scholarly journals Best Vascular Access in the Elderly: Time for Innovation?

2018 ◽  
Vol 47 (1-3) ◽  
pp. 236-239 ◽  
Author(s):  
Arif Asif ◽  
Mohamed M. Bakr ◽  
Michael Levitt ◽  
Tushar Vachharajani
Keyword(s):  
Arteriovenous Fistula ◽  
Ulnar Artery ◽  
The Elderly ◽  
Dialysis Access ◽  
Failure Rates ◽  
Early Failure ◽  
Upper Arm ◽  
Arteriovenous Access ◽  
Surgical Manipulation ◽  
Innovative Techniques

Background: Conflicting data continue to surround the optimal dialysis access for the elderly. Many propose that catheters are the best option for this population; others emphasize the creation of an arteriovenous fistula. Summary: While an arteriovenous access is the best available access, it has a high early failure rate, particularly in the elderly. However, significant differences exist in forearm (men ≥65 years ~70%; women ≥65 years ~80%) versus upper arm (men ≥65 years ~40%; women ≥65 years ~38%) fistula failure rates in the elderly, with upper arm having much lower failure rates. Two percutaneous innovative techniques that successfully establish fistulas at the upper arm using proximal radial/ulnar ­artery as the inflow have been recently introduced. These procedures have been successfully performed in the elderly. Importantly, these techniques bypass the open surgical exploration and as such avoid the surgical manipulation of the juxta-anastomotic region (a common cause for the development of juxta-anastomotic stenosis and early fistula failure). Key Message: This article discusses the arteriovenous fistula creation in the elderly, highlights the factors necessary for successful fistula creation, and describes the 2 innovative techniques that can be used to provide a robust platform for successful fistula creation in this population.

Chronic Ischemic Monomelic Neuropathy after Arteriovenous Fistula Creation: A Unique Presentation of Vascular Steal

2020 ◽  
Vol 3 (2) ◽  
pp. 147-150
Author(s):  
Kaczynski RE ◽  
Asaad Y ◽  
Valentin-Capeles N ◽  
Battista J
Keyword(s):  
Arteriovenous Fistula ◽  
Complete Loss ◽  
Dialysis Access ◽  
Loss Of Function ◽  
Access Site ◽  
Surgical Ligation ◽  
Arteriovenous Access ◽  
Vascular Steal ◽  
Steal Syndrome

We discuss a case of a 58 year old male who presented for left upper extremity steal syndrome including ischemic monomelic neuropathy (IMN) 1.5 months after arteriovenous fistula creation. He presented after three surgical attempts to salvage his fistula with rest pain, complete loss of function with contracture of the 4th and 5th digits, and loss of sensation in the ulnar distribution for more than three weeks. At our institution, he underwent surgical ligation of the distal fistula and creation of a new fistula proximally, resulting in complete resolution of his vascular steal symptoms almost immediately despite the chronicity prior to surgical presentation. Our patient provides a unique perspective regarding dialysis access salvage versus patient quality of life. The patients’ functional status and pain levels should take precedence over salvage of an arteriovenous access site, and early ligation of the access should be completed prior to chronic IMN development. However, if a patient presents late along the IMN course, we recommend strong consideration of access ligation in order to attempt to regain the full neurovascular function of the extremity as we experienced in our patient.

scholarly journals Early Failure of Dialysis Access among the Elderly in the Era of Fistula First

2015 ◽  
Vol 10 (10) ◽  
pp. 1791-1798 ◽  
Author(s):  
Karen Woo ◽  
Dana P. Goldman ◽  
John A. Romley
Keyword(s):  
The Elderly ◽  
Dialysis Access ◽  
Early Failure

scholarly journals Dialysis Access-Associated Steal Syndrome with Percutaneous Endovascular Arteriovenous Fistula Creation.

