A novel extra-catheter guide wire technique for in situ exchange of dysfunctional tunnelled central venous hemodialysis catheter

BACKGROUND

Tunneled central venous catheters (tCVC) exchange may be difficult in some situations. We retrospectively report our preliminary experience of a novel extra-catheter guide wire technique for exchange of dysfunctional tCVC.

MATERIALS AND METHODS

Retrospectively analyze the demographics, treatment details and outcomes data of 39 patients received tCVC exchange from January 2018 to January 2019. According to whether guide wire could pass through the catheter lumen, patients were divided into in-catheter group and extra-catheter group. The technical successful rate, peri-operative complications, 1-month and 6-month catheter flow rate was recorded and compared between the 2 groups.

RESULTS

The final study population consists of 39 patients, including 16 in-catheter group and 23 extra-catheter group. The technical successful rate was 100% in both groups. All patients achieved restoration of line patency and completed at least 1 hemodialysis section. The 1-month (267.69 ± 20.12 vs. 274.13 ± 17.69, p = 0.604) and 6-month (255.81 ± 12.93 vs. 256.97 ± 11.20, p = 0.403) catheter flow rate was comparable between the 2 groups.

CONCLUSION

The novel extra-catheter guide wire technique was helpful for in situ exchange of dysfunctional tunneled central venous hemodialysis catheters, especially when the guide wire could not pass through the catheter lumen.

A national co-design workshop of a mobile-based application for vascular access as a patient decision aid

BACKGROUND

Increasing options for vascular access have increased the need for more effective communication to optimize patient engagement and ensure effective consent. An advanced prototype of the mobile application (VA App) was developed over 3 years as a patient decision aid. For the first time, entry to the 2021 UK Kidney Week was opened to all professions and patients and was held online. The VA App was presented in an inter-active session. This report summarizes the findings.

METHODS

A 30-min interactive session was allocated with the session delivered in four sections: (1) demographic data was collected; (2) an overall opinion was obtained about current patient information sources and satisfaction with these; (3) the participants were asked a series of eight questions regarding the main problem areas previously identified; (4) following a 6-min demonstration video, the participants were then re-asked the same questions to determine if the VA App would improve/worsen these areas.

RESULTS

Completed data from 30 participants showed great variation in all demographics. The most cited source was verbal and rated the best, whilst all other sources were felt to be poor by 90%. All eight aspects of current information sources rated poorly. There was a unanimous agreement that the VA App could make this better. Interestingly, when the eight aspects were ranked by order of the worst to best, this matched the order of the benefits of the VA App.

DISCUSSION

This is the first report of an on-line, multi-professional co-design workshop. With a unanimous view that current systems are very limited and that better patient information systems are required, the VA App was found to be a potential solution as a patient decision aid. Interestingly, paper leaflets were widely viewed as the least used and the least effective mechanism for communicating information to patients. Funding for a commercially produced mobile application has been secured and will be further tested in the near future.

Double guidewire technique (DGT): Optimising endovascular revision of juxta-anastomotic stenosis in AV-fistulae: A retrospective analysis

BACKGROUND

Arteriovenous fistula (AVF) is the preferred angioaccess for haemodialysis but suffers from a high stenosis rate, juxta-anastomotic stenosis (JAS) being the most frequent. Percutaneous transluminal angioplasty (PTA) of JAS would have some advantage (such as mini-invasive and vein sparing treatment), but higher recurrence rate is observed as compared to surgery. We report results of juxta anastomotic stenosis PTA using the 'double guide technique' (DGT) as described by Turmel-Rodrigues, in a selected cohort from our Vascular Access Centre.

PATIENTS AND METHODS

From January to June 2018, 25 consecutive patients were treated by DGT. By means of retrograde access through the outflow vein by a 6 F introducer, two guide wires were navigated: one into proximal radial artery (GW1), the other into distal artery (GW2). GW2 was used to dilate juxta-anastomotic vein and anastomotic area with 6 mm high-pressure balloon, while by GW1 juxta-anastomotic artery was dilated with 4 mm semi-compliant balloon. Mean diameter of balloons were 6.7 and 4.1 mm for venous and arterial tract dilatation. Follow up was carried out up to 12 months. Prospectively collected data were analysed retrospectively.

RESULTS

One-year primary and secondary patency was 52% and 95% respectively. Recurrence rate was 0.56 procedure/pt/year. Mean access blood flow at 12 months was 830 ml/min.

CONCLUSION

Double Guidewire Technique is an effective and minimally invasive procedure. By avoiding under dilation of JAS the recurrence rate resulted quite satisfactorily in our population.

Effectiveness of Sternal Intraosseous Device in Patients Presenting with Circulatory Shock: A Retrospective Observational Study

BACKGROUND

Hemorrhagic shock requires timely administration of blood products and resuscitative adjuncts through multiple access sites. Intraosseous (IO) devices offer an alternative to intravenous (IV) access as recommended by the massive hemorrhage, A-airway, R-respiratory, C-circulation, and H-hypothermia (MARCH) algorithm of Tactical Combat Casualty Care (TCCC). However, venous injuries proximal to the site of IO access may complicate resuscitative attempts. Sternal IO access represents an alternative pioneered by military personnel. However, its effectiveness in patients with shock is supported by limited evidence. We conducted a pilot study of two sternal-IO devices to investigate the efficacy of sternal-IO access in civilian trauma care.

METHODS

A retrospective review (October 2020 to June 2021) involving injured patients receiving either a TALON® or a FAST1® sternal-IO device was performed at a large urban quaternary academic medical center. Baseline demographics, injury characteristics, vascular access sites, blood products and medications administered, and outcomes were analyzed. The primary outcome was a successful sternal-IO attempt.

RESULTS

Nine males with gunshot wounds transported to the hospital by police were included in this study. Eight patients were pulseless on arrival, and one became pulseless shortly thereafter. Seven (78%) sternal-IO placements were successful, including six TALON devices and one of the three FAST1 devices, as FAST1 placement required attention to Operator positioning following resuscitative thoracotomy. Three patients achieved return of spontaneous circulation, two proceeded to the operating room, but none survived to discharge.

CONCLUSIONS

Sternal-IO access was successful in nearly 80% of attempts. The indications for sternal-IO placement among civilians require further evaluation compared with IV and extremity IO access.

Nurses' perceptions of point-of-care ultrasound for haemodialysis access assessment and guided cannulation: A qualitative study

AIM

To explore nurses' perceptions of using point-of-care ultrasound for assessment and guided cannulation in the haemodialysis setting.

BACKGROUND

Cannulation of arteriovenous fistulae is necessary to perform haemodialysis. Damage to the arteriovenous fistula is a frequent complication, resulting in poor patient outcomes and increased healthcare costs. Point-of-care ultrasound-guided cannulation can reduce the risk of such damage and mitigate further vessel deterioration. Understanding nurses' perceptions of using this adjunct tool will inform its future implementation into haemodialysis practice.

DESIGN

Descriptive qualitative study.

METHODS

Registered nurses were recruited from one 16-chair regional Australian haemodialysis clinic. Eligible nurses were drawn from a larger study investigating the feasibility of implementing point-of-care ultrasound in haemodialysis. Participants attended a semistructured one-on-one interview where they were asked about their experiences with, and perceptions of, point-of-care ultrasound use in haemodialysis cannulation. Audio-recorded data were transcribed and inductively analysed.

FINDINGS

Seven of nine nurses who completed the larger study participated in a semistructured interview. All participants were female with a median age of 54 years (and had postgraduate renal qualifications. Themes identified were as follows: (1) barriers to use of ultrasound; (2) deficit and benefit recognition; (3) cognitive and psychomotor development; and (4) practice makes perfect. Information identified within these themes were that nurses perceived that their experience with point-of-care ultrasound was beneficial but recommended against its use for every cannulation. The more practice nurses had with point-of-care ultrasound, the more their confidence, dexterity and time management improved.

CONCLUSIONS

Nurses perceived that using point-of-care ultrasound was a positive adjunct to their cannulation practice and provided beneficial outcomes for patients.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Haemodialysis clinics seeking to implement point-of-care ultrasound to help improve cannulation outcomes may draw on these findings when embarking on this practice change.

REPORTING METHOD

This study is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ).

PATIENT OR PUBLIC CONTRIBUTION

Patients were not directly involved in this part of the study; however, they were involved in the implementation study.

TRIAL AND PROTOCOL REGISTRATION

The larger study was registered with Australian New Zealand Clinical Trials Registry: ACTRN12617001569392 (21/11/2017) https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373963&isReview=true.

Alternative Application Technique for the MANTA Vascular Closure Device for Percutaneous Large-Bore Arterial Access Closure: The Fluoroscopic DOT Technique

BACKGROUND

Vascular complications are a cause of increased morbidity and mortality when performing percutaneous procedures requiring large-bore arterial access. MANTA vascular closure device (VCD) is currently the only large-bore VCD using an intraluminal foot plate and an extraluminal collagen plug. The traditional depth locator approach might be compromised in; emergent cases without the required measurements, cases of hematoma formation, or other patient, procedure, or operator-specific variables. Furthermore, this technique can be used for postclosure in cases without the required measurement of depth. We describe vascular outcomes using fluoroscopy (fluoroscopic DOT technique) rather than traditional depth locator approach for vascular closure with the MANTA VCD.

