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Background: High-flow arteriovenous fistulae (HF-AVF) may lead to adverse cardiac remodeling in hemodialysis patients. We have investigated whether a novel external stent is safe and effective in reducing and stabilizing flow rates during a 1-year follow-up after HF-AVF reconstruction. Methods: All patients with HF-AVF (access flow rate ⩾ 1500 ml/min), who underwent HF-AVF reconstruction with external stenting in two centers between June 2018 and May 2020, were included in this retrospective analysis. During HF-AVF reconstruction, the dilated vein segment was resected, underwent volume reduction, and was externally stabilized using a braided cobalt-chromium external stent. AVF flow rates were assessed preoperatively, intraoperatively, and at follow up visits using duplex ultrasound. Results: Forty-three HF-AVFs in 42 patients were reconstructed and supported with an external stent (mean age 49 years, range 20–86 years; 74% men). Fifty-one percent were forearm AVFs, 49% were upper arm. The mean preoperative flow rate was 2622 ± 893 ml/min (range: 1500–6000 ml/min) and was decreased to 710 ± 221 ml/min (range: 300–1300 ml/min) intra-operatively after HF-AVF reconstruction. At 6 and 12-months follow-up, the mean flow rates were 1132 ± 320 ml/min (range: 470–1700 ml/min) and 1453 ± 888 ml/min (range: 300–3800 ml/min), respectively. Recurrence of high flow (>1500 ml/min) occurred in 16% and 25% of the patients at 6 and 12 months and primary patency rates were 86% and 70%, respectively. Conclusions: This early experience with novel external stenting for HF-AVF reconstruction demonstrates that it is a safe and effective method for reducing and stabilizing flow rates up to 1-year post procedure. Additional studies are required to evaluate the durability of this procedure over the longer term and assess its effect on cardiac remodeling.

Background: Arteriovenous grafts (AVGs) are used for patients deemed unsuitable for the creation of an autogenous arteriovenous fistula (AVF) or unable to await maturation of the AVF before starting hemodialysis. However, AVGs are prone to infection and thrombosis resulting in low long-term patency rates. The novel aXess Hemodialysis Graft consists of porous polymeric biomaterial allowing the infiltration by cells and the growth of neotissue, while the graft itself is gradually absorbed, ultimately resulting in a fully functional natural blood vessel. The Pivotal Study will examine the long-term effectiveness and safety of the aXess Hemodialysis Graft. Methods: The Pivotal Study is a prospective, single-arm, multicenter study that will be conducted in 110 subjects with end-stage renal disease who are not deemed suitable for the creation of an autogenous vascular access. The primary efficacy endpoint will be the primary patency rate at 6 months. The primary safety endpoint will be the freedom from device-related serious adverse events at 6 months. The secondary endpoints will include the procedural success rate, time to first cannulation, patency rates, the rate of access-related interventions to maintain patency, the freedom from device-related serious adverse events and the rate of access site infections. Patients will be followed for 60 months. An exploratory Health Economic and Outcomes Research sub-study will determine potential additional benefits of the aXess graft to patients, health care institutions, and reimbursement programs. Discussion: The Pivotal study will examine the long-term performance and safety of the aXess Hemodialysis Graft and compare the outcome measures with historical data obtained with other graft types and autogenous AVFs. Potential advantages may include superior long-term patency rates and lower infection rates versus currently available AVGs and a shorter time to first cannulation compared to an autologous AVF. As such, the aXess Hemodialysis Graft may fulfill an unmet clinical need in the field of hemodialysis access.

