Journal of Vascular Access最新文献

Background: Central venous access devices (CVAD) are widely used in patient care, providing an essential, reliable pathway for patients to receive chemotherapy, long-term infusions, and nutritional support. However, a system of exercise management has not been developed in patients with CVAD.

Purpose: To evaluate and summarize the evidence for management exercise in patients with CVAD and provide guidance for clinical practice.

Methods: Systematic searches were conducted in domestic and international databases for evidence on exercise in patients with CVAD. The types of literature included clinical decisions, guidelines, systematic reviews, expert consensus, and original research. The retrieval time is from the database construction to October 2023.

Results: We finally identified 20 articles that had high-quality results. We summarized the 26 pieces of best evidence from these articles, covering nine aspects: the effects of exercise interventions; ways of exercise; type of exercise tools; timing of exercise; dose of exercise; exercise precautions; monitoring of exercise safety; complications of exercise interventions; scales to assess the effect of exercise. Of these pieces of evidence, 12 were "strong" and 14 were "weak," 14 pieces of evidence were recommended in level 1, and 12 pieces of evidence were recommended in level 5.

Conclusion: The following 26 pieces of evidence for exercise management of CVAD in patients were finally recommended. However, as this evidence comes from only one country, relevant factors such as the clinical environment should be evaluated before application. Further studies should include diverse populations from multiple countries to ensure the findings are widely applicable and to identify any potential variations in exercise outcomes for patients.

Introduction: Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis. Whether acute arm movement impacts arteriovenous fistula (AVF) blood flow is unknown.

Methods: In this cross-sectional analysis, we evaluated AVF blood flow using an ultrasound device at resting and after three muscle movements for proximal (elbow flexion, shoulder adduction and abduction) or distal AVF (fist extension and flexion, fingers squeeze), without and with a 2 kg load.

Results: We included 23 patients (14 men), 53 ± 13 years, 26.1% with diabetes, on dialysis for a median time of 5.2 months. At rest, blood flow in proximal and distal AVF were 4355 (2470, 7233) mL/min and 2286 (2063, 2442) mL/min, respectively. There was no significant difference between blood flow at resting and any movement before and after load in either proximal or distal AVF (p > 0.05 for all comparisons).

Conclusion: Acute arm movement with or without load does not significantly alter the blood flow of mature AVF. These results demystify the general belief that patients should avoid AVF arm movement.

Background: Outpatient Parenteral Antibiotic Therapy (OPAT) services have expanded throughout the world thanks to elastomeric pumps (EP). Their flowrate is known to vary by ±15%. Treatment effectiveness and the organization of care at home may be impacted, especially with piperacillin/tazobactam infusion (TAZ). An in vitro study was conducted, following the guidelines of EP and drug manufacturers, to assess the impact of three parameters on the accuracy of the infusion flowrate: composition, volume, and temperature of the infused solution.

Methods: A test bench was created to evaluate the accuracy of flowrate infusion when changing one parameter at a time (addition of TAZ in the infused solution, minimal filling volume and flow regulator at ambient temperature) compared to the standard conditions provided by the manufacturer. Two types of EP were used and connected to a weighing scale. Instantaneous and average mass flowrates over the total infusion time were determined from the reservoir mass loss. These values  were compared with the nominal flowrates announced by the manufacturers to evaluate the performance of EP under the different conditions. The time the flowrate was within the expected ±15% around the nominal flowrate was calculated as the time in range (TIR).

Results: Deviations of the measured mean flowrate from the nominal flowrate range from -37% to 18% depending on the condition. TIR went from 0% to 80% of the total infusion duration. The test bench showed a reliability of more than 96%.

Conclusions: The test bench highlights differences in performance. These results raise several questions about the sensitivity of EPs for TAZ infusion in OPAT, the norm's requirements and the need to prescribe a medical device whose limits are well known, as well as therapeutic education or the course of care for treatment administration.

Background: Hemodialysis vascular access predisposes patients to exit-site infections (ESIs) and bloodstream infections (BSIs), resulting in significant morbidity and mortality. The objective was to characterize hemodialysis catheter-related (CR) ESIs and BSIs while considering potential factors associated with infection.

Methods: The study period was selected to coincide with new CR-infection prevention measures at the midpoint. These included masking during exit-site care, using chlorhexidine-alcohol versus povidone-iodine antiseptic, administering cefazolin prophylaxis with central venous catheter (CVC) insertions, and reducing temporary CVC use for chronic hemodialysis starts. Data were collected retrospectively, including patient characteristics, hemodialysis history, CVC details, and CR-infections. Quarterly infection rates were calculated per 1000 CVC days, and potential factors associated with infection were investigated. Modeling was used to characterize infection rates and covariates over time.

