Clinical Outcomes of Transradial vs Nontransradial Aortoiliac Endovascular Therapy.

BACKGROUND: The introduction of radial-specific equipment has made transradial (TR) aortoiliac (AI) endovascular therapy (EVT) more convenient. OBJECTIVES: The authors aimed to investigate the perioperative outcomes of the TR approach in patients undergoing AI EVT for symptomatic peripheral artery disease. METHODS: The COMFORT (Contemporary Strategy for Aortoiliac Intervention) registry was a prospective, multicenter, observational study enrolling patients with symptomatic peripheral artery disease undergoing AI EVT between January 2021 and June 2023. The primary outcome was perioperative complications, whereas the secondary outcomes included core laboratory-evaluated residual stenosis >30%, time to hemostasis, time to ambulation, 30-day patency, and 30-day limb symptoms. These outcomes were compared between TR and non-TR AI EVT after propensity score matching. RESULTS: The TR approach was selected for 231 of the 947 patients (24.3%). The TR approach was chosen more in patients with a higher ankle-brachial index, chronic total occlusion, aortic lesion, bare nitinol stent implantation, and plain angioplasty, whereas it was chosen less in patients with dialysis, a history of AI EVT, chronic limb-threatening ischemia, bilateral calcification, and simultaneous infrainguinal EVT (all P < 0.05). After propensity score matching, the incidence of perioperative complications did not differ significantly between the groups (TR group: 6.0% vs non-TR group: 5.1%; P = 0.69). The proportions of residual stenosis, 30-day patency, and 30-day limb symptoms were not significantly different (all P > 0.05); however, the time to hemostasis and the time to ambulation were shorter in the TR group (both P < 0.05). CONCLUSIONS: Non-TR AI EVT and TR AI EVT using radial-specific equipment were associated with a similar risk of perioperative complications. The TR approach helps shorten the time required for hemostasis and ambulation.

Computational model-based hemodynamic comparisons of traditional and modified idealized models of autologous radiocephalic fistula.

Autologous arteriovenous fistula (AVF) is a commonly used vascular access (VA) for hemodialysis, and hemodynamic changes are one of the main factors for its failure. To explore the effect of geometry on the hemodynamics in the AVF, a modified model is built with a gradual and smooth turn at the anastomosis and is compared with the traditional model, which has an abrupt sharp turn at the anastomisis. Transient computational fluid dynamics (CFD) simulations were performed for the comparison and analysis of the hemodynamic fields of the two models at different stages of the pulse cycle. The results showed that the low shear stress region and high oscillatory shear stress region in the modified AVF model coincided with regions of intimal hyperplasia that have been identified by previous studies. A comparison with the blood flow velocities measured in vivo was performed, and the error between the simulation results and the medical data was reduced by 22% in the modified model, which verifies the rationality and utility of the modified model.

Graft Patency and Clinical Outcomes in Patients With Radial Artery Grafts Previously Instrumented for Cardiac Catheterization.

