Distal versus proximal radial access in coronary angiography: a meta-analysis.

BACKGROUND: Distal radial access (DRA) represents a promising alternative to conventional proximal radial access (PRA) for coronary angiography. Substantial advantages regarding safety and efficacy have been suggested for DRA, but the ideal access route remains controversial. AIMS: The aim of this study was to compare safety, efficacy and feasibility of DRA to PRA. METHODS: National Library of Medicine PubMed, Web of Science, clinicaltrials.gov and Cochrane Library were systematically searched for randomized controlled trials and registry studies comparing DRA and PRA that were published between January 1, 2017 and April, 2024. Primary endpoint was the rate of radial artery occlusion (RAO). Secondary endpoints were access failure, access time, procedure time, arterial spasm, hematoma, and hemostasis time. Data extraction was performed by two independent investigators. Relative risks were aggregated using a random effects model. We applied meta-analytic regression to assess study characteristic variables as possible moderators of the study effects. RESULTS: 44 studies with a total of 21,081 patients were included. We found a significantly lower rate of RAO after DRA (DRA 1.28%, PRA 4.76%, p < .001) with a 2.92 times lower risk compared to the proximal approach (Log Risk Ratio = -1.07, p < .001). Conversely, the risk for access failure was 2.42 times higher for DRA compared to PRA (Log Risk Ratio = 0.88, p < .001). CONCLUSION: In this largest meta-analysis to date, we were able to show that rates of RAO are reduced with DRA compared to conventional PRA. This suggests DRA is a safe alternative to PRA.

Distal Versus Proximal Radial Arterial Access for Percutaneous Coronary Angiography and Intervention: Updated Meta-Analysis of Randomized Controlled Trials.

Radial artery occlusion (RAO) is a major impediment to reintervention in patients who underwent proximal transradial access (p-TRA) for coronary catheterization. Distal transradial access (d-TRA) at the level of snuffbox distal to the radial artery bifurcation is a novel alternative to p-TRA. We conducted an updated meta-analysis of all available randomized controlled trials (RCTs) to compare the incidence of RAO between p-TRA and d-TRA, along with access site-related complications. PubMed, Web of Science, and Google Scholar were searched for RCTs published since 2017 to October 2023 comparing d-TRA and p-TRA for coronary angiography and/or intervention. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals were calculated using the random-effects model for procedural and clinical outcomes for the 2 approaches. A total of 18 RCTs with 8,205 patients (d-TRA n = 4,096, p-TRA n = 4,109) were included. The risk of RAO (RR 0.31, 0.21 to 0.46, p ≤0.001) and time to hemostasis (minutes) (MD -51.18, -70.62 to -31.73, p <0.001) was significantly lower in the d-TRA group. Crossover rates (RR 2.39, 1.71 to 3.32, p <0.001), access time (minutes) (MD 0.93, 0.50 to 1.37, p <0.001), procedural pain (MD 0.46, 0.13 to 0.79, p = 0.006), and multiple puncture attempts (RR 2.13, 1.10 to 4.11, p = 0.03) were significantly higher in the d-TRA group. The use of d-TRA for coronary angiography and/or intervention is associated with a lower risk of RAO at the forearm and may preserve p-TRA site for reintervention in selective patients by reducing the incidence of RAO.

Stress Shielding around Press-Fit Radial Head Arthroplasty: Proposal for a New Classification System Based on the Analysis of 97 Patients with a Mid-Term Follow-Up and a Review of the Literature.

Stress shielding (SS) around press-fit radial head arthroplasty (RHA) was recently reported as a cause of a new type of proximal radial neck resorption (PRNR). Very few studies have analyzed this phenomenon. No comprehensive classification is currently available. We thus decided to clinically and radiographically analyze 97 patients who underwent a press-fit RHA and who were followed up for a mean period of 72 months (range: 2-14 years). PRNR in the four quadrants of the radial neck was assessed. We designed a novel SS classification based on (1) the degree of resorption of the length of the radial neck and (2) the number of neck quadrants involved on the axial plane. The mean PRNR (mPRNR) was calculated as the mean resorption in the four quadrants. mPRNR was classified as mild (<3 mm), moderate (3 to 6 mm), and severe (>6 mm). Eighty-four percent of the patients presented PRNR. mPRNR was mild in 33% of the patients, moderate in 54%, and severe in 13%. In total, 6% of the patients with mild mPRNR displayed resorption in one quadrant, 18% displayed resorption in two quadrants, 4% displayed resorption in three quadrants, and 72% displayed resorption in four quadrants. All four quadrants were always involved in moderate or severe mPRNR, with no significant differences being detected between quadrants (p = 0.568). mPRNR has no apparent effect on the clinical results, complications, or RHA survival in the medium term. However, longer-term studies are needed to determine the effects of varying degrees of PRNR on implant failure.

