Using CorMatrix for partial and complete (re)construction of arteriovenous fistulas in haemodialysis patients: (Re)construction of arteriovenous fistulas with CorMatrix

Introduction: CorMatrix is an acellular extracellular matrix that acts as a biological scaffold and remodels into site-specific tissue. We used it for the (re)construction of arteriovenous fistulas. Methods: In this prospective pilot case study, we used CorMatrix in six patients. We included patients who required vascular access reconstruction due to thrombosis of unsalvageable arteriovenous fistulas, patients with high-flow arteriovenous fistulas and patients with microvasculature in which autologous arteriovenous fistulas did not mature, requiring reconstruction with a graft. We sutured the CorMatrix plate into a tubular shape and then constructed arterial and venous anastomoses. Results: There were no periprocedural complications, CorMatrix-related infections, bleeding or limb swelling after the procedures. CorMatrix was first punctured after 8–10 weeks. In five patients, a percutaneous angioplasty due to CorMatrix stenosis was performed; in one patient, a stent was placed due to refractory stenosis. We observed eight thromboses during the observation period (four in one patient). Perianastomotic stenosis of CorMatrix and interdialytic hypotension were the causes of the thrombosis in five patients, cephalic arch stenosis in two patients and thromboembolism to the brachial artery and arteriovenous fistula in one patient. Thrombendarteriectomy was successful in 87.5% of patients, and one patient required arteriovenous fistula reconstruction. After a median observation period of 12.5 (range 4–23) months, all arteriovenous fistulas were patent, with a median brachial artery flow of 1450 (range 700–1700) mL/min. Conclusion: Arteriovenous fistula (re)construction with CorMatrix seems to be feasible and safe, with a relatively high incidence of neointimal hyperplasia, predominantly at venous anastomoses, but additional clinical studies are needed.

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Intraoperative use of transit time flow measurement improves patency of newly created radiocephalic arteriovenous fistulas in patients requiring hemodialysis

The Journal of Vascular Access ◽

10.1177/1129729820916561 ◽

2020 ◽

Vol 21 (6) ◽

pp. 990-996

Author(s):

Anna E Cyrek ◽

Johannes Bernheim ◽

Benjamin Juntermanns ◽

Peri Husen ◽

Arkadius Pacha ◽

...

Keyword(s):

Blood Flow ◽

Arteriovenous Fistula ◽

Transit Time ◽

Intraoperative Ultrasound ◽

Low Flow ◽

Flow Measurements ◽

Technical Problems ◽

Arteriovenous Fistulas ◽

Time Flow ◽

Observation Period

Background: The autologous arteriovenous fistula is the primary choice to establish hemodialysis access without high failure rates. Intraoperative ultrasound flow measurements of newly created autologous arteriovenous fistulas represent a possibility of quality control and may therefore be a tool to assess their functionality. The aim of our study was to correlate intraoperative blood flow with access patency. Methods: Between March 2012 and March 2015, intraoperative transit time flow measurements were collected on 89 patients. Measurements were performed 5–10 min after the creation of a standardized anastomosis using 3–6 mm flow probes. To examine the correlation between intraoperative blood flow and access patency, groups of patients with high (> 200 mL/min) versus low flow (< 200 mL/min) were enrolled. Patients were assessed clinically and with ultrasound every 3 months. Data were analyzed retrospectively. Results: In the current short-term follow-up, including 89 patients (age 62 ± 3 years), 61 (68.5%) of the autologous arteriovenous fistulas were currently being used in an observation period ranging from 3 months to 3 years (mean observation period 546 ± 95 days) postoperatively. The intraoperative blood flow in patients with functioning autologous arteriovenous fistula (78) was significantly higher than that of patients without functioning autologous arteriovenous fistulas (407 ± 25 vs 252 ± 42 mL/min, respectively; p < 0.005) (11). Conclusion: The intraoperative measurement of blood flow is a useful tool to predict the outcome of maturation in autologous arteriovenous fistula. With this method, technical problems can be detected and corrected intraoperatively. Routine implementation of intraoperative flow measurements has to be examined by prospective controlled trials.

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How to carry out monthly blood flow surveillance of fistula in large-scale hemodialysis units: A cross-sectional study

The Journal of Vascular Access ◽

10.1177/1129729820923939 ◽

2020 ◽

pp. 112972982092393

Author(s):

Ya-wen Mo ◽

Chun-yan Sun ◽

Li Song ◽

Li-fang Zhou ◽

Ting-ting Zhuang ◽

...

