Association of anesthetic modality and other variables on 1-year functional patency of cephalic-based arteriovenous fistulae.

OBJECTIVE: Some studies suggest that regional anesthesia provides better patency for arteriovenous fistula (AVF) for hemodialysis access as compared to local and general anesthesia. This study evaluates the impact of anesthetic modality on long term fistula function at 12 months. METHODS: A retrospective review of patients undergoing cephalic vein-based hemodialysis access in consecutive cases between 2014 and 2019 was conducted from five safety net hospitals. The primary endpoint was functional patency at 12 months. Subset analysis individually evaluated cephalic-based lower forearm and wrist vs upper arm AVFs. Bivariate and multivariate logistic regression models evaluated the relationship between anesthetic modality and fistula function at 12 months. RESULTS: There were 818 cephalic-based fistulas created during the study period. The overall 12-month functional patency rate was 78.7%, including an 81.3% patency for upper arm AVF and 73.3% for wrist AVF (P = .009). There was no statistically significant difference among patients with functional and nonfunctional AVFs at 12 months with respect to anesthetic modality when comparing regional, local, and general anesthesia (P = .343). Multivariate regression analysis identified that history of AVF/arteriovenous graft (odds ratio [OR], 0.24; P = .007), receiving intraoperative systemic anticoagulation (OR, 2.49; P < .001), and vein diameter (OR, 1.85; P = .039) as independently associated with AVF functional patency at 12 months. CONCLUSIONS: There was no association between anesthetic modality and functional patency of cephalic-based AVFs at 12 months. Further studies are needed to better define which patients may benefit from regional anesthesia.

Intra-pocket ultrasound-guided axillary vein puncture vs. cephalic vein cutdown for cardiac electronic device implantation: the ACCESS trial.

BACKGROUND AND AIMS: Intra-pocket ultrasound-guided axillary vein puncture (IPUS-AVP) for venous access in implantation of transvenous cardiac implantable electronic devices (CIED) is uncommon due to the lack of clinical evidence supporting this technique. This study investigated the efficacy and early complications of IPUS-AVP compared to the standard method using cephalic vein cutdown (CVC) for CIED implantation. METHODS: ACCESS was an investigator-led, interventional, randomized (1:1 ratio), monocentric, controlled superiority trial. A total of 200 patients undergoing CIED implantation were randomized to IPUS-AVP (n = 101) or CVC (n = 99) as a first assigned route. The primary endpoint was the success rate of insertion of all leads using the first assigned venous access technique. The secondary endpoints were time to venous access, total procedure duration, fluoroscopy time, X-ray exposure, and complications. Complications were monitored during a follow-up period of three months after procedure. RESULTS: IPUS-AVP was significantly superior to CVC for the primary endpoint with 100 (99.0%) vs. 86 (86.9%) procedural successes (P = .001). Cephalic vein cutdown followed by subclavian vein puncture was successful in a total of 95 (96.0%) patients, P = .21 vs. IPUS-AVP. All secondary endpoints were also significantly improved in the IPUS-AVP group with reduction in time to venous access [3.4 vs. 10.6 min, geometric mean ratio (GMR) 0.32 (95% confidence interval, CI, 0.28-0.36), P < .001], total procedure duration [33.8 vs. 46.9 min, GMR 0.72 (95% CI 0.67-0.78), P < .001], fluoroscopy time [2.4 vs. 3.3 min, GMR 0.74 (95% CI 0.63-0.86), P < .001], and X-ray exposure [1083 vs. 1423 mGy.cm², GMR 0.76 (95% CI 0.62-0.93), P = .009]. There was no significant difference in complication rates between groups (P = .68). CONCLUSIONS: IPUS-AVP is superior to CVC in terms of success rate, time to venous access, procedure duration, and radiation exposure. Complication rates were similar between the two groups. Intra-pocket ultrasound-guided axillary vein puncture should be a recommended venous access technique for CIED implantation.

The Study of the Feasibility of Ultrasound-guided Catheterization of the Right Brachiocephalic Vein in Adult Patients: A Prospective Observational Study.

