Journal of Vascular Access最新文献

Catheter lock solutions (CLs) are commonly used to reduce the risk of central line-associated bloodstream infections (CLABSI), but it remains uncertain which type is most beneficial for patients. This systematic review and Bayesian network meta-analysis synthesized available evidence by comparing different CLs directly and indirectly to prevent CLABSI and rank their effectiveness. A comprehensive search was performed across PubMed, Embase, Ovid, Scopus, Cochrane Library, and Google Scholar. After screening 2359 records by title and abstract and reviewing 374 full-text articles, 39 studies were included, covering seven CLs types. Bayesian network meta-analysis was conducted using STATA and ADDIS. Results showed that taurolidine-based (TCLs), ethanol-based (ECLs), gentamicin-based (GCLs), and EDTA-based (EDTA-CLs) solutions were more effective than saline or heparin in preventing CLABSI. According to the surface under the cumulative ranking curve (SUCRA), TCLs had the highest probability of reducing CLABSI (89.1%), followed by GCLs (82.6%) and EDTA-CLs (72.6%). In conclusion, this review underscores the clinical value of catheter lock solutions in CLABSI prevention, with strong evidence supporting the integration of TCLs into central venous catheter maintenance bundles due to their significant benefits.

The use of covered stents in hemodialysis vascular access has increased in recent years. The most frequently reported mode of stent failure is edge restenosis, whereas edge collapse is extremely rare and has seldom been described. We report the case of a 48-year-old man who initially underwent placement of a covered stent in the cephalic arch, followed 1 year later by deployment of a second stent for edge stenosis. Two months thereafter, collapse of the distal edge of the second stent resulted in thrombosis of the arteriovenous fistula. Although surgical thrombectomy combined with percutaneous transluminal angioplasty (PTA) temporarily restored the stent configuration, recurrent collapse was observed 2 days later. To address this, a limited skin incision was made near the distal edge of the stent, and under ultrasound guidance, the collapsed edge was sutured and fixed to the surrounding subcutaneous tissue to prevent further infolding. This approach achieved durable results, with follow-up examinations at 2 and 6 months showing no recurrence of collapse, preserved stent patency, and stable fistula function with reduced tension. This case highlights the potential role and effectiveness of surgical fixation in managing the rare complication of stent edge collapse in hemodialysis access.

Introduction: The 2019 KDOQI guidelines recommend fluoroscopy-guided placement of tunneled cuffed catheter tips within the right atrium. However, fluoroscopy may misidentify the cavoatrial junction. This study quantified the discrepancy between digital subtraction angiography and fluoroscopy in locating the cavoatrial junction and assessed its impact on intrathoracic central venous stenosis risk.

Methods: This retrospective cohort study analyzed 90 patients with right internal jugular tunneled cuffed catheters who underwent DSA at our hospital between June 2023 and May 2025; digital subtraction angiography and fluoroscopy were compared in locating the cavoatrial junction. Catheter tips were classified by DSA-defined location: superior vena cava upper segment (Group A), lower segment (Group B), or right atrium (Group C). Intrathoracic central venous stenosis risks were analyzed using logistic regression.

Results: The DSA-defined cavoatrial junction was consistently 21.64 ± 7.23 mm caudal to fluoroscopic landmarks. The incidence of central venous stenosis was 34.4%. Intrathoracic central venous stenosis incidence was significantly higher in Group A versus C (p < 0.0167) and Group B versus C (p < 0.0167). Catheter tip location within the superior vena cava was associated with 5.78-fold higher odds of intrathoracic central venous stenosis compared to placement within the right atrium (OR = 5.78, 95% CI: 1.75-19.06; p = 0.004).

Conclusion: Fluoroscopy overestimates the cavoatrial junction position. Given that right atrium placement reduces intrathoracic central venous stenosis risk, advancing the catheter tip 10-30 mm beyond fluoroscopically guided landmarks constitutes a key maneuver for achieving accurate positioning. Implementation of this optimization strategy is associated with a 5.78-fold reduction in odds of intrathoracic central venous stenosis, providing actionable optimization for hemodialysis access management.

Objective: This study aims to determine the impact and potential relationship between maturation rates of upper limb arteriovenous fistulas and a previous history of central venous catheter placement for hemodialysis.

Methods: A retrospective analysis was conducted on demographic and clinical data originating from vascular access procedures carried out at the prestigious National Institute of Medical Sciences and Nutrition Salvador Zubiran (INCMNSZ) in Mexico City between the years 2008 and 2019. Utilizing univariate inferential statistical methods, a meticulous comparison of demographic variables, comorbidities, and other pertinent factors were performed to elucidate potential impacts on the maturation of upper limb arteriovenous fistulas. Statistical significance was determined at p < 0.05, adopting a two-tailed approach.

