Experiences of Participation in a Study Investigating Feasibility of the Implantable Doppler Probe in Kidney Transplantation: An Embedded Qualitative Study.

OBJECTIVES: Kidney transplant survival can be improved with better graft surveillance postoperatively. In the quest to explore new technologies, we explored the feasibility of an implantable Doppler probe as a blood flow monitoring device in kidney transplant patients. This qualitative study was embeddedin a feasibility trial and aimed to test the device's clinical acceptability and obtain suggestions for the development of the intervention. Objectives included exploring the experiences of feasibility study participants and identifying barriers to the implementation of implantable Doppler probes in clinical practice. MATERIALS AND METHODS: We conducted semi-structured interviews containing open-ended questions with 12 feasibility study participants recruited by purposive sampling. All interviews were audio-recorded with verbatim transcription. Thematic data analysis was performed at the latent level by using an inductive approach with a previously published 6-phase guide. RESULTS: Three key themes emerged: (1) perceived value of the intervention in clinical practice, (2) challenges and barriers to implementation of the intervention, and (3) suggestions forthe development of the intervention. Due to functional limitations and lack of research, medical professional participants revealed clinical equipoise regarding the utility of implantable Doppler probes. However,the device was well received by patient participants. Challenges included device training needs for medical professionals and educational sessions for patients. Innovative ideas for development included the insertion of a display screen, adopting disposable units to reduce overall cost, online access allowing remote monitoring, decreasing external monitoring unit size, and integrating a wireless connection with the probe to reduce signal errors and increase patient safety. CONCLUSIONS: The clinical need for blood flow sensing technology in kidney transplants has been widely acknowledged. Implantable Doppler probes may be a beneficial adjunct in the early postoperative surveillance of kidney transplant patients. However, the device's technical limitations are the main challenges to its acceptance in clinical practice.

Are Signals from Implantable Doppler Probes Always Accurate for Prediction of Blood Flow in Kidney Transplant?

Vascular anastomotic occlusion has a catastrophic outcome in kidney transplant. The implantable Doppler probe is a blood-flow monitoring device that provides real-time information and direct assessment of anastomotic patency. We present the case of a complex kidney transplant recipient who was postoperatively monitored with an implantable Doppler probe attached to the renal artery. The patient showed clinical deterioration despite a continuous trace of Doppler signals. An urgent color duplex scan confirmed renal vein thrombosis. Interestingly,the Doppler signals persisted during the surgical exploration, which revealed a grossly discolored and congested graft with renal vein thrombosis. The persistent Doppler signals were caused by the back-and-forth blood flow in the renal artery due to the blood pressure shifts during the cardiac cycle against the high intrarenal resistance of the thrombosed graft. Therefore, the signals of implantable Doppler probes should be interpreted alongside the traditional clinical assessment techniques to ensure safe and effective postoperative monitoring. This information will inform the clinical practice in kidney transplant surgery.

The Use of the Implantable Doppler Probe as a Blood Flow Monitoring Device in Clinical Settings: A Narrative Review of the Evidence.

OBJECTIVES: In the past decade, the implantable Doppler probe has been studied widely as a blood flow-monitoring device in reconstructive and transplant surgical specialities. Its utility as an effective postoperative monitoring technique is still debatable, with no clear guidelines in clinical practice. Here, we mapped the current evidence on the usefulness of the implantable Doppler probe as a blood flow-monitoring device. The objective was to present an up-to-date assessment of the benefits and limitations of using implantable Doppler probes in clinical and experimental clinical settings. MATERIALS AND METHODS: We conducted a literature search using the Cochrane Library and Healthcare Databases Advanced Search and using implantable Doppler probe, transplant, graft, and flap as key words. The search yielded 184 studies, with 73 studies included after exclusions. We evaluated, synthesized, and summarized the evidence from the studies in tabular form. RESULTS: There is clinical equipoise regarding the effectiveness of implantable Doppler probe as a flow sensing technique. The main reason is the lack of information and gaps in the evidence regarding the benefits and limitations of using implantable Doppler probes in clinical practice. CONCLUSIONS: The implantable Doppler probe has the potentialto be used as an adjunctpostoperativeblood flow-monitoring device. However, keeping in view of technical limitations, its signals should be interpreted alongside traditional clinical assessment techniques to determine the patency of microvascular anastomosis. Although evidence in this review will inform clinical practice in transplant and reconstructive surgical specialties, a prospective randomized controlled study with a larger patient cohort is required to evaluate the effectiveness of this probe in clinical settings.