Results: Over 39 months, data for 267 patients, 499 CVCs, and 114,825 CVC days were captured. During the study period, there were 113 ESIs and 64 BSIs, with >80% of infections caused by gram-positive bacteria. ESI and BSI rates were 0.98 and 0.56 per 1000 CVC days, respectively. There were significant reductions in infection rates over time. The ESI rate dropped when new CR-infection prevention measures were introduced (p < 0.01), from a mean of 1.28 to 0.73 per 1000 CVC days (p = 0.003). The rate of BSI trended downward to a low of 0.10 per 1000 CVC days in the last quarter of the study. The BSI rates associated with temporary and permanent CVCs were 1.25 and 0.53 per 1000 CVC days, respectively (p = 0.1). There was a strong correlation between the declining BSI rates and declining temporary CVC use over time (rho = 0.73, p = 0.005).

Conclusions: CR-ESI rates dropped significantly when new hemodialysis CR-infection prevention measures were introduced. CR-BSI rates declined over the study period, as did the use of temporary CVCs.

Introduction: Effective pain management during peripheral intravenous cannulation (PIVC) poses a significant challenge for medical practitioners in the emergency department. A range of non-pharmacological interventions have been advanced to address this concern. This study aimed to compare the effects of the Valsalva maneuver (VM) and auriculotherapy on pain intensity during PIVC in adults.

Methods: A randomized clinical trial was conducted on 99 adult patients referred to Emergency department Hospital in Gonabad, Iran. Patients were randomly assigned into three groups VM (n = 33), auriculotherapy (n = 33), and control (n = 33). Pain levels were assessed using the Visual Analog Scale (VAS) immediately after PIVC. Data analysis was performed using SPSS version 25, with a significance level of less than 0.05.

Results: The mean pain scores in the VM, auriculotherapy, and control groups were 2.88 ± 3.81, 2.57 ± 3.45, and 7.13 ± 2.39, respectively. Kruskal-Walli's test revealed a significant difference among the groups (p < 0.001). Pairwise comparisons indicated no significant difference between VM and auriculotherapy groups in pain intensity (p = 0.67). However, significant differences were observed between the control group and the VM group (p < 0.001) as well as between the control group and the auriculotherapy group (p < 0.001).

Conclusion: The results of this study demonstrate that both auriculotherapy and the Valsalva maneuver effectively reduce pain during PIVC in adults. Healthcare providers can consider incorporating these methods to help alleviate pain during PIVC procedures.

Objective: The primary objective of this study is to develop and validate a high-risk model for Arteriovenous Fistula Thrombosis (AVFT) in patients undergoing autogenous arteriovenous fistula surgery for hemodialysis.

Methods: Retrospectively, we collected general information, clinical characteristics, laboratory examinations, and dialysis-related factors from a cohort of 1465 patients who received continuous arteriovenous fistula surgery at the Hemodialysis Access Center of Sichuan Provincial People's Hospital between January 2019 and June 2022. The patients were randomly divided into a training set and a validation set in a 2:1 ratio. The training set was utilized to select AVFT-related features using LASSO regression. A predictive model was constructed using logistic regression analysis, and its performance was assessed in the validation set.

Results: Through LASSO regression, we initially identified 13 candidate factors. Subsequently, based on the Akaike Information Criterion (AIC) principle, the following factors were selected to construct the AVFT prediction model: monocytes_ratio, Fistula blood velocity, cystatin-c, homocysteine, parathormone, artery_dysfunction, C-reactive protein, fibrinogen, and d-dimer. The discrimination C-index of the model in the training set was 0.8767. For this training set, the sensitivity was 48.05% and the specificity was 96.84%. In the validation set, the model's discrimination C-index, as evaluated by the ROC curve analysis, was 0.7888. The sensitivity was 14.29%, and the specificity was 97.04%. We assessed the calibration of the model using calibration curves, obtaining a maximum absolute difference of Emax = 0.205 and an average absolute difference of Eave = 0.032. Furthermore, we evaluated calibration and accuracy using the Spiegelhalter Z-test, yielding an S:P ratio of 0.704.

Conclusion: AVFT is a multifactorial outcome influenced by factors such as injury, inflammatory factors, blood glucose levels, blood velocity, coagulation, electrolyte metabolism, and vascular endothelial function.

Objective: This study aims to develop a risk assessment model for predicting haemodialysis access dysfunction and to construct a nomogram.

