Use of chronically occluded fistula to establish access outflow.

Maintaining a good quality vascular access in the long term can become particularly challenging especially in patients that are on dialysis for many years and present with exhausted venous capital and chronic access related complications. We present a 60-year-old female patient with multiple bilateral previous failed accesses, a previous distal revascularization interval ligation (DRIL) for hemodialysis access induced distal ischemia (HAIDI). Her chronically (more than a month) occluded arteriovenous fistula AVF was used to establish outflow and create a functioning forearm arteriovenous graft (AVG).

Creating reverse flow arteriovenous fistulas with a forearm cannulation target.

BACKGROUND: Establishing a forearm arteriovenous fistula (AVF) offers preferred cannulation sites and preserves proximal access opportunities. When a radiocephalic AVF at the wrist is not feasible and the upper arm cephalic and median cubital veins are inadequate, an AV graft or more complex access procedure is often required. Creating a retrograde flow forearm AVF (RF-AVF) is a valuable alternative where the mid-forearm median antebrachial or cephalic vein is adequate, offering forearm cannulation zones with AVF outflow through deep and superficial collaterals. We report our technique and results. METHODS: We retrospectively reviewed our vascular access data base of consecutive patients during an 11-year study period where a RF-AVF established the only available cannulation target in the forearm. In addition to physical examination, all patients had ultrasound vessel mapping. RESULTS: A forearm access was established with a RF-AVF as the only opportunity for cannulation in 48 patients. Ages were 14-86 years (median = 62 years). Forty-four percent female, 63% diabetic, 13% obese, and 29% had previous access operations. Inflow was proximal radial artery in 47 individuals and one proximal ulnar. Nine AVFs (19%) failed at 2-66 months (median 14 months). One RF-AVF was ligated due to arm edema. Follow-up was 2-111 months (median = 23.5 months). Primary and cumulative patency rates were 62% and 91% at 12 months, and 46% and 85% at 24 months. Five patients were lost to follow-up with functioning RF-AVFs (mean 41 months). Twenty-three patients (48%) died during F/U of causes unrelated to access procedures (mean 25 months). CONCLUSIONS: Establishing a reverse flow forearm AVF offers a successful autogenous access option in the forearm for selected patients with an inadequate distal radial artery and/or cephalic vein at the wrist, avoiding more complex or staged procedures and preserving upper arm sites for future use. A proximal radial artery inflow procedure is recommended.

Endovascular Arteriovenous Fistula Creation-Review of Current Experience.

Functioning vascular access is an essential element for life-saving hemodialysis therapy. A surgically-created arteriovenous fistula has been considered the best option for many years. Recently, two manufacturers developed systems for percutaneous/endovascular creation of an arteriovenous fistula (WavelinQ and Ellipsys). We provide a review of the available experience with these systems and discuss advantages and disadvantages.

Customizable modification of banding with external stenting for arteriovenous fistula flow reduction.

We performed a single-center retrospective study of prospectively collected data for all patients who had flow reduction surgery with FRAME FR between November 2020 and January 2021. Ten patients had arteriovenous fistula flow reduction surgery with this technique. One patient had a distal fistula, whereas nine were within the cubital fossa. In nine patients the device was applied over the postanastomotic arteriovenous fistula outflow vein and in one in the preanastomotic radial artery. Technical success was achieved in all patients with a median flow reduction from 2150 to 825 mL/min. There were no wound or device-specific complications.

Percutaneous arteriovenous fistula creation.

The first percutaneous systems used to create an arteriovenous fistula for hemodialysis were approved by the US Food and Drug Administration in 2018 and included the Ellipsys and WavelinQ devices. Early results and longer-term studies of these catheter-based devices suggest that they offer important benefits and potentially improved outcomes in patients with appropriate anatomy. The deep communicating vein in the cubital fossa and its relationship to the proximal radial artery or proximal ulnar artery are key vascular elements of both systems. The devices differ significantly in technical design, energy source, imaging requirements, procedure times, catheters, access vessel sites, and techniques. We review the two approved percutaneous arteriovenous fistula devices, including technical considerations, selecting the appropriate patient, postoperative evaluation, interventions, outcomes, potential complications, and cannulation issues.

Paclitaxel-Coated Balloons for the Treatment of Symptomatic Central Venous Stenosis in Vascular Access: Results From a European, Multicenter, Single-Arm Retrospective Analysis.