BACKGROUND: While transradial access is favored for cardiac catheterization, the radial artery (RA) is increasingly preferred for coronary artery bypass grafting. Whether the RA is suitable for use as a graft following instrumentation for transradial access remains uncertain. METHODS: Consecutive patients from 2015 to 2019 who underwent coronary artery bypass grafting using both the left and right RAs as grafts were included. Instrumented RAs underwent careful preoperative assessment for suitability. The clinical analysis was stratified by whether patients received an instrumented RA graft (instrumented versus noninstrumented groups). Eligible patients with both instrumented and noninstrumented RAs underwent computed tomography coronary angiography to evaluate graft patency. The primary outcome was a within-patient paired analysis of graft patency comparing instrumented to noninstrumented RA grafts. RESULTS: Of the 1123 patients who underwent coronary artery bypass grafting, 294 had both the left and right RAs used as grafts and were included. There were 126 and 168 patients in the instrumented and noninstrumented groups, respectively. Baseline characteristics and perioperative outcomes were comparable. The rate of major adverse cardiac events at 2 years following coronary artery bypass grafting was 2.4% in the instrumented group and 5.4% in the noninstrumented group (hazard ratio, 0.44 [95% CI, 0.12-1.61]; P=0.19). There were 50 patients included in the graft patency analysis. At a median follow-up of 4.3 (interquartile range, 3.7-4.5) years, 40/50 (80%) instrumented and 41/50 (82%) noninstrumented grafts were patent (odds ratio, 0.86 [95% CI, 0.29-2.52]; P>0.99). No significant differences were observed in the luminal diameter or cross-sectional area of the instrumented and noninstrumented RA grafts. CONCLUSIONS: There was no evidence found in this study that RA graft patency was affected by prior transradial access, and the use of an instrumented RA was not associated with worse outcomes in the exploratory clinical analysis. Although conduits must be carefully selected, prior transradial access should not be considered an absolute contraindication to the use of the RA as a bypass graft. REGISTRATION: URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12621000257864.

The importance of ankel-brachial index in prediction vascular complications in transradial access procedures.

OBJECTIVE: The study aimed to explore the predictors of vascular complications (VCs) associated with transradial access, as the occurrence and severity of these complications were found to be significantly lower compared to femoral access. However, it is important to note that the occurrence of these complications still has a negative impact on clinical outcomes. Nevertheless, there is limited available data on the predictors of complications specifically related to radial access. METHODS: A retrospective case-control study was conducted on individuals who underwent percutaneous coronary diagnostic or therapeutic procedures at Daping Hospital, following the inclusion and exclusion criteria. The study compared demographic characteristics, VC types, ankle brachial index (ABI), and severity of coronary artery stenosis between the two groups. RESULTS: We enrolled 300 subjects with VCs and 300 age- and sex-matched subjects without VCs as controls. There were no differences in the baseline characteristics or comorbidities between the groups. Compared to the control group, the VC group has a higher portion of left radial access (6.0%) and previous radial artery puncture history (29.7% vs. 18.3%, p<0.001). The ABI was significantly lower than the non-VC group (1.17 ± 0.17 vs. 1.23 ± 0.14, p<0.001). In the multivariate logistic regression analysis, several factors were found to be independently associated with the occurrence of VC. These factors include ABI (OR=0.060, 95% CI: 0.014-0.249, p<0.001), the procedure being performed by junior operators (OR=1.892, 95% CI: 1.314-2.745, p<0.001), and previous access on the same radial artery (OR=1.795, 95% CI: 1.190-2.707, p<0.01). CONCLUSIONS: Patients who exhibit a lower ABI and have a history of prior radial access procedures may be at an increased risk of developing radial access VC. Therefore, it is recommended to routinely measure ABI prior to these procedures, as it may serve as a predictive tool for assessing the risk of VC.

Distal Forearm Arteriovenous Fistula Maturation in Diabetic Hemodialysis Patients.

PURPOSE: Atherosclerotic disease of the forearm arteries can impede the maturation of distal fistulas in diabetic patients. The goal of this study was to look at the maturity of diabetic hemodialysis patients' distal forearm (radiocephalic snuffbox or distal forearm) arteriovenous fistulas. MATERIALS AND METHODS: Patients with chronic renal failure who were candidates for distal forearm radiocephalic arteriovenous fistula implantation were evaluated in this cross-sectional study. Patients' demographic details, underlying disorders, laboratory measurements, vital signs, and information on their surgery were all noted. Patients were checked for fistula development 1 week, 1 month, 2 months, and then monthly until 6 months after surgery. Arteriovenous fistula maturation characterized by optimal blood flow, vessel dilation, and structural adaptations. RESULTS: Among 343 patients (56% male, 44% female, mean age: 57.32 ± 12.48 years), hypertension prevailed (81.9%), followed by hyperlipidemia (42.3%) and coronary artery disease history (25.9%). AVFs achieved 58.3% maturation in 64.98 ± 11.05 days; higher BP during creation correlated with successful maturation (17.02 ± 1.46 mmHg vs 13.90 ± 1.93 mmHg, P < .05). No significant statistical difference found in distal forearm arteriovenous fistula maturation between males (57.8%) and females (58.9%) (P > .005). However, 41.7% of AVFs failed in 18.83 ± 17.89 days. Failed AVFs exhibited lower BP during operation and failure (11.75 ± 1.86 mmHg). Kaplan-Meier analysis depicted maturation probabilities over 90 days post-surgery. CONCLUSION: Diabetes and patient sex did not affect the maturation time of distal forearm AVFs in hemodialysis patients. Increased blood pressure during and after surgery correlated with shorter maturation time.

