Journal of Vascular Access最新文献

Background: While arteriovenous fistulas (AVFs) are preferred for hemodialysis access, the impact of prior central venous catheter (CVC) use on AVF outcomes and health-related quality of life (HRQoL) remain unclear. This study compared composite AVF non-use and complications between patients with prior CVC use and those with preemptive AVF creation over 24 months.

Methods: This prospective longitudinal study consecutively enrolled patients with chronic kidney disease (CKD) referral for attended long-term vascular access planning consultations at two tertiary hospitals in northern Thailand (2016-2017). Eligible participants (⩾18 years) undergoing first-time AVF creation were categorized into CVC (first hemodialysis via CVC) and non-CVC (preemptive AVF) groups. Baseline characteristics were compared between groups. Multivariable logistic regression with backward stepwise selection identified predictors of composite AVF non-use in an exploratory analysis. Outcomes included composite AVF non-use (AVF non-use, hemodialysis suitability failure, and early mortality within 12 months), complications, and HRQoL.

Results: Among 167 patients (73 CVC, 94 non-CVC), AVF non-use at 12 months was significantly higher in the non-CVC group (32.9% vs 4.7%, p < 0.001), resulting in lower composite AVF non-use in the CVC group (19.2% vs 47.9%, p < 0.001). Each 1 mL/min/1.73 m² eGFR increase raised composite non-use risk by 7%, while prior CVC use reduced it by 22%. The CVC group had more symptomatic central vein stenosis (11.0% vs 3.2%, p = 0.060) but similar mortality rates. HRQoL improved physically in the CVC group by 18 months, with mental improvements in both groups by 24 months.

Conclusions: Prior CVC use was associated with lower AVF non-use, reflecting better timing of AVF creation based on established dialysis need rather than CVC benefits. High preemptive AVF non-use often resulted from delayed dialysis initiation or changing preferences. These findings support kidney failure risk prediction tools and individualized ESRD life-planning to optimize AVF timing. For patients requiring urgent dialysis initiation, sequential CVC-to-AVF management may represent clinically appropriate care. Optimal results require individualized timing, ongoing reassessment, and strong multidisciplinary coordination.

Background: Clinical practice guidelines endorse arteriovenous fistulae (AVF) as the preferred form of vascular access. Despite recent advancements, concerns persist regarding variable AVF patency rates. This umbrella review aimed to evaluate and synthesize evidence on interventions and strategies associated with improved 12-month patency rates in AVF.

Methods: Systematic review and meta-analyses of randomized control trials (RCTs) providing data regarding primary patency (PP) and target-lesion primary patency (TLPP) of AVF (not grafts) were included. Covidence was used for screening and data extraction, while the AMSTAR-2 rating assessed the methodological quality. Credibility assessment followed Papatheodorou's criteria. Medline, EMBASE, CENTRAL and CINAHL were searched using a bespoke search strategy from inception to December 2024.

Results: Twenty-two reviews that included 136 RCTs involving 13,522 patients were included in the final review. Highly suggestive evidence supports functional end-to-side anastomosis (effect estimate (EE) 1.7) for improving PP. Drug-coated balloon angioplasty (DCB) showed varied results across nine reviews, with effect estimates ranging from 0.49 to 2.47. For TLPP, one review reported significant improvement (EE 2.47, 95% CI 1.53-3.99). Suggestive evidence favours flow-based access monitoring (RR 0.51-0.66), antithrombotic medication (EE 0.53), antiplatelet therapy (EE 0.54), far infrared therapy (EE 1.24-1.27) and pre-emptive correction of 'at-risk' AVF (EE 0.5) for prolonging PP. Button hole cannulation and side-to-side anastomosis showed mixed or non-significant results. Heterogeneity varied widely across reviews, ranging from 0% to 81%, and AMSTAR-2 ratings ranged from moderate to high.

Conclusion: This umbrella review synthesizes evidence on interventions for AVF patency, revealing varying levels of support for different strategies and highlighting areas requiring further investigation.

Background: This study investigates the relationship between national catheter use among hemodialysis (HD) patients and kidney transplantation (KTX) activity, exploring the hypothesis that higher KTX activity may be associated with increased catheter usage. The rationale is based on the idea that shorter waiting times for transplants in high-activity countries could make central venous catheters (CVCs) more favorable as a temporary bridge to transplantation compared to arteriovenous fistulas or grafts which require longer maturation times.