INTRODUCTION: This was a European, multicenter, investigator-initiated and run, single-arm retrospective analysis to assess the safety and the clinical benefit of the use of paclitaxel-coated balloon (PCB) for the treatment of symptomatic central venous stenosis (CVS). MATERIALS AND METHODS: Eleven centers from 7 countries across Europe, submitted 86 cases performed during the period between October 2015 and June 2018. Minimum follow-up was 6 months. Patient baseline demographics and procedural details were collected. Mean age was 62.6 years (SD 15.2 years). Median vascular access age was 3.0 years (IQR 1.2-4.8 years). A total of 55 were arteriovenous fistulas (64%) the rest arteriovenous grafts (31/86, 36%). Vessels treated were 43 subclavian veins, 42 brachiocephalic veins and 1 superior vena cava. Median drug-coated balloon diameter was 10 mm (IQR 8-12 mm). Primary outcome measures were clinically assessed intervention-free period (IFP) of the treated segment at 6 months and procedure-related minor and major complications. Secondary outcome measures included access circuit survival, patient survival, and the investigation of independent factors that influence the IFP. RESULTS: IFP was 62.7% at 6 months. Median patient follow-up time was 1.0 year (IQR 0.5-2.2 years). There was 1 minor complication (1/86; 1.2%) and no major complications. Access circuit survival was 87.7% at 6 months. Patient survival was 79.7% at 2 years according to Kaplan-Meier survival analysis. Higher balloon diameters significantly favored IFP [HR 0.71 (0.55-0.92), p=0.006; 5-7 mm group vs 8-12 mm group, p=0.025]. CONCLUSION: In this analysis, use of PCBs for the treatment of symptomatic CVS was safe. Efficacy was comparable to previous trials. Increased balloon size had a significant effect on patency rates.

Comparison of surgical versus percutaneously created arteriovenous hemodialysis fistulas.

OBJECTIVE: The aim of the present study was to compare the results between percutaneous arteriovenous fistulas (p-AVFs) created with the Ellipsys device (Ellipsys Vascular Access System; Avenu Medical, San Juan Capistrano, Calif) and surgical arteriovenous fistulas (s-AVFs). METHODS: A single-center retrospective comparative study of the first 107 patients who had undergone p-AVF creation with the Ellipsys system from May 2017 to May 2018 with an equal number of consecutive patients who had undergone s-AVF creation in our center during the same period. The primary endpoints included the maturation and patency rates. The secondary endpoints were reintervention, risk of infection, and the incidence of steal syndrome and aneurysm formation. RESULTS: The demographic, hypertension, and diabetes data were similar for both groups. The only difference between the two groups was that more p-AVF patients had already been receiving hemodialysis (61% vs 47%; P < .05). The p-AVFs showed superior maturation rates at 6 weeks (65% vs 50%; P = .01). The primary patency rates were greater for the s-AVFs at 12 months (86% vs 61%; P < .01). However, primary patency was comparable between the two groups at 24 months (52% vs 55%; P = .48). No significant difference was found in the secondary patency rates at 12 (90% vs 91%) and 24 (88% vs 91%) months. At the 2-year follow-up point, the rate of percutaneous reintervention was similar; however, the s-AVFs had required more frequent surgical revision (36% vs 17%; P = .01). Issues with wound healing and infection were also more frequent with s-AVFs (9% vs 0.9%; P < .01). CONCLUSIONS: Fistulas created percutaneously with the Ellipsys system showed superior maturation rates and similar patency with s-AVFs created in an experienced high-volume vascular surgery practice. p-AVFs had a lower risk of wound healing issues, infection, and surgical revision. Larger, prospective, randomized multicenter studies are needed to confirm these findings.

Iatrogenic jugulo-subclavian fistula.

Iatrogenic arteriovenous fistula of major neck vessels is a rare complication but can occur after central venous catheterization. Symptoms can range from nothing to severe heart failure and management can be particularly complex. We report a case that we treated recently in our department.

Ultrasound-guided percutaneous retrieval of transected radial artery catheter.

OBJECTIVE: To report our technique for percutaneous ultrasound-guided retrieval of accidentally transected arterial lines. CASES DESCRIPTION: Two patients are reported herein; in both of these patients, a part of the 20-gauge catheter inserted for invasive monitoring of their blood pressure in the intensive care unit was accidentally transected with part of the catheter remaining in the radial artery. Both patients were initially asymptomatic; therefore, a minimally invasive technique was sought to remove the catheters without inducing significant risk. Under local anesthesia and ultrasound guidance at the patient bedside, a 6Fr slender sheath was introduced and with the help of a Fogarty catheter in one case, and in the other case, a 0.014-in hydrophobic wire was used to cannulate the catheter, and it was withdrawn into the sheath and removed with it uneventfully.