METHODS

Fifty patients who underwent transcatheter aortic valve implantation (TAVI) were retrospectively analyzed using fluoroscopic DOT technique with 18F MANTA VCD between May and August 2021. All patients >18 years of age who qualified for transfemoral TAVI were included. Access was obtained with ultrasound guidance with vessel diameter of at least > 6 mm and free from anterior vessel wall calcification. Patient related factors and primary outcomes of access site bleeding and acute flow-limited limb ischemia requiring intervention were prospectively analyzed. Furthermore, 1 patient who failed hemostasis with suture-mediated VCD had successful hemostasis with fluoroscopic DOT technique as dry postclosure after balloon aortic valvuloplasty.

RESULTS

In total, 50 patients were analyzed with a mean age of 81 years and majority were male (56%). Majority had comorbidities of hypertension (88%) and hyperlipidemia (94%), 24% had peripheral arterial disease, 38% coronary artery disease, and 58% were former smokers. Importantly, 40% were obese with an average body mass index (BMI) of 29 kg/m2. There were no bleeding or ischemic limb complications post MANTA VCD deployment using the fluoroscopic DOT technique. Furthermore, none of the patients required peripheral intervention from index procedure to 1 month post verified during their 1-month post TAVR follow-up.

CONCLUSION

Fluoroscopic DOT technique using the MANTA VCD is highly reproducible and allows hemostasis in a predictable manner for procedures requiring large-bore arterial access in the absence of MANTA depth measurement.

Dialysis Needle-Related Distress: Patient Perspectives on Identification, Prevention, and Management

Introduction

Needle-related distress is common among people receiving hemodialysis and affects quality of life and treatment decisions, yet little evidence exists to guide management. This study explored patients' experiences of needle-related distress to inform the development of prevention, identification, and management strategies.

Methods

Semistructured interviews concerning dialysis cannulation, needle-related distress, and potential solutions were conducted with people with current or recent experience of hemodialysis (N = 15) from a tertiary hospital-based service. Interviews ceased at thematic saturation. Transcripts were analyzed thematically.

Results

There were 4 themes and 11 subthemes generated: (i) uncovering a hidden source of distress (dismissal and minimization by others; suffering in silence to stay alive; preparation, assessment, and education); (ii) coping with cannulation pain and trauma (interaction between physical damage, pain, and distress; operator dependency-the importance of nurse skill and technique); (iii) the environment created by dialysis nurses (emotional transference; communication during cannulation; valuing empathy and person-centered care; a psychosocially supportive dialysis unit); and (iv) supporting patient self-management of distress (accessing tools to help themselves; distraction to reduce distress).

Conclusion

Needle-related distress is an often-hidden element of the hemodialysis experience. Patients learn to tolerate it as an inevitable part of dialysis for survival. Nurses' technical skills and the dialysis environment they create are key determinants of the patient cannulation experience. Proposed solutions include psychological screening, education for patients to self-manage distress, and training for nurses in communication and providing relevant psychological support.

Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study

Background

Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making.

Objective

To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection.

Design

Qualitative descriptive study.

Setting

Five outpatient hemodialysis centers in Calgary, Alberta.

Participants

Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists).

Methods

We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective.

Results

While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers.

Limitations

Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study.

Conclusions

Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.

Arteriovenous access creation and hazards of hospitalization and death in patients starting hemodialysis

BACKGROUND

Recent evidence suggests overestimation of benefits associated with arteriovenous (AV) fistula versus graft in certain populations. We assessed hazards of all-cause and cause-specific hospitalization and death associated with AV access type in patients who started hemodialysis with a catheter in France, overall and by subgroups of age, sex, and comorbidities.

METHODS

From the REIN Registry, we included patients who initiated hemodialysis with a catheter from 2010 through 2018, and identified first-created fistula or graft through the French national health-administrative database. We used joint frailty models to deal with recurrent hospitalizations and potential informative censoring by death, and inverse probability weighting to account for confounding.

RESULTS

From the 18 800 patients included (mean age 68 ± 15 years, 35% women), 5% underwent AV graft creation first. Weighted hazard ratio (wHR) of all-cause hospitalization associated with graft was 1.08 (95% CI 1.02 to 1.15), that of vascular access-related hospitalization was 1.43 (95% CI 1.32 to 1.55), and those of cardiovascular- and infection-related hospitalizations were 1.14 (95% CI 1.03 to 1.26) and 1.11 (95% CI 0.97 to 1.28), respectively. Results were consistent for most subgroups, except that the highest hazard of all-cause, cardiovascular-, and infection- related hospitalizations with graft was blunted in patients with comorbidities (i.e. diabetes, wHR 1.01, 95% CI 0.93 -1.10; 1.10, 95% CI 0.96 to 1.26; and 0.94, 95% CI 0.78 to 1.12, respectively).

CONCLUSIONS

In patients starting hemodialysis with a catheter, AV graft creation is associated with increased hazard of vascular access-related hospitalizations compared to fistula. This may not be the case for death or other causes of hospitalization.

Outcomes of early cannulation arteriovenous graft versus PTFE arteriovenous graft in hemodialysis patients: A meta-analysis and systematic review

Arteriovenous graft (AVG) is an alternative for hemodialysis (HD) patients with end-stage renal disease when their permanent vascular accesses fail. Since the last decades, the most widely used materials in these patients have been polytetrafluoroethylene (PTFE)-AVGs. Recently, several studies have reported that early cannulation (EC)-AVG can be an alternative to PTFE-AVG. This systematic review and meta-analysis aimed to compare the outcomes of EC-AVG and PTFE-AVG in HD patients. We searched the Ovid Embase, Ovid MEDLINE, and Cochrane Central Register of Controlled Trials for the relevant studies published from 01.01.2000 to 19.12.2022 by keywords and free words. All randomized controlled trials (RCTs) and observational cohort studies comparing EC-AVG with PTFE-AVG were included. Ten studies were included in analysis: one RCT, six retrospective cohort studies, and three prospective cohort studies. The results showed shorter cannulation intervals (four studies, 1116 participants: mean difference -23.62 days, 95% CI [-32.03, -15.21], p < 0.05) and less central venous catheter (CVC) usage (four studies, 733 participants: OR 0.20, 95% CI [0.04, 0.92], p < 0.05) for EC-AVG compared with PTFE-AVG, while comparable outcomes of primary patency (eight studies, 1712 participants: HR 0.89, 95% CI [0.70, 1.12]), primary assisted patency (five studies, 1355 participants: HR 1.13, 95% CI [0.70, 1.84]), secondary patency (nine studies, 1920 participants: HR 0.93, 95% CI [0.66, 1.31]), and infection risk (four studies, 640 participants: HR 1.12, 95% CI [0.48, 2.58]). When compared to PTFE-AVG in HD patients, EC-AVG seems to exhibit shorter cannulation intervals, less CVC usage, and comparable outcomes of graft patency, and infection risk.

Clinical characteristics and preoperative ultrasound parameters related to low patency in radio-cephalic arteriovenous fistulas

INTRODUCTION

Our objective is to describe the clinical characteristics and preoperative ultrasound mapping parameters associated with primary and secondary patency of radio-cephalic arteriovenous fistulas (RCF).

METHODS

A retrospective, single-center, descriptive study, including patients undergoing a RCF creation between 2015 and 2019. Socio-demographic data and ultrasound parameters were collected and an analysis of primary and secondary patency was performed.

RESULTS

Eighty-four patients were included in this study. Mean age was 65.6 (±13.9) years; 76.6% were male. Mean preoperative ultrasound parameters: forearm cephalic vein diameter was 2.8 (±0.57) mm, radial artery diameter was 2.6 (±0.42) mm, radial artery systolic peak velocity was 68 (±14.3) cm/s radial artery resistance index was 0.76 (±0.9). At the end of the 4 years the follow-up, the mean primary and secondary patency were 47.2% and 80% respectively. Only female sex was significantly associated with a decrease in both primary patency (p = 0.043, HR = 0.48) and secondary patency (p = 0.021, HR = 0.023). Furthermore, radial artery systolic peak velocity (p = 0.007, HR = 2.6) showed a significant association with decreased primary patency and forearm cephalic vein diameter showed a borderline significant association with decreased secondary patency (p = 0.046, HR = 8.2).

CONCLUSIONS

A standardized evaluation by a vascular surgeon or nephrologist represent a key in the preoperative assessment of AVF candidates. Based on our results, we will consider to avoid distal vascular access in both female patients with lower radial artery systolic peak velocity (less than 68 cm/s) and borderline forearm cephalic vein diameter (less than 2.8 mm) after initial assessment in our clinical practice. Our results could encourage new studies in order to stablish the potential role of these parameters in the RCFs patency rates.

A New Method for Common Femoral Arterial Access Using a Mixed Reality-Assisted Technique on a Phantom Model

PURPOSE

The purpose of this study was to investigate the technical feasibility and usability of a mixed reality (MiR)-assisted common femoral arterial (CFA) access technique using a sonography-assisted registration method.

