-related safety events and 30-day target lesion primary patency. Secondary outcome measures included procedural success; device- and procedure-related adverse events; target lesion primary patency; access circuit primary patency; and secondary patency. In-person follow-up was scheduled at 1, 3, 6, and 12 months. An independent data monitoring/clinical event committee adjudicated all reinterventions and device/procedure-relatedness for adverse events. Results: All initial procedures were successful. All but one patient was free from safety events through the first 30 days (97.8% (45/46)). This event was not device-related. Over the remainder of the study, one adverse event was adjudicated as possibly device-related. Six- and 12-month target lesion primary patency rates were 97.7% (42/43) and 84.6.% (33/39), respectively. Six- and 12-month access circuit primary patency rates were 84.4% (38/45) and 65.9% (29/44), respectively. Conclusion: Results suggest that the study device is safe and effective for treatment of stenoses in the peripheral and central veins of arteriovenous access circuits. Level of Evidence: Level 2b, cohort study. [ABSTRACT FROM AUTHOR]

Arteriovenous (AV) access is the preferred hemodialysis modality to avoid the complications associated with tunneled dialysis catheters (TDCs). Despite efforts to create timely AV access, many patients still initiate hemodialysis through TDCs. Our goal was to determine the patient factors associated with having a TDC present at initial AV access creation and how this affects survival. We performed a single-center, retrospective review of all patients who had undergone initial AV fistula creation from 2014 to 2019. Patients with previous peritoneal or AV access were excluded. Univariable and multivariable analyses were used to identify associations with a TDC present at initial AV access creation and patient survival. Of 509 patients who had undergone initial AV access creation, a TDC was present in 280 (55%). The mean patient age was 59.7 ± 14.1 years. The access types were brachiocephalic (47.2%), brachiobasilic (22.4%), radiocephalic (15.5%), and prosthetic (12.6%). The patients with a TDC compared with those without a TDC were less likely to be obese (68.9% vs 54.2%), more likely to be homeless (10.4% vs 4.8%), and more likely to be an inpatient (44.6% vs 18.8%). They were less likely to have seen a primary care physician within 1 year preoperatively (54.3% vs 88.6%) and a nephrologist within 3 months preoperatively (39.3% vs 93%; P <.05 for all). On multivariable analysis, the presence of a TDC at initial AV access creation was associated with no nephrology visit within 3 months preoperatively (odds ratio [OR], 25; 95% confidence interval [CI], 12.5-50; P <.001), homeless status (OR, 2.6; 95% CI, 1.1-6.2; P =.03), and the absence of obesity (OR, 1.8; 95% CI, 1.1-2.9; P =.02). The 1-year survival was similar for patients with (95%) and without (94.8%) a TDC (P =.36) as confirmed by multivariable analysis (hazard ratio, 1.2; 95% CI, 0.65-2.1; P =.63). The absence of a preoperative nephrology visit, homeless status, and the absence of obesity were associated with a TDC present at initial AV access creation. However, the presence of a TDC did not appear to confer changes in short-term survival. Targeted improvements in high-risk populations such as increasing the frequency of preoperative subspecialty evaluation might be warranted to reduce TDC placement before AV access creation at urban safety-net hospitals. [ABSTRACT FROM AUTHOR]