Background: The brachiocephalic vein (BCV) is a feasible option for central venous access in the pediatric population and is rapidly developing as an alternative site for insertion of the central line in young children with faster insertion times, fewer attempts, and lower rates of complications. However, studies demonstrating the feasibility of BCV catheterization in adult patients are insufficient. The current study sought to assess the safety and effectiveness of ultrasound-guided supraclavicular right BCV cannulations in adults. Methods: A linear array Ultrasound (US) probe was used to obtain a longitudinal picture of the BCV beginning at the junction of the internal jugular vein and the subclavian vein in the supraclavicular region. Under US supervision, the needle was guided into the BCV using the in-plane approach. A prospective study was performed on 80 adult patients scheduled for elective and emergency operative procedures under general anesthesia requiring a central venous catheter (CVC). Success rates and complications that occurred during catheter insertion were analyzed. Results: CVC placement was successful in all adults. The procedure was successful at the first attempt in 74 cases (92.5%) and after 2 attempts in six patients (7.5%). The time to guide wire insertion was 31.26 s (19-58 s), and catheter insertion took 88.44 s (63-145 s). The mean length of catheter insertion was 10.46 cm. No complications were noted. Conclusion: Ultrasound-guided supraclavicular BCV catheterization offers a new and safe method for central venous line catheterization in adults. However, larger trials and meta-analyses are needed to confirm these findings and evaluate the safety of this technique.

Axillary vein puncture versus cephalic vein cutdown for cardiac implantable electronic device implantation: A meta-analysis.

INTRODUCTION: Cephalic vein cutdown (CVC) and axillary vein puncture (AVP) are both recommended for transvenous implantation of leads for cardiac implantable electronic devices (CIEDs). Nonetheless, it is still debated which of the two techniques has a better safety and efficacy profile. METHODS: We systematically searched Medline, Embase, and Cochrane electronic databases up to September 5, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary endpoints were acute procedural success and overall complications. The effect size was estimated using a random-effect model as risk ratio (RR) and relative 95% confidence interval (CI). RESULTS: Overall, seven studies were included, which enrolled 1771 and 3067 transvenous leads (65.6% [n = 1162] males, average age 73.4 ± 14.3 years). Compared to CVC, AVP showed a significant increase in the primary endpoint (95.7 % vs. 76.1 %; RR: 1.24; 95% CI: 1.09-1.40; p = .001) (Figure 1). Total procedural time (mean difference [MD]: -8.25 min; 95% CI: -10.23 to -6.27; p < .0001; I2  = 0%) and venous access time (MD: -6.24 min; 95% CI: -7.01 to -5.47; p < .0001; I2  = 0%) were significantly shorter with AVP compared to CVC. No differences were found between AVP and CVC for incidence overall complications (RR: 0.56; 95% CI: 0.28-1.10; p = .09), pneumothorax (RR: 0.72; 95% CI: 0.13-4.0; p = .71), lead failure (RR: 0.58; 95% CI: 0.23-1.48; p = .26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15-2.23; p = .43), device infection (RR: 0.95; 95% CI: 0.14-6.60; p = .96) and fluoroscopy time (MD: -0.24 min; 95% CI: -0.75 to 0.28; p = .36). CONCLUSION: Our meta-analysis suggests that AVP may improve procedural success and reduce total procedural time and venous access time compared to CVC.

Supraclavicular cephalic vein draining into the internal jugular vein via the external jugular vein.

PURPOSE: The aim of this study is to report rare anatomical variations of the cephalic vein (CV) in a 77-year-old Korean male cadaver. CASE REPORT: On the right upper arm, the CV located lateral to the deltopectoral groove passed anterior to the clavicle at the lateral one-fourth of the clavicle without anastomosis to the axillary vein. It was connected to the transverse cervical and suprascapular veins by two communicating branches in the middle of its course at the neck, and opened into the external jugular vein at its junction with the internal jugular veins. The suprascapular and anterior jugular veins were flowed into the subclavian vein at the jugulo-subclavian venous confluence, and were connected by a short communicating branch. CONCLUSION: Detailed knowledge of the variations in the CV is expected to be helpful in decreasing unpredicted injuries and possible postoperative complications when invasive venous access is performed through the CV.