MATERIALS AND METHODS

A total of 60 CFA punctures were performed on a phantom model by 2 observers. Thirty punctures were performed using MiR (MiR group) and 30 punctures were performed using a conventional sonography-guided access procedure (control group). In the MiR group, a virtual object was created based on a computed tomography (CT) angiography scan of the model and registered to the physical patient in an MiR environment utilizing a software prototype that allowed registration based on a sonography scan. Positional error assessment encompassed 4 measurements using cone beam CT scans: (1) distance of the needle tip to the centerline, (2) distance of the needle entry site from the mid-level of the ostium of the profound femoral artery, (3) angle of entry of the needle in coronal, and (4) sagittal planes. Technical success rates as well as positional errors were compared between both groups. In addition, the usability of the system was assessed according to the system usability scale (SUS).

RESULTS

Technical success was 96.7% and 100% in the MiR and control groups, respectively. The median distance between the needle tip and the centerline was 3.0 (interquartile range [IQR]: 2.0-4.6) in the MiR group and 3.2 mm (IQR: 2.3-3.9) (p=0.63) in the control group. Similarly, the median distance from the needle entry site to the mid-level of the ostium of the profound femoral artery was 3.0 mm (IQR: 2.0-5.0) in the MiR group and 4.5 mm (IQR: 2.0-7.8) (p=0.18) in the control group. The median coronal angles of needle entry were 7.5° (IQR: 6-11) and 6° (IQR: 2-12) (p=0.13), and the median sagittal angles were 50° (IQR: 47-51) and 51° (IQR: 50-55) (p<0.01) in the MiR and control groups, respectively. The mean SUS score provided by both observers was 51.3.

CONCLUSION

The feasibility of an MiR-assisted CFA access technique could be demonstrated on a phantom model. Further studies are needed to investigate the technique beyond phantom model experiments and in different anatomical settings.

CLINICAL IMPACT

This study demonstrates the technical feasibility of a Mixed-Reality-assisted common femoral arterial access procedure on a phantom model. The positional accuracy was comparable to a conventional sonography-guided technique. However, there are several limitations that need to be resolved prior to potential implementation into clinical practice. Further studies are needed to investigate its performance beyond phantom model experiments and the prototypical application requires further technical refinement to increase its usability.

Dialysis vascular access restoration by a transcollateral approach using the Surfacer® Inside-Out® Access Catheter System

Chronic thoracic venous occlusion (CTVO) as a result of repeated or prolonged central venous catheter insertion represents a significant problem in catheter-dependent patients. Different endovascular techniques techniques have been utilised for CTVO recanalization. The Surfacer® Inside-out® system represents a new approach to restore right-sided central venous access in CTVO by the inside-out recanalization technique. Standard approach for device implantation is through right femoral vein. In this case report, we report the first case to our knowledge of dialysis access restoration with Surfacer® system implantation via an unconventional and non-standard route by a transcollateral approach in a patient with exhausted vascular access options.

Delamination and dissection of arteriovenous grafts: A multicenter report of four cases

Arteriovenous (AV) grafts are an alternative vascular access for chronic hemodialysis. AV graft failure is often due to stenosis of the feeding artery, graft, or draining vein. We report four cases of AV graft dysfunction and failure rarely caused by graft delamination and dissection. Two males and two females aged 47-67 years had been on chronic hemodialysis. Ultrasound examination detected graft delamination and dissection between 1 and 33 months after Acuseal AV graft implantation. Two cases were successfully treated with stenting and partial graft replacement, respectively. False lumen volume reduction by fluid withdrawal failed to salvage the delaminated graft in one of the patients. The delamination and dissection of another case spontaneously resolved 5 months later. Graft delamination and dissection should be considered as a possible cause for AV graft dysfunction and failure. Stenting and graft replacement may be recommended to treat AV graft dissection and delamination.

Central venous catheter-related complications in older haemodialysis patients: A multicentre observational cohort study

BACKGROUND

Central venous catheters (CVC) remain a commonly used vascular access option in haemodialysis, despite guidelines advising to preferably use arteriovenous fistulae. Compared to younger patients, the risk-benefit ratio of CVC in older patients might be more beneficial, but previous studies mainly focussed on catheter-related bacteraemia and/or assessed tunnelled CVC (TCVC) only. This study's aim was to compare all catheter-related infections and malfunctions in older patients with younger patients using all CVC subtypes.

MATERIALS AND METHODS

We used data from DUCATHO, a multicentre observational cohort study in The Netherlands. All adult patients in whom a CVC was placed for haemodialysis between 2012 and 2016 were included. The primary endpoint was the occurrence of catheter-related infections, comparing patients aged ⩾70 years with patients aged <70 years (reference). As secondary endpoints, catheter malfunctions and catheter removal due to either infection or malfunction were assessed. Using Cox proportional hazards and recurrent events modelling, hazard ratios (HR) with 95% confidence intervals (CI) were calculated with adjustment of prespecified confounders. Additionally, endpoints were assessed for non-tunnelled CVC (NTCVC) and TCVC separately.

RESULTS

A total of 1595 patients with 2731 CVC (66.5% NTCVC, 33.1% TCVC) were included. Of these patients, 1001 (62.8%) were aged <70 years and 594 (37.2%) ⩾70 years. No statistically significant difference was found for the occurrence of catheter-related infections (adjusted HR 0.80-95% CI 0.62-1.02), catheter malfunction (adjusted HR 0.94-95% CI 0.75-1.17) and catheter removal due to infection or malfunction (adjusted HR 0.94-95% CI 0.80-1.11). Results were comparable when assessing NTCVC and TCVC separately.

CONCLUSION

Patients aged ⩾70 to <70 years have a comparable risk for the occurrence of catheter-related infections and catheter malfunction. These findings may help when discussing treatment options with older patients starting haemodialysis and may inform the current debate on the best vascular access for these patients.

Anesthetic effect of ultrasound-guided block of the musculocutaneous nerve during endovascular treatment of dysfunctional radiocephalic arteriovenous fistulas

BACKGROUND

Delivering requisite and minimal anesthesia for endovascular treatment (EVT) of dysfunctional arteriovenous fistulas (AVFs) under the target nerve block can achieve reasonable analgesia. We evaluated the anesthetic efficacy of ultrasound (US)-guided selective block of the musculocutaneous nerve (MCN) during the EVT of runoff venous strictures in the forearm through the radiocephalic (RC)-AVF at the wrist or the anatomical snuff box and analyzed the factors inhibiting the analgesia achieved under the MCN block.

METHODS

We enrolled 30 adult patients undergoing hemodialysis who had received 78 EVT sessions in an outpatient clinic mainly for long and/or multiple outflow-venous strictures in the forearm under US-guided blocks of the MCN, which provides sensory innervation to the anterolateral forearm where the cephalic vein courses. We assessed patients' pain during balloon dilations using the Wong-Baker FACES® Pain Rating Scale (WBFRS) and evaluated the factors increasing the pain (WBFRS score ⩾4), including patient characteristics, dilated strictures, additional nerve blocks, and types of balloon catheters.

RESULTS

In 25 EVT sessions (32.1%) out of 78 sessions, patients complained of stronger pain (WBFRS score ⩾4), while in the other 53 sessions (67.9%), presented with no pain and slight pain (WBFRS score = 0 or 2). Univariate analysis clarified that dilation of the AVF anastomosis, presence of dilated stenosis >4 cm, and a single block of the MCN or its sensory terminal significantly triggered more pain (p < 0.05). Consequently, multivariate analysis of all the factors with p < 0.1 in the univariate analysis, including multiple dilated stenosis sites, demonstrated that dilation of the AVF anastomosis significantly caused severe pain despite the anesthesia of the MCN block (p < 0.05).

CONCLUSION

US-guided selective block of the MCN could be a leading anesthetic option for EVT for multiple long stenoses of the cephalic vein draining through the RC-AVF in the wrist or anatomical snuff box.

Tunnelled central venous catheters for incident haemodialysis patients: a Victorian survey exploring reasons for use

BACKGROUND

Tunnelled central venous catheters (T-CVCs) are used globally as vascular access for patients on haemodialysis (HD) but are associated with increased sepsis, mortality, cost and length of hospitalisation compared with more permanent HD vascular access. The reasons for using T-CVC are varied and poorly understood. A significant and increasing proportion of incident HD patients in Victoria, Australia, have required T-CVC over the last decade.

AIM

To explore reasons for a significant and increasing proportion of incident HD patients in Victoria, Australia, having required T-CVC over the last decade.

METHODS

With rates of starting HD with definitive vascular access consistently below a Victorian quality indicator target of 70%, an online survey was developed to explore reasons why the rate remained lower than desired and to help inform future decisions about this quality indicator. The survey was completed by dialysis access coordinators over an 8-month period and involved all public nephrology services in Victoria.

RESULTS

Of the 125 surveys completed, 101 incident HD patients had no attempt at permanent vascular access prior to T-CVC insertion. For almost half of these (48 patients), there was no active medical decision not to create permanent vascular access prior to commencing dialysis. Reasons for insertion of the T-CVC included deterioration of kidney function faster than anticipated, surgical referral being overlooked, complications related to peritoneal dialysis requiring a change in dialysis modality and changes to initial decisions regarding dialysis modality for kidney failure.

CONCLUSIONS

These survey results provide an opportunity for quality improvement initiatives with respect to dialysis access planning and care.

