Shared decision making in elderly patients with kidney failure

'Elderly' is most commonly defined as an individual aged 65 years or older. However, this definition fails to account for the differences in genetics, lifestyle and overall health that contribute to significant heterogeneity among the elderly beyond chronological age. As the world population continues to age, the prevalence of chronic diseases, including chronic kidney disease (CKD), is increasing and CKD frequently progresses to kidney failure. Moreover, frailty represents a multidimensional clinical entity highly prevalent in this population, which needs to be adequately assessed to inform and support medical decisions. Selecting the optimal treatment pathway for the elderly and frail kidney failure population, be it haemodialysis, peritoneal dialysis or conservative kidney management, is complex because of the presence of comorbidities associated with low survival rates and impaired quality of life. Management of these patients should involve a multidisciplinary approach including doctors from various specialties, nurses, psychologists, dieticians and physiotherapists. Studies are mostly retrospective and observational, lacking adjustment for confounders or addressing selection and indication biases, making it difficult to use these data to guide treatment decisions. Throughout this review we discuss the difficulty of making a one-size-fits-all recommendation for the clinical needs of older patients with kidney failure. We advocate that a research agenda for optimization of the critical issues we present in this review be implemented. We recommend prospective studies that address these issues, and systematic reviews incorporating the complementary evidence of both observational and interventional studies. Furthermore, we strongly support a shared decision-making process matching evidence with patient preferences to ensure that individualized choices are made regarding dialysis vs conservative kidney management, dialysis modality and optimal vascular access.

Case series of peripherally inserted central catheter insertion in young children: A new approach to the axillary vein

BACKGROUND

We have developed a new approach for peripherally inserted central catheter (PICC) insertion that we think has several advantages, including ease of insertion, access to a larger vein and patient comfort.

METHODS

In this case series report, the first 19 cases were audited.

RESULTS

All PICCs were inserted without complications; 17 on the first attempt.

CONCLUSION

We conclude that the novel approach to the axillary vein for PICC insertion is feasible and appears to be safe when performed by an experienced operator.

Zero upper arm hemodialysis fistulas: utopian or realistic goal?

BACKGROUND

Although distal native fistula is the best first-line vascular access (VA), upper arm fistula (UAF) prevalence is increasing worldwide, except in Japan. Our previous survey on 50% of hemodialysis patients (HP) revealed a prevalence of UAF of less than 5%, which is lower than the findings published by the DOPPS 5 study in our country. We analyzed the VA prevalence on 100% of HPs from our department.

METHODS

In December 2021, we investigated the prevalence of vascular access of 1295 hemodialysis patients from 17 dialysis factories. VAs were classified according to location into distal forearm fistula (DFF), middle-proximal forearm fistula (MPFF), and UAF. The department manages VA using a Hub and Spoke model. The hub performs simple and complex VA including Graft placement, the Percutaneous Transluminal Angioplasty (PTA) of fistulas and central stenosis, and the surgical and endovascular rescue of thrombosed or stenotic fistulas. The spokes perform mainly simple DFFs.

RESULTS

The mean age of 1295 HP (35% females and 21% diabetics) was 69 ± 12.4 years; 506 (39%) were over 75 years old. The prevalence of DFF, MPFF, UAF, GRAFT, and CVC was 63.5%, 10.1%, 3%, 0.7%, and 22.5%, respectively. Data comparison between our two surveys revealed a lower MPFF, UAF, and GRAFT prevalence and increased CVC prevalence. Patients aged 75 years or older, women, and diabetics showed a higher frequency of CVC and a lower prevalence of DFF.

CONCLUSIONS

The findings confirm the low prevalence of UAF found in our prior survey, demonstrating that UAFs can be reduced to 5% or less, as seen in Japanese experience.

One-staged brachial-basilic vein transposition versus arm straight arteriovenous graft for hemodialysis

OBJECTIVES

After forearm and arm cephalic veins are no longer available as options, the choices of arm vascular access between one-staged brachial-basilic vein transposition (BBAVF) and arm straight arteriovenous graft (AS-AVG) for hemodialysis are controversial. This study aims to compare outcomes between groups.

METHODS

All one-staged BBAVF and AS-AVG from August 2014 to December 2019 were reviewed. In cases of suitable basilic vein of 3 mm or more present from cubital crease to axilla, one-staged BBAVF was preferred. AS-AVG was performed for patients who need timely functioning access or have no suitable basilic vein.

RESULTS

Twenty-eight one-staged BBAVF and 74 AS-AVG were included. Baseline characteristics were not significantly different, except AS-AVG had less previous ipsilateral access (9% vs 39%; p < .001). Postoperative complications were not different. With six loss follow-ups (3 in BBAVF and 3 in AS-AVG), 24 (96%) and 64 (90%) matured after one-staged BBAVF and AS-AVG, respectively (p = .676). BBAVF took about 30 days (95% CI: 10, 51) longer time to first successful cannulation. Primary patency was significantly better for one-staged BBAVF (hazard ratio (HR) of 3.0 (95%CI: 1.2, 7.7)), whereas secondary patency was not different. The total access failure (i.e. failure to mature combined with any thrombosis or intervention to maintain patency) significantly favored BBAVF (HR 2.7 (95%CI: 1.1, 6.6)).

CONCLUSIONS

Provided a suitable arm basilic vein is available, one-staged BBAVF is preferred over AS-AVG when forearm AVF, forearm AVG, and arm cephalic veins are out. However, it requires a longer time to start cannulating than AS-AVG.

Vascular access route venture of the chronic hemodialysis patient: A prospective cohort study

OBJECTIVES

This study aimed to collect evidence to improve the arteriovenous fistula practice by investigating vascular access routes and by identifying the factors influencing the preferred types of vascular access routes for the first-time hemodialysis in our center.

METHODS

We performed an epidemiological, prospective, cohort study. The study included 308 patients, who underwent hemodialysis for the first time between March 2023 and August 2023 in our hemodialysis center. We evaluated biochemical parameters, preferred vascular access routes for the first-time hemodialysis, planned/emergency hemodialysis status, the qualifications of the healthcare provider, who inserted the central venous catheter, if applicable, the presence of hypervolemia, anticoagulant use, nephrology follow-up findings, and in-hospital mortality in all patients and in those, who continued with chronic hemodialysis.

RESULTS

The number of patients, who continued with chronic hemodialysis, was 167 (54.2%) and a temporary internal jugular central venous catheter was the most commonly preferred vascular access route for the first-time hemodialysis (47.3%). A central venous catheter was most commonly inserted by a nephrologist (53.7%) in chronic hemodialysis patients. Of the patients continuing with chronic hemodialysis, 45.5% were followed up in the nephrology outpatient clinic, 9.6% initiated hemodialysis on a planned basis, and 8.4% initiated hemodialysis with an arteriovenous fistula. A temporary internal jugular central venous catheter was commonly preferred when patients were followed up in the nephrology clinic and when the insertion was performed by a nephrologist; a transient femoral central venous catheter was commonly preferred in case of hypervolemia (p < .001, p < .001, and p = .028, respectively). Age, gender, etiology, anticoagulant use, or biochemical test results did not act on the selection of the access site for the insertion of central venous catheter at the time of the first hemodialysis treatment. The access site for central venous catheter was not associated with in-hospital mortality (p = .644). In the overall patient group, the in-hospital mortality was significantly low in patients followed up in the nephrology clinic (p = .014).

