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Franchin M, Vergani B, Huber V, Leone BE, Villa A, Muscato P, Cervarolo MC, Piffaretti G, Tozzi M. Proposal of a classification of cannulation damage in vascular access grafts based on clinical, ultrasound, and microscopic observations. J Vasc Access 2024:11297298241248263. [PMID: 38679815 DOI: 10.1177/11297298241248263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
INTRODUCTION Arteriovenous grafts (AVGs) serve as an alternative to native arteriovenous fistulas (AVFs) in the context of hemodialysis patient life planning. AVGs are more susceptible to developing outflow stenosis (due to intimal hyperplasia), thrombosis, and infections. However, an often overlooked contributor to AVG failure is cannulation damage. The objective of this paper is to assess the impact of cannulations on AVGs. We aim to establish a classification of AVG damage by comparing clinical data and ultrasound images with microscopic morphological findings obtained from explanted grafts. MATERIALS AND METHODS This study is conducted at a single center. We included all patients who underwent AVG creation between 2011 and 2019. Comprehensive data on clinical history, follow-up, and complications were collected and reviewed. Duplex ultrasound (DUS) characteristics were documented, and all grafts explanted during the analysis period underwent optical microscopy evaluation. Finally, clinical data, along with DUS and microscopic findings, were integrated to derive a damage classification. RESULTS During the study period, 247 patients underwent 334 early cannulation AVGs. The median follow-up duration was 714 days (IQR 392, 1195). One hundred eleven (33%) grafts were explanted. Clinical data and DUS findings were utilized to formulate a four-grade classification system indicating increasing damage. CONCLUSION Cannulation damage alone does not solely account for AVG failure. It results from a biological host-mediated process that promotes the growth of intimal hyperplasia at the cannulation sites. This process is not clinically significant within the initial 2 years after AVG creation.
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Affiliation(s)
- Marco Franchin
- Vascular Surgery, University of Insubria, ASSTSettelaghi Universitary Teaching Hospital, Varese, Lombardy, Italy
| | - Barbara Vergani
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Lombardia, Italy
| | - Veronica Huber
- Unit of Immunotherapy of Human Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Lombardia, Italy
| | - Biagio Eugenio Leone
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Lombardia, Italy
| | - Antonello Villa
- Consorzio MIA, Microscopy and Image Analysis, University of Milan Bicocca, Monza, Lombardia, Italy
| | - Paola Muscato
- Vascular Surgery, University of Insubria, ASSTSettelaghi Universitary Teaching Hospital, Varese, Lombardy, Italy
| | - Maria Cristina Cervarolo
- Vascular Surgery, University of Insubria, ASSTSettelaghi Universitary Teaching Hospital, Varese, Lombardy, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, University of Insubria, ASSTSettelaghi Universitary Teaching Hospital, Varese, Lombardy, Italy
| | - Matteo Tozzi
- Vascular Surgery, University of Insubria, ASSTSettelaghi Universitary Teaching Hospital, Varese, Lombardy, Italy
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Sawaf H, Lane J, Shingarev R, Siuba M, Kwon AG, Hanane T, Vachharajani TJ. Validating the anatomical landmark technique for bedside tunneled central venous catheter placement in the medical intensive care unit. J Vasc Access 2024:11297298241244887. [PMID: 38600611 DOI: 10.1177/11297298241244887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND A non-tunneled dialysis catheter (nTDC) is often the vascular access of choice to initiate dialysis in an intensive care unit (ICU). In the absence of contraindications, if a patient remains dialysis dependent beyond 2-weeks, the options are either to replace the nTDC with another nTDC or convert to a tunneled dialysis catheter (TDC). As a standard of care, TDCs are placed under fluoroscopic guidance. OBJECTIVES To determine if TDCs and other tunneled central venous catheters (tCVC) can be placed safely using anatomical landmark techniques without the use of fluoroscopy. RESEARCH DESIGN Subjects that met a predetermined selection criteria underwent placement of tunneled catheters with the use of the anatomical landmark technique. We looked at various outcomes to determine the safety and effectiveness of this technique. SUBJECTS One hundred eleven TDCs and other tCVCs were placed using the anatomical landmark technique in the intensive care unit. RESULTS All but one (110/111) of the catheters placed had recommended tip placement confirmed by at least one blinded physician. Major complications encountered were bleeding (two cases), pneumothorax (one case), and line associated blood stream infection (one case). We did find a higher-than-expected rate of "unnecessary procedures" with 18/111 lines placed in patients who did not survive beyond 7 days after placement of the catheter. CONCLUSIONS Using the anatomical landmark technique for bedside tunneled catheter placement can be an effective approach in the right population.