Intractable arteriovenous access-related pain relieved after a single, pain-free hemodialysis session under selective block of the sensory nerves in the upper limb: A psychosocial factorial case

Intractable arteriovenous access (AVA)-related pain can not only lead to abandonment of a well-functioning AVA, but can also cause hemodialysis (HD) patients to be unwilling to accept, interrupt, or withdraw from HD. Such pain primarily derives from nociceptive and neuropathic factors caused by mechanical stimulation of needle cannulation; however, this might be related to psychosocial factors making it difficult for patients to accept their dependency on HD. Furthermore, the pain can be complicated by the interaction of biological and psychosocial factors, which hampers appropriate pain management and treatment. However, there have been few investigations pertaining to this matter. Herein, we describe the case of an HD patient who experienced chronic refractory AVA-related pain during a 32-month period of HD sessions, which occasionally caused treatment interruption. After clinical inquiry, physical evaluation, and ultrasonographic assessment of the blood circulation and cutaneous nerves in the ipsilateral upper limb to the radiocephalic arteriovenous fistula in the anatomical snuffbox, we diagnosed the patient with primarily psychosocially driven pain in consultation with an experienced pain clinician. A single, pain-free HD session under ultrasound-guided sensory nerve blocks in the upper limb markedly relieved her pain, followed by HD sessions with subtle but acceptable pain. This report provides insights into the mechanism underlying the vicious cycle of AVA-related pain, including the psychosocial aspects that might trigger such pain, as well as into the importance of treating such pain to improve the patient's quality of life, and underscores the need for cooperation of experts engaged in HD and pain management.

Taurolidine/Heparin Lock Solution and Catheter-Related Bloodstream Infection in Hemodialysis: A Randomized, Double-Blind, Active-Control, Phase 3 Study

BACKGROUND

Catheter-related bloodstream infections (CRBSIs) are one of the most prevalent, fatal, and costly complications of hemodialysis with a central venous catheter (CVC). The LOCK IT-100 trial compared the efficacy and safety of a taurolidine/heparin catheter lock solution that combines taurolidine 13.5 mg/ml and heparin (1000 units/ml) versus heparin in preventing CRBSIs in participants receiving hemodialysis via CVC.

METHODS

LOCK IT-100 was a randomized, double-blind, active-control, multicenter, phase 3 study that enrolled adults with kidney failure undergoing maintenance hemodialysis via CVC from 70 US sites. Participants were randomized 1:1 to taurolidine/heparin catheter lock solution or heparin control catheter lock solution (1000 units/ml). The primary end point was time to CRBSI as assessed by a blinded Clinical Adjudication Committee. Secondary end points were catheter removal for any reason and loss of catheter patency. On the basis of a prespecified interim analysis, the Data and Safety Monitoring Board recommended terminating the trial early for efficacy with no safety concerns.

RESULTS

In the full analysis population ( N =795), nine participants in the taurolidine/heparin arm ( n =397; 2%) and 32 participants in the heparin arm ( n =398; 8%) had a CRBSI. Event rates per 1000 catheter days were 0.13 and 0.46, respectively, with the difference in time to CRBSI being statistically significant, favoring taurolidine/heparin ( P < 0.001). The hazard ratio was 0.29 (95% confidence interval, 0.14 to 0.62), corresponding to a 71% reduction in risk of CRBSIs with taurolidine/heparin versus heparin. There were no significant differences between study arms in time to catheter removal for any reason or loss of catheter patency. The safety of taurolidine/heparin was comparable with that of heparin, and most treatment-emergent adverse events were mild or moderate.

CONCLUSIONS

Taurolidine/heparin reduced the risk of developing a CRBSI in study participants receiving hemodialysis via CVC compared with heparin with a comparable safety profile.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Study Assessing Safety & Effectiveness of a Catheter Lock Solution in Dialysis Patients to Prevent Bloodstream Infection, NCT02651428 .

The rapid atrial swirl sign for ultrasound-guided tip positioning of antegrade-tunneled hemodialysis catheters: A cross-sectional pilot study

BACKGROUND

We have previously reported that the rapid atrial swirl sign (RASS) is an accurate and safe procedure for ultrasound (US)-guided tip positioning of retrograde-tunneled hemodialysis catheters (HDCs). However, application of RASS for placement of antegrade HDCs has not been investigated yet. Therefore, we here report our first experience of applying RASS for US-guided tip positioning of antegrade-tunneled HDCs.

METHODS

We performed a cross-sectional study to assess the feasibility of applying the RASS for US-guided tip positioning of antegrade-tunneled HDCs. We included a total number of 15 antegrade-tunneled HDC insertions in 13 patients requiring placement of a HDC for the temporary or permanent treatment of ESKD in a single-center, cross-sectional pilot study.

RESULTS

The overall success rate of applying the RASS for US-guided tip positioning of antegrade-tunneled HDCs was 15/15 (100%) confirmed by portable anterior-posterior chest radiography, with no major adverse events after HDC insertions. In addition, this insertion technique demonstrated optimal HDC flow without any observed malfunction.

CONCLUSION

This study investigated the efficacy of the RASS for US-guided tip positioning of antegrade-tunneled HDCs in patients with ESKD. Application of the RASS for US-guided tip positioning is an accurate and safe procedure for proper placement of antegrade-tunneled HDCs.

Vascular access unit: Six-years experience report in France

BACKGROUND

The role of nurses in peripherally inserted central catheters (PICC) placement has been limited in France. Having a fully trained nurse-led PICC team can positively impact nursing profession and make better use of valuable human and economic healthcare resources. It can also improve the standards of patient's care, procedural experience, and safety.

AIM

The aim of this article is to report the successful outcomes of nurse-led PICC team performed over a 6-year period from a single central hospital in France.

METHODS

The authors reviewed all PICCs insertions performed by their trained nurse led team between 2014 and 2019. All quantitative and qualitative variables were considered: the patients admitted, the type of PICC inserted, overall procedural time, the mentor's help, the insert failures, the number of punctures required, the procedural pain utilizing Visual Analog Scale (VAS), any procedural complications, chest X-rays needed, the follow up to the eighth day (D8).

RESULTS

From 2014 to 2019, 12,687 PICC were inserted with 128 failed procedures (1%). In 2019, 73% of procedural insertion time was less than 10 min. The request of support rapidly decreased to 2 calls/month. More than 90% of procedures were associated with mild pain (VAS ⩽ 3). After the first month of training, 81% of all procedures were performed with a single insertion puncture. Accidental artery puncture during procedure was 0.5%. The authors found room for improvement, progressing from 97% in the first year to 99% in 2019. Furthermore, the authors found that only 1.85% of all catheters developed local infection within D8, and only 0.83% evolved in vein thrombosis. Total bloodstream infection was at 0.1%.

CONCLUSION

The authors report successful outcomes from data collected during the 6-year period demonstrating clear benefits of a nurse-led vascular access team with regard to system wide efficiencies and patient satisfaction.

Comparison of Clinical, Economic, and Humanistic Outcomes Between Blood Collection Approaches: A Systematic Literature Review

BACKGROUND

A systematic literature review was performed to understand the prevalence, advantages, and disadvantages of blood collection using different approaches (direct venipuncture or vascular access devices), and interventions used to mitigate the disadvantages.

METHODS

The review included a broad range of study designs and outcomes. Database searches (Embase, MEDLINE, Cochrane library, and Centre for Reviews and Dissemination) were conducted in March 2021 and supplemented by hand searching.

RESULTS

One hundred forty-one publications were included. The data indicate that blood sampling from vascular access devices is common in emergency departments, trauma centers, and intensive care units. Studies showed that hemolysis and sample contamination place a considerable economic burden on hospitals. Significant cost savings could be made through enforcing strict aseptic technique, or using the initial specimen diversion technique.

CONCLUSIONS

Hemolysis and sample contamination are far from inevitable in vascular access device-collected or venipuncture samples; both can be reduced through adherence to strict blood sampling protocols and utilization of the initial specimen diversion technique. Needle-free blood collection devices offer further hope for reducing hemolysis. No publication focused on the difficult venous access population; insertion success rates are likely to be lower (and the benefits of vascular access devices higher) in these patients.

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery

Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

Infectious Complications Associated to Buttonhole Cannulation of Native Arteriovenous Fistulas: A 22-year follow-up

BACKGROUND AND HYPOTHESIS

Buttonhole cannulation of native arteriovenous fistulas (AVFs) appears associated with an increased infectious risk. We previously reported a dramatic increase in the incidence of infectious events after shift to buttonhole in an in-center hemodialysis unit, largely reduced after staff (re)education regarding strict respect of the procedure. We assessed the evolution over the following 12-years period in our center.

METHODS

In this prospective follow-up of a previous, pre (rope-ladder)-post (buttonhole) comparison (2001-2010), all in-center hemodialysis patients with a native AVF were included from July 1st, 2010 to December 31st, 2022. Primary and secondary outcomes were infectious events (unexplained bacteraemia due to skin bacteria and/or local AVF infection) and complicated infectious events (metastatic infection, AVF surgery, death). Overall, the impact of several quality improvement strategies was tested according to the events rate over 6 periods: 1: Rope-ladder in all; 2: switch to buttonhole; 3: buttonhole in all, before workshops; 4: buttonhole in all, after workshops; 5: buttonhole withdrawal in problematic AVFs; 6: additional procedural changes.