Results: The analysis encompassed a total of 174 autologous upper limb fistulas, with a median patient age of 47 years (IQR 33-63). No statistically significant differences were identified in maturation rates among patients with a previous history of tunneled, jugular, or subclavian catheters. No statistically significant difference was observed in patients with a history of peritoneal dialysis. While the primary objective revealed no statistically significant difference, a trend toward favorable fistula maturation was observed in patients with ⩽1 catheters (p = 0.06).

Conclusions: Although no statistically significant difference was observed, a trend favoring fistula maturation was noted in patients with ⩽1 catheter (p = 0.06). With a larger sample size, results supporting the main hypothesis of this study may be identified.

Cephalic arch stenosis (CAS) is a common cause of arteriovenous fistula (AVF) dysfunction. Angioplasty, with or without bare-metal stent, is associated with a high risk of early restenosis. The use of a stent graft at the cephalic arch is gaining popularity, as it improves patency rates and decreases the number of reinterventions. This case report describes a 65-year-old woman with end-stage renal failure who had a right brachiocephalic AVF created for haemodialysis. She suffered from cephalic arch stenosis, which repeatedly recurred despite multiple angioplasties. A stent graft was deployed but was complicated by twisting, leading to recurrent dysfunction. The twist was finally resolved with additional venous bare stents to provide mechanical support. This case highlights the potential complication of stent graft twisting and illustrates an endovascular solution to that. The underlying reasons for the twist are also postulated, which may provide insights for future treatment planning in CAS.

Endovascular stenting is the standard of care for superior vena cava (SVC) obstruction, providing rapid symptom relief and high technical success rates. However, no guidelines exist for the concurrent use of centrally inserted central catheters (CICCs) within stents or for optimal antithrombotic strategies. We report a case of a 69-year-old woman with malignant Superior Vena Cava Syndrome (SVCS) treated with a central venous stent (CVS) placement who subsequently required a jugular CICC for antibiotic therapy. Six days later, she developed recurrent edema. Imaging revealed extensive thrombosis involving the stent and adjacent veins, while ultrasound demonstrated a prominent fibroblastic sleeve (fibrin sheath) at the catheter entry site. Despite thrombo-aspiration and catheter removal, the sleeve persisted, exhibiting the characteristic "ghost sign." Additional kissing stents restored partial patency, and anticoagulation was resumed.This case underscores the potential risks of placing a CICC within a previously inserted CVS. The coexistence of thrombosis and a fibroblastic sleeve on the same catheter-reported here for the first time-suggests that these entities, although distinct, can occur together. It is plausible that the flow reduction caused by the fibroblastic sleeve may increase the risk of thrombus formation, thereby raising the likelihood of stent thrombosis and recurrent SVCS. Imaging revealed that a fibroblastic sleeve, recognizable by the "ghost sign," persisted even after catheter removal, underscoring the diagnostic and therapeutic challenges of distinguishing it from thrombosis. Current guidelines do not address this situation, and data are limited. Until more evidence is available, clinicians should consider alternative access options-such as Femorally Inserted Central Catheters (FICCs)-when CVS are present and manage anticoagulation carefully. Multidisciplinary teamwork and regular follow-up are essential to improve outcomes and prevent recurrence.

Background: Conventional intraosseous (IO) access is typically reserved for emergency situations and limited to short-term use (⩽48 h). We introduce a novel, fully subcutaneous IO device designed to provide stable, longer-term vascular access in non-emergent settings. This device may benefit patients requiring intravenous therapies with challenging venous access or chronic kidney disease (CKD) who need to preserve peripheral and central veins for future arteriovenous fistula creation for hemodialysis.

Aim and methods: This prospective, single-arm, first-in-human study evaluated the feasibility and safety of the fully subcutaneous IO device over a 7-day implant with daily infusions in patients with challenging venous access or CKD. Patency was assessed radiographically after placement, clinically during infusion visits, and either radiographically or clinically before explant. Usability and tolerability were evaluated through clinician and patient surveys. Safety was assessed by monitoring device-related adverse events for 30 days after explant.

Results: Ten patients were successfully implanted with the device, and patency was maintained for a full 7-day duration without routine maintenance. Clinicians reported easy device implant, use, and explant. Three patients experienced pain during the first medullary infusion; one had additional pain during the second and third infusions. No patient discomfort was reported after day three. No adverse device effects (ADEs) occurred during the study or follow-up.

Conclusion: This novel, fully subcutaneous IO device appears to be a feasible, usable, and safe option for short-term infusion therapy in patients with CKD or challenging venous access. These findings support further investigation into its use as a long-term intraosseous vascular access option.

