Impact of Isometric Exercise in Adolescents With End Stage Kidney Disease and Unsuitable Vessels For An Autologous Arteriovenous Fistula.

INTRODUCTION: Despite the lack of calcification, to perform a native Arteriovenous Fistula (AVF) in young patients may pose a challenge due to small vessel diameter. We report a case series with no options of AVF in which vessel caliber improvement after isometric exercise allowed for radiocephalic fistula creation in all of them. METHODS: Since 2017 to 2019, four patients were referred to our unit to create an AVF. Following a first assessment with physical examination and doppler ultrasound, none of them were eligible for AVF performance due to small vessel caliber. Once they were considered unsuitable for it, they started an isometric exercise program. RESULTS: Age ranged from 13 to 19 years. There were three males and one female. Two were in predialysis and two in hemodialysis program. Initial diameters of the forearm cephalic vein and the radial artery respectively were: case A < 1.5/2.3 mm, case B 1.5/1.6 mm, case C < 1.5/1.6 mm and case D 2.1/1.3 mm. Median duration of exercise program was 13 weeks (range 5-23). Post-exercise vessel diameters were: case A 2.7/2.3 mm, case B 2.5/2 mm, case C 2.8/1.8 mm and case D 2.7/2 mm. Radiocephalic AVF were performed in the four cases. After a median follow up of 19 months (range 9-30 months), 75% of patients required further interventions but all of them had a functional AVF. CONCLUSIONS: In these four cases isometric preoperative exercise allowed the creation of AVF. Without the improvement in vessel diameter observed afterwards, all of them would have been rejected for AVF performance. Despite the high rate of adjunctive interventions needed, given the safety of the program and the potential risks of Central Venous Catheters, we consider it a valuable option.

Effect of preoperative exercise on vascular caliber and maturation of arteriovenous fistula: the physicalfav trial, a randomized controlled study.

BACKGROUND AND OBJECTIVES: Autologous arteriovenous fistula (AVF) is the best vascular access for hemodialysis. Distal forearm radiocephalic fistula is the best option, although the primary failure rate ranges from 20% to 50%. The main objective of the PHYSICALFAV trial was to evaluate the effect of preoperative isometric exercise on vascular caliber, percentage of distal arteriovenous fistula, and primary failure rate. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: The PHYSICALFAV trial (NCT03213756) is an open-label, multicenter, prospective, randomized, controlled trial (RCT). A total of 138 patients were randomized 1:1 to the exercise group (exercises combining a handgrip device and an elastic band for 8 weeks) or the control group (no exercise) and followed up with periodic Doppler ultrasound (DU) examinations. RESULTS: After 8 weeks of preoperative isometric exercise, in the exercise group, significant increases were detected in venous caliber (2.80 ± 0.95 mm vs 3.52 ± 0.93 mm [p < 0.001]), arterial caliber (2.61 ± 0.82 mm vs 2.74 ± 0.80 mm [p = 0.008]), arterial peak systolic velocity (66.34 ± 19.2 cm/s vs 71.03 ± 21.5 cm/s [p 0.043]), and maximum strength (28.35 ± 9.16 kg vs 32.68 ± 10.8 kg [p < 0.001]). Distal radiocephalic fistulas were performed in 75% of the exercise group patients compared with 50.8% in the control group (p = 0.030). The global primary failure rate was very low in both groups (7% exercise group vs 14% control group [p = 0.373]). CONCLUSION: Isometric preoperative exercise can improve vascular caliber and increase the possibility of performing distal arteriovenous fistula, with no significant differences in primary failure rate.

Endovascular Management of a Giant High-Flow Lower Limb Arteriovenous Malformation.

PURPOSE: High-flow arteriovenous malformations (AVMs) may pose a challenge for endovascular treatment due to high-flow rates. Incomplete treatment, recurrence, or even worsening can occur if a proper management is not performed. We report a case successfully treated with endovascular therapy. CASE REPORT: A 37-year-old male was referred to our hospital with a soft tumor in the left thigh, limb asymmetry and associated pain. Doppler ultrasound and magnetic resonance imaging showed an extensive high-flow AVM with a venous aneurysm of 40 mm diameter. Diagnostic angiography identified multiple feeding vessels from the profunda femoris and superficial femoral arteries. Two endovascular interventions were performed within 1 month, combining afferent vessel embolization and percutaneous thrombin injection into the nidus, to exclude the AVM. Two-year imaging follow-up revealed thrombosis of the malformation. The patient remained asymptomatic with normal thigh diameter. No complications were documented in any of the sessions. CONCLUSION: Endovascular therapy could be a safe and effective option for AVM as long as it includes not only feeding vessels embolization but also complete occlusion of the nidus.