A patient's body mass index (BMI) can affect both perioperative and postoperative outcomes across all surgical specialties. Given that obesity and end-stage renal disease are growing in prevalence, we aimed to evaluate the association between BMI and outcomes of upper extremity arteriovenous (AV) access creation. A retrospective single-institution review was conducted for AV access creations from 2014 to 2018. Patient demographics, comorbidities, and AV access details were recorded. BMI groups were defined as normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-39.9 kg/m2), and morbidly obese (>40 kg/m2). Perioperative complications and long-term outcomes including access maturation (defined as access being used for hemodialysis or the surgeon's judgment that access was ready for use in patients not yet on hemodialysis), occlusion, and reintervention were evaluated. A total of 611 upper extremity AV access creations were performed on patients who were normal weight (29.6%), overweight (31.3%), obese (29.6%), and morbidly obese (9.5%). Access type included brachiocephalic (43.2%), brachiobasilic (25.5%), and radiocephalic (14.2%) fistulas and AV grafts (14.2%). Median age was 60.9 years, and 59.6% were male. Univariable analysis showed no difference between BMI groups for perioperative steal, hematoma, home discharge, or 30-day primary patency. Freedom from reintervention at 2 years on Kaplan-Meier analysis differed by BMI (44.5% ± 4.6% normal weight, 29% ± 3.8% overweight, 39.8% ± 4.3% obese, 34.7% ± 8% morbidly obese; P =.041). There was no difference in 2-year freedom from new access creation or survival. AV access maturity within 180 days differed between BMI groups (74.3% normal weight, 66% overweight, 65.7% obese, 46.6% morbidly obese; P <.001). On multivariable analysis, failure to mature within 180 days was associated with overweight (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.14-3.29; P =.002), obese (OR, 2.12; 95% CI, 1.19-3.47; P =.009), and morbidly obese (OR, 3.68; 95% CI, 1.85-7.3; P <.001) relative to normal weight BMI. AV access reintervention was associated with overweight (hazard ratio [HR], 1.83; 95% CI, 1.34-2.5), obese (HR, 1.56; 95% CI, 1.12-2.16), and morbidly obese (HR, 1.69; 95% CI, 1.1-2.58; P =.02) relative to normal weight BMI. BMI was not independently associated with long-term readmission or survival. Obesity is associated with higher rates of AV access failure to mature and reintervention. Surgeons performing access creation on obese patients must consider this for planning and setting expectations. Weight loss assistance may need to be incorporated into treatment algorithms. [ABSTRACT FROM AUTHOR]

Rationale and Objective: This study aimed to develop a cosmesis scale to evaluate the cosmetic appearance of hemodialysis (HD) arteriovenous (AV) accesses from the perspective of the patient and clinician, which could be incorporated into clinical trials., Study Design: Using a modified Delphi process, two AV access cosmesis scale (AVACS) components were developed in a four-round Delphi panel consisting of two surveys and two consensus meetings with two rounds of patient consultation., Setting and Participants: The Delphi panel consisted of 15 voting members including five interventional or general nephrologists, five vascular surgeons, three interventional radiologists, and two vascular access nurse coordinators. Four patients experienced with vascular access were involved in patient question development., Analytical Approach: For a component to be included in the AVACS, it had to meet the prespecified panel consensus agreement of ⩾70%., Results: The clinician component of the AVACS includes nine questions on the following AV access features: scarring, skin discoloration, aneurysm/pseudoaneurysms and megafistula appearance. The patient component includes six questions about future vascular access decisions, interference with work or leisure activities, clothing choices, self-consciousness or attractiveness, emotional impact, and overall appearance., Limitations: Delphi panel methods are subjective by design, but with expert clinical opinion are used to develop classification systems and outcome measures. The developed scale requires further validation testing but is available for clinical trial use., Conclusions: While safety and efficacy are the primary concerns when evaluating AV access for HD, cosmesis is an important component of the ESKD patient experience. The AVACS has been designed to assess this important domain; it can be used to facilitate patient care and education about vascular access choice and maintenance. AVACS can also be used to inform future research on developing new techniques for AV access creation and maintenance, particularly as relates to AV access cosmesis., Competing Interests: Declaration of Conflicting InterestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare that they have no conflicts of interest regarding patents or royalties, stock/stock options, or first-degree relatives with any of these relationships related to this work. No reimbursement was received for the development of the manuscript.DR, VN, MM, CR, ED, CG, TV, SH, PB, LD and patients CS, DDR, FM, and MB (see acknowledgements) received remuneration from Becton Dickinson (BD) for their participation in the Delphi process.GW, AH, and NF are employees of CRG-EVERSANA Canada Inc., which was contracted by BD to facilitate the Delphi panel process and analyze the results.EK and DC are employees of the American Association of Kidney Patients (AAKP) which was contracted by BD to advise on patient input and recruited the Patient Ambassadors.DR is a consultant for BD and Gore Medical. VN is a consultant for the NACCME – Moderator for AV Access Webcast, supported by an educational grant from Medtronic. SH is a consultant/speaker for BD, Merit Medical, Medtronic, and Gore Medical. ED is a consultant for WL Gore, Angiodynamics, and 3M/KCI. ED is a scientific advisor for Boston Scientific. TY is a consultant for BD, WL Gore and Merit Medical and a scientific advisory board member of BD and Medtronic. CK is a consultant for BD and ACI/Humacyte and advisory board member for Boston Scientific. CL is a consultant for BD, Gore, and Medtronic.Other ConflictsED, KW, and TY are authors and ED is an editor for UpToDate.