2021 ◽  
Author(s):  
Rakesh Varma ◽  
Manuel Betancourt-Torres ◽  
Eric Bready ◽  
Alian Al-Balas
Keyword(s):  
Risk Factors ◽  
Arteriovenous Fistula ◽  
Clinical Symptoms ◽  
Ulnar Artery ◽  
Renal Dysplasia ◽  
Dialysis Access ◽  
Hemodialysis Access ◽  
Vessel Occlusion ◽  
Flow Through ◽  
Steal Syndrome

Abstract Background: Dialysis access-associated steal syndrome is an infrequent complication after hemodialysis access creation. Clinical symptoms depend on the degree of steal. Mild symptoms include coldness, numbness and pain during dialysis. Severe steal can present with rest pain, cyanosis and ulcerations, and may require surgical ligation of the fistula. With recent advances in arteriovenous fistula creation, percutaneous endovascular arteriovenous fistula creation has demonstrated better maturation and patency rates with lower risk of wound healing and infection rates as compared to surgically created hemodialysis access. Percutaneous creation offers a minimally invasive alternative, though complications have been reported. The following presents the first described case of DASS following the use of percutaneous endovascular arteriovenous fistula creation, and discusses risk factors and management. Case Presentation: Our case is that of a 27-year-old male with end stage renal disease due to congenital renal dysplasia, who underwent left percutaneous arteriovenous fistula creation for initiation of dialysis. Two months after the procedure the patient complained of coldness, pain, tingling, and numbness in the left arm during dialysis, concerning for steal syndrome. The patient subsequently underwent brachial artery angiogram, which showed predominant flow through the fistula and minimal antegrade flow through the ulnar and interosseous arteries towards the hand, with a focal, severe stenosis in the distal ulnar artery. Angioplasty of the stenosis was performed, though steal symptoms continued. Conclusions: DASS, though rare, can be seen with percutaneous arteriovenous fistula creation. Identification of the risk factors prior to creation, especially in patients who are at higher risk of peripheral vascular disease, can help avoid this complication. Management is largely guided by clinical presentation. As long as there is adequate collateral supply to the extremity, single vessel occlusion is not a contraindication to percutaneous arteriovenous fistula creation with the use of WavelinQ technology. Careful patient selection with pre-creation angiogram may reduce the risk of symptomatic steal.

Upper arm basilic vein elevation as a solution for forearm ulnar-basilic arteriovenous fistulae with cannulation problems

2018 ◽  
Vol 20 (3) ◽  
pp. 321-324
Author(s):  
Alexandros Mallios ◽  
William Jennings ◽  
Alessandro Costanzo ◽  
Benoit Boura ◽  
Myriam Combes
Keyword(s):  
Arteriovenous Fistula ◽  
Technical Note ◽  
Dialysis Access ◽  
Basilic Vein ◽  
Upper Arm ◽  
Arteriovenous Fistulae ◽  
Needle Position ◽  
Arterial Inflow

Background: Ulnar-basilic arteriovenous fistula is an alternative option when a radiocephalic arteriovenous fistula is not feasible. We review our technique of basilic vein transposition in the upper arm for difficult to puncture forearm ulnar-basilic non-transposed arteriovenous fistulae. Technical note: Three patients were referred for forearm ulnar-basilic arteriovenous fistulae with difficult cannulation where the forearm basilic vein was left in situ (non-transposed). Surgeon performed ultrasound examination confirmed a patent arteriovenous fistula with adequate diameter and flow, draining to the basilic vein in the forearm and into the upper arm. Recurrent new and resolving hematomas were present surrounding the forearm basilic vein resulting from difficult cannulation issues and problems maintaining needle position due the posterior-medial ulnar-basilic arteriovenous fistula position and mobility of the non-transposed forearm basilic vein. A basilic vein transposition elevation procedure was performed in the upper arm starting at the level of the elbow to a few centimeters below the axilla. Branches of the dilated basilic vein were ligated, the median cutaneous nerve was preserved, and the vein was elevated from its native position to a superficial and anterior location. Although difficult, dialysis access had been continued in the forearm during a brief period and none required catheter placement. Reliable dialysis access was successfully initiated using the newly transposed basilic vein in the upper arm 3–4 weeks after the procedure, maintaining arterial inflow based on the original ulnar-basilic arteriovenous fistula anastomosis at the wrist. None of the patients required further interventions with follow-up of 8, 15, and 22 months.