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Affiliation(s)
- Hanny Sawaf
- Cleveland Clinic Foundation, Cleveland, OH, USA
| | - James Lane
- Cleveland Clinic Foundation, Cleveland, OH, USA
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Pirozzi N, Scrivano J, Andracchio L, Fazzari L, Napoletano A, Pirozzi R. Double guidewire technique (DGT): Optimising endovascular revision of juxta-anastomotic stenosis in AV-fistulae: A retrospective analysis. J Vasc Access 2024; 25:308-312. [PMID: 35822896 DOI: 10.1177/11297298221109663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Nicola Pirozzi
- Nephrology and Dialysis, Interventional Nephrology Unit, Nuova ITOR, Rome, Italy
| | - Jacopo Scrivano
- Nephrology and Dialysis, Interventional Nephrology Unit, Nuova ITOR, Rome, Italy
| | - Ludovica Andracchio
- U.O.C. Nefrologia Dialsi e Trapianto, A.O. S. Camillo Forlanini, INMI L. Spallanzani, Rome, Italy
| | - Loredana Fazzari
- Nephrology and Dialysis, Interventional Nephrology Unit, Nuova ITOR, Rome, Italy
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Carroll J, Colley E, Cartmill M, Thomas SD. Robotic tomographic ultrasound and artificial intelligence for management of haemodialysis arteriovenous fistulae. J Vasc Access 2023:11297298231210019. [PMID: 37997016 DOI: 10.1177/11297298231210019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Arteriovenous fistulae (AVF) and Arteriovenous Grafts (AVG) may present a problematic vascular access for renal replacement therapy (RRT), reliant on recurrent specialist nurse and medical evaluation. Dysfunctional accesses are frequently referred 'out of the dialysis clinic' for specialist sonographic examination, with associated delays potentiating loss of vascular access viability and/or need for emergency intervention. Definitive anatomical and functional diagnostics based in the dialysis unit may help to solve these delays and associated complications. OBJECTIVES This publication reports a novel vascular access monitoring concept, Robotic Tomographic Ultrasound (RTU). RESEARCH DESIGN Robotic Tomographic Ultrasound incorporates a semi-autonomous, robotic vascular ultrasound system and purpose designed analysis software that can be deployed at the point of care. Three-dimensional scan data, as well as conventional B-Mode and Doppler data are obtained by the system and transferred to a cloud based reporting and analysis software. Scans are remotely annotated and interpreted by a sonographer, with diagnostic data presented securely to clinicians on their preferred web based application/web connected device. RESULTS Software developed specifically for pre AVF mapping, maturation and monitoring protocols, analyse the data and then present interpreted results to all caring clinicians to assist with decision making. Vascular access planning can be determined with high confidence with data from the Map module. Maturation data can be presented in line with institutional requirements to the dialysis nurse, facilitating precocious needle access. CONCLUSION Robotic Tomographic Ultrasound is a novel approach to vascular access management that may reduce the risk of loss of functional access by regular monitoring with the system; automated alerts guiding clinicians to the need for pre-emptive intervention, and the potential to increase longevity of the vascular access.
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Affiliation(s)
| | | | | | - Shannon D Thomas
- Vexev Pty Ltd, Sydney, NSW, Australia
- Department of Vascular Surgery, Prince of Wales Hospital, Sydney, NSW, Australia
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Giannikouris IE, Georgiadis GS, Giannakopoulos T, Passadakis P, Spiliopoulos S. Results of a hemodialysis vascular access routine ultrasound surveillance protocol and frequency of surveillance guided pre-emptive access maintenance interventions. J Vasc Access 2023:11297298231207427. [PMID: 37953744 DOI: 10.1177/11297298231207427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND To evaluate the implementation of routine surveillance using ultrasound on hemodialysis vascular access (VA) outcomes and determine the number and frequency of corrective, surveillance-guided procedures performed. METHODS Multicenter, prospective, observational study that includes consecutive hemodialysis patients receiving therapy from native arteriovenous fistulae (AVF) or grafts (AVG). Participants were assigned to a routine VA Color Doppler ultrasound surveillance (DUS) protocol from January 2019 to December 2021. Patients were referred for corrective procedures (endovascular or surgical) based on clinical or DUS findings (pre-emptive procedures; PEP). Primary endpoint was the estimation of primary unassisted (PUP) and secondary patency (SP) rates. Secondary endpoints were the determination of the number and frequency of PEP and VA survival rates. RESULTS In total, 223 patients with 243 VA (192 AVF and 51 AVG) were included. Access PUP and SP rates were 83% and 93% at 12 months, 75% and 88% at 24 months, and 72% and 83% at 36 months follow-up. Autologous fistulae PUP and SP were 89% and 96% at 12 months, 81% and 93% at 24 months, and 80% and 89% at 36 months, respectively. Graft PUP and SP were 56% and 80% at 12 months, 44% and 65% at 24 months, and 39% and 54% at 36 months, respectively. In total, 56 corrective procedures (38/56 PEP; 65.5%) were performed (0.13 procedures/year), of which 34 were in AVF patients (0.09 procedures/year) and 22 in AVG patients (0.40 procedures/year). Overall, 33 VA losses occurred (0.06 failures/year), 17 in AVF (0.04 failures/year), and 16 in AVG patients (0.20 failures/year). CONCLUSION The use of DUS resulted in the timely diagnosis of dysfunction, satisfactory overall VA survival, and patency rates, with a low PEP frequency. Randomized controlled trials are required to establish the value of DUS surveillance on access patency and whether DUS-guided interventions could improve VA outcomes.