A Study Protocol Exploring the Role of an Implantable Doppler Probe in Kidney Transplantation: A Feasibility Randomized Controlled Trial with an Embedded Qualitative Study.

OBJECTIVES: Vascular complications in kidney transplant surgery constitute one-third of early graft loss, which can be prevented by timely diagnosis of vascular compromise. A blood flow monitoring device may have a beneficial role in the early identification of graft hypoperfusion critical to reducing graft loss. This research protocol aims to evaluate the potential of an implantable Doppler probe as a blood flow monitoring device in kidney transplant recipients. MATERIALS AND METHODS: The potential study will be a mixed methodology, 2-arm feasibility randomized controlled trial with an embedded qualitative study. For the trial, we will compare demographic characteristics and outcome measures of kidney transplant patients receiving implantable Doppler probe monitoring (intervention group, n = 30) with those having standard clinical care (control group). For the qualitative study, we will conduct semi-structured interviews with stakeholders (n = 12) recruited by purposive sampling to explore experiences of participants. All interviews will be audio recorded with verbatim transcription. RESULTS: Our results will use the summarized quantitative data and descriptive statistics to determine differences between the groups. We will use CONSORT guidelines to determine the suitability of the research processes, availability of research resources, and potential challenges faced during the feasibility randomized controlled trial. We will use thematic analysis and NVivo software to analyze the acceptability of the intervention in clinical practice. We will compile the results according to the consolidated criteria for reporting qualitative research checklist. CONCLUSIONS: The goal of this protocol is to determine the feasibility of an implantable Doppler probe monitoring device in kidney transplant recipients. The feasibility study will collect preliminary information, fill gaps in evidence, and test research processes for the pragmatic future randomized controlled trial. The template of this study is transferable to other transplant centers across the United Kingdom.

Exploring the Risk Factors and Preventable Measures for Early Graft Loss in Kidney Transplantation: A Single-Center Analysis in the Southwest of the United Kingdom.

OBJECTIVES: Early graft loss due to vascular complications occurs in 3.5% to 5.7% of total kidney transplants. Two strategies to improve kidney graft outcomes have been advocated: (1) meticulous attention to modifiable risk factors and (2) exploration of monitoring technologies that assist in the early detection of vascular complications critical to rescue of a compromised graft.This study aimed to assess risk factors and preventable measures for early graft loss in kidney transplant recipients from the Southwest of UK. MATERIALS AND METHODS: In this retrospective observational study, the demographic characteristics, comorbidities, and use of a postoperative blood flow monitoring device in 472 kidney transplant recipients at the Southwest Transplant Centre between January 2015 and March 2023 were analyzed individually against early graft loss. We conducted bivariate analyses using chi-square tests with a contingency table to identify whether recipient risk factors (demographic characteristics, comorbidities) or the use of an implantable blood flow monitoring device was significantly associated with early graft loss. RESULTS: Twelve transplant recipients (2.5%) had early graft loss due to vascular complications. The results revealed that recipient's smoking habit, the number of prior kidney transplants, and a history of thromboembolism displayed a statistically significant association with early graftloss. Conversely,the use of an implantable blood flow monitoring device in kidney transplant recipients did not display a statistically significant association with early graft loss. CONCLUSIONS: Meticulous attention given to controlling risk factors before kidney transplant can reduce early graft loss. Surveillance by clinical observation and serial radiological monitoring can be offered to patients at high risk with nonmodifiable risk factors. Further controlled studies are warranted to evaluate the implantable blood flow monitoring device in clinical practice.

Exploring the Role of an Implantable Doppler Probe as a Blood Flow-Monitoring Device in Kidney Transplant: A Feasibility Randomized Controlled Trial.