Clinical and radiological evaluation of radial neck factures in children and adolescents treated by percutaneous leverage reduction with Kirschner wire stabilization.

PURPOSE: The aim of the study was to evaluate the clinical and radiological results of surgical treatment of radial neck fractures in children and adolescents by percutaneous leverage with Kirschner wire stabilization. METHODS: A retrospective clinical and radiographical evaluation was performed on a cohort of 61 patients (mean age 9.7 years; range 3 to 15) with isolated, unilateral radial neck fractures treated between 2009 and 2019. The mean duration of follow-up was 4.2 years (range 2 to 9 years). All fractures were types III and IV according to Judet's classification. RESULTS: After mean follow-up, the radiographic results according to Metaizeau were rated as excellent in 70.5% of respondents, good in 27.9%, satisfactory in 1.6%. According to Mayo Elbow Performance Score, 95.1% of respondents obtained a very good result, 3.3% good, and 1.6% satisfactory. The mean radial neck-shaft angle changed from a mean 51.5° before operation to 3.8° postoperatively (p<0.001). The mean translation was 3.1mm before surgery and 0.5mm postoperatively (p<0.001). No limb axis deviation, elbow joint instability, and infection of the implant insertion site were observed. No statistically significant differences were noted between girls and boys (p>0.05). CONCLUSIONS: Our findings indicate that percutaneous leverage with Kirschner wire stabilization is an effective and safe method for treating isolated radial neck fractures, characterized by a low risk of iatrogenic complications.

Factors Affecting Radial Artery Occlusion After Right Transradial Artery Catheterization for Coronary Intervention and Procedures.

Objective: To determine the factors influencing proximal radial artery occlusion (PRAO) right radial artery after coronary intervention. Methods: This is a single-center prospective observational study. A total of 460 patients were selected to undergo coronary angiography (CAG) or percutaneous coronary intervention (PCI) via the proximal transradial approach (PTRA) or distal transradial approach (DTRA). The 6F sheath tube were received by all patients. Radial artery ultrasound was performed 1 day before procedure and 1-4 days after procedure. Patients were divided into the PRAO group (42 cases) and the non-PRAO group (418 cases). General clinical data and preoperative radial artery ultrasound indexes of the two groups were compared to analyze related factors leading to PRAO. Results: The total incidence of PRAO was 9.1%, including 3.8% for DTAR and 12.7% for PTRA. The PRAO rate of DTRA was significantly lower than that of PTRA (p < 0.05). Female, low body weight, low body mass index (BMI) and CAG patients were more likely to develop PRAO after procedure (p < 0.05). The internal diameter and cross-sectional area of the distal radial artery and proximal radial artery were smaller in the PRAO group than in the non-PRAO group, and the differences were statistically significant (p < 0.05). Multifactorial model analysis showed that the puncture approach, radial artery diameter and procedure type were predictive factors of PRAO, and the receiver operating characteristic curve showed a good predictive value. Conclusion: A larger radial artery diameter and DTRA may reduce the incidence of PRAO. Preoperative radial artery ultrasound can guide the clinical selection of appropriate arterial sheath and puncture approach.

Effect of proximal artery restriction on flow reduction and cardiac function in hemodialysis patients with high-flow arteriovenous fistulas.