CONCLUSION

The use of pre-emptive arteriovenous fistula for the first hemodialysis treatment occurs much less commonly than expected. Hemodialysis initiation rates with pre-emptive arteriovenous fistula lag behind nephrology outpatient follow-up rates.

Arteriovenous Fistula Histology, Hemodynamics, and Wall Mechanics: A Case Report of Successful and Failed Access in a Single Patient

The low 1-year patency rate of mature arteriovenous fistulas (AVFs) remains a significant clinical problem. Although vessel properties and biomechanics have been suggested to affect AVF function, understanding their roles in AVF patency failure is challenging owing to the heterogeneity within the patient population, including demographics and comorbid conditions. In this study, we present a case of a patient with 2 upper-arm AVFs with different 1-year patency outcomes and investigate whether they had different histologic features before the AVF creation surgery and biomechanics at 1 day and 6 weeks after the AVF creation surgery using magnetic resonance imaging-based fluid structure interaction simulations. Despite both AVFs being in the upper arm, created <1 year apart by the same surgeon, and having similar preoperative vessel diameters, the 1-year patent AVF had less preoperative intimal collagen and higher wall shear stress 1 day after AVF creation, when compared with the AVF that failed by 1 year. Thus, a low intimal collagen content before the AVF surgery and higher wall shear stress immediately after the AVF creation surgery may be important for long-term AVF patency and should be investigated with larger cohorts.

Ultrasound-guided deployment of ProGlide™ device in transfemoral transcatheter aortic valve implantation and risk reduction of vascular complications: A propensity-matched cohort study

BACKGROUND

ProGlide is a percutaneous suture-mediated closure device used in arterial and venous closure following percutaneous intervention. Risk of vascular complications from use, particularly related to failure in hemostasis, or acute vessel closure, remains significant and often related to improper suture deployment. We describe a technique of ultrasound-guided ProGlide deployment in transfemoral transcatheter aortic valve implantation (TF-TAVI).

AIMS

The aim of this study is to assess vascular outcomes for ultrasound-guided deployment of ProGlide vascular closure devices in patients undergoing TF-TAVI.

METHODS

We collected relevant clinical data of patients undergoing TAVI in a large volume centre.

PRIMARY OUTCOME

main access Valve Academic Research Consortium 3 (VARC-3) major vascular complication.

SECONDARY OUTCOME

any major/minor VARC-3 vascular complication, its type (bleed or ischemia), and treatment required (medical, percutaneous, or surgical). We performed inverse weighting propensity score analysis to compare the population undergoing ultrasound-guided versus conventional ProGlide deployment for main TAVI access. Ultrasound technique for ProGlide insertion was performed as described below.

RESULTS

Five hundred and seventeen patients undergoing TF-TAVI were included.

PRIMARY OUTCOME

In 126 (ultrasound-guided) and 391 (conventional ProGlide insertion), 0% versus 1.8% (p < 0.001) had a major VARC-3 vascular complication, respectively.

SECONDARY OUTCOME

0.8% (one minor VARC-3 bleed) vs 4.1% (13 bleeds and three occlusions) had any VARC-3 vascular complication (major and minor) (p < 0.001). Surgical treatment of vascular complication was required in 0.8% versus 1.3% (p = NS).

CONCLUSIONS

Ultrasound-guided deployment of ProGlide for vascular closure reduced the risk of major vascular complications in a large population undergoing TAVI.

Elevated Leukocyte Glucose Index Is Associated with Long-Term Arteriovenous Fistula Failure in Dialysis Patients

(1) Background: Arteriovenous fistula (AVF) is the preferred type of vascular access for dialysis in patients with end-stage kidney disease (ESKD). However, the primary patency of AVF at one year is under 70% due to several risk factors and comorbidities. Leukocyte glucose index (LGI), a new biomarker based on blood leukocytes and glucose values, has been found to be associated with poor outcomes in cardiovascular disease. The aim of this study is to analyze the impact of LGI on the long-term primary patency of AVF following dialysis initiation. (2) Methods: We conducted a retrospective observational study in which we initially enrolled 158 patients with ESKD admitted to the Vascular Surgery Department of the Emergency County Hospital of Targu Mures, Romania, to surgically create an AVF for dialysis between January 2020 and July 2023. The primary endpoint was AVF failure, defined as the impossibility of performing a chronic dialysis session due to severe restenosis or AVF thrombosis. After follow-up, we categorized patients into two groups based on their AVF status: "functional AVF" for those with a permeable AVF and "AVF failure" for those with vascular access dysfunction. (3) Results: Patients with AVF failure had a higher prevalence of atrial fibrillation (p = 0.013) and diabetes (p = 0.028), as well as a higher LGI value (1.12 vs. 0.79, p < 0.001). At ROC analysis, LGI had the strongest association with the outcome, with an AUC of 0.729, and an optimal cut-off value of 0.95 (72.4% sensitivity and 68% specificity). In Kaplan-Meier survival analyses, patients in the highest tertile (T3) of LGI had a significantly higher incidence of AVF failure compared to those in tertile 1 (p = 0.019). Moreover, we found that patients with higher baseline LGI values had a significantly higher risk of AVF failure during follow-up (HR: 1.48, p = 0.003). The association is independent of age and sex (HR: 1.65, p = 0.001), cardiovascular risk factors (HR: 1.63, p = 0.012), and pre-operative vascular mapping determinations (HR: 3.49, p = 0.037). (4) Conclusions: In conclusion, high preoperative values of LGI are positively associated with long-term AVF failure. The prognostic role of the biomarker was independent of age, sex, cardiovascular risk factors, and pre-operative vascular mapping determinations.

