Risk factors for arteriovenous fistula dysfunction in hemodialysis patients: a retrospective study.

Arteriovenous fistula (AVF) is the first choice of vascular access in hemodialysis (HD) patients. However, the correlations between patient factors and the arteriovenous fistula patency remain unclear. Therefore, our study investigates the risk factors associated with AVF dysfunction in HD patients. A total of 233 end-stage renal disease (ESDR) patients who met the study inclusion criteria in the Nephrology Department of Hunan Provincial People's Hospital between December 2020 and June 2022 were included in this study. The baseline demographic, clinical and laboratory parameters were collected at the time of AVF creation and analyzed. Of the 233 ESRD patients, 146 (62.7%) were male and the mean age was 56.11 ± 12.14 (21-82) years. The patients were followed for a median time of 14 months. Kaplan-Meier analysis showed a 6-, 12- and 24-month post-placement survival of 87.1%, 82.8% and 80.7%, respectively. Univariate Cox regression analysis revealed weight (HR, 1.03; P = 0.03) as a predictor for the loss of vascular access functionality. In addition, multivariate Cox regression analysis further demonstrated that sex (HR, 3.41; P = 0.03), weight (HR 1.08; P < 0.01) and phosphorus level (HR: 3.03; P = 0.01) are independent risk factors for AVF dysfunction. AVF dysfunction is highly associated with several risk factors including weight, phosphorus level, and sex. Positive intervention strategies targeting these potential factors, such as weight loss or oral phosphate binders could improve the long-term success of AVF.

N-acetylcysteine treatment attenuates hemodialysis access-related limb pathophysiology in mice with chronic kidney disease.

The objective of the present study was to determine if treatment with N-acetylcysteine (NAC) could reduce access-related limb dysfunction in mice. Male and female C57BL6J mice were fed an adenine-supplemented diet to induce chronic kidney disease (CKD) prior to the surgical creation of an arteriovenous fistula (AVF) in the iliac vascular bundle. AVF creation significantly increased peak aortic and infrarenal vena cava blood flow velocities, but NAC treatment had no significant impact, indicating that fistula maturation was not impacted by NAC treatment. Hindlimb muscle and paw perfusion recovery and muscle capillary density in the AVF limb were unaffected by NAC treatment. However, NAC treatment significantly increased the mass of the tibialis anterior (P = 0.0120) and soleus (P = 0.0452) muscles post-AVF. There was a significant main effect of NAC treatment on hindlimb grip strength at postoperative day 12 (POD 12) (P = 0.0003), driven by significantly higher grip strength in both male (P = 0.0273) and female (P = 0.0031) mice treated with NAC. There was also a significant main effect of NAC treatment on the walking speed at postoperative day 12 (P = 0.0447), and post hoc testing revealed an improvement in NAC-treated male mice (P = 0.0091). The area of postsynaptic acetylcholine receptors (P = 0.0263) and motor endplates (P = 0.0240) was also increased by NAC treatment. Interestingly, hindlimb skeletal muscle mitochondrial oxidative phosphorylation trended higher in NAC-treated female mice but was not statistically significant (P = 0.0973). Muscle glutathione levels and redox status were not significantly impacted by NAC treatment in either sex. In summary, NAC treatment attenuated some aspects of neuromotor pathology in mice with chronic kidney disease following AVF creation.NEW & NOTEWORTHY Hemodialysis via autogenous arteriovenous fistula (AVF) is the preferred first-line modality for renal replacement therapy in patients with end-stage kidney disease. However, patients undergoing AVF surgery frequently experience a spectrum of hand disability symptoms postsurgery including weakness and neuromotor dysfunction. Unfortunately, no treatment is currently available to prevent or mitigate these symptoms. Here, we provide evidence that daily N-acetylcysteine supplementation can attenuate some aspects of limb neuromotor function in a preclinical mouse model of AVF.

The Effect of Acupressure and Cryotherapy on the Pain of Patients on Hemodialysis During Arteriovenous Fistula Cannulation: A Randomized Crossover Clinical Trial.

Various pharmacological and non-pharmacological measures are used to reduce pain of patients on hemodialysis during an arteriovenous fistula (AVF) cannulation. In this randomized, crossover clinical trial, 39 patients randomly received acupressure and cryotherapy. In cryotherapy, an ice cube was used to massage the Hegu point in the hand without the fistula for 10 minutes before AVF cannulation. In acupressure, a moderate pressure with the thumb was applied. The pain score was mild after cryotherapy and acupressure, with no significant difference between the two methods. In addition, acupressure significantly reduced pain compared with routine care, but cryotherapy did not significantly reduce pain compared with routine care. Pain intensity was mild after acupressure and cryotherapy, and neither of these two methods was preferred over the other to reduce the pain during AVF cannulation.

Evaluation of outcomes with permanent vascular access in an elderly Korean population based on the National Health Insurance Service database.

