Journal of Vascular Access最新文献

Background: There is growing evidence that type of anesthesia can significantly change vascular access surgery outcomes. Still, there is limited evidence on the impact of regional anesthesia (RA) on patency and failure rates compared to general anesthesia (GA). The aim of this study was to compare the outcomes of RA and GA in patients who underwent vascular access creation at our center.

Methods: Data collected in our prospectively maintained database of patients with chronic renal dysfunction requiring hemodialysis were analyzed, 464 patients were included. Outcome parameters such as maturation, primary failure, postoperative flow measurements, patency rates, and survival outcomes were compared between RA and GA groups.

Results: In this study 489 vascular access procedures were performed in 464 patients, 318 included in the RA group and 171 in the GA group. Median follow-up time was 29.9 (IQR 37.3) months in the RA group versus 33.0 (IQR 40.7) in the GA group (p = 0.252). Anesthesia type did not significantly affect patient survival (HR, 1.01; CI, 0.70-1.45; p = 0.976). No significant differences were found in vascular access flow volume, primary failure, or time to cannulation between the RA and GA groups for both radiocephalic arteriovenous fistulae and brachiocephalic arteriovenous fistulae. Anesthesia type did not significantly change patency outcomes.

Conclusions: Based on our results, both RA and GA demonstrate similar results regarding patient survival, maturation, failure, or patency after vascular access creation. Still, patient-specific factors for each type of anesthesia as well as patient preference should be considered.

Background: Dysfunctional distal arteriovenous fistulas (AVFs) with small caliber distal inflow arteries theoretically require percutaneous transluminal angioplasty (PTA) throughout the entire arterial length. However, in clinical practice, whole distal inflow arterial PTA is not frequently performed due to concerns about possible arterial rupture. Therefore, we investigated the safety and efficacy of this procedure at our center, comparing it with the standard venous PTA.

Methods: From March 2017 to December 2022, 48 cases of distal AVF salvaged by whole distal inflow arterial PTA were assigned into a treatment group and 121 cases of distal AVF salvaged by venous standard PTA not involving the whole inflow artery were assigned into a control group. These two groups were then compared.

Results: Those in the treatment group (who received whole distal inflow arterial PTA) were older than those in the control group (mean age, 69 vs 59 years, p < 0.001). Otherwise, differences between the two groups were unremarkable. After the salvage treatment, primary patency seemed to decrease in the treatment group with whole distal inflow arterial PTA compared to the control group with conventional PTA, although such decrease was not significant (p = 0.072). However, primary assisted patency and secondary patency were comparable between the two groups (p = 0.350 and p = 0.590, respectively). And in the treatment group, only one arterial dissection occurred, which was successfully managed with balloon tamponade so that no distal AVF was abandoned due to complications following whole distal inflow arterial PTA.

Conclusion: Whole distal inflow arterial PTA is an effective and safe option for distal AVF salvage with a narrowed inflow artery, frequently refractory to conventional venous PTA.

Central vein stenosis (CVS) is a common and challenging complication in hemodialysis patients with chronic central venous catheters (CVCs). CVS often remains asymptomatic and is discovered incidentally during follow-up imaging. CVS symptoms include arm swelling, venous hypertension, impaired dialysis flow rates, and development of collateral veins. However, these symptoms can be nonspecific and overlap with other conditions, making the diagnosis challenging. Timely recognition and appropriate intervention are crucial to prevent complications and optimize patient outcomes. Diagnostic tools commonly used include duplex ultrasonography and venography to assess the degree and location of stenosis. Management strategies for CVS encompass a multidisciplinary approach involving nephrologists, interventional radiologists, and vascular surgeons. Initial conservative measures may include anticoagulation therapy, along with pharmacological interventions such as antiplatelet agents and thrombolytics. The endovascular approach is the first line for managing CVS by using balloon angioplasty either alone or in combination with stent placement, but CVS typically recurs frequently, requiring repeated interventions with an increased risk of complications. Additionally, alternative vascular access options such as arteriovenous fistulas or grafts may be considered. In this report, we describe a case of a 25-year-old woman who presented with an extensive history of multiple dialysis access failure for left internal jugular vein central venous tunneled catheter exchange. The procedure was complicated by a fatal superior vena cava rupture likely related to the dislodgment of the guidewire causing perforation into the pericardium space with subsequent cardiopulmonary collapse. The post-mortem autopsy showed severe organized stenosis of SVC and transmural defect above the SVC/atrial junction.