OBJECTIVE: Arteriovenous fistula is the preferred vascular access for hemodialysis patients. High-flow arteriovenous fistula may cause high-output heart failure. Various procedures are used to reduce high-flow arteriovenous fistula. This study aimed to assess the efficacy of proximal artery restriction combined with distal artery ligation on flow reduction for high-flow arteriovenous fistula and on cardiac function and echocardiographic changes in patients undergoing hemodialysis. METHODS: A retrospective analysis was performed on data collected from the medical records of patients undergoing hemodialysis with heart failure and high-flow arteriovenous fistula between May 2018 and May 2021. Thirty-one patients were treated with proximal artery restriction (banding juxta-anastomosis of the proximal artery) combined with distal artery ligation (anastomosis distal artery ligation). Changes in the Acute Dialysis Quality Initiative Workgroup cardiac function class, blood pressure, and echocardiography before and 6 months after flow restriction were compared, and post-intervention primary patency was followed-up. RESULTS: The technical success rate of the surgery was 100%, and no surgery-related adverse events occurred. Blood flow and blood flow/cardiac output decreased significantly after flow restriction. Blood flow decreased from 2047.21 ± 398.08 mL/min to 1001.36 ± 240.42 mL/min, and blood flow/cardiac output decreased from 40.18% ± 6.76% to 22.34% ± 7.21% (P < .001). Post-intervention primary patency of arteriovenous fistula at 6, 12, and 24 months was 96.8%, 93.5%, and 75.2%, respectively. The Acute Dialysis Quality Initiative Workgroup cardiac function class improved significantly after 6 months of flow restriction (P < .001). The systolic and diastolic left heart function improved, as evidenced by a significant decrease in left atrial volume index, left ventricular end-diastolic/end-systolic diameters, left ventricular end-diastolic volume, left ventricular mass index, cardiac output, and cardiac index and an increase in lateral peak velocity of longitudinal contraction, average septal-lateral s', and lateral early diastolic peak velocity after flow restriction (P < .05). Systolic pulmonary artery pressure decreased from 32.36 ± 8.56 mmHg to 27.57 ± 8.98 mmHg (P < .05), indicating an improvement in right heart function. CONCLUSIONS: Proximal artery restriction combined with distal artery ligation effectively reduced the blood flow of high-flow arteriovenous fistula and improved cardiac function.

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.

Pronator teres nerve branch transfer to the extensor carpi radialis brevis nerve branch for wrist extension reconstruction in proximal radial nerve injury following humeral shaft fractures.

BACKGROUND: Tendon and nerve transfers are used for functional reconstruction in cases of proximal radial nerve injury complicated by humeral fractures in patients who do not show functional recovery after primary nerve repair. The effectiveness of pronator teres (PT) nerve branch transfer to the extensor carpi radialis brevis (ERCB) nerve branch for wrist extension reconstruction was investigated and compared to the results of tendon transfer. METHODS: This study included 10 patients with proximal radial nerve injury, who did not show functional recovery after primary nerve repair at our hospital between April 2016 and May 2019. The nerve transfer procedure included PT nerve branch transfer to the ECRB nerve branch to restore wrist extension and the flexor carpi radialis (FCR) nerve branch to the posterior interosseous nerve (PIN) to restore thumb and finger extension. Tendon transfer procedures included PT transfer to the ECRB for wrist extension, FCR transfer to the extensor digitorum communis (EDC) for finger extension and palmaris longus (PL) transfer to the extensor pollicis longus (EPL) for thumb extension. RESULTS: Five patients recovered Medical Research Council grade M4 muscle strength in the ECRB and EPL in both tendon and nerve groups. Two patients recovered grade M3 strength and three patients recovered grade M4 strength in the EDC in the tendon transfer group, and all five patients recovered grade M4 strength in the EDC in the nerve transfer group. Limited wrist flexion was observed only in one patient in the tendon transfer group. CONCLUSION: PT nerve branch transfer to the ECRB nerve branch combined with FCR nerve branch transfer to PIN is a useful strategy for wrist and fingers extension reconstruction in patients with proximal radial nerve injuries.

RailTracking: A Novel Technique to Overcome Difficult Anatomy During Transradial Approach.