Introduction: Arteriovenous (AV) access maturity and patency is critical for patients on hemodialysis. Maintaining a functioning AV access for these patients is of paramount importance. Salvage of failing AV accesses has been traditionally done mainly with angiographic techniques requiring significant amounts of contrast agent and radiation exposure. Ultrasound-guided angioplasty has been described, but its utility needs to be further studied. Methods: Group 1: 42 patients undergoing ultrasound-assisted angioplasty (UAA) for AV access salvage were assessed prospectively for 9 months (October 2016 to June 2017). Group 2: Retrospective data of 47 patients who underwent angioplasty for failing AV access without ultrasound assistance, over 9 months was collected (January to September 2016). This group was matched with Group 1 in terms of age, sex, type of AV access, and cause of AV access dysfunction. Results: There was a statistically significant decrease in the average number of angiographic runs (2.5 vs. 7.9) and fluoroscopy time in minutes (3.8 vs. 13.1) recorded during UAA (P < 0.01). The average quantity of contrast agent used in milliliters (17.6 vs. 49.8) was also significantly less when ultrasound assistance was used (P < 0.01). Conclusion: UAA for failing AV access reduces the radiation exposure and the amount of contrast agent used in these patients who require multiple of these sessions and need dialysis to get the contrast agent out of their circulation. This technique is feasible and reliable; hence should be used more frequently and effectively. Our model of UAA for AV access salvage allows all cases including complex cases to be performed with the added advantage of reduced radiation exposure and contrast agent; serving as a boon to these already distressed patients. Immediate complication management and adjunctive open procedures also become possible because of the hybrid operating room setup with fluoroscopy facility.

This study evaluated the effect of diabetes on outcomes of autogenous fistulas and prosthetic grafts for hemodialysis access in a large population-based cohort of patients. A retrospective cohort study was conducted of all patients who initiated hemodialysis in the United States Renal Database System (2007-2014). The χ 2 test, Student t -test, Kaplan-Meier analysis, log-rank test, and multivariable logistic and Cox regression analyses were employed to evaluate maturation, interventions, patency, infection, and mortality. The study of 381,622 patients comprised 303,307 (79.5%) autogenous fistulas and 78,315 (20.5%) prosthetic grafts placed in 231,134 (60.6%) diabetic patients and 150,488 (39.4%) nondiabetic patients. There was decrease in maturation for diabetics compared to nondiabetics who received autogenous fistulas (adjusted hazard ratio [aHR], 0.86; 95% confidence interval [CI], 0.83-0.88; P <.001) and prosthetic grafts (aHR, 0.88; 95% CI, 0.83-0.93; P <.001). Comparing diabetics vs nondiabetics, primary patency at 5 years was 19.4% vs 23.5% (P <.001) for autogenous fistulas and 9.1% vs 11.2% (P <.001) for prosthetic grafts. Primary assisted patency at 5 years was 35.2% vs 38.7% (P <.001) for autogenous fistulas and 17.2% vs 19.2% (P =.015) for prosthetic grafts. Secondary patency at 5 years was 44.8% vs 48.6% (P <.001) for autogenous fistulas and 34.1% vs 36.8% (P =.002) for prosthetic grafts. There was 5% decrease in primary patency (aHR, 0.95; 95% CI, 0.94-0.96; P <.001) for diabetics compared to nondiabetics who received autogenous fistulas. There was no difference in primary assisted and secondary patency for autogenous fistulas as well as primary, primary assisted, and secondary patency for prosthetic grafts in comparing diabetic to nondiabetic patients. There was also no significant difference in severe prosthetic graft infection between the groups (aHR, 0.99; 95% CI, 0.92-1.08; P =.90). There was a 19% increase in patient mortality for diabetic relative to nondiabetic autogenous fistula recipients (aHR, 1.19; 95% CI, 1.17-1.20; P <.001) and 12% increase for prosthetic graft recipients (aHR, 1.12; 95% CI, 1.10-1.15; P <.001). In this population-based cohort of hemodialysis patients, diabetes mellitus was associated with a decrease in patient survival, access maturation, and primary fistula patency. In contrast, there was no association between diabetes and prosthetic graft patency and severe prosthetic graft infection warranting excision. [ABSTRACT FROM AUTHOR]