RESULTS

This extended observation period allowed adding 195,180 AVF-days to our previous report. Overall, 381,661 AVF-days (366 AVFs, 345 patients) were analysed. After an increase of the infectious events rate in 2012, the shift to rope-ladder in problematic AVFs during Period 5 did not have a significant impact. The incidence of infectious events decrease significantly during Period 6 compared to Periods 3, 4 and 5 [IRR 0.24 (95%CI 0.09-0.52) p=0.0001, IRR 0.22 (95%CI 0.09-0.47) p<0.0001, and IRR 0.29 (95%CI 0.11-0.66) p=0.001, respectively] and became eventually for the first time comparable to Period 1 [IRR 0.59 (95%CI 0.21-1.62) p=0.27].

CONCLUSION

The constant observance of reinforced hygiene protocols by trained staff and central coordination succeeded in significantly mitigating the infectious risk associated with buttonhole.

Predialysis Vascular Access Placement and Catheter Use at Hemodialysis Initiation

BACKGROUND

Current guidelines encourage placement of an arteriovenous (AV) fistula in patients with advanced CKD to avoid initiation of hemodialysis with a central venous catheter. However, the relative merits of predialysis placement of an AV fistula or graft have been poorly studied.

METHODS

This study included 380 patients (mean age 59±14 years, 73% Black patients, 51% male) from a large academic medical center who underwent predialysis placement of an AV fistula (286) or AV graft (94). The study quantified three end points: time from access placement to initiation of dialysis, likelihood of starting hemodialysis without a catheter, and number of vascular access procedures before dialysis initiation.

RESULTS

The eGFR at access surgery was <10, 10-14, and ≥15 ml/min per 1.73 m 2 in 87 (23%), 179 (47%), and 114 (30%) patients, respectively. The median time from access surgery to hemodialysis initiation was 69, 156, and 429 days in patients with an eGFR of <10, 10-14, and ≥15 ml/min per 1.73 m 2 , respectively ( P < 0.001). Hemodialysis was initiated within 2 years of access surgery in 298 (78%) of the patients. Catheter-free hemodialysis initiation was higher in patients with an AV graft versus an AV fistula when the eGFR was <10 ml/min per 1.73 m 2 (88% versus 43%; odds ratio [OR], 9.10 [95% confidence interval, 2.74 to 26.4]) and when the eGFR was 10-14 ml/min per 1.73 m 2 (88% versus 54%; OR, 6.05 [2.35 to 15.0]) but similar when the eGFR was ≥15 ml/min per 1.73 m 2 (90% versus 75%; OR, 3.00 [0.48 to 34.9]). Patients undergoing an AV fistula were more likely to undergo an angioplasty (11% versus 0%, P < 0.001), surgical access revision (26% versus 8%, P < 0.001), a second access placement (16% versus 6%, P = 0.02), and a catheter insertion (32% versus 11%, P < 0.001).

CONCLUSIONS

Among patients with CKD undergoing vascular access surgery when their eGFR was <15 ml/min per 1.73 m 2 , catheter use at dialysis initiation was much less likely when an AV graft, rather than an AV fistula, was placed.

Leveraging AI in Postgraduate Medical Education for Rapid Skill Acquisition in Ultrasound-Guided Procedural Techniques

Ultrasound-guided techniques are increasingly prevalent and represent a gold standard of care. Skills such as needle visualisation, optimising the target image and directing the needle require deliberate practice. However, training opportunities remain limited by patient case load and safety considerations. Hence, there is a genuine and urgent need for trainees to attain accelerated skill acquisition in a time- and cost-efficient manner that minimises risk to patients. We propose a two-step solution: First, we have created an agar phantom model that simulates human tissue and structures like vessels and nerve bundles. Moreover, we have adopted deep learning techniques to provide trainees with live visualisation of target structures and automate assessment of their user speed and accuracy. Key structures like the needle tip, needle body, target blood vessels, and nerve bundles, are delineated in colour on the processed image, providing an opportunity for real-time guidance of needle positioning and target structure penetration. Quantitative feedback on user speed (time taken for target penetration), accuracy (penetration of correct target), and efficacy in needle positioning (percentage of frames where the full needle is visualised in a longitudinal plane) are also assessable using our model. Our program was able to demonstrate a sensitivity of 99.31%, specificity of 69.23%, accuracy of 91.33%, precision of 89.94%, recall of 99.31%, and F1 score of 0.94 in automated image labelling.

Changes in vascular access profile for pediatric hemodialysis patients over time: A registry-based study from Catalonia

BACKGROUND

The criteria for vascular access (VA) selection in pediatric hemodialysis (HD) population has changed over time until the current patient-centered approach using the individualized Life-Plan. We analyzed the type of VA used by incident and prevalent end-stage kidney disease (ESKD) pediatric patients (pts) treated with HD in Catalonia.

METHOD

Data from the Catalan Renal Registry of ESKD pts under 18 years of age undergoing kidney replacement therapy (KRT) were examined for a 22-year period (1997-2018).

RESULTS

ESKD children starting KRT through HD decreased progressively from 55.6% (1997-2001) to 38.2% (2012-2018) and, conversely, there was an increase in pts starting KRT by preemptive kidney transplantation (KT) from 28.9% to 42.6% between the same periods (for both comparisons, p = 0.007). Most ESKD pts started HD by fistula (AVF) from 1997 to 2001 (56.5%) but this percentage decreased over time and no AVFs were used to start HD in children from 2012 to 2018. Likewise, the percentage of children starting HD by tunneled catheter increased progressively from 8.7% to 72.2% between the same periods (for both comparisons, p < 0.001). Regarding prevalent ESKD pts, children on HD decreased from 34.9% in 1997 to 4.7% in 2018 and, conversely, pts with a functioning kidney graft increased from 62.8% to 92.4% during the same periods (for both comparisons, p < 0.001). There was a progressive decrease in the percentage of children dialyzed by AVF from 100% in 1997 to 0% in 2018 (p < 0.001). The KT rate increased from 5.4 per million population (pmp) in 1997 to 17.1 pmp in 2018 (p = 0.007). The median time on HD prior to the first KT progressively decreased to 6.6 months (2014-2018).

CONCLUSION

The high KT rate was a determining factor in choosing the VA type in the incident and prevalent pediatric population treated with HD in Catalonia.

Radial artery patency outcomes with saline flushing of the radial sheath after coronary intervention: A prospective cohort study

OBJECTIVE

The implications of saline flushing of the radial sheath have not been studied in terms of radial artery occlusion. We aimed to investigate radial artery patency outcomes after the saline flush of the radial sheath.

METHODS

In this prospective observational study, patients were selected to receive either radial sheath flushing with 10 mL of saline after pulling the sheath to one-third of its length (Group 1) or standard care (Group 2) after removal of the catheter sheath as per physician discretion. Radial artery patency was assessed by Doppler ultrasound at 24 h and 30 days after the procedure.

RESULTS

A total of 2877 patients were enrolled in the study, with 1340 receiving radial sheath flushing and 1537 receiving standard care. At 24 h after the procedure, the incidence of radial artery occlusion was significantly lower in the radial sheath flushing group compared to the standard care group (4.4% vs 12.6%, p = 0.027). This difference persisted 30 days after the procedure (6.1% vs 15.8%, p = 0.015). Radial sheath flushing was independently associated with a lower risk of radial artery occlusion 30 days after the procedure, after adjusting for potential confounders (OR 0.375, 95% CI 0.18-0.77, p = 0.008).

CONCLUSION

In conclusion, this prospective study provides evidence to support the use of radial sheath flushing after coronary intervention via the radial artery as a simple and effective strategy for reducing the risk of radial artery occlusion without increasing the risk of other adverse outcomes.

Combat Vascular Access: A Scoping Review

Medical leadership must decide how to obtain vascular access in a combat environment. Adequate combat trauma resuscitation requires efficient vascular access. A search of the Medline and EMBASE databases was conducted to find articles on combat vascular access. The primary dataset of interest was the type of vascular access obtained. Other data reviewed included who performed the intervention and the success rate of the intervention. The search strategy produced 1,339 results, of which 24 were included in the final analysis. Intravenous (IV), intraosseous (IO), and central venous access have all been used in the prehospital combat environment. This review summarizes the available combat literature to help commanders make an evidence-based decision about their prehospital vascular access strategy.

Expanded Utility of Human Acellular Vessel in Hemodialysis Access Surgery and Arterial Aneurysm Repair

Vascular access is essential for hemodialysis (HD) in patients with end-stage renal disease (ESRD). When the standard of care arteriovenous fistula (AVF) is limited, secondary to aneurysmal degeneration, trauma, and thrombus, interposition grafting is a reasonable reconstruction approach. As these grafts and comorbidities place ESRD patients at sustained risk of complications, reconstructions with regenerative medicine biologic conduits hold promise in improving safety and efficacy. Here, a biocompatible human acellular vessel (HAV) is our conduit of interest. With United States Food and Drug Administration use authorization under the Expanded Access Program, we report three cases of complex vascular access surgery with four aneurysm repairs using HAV. Patient selection focused on meeting unmet needs for those without adequate care alternatives, including active access and endoprosthetic stent graft infections, right heart failure due to high-output AVF, and arterial and access outflow aneurysms. In this high-risk expanded access population, operative technical success and interval success for patients given their inherent comorbidities, offer potential expanded utility of HAV in HD access surgery and arterial aneurysm repair.