scholarly journals Primary patency of native arteriovenous fistula in elderly at Abdul Wahab Sjahranie Hospital, Samarinda, Indonesia

2021 ◽  
Vol 1 (1) ◽  
pp. 4-7
Author(s):  
Muhammad Rizki Bachtiar ◽  
Ivan Joalsen ◽  
Izzati Nurmaya Sari ◽  
Made Angga Putra
Keyword(s):  
Elderly Patients ◽  
Arteriovenous Fistula ◽  
Survival Data ◽  
Demographic Data ◽  
The Elderly ◽  
Primary Patency ◽  
Dialysis Access ◽  
Term Survival ◽  
First Choice ◽  
The Right

Introduction. Arteriovenous fistula (AVF) is preferred to be selected by the patient and clinician due to long term survival and fewer complications than other vascular access. Radiocephalic (RC) fistula is the first choice for dialysis access and should be performed in elderly renal failure patients. Several authors have advocated that the brachiocephalic (BC) fistula should be considered the surgeons' first option. We aim to analyze the primary patency of RC and BC AVF in the elderly. Method. This prospective cohort study was conducted from June 2018 to March 2020, which included 58 elderly patients who underwent surgery to create AVF. Demographic data were collected from medical records. Meanwhile, information about patient’s primary patency of RC and BC AVF were followed up to first access dysfunction or any intervention by phone. The survival data were analyzed using the Kaplan-Meier method Result. There were 58 elderly patients divided into 51 (87.9 %) patients with RC, 4 (6.9%) patients with BC, and 3 (5.2%) patients with Basilic Vein Transposition (BVT). The survival rate of RC was 70.5 % after six months and 29.4 % after 12 months. Meanwhile, 50% of BC patients survived in the first six months, and 25% survive for a year. On the other hand, 1 of 3 patients died in the BVT group in the first month after access placement due to hemodialysis complication, and the remaining two BVT patients survived in three months. Conclusion. RC has a patency rate of 70.5% in six months and 29.4% in a year. Choosing the right type and site of the anastomosis is essential as life expectancy increases in the elderly to preserve the veins for future access site.

Does a failed DRIL mean the end for a fistula? A case report in the use of an Amplatzer plug post DRIL procedure for ongoing steal syndrome

2021 ◽  
pp. 112972982110069
Author(s):  
Gemma Fitzpatrick ◽  
Philip Kiely ◽  
Bora Jeong ◽  
Ewan Macaulay
Keyword(s):  
Case Report ◽  
Arteriovenous Fistula ◽  
Ulnar Artery ◽  
Hybrid Procedure ◽  
Fistula Formation ◽  
Dialysis Access ◽  
Retrograde Flow ◽  
Occlusion Device ◽  
Steal Syndrome

Dialysis access steal syndrome is a well-recognised complication, affecting 1%–8% of all patients who undergo arteriovenous fistula formation particularly those that are brachial based. We present a case of ongoing steal syndrome following a DRIL procedure via retrograde flow in the ulnar artery. This was managed via a hybrid procedure and the use of an Amplatzer plug. This case demonstrates a novel use for the Amplatzer occlusion device, it is also a reminder that failure to occlude the vessel close to the fistula anastomosis can result in continued steal despite a functioning DRIL bypass.

scholarly journals Age is just a number: Is frailty being ignored in vascular access planning for dialysis?