Intraoperative transit time flow measurement predicts maturation of radiocephalic arteriovenous fistulas.

OBJECTIVE: The arteriovenous fistula (AVF) is the first choice for gaining vascular access for hemodialysis. However, 20% to 50% of AVFs fail within 4 months after creation. Although demographic risk factors have been described, there is little evidence on the intraoperative predictors of AVF maturation failure. The aim of this study was to assess the predictive value of intraoperative transit time flow measurements (TTFMs) on AVF maturation failure. METHODS: In this retrospective cohort study, intraoperative blood flow, measured using TTFM, was compared with AVF maturation after 6 weeks in 55 patients. Owing to its significantly higher prevalence and risk of nonmaturation, the radiocephalic AVF (RCAVF) was the main focus of this study. A recommended cutoff point for high vs low intraoperative blood flow was determined for RCAVFs, using a receiver operating characteristic curve. RESULTS: The average intraoperative blood flow in RCAVFs was 156 mL/min. Patients with an intraoperative blood flow equal or lower than the determined cutoff point of 160 mL/min, showed a 3.03 times increased risk of AVF maturation failure after 6 weeks, compared with patients with a higher intraoperative blood flow (P < .001). CONCLUSIONS: The intraoperative blood flow in RCAVFs measured by TTFM provides an adequate means of predicting AVF nonmaturation 6 weeks after surgery. For RCAVFs, a cutoff point for intraoperative blood flow of 160 mL/min is recommended for maximum sensitivity and specificity to predict AVF maturation failure after 6 weeks.

Discrimination of vascular aging using the arterial pulse spectrum and machine-learning analysis.

Aging contributes to the progression of vascular dysfunction and is a major nonreversible risk factor for cardiovascular disease. The aim of this study was to determine the effectiveness of using arterial pulse-wave measurements, frequency-domain pulse analysis, and machine-learning analysis in distinguishing vascular aging. Radial pulse signals were measured noninvasively for 3 min in 280 subjects aged 40-80 years. The cardio-ankle vascular index (CAVI) was used to evaluate the arterial stiffness of the subjects. Forty frequency-domain pulse indices were used as features, comprising amplitude proportion (Cn), coefficient of variation of Cn, phase angle (Pn), and standard deviation of Pn (n = 1-10). Multilayer perceptron and random forest with supervised learning were used to classify the data. The detected differences were more prominent in the subjects aged 40-50 years. Several indices differed significantly between the non-vascular-aging group (aged 40-50 years; CAVI <9) and the vascular-aging group (aged 70-80 years). Fivefold cross-validation revealed an excellent ability to discriminate the two groups (the accuracy was >80%, and the AUC was >0.8). For subjects aged 50-60 and 60-70 years, the detection accuracies of the two trained algorithms were around 80%, with AUCs of >0.73 for both, which indicated acceptable discrimination. The present method of frequency-domain analysis may improve the index reliability for further machine-learning analyses of the pulse waveform. The present noninvasive and objective methodology may be meaningful for developing a wearable-device system to reduce the threat of vascular dysfunction induced by vascular aging.

Long-term results of ulnar and radial reconstruction with interpositional grafting using the deep inferior epigastric artery for chronic hand ischemia.

