Journal of Vascular Access最新文献

Although use of the autogenous arteriovenous fistula is the first choice for vascular access for hemodialysis, the tunneled cuffed catheter (TCC) remains an important alternative method that is applied widely in maintenance hemodialysis for patients with end-stage renal disease. In addition to common complications, such as thrombosis, infection, formation of a fibrin sheath, or central vein stenosis, TCC dysfunction, such as kinks, cuff detachment, or mechanical destruction, can be easily overlooked. The reasons for these clinical problems are multifactorial and include the insertion handling, presence of diabetes mellitus, catheter type, malnutrition, and the patient's body habitus. This minireview describes our experience with TCC and the current literature on managing TCC dysfunction.

Micropuncture vascular access is increasingly being used in the intensive care unit (ICU) due to its perceived reduction of bleeding complications in common ICU procedures. The authors report two rare complications associated with micropuncture kit use associated with vascular access. The first case involved a fracture of the micropuncture wire with a remnant retained in the blood vessel. The second case involved the formation of a knot within the flexible tip of the micropuncture wire in the subcutaneous tissue. The unique design of the flexible tipped 0.018-inch guide wire may be prone to unique complications for which an understanding of the proper technique for its use is necessary to prevent these complications.

Introduction: Hypertension (HTN) is highly prevalent among patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD), uncontrolled HTN as well as high blood pressure variability (BPV) can significantly impact cardiovascular health. This study aims to understand the impact of BPV in patients with ESKD following arteriovenous fistula (AVF) creation for hemodialysis, to better understand its association with age, sex, BMI, and cardiovascular risk.

Methods: A retrospective analysis was conducted on 83 patients who underwent AVF creation between February 2019 and October 2020 at University of Miami Hospital. During 20 months, blood pressure measurements were collected from medical records at four different times during AVF access creation process, and BPV was quantified using machine learning clustering techniques.

Results: The study identified three distinct clusters among the 83 patients with ESKD who underwent AVF creation. Cluster 1 (n = 28) was characterized by high blood pressure variability, with a mean systolic blood pressure standard deviation of 16.2 mmHg. This cluster exhibited a significantly higher cardiovascular risk rate of 42.9% compared to Cluster 2 (n = 30) and Cluster 3 (n = 25), which had lower variability with mean systolic blood pressure standard deviations of 10.3 and 8.7 mmHg, respectively, and cardiovascular risk rates of 16.7% and 12.0%. Age, sex, and BMI did not differ significantly across the clusters.

Conclusion: This study underscores the association between blood pressure variability and the increased risk of cardiovascular events, including myocardial infraction, stroke or heart failure in patients with ESKD undergoing AVF creation. Our findings highlight the critical need for vigilant monitoring of blood pressure fluctuations in this population and demonstrate how these variations are influenced by individual demographic factors. Further research is needed to develop targeted interventions to mitigate this risk.

Objective: This study is aimed at determining the prevalence of peripheral intravenous catheter-related phlebitis in patients with peripheral intravenous catheters.

Methods: This study is a point prevalence investigation involving 335 peripheral intravenous catheters among hospitalized patients in a teaching hospital in Iraq. Data collection utilized forms that documented patient characteristics, details about the peripheral intravenous catheters, and a phlebitis scale.

Results: The overall prevalence of phlebitis in the study was 64.5%, with the majority of cases classified as Grade 1. Phlebitis primarily developed on Day 1 and was most commonly observed in patients in the Emergency Department. A statistically significant relationship was found between phlebitis development and chronic diseases, with a significantly higher prevalence observed in patients diagnosed with heart failure (88.5%) compared to those with other chronic conditions (p = 0.004).

Conclusion: Although the study found a high prevalence of phlebitis, most cases were classified as Grade 1. These findings support the development of policies to enhance patient safety and contribute to improving healthcare systems and literature in Iraq.

Accidental vascular catheter removal (AVCR) by patients with cognitive impairment can result in loss of access for infusion therapy, significant blood loss, air embolism with large bore catheters, and withholding life-sustaining dialysis treatment. Chest-to-back (CTB) tunneling of central venous catheters is a technique described in the Rapid Assessment of Vascular Access Exit Site and Tunneling Options (RAVESTO) for patients at risk for AVCR. In this retrospective review, data was collected for all venous access devices inserted using CTB tunneling in patients requiring medium to long term intravenous access for infusion or hemodialysis, who had a history of self-removing medical devices due to an alteration in mental status, or patients with severely impaired skin integrity. Vascular access devices were placed using real-time ultrasound and intracavitary electrocardiography (ECG) guidance. In this case series, from January 2020 to October 2024, a total of 46 out of 47 patients successfully received CTB-tunneled venous access devices. There was no reported symptomatic deep vein thrombosis. CTB tunneling was unable to be completed in one case due to severe patient agitation. The mean dwell was 23 days (ranging from 1 to 130 days). Nineteen patients completed their prescribed therapy, 18 patients were discharged with the catheter but were lost to follow up, four patients self-removed their catheter, three patients developed fungal infections receiving TPN, one patient experienced a primary catheter malposition which was removed after unsuccessful attempts at repositioning, and one patient receiving dialysis had a catheter exchange on day 32 due to poor flow. CTB tunneling is useful in patients with cognitive impairment who are at risk for AVCR and require medium to long term intravenous access. This retrospective review suggests that the use of ultrasound and intracavitary ECG makes the bedside CTB tunneling a safe and minimally invasive procedure.