OBJECTIVES: Vascular thrombosis is a disastrous postoperative complication resulting in the loss of 3.5% to 5.7% of all kidney transplants. The use of blood flow-sensing technology in the early postoperative period may help in the early identification of vascular complications crucial to reducing graft loss. This study aimed to assess the feasibility of an implantable Doppler probe as a blood flow-monitoring device in kidney transplant recipients and to evaluate its usefulness in the prevention of early graft loss. MATERIALS AND METHODS: This 2-arm feasibility randomized controlled trial compared the demographic characteristics and surgical outcomes of kidney transplant recipients who received implantable Doppler probe monitoring (intervention group; n = 30) with those who had standard clinical care (control group; n = 30). Surgical outcomes compared between the groups included the number of early vascular complications identified,the number of departmental ultrasonography scans requested in the first 72 hours postoperatively, and month 3 graft loss. RESULTS: Both groups were similar in demographic characteristics. In the intervention group versus the control group, fewer ultrasonography scans were requested in the first 24 hours postoperatively (56% vs 91%) and lower graft loss (0% vs 6.6%) was recorded. The results addressed uncertainties around the feasibility study's research methods and required resources for a future pragmatic trial. CONCLUSIONS: An implantable Doppler probe may be a beneficial adjunct for graft monitoring after kidney transplants. This feasibility study provided the necessary preliminary information and filled initial gaps in the evidence that can inform future research. The prespecified progression criteria ofthe study were fulfilled. The study template used can be transferable to other transplant centers across theUnited Kingdom. A pragmatic large-scale randomized controlled trial is warranted to evaluate the effectiveness of implantable Doppler probes in clinical practice.

Iliofemoral Polytetrafluoroethylene Graft Interposition: A Rescue Procedure in External Iliac Artery Dissection to Restore Lower Limb Revascularization and Salvage Kidney Transplant.

External iliac artery dissection is a catastrophic complication during kidney transplant surgery. We present a technically challenging case of external iliac artery dissection that occurred in severely atherosclerotic vessels of a high-risk patient receiving his third kidney transplant. The intimal dissection constituted by the upstream application of a vascular clamp during the preparatory dissection ofthe vessels and progressed rapidly along the iliofemoral axis. The external iliac artery was severely diseased and in an irreparable condition, hence ligated and removed. After a common iliac endarterectomy, an iliofemoral polytetrafluoroethylene vascular graft interposition was performed. The transplant kidney was anastomosed directly on the vascular graft. Satisfactory lower limb vascularization and kidney transplant perfusion were achieved withouttechnical difficulties. The patient had an uneventful recovery without complications. The kidney transplant recipient retained stable graft function at 6 months postoperatively. This rare case highlights the benefit of a surgical strategy in a vascular emergency that threatens the lower limb during a kidney transplant, and we emphasize the technical details of the procedure. As patients with extended indications are accepted onto the transplant waiting list, it is important for transplant surgeons to acquire surgical skills of vascular graft interposition. A postoperative blood flow monitoring device may be beneficial in high-risk kidney transplant cases.

Exploring Views and Expectations of Clinicians, Nurses, and Kidney Transplant Recipients Regarding Protocol Development of a Study to Investigate Feasibility of the Implantable Doppler Probe in Kidney Transplantation: Patient-Public Involvement Consultations.

OBJECTIVES: The shortage of donor organs is the most limiting factor in kidney transplant practice today. New monitoring technologies are being investigated to reduce graft loss due to vascular complications. We assessed the feasibility of a novel blood flow monitoring device, the implantable Doppler probe, in kidney transplant surgery. This patient-public involvement consultation explored the views and expectations of the stakeholders (kidney transplant recipients, surgeons, clinicians, and nurses with direct experience of the implantable Doppler probe) on the protocol development of our feasibility study. Our objective was to improve the protocol, understand stakeholder perceptions regarding research in postoperative graft surveillance, and identify potential confounding factors to the research and challenges to implementation of implantable Doppler probe in clinical practice. MATERIALS AND METHODS: We conducted semi-structured interviews containing open-ended questions with 12 stakeholders. We performed thematic analysis of the data at the latent level by an inductive approach according to a 6-phase guide by Braun and Clarke using NVivo 12 software. RESULTS: Three key themes emerged. (1) Experiences with the implantable Doppler probe as a monitoring device showed that it was well received by the patients; however, there was a clinical equipoise among the health care professionals. (2) Recognition of the need for research in the early postoperative graft monitoring displayed stakeholder understanding regarding the role of a blood flow monitoring device to improve surgical outcomes. (3) Recommendations for smooth conduct of the proposed study include suggestions for improvement of the study protocol, informative sessions for the patients and nurses, and innovative ideas to improve the monitoring device. CONCLUSIONS: Patient-public involvement consultation was crucial for the research design of our proposed feasibility study. Useful strategies and a patient- centered approach were incorporated to mitigate the potential challenges to the conduct of the research.

Implantable Doppler Probe as a Vascular Monitoring Device in Kidney Transplant Patients: Investigation of Use at a Single Center.