INTRODUCTION: As nearly half of patients with end-stage kidney disease (ESKD) who initiate hemodialysis (HD) are over 65 years old (commonly defined as elderly), the fistula first strategy is controversial even in HD patients ≥65 years. METHODS: In Korea's National Health Insurance Service database from 2008 to 2019, 41,989 elderly (≥ 65 years) HD patients were retrospectively reviewed to identify their clinical characteristics and outcomes. Vascular access (VA) patencies, risk factors associated with patencies and patient survival between arteriovenous fistula (AVF) and arteriovenous graft (AVG) were compared. RESULTS: Elderly AVF group (n = 28,467) had superior primary, primary assisted, and secondary patencies than elderly AVG group (n = 13,522) (all p values are <0.001). Patient survival was also better in the elderly AVF group than in the elderly AVG (p < 0.001). In multivariate Cox regression analyses for diverse outcomes, AVG (vs. AVF) was identified as a risk factor for all-cause mortality (adjusted hazard ratio [HR]: 1.307; 95% confidence interval [CI]: 1.272-1.343; p < 0.001), primary patency (adjusted HR: 1.745; 95% CI: 1.701-1.790; p < 0.001), primary-assisted patency (adjusted HR: 2.163; 95% CI: 2.095-2.233; p < 0.001), and secondary patency (adjusted HR: 3.718; 95% CI: 3.533-3.913; p < 0.001). CONCLUSION: Our study demonstrated that as a permanent VA for HD, AVF should be strongly considered in elderly (≥ 65 years) ESKD Korean patients. The age limit for AVF creation in ESKD patients should be adjusted more upward.

Metabolomic profiling reveals muscle metabolic changes following iliac arteriovenous fistula creation in mice.

End-stage kidney disease, the most advanced stage of chronic kidney disease (CKD), requires renal replacement therapy or kidney transplant to sustain life. To accomplish durable dialysis access, the creation of an arteriovenous fistula (AVF) has emerged as a preferred approach. Unfortunately, a significant proportion of patients that receive an AVF experience some form of hand dysfunction; however, the mechanisms underlying these side effects are not understood. In this study, we used nuclear magnetic resonance spectroscopy to investigate the muscle metabolome following iliac AVF placement in mice with CKD. To induce CKD, C57BL6J mice were fed an adenine-supplemented diet for 3 wk and then randomized to receive AVF or sham surgery. Two weeks following surgery, the quadriceps muscles were rapidly dissected and snap frozen for metabolite extraction and subsequent nuclear magnetic resonance analysis. Principal component analysis demonstrated clear separation between groups, confirming a unique metabolome in mice that received an AVF. AVF creation resulted in reduced levels of creatine, ATP, and AMP as well as increased levels of IMP and several tricarboxylic acid cycle metabolites suggesting profound energetic stress. Pearson correlation and multiple linear regression analyses identified several metabolites that were strongly linked to measures of limb function (grip strength, gait speed, and mitochondrial respiration). In summary, AVF creation generates a unique metabolome profile in the distal skeletal muscle indicative of an energetic crisis and myosteatosis.NEW & NOTEWORTHY Creation of an arteriovenous fistula (AVF) is the preferred approach for dialysis access, but some patients experience hand dysfunction after AVF creation. In this study, we provide a detailed metabolomic analysis of the limb muscle in a murine model of AVF. AVF creation resulted in metabolite changes associated with an energetic crisis and myosteatosis that associated with limb function.

Pain after Arteriovenous Access Creation.

OBJECTIVES: Dialysis access creation is a common outpatient procedure that can be completed using general, regional, or local anesthetic techniques. There are few endorsed guidelines regarding opioid-based pain control following fistula creation. The purpose of this study was to determine whether utilization of regional anesthesia (RA) is associated with the decreased use of narcotics postoperatively. METHODS: We performed a prospective cohort study including all patients undergoing arteriovenous fistula creation with one vascular surgeon from August 2019 to February 2020. Patients were selected for regional versus general anesthesia. Selection for anesthesia type was determined by the primary anesthesiologist. Patients selected for RA underwent supraclavicular brachial plexus block with 30 cm3 of 0.5% ropivacaine. Patients were seen in clinic follow-up and completed a questionnaire regarding their postoperative opiate use and pain control. RESULTS: In the study period, 52 patients underwent arteriovenous fistula creation and completed the follow-up questionnaire. Forty patients received RA. Seventy-five percent of patients sent home with a narcotic prescription filled the prescription. There was a significant difference in postoperative opioid use between the two study groups. Patients who received regional block took on average 3.3 pills totaling 16.5 morphine milligram equivalents, whereas patients who received general anesthesia took on average 6.64 pills totaling 33.2 morphine milligram equivalents (P = 0.04). CONCLUSIONS: Morbidity and mortality related to opiate use continues to be a public health issue in the United States. This study demonstrates that regional anesthetic techniques in comparison to general anesthesia can result in a significant decrease in postoperative opiate consumption.