Methods: Nine national dialysis and transplant registries (Argentina, Australia, Austria, New Zealand, Portugal, Scotland, Sweden, USA, Turkey) were included in this analysis. The included descriptive analysis of baseline information from included countries, followed by crude association analyses using correlation and regression analyses to explore the relationship between CVC usage and kidney transplants per million inhabitants, considering relevant confounders. Adjusted analyses were performed to account for these confounders, providing a more nuanced understanding of the relationship.

Results: Data from nine different national registries was analyzed. CVC use and KTX activity had a weak to moderate positive correlation (r = 0.23, 95% CI: 0.07, 0.39). In all included countries CVC use increased over time. Adjusting for temporal patterns, country-specific factors, and the proportion of female HD patients, there was still strong evidence for a moderate increase of CVCs among prevalent HD patients with increasing KTX activity.

Conclusion: Higher national KTX activity is associated with a moderate increase in CVCs among prevalent HD patients.

Removal of totally implanted central venous access devices (brachial ports, chest-ports, femoral ports) is potentially associated with the risk of untoward events, some of them negligible (prolonged maneuver time due to technical difficulties), some relevant (hematoma), and some severe (embolization of catheter fragments into the circulation). The removal technique suitable for minimizing such complications has been described only in few manuals, but it has never been standardized. This paper describes a standardized protocol (SaRePo: Safe Removal of Ports) which consists of seven basic strategies to be adopted systematically during removal of totally implanted venous access devices, so to minimize the risk of adverse events. These strategies include: evaluation of the patient's history, preprocedural ultrasound scan of the veins, appropriate aseptic technique, proper local anesthesia, catheter extraction, removal of the reservoir from the pocket, closure of the surgical incision.

Two major innovations-ultrasound guidance and catheter tunneling-have transformed central venous catheterization, significantly reducing early and late complications. Ultrasound enables accurate vein selection based on anatomical and functional criteria, facilitates safer venipuncture, and broadens access to previously avoided veins (e.g. brachiocephalic, axillary). It also allows real-time guidance for wire direction, tip navigation, and the immediate diagnosis of complications. Tunneling, once exclusive to cuffed catheters, is now increasingly used for non-cuffed devices to optimize the exit site independently of the venipuncture site. This strategy reduces infection, thrombosis, and dislodgment risks by relocating exit from high-risk zones (e.g. groin, neck) to cleaner, more secure areas. Despite widespread adoption of these innovations, current guidelines often confuse puncture and exit sites, leading to outdated recommendations. For example, guidelines labeling femoral or jugular access as high-risk often fail to differentiate between venipuncture and exit locations. Ultrasound-guided femoral puncture with tunneling can yield low-thrombosis, low-infection configurations, especially with mid-thigh or abdominal exit sites. Similarly, supraclavicular puncture of the internal jugular vein with tunneling avoids the traditional high-neck exit and its associated complications. Recommendations promoting subclavian access are also problematic, as safe ultrasound access is often only feasible via supraclavicular routes, not by traditional blind infraclavicular approaches. The field must shift from old anatomical dogma to ultrasound-based, tunneled approaches tailored to each patients need. Clear distinction between venipuncture and exit sites is essential for modern, evidence-based vascular access practices.

Percutaneous arterial cannulation for arterial catheter placement is a commonly performed procedure in intensive care. In many cases routinely cannulated radial arteries may be inaccessible because of shock, arteriosclerosis, or vasoconstriction. In this scenario, femoral or axillary artery may be chosen for arterial catheter placement. Percutaneous cannulation of the axillary artery via the infraclavicular route has two main advantages over cannulation of the femoral artery: avoidance of cannulation of the artery affected by arteriosclerosis and microbiological safety by avoiding cannulation in the inguinal area. This paper describes ultrasound-guided, real-time infraclavicular cannulation of the axillary artery for arterial catheter placement in critically ill patients. The cannulation technique is described in a step-by-step manner. In addition, the limitations of this arterial approach are presented together with the indications and contraindications. The pitfalls that are likely to occur during cannulation via the infraclavicular route are also reviewed.

A 66-year-old transfeminine patient presented to our institution with a central-venous stenosis causing dysfunction of her arteriovenous (AV) graft on her left arm. The patient was treated repeatedly, because of restenosis. Due to complete occlusion of the graft and subclavian vein as well as a liquid tumor located around the stenotic segment of the vein, we resected the left subclavian vein via a trap-door thoracotomy and inserted a PTFE-graft. Histological examination of the resected tissue identified metastasis from the urothelial carcinoma as the underlying cause of the stenosis. Malignant tumors are an infrequent etiology of AV-access dysfunction, and there are hardly any data on transgender patients. This case report provides an overview of the current data concerning these unique circumstances.