Rationale & Objective Left-sided internal jugular and all subclavian central venous catheters (CVCs) cause thoracic central vein occlusions (TCVOs) more often than right-sided internal jugular catheters. To enable right-sided CVC placement in patients with TCVO, an inside-out access (IOA) approach was established at 3 vascular access centers in Europe involving use of a novel IOA device advanced from the right femoral vein. In the current analysis, we assessed the eligibility and success rate of this IOA approach in a cohort of patients with TCVO requiring a tunneled dialysis catheter. Study Design Retrospective multicenter observational study. Setting & Participants 36 patients with TCVO treated in Vienna, Austria; Oxford, England; or Cologne, Germany, who required hemodialysis access between July 2016 and June 2018. Exposure Application of the IOA approach to gain vascular access. Outcome The primary end point was the success rate of passing the TCVO to gain dialysis access using the IOA approach. Secondary end points were catheter patency at 3 months and procedure-related complications (early infections, bleeding, hematoma, and pericardial effusions). Analytical Approach Descriptive statistics to characterize eligibility, success rate, and complications of the IOA approach. Results 36 patients with TCVO and history of multiple CVCs and arteriovenous fistulas were referred to the participating centers for vascular access. 32 (89%) patients were eligible for the IOA approach. 39 treatments were performed, with 7 patients undergoing the IOA procedure a second time more than 3 months after initial CVC placement. Dialysis access was established successfully in 38 of 39 (97%) implementations of the IOA procedure. Median intervention time was 43 minutes. No complications occurred. Limitations No comparison to other methods to place CVCs and the observational study design. Conclusions The IOA approach is a promising method to enable rapid access to the right jugular vein in the setting of pre-existing TCVO. Additional experience is needed to understand the generalizability of these observations.

Background: The VasQTM device was designed to improve the outcome of arteriovenous fistulae by optimizing the hemodynamics of the flow in the juxta-anastomotic region of the arteriovenous fistulae through tailored external support. The aim of the study was to evaluate the impact of the VasQ on outcome of radiocephalic arteriovenous fistulae in a real-world setting. Methods: This was a single-center, retrospective analysis of patients with either fistula creation before or after dialysis initiation with implantation of the VasQ device during creation of end-to-side radiocephalic arteriovenous fistulae between June 2018 and May 2019. The flow rate and vein diameter were evaluated intraoperatively, at discharge within 48 h postprocedure and at a follow-up of 1, 3, 6, 9, and 12 months. Results: Thirty-three VasQ devices were implanted during 33 radiocephalic arteriovenous fistula procedures. The study population comprised mostly of men, with an average age of 66 years. Mean intraoperative flow was 428 mL/min (range: 130–945). All patients were discharged with patent arteriovenous fistulae and mean fistula flow of 740 mL/min (range: 230–1300 mL/min). The primary patency was 100% and 79% at 3 and 6 months, respectively. Cumulative/secondary patency was 100% and 90% at 3 and 6 months, respectively. Conclusion: Data presented here suggest that the VasQ device has the potential to provide benefit to the functionality of radiocephalic arteriovenous fistulae.

Background: Sixty years after the first description of Scribner-shunt, and 54 years after publication of the first radio-cephalic arterio-venous fistula (AVF), endovascular percutaneous AVF (pAVF) was introduced. We report a successful case of Ellipsys-pAVF creation and use for hemodialysis in a patient with a previous ipsilateral Scribner-shunt. Case: A 72-year old female patient with chronic kidney disease (CKD), previous right-sided Scribner-shunt and kidney transplant, underwent a successful creation of right-sided Ellipsys-pAVF. The procedure time was 12 min with intraoperative brachial artery volume flow of 720 ml/min. At 39 days, an ultrasound-guided balloon-angioplasty of the outflow cephalic vein stenosis was performed. Cannulations were started 41 days after the creation of pAVF. No additional interventions were required during the follow-up of 258 days with last follow-up volume flow of 1400 ml/min. Conclusions: This is the first report of the creation of pAVF in a patient with previous “traumatic” ipsilateral placement of a Scribner-shunt. It allows the creation of a small anastomosis in very short time, which can be successfully used for hemodialysis treatment on the same day, if necessary, and reduces the expected risk of high-flow AVF with associated peripheral steal and cardiac outcomes (especially in a patient with cardiomyopathy such this one).