Method: The clinical data of patients with haemodialysis access dysfunction treated at our hospital from October 2020 to January 2024 were retrospectively analysed. The least absolute shrinkage and selection operator regression method was used to filter variables and select predictors, while Cox regression was applied to filter variables and construct a nomogram. The discriminatory ability of the model was determined by calculating the area under the curve (AUC). Calibration was evaluated using bootstrap internal validation and the Hosmer-Lemeshow test. The clinical utility and applicability of the model were assessed through decision curve analysis (DCA) and the clinical impact curve (CIC). Subgroup analysis of risk factors for haemodialysis access dysfunction was performed using Kaplan-Meier survival curves.

Result: The study included 423 patients, and seven variables were used to construct the risk prediction model and nomogram for haemodialysis access dysfunction. The C-index of the prediction model was 0.783, and the time-dependent AUC (>0.8) at 6, 12, 18 and 24 months post-surgery indicated strong discriminatory ability. The calibration curve and Hosmer-Lemeshow test demonstrated good agreement between the prediction of the nomogram and the observed values. The DCA and CIC curves further confirmed the clinical practicability of the model.

Conclusion: A risk assessment model and nomogram for haemodialysis access dysfunction based on seven variables were successfully constructed. This model demonstrates good discrimination and calibration, offering valuable guidance for clinical decision-making and significant clinical utility.

The introduction of devices for endovascular dialysis access creation (WavelinQ and Ellipsys) offers practitioners more options for access management in dialysis patients. Especially in terms of reducing the usage of central venous catheters, a native fistula is desirable as an initial dialysis access. We present a case in which a failed WavelinQ type fistula was reactivated using the Ellipsys procedure on the same arm. This specific rescue method is based on the idea that the proximal part of an endoAVF from an earlier WavelinQ procedure which resulted in adequately dilated veins, comprising the perforating vein, may allow a subsequent Ellipsys procedure. This case report shows how the use of endovascular techniques such as WavelinQ and Ellipsys can be incorporated in a clinical context and create new options for the patient.

Objective: Peripheral intravenous catheter (PIVC) failure occurs in approximately 50% of insertions. Unexpected PIVC failure leads to treatment delays, longer hospitalizations, and increased risk of patient harm. In current practice there is no method to predict if PIVC failure will occur until it is too late and a grossly obvious complication has occurred. The aim of this study is to demonstrate the diagnostic accuracy of a predictive model for PIVC failure based on artificial intelligence (AI).

Methods: This study evaluated the capabilities of a novel machine learning algorithm. The algorithm was trained using real-world ultrasound videos of PIVC sites with a goal of predicting which PIVCs would fail within the following day. After training, AI models were validated using another, unseen, collection of real-world ultrasound videos of PIVC sites.

Results: 2133 ultrasound videos (361 failure and 1772 non-failure) were used for algorithm development. When the algorithm was tasked with predicting failure in the unseen collection of videos, the best achieved results were an accuracy of 0.93, sensitivity of 0.77, specificity of 0.98, positive predictive value of 0.91, negative predictive value of 0.93, and area under the curve of 0.87.

Conclusions: This proprietary and novel machine learning algorithm can accurately and reliably predict PIVC failure 1 day prior to clinically evident failure. Implementation of this technology in the patient care setting would provide timely information for clinicians to plan and manage impending device failure. Future research on the use of AI technology and PIVCs should focus on improving catheter function and longevity, while limiting complication rates.

Introduction: Nicaragua is a Central American country with a high prevalence of patients with chronic kidney disease, particularly among young men. This is largely attributable to Mesoamerican nephropathy, a form of interstitial nephritis that predominantly affects young agricultural workers. While the majority of patients have access to chronic dialysis programs, a very small number have an option of receiving a renal transplant. Consequently, they must spend years on hemodialysis (HD), where the vascular access issue is of vital importance for their survival. Given that prosthetic arteriovenous grafts (AVG) are expensive devices with a lower cost-benefit ratio, limited availability within the health system and are unaffordable for the majority of patients, it is crucial to perform autogenic arteriovenous fistula (AVF) whenever possible.

Patients and methods: This paper presents a 4-year period review (2020-2023) of a single-center vascular access program that optimizes vasculature utilization of each patient for creation of AFV and describes the surgical revision techniques used to prolong the patency of vascular accesses.

Results: The autogenic vascular access program has resulted in more than 80% of prevalent patients undergoing HD at our center being hemodialyzed through an autogenic AVF by the end of 2023.

Conclusions: It can be concluded that it is possible to significantly increase the proportion of autogenic vascular accesses in each center by optimizing the patient's own vasculature. This approach has the potential to reduce morbidity and costs, particularly in low-income countries.