Evidence of the costly effects of first-attempt peripheral intravenous catheter (PIVC) insertion failures continues to mount. This study was conducted to determine if a unique catheter design can improve operative error, promote PIVC first-stick success and reduce the costs of first-attempt failures. In Phase One of this comparative simulation use in vitro study, 16 nurses from acute care hospitals inserted four PIVC types into a training model, each type characterized by distinct timing of flashback occurrence and needle design. Each nurse performed three attempts per catheter type (12 total per inserter). Insertions were video-recorded and analyzed for the effect of the needle on a vessel during insertion, double punctures and catheter placement failure or success. In Phase Two, 100 nurses and 25 purchasing agents nationwide identified items used and associated costs for PIVC insertions. In Phase One, nurses using a grooved needle flashback with a thin-tipped needle were 20% more successful with catheter placement than those using a notched needle flashback and 22% more successful than those placing a capillary flashback design. Catheter placement success with a grooved needle flashback was 15% higher than with a capillary flashback and 13% higher than with a notched needle flashback. Double punctures were highest among nurses using a capillary flashback catheter, and catheter placement failure was highest among nurses using notched needle flashback. In Phase Two, nurses reported an average of 51% first-attempt success. The authors calculated the estimated annual cost of first-stick failure to be $US 35,919.15 per nurse, including labor and materials used in the second and third attempts. In this study, the authors found the insertion technique with grooved flashback needle design reduced operative error, double punctures and improved first-attempt success. This flashback needle design could significantly improve patient outcomes, speed time to treatment and reduce hospital costs.

Background and aims: Ventriculoatrial (VA) shunts are frequently used for hydrocephalus (HS) management when peritoneal catheter placement is inappropriate. Historically, open surgical cut-down (OSC) on the internal jugular vein has been the standard method for distal catheter insertion. In contrast, percutaneous Seldinger-type ultrasound-guided (USG) venipuncture offers advantages such as reduced operating times and lower postoperative pain. However, its use in pediatric patients is limited.

Methods: This study reviewed patients diagnosed with HS who underwent VA shunt procedures (OSC vs USG) at Bambino Gesù Children's Hospital from January 1, 2014, to February 29, 2024. The analysis focused on surgical times for VA shunt placements and associated neurosurgical operations, as well as catheter replacement rates.

Results: Thirteen patients (6 males, 7 females; median age 12 years, range 0.5-14.2) were enrolled, with a total of 23 procedures performed. The mean surgical time for distal VA placement using the USG technique was significantly shorter than for the OSC method (13.36 min vs 30.22 min, p = 0.00001). Conversely, neurosurgical operations performed using OSC had a 15-min reduction in average operative time compared to USG, though this difference was not statistically significant. Catheter replacement was required in 35.7% of the USG group compared to 55.5% in the OSC group (p = ns).

Conclusions: USG VA shunt placement demonstrates reduced operating times and lower perioperative complication rates compared to OSC. Our findings indicate that percutaneous VA shunts are technically simpler and do not necessitate specialized pediatric vascular surgery skills, enhancing their applicability in pediatric hydrocephalus management.

Background: The backflow phenomenon represents a challenge when using needleless connectors. This bench study investigated backflow volume (i.e. the quantifiable amount of backflow) into a long peripheral catheter by evaluating needleless connectors with four technologies (positive, negative, neutral, and anti-reflux) and three clamping sequences.

Methods: Four different connectors with varying displacement technologies were tested to assess backflow volume using the manufacturer's recommended clamping sequences and a sequence in which the clamp was not foreseen. A high-fidelity experimental model was used. Neutral and anti-reflux needleless connectors were evaluated with varying clamping sequences. The backflow volume values are presented as median and interquartile range.

Results: Backflow was observed in all cases, with a wide range of results: the lowest backflow volume was recorded with the anti-reflux connector, while the highest was recorded with the negative connector, both when no clamp was used. The clamp significantly reduced backflow volume in negative and positive connectors, while no differences were noted between neutral and anti-reflux types across the sequences.

Conclusion: Using only needleless connectors in long peripheral catheters does not prevent the backflow phenomenon. Using clamps significantly reduced the backflow volume in needleless connectors with positive and negative displacement. Neutral and anti-reflux connectors perform similarly in the clamping sequences with and without clamps.