Chronic hand ischemia causes cold intolerance, intractable pain, and digital ulceration. If ischemic symptoms persist despite pharmacologic treatments, surgical interventions should be considered. This retrospective study evaluated the long-term results after ulnar and radial reconstruction using an interpositional deep inferior epigastric artery (DIEA) graft combined with periarterial sympathectomy. Patients who underwent this surgery from March 2003 to February 2019 were included. To evaluate variables influencing recurrence after the procedure, patients were divided into the recurred and non-recurred groups and their data were compared. Overall, 62 cases involving 47 patients were analyzed (16 and 46 cases in the recurred and non-recurred groups, respectively). The median DIEA graft length was 8.5 cm. The rates of rheumatic disease and female patients were significantly higher in the recurred than in the non-recurred group, without significant between-group differences in postoperative complication rates. In the multivariate analysis, underlying rheumatic disease and graft length had significant effects on recurrence. In Kaplan-Meier analysis, the 5- and 10-year symptom-free rates were 81.3% and 68.0%, respectively, with lower rates for cases with rheumatic disease. Thus, arterial reconstruction using an interpositional DIEA graft provides long-term sustainable vascular supply in patients with chronic hand ischemia, especially in those without rheumatic disease.

Determination of aortic pulse transit time based on waveform decomposition of radial pressure wave.

Carotid-femoral pulse transit time (cfPTT) is a widely accepted measure of central arterial stiffness. The cfPTT is commonly calculated from two synchronized pressure waves. However, measurement of synchronized pressure waves is technically challenging. In this paper, a method of decomposing the radial pressure wave is proposed for estimating cfPTT. From the radial pressure wave alone, the pressure wave can be decomposed into forward and backward waves by fitting a double triangular flow wave. The first zero point of the second derivative of the radial pressure wave and the peak of the dicrotic segment of radial pressure wave are used as the peaks of the fitted double triangular flow wave. The correlation coefficient between the measured wave and the estimated forward and backward waves based on the decomposition of the radial pressure wave was 0.98 and 0.75, respectively. Then from the backward wave, cfPTT can be estimated. Because it has been verified that the time lag estimation based on of backward wave has strong correlation with the measured cfPTT. The corresponding regression function between the time lag estimation of backward wave and measured cfPTT is y = 0.96x + 5.50 (r = 0.77; p < 0.001). The estimated cfPTT using radial pressure wave decomposition based on the proposed double triangular flow wave is more accurate and convenient than the decomposition of the aortic pressure wave based on the triangular flow wave. The significance of this study is that arterial stiffness can be directly estimated from a noninvasively measured radial pressure wave.

Comparison of one-year patency rates of end-to-side and side-to-side anastomosis technique in proximal forearm region radial-cephalic fistulas.

OBJECTIVES: In this study, the effects of anastomosis techniques on the results of patients with autogenous radial-cephalic proximal forearm fistula were investigated. METHODS: Patients who underwent radial-cephalic proximal forearm fistula surgery (arteriovenous fistula) between April 2015 and August 2017 at the Department of Cardiovascular Surgery of Ordu University were compared retrospectively in terms of the results of anastomosis techniques. The study included 131 patients who had arteriovenous fistulas created by side-to-side and end-to-side anastomosis technique. RESULTS: There was no significant difference in demographic data, comorbidities, radial artery, and cephalic vein diameters in patients undergoing radial-cephalic proximal forearm fistula surgery. However, it was observed that fistula maturation was earlier in the group with end-to-side anastomosis technique, and the one-year patency rates were higher in the group with side-to-side anastomosis technique. CONCLUSION: In Arteriovenous fistulas created in the proximal forearm region, the one-year patency rate of the side-to-side anastomosis technique was higher, while the maturation of the end-to-side technique observed earlier.

Blood flow changes in the forearm arteries after ultrasound-guided costoclavicular brachial plexus blocks: a prospective observational study.