Ultrasonographic Evaluation of Intravenous Lobular Capillary Hemangioma in the Cephalic Vein.

A 60-year-old man presented with focal swelling on the dorsal surface of the left wrist. The sonographic exam revealed the presence of a smoothly rounded hypoechoic mass, with internal blood flow in the lumen of the vein. The histopathological findings led to the diagnosis of intravenous lobular capillary hemangioma (LCH). Here, we reported an intravenous LCH arising from the cephalic vein on the dorsal surface of the left wrist hand and discussed the related ultrasonographic findings.

Immersion ultrasonography improves the repeatability of cephalic vein diameter measurements for inexperienced operators.

OBJECTIVE: To reduce the empirical dependence of ultrasound measurement of the cephalic vein diameter, improve the repeatability of measurements for inexperienced operators, and provide a new method for inexperienced operators. METHODS: Operators without ultrasound experience used contact ultrasound and immersion ultrasound to measure the diameter of the cephalic vein. The intraobserver and interobserver repeatability of measurements obtained via the two methods were analyzed. RESULTS: The intraobserver and interobserver repeatability of the cephalic vein diameter measured via contact ultrasound by inexperienced operators were average, with intraclass correlation coefficients (ICCs) of 0.572 (95% CI: 0.239-0.759) and 0.405 (95% CI: -0.057-0.666), respectively. The intraobserver and interobserver reproducibility of the cephalic vein diameter measured by immersion ultrasound were very good, with ICCs of 0.955 (95% CI: 0.922-0.975) and 0.943 (95% CI: 0.900-0.967), respectively. In the Bland-Altman diagram of the intraobserver and interobserver agreement of the immersion ultrasound measurements of the cephalic vein diameter, 96% of the points fell within the 95% limits of agreement. CONCLUSION: Immersion ultrasonography can be used to measure the cephalic vein diameter while reducing the dependence of the results on operator experience; inexperienced operators can achieve very good repeatability.

Distal arteriovenous fistula formation after percutaneous coronary intervention: An old complication of a new access site.

Dorsal or distal transradial artery access has recently gained popularity due to several perceived benefits that include favorable ergonomics, the potential for rapid hemostasis and lower rates of vascular complications. Still, no vascular access site is free of complications and reports of hematoma and pseudoaneurysm formation related to distal radial artery access have been reported in the literature. We present a case of a 71-year-old male who developed an arteriovenous fistula (AVF) involving the distal left radial artery following repeated access of the artery. This rare complication is likely avoidable with a comprehensive understanding of the surrounding anatomy and proper procedural technique, including the routine use of ultrasound for access.

Exclusively cephalic venous access for cardiac resynchronisation: A prospective multi-centre evaluation.

BACKGROUND: Small series has shown that cardiac resynchronisation therapy (CRT) can be achieved in a majority of patients using exclusively cephalic venous access. We sought to determine whether this method is suitable for widespread use. METHODS: A group of 19 operators including 11 trainees in three pacing centres attempted to use cephalic access alone for all CRT device implants over a period of 8 years. The access route for each lead, the procedure outcome, duration, and complications were collected prospectively. Data were also collected for 105 consecutive CRT device implants performed by experienced operators not using the exclusively cephalic method. RESULTS: A new implantation of a CRT device using exclusively cephalic venous access was attempted in 1091 patients (73.6% male, aged 73 ± 12 years). Implantation was achieved using cephalic venous access alone in 801 cases (73.4%) and using a combination of cephalic and other access in a further 180 (16.5%). Cephalic access was used for 2468 of 3132 leads implanted (78.8%). Compared to a non-cephalic reference group, complications occurred less frequently (69/1091 vs 12/105; P = .0468), and there were no pneumothoraces with cephalic implants. Procedure and fluoroscopy duration were shorter (procedure duration 118 ± 45 vs 144 ± 39 minutes, P < .0001; fluoroscopy duration 15.7 ± 12.9 vs 22.8 ± 12.2 minutes, P < .0001). CONCLUSIONS: CRT devices can be implanted using cephalic access alone in a substantial majority of cases. This approach is safe and efficient.