Background: There are limited data focusing specifically on the types of arteriovenous (AV) access used and outcomes of AV access among cancer patients as a consequence of cancer. We aimed to describe outcomes of AV access among cancer patients requiring chronic haemodialysis, and also to compare outcomes between patients with and without cancer.Methods: In this single-centre, retrospective, observational cohort study, 84 patients diagnosed with cancer before AV access placement were included; we analysed outcomes of AV access among these patients and compared these outcomes with our previous results. The study endpoints were AV access patency and early failure, defined as AV access abandonment within 12 months after AV access placement.Results: Various cancer types, stages, and treatments were identified in our analysis. Autologous arteriovenous fistulas (AVFs) were used for 92.9% of this study population. Using our previous results for comparison, we found no significant difference in death-censored primary (P = 0.546) and secondary (P = 0.266) patency of AV access between patients with and without cancer; however, the rate of early AVF failure was statistically significantly higher among cancer patients (25.6% vs 13.9%; P = 0.008), and the most common cause of AVF failure was patient death. The rate of early failure was significantly higher among patients with advanced-stage cancer (59.1%) than among those with early-stage cancer (12.9%) (P <  0.001).Conclusions: Although AV access patency rates were similar among patients with and without cancer in the death-censored analysis, cancer patients were more prone to early AVF failure, mainly due to cancer-associated deaths, and this consideration needs to be carefully balanced against individual patients' life expectancies, according to cancer type and stage. [ABSTRACT FROM AUTHOR]

Complications from vascular access are the leading cause of morbidity in the hemodialysis population. The use of tunneled catheters is associated with a greater risk of bacteremia and mortality when compared to other types of hemodialysis access. Infective endocarditis is a serious complication occurring in 2–5% of patients undergoing hemodialysis and is likely secondary to transient bacteremia from repetitive vascular access. Objective: To review outcomes in hemodialysis-dependent patients requiring cardiac valve replacement for infective endocarditis. Methods: A retrospective chart review was conducted to identify all patients who underwent valve replacement within a six-year period (January 2009–December 2014). Inclusion criteria included a diagnosis of infective endocarditis and end stage renal disease on hemodialysis. Relevant clinical information including demographics, comorbidities, valve involvement, causative organisms, and type of hemodialysis access (arteriovenous fistula, arteriovenous graft, or tunneled catheter) was collected. Results: A total of 1497 patients underwent cardiac valve replacement within the six-year period. Of these, 167 patients (11.2%) had infective endocarditis and 119 patients (7.9%) had end stage renal disease on hemodialysis. Overall 30-day mortality for valve replacement was 5.0% (75/1497). Mortality for patients with infective endocarditis was 7.2% (12/167) and for patients with end stage renal disease on hemodialysis was 10.1% (12/119). Thirty-three patients (2.2%) had infective endocarditis and end stage renal disease on hemodialysis. Of these, 12 patients were being dialyzed via arteriovenous fistula, 4 via arteriovenous graft, and 17 via tunneled catheter. Mortality occurred in 2 of 12 patients with arteriovenous fistula, 1 of 4 patients with arteriovenous graft, and 2 of 17 patients with tunneled catheter for an overall mortality of 15.2% (5/33). Conclusion: Infective endocarditis remains a significant problem in patients with end stage renal disease on hemodialysis, particularly when tunneled catheters are utilized for hemodialysis access. Although appropriate algorithms have been developed to minimize long term use of tunneled catheters, bacteremia remains a significant problem. We reviewed our institutional experience and the medical literature to determine outcomes in hemodialysis-dependent patients with infective endocarditis requiring valve replacement. Despite mortality rates between 42 and 73% reported in the literature, our mortality rate was 15.2%. 1 Care of these critically ill patients must emphasize early diagnosis and aggressive management to optimize outcomes. [ABSTRACT FROM AUTHOR]

Background: In dialysis-dependent end-stage renal disease patients, arteriovenous access (AV access) is the chief mode of hemodialysis access. Basilic vein transposition (BVT) is an alternative in patient with failed multiple AV access. The aim of the study is to assess the outcomes of BVT at 1 year of follow-up. Materials and Methods: This prospective, nonrandomized, observational study was conducted in the Department of Vascular Surgery at Sir Ganga Ram Hospital, New Delhi. Forty consenting patients with end-stage renal failure on maintenance hemodialysis having no other options utilizing superficial veins of the upper limb for AV access formation were included. All the complications, secondary interventions and patency rates were calculated at 1 year of follow-up. Statistical analysis was performed using Chi-square test, and patency rates were assessed using Kaplan–Meier survival curve. Results: Most of the patients were in the age group of 51–70 year with the mean age of 51.98 year. The mean basilic vein diameter was 2.84 mm. Fistula thrombosis was the most common complication and was seen in 17.5% cases followed by limb edema in 13% of cases. Re-interventions (fistula thrombectomy, balloon angioplasty etc.) were performed in 27.5% of the patients. The primary patency rate and secondary patency rate at 1 year of follow-up were 77.5% and 85%, respectively. Conclusions: BVT is a feasible and suitable surgical option to provide a durable and autogenous AV access to end-stage renal disease patients requiring maintenance hemodialysis.