OBJECTIVE: We aim to investigate the safety and efficacy of a new technique, "RailTracking," in the management of challenging transradial routes during percutaneous coronary interventions (PCI). BACKGROUND: The transradial access (TRA) currently represents the access site of choice in PCI, but complex anatomy could lead to complications and access-site crossover. The assisted-tracking techniques described in the past (such as balloon-assisted tracking and pigtail-assisted tracking) are based on the concept of a "guiding tapered tip" to improve trackability. The RailTracking technique creates a tapered catheter tip using a dedicated device. METHODS: We collected patient data from January 2021 to January 2022 in 2 high-volume centers using the RailTracking technique as a bail-out solution. A prospective analysis of the anatomical characteristics and outcomes of the study population was performed. RESULTS: Seventy-seven patients were included in the study. All patients presented with challenging anatomies; 35.1% of the patients (n = 27) had small radial arteries, 19.5% (n = 15) had significant radial tortuosity, 2.6% (n = 2) had significant brachial tortuosity, 2.6% (n = 2) had subclavian tortuosity, and 1.29% (n = 1) had a critical subclavian lesion. In addition, 38.9% presented with severe radial spasm. The procedural success rate of the RailTracking technique was 98.7% (76/77 patients). The only case of failure presented with calcifications and a critical lesion in the subclavian artery. However, no periprocedural vascular complications occurred. This new technique appears safe, with a radial artery occlusion rate of 3.89% (n = 3) at 1-month follow-up. CONCLUSION: The new RailTracking technique improves catheter crossing in challenging anatomies and seems safe and effective in cases of failure with currently available approaches.

Switching From Proximal to Distal Radial Artery Access for Coronary Chronic Total Occlusion Recanalization.

Background: Distal radial access (DRA) was recently introduced in the hopes of improving patient comfort by allowing the hand to rest in a more ergonomic position throughout percutaneous coronary interventions (PCI), and potentially to further reduce the rate of complications (mainly radial artery occlusion, [RAO]). Its safety and feasibility in chronic total occlusion (CTO) PCI have not been thoroughly explored, although the role of DRA could be even more valuable in these procedures. Methods: From 2016 to 2021, all patients who underwent CTO PCI in 3 Hungarian centers were included, divided into 2 groups: one receiving proximal radial access (PRA) and another DRA. The primary endpoints were the procedural and clinical success and vascular access-related complications. The secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and procedural characteristics (volume of contrast, fluoroscopy time, radiation dose, procedure time, hospitalization time). Results: A total of 337 consecutive patients (mean age 64.6 ± 9.92 years, 72.4% male) were enrolled (PRA = 257, DRA = 80). When compared with DRA, the PRA group had a higher prevalence of smoking (53.8% vs. 25.7%, SMD = 0.643), family history of cardiovascular disease (35.0% vs. 15.2%, SMD = 0.553), and dyslipidemia (95.0% vs. 72.8%, SMD = 0.500). The complexity of the CTOs was slightly higher in the DRA group, with higher degrees of calcification and tortuosity (both SMD >0.250), more bifurcation lesions (45.0% vs. 13.2%, SMD = 0.938), more blunt entries (67.5% vs. 47.1%, SMD = 0.409). Contrast volumes (median 120 ml vs. 146 ml, p = 0.045) and dose area product (median 928 mGy×cm2 vs. 1,300 mGy×cm2, p < 0.001) were lower in the DRA group. Numerically, local vascular complications were more common in the PRA group, although these did not meet statistical significance (RAO: 2.72% vs. 1.25%, p = 0.450; large hematoma: 0.72% vs. 0%, p = 1.000). Hospitalization duration was similar (2.5 vs. 3.0 days, p = 0.4). The procedural and clinical success rates were comparable through DRA vs. PRA (p = 0.6), moreover, the 12-months rate of MACCE was similar across the 2 groups (9.09% vs. 18.2%, p = 0.35). Conclusion: Using DRA for complex CTO interventions is safe, feasible, lowers radiation dose and makes dual radial access more achievable. At the same time, there was no signal of increased risk of periprocedural or long-term adverse outcomes.

Distal Versus Proximal Radial Artery Access for Cardiac Catheterization and Intervention: Design and Rationale of the DIPRA Trial.