OBJECTIVES: Vascular complications account for 30% to 35% of total kidney grafts lost during the first 3 months posttransplant. Early detection of vascular complications allows an opportunity for prompt intervention, which is critical to reducing graft loss. In this study, we evaluated the usefulness of an implantable Doppler probe as a vascular monitoring device in kidney transplant patients. MATERIALS AND METHODS: An implantable Doppler probe is used intermittently for postoperative monitoring of kidney transplant patients at our center. In this retrospective study, we analyzed prospectively maintained medical data in which we compared clinical outcomes of kidney transplant recipients who had postoperative implantable Doppler probe monitoring versus standard care clinical observation. Between January 2016 and October 2021, 324 kidney transplant patients were seen at our center. Patients were divided into 2 groups: group 1 (n = 194; 60%) included kidney transplant recipients with postoperative implantable Doppler probe monitoring and group 2 (n = 129; 40%) included kidney transplant recipients with standard care clinical observation. We compared number of vascular complications, number of departmental ultrasonographic scans required posttransplant, and graftloss at 3 months between the 2 groups. RESULTS: Vascular complications were identified in 13.5% of total patients, with graft loss identified in 2.1%. Both groups were similar in demographical characteristics. Group 1 had more vascular complications (17.5% vs 9.3%; relative risk = 1.88), fewer ultrasonographic scans during the first 24 hours posttransplant (71.1% vs 83.7%; relative risk = 0.84), and lower graft loss (1.5% vs 3.1%; relative risk = 0.48) than group 2. All probes were removed safely after 72 hours, and no complications related to the device were reported. CONCLUSIONS: The monitoring device may be used as an additional adjunct for graft monitoring in kidney transplant patients. Further controlled studies are warranted to evaluate this device in clinical practice.

Vascular access infections: epidemiology, diagnosis, and management.

Infection is the most challenging and life-threatening complication of vascular access and causes significant morbidity, loss of access, and mortality. The aims of this review are to determine the magnitude of the infection problem, identify possible factors, and provide an update on the management of vascular access infections. Infections account for approximately 15% to 36% of all deaths in dialysis patients (the second leading cause after cardiovascular events) and for about 20% of admissions. Several studies demonstrate a hierarchy of infection risk from temporary catheter, tunnelled cuffed catheter, arteriovenous grafts, to arteriovenous fistula in decreasing order. Suspicion of infection must be followed by appropriate blood cultures, including possible simultaneous sampling from a peripheral vein and the access. The best way to treat vascular access infection is prevention, bearing in mind the idea "fistula first" and "lines last", with the appropriate use of arteriovenous grafts and newer devices sandwiched in between.

Survey of Patient's Experience of Altruistic Nondirected Kidney Donation.

The scarcity of organs for donation is an ongoing issue. Change in legislative framework allows for altruistic donations in the UK, but, whereas the number of donations from deceased donors has increased, there has been a slow decline in altruistic living donors. The aim of this study was to review perspectives of altruistic nondirected kidney donors (ANDKD) at our center and outcome of all enquiries to inform service improvement and increase the numbers of donors. All enquiries by potential ANDKD at our center from September 2005 to September 2017 were analyzed. Donor assessment was performed as per the UK Guidelines, prior to obtaining Human Tissue Authority approval. The outcome of donation and results of questionnaires sent to 50 ANDKD were analyzed. During the period, 51 of the 180 enquiries (28.3%) resulted in kidney donation. Questionnaire responses were: 66% donors were retired; most heard about altruistic donation through media (60%); 72% thought psychological or psychiatric assessment was necessary; 95% found the information provided prior to donation adequate; 82% rated their overall experience as good/excellent; and 90% would recommend kidney donation to others. Thirteen of 50 donated kidneys were fed into the kidney exchange program. The mean ± standard error of the mean of the duration from human tissue authority approval to donation were 60.4 ± 5.4 and 131.2 ± 11.2 days, respectively (P = 0.00001). A significant proportion of enquiries for altruistic donation would result in donation but the assessment process needs to be quicker. ANDKD is useful way of priming the National Living Donor Kidney Sharing Scheme.

Living kidney donor assessment: Kidney length vs differential function.