Keyword(s):

Blood Flow ◽

Arteriovenous Fistula ◽

Doppler Ultrasound ◽

Radial Artery ◽

Brachial Artery ◽

Dilution Technique ◽

Cross Sectional ◽

Duplex Doppler Ultrasound ◽

Duplex Doppler ◽

Artery Flow

Background: The important effect of regular blood flow surveillance on arteriovenous fistula maintenance is emphasized. The ultrasonic dilution technique for blood flow surveillance can be performed during hemodialysis, but there are some limitations. Blood flow is traditionally measured by duplex Doppler ultrasound during the nondialysis period. However, the surveillance workload for arteriovenous fistula has increased with the rapid increase in the hemodialysis population size. Efficient methods for blood flow surveillance during hemodialysis are needed. Methods: Eighty-four hemodialysis patients with a forearm radiocephalic arteriovenous fistula were enrolled in this cross-sectional study. Each received blood flow measurements using ultrasonic dilution technique and duplex Doppler ultrasound during hemodialysis. Duplex Doppler ultrasound measurements included the blood flow of the brachial artery and radial artery. The correlations between these variables were analyzed. Results: The correlation coefficients ( r) between flow measured by ultrasonic dilution technique and brachial artery flow measured by duplex Doppler ultrasound, between flow measured by ultrasonic dilution technique and radial artery flow measured by duplex Doppler ultrasound, and between brachial artery flow and radial artery flow measured by duplex Doppler ultrasound were 0.724, 0.784, and 0.749, respectively (all p < 0.001). Conclusion: Blood flow measured by ultrasonic dilution technique was positively correlated with blood flow measured by duplex Doppler ultrasound during hemodialysis, suggesting that duplex Doppler ultrasound can be used to monitor the trends in the blood flow of the brachial artery and radial artery for timely intervention to improve patency during hemodialysis.

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A novel technique of reimplantation of a radial artery that makes a hairpin turn to reduce the excessive vascular access flow in a dialysis patient

The Journal of Vascular Access ◽

10.1177/1129729820927910 ◽

2020 ◽

pp. 112972982092791

Author(s):

Sotaro Katsui ◽

Yoshinori Inoue ◽

Nishizawa Masato ◽

Kimihiro Igari ◽

Toshifumi Kudo

Keyword(s):

Arteriovenous Fistula ◽

Radial Artery ◽

Vascular Access ◽

Brachial Artery ◽

Chest Radiography ◽

Small Diameter ◽

Cardiac Preload ◽

A New Technique ◽

Artery Flow ◽

Distal Radial Artery

We report a new technique called “reimplantation of an artery with a hairpin turn (RAHT)” to reduce excessive vascular access flow. A 73-year-old woman on dialysis consulted us for vascular surgery because of an increased cardiac preload. Chest radiography and echocardiography revealed an excessive shunt flow in the brachial artery (flow rate, 2336 mL/min). Vascular echo-Doppler of the left upper limb showed that the radial artery made a hairpin turn at the arteriovenous fistula (diameter, 9 mm). Diameters of the radial artery proximal and distal to the arteriovenous fistula were 5.4 and 3.7 mm, respectively. We ligated and divided the juxta-anastomosis proximal radial artery and subsequently created an end-to-side anastomosis between the proximal radial artery and the distal radial artery. The anastomosis ostium in the distal radial artery (the recipient) was formed with a 4-mm longitudinal and gently curved incision. We performed RAHT so that the small anastomosis between both arteries and the small diameter of the distal radial artery juxta-anastomosis segment could reduce the vascular access flow. The flow rates in the brachial artery were 500 mL/min just after surgery and 560 mL/min at 2 months after surgery. Postoperative chest radiography and echocardiography confirmed a decrease in cardiac preload. We believe that this RAHT technique could be useful as one of the options to reduce the flow in patients who have excessive vascular access flow with a radial artery that makes a hairpin turn.