BACKGROUND: Radial artery (RA) catheterization is the access of choice over femoral artery access for most interventional vascular procedures given its safety and faster patient recovery. There has been growing interest in distal radial artery (dRA) access as an alternative to the conventional proximal radial artery (pRA) access. Preserving the RA is important which serves as a potential conduit for future coronary artery bypass surgery, dialysis conduit or preserve the artery for future cardiovascular procedures. The dRA runs in close proximity to the radial nerve, which raises the concern of potential detrimental effects on hand function. STUDY DESIGN: The Distal versus Proximal Radial Artery Access for cardiac catheterization and intervention (DIPRA) trial is a prospective, randomized, parallel-controlled, open-label, single center study evaluating the outcomes of hand function and effectiveness of dRA compared to pRA access in patients undergoing cardiac catheterization. The eligible subjects will be randomized to dRA and pRA access in a (1:1) fashion. The primary end point is an evaluation of hand function at one and twelve months follow-up. Secondary end points include rates of access site hematoma, access site bleeding, other vascular access complications, arterial access success rate, and RA occlusion at one and twelve months follow up. CONCLUSION: Effects of dRA on hand function remains unknown and it's use questionable in the presence of a widely accepted pRA. DIPRA trial is designed to determine the safety and effectiveness of dRA for diagnostic and interventional cardiovascular procedures compared to the standard of care pRA.

Outcomes of distal versus conventional transradial access for coronary angiography and intervention: An updated systematic review and meta-analysis.

INTRODUCTION: Distal transradial artery access (DTRA) has recently gained attention due to potential benefits in terms of local complications. In this meta-analysis, we aimed to evaluate the utility of DTRA compared to conventional transradial artery access (CTRA) for coronary angiography and intervention. METHOD: Multiple databases were searched from inception through May 2021 for all the studies that evaluated the efficacy and safety of DTRA in the coronary field. The primary outcome was the access success rate. The secondary outcomes were periprocedural local complications (site hematoma, radial artery occlusion, and spasm) and procedural characteristics (cannulation, fluoroscopy, procedure, and radial artery compression times). All meta-analyses were conducted using a random-effect model. RESULTS: A total of 12 studies (including four randomized control trials) with 1634 patients who underwent DTRA vs. 1657 with CTRA were included in the final analysis. The access success rate was similar between the two groups (odds ratio (OR):0.62; 95% confidence interval (CI):0.30-1.26; P = 0.18; I2 = 61%). DTRA was associated with a statistically significant lower rate of radial artery occlusion (OR:0.36; 95% CI: 0.22-0.59; P < 0.001; I2 = 0%) but similar rates of radial artery spasm and site hematoma when compared to CTRA. Regarding the procedural characteristics, despite having a longer canulation time (mean difference (min.) [MD] 0.89, 95% CI 0.36-1.42; P < 0.0001), DTRA was associated with shorter compression time and comparable fluoroscopy and procedure times. CONCLUSIONS: Our meta-analysis demonstrates that the DTRA is effective and safe with superiority in preventing radial artery occlusion when compared to CTRA.

Staged brachioradial artery to brachioradial vein arteriovenous fistula creation for hemodialysis access in three patients with a high origin of the radial artery.

When patients lack suitable superficial veins in the upper extremity to create an arteriovenous fistula, surgeons are faced with a decision between a synthetic graft or autologous fistula using deep veins, such as a brachial artery to brachial vein arteriovenous fistula. In patients with a high radial artery origin (or brachioradial artery) and inadequate superficial veins, arteriovenous fistula creation will be even more challenging. In the present report, we describe a technique used in three such patients who underwent successful staged brachioradial artery to brachioradial vein arteriovenous fistula creation.

Open reduction of radial neck fractures in children: injury severity predicts the radiographic and clinical outcomes.