Hemodialysis nurses' knowledge, attitude, and practices in managing vascular access: A cross-sectional study in Saudi Arabia

Hemodialysis continues to be the primary approach for renal replacement therapy. Vascular access (VA), particularly arteriovenous fistula or arteriovenous graft, is the preferred technique for establishing hemodialysis access due to its lower risk of infection and central venous stenosis compared to catheters. The aim of this cross-sectional investigation was to examine hemodialysis nurses' knowledge, confidence, and practices in managing VA in Saudi Arabia. This is an online cross-sectional survey study that was conducted in Saudi Arabia between June and August 2023. This study utilized a previously validated questionnaire. Examined dialysis nurses' knowledge, attitude, practice, and self-efficacy pertaining to VA cannulation and evaluation. Binary logistic regression analysis was used to identify predictors of better knowledge of dialysis VA. A total of 197 participants were involved in this study. Around one-third of the study participants (37.0%) reported that they have received specialized training in managing VA. Participants agreement (answered agree or strongly agree) on statements that examined attitudes toward dialysis VA cannulation and management was high and ranged between 75.0% and 93.0%. The majority of participants (97.5%) reported that they perform this assessment. Most nurses (65%) preferred the rope-ladder technique. Participants agreement on statements that examined self-efficacy on dialysis VA cannulation and management was high and ranged between 72.1% and 98.0%. The most commonly agreed upon statement was that "they have confident in performing hemodialysis access (arteriovenous fistula and arteriovenous graft) assessment before cannulation." With 98.0% (answered agree and strongly agree). The mean knowledge score for our study sample was 6.4 (SD: 2.0) out of 12 (53.3%); which reflects marginal-level of knowledge on dialysis VA. Binary logistic regression analysis identified that nurses who have undergraduate degree are 92% more likely to be knowledgeable on dialysis VA compared to others (P < .05). Concerning VA, the level of knowledge among hemodialysis nurses working in Saudi Arabia was inadequate. Nurses who hold an undergraduate degree are presumed to have a more extensive understanding of dialysis VA. Further education programs are necessary for HD nurses to enhance their knowledge of VA, thereby optimizing their professional practices and enhancing the outcomes for their patients.

Lipectomy as an alternative for superficialization of autologous AVF in obese patients: experience of a referral center in Amazon

Background

The preferred vascular access for hemodialysis is a native arteriovenous fistula (AVF) because it offers the best results in the short and long terms, lower morbidity and mortality, and has additional advantages in relation to central venous catheters or arteriovenous grafts. However, obesity can present an additional challenge because of the barrier of subcutaneous cellular tissue covering the surface of the vein to be punctured.

Objectives

The authors review their experience with excision of subcutaneous tissue (lipectomy) overlying upper arm cephalic vein arteriovenous fistulas in obese patients.

Methods

Consecutive vascular access patients undergoing lipectomy for cannulation with difficult access because of vein depth were reviewed. Cephalic vein depth was measured by ultrasound in all cases.

Results

Twenty-two patients were reviewed (15 men and 7 women), with a mean body mass index of 34.0 kg/m2 (range: 28-40 kg/m2). Mean age was 58.4 years. The mean preoperative vein depth of 7.9 mm (range: 7.0-10.0 mm) was reduced to 4.7 mm (range: 3.0-6.0 mm) (P 0.01). The mean follow-up period for patients was 13.2 months. Four patients were lost to follow-up and four died during the period due to causes unrelated to vascular access.

Conclusions

Obesity should not be a limiting factor to creation of a native AVF, since lipectomy is a relatively simple option for superficialization, enabling functioning native and deep arteriovenous fistulas in obese patients.

Benefits of simulation for ultrasound-guided midline placement training: MC-in-Sim pilot study

INTRODUCTION

Ultrasound-guided placement of Midlines catheters (MCs) is a standard procedure with many benefits for patients. Even if there are some guidelines worldwide, this invasive technique is still taught at the patient's bed and relies on mentoring in many care centers. The performance of this care by novice practitioners raises ethical and quality of care issues mainly because of its risk of complications. This study aimed to propose and assess a simulation-based learning method for the placement of MCs in novice practitioners.

METHODS

A single-center prospective observational study was conducted with anesthesia residents who had no prior experience of Midline placement. Two workshops were planned. The first one consisted of a theoretical training and a simulated practical phase. The second workshop included an assessment of theoretical memorization, a practical exercise and adherence to the training program.

RESULTS

The median score of the theoretical memorization was 14.6 (interquartile range [IQR]: 13.5-15.8). The MCs placement time was significantly higher (Med: 12.23 min; IQR: 12.21-12.80) for novice practitioners who did not successfully complete solo MCs placement in simulation versus novice practitioners who successfully completed solo MCs placement in simulation 6.66 min (IQR: 5.92-8.93) (p = 0.002). The number of attempts was significantly higher (p = 0.034) for the novice practitioners who did not successfully complete solo MCs placement in simulation with 67% having performed three punctures, against 0% for the novice practitioners who successfully completed solo MCs placement in simulation. All novice practitioners found this training model efficient for learning how to place MCs and considered it allows for reproducibility in care situations.

CONCLUSION

This ultrasound-guided MCs training on simulation is an agile and fast alternative to traditional bedside training for anesthesia novice practitioners.

Thoracic endovascular repair of descending thoracic aorta aneurysm using thoracic stent graft in a challenging complex patient: An innovative access technique during an emergency using a mini-thoracotomy approach

OBJECTIVES

Repairing thoracic aortic aneurysms with endovascular aortic repair (TEVAR) is a safe and minimally invasive method with low morbidity and short postoperative recovery. We developed a novel method to treat descending thoracic aortic aneurysms using a mini-thoracotomy approach in complex patients with difficult access.

METHODS

A 56-year-old male patient presented with a 3-day history of chest pain. His past surgical history included infrarenal aortic ligation and right axillobifemoral bypass. Thoracic computed tomography angiography (CTA) revealed a saccular aortic aneurysmal dilatation at zone 2 measuring 4.4 × 4 cm. Owing to his surgical history, vascular access through the femoral and iliac arteries or abdominal aorta was impossible. We developed a new technique using a left posterolateral mini-thoracotomy approach to gain vascular access and perform TEVAR, avoiding the need for an open thoracotomy repair.

RESULTS AND CONCLUSIONS

Thoracic CTA performed before discharge revealed complete aneurysmal exclusion and no endoleaks. Postoperative follow-up CTA (6 months and annually thereafter) revealed no aneurysm formation or aortic restenosis. The femoral artery, followed by the iliac artery, is the traditional access route for TEVAR. Left posterolateral mini-thoracotomy may be required as an alternative access in complex patients.

Does central venous stenosis affects the brachial artery flow volume and peripheral vascular resistive index in patients on maintenance hemodialysis? A retrospective study

BACKGROUND

A well-functioning vascular access (VA) is crucial for the patients on maintenance hemodialysis (HD). Central venous stenosis (CVS) is a common, yet, overlooked complication of VA as its diagnosis is challenging. Moreover, its effect on the flow volume (FV) and the peripheral resistive index (RI) was not well discussed before. Despite the availability of doppler ultrasound (DUS) in most centers, direct visualization of central veins using DUS is quite difficult.

METHODS

This is a retrospective single-center self-controlled cohort study that was conducted in a specialized vascular access management tertiary center in Japan and included all patients with CVS who underwent percutaneous transluminal angiography (PTA) with or without vascular stenting in the period from January 2014 to September 2022. The patients were divided according to their VA type into arteriovenous fistula (AVF), and arteriovenous graft (AVG) groups, then subdivided, according to the type of stenosis, into two subgroups: CVS, and mixed central and peripheral venous stenosis (MVS) groups. The FV and RI of the feeding artery were compared in the same procedure before and after PTA to assess the impact of the procedure itself.