Background: Guidewire-facilitated access to peripheral vessels is commonplace in vascular access, but guidewire insertion into small vessels, such as the radial and distal radial arteries, can still be challenging. Failure to gain access on the first attempt may contribute to increased risks of procedural complications, such as vessel dissection, spasm, and occlusion. This research assessed the safety and efficacy of radial and distal radial artery access using a novel, FDA-cleared, small-core-diameter guidewire with an articulating tip, under ultrasound guidance.

Methods: This was a prospective, single-arm, single-center trial. Patients in need of vascular access were screened for participation and enrolled in the study. Guidewire insertion was attempted by four physicians (three interventional radiologists and an interventional nephrologist) at 162 arterial sites-65 radial and 97 distal radial, having a mean diameter of 2.0 mm.

Results: First-attempt successful placement of the guidewire in the artery occurred at 87.6% of access sites (142/162) and differences in the success rate between the radial and distal radial arteries or between vessels with diameter smaller or larger than 2 mm were not observed (62/68 and 67/77, respectively; p = 0.6). Four of the five reported adverse events were unrelated to the study device or procedure. Two of the three distal radial artery spasms occurred before the guidewire was used. The other two events were a radial artery spasm, and a distal radial artery site hematoma. All adverse events resolved spontaneously.

Conclusions: First-attempt placement of a novel articulating tip guidewire in the radial and distal radial arteries occurred at a high rate in our study and was not associated with safety concerns.

Background: This study aimed to evaluate patency outcomes of arteriovenous grafts (AVGs) before and after using Duplex doppler ultrasonography (DUS) in preoperative mapping and surveillance of AVG.

Methods: In this single-centre, retrospective cohort study 212 patients receiving AVGs from January 2009 to December 2022 were included. In group 1, the creation of AVG as well as screening was based on physical examination alone. In contrast, DUS was used in the preoperative mapping and surveillance of AVG in group 2. The patients also received sulodexide as supplemental medication. Outcomes included primary and secondary patency. The Mann-Whitney U-test was used to compare the differences between groups in number of thrombectomies and preemptive percutaneous transluminal angioplasties (PTAs).

Results: Group 1 included 90 AVGs. The mean follow-up time was 333 days (range: 1-1230 days, standard deviation: 318 days). The primary and secondary graft patency rates were 13.3%, 62.2% at 6 months; 2.2%, 52.1% at 12 months; 0%, 44.3% at 24 months and 0%, 44.3% at 36 months respectively. During the 7-year surveillance of AVG, significantly more thrombectomies were performed than preemptive PTA (p < 0.0001). Group 2 included 122 AVGs. The mean follow-up time was 584 days (range: 1-2040 days, standard deviation: 463 days). The primary and secondary graft patency rates were 54.9%, 95.9% at 6 months; 29.5%, 77.8% at 12 months; and 9.8%, 56.5% at 24 months; 2.5%, 47.1% at 36 months respectively. The primary and secondary graft patency was significantly longer (p < 0.0001, p = 0.002). During the 7-year surveillance of AVG there were significantly more preemptive PTAs performed (p = 0.0004).

Conclusions: The primary and secondary patency of AVG were significantly improved after using DUS in preoperative mapping and surveillance. DUS surveillance led to a decrease in AVG occlusion. A potential positive effect of sulodexide on patency rate of AVG needs more research.

The fibroblastic sleeve is a structure potentially enveloping any intravascular device. At ultrasound scan, it typically presents as a thin layer of variably echogenic material covering the catheter surface, which usually tends to remain into the vessel after the catheter removal. However, several case reports have documented its migration toward the heart or pulmonary artery after a central venous catheter removal. No case of fibroblastic sleeve embolization has ever been documented after a peripheral catheter removal. Here we report the case of a 76-year-old woman with a 3 Fr/20 cm polyurethane midline catheter on which the development of a surrounding fibroblastic sleeve was documented during serial, routine ultrasound follow-up. A few minutes after the catheter removal, a 7 cm-echogenic floating mass attached to the anterior leaflet of the tricuspid valve-which was absent the days before-was noticed by a routinely-planned transthoracic cardiac ultrasonography. Due to the very close interval between the catheter removal and the appearance of the tricuspidal mass, together with the disappearance of the fibroblastic sleeve from the cannulated vein, the ultrasound finding was attributed to the acute embolization of the fibroblastic sleeve. No respiratory, cardiovascular, or septic complication was documented in the following weeks, during which the fibroblastic tricuspidal mass progressively reduced and completely disappeared after 45 days. Despite being an extremely frequent and totally expected occurrence associated to any intravascular device, fibroblastic sleeve may occasionally lead to potentially serious complications. An accurate ultrasound follow-up of catheters positioned either in central or in deep peripheral veins should be recommended to monitor the development and the evolution of a fibroblastic sleeve or thrombosis, both during the catheter dwelling time and after its removal.