Arteriovenous fistulas (AVFs) remain the preferred vascular access for haemodialysis globally. Malaysia has a rapidly rising burden of end-stage renal disease (ESRD), but reported AVF outcomes vary across institutions, and no national synthesis has previously been performed. This review aimed to evaluate AVF outcomes in Malaysia, consolidate available evidence, and provide baseline reference values to guide future access planning and research. A systematic search of PubMed, Scopus, Web of Science, Google Scholar and Malaysian databases was conducted from inception to June 2025. Eligible studies reported outcomes of native AVFs in Malaysian populations. The primary outcome was 12-month primary patency. Secondary outcomes included primary failure (early thrombosis or non-maturation), maturation at ~6 weeks, complications and predictors of outcome. Random-effects meta-analysis was used. Risk of bias was assessed using RoB 2 and ROBINS-I. Twelve studies (n = 1426 patients) were included: two randomized trials and ten observational cohorts. The pooled 12-month primary patency rate was 73.5% (95% CI, 62.4%-84.6%; I² = 93%, considerable heterogeneity). The pooled primary failure rate was 19.3% (95% CI, 14.1%-24.5%; I² = 69% - substantial heterogeneity), and pooled early maturation was 84.2% (95% CI, 78.1%-90.4%; I² = 73%, substantial heterogeneity). Upper-arm AVFs demonstrated consistently higher maturation than forearm sites. Diabetes, small vessel calibre and central venous catheter dependence were the most common predictors of poor outcome. Intraoperative heparin significantly reduced early thrombosis (RR 0.36; 95% CI, 0.13-0.99), whereas fish oil and aspirin had no measurable benefit. Complication profiles resembled international reports, dominated by stenosis and thrombosis. Malaysian AVF outcomes demonstrate favourable early maturation and acceptable 12-month patency, consistent with international experience despite a high comorbidity burden. These data provide the first consolidated national benchmark for vascular access outcomes in Malaysia and highlight priorities for future multicentre collaboration, surveillance strategies and standardized reporting.

Background: Arterial blood gas (ABG) analysis is essential in the emergency department (ED) for the rapid assessment of acid-base status, oxygenation, and metabolic disturbances in critically ill patients. The distal forearm (DF) is the conventional site for radial arterial puncture. Recent studies in interventional cardiology have explored the anatomical snuffbox (ASB) approach as an alternative vascular access site; however, its utility for ABG sampling in the ED remains unclear.

Methods: In this single-center, randomized controlled non-inferiority trial conducted from May 2022 to October 2023, 356 adult patients requiring ABG analysis in the ED were randomized in a 1:1 ratio to undergo sampling via either the ASB or DF approach. Eligible patients had a palpable radial pulse at both access sites, while those with hypotension, local site abnormalities, or a positive Allen's test were excluded. The primary outcome was the first-pass success rate; secondary outcomes included the number of attempts, failure rates (defined as failure to obtain a sample after three attempts), and procedure-related complications observed during a 12-h ED stay.

Results: The DF approach demonstrated a significantly higher first-pass success rate (74.7%) compared with the ASB approach (60.7%; p = 0.006). The failure rate was lower in the DF group (5.1%) relative to the ASB group (21.3%; p < 0.001). Although minor complications such as hematoma, arterial spasm, and bleeding were noted in both groups, there were no statistically significant differences in overall complication rates.

Conclusions: Although the anatomical snuffbox (ASB) approach has been proposed as an alternative access site based on potential benefits in other procedural settings, this trial found that it did not meet non-inferiority compared with the conventional distal forearm (DF) method for ABG sampling in the ED. Given the higher failure rate with the ASB approach, the DF method remains the preferred sampling site in this setting.

Trial registration: The Clinical Trials Registry - India (CTRI/2022/07/044216).

Background: The maturation and patency of arteriovenous fistula (AVF) are crucial in patients requiring hemodialysis (HD). Although several trials have been conducted to evaluate the impact of various medications on AVF maturation, little has been observed. Apixaban, a direct oral anticoagulant, has been shown to have a protective effect against intimal hyperplasia (IH). We therefore aimed to determine the effect of Apixaban on the patency, maturation, and anastomotic size of AVF after creation.

Methods: This two-center randomized study included all patients who underwent AVF creation between July 2023 and November 2024. The primary outcome was AVF maturation. Secondary outcomes were complications and mortality. Patients were divided randomly into two groups. The first group (treatment group, N = 44) received Apixaban 2.5 mg twice daily, while the second group (control group, N = 48) received no treatment. A Doppler ultrasound was performed for measurement of anastomotic size, vein diameter, and flow volume based on subsequent fistula adequacy. Autogenous AVFs were constructed with end to side anchor technique anastomosis as distally as possible in all patients. Both groups were followed‑up for 6 months.

Results: Ninety two patients underwent AVF creation during the study period. After 6 months follow up, the primary patency in the Apixaban group was 90.9%, while it was 79.2% in the control group (p = 0.117). The incidence of anastomotic stenosis was significantly lower in the Apixaban group compared to the control group (9.1% vs 29.2%, p = 0.015). A thrombosis event was reported in three cases (6.8%) and nine cases (18.8%), in Apixaban and control groups respectively (p = 0.09). Patients who received Apixaban encountered a total of ten bleeding episodes (one major and nine minor incidents), accounting for 22.7% of the group (p = 0.11). It is important to highlight that none of these incidents led to fatalities.

Conclusion: Apixaban might be beneficial for decreasing early AVF maturation failure in patients requiring HD.