BACKGROUND: An increase in blood flow in the forearm arteries has been reported after brachial plexus block (BPB). However, few studies have quantitatively analysed the blood flow of the forearm arteries after BPB or have studied only partial haemodynamic parameters. The purpose of the present study was to comprehensively assess blood flow changes in the distal radial artery (RA) and ulnar artery (UA) after BPB performed via a new costoclavicular space (CCS) approach using colour Doppler ultrasound. METHODS: Thirty patients who underwent amputated finger replantation and received ultrasound-guided costoclavicular BPB were included in the study. The haemodynamic parameters of the RA and UA were recorded before the block and 10 min, 20 min, and 30 min after the block using colour Doppler ultrasound to determine the peak systolic velocity (PSV), end-diastolic velocity (EDV), mean velocity (Vmean), pulsatility index (PI), resistance index (RI) and area. The volumetric flow rate (VFR) was calculated using the formula Q = area×Vmean. The aforementioned parameters were compared not only before and after the BPB but also between the RA and UA. RESULTS: Compared with those of the respective baselines, there was a significant increase in the PSV, EDV, Vmean, area, and VFR and a significant decrease in the PI and RI of the RA and UA 10 min, 20 min, and 30 min post-block. The increase 30 min post-block in EDV (258.68 % in the RA, 279.63 % in the UA) was the most notable, followed by that in the Vmean (183.36 % in the RA, 235.24 % in the UA), and the PSV (139.11 % in the RA, 153.15 % in the UA) changed minimally. The Vmean and VFR of the RA were significantly greater than those of the UA before the BPB; however, there was no significant difference in the VFR between the RA and UA after the BPB. CONCLUSIONS: A costoclavicular BPB can increase blood flow in the forearm arteries. The RA had a higher volumetric flow rate than the UA before the BPB; however, the potential blood supply capacity of the UA was similar to that of the RA after a BPB. TRIAL REGISTRATION: This study was registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/searchproj.aspx, clinical trial number: ChiCTR 1900023796, date of registration: June 12, 2019).

Monitoring the Patient Following Radio-Cephalic Arteriovenous Fistula Creation: Current Perspectives.

Autogenous radial-cephalic direct wrist arteriovenous fistula (RC-AVF) in the non-dominant arm is the gold standard for dialysis vascular access. However, the RC-AVF non-maturation rate is significant (≃ 40%) due to an increasingly elderly and comorbid population incidence. A detailed identification of the biological cascade underlying arteriovenous fistula (AVF) maturation could be the key to clinical research aimed at identify the group of patients at risk of primary AVF failure. Currently, careful post-operative monitoring remains the most crucial aspect to overcome the problem of impaired maturation. Up to 80% of patients with immature RC-AVF have problems potentially solvable with early endovascular or surgical correction. Physical examination by experienced practitioners in conjunction with duplex ultrasound examination (DUS) can identify physical signs of non-maturation, understand the underlying cause, and drive for a tailored early planning to treat the complication. New approaches for the early assessment of AVF maturation are under study. Techniques to promote RC-AVF maturation performed through the administration of pre-or peri-operative drugs have missed up to now to prove an efficacy in improving fistula success. The new techniques tested after surgery appear to hold future promise for improving fistula maturation.

The Use of Radial Artery for CABG: An Update.

We used the radial artery as a second target conduit for coronary artery bypass grafting since 1971. However, randomized clinical studies have demonstrated differences in clinical outcomes between the radial artery and other grafts because these trials are underpowered. As we proceed toward 50 years of experience with radial artery grafting, we examined the literature to define the best second-best target vessel for coronary artery bypass grafting. The literature was reviewed with emphasis, and a large number of randomized controlled trials, propensity-matched observational series, and meta-analyses were identified with a large patient population who received arterial conduit and saphenous vein grafts. The radial artery has been shown to be effective and safe when used as a second target conduit for coronary artery bypass grafting. Results and patency rates were superior to those for saphenous vein grafting. It has also been shown that the radial artery is a safe and effective graft as a third conduit into the territory of the artery right coronary artery. However, there is little evidence based on a few comparable series limiting the use of the gastroepiploic artery. In its fifth decade of use, we can finally deduced that the aorto-to-coronary radial bypass graft is the conduit of choice for coronary operations after the left internal thoracic artery to the left anterior descending artery.