2021 ◽  
pp. 112972982198990
Author(s):  
Kulli Kuningas ◽  
Nicholas Inston
Keyword(s):  
Decision Making ◽  
Kidney Disease ◽  
Vascular Access ◽  
Clinical Condition ◽  
The Elderly ◽  
Dialysis Access ◽  
Adverse Health Outcomes ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
First Choice

Current international guidelines advocate fistula creation as first choice for vascular access in haemodialysis patients, however, there have been suggestions that in certain groups of patients, in particular the elderly, a more tailored approach is needed. The prevalence of more senior individuals receiving renal replacement therapy has increased in recent years and therefore including patient age in decision making regarding choice of vascular access for dialysis has gained more relevance. However, it seems that age is being used as a surrogate for overall clinical condition and it can be proposed that frailty may be a better basis to considering when advising and counselling patients with regard to vascular access for dialysis. Frailty is a clinical condition in which the person is in a vulnerable state with reduced functional capacity and has a higher risk of adverse health outcomes when exposed to stress inducing events. Prevalence of frailty increases with age and has been associated with an increased risk of mortality, hospitalisation, disability and falls. Chronic kidney disease is associated with premature ageing and therefore patients with kidney disease are prone to be frailer irrespective of age and the risk increases further with declining kidney function. Limited data exists on the relationship between frailty and vascular access, but it appears that frailty may have an association with poorer outcomes from vascular access. However, further research is warranted. Due to complexity in decision making in dialysis access, frailty assessment could be a key element in providing patient-centred approach in planning and maintaining vascular access for dialysis.

The Pre-dilatation of vessels: A simple method to recruit small caliber veins for creating distal fistulas

2021 ◽  
pp. 112972982098317
Author(s):  
Marcello Napoli ◽  
Anna Zito ◽  
Maria Luisa Lefons ◽  
Paolo Ria ◽  
Emiliana Ferramosca ◽  
...  
Keyword(s):  
Heart Disease ◽  
Arteriovenous Fistula ◽  
Clinical Problem ◽  
Early Failure ◽  
Simple Method ◽  
Maturation Rate ◽  
Vein Diameter ◽  
Major Clinical Problem

Maturation failure remains a major clinical problem of distal arteriovenous fistula (AVF). Early failure (EF) is associated with the small size of the veins. For about 10 years we have used in more than 1000 fistulas, the Vessels Pre-Dilatation (VPD) to increase the recruitment of small veins for creating distal AVFs. The purpose of this study is to highlight if the VPD can reduce the incidence of EF or failure to mature (FTM) in AVFs created with small veins. Data of all the consecutive patients directly admitted to our Department for their first distal AVF from January to December 2019 were collected. The patients were divided in two groups, one with a vein diameter after the tourniquet ⩽2.0 mm (G1) and one >2 mm (G2). Both in G1 then in G2 the vessels had undergone VPD. Immediate failure (IF), EF, FTM, delayed or arrested maturation rate (DAM), unassisted AVFs and matured AFVs were evaluated. The patients recruited totalled 104, 37 in G1, and 67 in G2. The two groups were homogeneous in age, incidence of diabetes, obesity, heart disease, peripheral vasculopathy, and race. Female were more numerous in G1 (51% vs 12%, p < 0.001). In G1 and G2 occurred respectively 3 IF versus zero ( p < 0.05), 10 EF (29%) versus 6 (9%) ( p < 0.05), 6 DAM (16%) versus 6 (9%), 21 unassisted AVFs (57%) versus 57 (85%) ( p < 0.01). Dividing the patients into groups of unassisted and assisted AVFs, female and low vein diameter are more represented in the assisted group. There were 32 matured AVFs (86%) in G1 and 65 (97%) in G2. In order to increase the incidence of the distal AVF, the PDV allows to include small veins. However, more patients require further interventions to achieve maturation of the fistula.

Effectiveness and safety of repeated percutaneous intervention in an office-based endovascular center in maintaining hemodialysis access

Vascular ◽  
2021 ◽  
pp. 170853812110043
Author(s):  
Jay Patel ◽  
Stephanie Chang ◽  
Shaan Manawar ◽  
John Munn ◽  
Mark C Rummel ◽  
...  
Keyword(s):  
Percutaneous Intervention ◽  
Dialysis Access ◽  
Arteriovenous Graft ◽  
Hemodialysis Access ◽  
Upper Arm ◽  
Access Site ◽  
Arteriovenous Fistulas ◽  
Arteriovenous Grafts ◽  
The Mean

