Optimal vascular access to hemodialysis, or what modern medicine offers us.

Hemodialysis is a life-saving method for patients with acute and chronic kidney failure. This treatment requires sufficiently large and safe vascular access. Ensuring optimal vascular access is therefore a prerequisite and an integral part of the care of these patients. In addition to commonly known vascular approaches such as non-tunnelized or tunneled hemodialysis catheters and AV fistulas, less well-known methods are also available, such as a translumbar or directly surgically inserted hemodialysis catheter into the right atrium. However, these alternative approaches are the only, life-saving alternative for some patients. The ambition of this review article is to offer a comprehensive view of the available options for vascular access, the algorithm for its selection and solutions to the most common complications in clinical practice.

Fresh Cold-Stored Vascular Allografts in Subgenicular Location: Our Experience with Rescue Endovascular Techniques.

BACKGROUND: Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease. CLI is associated with high rates of morbidity and mortality with high risk of limb amputation. In the absence of appropriate autologous grafts, unsuitability of prosthetic bypasses, and endovascular methods, fresh cold-stored venous allografts is an option. Endovascular interventional methods are essential methods for maintaining primary and secondary patency. METHODS: A single-centre retrospective analysis of 82 surgical revascularizations using allogeneic vascular grafts and rescue endovascular techniques restoring and maintaining the patency of these allogeneic revascularizations in the period between July 2005 and July 2021. RESULTS: We have performed 82 allogeneic revascularizations in 75 patients (52 reconstructions in men/63.4%/, 30 reconstructions in women/36.6%/). The median age of patients was 68 years (49 min, 87 max). We subsequently had to intervene a total of 26 bypasses. We intervened in 30 acute occluded allogeneic bypass grafts and 9 failing stenotic bypass grafts. We performed 52 angiographies. The success rate of rescue endovascular procedures in primary allogeneic reconstruction with distal anastomosis to the popliteal artery is statistically significant (P < 0.02) compared to procedures with distal anastomosis to the tibial and pedal bed. The cumulative patency (primary at time) of allogeneic reconstructions in our group was 89% after 1 month, 51.9% after 12 months, 24.2% after 3 years, 9.8% after 5 years. Limb salvage was 72.6% in 1 year, 53% in 3 years, 36.5% in 5 years, respectively. CONCLUSIONS: Cold-stored venous allografts may be used for performing below-the-knee revascularization for CLI with acceptable results, despite the poor long-term patency. Rescue endovascular techniques are an essential method for restoring or maintaining the patency of these reconstructions. These techniques have a high success rate and no other alternative.

Kidney function after off-pump or on-pump coronary artery bypass graft surgery: a randomized clinical trial.

IMPORTANCE: Most acute kidney injury observed in the hospital is defined by sudden mild or moderate increases in the serum creatinine concentration, which may persist for several days. Such acute kidney injury is associated with lower long-term kidney function. However, it has not been demonstrated that an intervention that reduces the risk of such acute kidney injury better preserves long-term kidney function. OBJECTIVES: To characterize the risk of acute kidney injury with an intervention in a randomized clinical trial and to determine if there is a difference between the 2 treatment groups in kidney function 1 year later. DESIGN, SETTING, AND PARTICIPANTS: The Coronary Artery Bypass Grafting Surgery Off- or On-pump Revascularisation Study (CORONARY) enrolled 4752 patients undergoing first isolated coronary artery bypass graft (CABG) surgery at 79 sites in 19 countries. Patients were randomized to receive CABG surgery either with a beating-heart technique (off-pump) or with cardiopulmonary bypass (on-pump). From January 2010 to November 2011, 2932 patients (from 63 sites in 16 countries) from CORONARY were enrolled into a kidney function substudy to record serum creatinine concentrations during the postoperative period and at 1 year. The last 1-year serum creatinine concentration was recorded on January 18, 2013. MAIN OUTCOMES AND MEASURES: Acute kidney injury within 30 days of surgery (≥50% increase in serum creatinine concentration from prerandomization concentration) and loss of kidney function at 1 year (≥20% loss in estimated glomerular filtration rate from prerandomization level). RESULTS: Off-pump (n = 1472) vs on-pump (n = 1460) CABG surgery reduced the risk of acute kidney injury (17.5% vs 20.8%, respectively; relative risk, 0.83 [95% CI, 0.72-0.97], P = .01); however, there was no significant difference between the 2 groups in the loss of kidney function at 1 year (17.1% vs 15.3%, respectively; relative risk, 1.10 [95% CI, 0.95-1.29], P = .23). Results were consistent with multiple alternate continuous and categorical definitions of acute kidney injury or kidney function loss, and in the subgroup with baseline chronic kidney disease. CONCLUSIONS AND RELEVANCE: Use of off-pump compared with on-pump CABG surgery reduced the risk of postoperative acute kidney injury, without evidence of better preserved kidney function with off-pump CABG surgery at 1 year. In this setting, an intervention that reduced the risk of mild to moderate acute kidney injury did not alter longer-term kidney function. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00463294.