Radial artery catheterization is commonly performed using the pulse palpation method. However, anatomical variations, such as the persistent median artery-an embryonic structure that may persist into adulthood-can complicate this procedure. A 47-year-old female scheduled for laparoscopic surgery required radial artery catheterization for hemodynamic monitoring. Multiple attempts to place a 22-gauge catheter in the left radial artery were unsuccessful. During the procedure, a pulsating vessel was identified on the ulnar side of the radial artery. Vascular visualization devices revealed the presence of a persistent median artery, accompanied by the median nerve. Subsequently, real-time ultrasound guidance facilitated successful radial artery catheterization. Anatomical variations, such as the persistent median artery, can complicate radial artery catheterization and are not easily identified through pulse palpation alone. The use of vascular visualization devices is recommended to identify and navigate such variations, ensuring accurate catheter placement.

Background and aim: 2% Chlorhexidine gluconate in 70% isopropyl alcohol (2% CHG in 70% IPA) is the recommended skin antiseptic for adult and children during central venous catheter (CVC) insertion but neonatal data are limited. We assessed skin toxicity of 2% CHG in 70% IPA for vascular catheter site preparation in preterm neonates using sterile disposable pre-measured devices.

Study design: Monocentric, retrospective, observational study conducted in tertiary level NICU on 146 neonates less than 32 weeks gestational age (GA) and younger than 15 days.

Methods: Infants were stratified in Group I (GA ⩽ 28 weeks) and Group II (GA = 29-32 weeks) and received skin disinfection with 2% CHG in 70% IPA for either umbilical venous catheters or epicutaneous caval catheters. We evaluated the incidence of skin lesions in preterm neonates who received skin disinfection 2% CHG in 70% IPA with the Neonatal Skin Condition Score. Numeric thresholds ⩽5, 5-7, and >7 were used to define mild, moderate, and severe skin infection respectively. The rate of central line associated bloodstream infection (CLABSI) was also calculated.

Results: Two hundred implanted catheters (100 per group) from 146 neonates were reviewed. While two cases of severe skin lesions occurred locally on the abdomen of two 24 weeks babies, no lesion was reported in Group II infants. We found a CLABSI rate of 16% with a rate of 17 infections per 1000 catheter days.

Conclusion: The use of 2% CHG in 70% IPA for skin disinfection during CVC implantation in preterm infants over 24 weeks GA does not lead to severe skin lesions.

Background: In the creation of arteriovenous fistulas (AVF) for hemodialysis, regional brachial plexus block (BPB) has a sympatholytic effect, increasing blood flow and diameters in the vessels.

Methods: A prospective, randomized, clinical-surgical pilot study was carried out, comprising 40 patients, randomly allocated into two groups (BPB or local anesthesia-LA). The diameter (veins and arteries), and the flow, peak systolic velocity (PSV), pulsatility index (PI), and pulsatility index ratio (PIR) of the arteries were evaluated before and after anesthesia. Flow was measured in the AVF at the end of the procedure and 30 days after. To analyze pain perception, the visual analog scale (VAS) was applied during anesthesia (T1), during surgery (T2), and at discharge (T3). All analyses were performed using R v. 4.3.1. A p-value <0.05 was considered statistically significant.

Results: Comparing BPB with LA, in the pre- and post-anesthesia periods, there was an increase in the diameters of the cephalic and basilic veins (p < 0.001) and the ulnar artery (p < 0.001). There was a significant increase in the PSV of the radial and brachial (p < 0.001) and ulnar (p = 0.0017) arteries. There was an increase in flow in the radial, ulnar, and brachial arteries (p < 0.001). There was a significant decrease in the PI for the radial (p = 0.0022), ulnar and brachial (p < 0.001) arteries. The BPB group had a significant change in the PIR of the arteries (p < 0.001). Regarding pain perception, the BPB group presented a decrease at T2 (p < 0.001).

Conclusions: For this study, in the group that received BPB, there was an increase in the diameters of the arteries and veins as well as the flow and PSV of the arteries, and decreasing the PI, the PIR, and in the perception of intraoperative pain.

Background: Use of a nitinol extravascular support implanted during AVF (arteriovenous fistula) creation has been gaining traction due to its potential to improve functional success and reduce interventions; however, comparative effectiveness data with traditional unsupported AVFs are lacking. The objective of this study was to compare outcomes of AVFs created with a vascular support device versus traditional unsupported AVFs in patients with advanced kidney disease.

Methods: This was a comparative effectiveness retrospective observational cohort study conducted using data from the prospective, multi-center, single-arm VasQ US Pivotal trial (extravascular support AVF group) matched with an unsupported AVF control group developed using Medicare claims data from the same surgeons that participated in the trial. Eligible control participants were Medicare fee-for-service beneficiaries who underwent AVF creation (2017-2019). Endpoints included 6-month primary patency (primary endpoint), intervention rate, and functional success. Propensity score methods using inverse probability treatment weighting were used to examine the association between supported device use and outcomes.

Results: A total of 782 unsupported AVF patients were compared to the 144 supported AVF patients from the Pivotal study. Compared with unsupported AVFs, primary patency at 180 days was superior for supported AVFs (66% vs 36% for control; OR, 3.27; 95% CI, 2.15-5.17; p < 0.0001). Intervention rate for supported AVFs (0.97 per patient-year; 95% CI, 0.71-1.28) was nearly half of unsupported AVFs (1.91 per patient-year; 1.58-2.07; p < 0.0001). Functional success for supported AVF patients was significantly greater than unsupported AVFs at 90 days (43.4% vs 26.7%, respectively; p = 0.005) and 180 days (72.5% vs 53.7%, respectively; p = 0.004).

Conclusions: AVFs created with extravascular support maintained higher primary patency, improved functional success, and had less reinterventions than unsupported AVFs. More patients may begin using their AVF for dialysis sooner with a lower risk of requiring a maturation procedure if created with extravascular support.