Classification of patients with Alzheimer's disease using the arterial pulse spectrum and a multilayer-perceptron analysis.

Cerebrovascular atherosclerosis has been identified as a prominent pathological feature of Alzheimer's disease (AD); the link between vessel pathology and AD risk may also extend to extracranial arteries. This study aimed to determine the effectiveness of using arterial pulse-wave measurements and multilayer perceptron (MLP) analysis in distinguishing between AD and control subjects. Radial blood pressure waveform (BPW) and finger photoplethysmography signals were measured noninvasively for 3 min in 87 AD patients and 74 control subjects. The 5-layer MLP algorithm employed evaluated the following 40 harmonic pulse indices: amplitude proportion and its coefficient of variation, and phase angle and its standard deviation. The BPW indices differed significantly between the AD patients (6247 pulses) and control subjects (6626 pulses). Significant intergroup differences were found between mild, moderate, and severe AD (defined by Mini-Mental-State-Examination scores). The hold-out test results indicated an accuracy of 82.86%, a specificity of 92.31%, and a 0.83 AUC of ROC curve when using the MLP-based classification between AD and Control. The identified differences can be partly attributed to AD-induced changes in vascular elastic properties. The present findings may be meaningful in facilitating the development of a noninvasive, rapid, inexpensive, and objective method for detecting and monitoring the AD status.

Higher carotid-radial pulse wave velocity is associated with non-melancholic depressive symptoms in men - findings from Helsinki Birth Cohort Study.

BACKGROUND: Depression and cardiovascular disease (CVD) are major causes of global disease burden that are interrelated through mostly unknown mechanisms. We studied the relationship of melancholic and non-melancholic depressive symptoms with arterial stiffness, an important underlying mechanism of CVD. METHODS: The Helsinki Birth Cohort Study recruited 683 previously extensively phenotyped subjects for this sub-study. Cross-sectional data along with responses regarding depressive symptoms were obtained for each participant. For evaluation of depressive symptoms, the Beck Depression Inventory (BDI)and subscales were used to measure melancholic and non-melancholic depressive symptoms. Arterial stiffness was assessed as pulse wave velocity (PWV) that was measured between the carotid and radial artery, and carotid and femoral artery. RESULTS: Of the participants, 532 scored <10 on the BDI and were classified as not having depressive symptoms. Of the 151 participants that scored ≥10 on the BDI, 122 were classified as having non-melancholic depressive symptoms and 29 as having melancholic depressive symptoms. Men had higher carotid-radial PWV (crPWV) values than women (p < .001). A positive relationship between BDI scores and crPWV (p < .001) was found in men. We also found higher crPWV in men with non-melancholic depressive symptoms compared to all others. No such differences were found in women. DISCUSSION: Arterial stiffness has a relationship with depressive symptoms and subtypes of depressive symptoms, at least in men. There is a significant relationship between higher PWV and non-melancholic depressive symptoms in men. Due to the intricate nature of the disease causality or directionality is impossible to infer solely based on this study. Further studies into the subtypes of depressive symptoms may be of benefit to understanding depression.KEY MESSAGESIt is known that arterial stiffness contributes to cardiovascular disease, and is associated with depression.Higher Beck Depression Inventory scores are associated with higher carotid-radial pulse wave velocity in men.Non-melancholic depressive symptoms are associated with higher carotid-radial pulse wave velocity in men.

Accuracy of noninvasive continuous arterial pressure monitoring using ClearSight during one-lung ventilation.