Ultrasound-Guided Cradle-Like Infiltrative Anesthesia for Percutaneous Transluminal Angioplasty of Stenotic Autogenous Arteriovenous Hemodialysis Access.

BACKGROUND: Percutaneous transluminal angioplasty (PTA) is an effective treatment for autogenous arteriovenous hemodialysis access (AAVA) stenosis; however, it causes pain in most cases. Therefore, safe and effective anesthesia for PTA is required. METHODS: We introduced a method of ultrasound-guided cradle-like infiltration anesthesia (UCIA) to administer analgesia during PTA. Using ultrasound guidance, 1% lidocaine was injected into the bilateral and inferior perivascular spaces of the stenosis to form a cradle-like region. In this study, 100 consecutive patients were divided into two groups, and the analgesic effect of UCIA was evaluated using a numerical rating scale with non-ultrasound-guided infiltration anesthesia as a control. Meanwhile, we compared the effect of PTA between the two groups with the postoperative internal diameter of the stenosis. RESULTS: The numerical rating scale score was 4.6 ± 1.9 and 2.0 ± 1.6 (P < 0.001) in UCIA group and non-ultrasound-guided infiltration anesthesia group, respectively. The postoperative internal diameter of stenosis was 3.9 ± 0.6 mm and 4.1 ± 0.7 mm (P = 0.113); the postoperative AAVA flow volume was 627 ± 176 mL/min and 644 ± 145 mL/min (P = 0.600). CONCLUSIONS: This study preliminarily showed that UCIA is effective and safe for the analgesia of AAVA PTA.

Music Therapy in Dialysis Access Procedures With Moderate Sedation.

BACKGROUND: The aim was to evaluate the effects of music on patients' anxiety and satisfaction after undergoing dialysis access procedures under moderate sedation. METHODS: Patients (n = 30) undergoing moderate sedation for dialysis access procedures were evaluated at a single institution. Each patient filled out a survey preoperatively and postoperatively using the short form State-Trait Anxiety Inventory (STAI-6). Patient-selected music was provided by using a MP3 player with noise canceling headphones. RESULTS: Postoperatively, 77% of patients perceived music intervention as very or extremely helpful in decreasing anxiety during the procedure. Further, 93% of patients were somewhat or very satisfied with their procedure. The average pain rating was 3.1 on a scale of 0-10, in which 70% of patients had no to mild pain and 30% of patients rated moderate to severe pain. In comparison to prior procedures without music, 63% of patients rated better experience with the music intervention, 37% rated a similar experience, and 3.7% rated having a worse experience. Approximately, 93% of patients were willing to repeat procedure with music and would recommend it to other patients. Preoperative anxiety average score was 35.6 ± 13 and was reduced postoperatively to 28.9 ± 12.9 (P = .006). Preoperatively, 23% of patients rated high anxiety and postoperatively only 6.7% of patients rated high anxiety (P = .016). CONCLUSION: Music is an easy, feasible, inexpensive intervention that may reduce patients' anxiety and improve satisfaction during moderate sedation procedures and in the postoperative period.

Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts.