Purpose To report device performance and safety for the Surfacer® Inside-Out® access catheter system in patients with thoracic central venous obstruction (TCVO) requiring central venous access (CVA). Materials and Methods Five sites prospectively enrolled 30 patients requiring a tunneled dialysis catheter between February 2017 and September 2018 in the Surfacer System to Facilitate Access in Venous Obstructions (SAVE) Registry (NCT02875899). Patient demographics, medical history and type of TCVO were documented at enrollment. Device performance and adverse events were collected during the procedure and upon hospital discharge. Twenty-nine of the 30 patients enrolled required CVA for hemodialysis. Retrospective classification of TCVOs according to SIR Reporting Standards showed 9 patients (30%) had Type 4 obstructions, 8 (26.7%) had Type 3, 5 (16.7%) had Type 2 and 8 (26.7%) had Type 1 obstructions. Results Central venous cathters (CVCs) were successfully placed in 29 of 30 patients (96.7%). The procedure was discontinued in one patient due to vascular anatomical tortuosity. All 29 patients with successful CVC placement achieved adequate catheter patency and tip positioning. There were no device-related adverse events, catheter malposition, intra- or postprocedural complications. Mean time from device insertion to removal for the 29 patients who successfully completed the procedure was 24±14.9 (range 6 to 70) minutes. Mean fluoroscopy time was 6.8±4.5 (range 2.2 to 25.5) minutes. Conclusion The Surfacer Inside-Out procedure provides an alternative option to restore right-sided central venous access in patients with TCVO.

Obwohl die fruhzeitige Nierentransplantation die Therapie der Wahl bei padiatrischen und jugendlichen Patienten im Endstadium einer Nierenerkrankung (ESRD) ist, benotigen bis zu 30 % dieser Patienten eine Hamodialyse- (HD-)Behandlung. Das Anlegen eines AV-Shunts (AVS) ist recht anspruchsvoll und das Reifen des AVS zeitraubend, besonders bei Kleinkindern. Dies fuhrt zu einem uberproportional haufigen Einsatz von Vorhofkathetern (VK) anstatt von AV-Shunts. In dieser Arbeit beschreiben wir unsere Erfahrungen mit dem Anlegen von AVS bei Kindern und Jugendlichen, die es uns erlaubt, den Einsatz von Dialysekathetern deutlich zu reduzieren bzw. aktuell auf diese zu verzichten. In der Zeit von Januar 2009 bis Dezember 2013 gab es 34 Patienten, die absehbar im Verlauf der nachsten 6 Monate kein Nierentransplantat erhalten bzw. die bereits seit einigen Monaten uber einen Vorhofkatheter (VK) dialysiert wurden. 31 Patienten, 6 bis 19 Jahre alt, erhielten einen nativen AV-Shunt. Drei weitere Patienten im Alter von 12 Monaten bis 3 Jahren und einem Gewicht von 9–12 kg dialysierten weiter uber einen V.-jugularis-interna-VK. Wahrend der Studienzeit wurden bei 31 Patienten 32 AVFs angelegt. Sechsundzwanzig von ihnen erhielten einen Cimino-Shunt (peripher), funf einen Gracz-Shunt (am proximalen Unterarm) und ein Kind bekam einen primaren A.-brachialis-V.-basilica-Shunt. Alle bis auf zwei Shunts reiften regelgerecht mit einer medianen Reifungszeit von 45 Tagen (Bereich: 16–191) bis zur ersten Hamodialyse. Nach 12 Monaten lag die primare Offenheitsrate bei 78 % und die primar assistierte Offenheitsrate bei 94 %. Ein nativer arteriovenoser Shunt ist ein effektiver, adaquater Hamodialysezugang auch fur Kinder und Jugendliche. Das Verfahren erlaubt es, den Einsatz von Vorhofkathetern zu reduzieren und kann sowohl fur die Langzeitdialyse als auch zur Uberbruckung bis zur Nierentransplantation eingesetzt werden.