Does ligation of the dorsal branch of the cephalic vein affect the patency of a distal forearm arteriovenous fistula? A randomised study.

BACKGROUND: Whether ligation of the dorsal branch of the cephalic vein during the surgical establishment of the radiocephalic arteriovenous fistula (RCAVF) favorably or adversely affects the patency rate of the RCAVF remains controversial. We performed a randomized controlled trial to evaluate the effect of dorsal branch ligation on the patency rate of RCAVF. METHODS: A total of 115 patients who underwent surgical establishment were randomized to two groups treated with or without ligation of the dorsal branch of the cephalic vein during the surgical process. The primary patency rates of the RCAVF at 90, 270, and 360 days after the surgery and the secondary patency rates during a follow-up up to 1 year were compared. RESULTS: The patency rate did not differ significantly between the two groups at 3, 9, or 12 months after the procedure (P > 0.05). The combined primary patency rates of the RCAVF in patients from both groups at 3, 9 and 12 months after the procedure were 87.6, 82, and 74.5% respectively, while the combined secondary patency rate was 92.2% at the 1-year follow-up. The Log-rank test indicated that the initial patency rate and secondary patency rate did not differ significantly between the two groups (P = 0.674 and 0.759, respectively). CONCLUSION: This clinical study indicated that ligation of the dorsal branch of the cephalic vein does not significantly affect the patency of the arteriovenous fistula with a 1-year follow-up. TRIAL REGISTRATION: ISRCTN ISRCTN12288675, Registered 25 September 2019 in the ISRCTN registry. retrospectively registered.

Fluoroscopy-guided axillary vein access vs cephalic vein access in pacemaker and defibrillator implantation: Randomized clinical trial of efficacy and safety.

INTRODUCTION: The most widespread venous sites of access for implantation intravenous implantable cardiac electronic device (CIED) are the cephalic and subclavian vein. Fluoroscopy-guided axillary venous access is an alternative, but efficacy and safety have not been studied under equal conditions. The aim of the present study is to compare the efficacy and safety of fluoroscopy-guided axillary vs cephalic vein access in CIED implant. METHODS AND RESULTS: Two hundred and forty patients were randomized to receive CIED implantation by the fluoroscopy-guided axillary vein access vs cephalic vein access. The implantation success, the procedure times and the complications were recorded. A comparison of the results of operators was made. The success rate of the randomized venous access was superior in the axillary group than in cephalic (98.3% vs 76.7%, P < .001). Time to access (6.8 ± 3.1 minute vs 13.1 ± 5.8 minutes, P < .001) and implantation duration was significantly shorter in the axillary group than in the cephalic group (42.3 ± 11.6 minutes vs 50.5 ± 13.3 minutes, P < .001). There was no difference in the incidence of complication and inter-operator success rate, complications rate and time to access. CONCLUSION: The fluoroscopy-guided axillary venous access is safe and has a better success rate and faster execution time compared with the cephalic vein access. When the results were compared among the study operators, neither in the axillary nor in the cephalic group there were differences in the success rate, the complication rate, and the time to access. TRIAL REGISTRATION: www.clinicaltrials.gov, NCT03860090.

Long-term durability of Oakes salvage procedure to preserve Brescia-Cimino arteriovenous fistula.