RESULTS

Data of 485 percutaneous transluminal angiography procedures (PTA), performed in 95 patients during the period from January 2014 to September 2022, were collected. FV and RI were significantly affected in the patients with MVS than patients with CVS. After PTA, both FV and RI were significantly improved. The improvement rate of FV and RI after PTA were significantly higher in patients with MVS than patients with CVS. However, it was difficult to determine the cut-off value to diagnose or to assess the improvement of CVS.

CONCLUSION

Our findings suggest that FV and RI measurement by DUS are good tools, along with the clinical findings for assessment of CVS in certain situations.

Restoring Access in a Thrombosed Hemodialysis Reliable Outflow Graft Using the InThrill Thrombectomy System

Arteriovenous grafts (AVGs) provide vascular access for hemodialysis in patients with end-stage renal disease (ESRD). However, vascular access thrombosis often occurs, requiring frequent reinterventions to maintain access patency. This report describes the successful use of the InThrill Thrombectomy System (Irvine, CA: Inari Medical) for macerating and removing thrombus from an occluded and heavily thrombosed AVG. A 47-year-old male was sent to our institute for a thrombosed right upper extremity arteriovenous access with a HeRO graft (South Jordan, UT: Merit Medical). The patient underwent interventions for the thrombosis of the same AVG two weeks prior using an Aspirex catheter (Franklin Lakes, NJ: BD Medical), and again two days prior with a Fogarty balloon catheter (Irvine, CA: Edwards Lifesciences). The patient presented with a recurrent completely occluded AVG. Using the InThrill Thrombectomy System and balloon angioplasty, the stenosis was reduced to less than 20%, resulting in brisk flow. The patient tolerated the procedure well without complication and recovered in the holding area with no acute distress. He was discharged the same day on anticoagulation therapy. This study highlights the successful use of the InThrill Thrombectomy System for the treatment of thrombosed AVG in a hemodialysis-dependent ESRD patient. The device was easy to use and efficient. Device and procedure times are unparalleled when compared with thrombolytic-based procedures. The patient's AVG remained patent at a 14-day follow-up.

The hand grip training device: A new therapeutic option in arteriovenous fistula maturation

INTRODUCTION

Postoperative exercise improves arteriovenous fistula maturation for hemodialysis. However, scarce evidence exists about hand grip device on fistula maturation process.

OBJECTIVE

To evaluate the efficacy of a hand grip training program on arteriovenous fistula maturation in population with Chronic Kidney Disease 5-5D.

METHODOLOGY

Prospective study (15 months). Patients were randomized to handgrip (HG) or control group (CG) postoperatively. HG performed a training program using a hand grip device. CG received conventional care. Upper limb muscle strength (ULMS), Duplex ultrasonography, and clinical arteriovenous fistula maturation were assessed at 4 and 8 weeks postoperatively.

RESULTS

At 8 weeks after fistula creation, upper limb muscle strength was increased only in the handgrip group (from 18 ± 6 to 23 ± 9 kg, p = 0.023). Clinical maturation was significantly greater in handgrip group versus control group, both at 4 weeks after intervention (62% vs 23%, p = 0.004) and at 8 weeks (65% vs 27%, p = 0.004). Similarly, the Doppler ultrasonography maturation rates were significantly greater in the HG, both at 4 weeks (HG: 84% vs CG: 47%; p = 0.004) and at 8 weeks (HG: 89% vs CG: 50%; p = 0.002).

CONCLUSIONS

The hand grip is a useful and safety training device to improve the arteriovenous fistula maturation. This device results a new therapeutic option for maturation in arteriovenous fistula, particularly in distal arteriovenous fistula. Further studies are required to support these results.

Case report: Arteriovenous graft for hemodialysis using abdominal vessels

The improvement of dialysis therapy and clinical support has increased the life expectancy of patients with end stage renal disease (ESRD) over the last years. However, in Brazil, the renal transplant rate cannot follow this growth. This fact, in association with the unavailability of adequate healthcare services in the country, substantially enlarges the use of dual lumen catheters and, consequently, access-related complications. The result is a high rate of patients with access failure, which brings a challenge: how to maintain dialysis in this group? This case report describes a non-conventional surgical approach to create a definite access using abdominal vessels, in an end stage vascular access patient.

Hemodialysis patients and complications management costs in Italy: Plastic cannulae a potentially cost-effective strategy

BACKGROUND

The treatment of end-stage chronic renal failure involves substantial costs for health care, which could be higher considering hemodialysis access complications management costs. Complications could be addressed by cannulation technique, but also by the needle. In particular, the use of a metal needle for cannulation is responsible for several complications that compromise dialysis delivery and require interventions. This analysis aims to evaluate, from a hospital perspective, the direct costs related to complications that may occur in hemodialysis patients in Italy.

METHODS

To identify the main complications to consider in our analysis and related patient pathway for their management, we conducted an international literature search on PubMed and validated the data for Italy with an Italian Key Opinion Leader (KOL). A micro-costing analysis was developed to precisely assess the economic costs of healthcare interventions to manage complications due to vascular access cannulation.

RESULTS

The major complications identified, and the average cost/per episode for their management are the following ones: Local infection € 1455 (min € 745 and max € 2160); Sepsis, that requires hospitalization in ward € 4401 (min € 3693 and max € 4623); Sepsis (ICU) € 17,190; Hematoma € 304 (min € 252 and max € 728); Aneurysm € 3632 (min € 3139 and max € 4014); Pseudoaneurysm € 3695 (min € 3615 and max € 4014); Stenosis € 2229 (min € 1874 and max € 4857); Thrombosis € 2151 (min € 1941 and max € 3395).

CONCLUSIONS

In making decisions, hospital administration, and payer should take into consideration, not just the price of devices, but the entire patient's pathway. The use of plastic cannulae in hemodialysis patients shows improved outcomes compared to traditional metal needles. Furthermore, combining it with accurate and efficient cannulation techniques reduces complication rates, improves patients' quality of life, and reduces healthcare resource consumption.

Evaluating Effectiveness of the Use of an Extremity Stabilization Device for Vascular Access Procedures in Pediatrics

The purpose of this study is to evaluate the effectiveness of SafeBoard, a Food and Drug Administration-approved extremity stabilization device, as an assistive method in performing peripherally inserted central catheter procedures on children 0 to 3 years of age. This is a retrospective chart review ( n  = 59) of vascular access procedures where SafeBoard was utilized ( n  = 32 ) in comparison to those procedures which utilized a traditional approach to placement ( n  = 27). Statistical analysis demonstrated significant effect on length of procedure time, number of personnel needed for procedure, and success of placement when SafeBoard was utilized. Obtaining vascular access in pediatrics can be a challenging endeavor. Most young pediatric patients require procedural sedation and/or assistive personnel as a "holder" for successful vascular access placement to occur. An alternative option for extremity stabilization may provide improved workflow and improved placement success, which in turn may positively affect workflow.