BACKGROUND: People with end-stage renal disease (ESRD) often require either the formation of an arteriovenous fistula (AVF) or an interposition prosthetic arteriovenous graft (AVG) for haemodialysis. These access sites should ideally have a long life and a low rate of complications (e.g. thrombosis, infection, stenosis, aneurysm formation and distal limb ischaemia). Although some of the complications may be unavoidable, any adjuvant technique or medical treatment aimed at decreasing complications would be welcome. This is the fourth update of the review first published in 2003. OBJECTIVES: To assess the effects of adjuvant drug treatment in people with ESRD on haemodialysis via autologous AVFs or prosthetic interposition AVGs. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and ClinicalTrials.gov trials register to 6 August 2020. SELECTION CRITERIA: Randomised controlled trials of active drug versus placebo in people with ESRD undergoing haemodialysis via an AVF or prosthetic interposition AVG. DATA COLLECTION AND ANALYSIS: For this update, two review authors (IM, MFAK) independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the certainty of the evidence according to GRADE. We resolved disagreements by discussion or consultation with another review author (ADS). The primary outcome was the long-term fistula or graft patency rate. Secondary outcomes included duration of hospital stay; complications such as infection, aneurysm formation, stenosis and distal limb ischaemia; and number of related surgical or radiological interventions. MAIN RESULTS: For this update, one additional study was suitable for inclusion, making a total of 13 trials with 2080 participants. Overall the certainty of the evidence was low or moderate due to short follow-up periods, heterogeneity between trials, small sample sizes, and risk of bias due to incomplete reporting. Medical adjuvant treatments used in the included trials were aspirin, ticlopidine, dipyridamole, dipyridamole plus aspirin, warfarin, fish oil, clopidogrel, sulphinpyrazone and glyceryl trinitrate (GTN) patch.  All included studies reported on graft patency by measuring graft thrombosis. There was insufficient evidence to determine if there was a difference in graft patency in studies comparing aspirin versus placebo (odds ratio (OR) 0.40, 95% confidence interval (CI) 0.07 to 2.25; 3 studies, 175 participants; low-certainty evidence). The meta-analysis for graft patency comparing ticlopidine versus placebo favoured ticlopidine (OR 0.45, 95% CI 0.25 to 0.82; 3 studies, 339 participants; moderate-certainty evidence). There was insufficient evidence to determine if there was a difference in graft patency in studies comparing fish oil versus placebo (OR 0.24, 95% CI 0.03 to 1.95; 2 studies, 220 participants; low-certainty evidence); and studies comparing clopidogrel and placebo (OR 0.40, 95% CI 0.13 to 1.19; 2 studies, 959 participants; moderate-certainty evidence). Similarly, there was insufficient evidence to determine if there was a difference in graft patency comparing the effect of dipyridamole versus placebo (OR 0.46, 95% CI 0.11 to 1.94; 1 study, 42 participants, moderate-certainty evidence) and dipyridamole plus aspirin versus placebo (OR 0.64, CI 0.16 to 2.56; 1 study, 41 participants; moderate-certainty evidence); comparing low-intensity warfarin with placebo (OR 1.76, 95% CI 0.78 to 3.99; 1 study, 107 participants; low-certainty evidence); comparing sulphinpyrazone versus placebo (OR 0.43, 95% CI 0.03 to 5.98; 1 study, 16 participants; low-certainty evidence) and comparing GTN patch and placebo (OR 1.26, 95% CI 0.63 to 2.54; 1 study, 167 participants; moderate-certainty evidence). The single trial evaluating warfarin was terminated early because of major bleeding events in the warfarin group. Only two studies published data on the secondary outcome of related interventions (surgical or radiological); there was insufficient evidence to determine if there was a difference in related interventions between placebo and treatment groups. None of the included studies reported on the duration of hospital stay.  Most studies reported complications ranging from mortality to nausea. However, data on complications were limited and reporting varied between studies. AUTHORS' CONCLUSIONS: The meta-analyses of three studies for ticlopidine (an antiplatelet treatment), which all used the same dose of treatment but with a short follow-up of only one month, suggest ticlopidine may have a beneficial effect as an adjuvant treatment to increase the patency of AVFs and AVGs in the short term. There was insufficient evidence to determine if there was a difference in graft patency between placebo and other treatments such as aspirin, fish oil, clopidogrel, dipyridamole, dipyridamole plus aspirin, warfarin, sulphinpyrazone and GTN patch. The certainty of the evidence was low to moderate due to short follow-up periods, the small number of studies for each comparison, small sample sizes, heterogeneity between trials and risk of bias due to incomplete reporting. Therefore, it appears reasonable to suggest further prospective studies be undertaken to assess the use of these antiplatelet drugs in renal patients with an AVF or AVG.

Cost-effectiveness analysis of immediate access arteriovenous grafts versus standard grafts for hemodialysis.

OBJECTIVE: Immediate-access arteriovenous grafts (IAAVGs), or early cannulation arteriovenous grafts (AVGs), are more expensive than standard grafts (sAVGs) but can be used immediately after placement, reducing the need for a tunneled dialysis catheter (TDC). We hypothesized that a decrease in TDC-related complications would make IAAVGs a cost-effective alternative to sAVGs. METHODS: We constructed a Markov state-transition model in which patients initially received either an IAAVG or an sAVG and a TDC until graft usability; patients were followed through multiple subsequent access procedures for a 60-month time horizon. The model simulated mortality and typical graft- and TDC-related complications, with parameter estimates including probabilities, costs, and utilities derived from previous literature. A key parameter was median time to TDC removal after graft placement, which was studied under both real-world (7 days for IAAVG and 70 days for sAVG) and ideal (no TDC placed with IAAVG and 1 month for sAVG) conditions. Costs were based on current Medicare reimbursement rates and reflect a payer perspective. Both microsimulation (10,000 trials) and probabilistic sensitivity analysis (10,000 samples) were performed. The willingness-to-pay threshold was set at $100,000 per quality-adjusted life-year (QALY). RESULTS: IAAVG placement is a dominant strategy under both real-world ($1201.16 less expensive and 0.03 QALY more effective) and ideal ($1457.97 less expensive and 0.03 QALY more effective) conditions. Under real-world parameters, the result was most sensitive to the time to TDC removal; IAAVGs are cost-effective if a TDC is maintained for ≥23 days after sAVG placement. The mean catheter time was lower with IAAVG (3.9 vs 8.7 months; P < .0001), as was the mean number of access-related infections (0.55 vs 0.74; P < .0001). Median survival in the model was 29 months. Overall mortality was similar between groups (76.3% vs 76.7% at 5 years; P = .33), but access-related mortality trended toward improvement with IAAVG (6.1% vs 6.8% at 5 years; P = .052). CONCLUSIONS: The Markov decision analysis model supported our hypothesis that IAAVGs come with added initial cost but are ultimately cost-saving and more effective. This apparent benefit is due to our prediction that a decreased number of catheter days per patient would lead to a decreased number of access-related infections.