Objectives Percutaneous dialysis access interventions are routinely used to maintain the patency of dialysis access despite the lack of data regarding their long-term effectiveness. This retrospective study was undertaken to study the effectiveness and safety of percutaneous dialysis access interventions in arm fistulas and bridge grafts in an office-based endovascular center. Methods Patients who had a percutaneous dialysis access intervention in their upper extremity access site, performed at a single office-based endovascular center over a nine-year period (2007–2016) were included in this study. The patients’ demographic factors, patency, and complications were analyzed. Patients were entered in the study after first percutaneous dialysis access intervention. Results A total of 298 limbs in 259 patients had 913 procedures carried out over a nine-year period. There were 190 access arteriovenous fistulas and 108 arteriovenous grafts. The two most common arteriovenous fistulas were the brachiocephalic fistula ( n = 74, 39%) and radio cephalic fistula ( n = 69, 36%). Arteriovenous grafts were most commonly placed in the upper arm ( n = 66, 61%) followed by the forearm ( n = 42, 39%). The mean overall patency for all limbs was 50.86 months. Arteriovenous fistulas had a significantly longer patency than arteriovenous grafts (51.65 vs. 42.09 months; P = 0.01). In addition, patients with two or more percutaneous dialysis access intervention in their arteriovenous fistula had significantly greater patency than those with only one percutaneous dialysis access intervention (58.5 vs. 7.6 months; hazard ratio 0.41; P = 0.0008). This was not true for the arteriovenous graft group. Women represented 49% of the patient group. Their accesses had shorter patency than men (39.8 vs. 60 months; P = 0.0007). Conclusions This data support the use of repeated percutaneous dialysis access intervention to maintain long-term patency of dialysis access sites in an office-based endovascular center. Overall, fistulas have longer patency than grafts and women have poorer outcomes as compared to men

Comparison of postal and non-postal post-vasectomy semen sample submission strategies on compliance and failures: an 11-year analysis of the audit database of the Association of Surgeons in Primary Care of the UK

2021 ◽  
pp. bmjsrh-2021-201064
Author(s):  
Melanie Atkinson ◽  
Gareth James ◽  
Katie Bond ◽  
Zoe Harcombe ◽  
Michel Labrecque
Keyword(s):  
Primary Care ◽  
Semen Analysis ◽  
Failure Detection ◽  
Semen Sample ◽  
Failure Rates ◽  
Early Failure ◽  
Detection Rates ◽  
Late Failure ◽  
The Difference ◽  
The Uk

BackgroundVasectomy occlusive success is defined by the recommendation of ‘clearance’ to stop other contraception, and is elicited by post-vasectomy semen analysis (PVSA). We evaluated how the choice of either a postal or non-postal PVSA submission strategy was associated with compliance to PVSA and effectiveness of vasectomy.MethodsWe studied vasectomies performed in the UK from 2008 to 2019, reported in annual audits by Association of Surgeons in Primary Care members. We calculated the difference between the two strategies for compliance with PVSA, and early and late vasectomy failure. We determined compliance by adding the numbers of men with early failure and those given clearance. We performed stratified analyses by the number of test guidance for clearance (one-test/two-test) and the study period (2008–2013/2014–2019).ResultsAmong 58 900 vasectomised men, 32 708 (56%) and 26 192 (44%) were advised submission by postal and non-postal strategies, respectively. Compliance with postal (79.5%) was significantly greater than with non-postal strategy (59.1%), the difference being 20.4% (95% CI 19.7% to 21.2%). In compliant patients, overall early failure detection was lower with postal (0.73%) than with non-postal (0.94%) strategy (−0.22%, 95% CI −0.41% to −0.04%), but this difference was neither clinically nor statistically significant with one-test guidance in 2014–2019. There was no difference in late failure rates.ConclusionsPostal strategy significantly increased compliance to PVSA with similar failure detection rates. This resulted in more individuals receiving clearance or early failure because of the greater percentage of postal samples submitted. Postal strategy warrants inclusion in any future guidelines as a reliable and convenient option.

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