Systemic inflammation index as useful tool to predict arteriovenous graft stenosis: Our experience and literature review

OBJECTIVE

Many studies show that settings of severe inflammatory stress might be responsible for changes in circulating blood cells count. Effective inflammation indices are created calculating the quantitative relationship between these cells. No previous studies have been proposed on hemodialysis patients exploring the association between arteriovenous graft (AVG) stenosis and systemic inflammation markers, such as Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and systemic-immune-inflammation index (SII).

METHODS

Patients undergone surgery for AVG creation in a 2-year period are examined. Examining their full blood count, we have established the value of inflammatory indices (NLR, PLR, SII) and we have compared their mean values in patients who have developed significant stenosis or not. Finally, we have considered the connection between those values and stenosis onset and recurrence in AVG.

RESULTS

Fifty-two patients are included in the study [male: 40%, mean age 70 ± 15 years (range 55-86)]. We have found out there is not statistical significance in preoperative values of inflammatory index (NLR p 0.33, PLR p 0.15, SII p 0.98) Otherwise NLR and SII indices were statistically significant 3 months after surgery (NLR 2.04 ± 0.98 vs 3.91 ± 2.10, p < 0.001; SII 415.32 ± 255.15 vs 636.91 ± 349.01, p 0.014).

CONCLUSIONS

Increased post-operative values of NLR and SII have proved a strong association with AVG outflow stenosis onset and recurrence.

The association between vascular access satisfaction and quality of life and depression in maintained hemodialysis patients

BACKGROUND

Vascular access (VA) is known to be critical for the survival of patients on maintained hemodialysis (MHD) treatment. However, the association between VA satisfaction and psychiatric state in MHD patients is still not fully elucidated. Thus, the aim of this study is to evaluate the relationship among VA satisfaction, health-related quality of life (HRQOL) and depression in MHD patients with different VA types.

METHODS

This cross-sectional study was conducted at two dialysis centers with MHD-dependent patients. The Short Form Vascular Access Questionnaire (VAQ) was administered to estimate the level of MHD patients' satisfaction with their VA. HRQOL was assessed using the Short Form 36 (SF-36) questionnaire. Depression was assessed using the Zung's self-rating depression scale (SDS).

RESULTS

Of the total 252 patients, AVF was used by 84.13%, AVG was used by 2.78%, and TCC was used by 13.09%. There was no significant difference in satisfaction and SDS scores by access type in patients with AVF, AVG, and TCC. However, HRQOL was worst in patients with TCC, and highest in the AVF group. Further analysis showed that VAQ scores in the domains of overall and dialysis-related complications exhibited a negative correlation with HRQOL. And SF-36 HRQOL scores, including the total score, PCS and MCS, were all negatively correlated with SDS scores (p < 0.05). The results of multivariable analyses found that VAQ scores in the domains of overall score and physical symptom, and total score of HRQOL influenced the depression.

CONCLUSIONS

In the present study, no significant difference in satisfaction scores by access type was found in patients with AVF, AVG, and TCC. The HRQOL score was higher in patients with AVF than in those with AVG or TCC. And the result suggested a negative association between HRQOL and depression. Vascular access satisfaction and HRQOL might be risk factors for the presence of depression in MHD patients.

Global variability of vascular and peritoneal access for chronic dialysis

AIM

Vascular and peritoneal access are essential elements for sustainability of chronic dialysis programs. Data on availability, patterns of use, funding models, and workforce for vascular and peritoneal accesses for dialysis at a global scale is limited.

METHODS

An electronic survey of national leaders of nephrology societies, consumer representative organizations, and policymakers was conducted from July to September 2018. Questions focused on types of accesses used to initiate dialysis, funding for services, and availability of providers for access creation.

RESULTS

Data from 167 countries were available. In 31 countries (25% of surveyed countries), >75% of patients initiated haemodialysis (HD) with a temporary catheter. Seven countries (5% of surveyed countries) had >75% of patients initiating HD with arteriovenous fistulas or grafts. Seven countries (5% of surveyed countries) had >75% of their patients starting HD with tunnelled dialysis catheters. 57% of low-income countries (LICs) had >75% of their patients initiating HD with a temporary catheter compared to 5% of high-income countries (HICs). Shortages of surgeons to create vascular access were reported in 91% of LIC compared to 46% in HIC. Approximately 95% of participating countries in the LIC category reported shortages of surgeons for peritoneal dialysis (PD) access compared to 26% in HIC. Public funding was available for central venous catheters, fistula/graft creation, and PD catheter surgery in 57%, 54% and 54% of countries, respectively.

CONCLUSION

There is a substantial variation in the availability, funding, workforce, and utilization of vascular and peritoneal access for dialysis across countries regions, with major gaps in low-income countries.

The distal radial artery: Versatile vascular access for transcatheter interventions

Conventional transradial access has been established as the gold standard for invasive coronary angiography and percutaneous interventions by the current European and American guidelines. The distal or snuffbox radial artery access represents an alternative transradial access site that allows radial sheath insertion with the patient's hand pronated. Firstly described 40 years ago, it exploded in popularity only recently. Promising additional benefits, the distal radial access is increasingly being adopted in various types of percutaneous interventions, being preferred by many interventional cardiologists and radiologists for its reduced vascular complications and time to hemostasis, and improvement of patient and operator comfort. Other centers consider it a fad, waiting for solid clear evidence and benefits. The evidence is dynamic and discrepant, depending on the center, the operator, and how it was collected (randomized controlled vs observational studies). Another essential aspect raised by "skeptics" was whether distal radial access, by its smaller diameter and more angled course, can support all types of interventions. The aim of this review is to gather all the scenarios where distal radial access has been utilized and to conclude whether this vascular access is feasible across all transcatheter interventions.

A Prospective Comparison of Standard Technique, Doppler Ultrasonography, and Pressure Waveform Analysis for Confirming Intraosseous Catheter Placement

Purpose: Intraosseous (IO) catheters allow healthcare workers to rapidly administer fluids and medications to critically ill patients when intravenous access is inadequate or unable to be obtained. An improperly placed IO catheter can lead to delays in care, as well as serious complications such as limb necrosis. Methods: In this single-center, prospective, observational study, we compared 2 established methods of confirming proper IO catheter placement to a novel pressure waveform analysis technique in which the IO catheter is attached to a standard pressure transducer. Attaching a pressure transducer to a properly placed IO catheter produces a pulsatile waveform. Misplacement of the IO catheter produces a flatline waveform. Results: Of 42 IO catheters, 8 (19%) were incorrectly placed per the waveform analysis technique. Compared to the pressure waveform analysis technique, the standard method and the power Doppler method incorrectly classified 4/8 (50%) and 5/8 (62.5%) of the misplaced catheters, respectively. The standard method had a higher positive predictive value for detecting incorrectly placed IO catheters than the power Doppler method (100% vs 63%, respectively). Blinded reviewers demonstrated better agreement using the pressure waveform analysis technique than using power Doppler (k = 0.77 vs k = 0.58, respectively). Conclusion: The standard and power Doppler ultrasonography techniques identify incorrectly placed IO catheters sub-optimally. The pressure waveform analysis technique is more accurate than the standard of care and has superior interrater agreement compared to the ultrasound method of confirmation. With more than 500 000 IO catheters placed in the United States each year, this novel technique may improve overall IO safety. Trial Registration Number: NCT03908879.