Optimal Time of Thermotherapy for Reducing Pain, Anxiety, and Side Effects in Arteriovenous Fistula Puncture Patients: A Randomized Controlled Trial.

Chronic renal failure patients undergoing hemodialysis complain of moderate pain from repeated punctures of the arteriovenous fistula. This study examined the optimal application time of thermotherapy for reducing pain, anxiety, and side effects during arteriovenous fistula puncture. This study was conducted as a single-blinded randomized controlled trial. The participants were arteriovenous fistula puncture patients with chronic renal failure who were divided into two thermotherapy groups and one control group. This study was approved by the institutional review board and registered with the Clinical Research Information Service (KCT0003768). Differences between groups regarding pain, anxiety, and side effects were analyzed using one-way ANOVA, the χ2 test, and the Scheffé test. A significant difference was observed between the 10-min and 20-min thermotherapy groups and the control group in terms of the pain they experienced. Additionally, more side effects were encountered in the 20-min thermotherapy group than in the 10-min group. The 10-min application of thermotherapy for an arteriovenous fistula puncture showed the same pain-reducing effect as the conventional 20-min application. The study confirmed a 10-min application of thermotherapy to be an effective nursing intervention for pain relief without side effects.

Association of Anesthesia Type with Outcomes after Outpatient Brachiocephalic Arteriovenous Fistula Creation.

BACKGROUND: Brachiocephalic arteriovenous fistulas (BCFs) are commonly placed in outpatient settings. The impact of general anesthesia (GA), regional anesthesia (RA), or local anesthesia (LA) on perioperative recovery and fistula maturation/patency after outpatient BCF creations is unknown. We evaluated whether outcomes of outpatient BCF creations vary based on anesthesia modality. METHODS: The Vascular Quality Initiative (2011-2018) national database was queried for outpatient BCF creations. Anesthesia modalities included GA, RA, and LA. Perioperative, 3-month, and 1-year outcomes were compared between GA versus RA/LA anesthesia types. RESULTS: Among 3,527 outpatient BCF creations, anesthesia types were GA in 1,043 (29.6%), RA in 1,150 (32.6%), and LA in 1,334 (37.8%). Patients receiving GA were more often younger, obese, Medicaid recipients, without coronary artery disease, and treated in non-office-based settings (P < 0.05 for all). GA compared with RA/LA cohorts were more often admitted postoperatively (5.3% vs. 2.4%, P < 0.001) but had similar rates of thirty-day mortality (0.9 vs. 0.6%, P = 0.39). 3-month access utilization for hemodialysis was lower in GA than in RA/LA cohorts (12.6% vs. 23.6%, P < 0.001). The Kaplan-Meier analysis showed that GA and RA/LA cohorts had similar 1-year primary access occlusion-free survival (43.6% vs. 47.1%, P = 0.24) and endovascular/open reintervention-free survival (57.2% vs. 57.6%, P = 0.98). On multivariable analysis, GA compared with RA/LA use was independently associated with increased postoperative admission (odds ratio [OR]: 1.7, 95% confidence interval [CI]: 1.08-2.67, P = 0.02) and decreased 3-month access utilization (OR: 0.39, 95% CI: 0.25-0.61, P < 0.001) but had similar 1-year access occlusion (hazard ratio [HR]: 1.09, 95% CI: 0.9-1.32, P = 0.36) and reintervention (HR: 1.02, 95% CI: 0.82-1.26, P = 0.88). On subgroup analysis of the RA/LA cohort, RA compared with LA was associated with increased 3-month access utilization (OR: 1.6, 95% CI: 1.01-2.5; P = 0.04) and 1-year access reintervention (HR: 1.46, 95% CI: 1.12-1.89), but had similar 1-year access occlusion (HR: 1.2, 95% CI: 0.95-1.51, P = 0.13). CONCLUSIONS: Compared with RA/LA use, GA use in patients undergoing outpatient BCF creations was associated with increased hospital admissions, decreased access utilization at 3 months, and similar 1-year access occlusion and reintervention. RA/LA is preferable to expedite recovery and access utilization.

Intravenous Iron Dosing and Infection Risk in Patients on Hemodialysis: A Prespecified Secondary Analysis of the PIVOTAL Trial.