BACKGROUND: In 2002, Oakes et al described a novel procedure designed to salvage the distal cephalic venous outflow of a Brescia-Cimino fistula by placing a prosthetic graft between the brachial artery in the antecubital space and the cephalic vein at the wrist. In this fashion, the more proximal veins were saved for future procedures. Their approach was reported and found to be successful in the short term, but the long-term durability of the Oakes procedure has not been described. This study aimed to determine the long-term primary, primary-assisted, and secondary patency rates of the brachial to distal cephalic vein Oakes procedure. METHODS: This is a retrospective review of a prospective database in a large, single institution. All patients who underwent the Oakes procedure from 1998 to 2012 were followed up to 2018. We reviewed the time to intervention, type of intervention, patency rates, and mortality of this patient population. RESULTS: Over the 5-year study period, 14 patients were identified who underwent the Oakes procedure, of whom seven (50%) were female. The average age was 55.7 years (range, 38-73 years). All patients had a previously placed Brescia-Cimino that was not suitable for dialysis but was patent. The average number of days to placement of an Oakes brachial to distal cephalic graft was 396 (range, 119-1167) days. A total of 71% (10) of patients underwent an intervention to maintain the graft, of whom 50% (5) underwent an angioplasty and 50% (5) had a thrombectomy/revision procedure. The average number of days to first intervention was 367.3 (range, 21-1048) days from Oakes placement. Of this cohort, 30% (3) of patients had a second intervention, of whom one (33%) underwent an angioplasty and two (66%) had revisions. One patient had a third and a fourth intervention at 39 days and 74 days, respectively, that were both angioplasties. The overall number of days the Oakes procedure remained usable from placement was 843.6 (range, 21-3790) days or 2.3 years. CONCLUSIONS: This study concluded that the Oakes procedure may extend the use of the distal dialysis access site by 2.3 years without increasing infection and is hence a durable solution that should be considered in patients requiring dialysis access.

Investigating the effect of local warming on vein diameter in the antecubital area in adults aged 20-40 years.

BACKGROUND: peripheral intravenous cannulation is the most prevalent invasive procedure performed on patients admitted to hospital. The procedure is not always easy to undertake and can lead to problems for the patient and nurse. Alongside various procedures, local warming is one technique that could be used to increase the diameter of superficial veins. This prospective non-randomised trial aimed to determine the effect of local warming on vein diameter in the antecubital area in adults aged 20-40 years. METHOD: the subjects included 55 volunteers who were in good health. The cephalic vein diameter of the right arm cubital area was measured for each participant using ultrasound guidance. The arm was warmed for 10 minutes using a heating device maintained at 42ºC. A second ultrasound scan was then undertaken immediately afterwards and cephalic vein diameter measured. RESULTS: local warming increased the cephalic vein diameter in the cubital area by 0.43±0.4 mm. There was no significant relationship between change in cephalic vein diameter and participants' gender, age or body mass index. CONCLUSION: the results indicate that the application of heat is an effective technique for venodilation and could be considered in emergencies or in cases when other veins are difficult to access.

The effect of oral hydration and localised heat on peripheral vein diameter and depth: A randomised controlled trial.

BACKGROUND: Accessing the peripheral veins for blood sampling and short-term peripheral intravenous catheter insertion is common in contemporary healthcare. Clinicians may apply heat or promote oral hydration to increase vein diameter and reveal veins to improve success rates. However, there is limited research that has examined the effect of these interventions on vein diameter and depth. OBJECTIVES: To determine the effect of localised heat and oral hydration on vein diameter and depth. DESIGN: A three arm parallel randomised controlled trial was undertaken with 39 healthy participants from a University. All participants fasted from food and fluid from midnight. At 10 am the next day, a mark was made at the cephalic (120 mm proximal from the radial styloid) and median cubital veins (at cubital fossa) with non-permanent ink and participants underwent baseline vein diameter and depth measurement using ultrasound. Participants were randomised to either a control, heat or hydration group. Participants in the hydration arm consumed 1 L of room temperature tap water, those in the heat group had a wheat bag applied to the area for 10 min and those in the control group had no intervention and were asked to sit quietly. A second measurement was undertaken immediately after the heat intervention and 1 h after the baseline measurement for those in the hydration and control groups. RESULTS: The application of localised heat and oral hydration did not affect the depth of the cephalic vein. Whilst hydration had no effect on median cubital vein depth, the application of heat did make this vein more superficial compared to the control group (p = 0.033). The application of heat resulted in a statistically significant (p = 0.006) increase in cephalic vein diameter compared to the control group, this effect did not occur with the median cubital vein (p = 0.087). Oral hydration resulted in a reduction in the mean diameter of both veins. Compared to the control group, the average median cubital vein diameter decreased by 0.57 mm (p = 0.003; 95% CI -0.940 to -0.193) and the cephalic vein reduced by 0.33 mm (p = 0.015; 95% CI -0.593 to -0.064) after oral hydration. CONCLUSION: The use of localised heat was inconsistent in its effect on vein diameter and depth. Oral hydration caused a reduction in vascular calibre in both the cephalic and median cubital veins. The promotion of water consumption to improve venepuncture success is not supported.