The challenge of stent placement within cannulation zones of Arteriovenous Fistulae.

BACKGROUND: Stent placement in the cannulation zone of AVF is becoming alarmingly frequent and sometimes in cases where surgical management would be more appropriate. When complications arise repair can be particularly challenging. We present our experience and management of this problem. METHODS: We report our experience on three patients (two females and one male, mean age 72) that were referred to our department for problems related to stents placed at the cannulation segments. RESULTS: All patients required complex surgical interventions. In two of them maintenance of access was possible but required the use of a graft. In one complete resection of the AVF and all stents was necessary, and the patient remained on dialysis through catheter. CONCLUSION: Stent placement at the cannulation zones may complicate access management in the future and should be avoided if possible.

Creating percutaneous radiocephalic arteriovenous fistulas at the wrist.

BACKGROUND: The first arteriovenous fistulas were created at the wrist more than 60 years ago. Basic surgical construction techniques remain unchanged with mobilization and repositioning of the vessels followed by a sutured anastomosis. We used the Ellipsys device to construct percutaneous radiocephalic-arteriovenous fistulas at the wrist and report the results. METHODS: Data were reviewed retrospectively for all patients who had a percutaneous radiocephalic-arteriovenous fistula created during a 6-month period. Each individual underwent ultrasound vessel mapping in addition to physical examination. When a radiocephalic-arteriovenous fistula was feasible and a communicating vein ⩾ 2 mm in diameter was noted in the distal forearm along with a radial artery ⩾ 2 mm, a percutaneous radiocephalic-arteriovenous fistula was considered and reviewed with the patient. RESULTS: Four individuals met the criteria to consider a percutaneous radiocephalic-arteriovenous fistula and all elected to have the procedure performed. Ages were 54-85 years. Three were diabetic and one was female. All percutaneous radiocephalic-arteriovenous fistulas were technically successful. Two individuals had not yet started dialysis therapy. Successful and repetitive cannulation for the two individuals with catheters was initiated at 4 and 8 weeks post procedure. The two pre-dialysis patients had physiologic arteriovenous fistula maturation (6 mm vein diameter and >500 mL/min flow) at 4 and 12 weeks. There were no procedural or late complications and none required intervention. Follow-up was 8-23 months (mean 16 months). CONCLUSION: The success of these percutaneous radiocephalic-arteriovenous fistulas suggests that use of the Ellipsys device will be applicable at the wrist in selected patients where appropriate vessel sizes and configurations are found.

Percutaneous creation of proximal radio-radial arteriovenous hemodialysis fistula before secondary brachial vein elevation.

OBJECTIVE: We evaluate the creation of a percutaneous proximal radial artery-radial vein arteriovenous fistula with Ellipsys® instead of the usual first-stage brachial artery fistula prior to a second-stage brachial vein elevation, in patients with inadequate cephalic and basilic veins. METHODS: Single center study of eight patients (six males, mean = 54 years) who underwent a two-stage brachial vein elevation procedure between May 2017 and October 2019. Inclusion criteria were life expectancy > 6 months, patent brachial and proximal radial artery (>2 mm in diameter) absent/inadequate cephalic and basilic veins, existence of a brachial vein >3 mm in diameter, and in continuity with a proximal radial vein > 2 mm in diameter. RESULTS: Technical success was 100%. Four patients required angioplasty of a juxta-anastomotic stenosis, accounting for a 6-month primary and secondary patency rates were 68% and 100%, respectively. Access flow averaged 982 mL/min (range 768-1586) at final follow-up evaluation. There were no significant adverse events related to the procedures. All fistulae were elevated at 4-12 (mean: 8) weeks post creation and were successfully cannulated with two needles after healing was completed (2-4 weeks after elevation). No patients developed hand ischemia or arm edema. CONCLUSIONS: Percutaneous creation of a proximal radial artery-radial vein fistula followed by brachial vein elevation is a safe and reliable option for autogenous access creation in patients with inadequate cephalic or basilic veins. Minimally invasive radial artery inflow and longer available length of the targeted brachial vein available for elevation are the main advantages in skilled hands.