Crisis intervention is crucial in managing acute medical crises to improve outcomes. Toxic Epidermal Necrolysis (TEN), a severe skin reaction often triggered by drug exposure, poses challenges, especially in chemotherapy patients. Evidence on nursing care for TEN patients with Peripherally Inserted Central Catheter (PICC) retention during chemotherapy is limited. We present a 69-year-old male with recurrent bladder tumor receiving atezolizumab via PICC, developing TEN and catheter-associated skin impairment (CASI). Despite extensive skin breakdown, PICC retention was essential and innovative PICC care was necessary. A crisis management team implemented a six-step crisis intervention model, ensuring safety and treatment adherence. A three-layer dressing protocol was used to optimize wound care, prevent further CASI, and ensure the patient's comfort. This case underscores the efficacy of crisis intervention in managing TEN with PICC during chemotherapy, highlighting interdisciplinary collaboration and innovation in complex medical scenarios.

Introduction: Vascular access (VA) is essential for patients with hemodialysis, and its dysfunction is a major complication that can reduce quality of life or even threaten life. VA patency is not only difficult to predict on an individual basis, but also challenging to predict in real-time. To overcome this challenge, this study aimed to develop a machine learning approach to predict 6-month primary patency (PP) using photoplethysmography (PPG) signals acquired from the tips of both index fingers.

Materials and methods: PPG signals were obtained from hemodialysis patients who received an arteriovenous fistula or an arteriovenous graft as primary VA in a single center from April 2023 to December 2023. With PPG wearables, we propose a method that can efficiently and quickly generate the morphological features of the PPG signal to recognize different groups of patients. For the generated features, an independent sample t-test was used to evaluate their effectiveness for machine learning. Then, two supervised learning algorithms, k-nearest neighbors (kNN) and support vector machine (SVM), are used further to identify VA patency in advance.

Results: The study involved 31 patients, of whom 14 had 6-month PP, while 17 did not. Using the kNN algorithm, machine learning classified patients into two groups with 82% precision based on PPG signals, while the SVM algorithm showed a precision of 82%.

Conclusions: Our approach can provide reliable classifications for VA patency. It is effective to use the proposed PPG signal features to predict 6-month PP of VA.

Background: The decision to place a subcutaneously tunneled catheter is an infection prevention strategy for long term venous access allowing the proceduralist to access a vein and relocate the catheter exit site to a region on the body where care and maintenance can be safely performed. Subcutaneously tunneled centrally inserted dialysis catheter (ST-CIDC) placement is commonly performed in patients with renal disease and is traditionally performed with fluoroscopy in the interventional radiology suite or the operating theater. However, today's interventional radiologists and surgeons perform advanced invasive procedures that can be time-consuming resulting in delays in the scheduling of elective tunneled catheter placements.

Methods: In this retrospective case series, we present data from a quality improvement initiative aimed at integrating available evidence for bedside tunneled dialysis catheter placement with electrocardiograph (ECG) tip positioning, to expedite care, improve patient safety outcomes, and reduce healthcare costs associated with the procedure.

Results: Most patients in the study had end-stage renal disease (59%) or acute kidney injury (37%) and were receiving placement for the first time (91%). The right jugular vein was cannulated in 84% of the placements and rates of post-insertion complications were <1%, regardless of the vessel cannulated. Performing bedside tunneled dialysis catheter placement resulted in a cost savings of $385,938.76 over a 2-year period.

Conclusions: The placement of ultrasound guided tunneled dialysis catheters at the bedside following a pre-procedural evaluation of the right jugular, brachiocephalic, and femoral veins is a safe option resulting in expedited patient care, decreased resource utilization, and significant cost savings. Non-bedside techniques performed in interventional radiology, or the operating room should remain a consideration for patients requiring left sided venous access, signs of central stenosis, a history of multiple tunneled catheters, or patients requiring moderate sedation outside of the ICU.