Performance Characteristics of Candidate Criteria for Hemodialysis Arteriovenous Fistula Maturation

BACKGROUND

Twenty to 60% of newly created hemodialysis arteriovenous fistulas do not mature adequately for use. One barrier to developing interventions to improve fistula outcomes is a lack of standardized criteria for maturation.

METHODS

Using data from the multicenter, prospective Hemodialysis Fistula Maturation (HFM) Study, we determined sensitivities, specificities, and positive and negative predictive values of multiple candidate maturation criteria using the HFM Study maturation criteria as the reference. We also compared, across the maturation criteria, relationships between maturation and fistula survival using Cox proportional hazards models.

RESULTS

We included 535 of the 602 HFM Study participants. The median (interquartile range) age was 57 (47-65) years, 70% were men, and 45% were Black participants. Depending on the criterion and time frame for ascertainment (3, 4, 5, 6, or 9 months), sensitivities ranged from 57% to 100%, specificities ranged from 85% to 100%, positive predictive values ranged from 88% to 100%, and negative predictive values ranged from 65% to 100%. For all criteria, areas under the curve for the 6-month (0.90-0.97 for unassisted maturation and 0.89-0.95 for overall maturation) and 9-month time frames were similar. Attainment of unassisted maturation was associated with lower risks of fistula abandonment, with hazard ratios ranging from 0.10 to 0.40 depending on the criterion and time frame. Eliminating dialysis adequacy indicators, or simplifying the criteria in other ways, had little effect on performance characteristics.

CONCLUSIONS

High performance characteristics are maintained with maturation criteria that are simpler and less burdensome to ascertain than the HFM Study outcome measure.

Feasibility Analysis of Ultrasound-Guided Placement of Tunneled Hemodialysis Catheters

Introduction

Radiographic fluoroscopy is the current standard for placement of tunneled central venous catheters (CVCs) for hemodialysis. Radiographic fluoroscopy requires structural and personnel infrastructure and exposes the patient to ionizing radiation. Here, we investigate the feasibility of solely ultrasound-guided placement of tunneled central venous dialysis catheters (USCVCs).

Methods

We evaluated prospectively collected single-center data regarding safety and catheter function of 134 consecutive patients who underwent USCVC implantation between 2020 and 2021. We used the inset guidewire to visualize the position of the catheter tip. In the case of inadequate visibility by ultrasound, we used intracardiac electrocardiography (ECG) recording or agitated saline. A total of 1844 catheter days were assessed. The optimal CVC position was defined as being within the upper right atrium (URA) and middle to deep right atrium.

Results

Of the 134 USCVCs, 87% were placed on the right side. The primary success rate for optimal tip position and catheter function was 98%. Of the USCVCs, 97% were placed solely by ultrasound. Regarding positioning, 6% were in the vena cava superior zone, 70% in the URA and 24% in the middle to deep right atrium, resulting in a rate of 94% with optimal positioning. Effective blood flow averaged 292 ± 39 ml/min. There were no immediate procedure-associated complications.

Conclusion

Placement of CVC for hemodialysis solely by ultrasound is an effective alternative to fluoroscopy-assisted placement.

Long-term patency of arteriovenous fistulas for hemodialysis: A decade's experience in a transplant unit

BACKGROUND

The heterogeneous quality of studies on arteriovenous fistulas outcome, with variable clinical settings and large variations in definitions of patency and failure rates, leads to frequent misinterpretations and overestimation of arteriovenous fistula patency. Hence, this study aimed to provide realistic and clinically relevant long-term arteriovenous fistula outcomes.

METHODS

We retrospectively analyzed all autologous arteriovenous fistulas at our center over a 10-year period (2012-2022). Primary and secondary patency analysis was conducted using the Kaplan-Meier method; multivariate analysis of variance was used to detect outcome predictors. Vascular access-specific endpoints were defined according to the European guidelines on vascular access formation.

FINDINGS

Of 312 arteriovenous fistulas, 57.5% (n = 181) were radio-cephalic (RC_AVF), 35.2% (n = 111) brachio-cephalic (BC_AVF), and 6.3% (n = 20) brachio-basilic (BB_AVF). 6, 12, and 24 months follow-up was available in 290 (92.1%), 282 (89.5%), and 259 (82.2%) patients, respectively. Primary patency rates at 6, 12, and 24 months were 39.5%, 34.8%, and 27.2% for RC_AVF, 58.3%, 44.4%, and 27.8% for BC_AVF, and 40.0%, 42.1%, and 22.2% for BB_AVF (p = 0.15). Secondary patency rates at 6, 12, and 24 months were 65.7%, 63.8%, and 59.0% for RC_AVF, 77.7%, 72.0%, and 59.6% for BC_AVF, and 65.0%, 68.4%, and 61.1% for BB_AVF (p = 0.29). Factors associated with lower primary and secondary patency were hemodialysis at time of arteriovenous fistula formation (p = 0.037 and p = 0.024, respectively) and higher Charlson Comorbidity Index (p = 0.036 and p < 0.001, respectively). Previous kidney transplant showed inferior primary patency (p = 0.005); higher age inferior secondary patency (p < 0.001).

DISCUSSION

Vascular access care remains challenging and salvage interventions are often needed to achieve maturation or maintain patency. Strict adherence to standardized outcome reporting in vascular access surgery paints a more realistic picture of arteriovenous fistula patency and enables reliable intercenter comparison.

Relationship between vascular access and angulation of vena cava filter at placement and retrieval: a multicenter retrospective cohort study

Background

Inferior vena cava (IVC) filters are commonly used intravascular devices designed to prevent fatal pulmonary embolism (PE), maintaining the IVC filter as centered as possible is fundamental for achieving its filtration function.

Objective

This study aimed to characterize the tilt angles of IVC filter between the vascular access of internal jugular vein (IJV) and femoral vein (FV), as well as to identify factors associated with increased or decreased tilt angles between placement and retrieval.

Design

This is a multicenter retrospective study.

Methods

A multicenter retrospective study was conducted from October 2017 to March 2019. The primary outcome was the change in filter tilt between placement and retrieval. The secondary outcome was the identifications of factors associated with increased or decreased tilt angle. Relevant variables were analyzed using t-tests, Chi-square tests, Fisher's exact tests, while multivariate logistic regression analysis was used to determine risk factors.

Results

A total of 184 eligible patients were included in this study. The IJV group had a lower likelihood of tilt angle over 10° at the time of placement compared to the FVs group (0% versus 12.5%, p = 0.040). Among the 171 patients with a mean dwell time of 22.1 days, the IJV group had a higher likelihood of tilt angle over 10° than the FVs group (10.3% versus 2.3%, p = 0.080). The use of FVs access at placement was associated with a higher difference between placement and retrieval filter tilt angles (p < 0.01). Multivariate logistic regression analysis showed that hypertension [odds ratio (OR) 0.668; 95% confidence interval (CI) 0.328-1.358, p = 0.265], cardiologic artery disease (OR 0.537; 95% CI 0.136-2.130, p = 0.377), cerebral venous disease (OR 0.555; 95% CI 0.186-1.651, p = 0.290), filter types (OR 1.624; 95% CI 0.851-3.096, p = 0.141), and IVC filter thrombosis (OR 1.634; 95% CI 0.804-3.323, p = 0.175) were not associated with increased filter tilt angle. Right side (OR 0.434; 95% CI 0.202-0.930, p = 0.032) or bilateral lower extremity deep vein thrombosis (LEDVT) (OR 0.383; 95% CI 0.148-0.995, p = 0.049) were identified as protective factors.

Conclusion

IJV access was associated with a lower filter tilt angle at the time of placement, while FVs access was linked to a higher difference between placement and retrieval tilt angles. Right side or bilateral LEDVT were identified as protective factors against increased IVC filter tilt angle.

Bedside placement of tunneled femorally inserted central catheters in pediatric patients on extracorporeal life support: A case series and discussion

BACKGROUND

Pediatric patients requiring extracorporeal life support (ECLS) often need central venous access for extended periods of time. In this population, the placement of an upper extremity peripherally inserted central catheter (PICC) can be challenging due to the location and size of the venous ECLS cannula. Bedside placement of a tunneled femorally inserted central catheters (T-FICC) can be a viable alternative to a traditional PICC.

METHODS

In this case series we present five children who were on ECLS and had a T-FICC placed at the bedside.

RESULTS

In this series of five patients we successfully placed T-FICCs while the patients were on ECLS. The T-FICCs dwelled from 15 to 182 days. There were no events of central line associated blood stream infections or deep vein thrombosis. There was only one unintentional line dislodgement noted.

CONCLUSION

The use of T-FICCs placed at the bedside is a safe and reliable alternative for secure long-term venous access in children who are on ECLS.

Cephalic arch stenosis in the arteriovenous fistula: A retrospective analysis of predisposing factors

BACKGROUND

Cephalic Arch Stenosis (CAS) is a frequently observed complication in brachiocephalic and radiocephalic arteriovenous fistulae (AVF) associated with high morbidity and healthcare expenditure. The predisposing factors and preventative strategies for CAS remain unclear. Our aim was to examine predisposing factors for CAS development in the AVF.

METHODS

A retrospective case-control study was performed at Gold University Coast Hospital on patients with AVFs created from 2009 to 2018 with ⩾18 months follow-up. CAS was defined as a >50% narrowing on angiographic assessment with clinically significant symptoms (dialysis dysfunction, arm swelling, prolonged bleeding after access).