BACKGROUND: The key question in living kidney donor assessment is how best to determine the contribution of each kidney to overall renal function and guide selection of which kidney to donate, ensuring safety of procedure and good outcome for both recipient and donor. It is thought that a length difference > 2 cm may indicate significant difference in function and therefore need for measurement of differential function. AIM: To determine the effect of using kidney length to decide which kidney to donate in a retrospective cohort of potential donors. METHODS: All 333 potential living kidney donors between January 2009 and August 2018 who completed assessment were retrospectively evaluated. Donor assessment was performed as per United Kingdom guidelines. Data included age, sex, kidney length (cranio-caudal) obtained by computed tomography/ultrasono-graphy,51-chromium ethylenediamine tetraacetatic acid measured glomerular filtration rate, mercapto acetyl tri glycine split function and vascular anatomy. There were 48 exclusions due to inadequate data or incomplete investigations. Statistical analysis was performed using Excel pivot tables and GraphPad Prism. Correlation between kidney length and differential function was determined with Pearson's correlation coefficient. RESULTS: Of 285 potential donors included in the study, there were 144 males (mean age 49.9 ± 14.75) and 141 females (mean age 51.2 ± 11.23). Overall, the Pearson's correlation between differences in length and divided function of kidney pairs was 0.1630, P = 0.0058. Of 73 with significant difference (> 10%) in divided function, 18 (24.7%) had no difference in kidney length; 54 (74%) had a difference of < 2 cm and only one of > 2 cm. Using a length difference of > 1 cm would only predict significant difference in divided function in 8/34 (23.5%) of cases. Using a difference of > 2 cm as cut off for performing split function would lead to false reassurance in 72 patients (6 had > 20% difference in divided function whereas 66 had 10%-20% difference). CONCLUSION: Length difference between kidney pairs alone is not sufficient to replace measurement of divided function. This issue requires a randomised controlled trial to resolve it.

Early results of a controlled non-heart-beating kidney donor programme.

BACKGROUND: We present our experience of a controlled non-heart beating donation (CNHBD) programme in a University Hospital. METHODS: Data from all referrals for CNHBD between January 2005 and January 2008 were collected prospectively. Donor and recipient data were analysed and compared to other cadaveric and HBD transplants performed during the same period. RESULTS: During the period, 79 donors were referred resulting in 35 proceeding to retrieval and 61 kidneys being successfully transplanted. The median time from withdrawal of therapy to asystole was 15 min (IQR 10.0-23.0). The median primary warm ischaemic time was 20 min (IQR 16.0-27.0). The mean cold ischaemia time was 16.6 +/- 4.21 h for CNHBD (16.6 +/- 5.91 for HBD) kidneys. Compared to HBD kidneys, CNHBD kidneys had more HLA mismatches and significantly more delayed graft function (44% versus 14%), and the mean time to halving of serum creatinine was significantly greater (12.8 versus 5 days). However, 1-year patient and graft survival (88% and 93%) were excellent and mean creatinine at 12 months for CNHB kidneys was not significantly different from HBD kidneys (141 mumol/l versus 131 mumol/l). CONCLUSIONS: Structured implementation resulted in a successful CNHBD programme providing 61 successful renal transplants from 35 donors in 3 years-contributing to approximately 50% of the total number of cadaveric renal transplants during the period. At 12 months, CNHBD kidney graft function was equivalent to HBD organs.

Management of patients with challenging vascular access needs.

The proportion of patients on dialysis with multiple access procedures, failed transplant(s), or no suitable sites for conventional arteriovenous (AV) fistula is increasing. We report on 4 patients at our institution requiring unusual measures to achieve vascular access for dialysis. All 4 patients had temporary femoral vein catheters for dialysis, but 3 had tunneled femoral catheters, with 1 patient using this modality of access for 28 months. One patient who had 13 vascular access procedures developed collateral circulation that was amenable to a new autogenous AV fistula. Two patients died of causes unrelated to vascular access, whereas 1 died from infection of an access device. In patients with challenging vascular access requirements, the use of simple procedures such as the insertion of a tunneled femoral catheter should be considered. A thorough assessment must be made before each new access procedure as collateral circulation may present new options.

Prosthetic arteriovenous grafts for hemodialysis.

