Vascular access for hemodialysis in Italy: What a national survey reveals.

BACKGROUND: Since in Italy there are no official data on vascular access (VA) for hemodialysis the Vascular Access Project Group (VAPG) of the Italian Society of Nephrology (SIN) designed a national survey. METHODS: A 35-question survey was designed and sent it to the Italian facilities through the SIN website. The basic questions were the prevalence, the location, and the surveillance of VA, the bedside use of ultrasound, the use of fluoroscopy for central venous catheter (CVC) placement, and of buttonhole technique, the role of nephrologist in the access creation. RESULT: The questionnaire was completed in June 2022 by 161 facilities. The survey registered 15,499 patients, approximately one-third of the Italian dialysis population. The prevalence of arteriovenous fistula (AVF), arteriovenous Graft (AVG), and CVC were 61.8%, 3.7%, and 34.5% respectively. The AVF location was 50% in distal forearm, 20% in meanproximal forearm, 30% in upper arm. For AVF creation, nephrologists were involved in 72% of facilities while for CVC placement in 62%. As regards VA monitoring, 21% of the facilities did not have a surveillance protocol; 60% did not register AVF thrombosis and 53% did not register CVC infections. Most of facilities use the fluoroscope during CVC placement, 37% when needed, and 22% never. Ultrasound-guided puncture of complex AVFs was used by 80% of facilities. Buttonhole puncture was used in 5% of patients. CONCLUSIONS: Some considerations emerge from the survey data: (1) The increasing CVC prevalence compared to DOPPS 5 study. (2) The low rate of AVG prevalence. (3) The nephrologist is the operator in many VA procedures. (4) The fluoroscopy for CVC placement and the US-guide puncture of the complex AVF are widely used in most facilities. (5) The practice of the buttonhole is not widespread. (6) When the operator is the nephrologist more distal fistulas are performed.

Report on an Italian survey of 72 stuck hemodialysis catheters.

BACKGROUND: Reports of stuck hemodialysis catheters have been on the rise in recent years. Aim of this work is to report how this complication has been managed and the relative outcomes in a multicente Italian survey. METHODS: Since 2012, the Italian Society of Nephrology (SIN) Project Group of Vascular Access has collected data among nephrologists on this complication. Data regarding 72 cases of stuck tunnelled central venous catheter (tCVC) in 72 patients were retrieved thanks to this survey. RESULTS: In 11 patients (15%) the stuck catheter was directly buried or left in place. Sixty-one cases were managed through advanced removal techniques. Among these, 47 (77%) stuck tunnelled central venous catheters were successfully removed, while 14 (23%) failed to be withdrawn. Considering removed tCVCs, the use of endoluminal balloon dilatation alone or in combination with other tools showed a percentage of success of 88%. The removal procedure involved numerous specialists. Some complications occurred, such as breakage of the line or bleeding, and two cases of haemopericardium during an advanced procedure. CONCLUSION: The survey shows how the stuck catheter complication was managed in different ways, with conflicting results. When utilized, endoluminal balloon dilatation proved to be the most effective and most often utilized technique, while some cases had suboptimal management or failure. This underlines how delicate the procedure is, and the need for both precise knowledge of this complication and timely organization of removal attempts.

Vascular access scenario in Italy: evolution and comparison by two surveys (1998-2013).

PURPOSE: Dialysis settings have generally improved over the last decades, but the vascular access setting did not see significant advances and experienced a progressive worsening in epidemiology and clinical features. The aim of the study was to describe and compare evolution of vascular access in Italy over time. METHODS: A national survey implemented in Italy last year is presented and compared to a previous survey performed in 1998. Present survey collected data from almost 50% of centers involved in vascular access. RESULTS: The nephrologist participates in the management of vascular access in 97% of centers. Almost 40% of centers declare more than 40% of central venous catheters (CVCs) at first dialysis with maximum value being 60%. Prevalence of CVCs is greater than 20% in chronic prevalent patients in 38.8% of centers. According to the 2013 survey, CVCs account for 51.6% of procedures, while arteriovenous fistulae (AVF) and prostheses represent 42.4% and 6%, respectively. Nephrologists perform 73% of procedures on CVCs.From 1998 to 2013, a sharp increase in CVC prevalence was seen, in both incident and prevalent dialysis patients. This activity, mostly due to CVC management, is almost completely carried by nephrologists. DISCUSSION: The variability in CVC utilization among centers suggests the lack of a shared policy in patients and access coupling. Quantitative criteria should be used to reduce inappropriate strategy in vascular access creation. Since this activity in Italy is organized at a local level without a shared organizational model, we should inquire whether a system managed so well in the past should now be rebuilt on the model of organ transplantation.