RESULTS

About 187 patients with AVF were included in the analysis (36 brachiocephalic, 151 radiocephalic). CAS developed in 22 of 36 (61%) of brachiocephalic AVF and 9 of 151 (6%) of radiocephalic AVFs. Brachiocephalic AVF were ⩾12 times more likely to develop CAS than radiocephalic AVF (Hazard Ratio (HR) 12.7, 95% CI [5.6-28.3], p < 0.001). Each 1 mL/min increase in flow rate through the AVF, correlated with a 0.07% increase in the probability of development of CAS (HR 1.0007, 95% CI [1.0001-1.0012], p = 0.011). Brachiocephalic AVFs with CAS were associated with a higher number of interventional procedures per access-year compared with their non-CAS counterparts (Median [Interquartile range]: 1.76 [0.74, 3.97] vs 0.41 [0.27, 0.67], p = 0.003).

CONCLUSION

Brachiocephalic AVF with higher access flow rates are more likely to develop CAS and earlier than radiocephalic AVF, and in a dose dependent fashion. AVF flow rate is a major factor in CAS development within brachiocephalic AVF and has potential utility in surveillance thresholds for prophylactic blood flow reduction procedures. AVFs with CAS are associated with a greater number of interventional procedures per access-year, heralding higher patient morbidity and healthcare expenditure. Further prospective studies will help define an AVF access flow rate threshold in the implementation of prophylactic strategies for CAS.

Persistent median artery on computed tomographic arteriovenous fistulograms in patients on haemodialysis

INTRODUCTION

Cadaveric studies suggest an increasing prevalence of the persistent median artery (PMA) over a prolonged timeframe. The aim of this retrospective cross-sectional study was to evaluate the PMA prevalence in haemodialysis patients who had computed tomographic fistulograms (CTFs), and if present, their calibres and origins.

METHODS

All consecutive adult patients referred for an upper limb CTFs for assessment of arteriovenous fistula (AVF) dysfunction from 2006 to 2021 were included. Patients whose CTF did not include the forearm were excluded. PMA was identified as an artery running alongside the median nerve between flexor digitorum superficialis and flexor digitorum profundus. Patient demographics, presence of PMA including size and origin were recorded.

RESULTS

A PMA was found in 91/170 (53.5%) CTFs (7:3 male-to-female ratio, mean age 71-years). When stratified by age, prevalence increased with decreasing age; 51% in >70-year-olds, 54% in 50-70-year-olds and 67% in <50-year-olds. The average PMA diameter was 2.2 mm proximally and 1.8 mm distally. No stenosis was observed in the PMAs.

CONCLUSION

The PMA prevalence appears to increase with decreasing age and is a frequently encountered anatomical variant. Radiologists assessing forearm vasculature need to be aware of this anatomical variant and potentially include it in their future reports. Further research into the PMA may make its potential use as arterial conduits for AVF, potential donor grafts for coronary artery bypass surgery or additional vascular access options possible. Whether the reducing prevalence with age reflects an overall increasing prevalence is yet to be determined.

Screening and surveillance of venous stenosis in AVG: Is it time to rethink our assumptions?

Guidelines make no firm recommendations about surveillance of arteriovenous grafts as several randomised trials (RCT) have not shown a clear benefit in patency. However a more thorough review of these RCT based on epidemiological principles reveals significant limitations. In particular a key weakness of these older studies is the interventions performed for venous stenosis detected that was largely angioplasty. However, the observational data of modern stent-grafts shows a clear benefit over angioplasty, and thus seems to suggest that a modern well considered RCT is now mandated.

Point-of-care ultrasound-guided cannulation versus standard cannulation in hemodialysis vascular access: A controlled random order crossover pilot feasibility study

BACKGROUND

Standard cannulation practice for hemodialysis consists of inserting needles "blindly" through skin into an arteriovenous fistula (AVF), which is more likely to cause damage. Point-of-care ultrasound (POCUS) guided cannulation has potential for less damage; however, efficacy of this technique has not been explored. Our purpose was to test the feasibility and effectiveness of POCUS guidance for cannulation of AVFs in hemodialysis patients.

METHODS

A random-order crossover research design was used; patients and nurses acted as their own control. Sample included 13 patients with functioning AVFs and 9 nurses, recruited from a single hemodialysis center. All nurses cannulated all patients using standard and POCUS-guided cannulation. Data were collected at each cannulation (time taken, nurse position, probe direction, pressures, patient satisfaction, pain scores). Ultrasound images of needle position were collected from which needle tip locations inside vessels were measured. Nurses were surveyed at three timepoints and were interviewed at conclusion of data collection. Analysis involved linear mixed-models for clinical data, descriptive statistics for binary and feasibility data, and content analysis for interview data.

RESULTS

Eleven patients and seven nurses completed. Protocol adherence was 94.4%. Two miscannulations occurred, both during standard cannulation. Cannulation time using POCUS guidance was significantly higher than standard cannulation (p = 0.008, 95% CI 39-166). All other variables showed no statistically significant difference. Content analysis of interview data showed cultural shift toward use of POCUS; nurses gained confidence and become more proficient in their POCUS technique.

CONCLUSIONS

Random-order crossover is a feasible design to measure differences in POCUS-guided and standard cannulation. It is also feasible to implement POCUS into hemodialysis centers and whilst POCUS guidance takes longer, nurses become more proficient, and confident with persistent use.

Patients' experiences of cannulation of arteriovenous access for haemodialysis: A qualitative systematic review

INTRODUCTION

Cannulation is an essential part of haemodialysis with arteriovenous access. Patients' experiences of cannulation for haemodialysis are problematic but poorly understood. This review aims to synthesise findings related to patients' experiences of cannulation for haemodialysis from qualitative studies, providing a fuller description of this phenomenon.

METHODS

Eligibility criteria defined the inclusion of studies with a population of patients with end-stage kidney disease on haemodialysis. The phenomena of interest was findings related to patients' experiences of cannulation for haemodialysis and the context was both in-centre and home haemodialysis. MedLine, CINAHL, EMBASE, EMCARE, BNI, PsycInfo and PubMed were last searched between 20/05/2019 and 23/05/2019. The quality of studies was assessed using the using Joanna Briggs Critical Appraisal Checklist for Qualitative Research. Meta-aggregation was used to synthesise findings and CERQual to assess the strength of accumulated findings.

RESULTS

This review included 26 studies. The subject of included studies covered cannulation, pain, experiences of vascular access, experiences of haemodialysis and a research priority setting exercise. From these studies, three themes were meta-aggregated: (1) Cannulation for haemodialysis is an unpleasant, abnormal and unique procedure associated with pain, abnormal appearance, vulnerability and dependency. (2) The necessity of cannulation for haemodialysis emphasises the unpleasantness of the procedure. Success had multiple meanings for patients and patients worry about whether the needle insertion will be successful. (3) Patients survive unpleasant, necessary and repetitive cannulation by learning to tolerate cannulation and exerting control over the procedure. Feeling safe can help them tolerate cannulation better and the cannulator can invoke feeling safe. However, some patients still avoid cannulation, due to its unpleasantness.

CONCLUSIONS

Cannulation is a pervasive procedure that impacts on patients' experiences of haemodialysis. This review illuminates further patients' experiences of cannulation for haemodialysis, indicating how improvements can be made to cannulation.

REGISTRATION

PROSPERO (CRD42019134583).

Effects of a More Selective Arteriovenous Fistula Strategy on Vascular Access Outcomes

SIGNIFICANCE STATEMENT

The optimal choice of vascular access for patients undergoing hemodialysis-arteriovenous fistula (AVF) or arteriovenous graft (AVG)-remains controversial. In a pragmatic observational study of 692 patients, the authors found that among patients who initiated hemodialysis with a central vein catheter (CVC), a strategy that maximized AVF placement resulted in a higher frequency of access procedures and greater access management costs for patients who initially received an AVF than an AVG. A more selective policy that avoided AVF placement if an AVF was predicted to be at high risk of failure resulted in a lower frequency of access procedures and access costs in patients receiving an AVF versus an AVG. These findings suggest that clinicians should be more selective in placing AVFs because this approach improves vascular access outcomes.

BACKGROUND

The optimal choice of initial vascular access-arteriovenous fistula (AVF) or graft (AVG)-remains controversial, particularly in patients initiating hemodialysis with a central venous catheter (CVC).

METHODS

In a pragmatic observational study of patients who initiated hemodialysis with a CVC and subsequently received an AVF or AVG, we compared a less selective vascular access strategy of maximizing AVF creation (period 1; 408 patients in 2004 through 2012) with a more selective policy of avoiding AVF creation if failure was likely (period 2; 284 patients in 2013 through 2019). Prespecified end points included frequency of vascular access procedures, access management costs, and duration of catheter dependence. We also compared access outcomes in all patients with an initial AVF or AVG in the two periods.

RESULTS

An initial AVG placement was significantly more common in period 2 (41%) versus period 1 (28%). Frequency of all access procedures per 100 patient-years was significantly higher in patients with an initial AVF than an AVG in period 1 and lower in period 2. Median annual access management costs were significantly higher among patients with AVF ($10,642) versus patients with AVG ($6810) in period 1 but significantly lower in period 2 ($5481 versus $8253, respectively). Years of catheter dependence per 100 patient-years was three-fold higher in patients with AVF versus patients with AVG in period 1 (23.3 versus 8.1, respectively), but only 30% higher in period 2 (20.8 versus 16.0, respectively). When all patients were aggregated, the median annual access management cost was significantly lower in period 2 ($6757) than in period 1 ($9781).