ObjectivesSeveral studies have documented a slight but significant deterioration of renal function after endovascular repair of abdominal aortic aneurysm (AAA) (EVAR). The aim of this retrospective study was therefore to investigate whether medication with statins may favourably affect perioperative renal function.Material and MethodsFrom January 2000 to January 2008, out of a total cohort of 287 elective patients receiving endovascular repair of their AAA or aortoiliac aneurysm, 127 patients were included in the present study, as their medication was reliably retrievable. Patients were divided according to whether their medication included statins (>3 months). Second, they were subdivided according to their supra- (SR) or infrarenal (IR) endograft fixation. Serum creatinine (SCr) and creatinine (CrCl) clearance were determined preoperatively, postoperatively, at 6 and 12 months. Patients with known pre-existing renal disease, with incorrect placement of the stent graft resulting in severe renal artery stenosis, and with occlusion or renal parenchymal infarction were excluded from the study.ResultsPatients receiving an infrarenal fixation of their graft had no change in the renal function, regardless whether they were on statins or not. In patients with SR fixation not receiving statins, a deterioration in renal function was observed in the early postoperative period ((SCr) preoperative vs. SCr postoperative: 1.02±0.2 vs. 1.11±0.28, p

Absorbable sutures are not well accepted for reconstruction in high-pressure arterial segments because the suture line might break and aneurysmal changes could develop. This hypothesis was checked in the clinical setting of carotid surgery. The morphology of the carotid artery was evaluated by color-coded ultrasound in four groups of patients: group A, 25 patients who underwent standard carotid endarterectomy and patchplasty, including a transverse plication for which absorbable sutures had been used; group B, 10 patients who underwent eversion endarterectomy and reinsertion using absorbable sutures; group C, 15 patients who underwent standard carotid endarterectomy and patchplasty without a transverse placation; group D, 20 patients who suffered from atherosclerotic disease but did not have previous carotid surgery or other carotid pathology. All operations had been performed at least 3 years earlier than the actual examination. Along the internal carotid artery, where an aneurysmal change would have been expected to occur, no differences in absolute size or calculated elliptical cross-sectional vessel area were found. Patients after eversion endarterectomy did not show signs of aneurysmal changes in the area of reinsertion at the carotid bifurcation. Even in the long-term, for this group of patients, no significant aneurysmal changes of arterial reconstructions in carotid surgery performed with absorbable sutures were observed.

Background: Arterial groin infections in drug addicts are associated with a risk of amputation and are potentially lethal. Primary revascularization with an obturator bypass represents a potential alternative to local revision and arterial ligation alone. We report our experience with this approach. Patients and methods: From January 1999 until December 2005 twelve drug addicts were treated due to arterial infections in the groin. In eight patients (seven men, one woman, 31 years old on average), the defect in the artery could not be repaired and ligation of the femoral vessels led to critical ischemia. Therefore, an iliaco-popliteal bypass via the foramen obturatorium was implanted either primarily or secondarily. In three patients a cryopreserved homologous vein was used, five patients received alloplastic grafts. Results: Four of eight obturator bypasses were implanted primarily. In the other four patients the initial treatment was limited to local debridement and artery ligation and an obturator bypass was implanted at a later date. Two grafts occluded within the first 30 days. Thereof, one was successful thrombectomized. The other patient had no critical ischemia and he refused further surgery. Three more grafts occluded at 74, 90 and 103 days after surgery. No patient demonstrated signs of graft infection and all groin incisions healed uneventfully. A lower limb amputation became necessary in one patient even though the reconstruction was patent due to embolisation of mycotic material. All patients remained drug dependent throughout the follow-up time which was 3 months on average and ranged from one to 40 months. Conclusions: The patency of obturator bypasses was 75% at one month. This appears low, especially if one considers the youthful age of the patients and the absence of arterial occlusive disease. Nevertheless, the amputation rate also remained low. Therefore, we feel that this technique may contribute to limb salvage in groin infections in drug addicts.