BACKGROUND: Radial neck fractures are the third most common elbow fracture in children. Open reduction may be required if closed or mini-open techniques are not successful in reducing the fracture. Previous reports on open reduction have noted poor outcomes and complications with this treatment approach. However, it is unknown whether it is the open procedure itself or the severity of the initial injury that leads to the poor results. The purpose of this study was to evaluate the correlation between intraoperative findings at the time of open reduction of radial neck fractures and the clinical and radiographic outcomes. METHODS: Data from patients who underwent open reduction for an acute radial neck fracture between January 2009 and December 2018 were abstracted and reviewed. Patients undergoing open treatment for a nonunion or malunion and those with inadequate follow-up were excluded. Demographic data, injury characteristics, treatment strategies, intraoperative findings, and clinical and radiographic outcomes were assessed. RESULTS: Twenty-two patients met the inclusion criteria. Of these patients, 14 were girls. The mean age was 9.7 ± 3 years, and the mean follow-up period was 15.8 months. Fifteen patients had a Judet grade IV displacement. Fair or poor outcomes were observed in 12 patients (55%). Ten reoperations were recorded during the study period. Age, weight, and associated injuries were not predictive of poor outcomes. Intraoperative findings of soft-tissue stripping and radial head comminution were the only significant predictors of fair or poor clinical outcomes (P < .001) and subsequent radiographic changes including fragmentation and collapse of the radial head and arthritic changes (P < .001). The quality of reduction and the choice of hardware were not significantly associated with either clinical or radiographic outcomes. CONCLUSION: Our findings support the notion that the outcomes of open reduction of radial neck fractures are most closely correlated with the injury severity, with the intraoperative findings of complete soft-tissue stripping or comminution of the radial head fragment being significant predictors of poor clinical and radiographic outcomes. The choice of hardware and the quality of reduction achieved at the time of surgery have less significance than injury severity.

Feasibility for arteriovenous fistula creation with Ellipsys®.

OBJECTIVE: To investigate the feasibility of percutaneous arteriovenous fistula creation in consecutive patients screened for first access creation. METHODS: Prospective study of ultrasound mapping based on the following minimal anatomic requirements: a patent proximal radial artery and adjacent elbow perforating vein with straight trajectory, each greater than or equal to 2 mm in diameter and within 1.5 mm of each other. In addition, the same population was evaluated for feasibility of a distal radiocephalic fistula established. RESULTS: One hundred consecutive patients were examined between November 2018 and January 2019. Sixty-seven were male (67%) and mean age was 61 years. Sixty-three patients (63%) and a total of 100 limbs (50%) were found to be eligible for a percutaneous fistula creation with Ellipsys®. Thirty-seven percent of patients were ineligible because of the absence of both median cephalic and median cubital veins (15%), absence or inadequate elbow perforating vein and/or smaller than 2 mm proximal radial artery (14%), and/or distance greater than 1.5 mm (8%). We found suitable vessels for a surgical distal fistula creation in 91 extremities (45%), but this percentage dropped to 17% in patients over 70 years old. Among the 100 limbs eligible for percutaneous arteriovenous fistula, only 30 (30%) were eligible for radiocephalic arteriovenous fistula. CONCLUSION: More than 60% of patients were eligible for Ellipsys. The absence of veins at the elbow and a large distance between vessels were the most common limiting factors. Less than one half of the patients were candidates for surgical fistula and this percentage dropped significantly for older individuals.

Two-year cumulative patency of endovascular arteriovenous fistula.

BACKGROUND AND OBJECTIVES: The recent advent of a device to create a proximal radial artery arteriovenous fistula using an endovascular approach to create the anastomosis represents a significant advance in dialysis access creation. This endovascular arteriovenous fistula offers the beneficial attributes of the proximal radial artery arteriovenous fistula while adding the advantages of avoiding a surgical procedure. The endovascular arteriovenous fistula can be created safely, functions well, has excellent patency, and has a high degree of patient satisfaction. The purpose of this study is to report the 2-year cumulative patency rate for a large multicenter cohort of endovascular arteriovenous fistula cases. DESIGN: An endovascular arteriovenous fistula was created in 105 patients using either local or regional anesthesia and conscious sedation. Patient data were obtained from each program's electronic health record system. Data collection was truncated at 2 years postprocedure and used to calculate cumulative patency. Post-access creation patient satisfaction was assessed. RESULTS: A physiologically mature arteriovenous fistula (blood flow ⩾500 mL/min and a target vein internal diameter ⩾4 mm) was obtained in 98%. A clinically functional arteriovenous fistula (supporting two-needle dialysis according to the patient's dialysis prescription) was demonstrated in 95%. Access failure resulting in the loss of access occurred in eight cases during the study period. The cumulative patency rate at 6, 12, 18, and 24 months was 97.1%, 93.9%, 93.9%, and 92.7%, respectively. The post-procedure patient evaluation emphasized a high level of patient satisfaction. CONCLUSION: The proximal radial artery arteriovenous fistula created using an endovascular approach for the anastomosis is associated with excellent 2-year cumulative patency and is associated with a high level of patient satisfaction.