CONCLUSIONS

A more selective approach to AVF placement reduces frequency of vascular access procedures and cost of access management.

Implementation frameworks, strategies and outcomes used in peripheral intravenous catheter studies: A systematic review

AIMS

The aim of this study was to critically evaluate implementation frameworks, strategies and/or outcomes used to optimise peripheral intravenous catheter (PIVC) care and/or promote guideline adherence.

BACKGROUND

Although a considerable volume of research has investigated the effectiveness of PIVC interventions and treatments to promote performance and prevent harm, how to best implement this evidence into dynamic clinical settings and populations is not well understood. Implementation science is central to translating evidence-based knowledge to the bedside; however, there is a gap in identifying the best implementation framework, strategies and/or outcomes to optimise PIVC care and/or guideline adherence.

DESIGN

A systematic review.

METHOD

The review was conducted using innovative automation tools. Five databases and clinical trial registries were searched on 14 October 2021. Qualitative and quantitative PIVC intervention studies reporting implementation strategies were included in the review. Data were extracted independently by experienced researchers in pairs. The Mixed Method Appraisal tool was used to assess the quality of individual studies. Narrative synthesis was used to present the findings. The systematic review was reported following the PRISMA checklist.

RESULTS

Of 2189 references identified, 27 studies were included in the review. Implementation frameworks were used in 30% (n = 8) of studies, with most used during the preparation (n = 7, 26%) and delivery phase (n = 7, 26%) and then evaluation phase (n = 4, 15%). Multifaceted strategies were commonly adopted (n = 24, 89%) to promote PIVC care or study interventions which were clinician (n = 25, 93%) and patient-targeted (n = 15, 56%). The most commonly reported implementation outcomes were fidelity (n = 13, 48%) and adoption (n = 6, 22%). Most studies were scored as low quality (n = 18, 67%).

CONCLUSION

We call for researchers and clinicians to work together and use implementation science frameworks to guide study design, implementation and evaluation in future PIVC studies, to improve evidence translation and thereby improve patient outcomes.

The use of AVF.SIM system for the surgical planning of arteriovenous fistulae in routine clinical practice

BACKGROUND

The number of patients treated with hemodialysis (HD) in Europe is more than half a million and this number increases annually. The arteriovenous fistula (AVF) is the vascular access (VA) of first choice, but the clinical outcome is still poor. A consistent number of AVFs fails to reach the desired blood flow rate for HD treatment, while some have too high flow and risk for cardiac complications. Despite the skill of the surgeons and the possibility to use Ultrasound investigation for mapping arm vasculature, it is still not possible to predict the blood flow volume that will be obtained after AVF maturation.

METHODS

We evaluated the potential of using a computational model (AVF.SIM) to predict the blood flow volume that will be achieved after AVF maturation, within a multicenter international clinical investigation aimed at assessing AVF.SIM predictive power. The study population included 231 patients, with data on AVF maturation in 124 patients, and on long-term primary patency in 180 patients.

RESULTS

At 1 year of follow-up, about 60% of AVFs were still patent, with comparable primary patency in proximal and distal anastomosis. The correlation between predicted and measured blood flow volume in the brachial artery at 40 days after surgery was statistically significant, with an overall correlation coefficient of 0.58 (p < 0.001). The percent difference between measured and predicted brachial blood flow 40 days after surgery was less than 30% in 72% of patients investigated.

CONCLUSIONS

The results indicate that the use of the AVF.SIM system allowed to predict with a good accuracy the blood flow volume achievable after VA maturation, for a given location and type of anastomosis. This information may help in AVF surgical planning, reducing the AVFs with too low or too high blood flow, thus improving AVF patency rate and clinical outcome of renal replacement therapy.

Evaluation of point of care ultrasound (POCUS) training on arteriovenous access assessment and cannula placement for haemodialysis

BACKGROUND

Haemodialysis requires a permanent vascular access and relies on cannulation with two large bore needles. Point Of Care Ultrasound (POCUS) is a tool that may assist nursing staff with visualising cannula placement and prevent miscannulation. This can be particularly useful in regional hospitals with limited access to vascular access specialists.

AIMS

To examine the impact of POCUS provision and education for nursing staff on confidence in cannulation and to understand the patient experience at three regional hospital haemodialysis units in South Australia.

METHODS

A POCUS machine and dedicated nursing education were provided at each of the three sites. A pre-test post-test model was used to assess the individual nurses perceived competency before and after the delivery of a series of online ultrasound education modules and face to face training. Patient reported outcome measures (PROMs) were collected to understand the use of POCUS from the client perspective.

RESULTS

There was a shift towards 'agree' or 'strongly agree' for all nursing surveys in regard to perceived competency (n = 15). This was statistically significant (p ⩽ 0.05) for all questions other than question 1 'I am confident in my ability to physically assess vascular access' (p = 0.06). The patients that completed the PROMs (n = 17) overall supported the ease and use of POCUS for haemodialysis cannulation and felt that it contributed to the nursing staff competency in cannulation.

CONCLUSION

POCUS has the potential to be a valuable tool in regional haemodialysis units to support vascular access cannulation and potentially avoid metropolitan transfer due to cannulation difficulties. The non-significant change post intervention for question 1 likely reflects the haemodialysis nurses inherent pre-existing capacity to assess vascular access without the use of POCUS using the standard process of visual inspection, the use of a stethoscope and palpation ('look, listen and feel').

Right Heart Catheterization: An Antecubital Vein Approach to Reduce Fluoroscopy Time, Radiation Dose, and Guidewires Need

Antecubital access for right heart catheterization (RHC) is a widespread technique, even though there is a need to clarify if there are differences and significant advantages compared to proximal vein access. To pursue this issue, we retrospectively identified patients who underwent RHC in our clinic over a 7 year period (between January 2015 and December 2022). We revised demographic, anthropometric, and procedural data, including the fluoroscopy time, the radiation exposure, and the use of guidewires. The presence of any complications was also assessed. In patients with antecubital access, the fluoroscopy time and the radiation exposure were lower compared to proximal vein access (6 vs. 3 min, mean difference of 2 min, CI 95% 1-4 min, p < 0.001 and 61 vs. 30 cGy/m2, mean difference 64 cGy/m2, CI 95% 50-77, p < 0.001). The number of patients requiring the use of at least one guidewire was lower in the group undergoing RHC through antecubital access compared to proximal vein access (55% vs. 43%, p = 0.01). The feasibility was optimal, as just 0.9% of procedures switched from antecubital to femoral access, with a negligible rate of complications. The choice of the antecubital site exhibits advantages, e.g., a shorter fluoroscopy time, a reduced radiation dose, and a lower average number of guidewires used compared to proximal vein access.

Non-cuffed central venous catheter for unplanned and urgent start haemodialysis in chronic kidney disease: A multi-centre experience from India

BACKGROUND

Central Venous Catheter (CVC) is indispensable to unplanned and urgent start haemodialysis in chronic kidney disease (CKD). While cuffed CVC is preferred to non-cuffed CVC for urgent start haemodialysis, patient's clinical condition might warrant immediate insertion of non-cuffed CVC. In the resource poor setting, non-cuffed CVCs might have to be retained longer than guideline recommended limit of 2 weeks. In this multi-centre retrospective observational study, the real-world survival of non-cuffed CVC was assessed among CKD patients who initiated dialysis urgently.

METHODS

CVC survival was assessed by Kaplan-Meier survival estimate. Predictors of premature CVC loss were assessed using multi-level multi-variate Cox frailty model wherein, each centre was provided with a random intercept to account for within-centre correlation of practice patterns.

RESULTS

Among 433 non-cuffed CVCs, there were 393 removals out of which 80% were elective and 20% were premature. The median CVC survival was 37 days (95% CI: 35-41). The rate of premature CVC removal was 4.5/1000 CVC-days (95% CI: 3.6-5.6). Mechanical complications followed by central line associated blood stream infection (CLABSI) were the most common reasons for premature removal. Rate of CLABSI was 1.7/1000 CVC-days (95% CI: 1.2-2.5). Diabetic CKD significantly increased the hazard of premature CVC removal (HR 1.91, 95% CI: 1.01-3.63, p = 0.04) while right internal-jugular location decreased the hazard (HR 0.22, 95% CI: 0.13-0.38, p < 0.001).

CONCLUSION

Prolonged retention of non-cuffed CVC (median 37 days) is common in resource-poor setting. It is worrisome and calls for pre-emptive access creation.

Native Arteriovenous Fistula Creation in Patients With Continuous Flow Left Ventricular Assist Devices: A Case Report and a Narrative Review

Worsening of kidney function after left ventricular assist device (LVAD) implantation is common, and many patients reaching end-stage kidney disease require long-term dialysis. Permanent vascular access in a patient with LVAD remains a clinical dilemma. There is a theoretical concern about the maturation of the arteriovenous fistula in a patient with LVAD due to the absence of a pulsatile flow in these patients. We described a case of successful creation of a left brachial-cephalic AVF in a patient with continuous flow LVAD (Abbott's HeartMate 3TM), which was used for dialysis without issue.