Purpose Even though early transplantation is still the first-line therapy in paediatric patients with end-stage renal disease (ESRD), up to 30% of these patients still require haemodialysis (HD). Creating an arteriovenous fistula (AVF) is quite challenging, particularly in children, leading to disproportional use of catheters. In this paper, we describe our experience in the creation of AVF with currently no in-dwelling catheters in children and adolescents on HD. Methods From January 2009 to December 2013, there were 34 patients rated as unfit for transplantation for at least the next 6 months or who had already been on HD through a central venous catheter (CVC). Three patients aged between 12 months and 3 years and weighing 9-12 kg were not suitable for AVF. Finally 31 patients, from 6 to 19 years of age with a mean weight of 43.3 ± 14.5 kg (19-80 kg), were assigned to the alternative of AVF. Results During the above-mentioned time period, 31 patients were provided with 32 AVFs; 26 received a distal radiocephalic fistula, five a Gracz-type fistula and one a brachio-basilic fistula. All but two fistulae matured primarily, within an average time of 45 (range: 16-191) days until the first dialysis. The fistula's 1-year primary and primary assisted patency rates were 78% and 94%, respectively. Conclusions The creation of a native vascular access is an effective and durable procedure in paediatric and adolescent patients. It reduces using of CVCs and is appropriate both for long-term treatment and as a bridging procedure until renal transplantation.

AimThe aim of this study was to investigate whether there was an association between the degree of the stenosis of the internal carotid artery (ICA) and post-operative increase of blood flow.Methods and materialsIn 200 out of 660 patients undergoing carotid endarteriectomy (CEA) for a high-degree ICA stenosis, pre-operatively a bilateral selective carotid and intracerebral angiography was performed. The degree of the ipsilateral and contralateral stenosis was digitally assessed by using computer software according to the CC-Index. Intraoperatively, the pressure ratio over the stenosis (ICA/CCA) was measured by direct arterial puncture. Blood flow in the ICA was measured before and after CEA with an ultrasound flowmeter using the transit-time principle. These findings were correlated to the degree of stenosis revealed by angiographic analysis and the pressure ratio.ResultsBefore CEA the median blood flow in the ICA was 171ml/min (range 620ml/min) with a significant (p

Objective. To evaluate the prognostic value of angiographic criteria and internal carotid artery (ICA) stump pressure for shunt placement in carotid surgery under local anaesthesia. Design. Prospective clinical trial at a university hospital. Materials and methods. In 120 patients a cerebral angiography was initiated before undergoing carotid surgery. Seventy-five percent of the patients were neurologically asymptomatic, 13% had transient ischaemic attacks and 12% suffered from previous strokes. The operation was exclusively performed under local anaesthesia and prior to cross-clamping the ICA stump-pressure was measured. A shunt was inserted only if hemispheric symptoms or unconsciousness occurred independent of the angiographic findings or stump pressure. Results. In 23% (27/120) a shunt became necessary and significantly (p

To introduce a novel percutaneous technique to stop blood entry at the lesser aortic arch curvature by coil embolisation in type Ia endoleak after TEVAR. A 61-year-old Marfan patient presented with type Ia endoleak of the aortic arch and a growing aortic arch pseudoaneurysm after TEVAR. Multiple preceding operations and interventions made an endovascular approach unsuccessful. Direct percutaneous puncture of the aneurysmal sac would have cured the sign, but not the cause of blood entry at the lesser curvature of the aortic arch. Direct CT-guided percutaneous puncture of the blood entry site in the aortic arch with fluoroscopically guided coil embolisation using detachable extra-long coils was successfully performed. Three weeks after the intervention, the patient developed fever because of superinfection of the pseudoaneurysm. The blood cultures and CT-guided mediastinal aspirate were sterile. After intravenous administration of antibiotics, the fever disappeared and the patient recovered. Six-month follow-up showed permanent closure of the endoleak and a shrinking aneurysmal sac. Direct percutaneous puncture of the aortic arch at the blood entry site of a thoracic type Ia endoleak after TEVAR and double-chimney stent-grafts with coil embolisation of the wedge-shaped space between the lesser aortic curvature and the stent-graft is possible. • Endoleaks after thoracic endovascular aortic repair are common in 15-30 %. • Most endoleaks can be treated by endovascular means. • Direct percutaneous endoleak repair is described as a bail-out option. • Direct percutaneous aortic arch coil embolisation of type 1a endoleak is possible. • Antibiotic prophylaxis should be administered case by case, considering individual risk factors.