BACKGROUND: Experimental and observational studies have raised concerns that giving intravenous (IV) iron to patients, such as individuals receiving maintenance hemodialysis, might increase the risk of infections. The Proactive IV Iron Therapy in Haemodialysis Patients (PIVOTAL) trial randomized 2141 patients undergoing maintenance hemodialysis for ESKD to a high-dose or a low-dose IV iron regimen, with a primary composite outcome of all-cause death, heart attack, stroke, or hospitalization for heart failure. Comparison of infection rates between the two groups was a prespecified secondary analysis. METHODS: Secondary end points included any infection, hospitalization for infection, and death from infection; we calculated cumulative event rates for these end points. We also interrogated the interaction between iron dose and vascular access (fistula versus catheter). RESULTS: We found no significant difference between the high-dose IV iron group compared with the lose-dose group in event rates for all infections (46.5% versus 45.5%, respectively, which represented incidences of 63.3 versus 69.4 per 100 patient years, respectively); rates of hospitalization for infection (29.6% versus 29.3%, respectively) also did not differ. We did find a significant association between risk of a first cardiovascular event and any infection in the previous 30 days. Compared with patients undergoing dialysis with an arteriovenous fistula, those doing so via a catheter had a higher incidence of having any infection, hospitalization for infection, or fatal infection, but IV iron dosing had no effect on these outcomes. CONCLUSIONS: The high-dose and low-dose IV iron groups exhibited identical infection rates. Risk of a first cardiovascular event strongly associated with a recent infection.

Effect of cryotherapy on arteriovenous fistula puncture-related pain in hemodialysis patients: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Patients undergoing continuous hemodialysis experience the arteriovenous fistula puncture-related pain approximately 300 times per year. Pain management is important priorities in painful procedures. Therefore, this systematic review and meta-analysis study was conducted to determine the effect of cryotherapy on arteriovenous fistula puncture-related pain in hemodialysis patients. METHODS: This systematic review and meta-analysis study was conducted by searching the related article with using the keywords including Cryotherapy, Ice, Punctures, Catheterization, Pain, and Fistula (using AND & OR operators) through Iranian (including SID, and Magiran) and international databases (including Embase, Web of Science, Medline via PubMed, Scopus, and ProQuest). Interventional studies in English or Persian languages were included in the study without time limitation. Finally, after excluding duplicates, screening based on inclusion and exclusion criteria, and quality assessment (based on the JADAD standard checklist), 8 studies entered the systematic review process (Qualitative Synthesis) and 6 studies entered the meta-analysis process (Quantitative Synthesis). RESULTS: Based on the results of the review, the included studies were conducted between 2008-2017. The total number of participants in all studies obtained through systematic review (8 studies) was 422 with an age of 16 years old and above. The review of studies showed a positive effect of cryotherapy on reducing the arteriovenous fistula puncture-related pain in hemodialysis patients. CONCLUSION: Regarding the positive effect of cryotherapy on arteriovenous fistula puncture-related pain, cryotherapy as a low-risk and uncomplicated procedure seems to be effective and useful in reducing pain and ultimately reducing its unpleasant psychological and physical side effects.

Closed incisional negative pressure therapy may reduce surgical site infection rate following endophlebectomy with complementary polytetrafluoroethylene arteriovenous fistula of the common femoral vein.

OBJECTIVE: Surgical desobliteration or endophlebectomy of the common femoral vein during deep venous recanalization with complementary polytetrafluoroethylene (PTFE) arteriovenous fistula (AVF), may lead to higher rates of surgical site infection (SSI). It has been reported that closed incisional negative pressure wound therapy (cINPT) may decrease SSI rates after different surgical procedures. The aim of this study was to determine the potential effect of cINPT on the SSI rate of femoral endophlebectomy with a complimentary PTFE AVF. METHODS: Patients with recanalization of the femoral-iliac veins and femoral endophlebectomy with a complementary PTFE AVF and postoperative cINPT were identified. SSI, patency, and complication rates were analyzed. RESULTS: This study included 65 patients with a mean age of 41 ± 14 years. The mean procedure time was 240 ± 11.9 minutes. Primary patency rate was 69.2% and secondary patency rate was 78.4%. SSI classified as Szilagyi I, II, and III occurred in 7.6% (n = 5), 3% (n = 2), and 7.6% (n = 5), respectively, with an overall SSI rate of 18.2%. Surgical wound revision with the application of a vacuum pump was required in 10.7% (n = 7). A multivariate analysis showed that the duration of the surgical procedure (P = .003) as well as lymphatic fistulas (P = .044) to have a significant impact on the SSI rate. CONCLUSIONS: Endophlebectomy with complementary PTFE AVF of the femoral vein is related to an increased rate of lymphatic leakage and SSI. Lymphatic fistula and the duration of surgery could be assessed as relevant influencing factors of SSI. Application of cINPT in this surgical setting may reduce the SSI rate. Despite this potential improvement, SSI rates still limit the clinical success of a deep venous recanalization.