ABSTRACT: Noninvasive continuous arterial pressure monitoring may be clinically useful in patients who require continuous blood pressure monitoring in situations where arterial catheter placement is limited. Many previous studies on the accuracy of the noninvasive continuous blood pressure monitoring method reported various results. However, there is no research on the effectiveness of noninvasive arterial pressure monitoring during one-lung ventilation. The purpose of this study was to compare arterial blood pressure obtained through invasive method and noninvasive method by using ClearSight during one-lung ventilation.In this retrospective observational study, a total of 26 patients undergoing one-lung ventilation for thoracic surgery at a single institution between March and July 2019 were recruited. All patients in this study were cannulated on their radial artery to measure continuously invasive blood pressures and applied ClearSight on the ipsilateral side of the cannulated arm. We compared and analyzed the agreement and trendability of blood pressure recorded with invasive and noninvasive methods during one-lung ventilation.Blood pressure and pulse rate showed a narrower limit of agreement with a percentage error value of around 30%. In addition, the tracking ability of each measurement could be determined by the concordance rate, all of which were below acceptable limits (92%).In noninvasive arterial blood pressure monitoring using ClearSight, mean blood pressure and pulse rate show acceptable agreement with the invasive method.

Contemporary outcomes of a "snuffbox first" hemodialysis access approach in the United States.

OBJECTIVE: The Society for Vascular Surgery guidelines for permanent hemodialysis (HD) access creation recommend prioritizing the most distal possible autogenous access to minimize complications and preserve more proximal options. The "snuffbox" arteriovenous fistula (AVF) is the most distal radial artery-cephalic vein AVF. Despite the theoretical benefits of the snuffbox approach, recent trends have been toward upper arm access. Our study sought to investigate the feasibility of a snuffbox-first strategy for HD access in all anatomically appropriate candidates. METHODS: From January 2016 to August 2019, all patients with end-stage renal disease (ESRD) or pre-ESRD under consideration for HD access were evaluated for a snuffbox-first approach by a team of vascular surgeons and nephrologists at a single, urban academic medical center in the United States. Data were collected prospectively and supplemented by medical record review. A survival analysis was performed to evaluate primary unassisted and secondary patency and clinical and functional maturation. Patients were censored if they had received a kidney transplant or had died. Cox proportional hazards regression was used to determine the risk factors for prolonged clinical maturation and functional maturation. RESULTS: A total of 55 snuffbox AVFs were created. The median patient age was 60 years (interquartile range [IQR], 52-70 years), and 52.7% of the patients were men. The median follow-up was 369 days (IQR, 166-509 days). The median survival for primary unassisted patency was 90 days (95% confidence interval [CI], 79-111). Secondary patency at 1 year was 92.3% (95% CI, 85.3%-99.9%). The clinical maturation rate at 1 year was 83.7% (n = 55; 95% CI, 66.8%-91.9%), and the functional maturation rate at 1 year was 85.6% (n = 40; 95% CI, 63.3%-94.4%). Of the patients who were pre-ESRD at AVF creation and had initiated HD during the study period, 87.5% had successfully received incident HD with their snuffbox AVF. Twenty-four patients were receiving HD via a catheter at snuffbox creation. Of those patients, the functional maturation rate at 1 year was 82.5% (95% CI, 44.8%-94.4%). The patients had undergone a median of two interventions (IQR, zero to seven interventions) in the first year. Of these, 46.9% were percutaneous angioplasty and 31.2% were side-branch ligation. Diabetes was associated with slower AVF clinical maturation (multivariate hazard ratio, 0.35; 95% CI, 0.15-0.82; P = .016). A larger artery diameter was associated with earlier AVF clinical maturation (multivariate hazard ratio, 6.64; 95% CI, 2.11-20.9). CONCLUSIONS: A snuffbox-first approach to HD access is a viable option for distal access creation in a cohort of patients requiring HD in the United States. Subsequent ancillary interventions to facilitate access maturation were required for most patients.

Coronary Collateral Flow Index Is Correlated With the Palmar Collateral Flow Index: Indicating Systemic Collateral Coherence in Individual Patients-Brief Report.

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