Background: Although it is recognized that carotid endarterectomy (CEA) is the treatment of choice in symptomatic internal carotid artery (ICA) stenosis, in the past, very early CEA has been shown to carry substantial risks. We assessed an interdisciplinary concept of very early CEA in patients with high-grade (>70%) symptomatic ICA stenosis at a single center. Patients and Methods: The course of treatment and outcomes of patients who underwent CEA as early as possible after being referred to the stroke unit for symptoms of transient ischemic attack and stroke were prospectively evaluated, including the following parameters: age, severity of ischemia-related symptoms according to the modified Rankin scale, duration of symptoms until admission, multimodal imaging findings (color-coded duplex, cranial computed tomography, magnetic resonance imaging, positron emission tomography), duration until CEA, perioperative course and complications, as well as duration of in-hospital care. Results: Fifty consecutive patients (median age 68 years, range 44–90) with clinical and imaging signs of transient ischemic attack (n = 19) or stroke (n = 31) were included from January 2000 until December 2004. All except 1 patient showed a preoperative Rankin Conclusions: After careful selection and preparation in a stroke unit, patients with acute stroke due to carotid stenosis can undergo very early CEA under local anesthesia with a perioperative risk comparable with the risk of later endarterectomy, therefore preventing very early stroke recurrences.

Die Nachsorge ist ein elementarer Bestandteil der gefaschirurgischen Therapie. Insbesondere bei komplizierten extraanatomischen Rekonstruktionen ist eine konsequente Verlaufskontrolle fur ein fruhzeitiges Problemmanagement notwendig. Bei der speziellen Patientengruppe der i.v. Drogenabhangigen soll im Folgenden sowohl das funktionelle Ergebnis als auch die postoperative Compliance nach derartigen aufwendigen Eingriffen evaluiert werden.

WHAT THIS PAPER ADDS In the present paper, a novel technique is described for the proximalization of arteriovenous inflow without the use of a prosthetic graft. This is a development of a well-known procedure, but has not been reported before. This could offer a welcome alternative approach for the management of severe access-related ischemia, even though it is not feasible for all patients.The technique provides equivalent results to other procedures, but lacks the typical drawbacks of ligation of healthy vessels, a high rate of recurrent ischemia, and the use of prosthetic grafts. Objective: Proximalization of arteriovenous inflow (PAI) is an established technique for treating patients with access-induced hand ischemia. However, a prosthetic graft, used as arterial inflow, could minimize the benefits of a purely native fistula. In this study, a new PAI technique is reported, which avoids the use of prosthetic grafts in patients with matured basilic and cephalic veins. Patients and methods: Eight patients (seven men, one woman; mean age 62 (45e82) years old) with grade III/IV critical dialysis access-related ischemia (DARI) and with a pre-existing Gracz fistula underwent an operation using modified PAI. The basilic and cephalic veins were preoperatively matured. During the operation, the former arteriovenous anastomosis was closed and the basilic vein was used as arterial inflow. Results: All procedures were technically successful. All patients but one could be discharged with a warm, neurologically improved extremity with a significant reduction in pain. After a mean follow-up of 43.5 (0e52) months, there were no recurrent steal symptoms and all necrotic hand lesions healed. Two patients died during the follow-up, but with well-functioning fistulae. One fistula failed during follow-up and one further fistula was ligated because of chronic neurological damage, which was not improved after the PAI procedure. Four AVFs are still available for hemodialysis. Conclusions: The modification of the PAI technique with a basilic vein as presented here showed similar results to the original PAI procedure. This new procedure does not require prosthetic grafts as in the original PAI technique or a central venous catheter and leads to the enlargement of the puncture site as a result of the superficialization of the basilic vein. Therefore, it is believed that this new technique could be a good option for those patients with matured cephalic and basilic veins who suffer from severe access-related ischemia.