INTRODUCTION: Prosthetic arteriovenous (AV) grafts are indicated in patients with failed AV fistula (AVF), exhausted superficial veins or unsuitable vessels. Increasing the proportion of prevalent hemodialysis (HD) patients using autogenous AVF should reduce the need for AV grafts and associated morbidity. This paper reviews the current role of prosthetic AV grafts in vascular access for HD. TECHNICAL CONSIDERATIONS: Prior to the insertion of a prosthetic AV graft, a comprehensive review of previous access procedures and full physical examination in addition to vessel mapping is required. Anastomotic technique should take into account the flow diffuser concept, graft geometry and an anastomotic angle of 15 degrees in order to reduce the incidence of intimal hyperplasia. RESULTS: Many authors report 1 and 2-yr cumulative graft patency rates of 59-90% and 50-82%, respectively. The major drawbacks with synthetic grafts include: thrombosis, a five-fold increase in infection risk and steal syndrome. The choice between surgical and percutaneous methods of dealing with blocked AV grafts remains controversial, though percutaneous techniques are assuming an increasingly important role. Percutaneous strategies are successful in declotting access in 67-95% of cases. Stenting of stenotic lesions following thrombectomy improves secondary patency rates. Strategies for dealing with AV graft infection include antibiotic prophylaxis, partial, subtotal or total graft excision and the use of biological prosthesis. CONCLUSIONS: Though more prone to complications than autogenous AVFs, AV grafts offer a short maturation period and are more amenable to thrombectomy by radiological or surgical means. Complex AV grafts may be appropriate in patients with exhausted access sites.

Morbidity Following Hand-Assisted Laparoscopic Donor Nephrectomy.

Background: The incidence of morbidity and readmission rate after hand-assisted laparoscopic donor nephrectomy (HALDN) is not clear. Aims: Our study aims to review our experience with HALDN, mainly the reasons for patient readmissions. Methods: Prospectively collected data on all patients undergoing HALDNs between August 2007 and June 2015 were retrieved. The primary outcome was 30-day readmission rate. Secondary outcomes were complications and readmission etiology. Results: There were 161 nephrectomies with a median age of 51 years, 72 (44.7%) men, and 114 (70.8%) left-sided operations. Twenty-one (13%) individuals were readmitted within 30 days. There were total 25 (15.5%) readmissions during the study period. The characteristics of patients readmitted and patients not readmitted were broadly similar. Nine of 21 (43%) individuals readmitted had nonspecific findings (nonspecific findings on imaging, negative blood cultures, and raised inflammatory markers). The reasons for readmission were unrelated to nephrectomy in 24% and 19% required surgery for complications unrelated to nephrectomy. Conclusion: We observed a high readmission rate after HALDN. A significant proportion of readmissions were due to nonspecific abdominal pain associated with raised inflammatory markers and no obvious source of sepsis. Living donors should be fully informed about the risks including the possibility of complications unrelated to HALDN.

Perforated appendicitis masquerading as acute pancreatitis in a morbidly obese patient.

Diagnosis and treatment of common conditions in morbidly obese patients still pose a challenge to physicians and surgeons. Sometimes too much reliance is put on investigations that can lead to a misdiagnosis. This case demonstrates an obese woman admitted under the medical team with a presumed diagnosis of pneumonia, who was later found to have an acute abdomen and raised amylase, which led to an assumed diagnosis of pancreatitis. She died within 24 h of admission and post mortem confirmed the cause of death as systemic sepsis due to perforated appendicitis, with no evidence of pancreatitis. Significantly elevated serum amylase level may occur in non-pancreatitic acute abdomen.

Adoption of transposed basilic vein as access for hemodialysis.

The fistula first initiative has rekindled interest in transposition of basilic vein (TBV) in preference to arteriovenous grafts (AVG). TBV is considered to have advantages over AVG. The aim of this study was to analyze the outcome of TBVs in our center comparing them to a historically matched group of patients who had AVG. Thirty-two patients who underwent TBV as a vascular access procedure in Derriford Hospital between January 2010 and October 2014 were included in the study. The historical control group comprised 31 patients who had AVG inserted in the upper arm between January 1999 and December 2010. Patients who had looped AVG were excluded from the study. The primary failure rates were 22% (7/32) and 16% (5/31) for TBV and AVG, respectively (P = 0.7500). AVGs were associated with a higher incidence of infection and steal syndrome, but the differences were not statistically significant (P = 0.286 and P = 0.286, respectively). Twenty-two interventions were undertaken in the TBV group compared to 18 in the AVG group. This study shows that adoption of TBV reduces the need for AVG. To improve TBV access maturation and survival, it is necessary to consider adopting a selection criteria based on findings on vessel mapping.

Strangulated diaphragmatic hernia presenting clinically as pericarditis.

A case of strangulation of the transverse colon in a traumatic left diaphragmatic hernia manifesting as pericarditis is reported. This is unusual because pericardial signs in traumatic diaphragmatic hernia have been previously described in association with direct pericardial injury. This is the only such case where electrocardiographic changes of pericarditis were seen without direct pericardial trauma. The possibility of internal herniation through a traumatic diaphragmatic hernia must be considered in patients with chest symptoms and a compatible history.