Vasoconstrictive responses of the cephalic vein during first-time cardiac implantable electronic device placement.

BACKGROUND: During cardiac implantable electronic device (CIED) implantation procedures cardiac leads have been mostly introduced transvenously. The associated injury to the selected vessel and adjacent tissues may induce reflex vasoconstriction. The aim of the study was to assess the incidence of cephalic vein (CV) vasoconstriction during first-time CIED implantation. MATERIALS AND METHODS: Of the 146 evaluated first-time CIED implantation procedures conducted in our centre in 2016, we selected those during which CV vasoconstriction was recorded. We focused on the stage of the procedure involving CV cutdown and/or axillary vein (AV)/subclavian vein (SV) puncture for lead insertion. Only cases documented via venography were considered. RESULTS: Vasoconstriction was observed in 11 patients (5 females and 6 males, mean age 59.0 ± 21.2 years). The presence of this phenomenon affected the stage of CIED implantation involving cardiac lead insertion to the venous system, in severe cases, requiring a change of approach from CV cutdown to AV/SV puncture. The extent of vasoconstriction front propagation was limited to the nearest valves. Histological examinations of collected CV samples revealed an altered spatial arrangement of myocytes in the tunica media at the level of leaflet attachment. CONCLUSIONS: Cephalic vein vasoconstriction is a rare phenomenon associated with accessing the venous system during first-time CIED implantation. The propagation of CV constriction was limited by the location of the nearest valves.

A novel technique for ligation of the cephalic vein reduces hemorrhaging during a two-in-one insertion of dual cardiac device leads.

The cutdown technique for the cephalic vein is a common access route for transvenous cardiac device leads (TVLs), and sometimes one cephalic vein can accomodate two TVLs. We examined a novel ligation technique to balance the hemostasis and lead maneuverability for this two-in-one insertion. A total of 22 patients scheduled for cardiac device implantations with two or more leads were enrolled. The ipsilateral cephalic vein was identified for inserting the TVLs with a cutdown. If two TVLs could be introduced into one cephalic vein, hemostasis was established by ligating the venous wall between the TVLs. We measured the amount of hemorrhaging per minute and the operators assessed the lead maneuverability before and after the ligation. We successfully implanted cardiac devices in 15 patients (68%) with this novel method, whereas only one TVL could be introduced via the cephalic vein in 7 patients. As for the successful patients, hemorrhaging from the gap was significantly reduced (5.6 ±â€¯7.3 to 0.41 ±â€¯0.36g/min, p = 0.016) after the novel ligation. The lead maneuverability was well maintained so there was no difficulty placing the leads into the cardiac chambers in all cases. No major complications were observed. In the present study, the novel ligation method provided significant hemostasis as well as a preserved maneuverability. It could be an optional choice for insertion of multiple TVLs.

Embryological and comparative description of the cephalic vein joining the external jugular vein: A case report.