Outcomes of Local and Regional Anesthesia for Superficialization of Brachiobasilic Arteriovenous Fistulas.

BACKGROUND: Superficialization, the second stage of a two-stage brachiobasilic arteriovenous fistula (BB-AVF), can be performed under local (LA), regional (RA), or general anesthesia (GA). Given the numerous comorbidities in patients with end-stage renal disease (ESRD), our preference is to use RA or LA when feasible. Our goal was to review the success rate of RA and LA, need for conversion to GA, and cardiac morbidity and mortality for BB-AVF superficialization. METHODS: We performed a retrospective cohort analysis of patients who underwent BB-AVF creation with second-stage superficialization over a 4-year period. The primary outcome measures included need for conversion to GA, myocardial infarction (MI), and 30-day mortality. A secondary outcome was total operative time (time from preoperative briefing to the time the patient left the operating room). We analyzed the data using Fisher Exact test for categorical data and nonparametric analysis for continuous data. RESULTS: There were 42 patients who underwent BB-AVF superficialization. The median age was 56 years, with a mean body mass index of 29. Most patients were male (55%) and predominantly Hispanic/Latino (60%). RA was utilized in 35 patients (83%), LA in 5 (12%), and GA in 2 (5%). The conversion rate from RA to GA was 0% and was 20% (n = 1) from LA to GA. There were no postoperative MI or deaths. There was no significant difference in total operative time (219.6 min for RA, 234.5 min for LA, and 278 min for GA, (P = 0.37)). CONCLUSIONS: Local and/or regional anesthesia can be successfully used in the majority of patients undergoing BB-AVF superficialization. LA and RA are associated with negligible cardiac morbidity and mortality. Conversion from RA to GA is rare. Use of RA does not result in a longer total operative time.

General anesthesia is associated with reduced early failure among patients undergoing hemodialysis access.

BACKGROUND: Despite recent reports of improved patency with regional anesthesia (RA), general anesthesia (GA) remains the most common choice for anesthesia for patients undergoing arteriovenous fistula (AVF) or arteriovenous graft (AVG) creation, with nearly 85% utilization. Previous studies of the effect of anesthesia type on outcomes have been conducted through single institutions or a national database with poor granularity for vascular-specific data. Given the high variability of practice patterns and the high prevalence of end-stage renal disease requiring access creation, further study of the impact of anesthesia choice during AVF or AVG creation is warranted. METHODS: The Vascular Quality Initiative hemodialysis data set was queried to identify patients undergoing AVF or AVG creation between 2011 and 2017. Patients were grouped according to access type and anesthesia method (GA vs local anesthesia/RA). The primary outcome was early access failure within 120 days. Secondary outcomes were in-hospital and 30-day complications, including steal, swelling, hemorrhage, and wound infection. RESULTS: There were 31,028 patients undergoing AVG (6961) or AVF (24,067) identified. Compared with patients with GA, patients undergoing access creation with RA had higher early failure rates (AVG, 26.2% vs 23%; AVF, 22.3% vs 20.6%; both P = .04). However, in the GA group undergoing AVF creation, there was a 26% increase (adjusted odds ratio, 1.26 [1.06-1.55]) in bleeding complications and a 3.4-fold increase (adjusted odds ratio, 3.43 [1.38-8.51]) in wound infection rates. CONCLUSIONS: Whereas it is traditionally performed under GA, hemodialysis access with fistula or graft creation is increasingly being performed under RA. In our analysis, rates of perioperative complications, including infection and bleeding, may be lessened by using RA, especially among patients undergoing AVF creation. However, this was accompanied by a 3.2% absolute (21% relative) increased risk of early failure within the first 120 days after dialysis creation among patients undergoing AVG.

Vascular access surgery can be safely performed in an ambulatory setting.

INTRODUCTION:: Ambulatory surgery is associated with lower costs, but there is lack of evidence of the safety for ambulatory vascular access surgery. The objective of this study is to substantiate the safety and effectiveness of performing vascular access surgery in an ambulatory setting. METHODS:: A review of our prospectively maintained database including all vascular access open surgeries (creations and repairs) performed by our Vascular Access Unit between 2013 and 2017 was compiled. Patient comorbidities, surgery details, hospital admission conditions, and 1-week and 1-month follow-up patency and complications (death, infection, bleeding, and readmission/reintervention) were scrutinized. RESULTS:: In the last 5 years, 1414 vascular access procedures were performed (67.8% access creations, 32.2% previous access repairs) in 1012 patients. Most surgeries were performed under local anesthesia (59.2%) or axillary plexus block (38.4%) and mainly in an ambulatory setting, without overnight hospital stays (90.9%). During the first postoperative week follow-up, 9 cases (0.6%) needed readmission or reintervention; significant infection materialized in 11 (0.8%) and 10 cases (0.7%) showed noteworthy hematoma or bleeding, only three (0.2%) requiring reintervention. The primary composite endpoint of 24-h death and 1 week readmission, reintervention, infection, or bleeding was 1.9% (27 cases); 1-month access failure was 6.2%. After univariate analysis, ambulatory settings were not related to higher rates of complications or readmissions. CONCLUSION:: Arteriovenous access surgery can be safely performed in an ambulatory setting, in spite of complex cases, comorbidities, or the increasing implementation of axillary plexus blocks. Surgical results and patency are good, and complications necessitating readmission remain very low.