Characteristics of Vascular Access Cannulation Complications in End Stage Kidney Disease Patients in West Java from 2018 to 2022: A Retrospective Observational Study

Background

End-stage kidney disease (ESKD) is associated with a tremendous financial burden. Data in Indonesia shows an increasing number of patients with ESKD taking hemodialysis as a routine procedure every year. Establishment and maintenance of vascular access are important in the management of ESKD. Vascular complications that often arise due to hemodialysis are common and one of the main reasons for hospitalization. Cannulation complications ranged from minor hematomas to acute bleeding from pseudoaneurysms that required emergency surgical procedures. This study aims to assess the different clinicopathological characteristics of ESKD patients with vascular access cannulation complications and the surgical management related to the complications.

Materials and Methods

This research is a retrospective observational study. The research subjects in this study were ESKD patients in the vascular and endovascular surgery division of the tertiary hospital in West Java, Indonesia. There were 121 study subjects. Clinicopathological characteristics of vascular cannulation complications and surgical management are extracted from the medical record.

Results

Three major vascular complications were ruptured pseudoaneurysms 64/121 (52.9%), impending rupture pseudoaneurysms 28/121 (23.1%), and pseudoaneurysms 21/121 (17.4%). Common surgical procedures were ligation of the draining vein 47/121 (38.8%), arterial primary repair 28/121 (23.1%), and arterial patch repair 18/121 (14.9%). There was a significant relationship between symptoms of bleeding in ruptured pseudoaneurysms and bulging masses in pseudoaneurysms (p = 0.001). There was a significant relationship between the diameter of the vascular mass, vascular defect size, and hematoma and the type of surgical procedure taken (p < 0.010).

Conclusion

Ruptured, impending rupture, and pseudoaneurysms are major complications of vascular access in ESKD patients, and there was a significant relationship between the carried-out surgical procedure and the size of the vascular mass, defect, and hematoma.

Safety and efficacy of a new covered stent in hemodialysis vascular access outflow stenosis: A Brazilian multicenter retrospective study

BACKGROUND

Vascular stenosis commonly leads to dysfunction in hemodialysis vascular access. Although percutaneous transluminal angioplasty is an established treatment, stent utilization has increased in the last decade as an alternative solution to extend the access function. This study evaluated the safety and initial results of a new impermeable covered stent for treating vascular access outflow stenosis.

METHODS

Investigators retrospectively analyzed 114 hemodialysis patients treated with polytetrafluorethylene-covered stents from September 2018 to September 2022 across four centers. Lesions treated were de novo or restenotic and located in the venous graft anastomosis, outflow segment, cephalic arch, and basilic swing point. Patients were followed by in-person physical examination at 1, 3, and 6 months, and Duplex ultrasound was performed to evaluate the vascular access circuit and in-stent restenosis. The primary efficacy endpoint was target lesion primary patency at 1, 3, and 6 months. Secondary endpoints included access circuit primary patency and secondary patency at 1, 3, and 6 months. The primary safety endpoint was freedom from local or systemic serious adverse events through 30 days post-procedure.

RESULTS

Forty-four patients had thrombosed access at the initial presentation, and 41 patients presented with recurrent stenosis. The target lesion primary patency rates at 1, 3, and 6 months were 100%, 89.4%, and 74%, respectively. The access circuit primary patency rates were 100% at 1 month, 85% at 3 months, and 62.7% at 6 months. The secondary patency rates at 1, 3, and 6 months were 100%, 96.4%, and 94.6%, respectively. In the adjusted multivariate Cox regression analysis, only recurrent lesions and female gender were associated with reduced primary patency rates. No serious adverse event was observed through the first 30 days post-procedure.

CONCLUSION

In this retrospective analysis, a new covered stent was shown to be safe and effective for treating peripheral outflow stenosis in vascular access.

The economic burden of difficult intravenous access in the emergency department from a United States' provider perspective

Background

Peripheral intravenous catheter placement is one of the most common invasive procedures that nurses will perform, especially in emergency departments.

Aims

This early analysis aimed to quantify the economic burden associated with intravenous therapy in patients presenting in emergency departments with difficult intravenous access, receiving traditional peripheral intravenous catheters. This may inform the opportunity for improvement for investment in nursing tools and services regarding difficult venous access burden reduction.

Methods

Model parameter data were obtained from published literature where possible via a targeted literature review for the terms including relative variations of 'Difficult Venous Access', 'burden', and 'costs', or elicited from expert clinical opinion. A simple decision tree model was developed in Microsoft® Excel 2016. Results included number of insertion attempts, number of patients requiring escalation, catheter failures due to complications, healthcare professional (e.g. nurse) time, and total costs (including/excluding health care professional time). Sensitivity analyses were performed.

Results

The model considers 64,000 individuals presenting in the emergency department annually, of which 75% (48,000) require a peripheral intravenous catheter; of these 22% (10,560) are estimated to have difficult venous access. The total cost burden of difficult venous access is estimated to be $890,095 per year/$84.29 per patient with difficult venous access, including the cost of clinician time. Key total cost drivers include the population size treated in the emergency department annually, the proportion of midlines placed by a specialist IV (intravenous access) nurse and the percentage of patients with difficult venous access.

Conclusion

This is the first formal analysis estimating the significant economic burden of difficult venous access in emergency departments via peripheral intravenous catheter placement, a task frequently performed by nurses. Further studies are needed to evaluate nursing-centric strategies for reducing this burden. Additionally, adoption of a concise definition is needed, as is routine use of reliable assessment tools so that future cost analyses can be better contextualised.

Vascular access for autologous peripheral blood stem cells collection by large volume leukapheresis: Single center experience

INTRODUCTION

Peripheral blood stem cell (PBSC) harvesting requires reliable and safe vascular access. In our institution, a change of practice was implemented and the central venous catheter (CVC) placement for all autologous PBSC collections was abandoned in favor of a careful evaluation of peripheral venous access (PVA) for each individual patient. The aim of this prospective study was to evaluate the rate of patients with adequate peripheral veins for autologous PBSC collection and compare patient characteristics, collection efficacy, and complication rate between patients with PVA and CVC.

METHOD

Peripheral veins were assessed by the apheresis nurse team in all patients referred between January 2020 and July 2021 to autologous PBSC collection. Only in case of difficult venous access, CVC was inserted. Large volume leukapheresis (LVL) procedures, which processed ≥3 total blood volumes, were performed.