On the basis of examination of 35 dialytic patients, who had clinical findings of progressed chronic cardiac insufficiency against the background of the large arteriovenous shunt through existing vascular access, the authors show the complications. The volume of blood circulation along the arteriovenous fistula, which was more than 30% of cardiac output, caused dilatation of heart cavities with cardiac decompensation. If the largest potency to volume remodeling of native proximal arteriovenous fistulas is taken into account, this kind of access could cause hemodynamic abnormalities more often than others (in 22 (62.9%) of patients). The best primary survival was demonstrated by arteriovenous shunts (87.1%) during 2 years. However, long-term survival of native arteriovenous fistulas dramatically outperformed the other kinds of accesses. The choice of constant vascular access for hemodialysis is an important and difficult task in chronic renal disease of V degree patients.

Introduction: Bleeding from a ruptured or infected arteriovenous (AV) access is a life-threatening situation leading to increased mortality in chronic kidney disease (CKD) patients. All these patients need emergent and expeditious management. The procedures described for bleeding complications in AV access are associated with high morbidity and mortality. In some cases, there is a need for a major surgery or bypass. Aim: The aim was to evaluate the safety and efficacy of brachial artery ligation (BAL) in bleeding AV access. Materials and Methods: This was a single-center retrospective analysis of 106 patients who underwent BAL for bleeding AV access (AV graft [AVG]/brachiocephalic [BC] AV fistula [AVF]) from January 2007 to 2017. Results: During this study period, BAL was done in a total of 106 patients, out of which 51 patients underwent AVG explantation with BA ligation and 55 with ligation in BC fistulas. There were 73 males and 33 females with a mean age of 45 years (11–90). The primary etiology was hypertension (66%), diabetes (23.58%), and other causes (10.3%). Twenty patients presented with acute bleeding due to graft erosion and 31 patients had purulent discharge from puncture site with sepsis. Infection was involving anastomosis in all patients. Out of 55 patients who underwent AVF, 5 patients had infection at puncture site 3–4 cm near the anastomosis. Fifty patients had infected pseudoaneurysms at the anastomotic site that developed within 1 week of the creation of fistula. All patients were evaluated and assessed for signs of ischemia in the postoperative period till the time of discharge. Conclusion: BAL is a safe alternative in patients with access site bleeding as it reduces not only the operative time but also the morbidity and mortality associated with CKD patients. Ligation of the brachial artery at the elbow can be used as a primary approach in complicated vascular access.

Background: Data about vascular access (VA) use in failed kidney transplant (KT) patients returning to haemodialysis (HD) are limited. We analysed the VA profile of these patients, the factors associated with the likelihood of HD re-initiation through fistula (AVF) and the effect of VA in use at the time of KT on kidney graft (KTx) outcome., Method: Data from the Catalan Registry on failed KT patients restarting HD and incident HD patients with native kidney failure were examined over an 18-year period., Results: The VA profile of 675 failed KT patients at HD re-initiation compared with that before KT and with 16,731 incident patients starting HD was (%): AVF 79.3 versus 88.6 and 46.2 ( p  = 0.001 and p  < 0.001), graft AVG 4.4 versus 2.6 and 1.1 ( p  = 0.08 and p  < 0.001), tunnelled catheter TCC 12.4 versus 5.5 and 18.0 ( p  = 0.001 and p  < 0.001) and non-tunnelled catheter 3.9 versus 3.3 and 34.7 ( p  = 0.56 and p  < 0.001). The likelihood of HD re-initiation by AVF was significantly lower in patients with cardiovascular disease, KT duration >5 years, dialysed through AVG or TCC before KT, and females. The analysis of Kaplan-Meier curves showed a greater KTx survival in patients dialysed through arteriovenous access than in patients using catheter just before KT (λ 2  = 5.59, p  = 0.0181, log-rank test). Cox regression analysis showed that patients on HD through arteriovenous access at the time of KT had lower probability of KTx loss compared to those with catheter (hazard ratio 0.71, 95% CI 0.55-0.90, p  = 0.005)., Conclusions: The VA profile of failed KT patients returning to HD and incident patients starting HD was different. Compared to before KT, the proportion of failed KT patients restarting HD with AVF decreased significantly at the expense of TCC. Patients on HD through arteriovenous access at the time of KT showed greater KTx survival compared with those using catheter., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Vascular access for hemodialysis has a long and rich history. This article highlights major innovations and milestones in the history of angioaccess for hemodialysis. Advances in achievement of lasting hemodialysis access, swift access transition, immediate and sustaining access to vascular space built the momentum at different turning points of access history and shaped the current practice of vascular access strategy. In the present era, absent of large-scale clinical trials to validate practice, the ever-changing demographic and comorbidity makeup of the dialysis population pushes against stereotypical angioaccess goals. The future of hemodialysis vascular access would benefit from proper randomized clinical trials and acclimatization to clinical contexts. [ABSTRACT FROM AUTHOR]