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Affiliation(s)
- Ioannis E Giannikouris
- Department of Nephrology and Hemodialysis Unit, Mediterraneo Hospital, Glyfada, Athens, Attika, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, Democritus University of Thrace School of Health Sciences, Alexandroupolis, Thrace, Greece
| | | | - Ploumis Passadakis
- Department of Nephrology, Democritus University of Thrace School of Health Sciences, Alexandroupolis, Thrace, Greece
| | - Stavros Spiliopoulos
- 2nd Radiology Department, Division of Interventional Radiology, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Chaidari, Athens, Attika, Greece
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Peden EK, Lucas JF, Browne BJ, Settle SM, Scavo VA, Bleyer AJ, Ozaki CK, Teruya TH, Wilson SE, Mishler RE, Ferris BL, Hendon KS, Moist L, Dixon BS, Wong MD, Magill M, Lindow F, Gustafson P, Burke SK. PATENCY-2 trial of vonapanitase to promote radiocephalic fistula use for hemodialysis and secondary patency. J Vasc Access 2021; 23:265-274. [PMID: 33482699 DOI: 10.1177/1129729820985626] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Arteriovenous fistulas created for hemodialysis often fail to become usable and are frequently abandoned. This prospective trial evaluated the efficacy of vonapanitase, a recombinant human elastase, in increasing radiocephalic fistula use for hemodialysis and secondary patency. METHODS PATENCY-2 was a randomized, double-blind, placebo-controlled trial in patients on or approaching the need for hemodialysis undergoing radiocephalic arteriovenous fistula creation. Of 696 screened, 613 were randomized, and 603 were treated (vonapanitase n = 405, placebo n = 208). The study drug solution was applied topically to the artery and vein for 10 min immediately after fistula creation. The primary endpoints were fistula use for hemodialysis and secondary patency (fistula survival without abandonment). Other efficacy endpoints included unassisted fistula use for hemodialysis, primary unassisted patency, fistula maturation and unassisted maturation by ultrasound criteria, and fistula procedure rates. RESULTS The proportions of patients with fistula use for hemodialysis was similar between groups, 70% vonapanitase and 65% placebo, (p = 0.33). The Kaplan-Meier estimates of 12-month secondary patency were 78% (95% confidence interval [CI], 73-82) for vonapanitase and 76% (95% CI, 70-82) for placebo (p = 0.93). The proportions with unassisted fistula use for hemodialysis were 46% vonapanitase and 37% placebo (p = 0.054). The Kaplan-Meier estimates of 12-month primary unassisted patency were 50% (95% CI, 44-55) for vonapanitase and 43% (95% CI, 35-50) for placebo (p = 0.18). There were no differences in the proportion of patients with fistula maturation or in fistula procedure rates. Adverse events were similar between groups. Vonapanitase was not immunogenic. CONCLUSIONS Vonapanitase treatment did not achieve clinical or statistical significance to meaningfully improve radiocephalic fistula surgical outcomes. Outcome in the placebo group were better than in historical controls. Vonapanitase was well-tolerated and safe. TRIAL REGISTRATION clinicaltrials.gov: NCT02414841 (https://clinicaltrials.gov/ct2/show/NCT02414841).
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Affiliation(s)
| | - John F Lucas
- Surgery, Greenwood Leflore Hospital, Greenwood, MS, USA
| | | | | | | | | | | | - Theodore H Teruya
- Cardiovascular and Thoracic Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Samuel E Wilson
- Vascular Surgery, University of California Irvine Medical Center, Irvine, CA, USA
| | - Rick E Mishler
- Arizona Kidney Disease & Hypertension Centers, Phoenix, AZ, USA
| | | | | | - Louise Moist
- Division of Nephrology, Western University, London, ON, Canada
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