RESULTS

In 65 (57%) patients PVA was used, while 49 (43%) patients required placement of short-term CVC. Peripheral venous access was successfully used significantly more often in males (69.8%) (P = 0.010), and patients with multiple myeloma (71.0%) than in patients with non-Hodgkin's lymphoma (35.9%) and Hodgkin's lymphoma patients (33.3%) (P < 0.001). There was a significant difference in the type of prior administered chemotherapy; in the patients who received cytostatics free chemotherapy, PVA was used more often (75.0%) (P = 0.007). In terms of the efficacy and safety of LVLs, there were no differences between procedures performed using PVA and CVCs.

CONCLUSION

Peripheral venous access is feasible for autologous PBSC collection in more than a half of patients, in particular in those with multiple myeloma. Changes in the treatment of multiple myeloma, using new proteasome inhibitors-based and immunomodulatory agents that do not adversely affect peripheral veins, have enabled the use of PVA even at the high blood flow rates required by LVL. Peripheral venous access is not associated with safety issues or with a lesser collection efficiency, and it is cost-effective as well. Each patient referred to autologous PBSC collection needs to be evaluated individually by the experienced apheresis team for the most appropriate venous access.

Use of Covered Stents in Cannulation Sites as a Last Option to Salvage Failing Vascular Access

PURPOSE

Controversy exists regarding the treatment of recurrent stenosis in vascular access at cannulation sites with a covered stent as repeated cannulation may damage the stent. The purpose of this study was to review covered stent placement at cannulation sites to salvage failing vascular access.

MATERIALS AND METHODS

A total of 11 patients were included for the purpose of this study. Eight patients (72.7%) received a covered stent due to recurrent stenosis, 2 (18.2%) due to an acute occlusion, and in 1 case (9.1%), the covered stent was used to repair a damaged polytetrafluoroethylene arteriovenous graft (PTFE AVG).

RESULTS

Primary patency after stent placement was 40.9% at 6 months, primary-assisted patency was 79.5% at 12 months, and secondary patency was 80% at 24 months. No significant problems were observed during the dialysis sessions after stent placement. The intervention rate per patient-year was not significantly different before or after covered stent placement, at 3.8 (IQR=9.5) interventions per year versus 2.5 (IQR=3.0) interventions per year (p=0.280).

CONCLUSION

In conclusion, treating failing vascular access with problems at cannulation sites with covered stents can be considered.

CLINICAL IMPACT

Treating vascular access stenosis at cannulation sites with covered stents can successfully prolong vascular access life.

Kidney Failure Risk Equation in vascular access planning: a population-based study supporting value in decision making

Background

The Kidney Failure Risk Equation (KFRE) can play a better role in vascular access (VA) planning in patients with chronic kidney disease (CKD) requiring hemodialysis (HD). We described the VA creation and utilization pattern under existing estimated glomerular filtration rate (eGFR)-based referral, and investigated the utility of KFRE score as an adjunct variable in VA planning.

Methods

Patients with CKD aged ≥18 years with eGFR <20 mL/min/1.73 m2 who chose HD as dialysis modality from January 2010 to August 2020 were included from a population-based database in British Columbia, Canada. Modality selection date was the index date. Exposures were categorized as (i) current eGFR-based referral, (ii) eGFR-based referral plus KRFE 2-year risk score on index date (KFRE-2) >40% and (iii) eGFR-based referral plus KFRE-2 ≤40%. We estimated the proportion of patients who started HD on arteriovenous fistula/graft (AVF/G) within 2 years, indicating timely pre-emptive creation, and the proportion of patients in whom AVF/G was created but did not start HD within 2 years, indicating too-early creation.

Results

Study included 2581 patients, median age 71 years, 60% male. Overall, 1562(61%) started HD and 276 (11%) experienced death before HD initiation within 2 years. Compared with current referral, the proportion of patients who started HD on AVF/G was significantly higher when KFRE-2 was considered in addition to current referral (49% vs 58%, P-value <.001). Adjunct KFRE-2 significantly reduced too-early creation (31% vs 18%, P-value <.001).

Conclusions

KFRE in addition to existing eGFR-based referral for VA creation has the potential to improve VA resource utilization by ensuring more patients start HD on AVF/G and may minimize too-early/unnecessary creation. Prospective research is necessary to validate these findings.

Umbilical vein catheterisation for the family physician working in primary health care

This is part of a series of articles on vascular access in emergencies. The other two articles were on intra osseous lines and central venous lines. These are critical lifesaving emergency skills for the primary care professional. In this article, we will provide an overview of umbilical vein catheterisation highlighting its importance, the indications, contraindications, techniques, complications and nursing considerations. By familiarising healthcare providers with this procedure, we hope to enhance their knowledge and skills, ultimately leading to improved outcomes in the neonatal population.

Impact of Vascular Access Flow Suppression Surgery on Cervical Artery Circulation: A Retrospective Observational Study

Vascular access (VA) flow suppression surgery augments VA flow resistance and can increase other circulation flows hindered by high-flow VA. However, whether VA flow suppression surgery affects cervical circulation has rarely been reported. We aimed to determine the effect of VA flow suppression surgery on the cervical circulation in patients with high-flow VA. This single-center, retrospective, observational study included 85 hemodialysis patients who underwent VA flow suppression surgery at the Kanno Dialysis and Access Clinic between 2009 and 2018. Blood flow in the VA, bilateral vertebral arteries, and common carotid artery was measured before and after VA flow suppression surgery. The VA flow decreased from 1548 mL/min to 693 mL/min postoperatively. The flow of the vertebral artery on the VA side increased from 55 mL/min to 81 mL/min. The flow in the bilateral common carotid arteries also increased. Patients whose symptoms improved postoperatively showed better improvement in the vertebral artery on the VA side. VA flow suppression surgery in patients with high-flow VA increases the flow of the vertebral artery on the VA side and of the bilateral common carotid arteries. High-flow VA can hinder the vertebral and common carotid circulation.

POCUS in the PICU: A Narrative Review of Evidence-Based Bedside Ultrasound Techniques Ready for Prime-Time in Pediatric Critical Care

Point-of-care ultrasound (POCUS) is an accessible technology that can identify and treat life-threatening pathology in real time without exposing children to ionizing radiation. We aim to review current evidence supporting the use of POCUS by pediatric intensivists with novice-level experience with bedside ultrasound. Current evidence supports the universal adoption of POCUS-guided internal jugular venous catheter placement and arterial line placement by pediatric critical care physicians. Focused cardiac ultrasound performed by PICU physicians who have completed appropriate training with quality assurance measures in place can identify life-threatening cardiac pathology in most children and important physiological changes in children with septic shock. POCUS of the lungs, pleural space, and diaphragm have great potential to provide valuable information at the bedside after validation of these techniques for use in the PICU with additional research. Based on currently available evidence, a generalizable and attainable POCUS educational platform for pediatric intensivists should include training in vascular access techniques and focused cardiac examination. A POCUS educational program should strive to establish credentialing and quality assurance programs that can be expanded when additional research validates the adoption of additional POCUS techniques by pediatric intensive care physicians.