Early results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System.

OBJECTIVE: We reviewed our initial experience creating a percutaneous arteriovenous fistula (pAVF) using a thermal resistance anastomosis device with proximal radial artery inflow. METHODS: A retrospective review was conducted of all patients who underwent a pAVF creation procedure between May 2017 and October 2017. Primary end points of the study were technical success, patency by Doppler ultrasound examination or angiography, flow levels achieved, time to first use, and pAVF-related complications. RESULTS: A pAVF was attempted in 34 patients with technical success in 33 individuals (97%). Patency of the pAVF was 94%. Mean access flow was 946 mL/min (brachial artery measurement) at the latest follow-up visit (53-229 days; average, 141 days). At 6 weeks, all fistulas have been used or were ready for dialysis by clinical examination or ultrasound examination. Only one patient required superficialization of the upper arm cephalic vein by lipectomy. There were no adverse events related to the pAVF creation or use, nor was there need for further interventions. CONCLUSIONS: Successful pAVFs with proximal radial artery inflow were created with excellent initial results regarding technical success, patency, and safety. Advantages include avoidance of a surgical incision, short procedure times, good acceptance by patients, prompt access maturation, moderate flow, and low-pressure access, with possible reduction of risk for ischemic complications. Avoidance of vessel manipulation and side branch ligation might reduce risk of thrombosis and improve long-term patency and reduce need for further interventions. These early findings need to be confirmed in larger and longer follow-up studies.

Radial axial interosseous load (RAIL) test for essex lopresti type injuries.

BACKGROUND: When approaching radial head and neck fractures, the decision for ORIF, resection, or arthroplasty is often performed intraoperatively. Factors that contribute include ligamentous and bony stability, cartilage injury, mechanical alignment as well as patient factors. Recent data has suggested conventional methods may not be sufficiently sensitive in detecting Essex Lopresti injuries. Here we describe an intraoperative technique that could objectively assess proximal radio-ulnar stability with subsequent disruption of the ligamentous structures. METHODS: Eight cadaveric specimens were used to evaluate amount of radial proximal migration between three groups of forearms. After radial head resection, proximal migration of the radial shaft was measured in three distinct groups. Group A included intact forearms, Group B included forearms with resected interosseous membranes (IOM), and Group C included forearms with resected interosseous membranes and distal radioulnar joint (DRUJ) disruptions. RESULTS: As compared to group A, group B averaged 4 mm of proximal radial migration (p < 0.01), while Group C demonstrated >6 mm of migration (p < 0.01). CONCLUSION: In the setting of a non-repairable radial head, the RAIL test may provide a more objective means of assessing for Essex-Lopresti injuries.

The titanium elastic nail serves as an alternative treatment for adult proximal radial shaft fractures: a cohort study.

BACKGROUND: To investigate whether closed reduction and internal fixation (CRIF) with titanium elastic nails (TENs) is a viable alternative treatment in proximal radial fractures. METHODS: In Kaohsiung Veterans General Hospital, from November 2013 to April 2015, five adult male patients with forearm injuries (average age 43 years; range 35-64 years) were treated for proximal radial shaft fractures. CRIF with TENs for radial shaft fractures was performed in these five patients. Radiographs; range of motions; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Quick DASH) questionnaire; and time to union were evaluated in our study. RESULTS: Mean follow-up period was 30 months (range 28-36 months). Average time of radius union was 7.3 months (range 6-10 months). Functional outcomes 1 year after operation revealed an average Quick DASH score of 7.92 (range 4.5-25), an average VAS of 1.5 (range 1-3), and average forearm supination and pronation of 69.2° (range 45°-75°) and 82.5° (range 80°-85°). No major complication was noted. CONCLUSIONS: CRIF with TEN for adult proximal radial fractures is a method to avoid extensive exposure or nerve injury during ORIF, especially in multiple trauma patients who require short operative time, uremia patients with ipsilateral forearm AV shunt, severe soft tissue swelling due to direct muscle contusion or strong muscularity before surgery, extensive radial fracture, and those in pursuit of cosmetic outcomes.