The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology.

The incident hemodialysis (HD) population is aging, and the elderly group is the one with the most rapid increase. In this context it is important to define the factors associated with outcomes in elderly patients. The high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and congestive heart failure, usually make vascular access (VA) creation more difficult. Furthermore, many of these patients may have an insufficient vasculature for fistula maturation. Finally, many fistulas may never be used due to the competing risk of death before dialysis initiation. In these cases, an arteriovenous graft and in some cases a central venous catheter become a valid alternative form of VA. Nephrologists need to know what is the most appropriate VA option in these patients. Age should not be a limiting factor when determining candidacy for arteriovenous fistula creation. The aim of this position statement, prepared by experts of the Vascular Access Working Group of the Italian Society of Nephrology, is to critically review the current evidence on VA in elderly HD patients. To this end, relevant clinical studies and recent guidelines on VA are reviewed and commented. The main advantages and potential drawbacks of the different VA modalities in the elderly patients are discussed.

A refinement of Hong's technique for the removal of stuck dialysis catheters: an easy solution to a complex problem.

AIM: A long-term tunneled hemodialysis catheter can be difficult or impossible to pull out if a fibrin sleeve has attached it to the venous wall. We report the outcome of a refinement of Hong's technique for removing incarcerated catheters aimed at improving its feasibility and safety. METHODS: We applied a modification of Hong's technique in four patients (two males, age ranging from 51 to 68 years) with jugular twin hemodialysis catheters (five of eight lines incarcerated). Hong pioneered the technique of endoballooning to expand a stuck central venous catheter, thus freeing it from adhesions. In our technical refinement, we cut the catheter close to its venous entry point in order to facilitate pullout and inserted a valved introducer as access for guide wires as well as for inflations of the catheter balloon. A stiff guide wire was placed in the inferior vena cava to avoid potential damage to heart cavities. Dilation was monitored under fluoroscopy with constrictions showing points where the catheter was incarcerated. If adhesions persisted through the same introducer, endoluminal dilations were repeated with a larger diameter balloon until the catheter was released. New catheters can be positioned using the stiff guide wire already in place. All removals were carried out under local anesthesia in an angiographic room by interventional radiologists. RESULTS: All catheters were successfully removed without complications. Average fluoroscopy time for removal was 12 minutes. In the case of a Tesio catheter removed after 12 years because of infection, a computed tomography scan 2 months later revealed persistence of a calcified fibrin sleeve in the vessel. CONCLUSIONS: Hong's technique was confirmed to be a simple, safe and highly effective way to remove incarcerated long-term central venous catheters. The refinements we adopted made the procedure more flexible and possibly less prone to complications. By properly using ordinary tools available anywhere, Hong's technique could be considered Columbus' egg in this previously risky field.

[The Italian Registry of Vascular Access]. / Il registro nazionale degli accessi vascolari.

The Vascular Access Study Group of Italian Society of Nephrology has designed a National Register in order to create an archive that collects the data on vascular accesses more detailed than the mere indication of arteriovenous fistula with native vessels, prosthetic fistula and central venous catheter. The obstacles to such a project are represented by the absence of "uniformity" in the name of the arterovenous fistula, the difficulty in increasing the daily work of dialysis centers with another registry and finally by privacy concerns. In order to standardize the vascular accesses name the Study Group proposal is to eliminate any denomination and adopt a code-descriptive system, indicating the seat of the anastomosis (1/3 distal, middle and proximal forearm, arm or lower limb), the limb (if dominant or non-dominant), the vessels involved, the type of anastomosis and the number of interventions that the pt has undergone including the last one. In this way, uniformity and universality are guaranteed. Every aspect scribed will be a cell of a data base and can used to statistical analysis. The study group has set up a software (Gev@) in order to facilitate data storage. The software is based on a form compiled at the end of each surgical procedure. The form will then be archived in digital format thereby generating automatically the data base. The advantage of this system, is represented by the possibility of turning a routine medical procedure, namely the recording of a surgical procedure, in a data base exportable for the creation of the register. As regards the issue of privacy will be obtained the patient's consent to the processing of data and the register will be stored and managed according to the regulations in terms of privacy. In the coming months, after a time of testing, the software will be available to each italian dialisys center.