A rare hemodialysis vascular access complication-Internal jugular vein reflux

Hemodialysis (HD) arteriovenous fistulas commonly present with late vascular access complications, but are rarely in association with internal jugular vein (IJV) reflux. We reported two patients who had severe and mild IJV reflux, respectively. Case 1 was a 48-year-old male with end-stage renal disease (ESRD) who had been treated with HD for 5 years. He presented with persistent headaches, nausea, and vomiting. Combined with all the examinations, it was revealed severe IJV reflux, brachiocephalic vein stenosis, high-flow vascular access, and IJV valve dysfunction. Case 2 was a 59-year-old female with ESRD who had constructed an AVF for 4 months and had been on HD for only 1 day. She presented with dizziness and nausea after the first hemodialysis and duplex ultrasonography showed slightly continuous IJV reflux, high-flow vascular access, and IJV valve dysfunction. Furthermore, we reviewed 16 case reports to identify the characteristics of IJV reflux in HD patients. IJV reflux in HD patients may be caused by high-flow access, central venous stenosis or occlusion, and valve dysfunction. Severe IJV reflux can develop neurological symptoms secondary to intracranial venous reflux in this article. Etiological treatment is helpful for these patients, but there is a risk of recurrence.

Virtual sedation as a substitute to pharmacological sedation during PICC placement in pediatric patients: A feasibility study

INTRODUCTION

In pediatric patients, PICC insertion is often performed under sedation to reduce pain and anxiety, which is associated with risks such as laryngospasm, apnea, and hypoxia. Furthermore, it requires a pediatric anesthesiologist. The aim of our study was to evaluate the VR as an alternative to pharmacological sedation to reduce those risks and the overall cost.

METHODS

We tested a VR immersive experience for ten children requiring a PICC. To achieve this, we ran a software, specifically designed for the pediatric healthcare setting, on a commercially available VR headset.In order to evaluate this new practice, we recorded the following data:Patient's anxiety before and after the procedure, recorded through a modified numeric rating scale from 0 (no anxiety) to 10 (worst anxiety imaginable).Patient's pain before (e.g., because of preexisting medical conditions) and after the procedure through a Wong-Baker scale.Caregiver's satisfaction.No active or passive restraint was enforced during the whole procedure, patients had to keep their arms still all by themselves.

RESULT

Out of the 10 patients only in a single case, we had to interrupt the attempt with the VR technique and let the anesthesiologist perform a sedation. From the immediate beginning said patient had trouble adapting to the virtual environment and tried to remove the headset.In all other cases, we noticed a drop in the anxiety level of the patient and the pain never increased. Globally, caregivers were pleased with the experience and reported an average satisfaction rate of 9.3 out of 10.

CONCLUSION

Virtual reality seems a valid alternative to traditional sedation in pediatric patients undergoing a PICC placement procedure. Additional studies, with adequate sample size, of patients are necessary to assess the benefit from this new approach, as well as its impact on the overall procedure length.

Elevated intraneural vascularization of the median nerve proximal to the arteriovenous fistula in hemodialysis patients suspected of carpal tunnel syndrome: A case series

Patients with end-stage kidney disease may require creation of an arteriovenous fistula in order to receive hemodialysis treatment. The creation may result in several complications, including carpal tunnel syndrome. Early diagnosis and treatment are essential to relieve symptoms, prevent permanent nerve damage, and improve quality of life. However, the sensory and motor disturbances resembling carpal tunnel syndrome could be related to other etiologies than external compression of the median nerve underneath the transverse ligament. This case report presents eight patients with a radiocephalic arteriovenous fistula, who all had symptoms of carpal tunnel syndrome. Ultrasonographic examination showed a segmental intraneural hypervascularization of a large vessel inside the median nerve proximal to the wrist and arteriovenous fistula anastomosis with garland-like course as well as multiple flow velocities. The neurophysiological findings showed a significant decreased velocity in the ipsilateral forearm to the arteriovenous fistula.

Reliability and compliance of peripheral intravenous catheter documentation: A prospective observational study

OBJECTIVE

Proper documentation of the functionality and complications of peripheral intravenous catheters (PIVC) is the standard of care. This data can improve communication among team members about access concerns and highlight opportunities to improve PIVC care. Our objective is to determine if nursing personnel are compliant with institutional standards for documentation and documentation is reliable.

METHODS

This prospective observational analysis was conducted at a tertiary care academic center with 120,000 ED visits and 1100 hospital beds. Adults over 18 with a PIVC placed in the ED via palpation technique who were being admitted to regular medical/surgical wards were eligible. The primary outcome was compliance with PIVC documentation per institutional standards. Secondary outcomes included compliance subcategorized as insertion, daily assessment, and removal and reliability of assessments.

RESULTS

During July and August 2020, 77 patients were enrolled with a total of 1201 observations of PIVC compliance. PIVC documentation compliance was 86.0% (1033/1201). Compliance on insertion and removal was 93.3% (431/462) and 80.5% (186/231), respectively, with removal assessment being the least compliant at 49.4%. Daily catheter assessments were compliant 81.9% (416/508) of the time. PIVC documentation reliability was based on 693 total observations with 87.9% (609/693) reliability overall, and a reliability of 91.6% (423/462) and 74.9% (173/231) for insertion and removal, respectively. PIVC orientation had the highest reliability (98.7%) while post-removal assessment had the lowest reliability (45.5%).

CONCLUSIONS

We observed moderate documentation compliance and reliability for PIVC assessments for catheters placed in the ED. Documentation of removal-related variables was the most deficient aspect of the assessments. Given the high rate of PIVC failure and its vast array of consequences, improvement of PIVC documentation of removal reasons is essential to better identify type and incidence of complications and help develop targeted solutions. Further larger studies are needed to survey PIVC documentation practices.

Long-term results of autologous scaffold-free tissue-engineered vascular graft for hemodialysis access

BACKGROUND

The growing size of the end stage renal disease (ESRD) population highlights the need for effective dialysis access. Exhausted native vascular access options have led to increased use of catheters and prosthetic shunts, which are both associated with high risks of access failure and infection. Emerging alternatives include tissue-engineered vascular grafts (TEVG). Here we present the endpoint results for 10 ESRD patients with the scaffold-free tissue-engineered vascular access produced from sheets of extracellular matrix produced in vitro by human cells in culture.

METHODS

Grafts were implanted as arteriovenous shunts in 10 ESRD patients with a complex history of access failure. Follow-up included ultrasound control of graft morphology and function, dialysis efficiency, access failure, intervention rate, as well as immunohistochemical analysis of graft structure.

RESULTS

One patient died of unrelated causes and three shunts failed to become useable access grafts during the 3-month maturation phase. The 12-month primary and secondary patency for the other six shunts was 86%. Survival of six shunts functioning as the vascular access was 22 ± 12 months with longest primary patency of 38.6 months. The dialysis event rate of 3.34 per patient-year decreased significantly with the use of this TEVG to 0.67.

CONCLUSIONS

This living autologous tissue-engineered vascular graft seems to be an alternative to synthetic vascular access options, exhibiting advantages of native arteriovenous fistula.

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.