Comparison between Surgical and Endovascular Hemodialysis Arteriovenous Fistula Interventions and Associated Costs.

PURPOSE: To compare: (i) rate of arteriovenous fistula (AVF) interventions in both incident and prevalent end-stage kidney disease patients; (ii) their associated costs; and (iii) intervention-free survival between patients with surgical hemodialysis arteriovenous fistula (SAVF) versus those with an endovascularly created fistula (endoAVF). MATERIALS AND METHODS: Data from the United States Renal Data System (USRDS) were abstracted to determine the rate of AVF interventions performed in the first year and associated costs (based on Medicare payment rates) for SAVFs created from 2011 to 2013 in the incident and prevalent patient cohorts. Comparative data for endoAVF were obtained from the Novel Endovascular Access Trial (NEAT). Event rates, intervention-free survival, and costs were compared between endoAVF and SAVF cohorts after 1:1 propensity score (PS) matching. RESULTS: In the matched incident patients, the event rate was 0.74 per patient-year (PY) for endoAVF versus 7.22/PY for SAVF (P < .0001), with a difference in expenditures of $16,494. Similarly, in matched prevalent patients the event rate was 0.46/PY for endoAVF vs 4.10/PY for SAVF (P < .0001), resulting in a cost difference of $13,389. Time-to-event analysis showed that at 1 year, 70% of endoAVF patients experienced freedom from intervention versus only 18% of SAVF patients for incident patients; these numbers were 62% and 18% for endoAVF and SAVF prevalent patients, respectively (P < .0001 for both). CONCLUSIONS: Both incident and prevalent patients with endoAVF required fewer interventions and had lower costs within the first year compared with matched patients with SAVF.

Omega-3 Polyunsaturated Fatty Acid Supplementation to Prevent Arteriovenous Fistula and Graft Failure: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Arteriovenous access failure frequently occurs in people on hemodialysis and is associated with morbidity, mortality and large healthcare expenditures. Omega-3 polyunsaturated fatty acids (omega-3 PUFA) may improve access outcomes via pleiotropic effects on access maturation and function, but may cause bleeding complications. STUDY DESIGN: Systematic review with meta-analysis. SETTING & POPULATION: Adults requiring hemodialysis via arteriovenous fistula or graft. SELECTION CRITERIA: Trials evaluating omega-3 PUFA for arteriovenous access outcomes identified by searches in CENTRAL, MEDLINE, and Embase to 24 January 2017. INTERVENTION: Omega-3 PUFA. OUTCOMES: Primary patency loss, dialysis suitability failure, access abandonment, interventions to maintain patency or assist maturation, bleeding, gastrointestinal side-effects, all-cause and cardiovascular mortality, hospitalization, and treatment adherence. Treatment effects were summarized as relative risks (RR) and 95% confidence intervals (CI). Evidence was assessed using GRADE. RESULTS: Five eligible trials (833 participants) with a median follow-up of 12 months compared peri-operative omega-3 PUFA supplementation with placebo. One trial (n=567) evaluated treatment for fistulae and four (n=266) for grafts. Omega-3 PUFA supplementation prevented primary patency loss with moderate certainty (761 participants, RR 0.81, CI 0.68-0.98). Low quality evidence suggested, that omega-3 PUFA may have had little or no effect on dialysis suitability failure (536 participants, RR 0.95, CI 0.73-1.23), access abandonment (732 participants, RR 0.78, CI 0.59-1.03), need for interventions (732 participants, RR 0.82, CI 0.64-1.04), or all-cause mortality (799 participants, RR 0.99, CI 0.51-1.92). Bleeding risk (793 participants, RR 1.40, CI 0.78-2.49) or gastrointestinal side-effects (816 participants, RR 1.22, CI 0.64-2.34) from treatment were uncertain. There was no evidence of different treatment effects for grafts and fistulae. LIMITATIONS: Small number and methodological limitations of included trials. CONCLUSIONS: Omega-3 PUFA supplementation probably protects against primary loss of arteriovenous access patency, but may have little or no effect on dialysis suitability failure, access interventions or access abandonment. Potential treatment harms are uncertain.