Long-term hemodialysis, the main treatment modality for patients with end-stage renal disease, requires reliable vascular access. The arteriovenous fistula is the preferred access but remains susceptible to complications, among which ischemic steal syndrome is the most serious. The pathophysiology of ischemic steal syndrome results from the diversion of arterial flow, antegrade, retrograde, or both, into the access. Although antegrade diversion alone can cause steal syndrome, retrograde diversion plays a significant role in the development of ischemia, especially in patients with distal brachial artery-based access. Recently, the role of retrograde steal was disputed, but this paper will elucidate the significant role of retrograde steal in the pathogenesis of ischemia by reviewing the successful outcomes achieved by widely employed surgical procedures. These successful interventions share an important hemodynamic feature to reverse distal ischemia: namely, the conversion of a straight access configuration to a loop configuration. This conversion reduces retrograde steal, thereby increasing distal pressure and flow, resulting in the successful treatment of ischemic steal syndrome. [ABSTRACT FROM AUTHOR]

Introduction: The first choice of vascular access for hemodialysis in patients with end‐stage renal disease is a distal radiocephalic arteriovenous fistula (AVF). Early failure rates for these AVFs vary from 10% to 53%. The effects of predialysis hypotension on failure of AVFs have been described in the literature. Weather lower blood pressures affect early AVF failure has not been extensively studied. We conducted this study to evaluate the effects of preoperative blood pressures on early AVF failure. Methods: Ours was a prospective observational study over a period of 2 years that included 224 patients who underwent distal radiocephalic AVF creation. Only those patients were included whose fistulas were made by surgeons with an experience of greater than five cases. The systolic, diastolic, and mean arterial pressures (MAPs) were recorded preoperatively. Early failure was defined as failure to achieve vascular access from the fistula within first 4 months of its creation. Findings: The overall early failure rate was 27.7%. Early failure was more common in females and diabetic patients. The systolic, diastolic, and MAPs were significantly lower in patients with early failure (P < 0.05). In a multivariable adjusted analysis, lower preoperative diastolic and MAPs were predictors for early failure of distal radiocephalic AVF. Discussion: Our study shows that patients with early failure of AVFs have lower preoperative blood pressure. A larger study is required to substantiate our findings and define target preoperative blood pressure for AVF creation. [ABSTRACT FROM AUTHOR]

The authors aimed to improve the rate of pre-dialysis arteriovenous (AV) access placement for hospitalized patients with advanced chronic kidney disease. The authors developed and implemented a protocol for hospitalized adult patients with an estimated glomerular filtration rate <20 mL/min to streamline the workflow for obtaining AV access. The protocol was piloted on 5 inpatient medical services over 3 months at 1 institution. Specific-Measurable-Achievable-Realistic-Timely (SMART) aims, Fishbone diagrams, Plan-Do-Study-Act cycles, and run charts were used to assess the process and outcomes of the intervention. There were 22 patients in the baseline group and 27 patients in the intervention group. Pre-dialysis AV access increased from 23% to 46%. Length of stay did not differ significantly between the baseline group (8.31 days) and the intervention group (8.4 days). Pathways can improve pre-dialysis AV access without significantly increasing length of stay. [ABSTRACT FROM AUTHOR]