The cephalic vein arises from the radial end of the dorsal venous arch. It turns around the radial border of the forearm and passes proximally along the arm to the shoulder, where it enters the axillary vein by penetrating the clavipectoral triangle. The cephalic vein is prone to vary at the antecubital fossa, where it forms numerous anastomoses. A male cadaver fixated with a 10% formalin solution was dissected during regular anatomy lessons. It was found that the cephalic vein crossed the upper third of the arm between two fasciculi of the deltoid muscle and reached the shoulder, where it passed above the acromion and crossed the posterior border of the clavicle in order to join the external jugular vein. The cephalic vein is one of the most used veins for innumerous activities, such as venipunctures and arteriovenous fistula creation. Furthermore, it is an anatomical landmark known for its consistent anatomy, as it possesses low rates of variability. Despite that, its anatomical variations are clinically and surgically significant and healthcare professionals must be aware of the variations of this vessel. We aim to report a rarely described variation of the cephalic vein and discuss its embryological, phylogenetic and clinical features.

[Transposition of the cephalic vein in free flap breast reconstruction: Technical note]. / Déroutage de la veine céphalique dans la reconstruction mammaire par lambeaux libres : note technique.

Free flaps have become a reliable practice for breast reconstruction. However, the venous congestion is still the most frequent reason of flap failure. It is due to bad quality of the internal mammary veins, a preferential superficial venous outflow of the flap or due to venous thrombosis. The transposition of the cephalic vein could useful in some cases. We describe the surgical technique and suggest an intraoperative algorithm. Seventeen patients (15 DIEP and 2 PAP) were included. Twenty nine point four percent had an unusable internal mammary vein, 23.5% a preferential superficial venous outflow and 47.1% a venous thrombosis. The length of the cephalic vein dissected varied from 15 to 25cm. The mean time of dissection was 39min. There was no flap failure after cephalic vein transposition. The sequelae were one or two scars on the arm without any functional morbidity. The transposition of the cephalic vein is a reliable, less morbid alternative in case of bad quality internal mammary vein with a good quality internal mammary artery, in case of an additional venous outflow necessity or in case of venous thrombosis.

Thrombolysis for pulmonary embolism using the superficial veins of the upper extremity.

This report describes a novel approach of accessing the superficial veins of the upper extremity for the treatment of pulmonary emboli (PE) with an ultrasound enhanced thrombolytic infusion catheter. In a patient suffering from saddle PE and impending right heart failure, separate basilic and cephalic venous access sites in the right arm were utilized to insert EKOS EndoWave Infusion Catheter (EKOS Corporation, Bothell, WA) insertion in each pulmonary artery (PA). This technique could be advantageous, particularly for patients at high risk for access site complications and those unable to lie supine for prolonged duration of infusion therapy.

The Impact of Patient Demographics, Anatomy, Comorbidities, and Peri-operative Planning on the Primary Functional Maturation of Autogenous Radiocephalic Arteriovenous Fistula.

OBJECTIVES: The aim of this study was to evaluate the collective and/or independent impact of patient demographics, comorbidities, anatomical factors, and peri-operative parameters on the primary functional maturation of RCAVFs. This study also aimed to identify the range and best cut off value for each variable and evaluate the likelihood, significance and percentage of primary functional maturation of RCAVFs. METHODS: This was a prospective consecutive single centre cohort study over a 4 year period; it was conducted on patients with the intention-to-treat using a radiocephalic arteriovenous fistula (RCAVF) (Brescia-Cimino). During this period 548 vascular access procedures, inclusive of RCAVF, were performed. Variables included patient demographics (age, gender), anatomical variance (cephalic vein, radial artery diameter, laterality), comorbidities (diabetes mellitus, ischaemic heart disease, congestive cardiac failure, hypertension), aetiology of renal failure, and anaesthesia type (local versus general anaesthesia). RESULTS: Of the total, 324 patients, cephalic vein diameter > 1.5 mm (OR 4.57, 95% CI, 2.42-8.63, p < .001) (non-augmented) and radial artery diameter > 1.6 mm (OR 12.26, 95% CI, 6.27-23.97, p < .001) were found to be independently associated with the primary functional maturation of 86% in the RCAVF formation. CONCLUSION: Of all the variables, cephalic vein and radial artery diameter are independently associated with the primary functional maturation of RCAVFs.