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Diameter of inflow as a predictor of radiocephalic fistula flow

The Journal of Vascular Access ◽

10.1177/1129729818761306 ◽

2018 ◽

Vol 19 (6) ◽

pp. 548-554 ◽

Cited By ~ 5

Author(s):

Lukas K Kairaitis ◽

James P Collett ◽

Jan Swinnen

Keyword(s):

Arteriovenous Fistula ◽

Doppler Ultrasound ◽

Brachial Artery ◽

Indicator Dilution ◽

Low Flow ◽

Optimal Method ◽

Luminal Diameter ◽

Minimal Luminal Diameter ◽

Artery Flow ◽

The Relationship

Introduction: The optimal method for vascular access surveillance is largely unknown. A previous case–control study suggested a simplified anatomical measure obtained by Doppler ultrasound—the narrowest segment of the circuit or “minimal luminal diameter” may identify patients with a dysfunctional radiocephalic arteriovenous fistula. The relationship between minimal luminal diameter and access flow (Qa) in the radiocephalic arteriovenous fistula has not previously been studied. Methods: Patients undergoing Doppler ultrasound of a radiocephalic arteriovenous fistula over an 8-month period were identified retrospectively. Minimal luminal diameter was identified and demographic and clinical data were collected. Qa was estimated by Doppler estimation of brachial artery flow. The relationship between minimal luminal diameter and Qa was examined by correlation and using different levels of minimal luminal diameter as a simplified measure to detect or exclude low Qa (<600 mL/min). Results: A total of 81 Doppler ultrasound scans were performed. In all, 26 scans demonstrated brachial artery flow <600 mL/min. Simple logistic regression indicated a weak statistical relationship between the minimal luminal diameter and Qa (R2 = 0.27, p < 0.01). Minimal luminal diameter performed poorly as a marker of low Qa with low specificity, however, showed high negative predictive value for ruling out low Qa at a minimal luminal diameter of 3.2 mm or higher (94%). Qa estimated by brachial artery flow correlated well with Qa estimated by indicator dilution (R2 = 0.83, p < 0.01) without significant mean difference or proportional bias. Conclusion: Minimal luminal diameter correlates weakly with Qa. Low minimal luminal diameter values should not be used in isolation to determine low Qa for a radiocephalic arteriovenous fistula. Conversely, minimal luminal diameter >3.2 mm largely excludes a low-flow radiocephalic arteriovenous fistula in this cohort. Brachial artery flow is a reasonable measure of Qa in comparison with indicator dilution.

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Long-term outcomes of lateral tunneled transposed brachiobasilic arteriovenous fistulas in elderly hemodialysis patient

The Journal of Vascular Access ◽

10.1177/1129729818820184 ◽

2019 ◽

Vol 20 (5) ◽

pp. 557-562 ◽

Cited By ~ 2

Author(s):

Yen-Chin Lin ◽

Yu-Ying Huang ◽

Ming-Yen Lin ◽

Yi-Wen Chiu ◽

Lee-Moay Lim ◽

...

Keyword(s):

Arteriovenous Fistula ◽

Medical Center ◽

Adverse Outcomes ◽

Long Term Outcomes ◽

Two Stage ◽

Vascular Intervention ◽

Arteriovenous Fistulas ◽

Significant Difference ◽

Observation Period

Background: Arteriovenous fistula is recommended for the general dialysis population, but its use remains controversial in the elderly population. We evaluated the long-term outcomes of lateral tunneled transposed brachiobasilic arteriovenous fistulas in older patients who underwent hemodialysis. Methods: In this retrospective cohort study, we included patients who received a two-stage transposed brachiobasilic arteriovenous fistula in a medical center from May 2005 to January 2014. The patients were followed up from the fistula placement date until any intervention, death, failure, January 2015, or the end of the sixth year. Death and arteriovenous fistula failure during the observation period were considered as adverse outcomes, and the cause of death was identified. The cumulative patency rate was calculated using the Kaplan–Meier approach to reveal the long-term outcomes of this procedure. Results: Among the 66 patients who underwent surgery, the average age was 65.8 ± 13.5 years and the majority were females (62.1%). After a median follow-up of 20.6 months, 19 patients died, 12 (18.2%) received vascular intervention, and 3 experienced fistula failure. No significant difference was observed in the 6-year cumulative patency rates between younger and older adults (96.3% vs 80.3%, p = 0.58). None of the deaths during the observation period were related to bloodstream infection. Conclusion: A two-stage lateral tunneled transposed brachiobasilic arteriovenous fistula can be applied to patients undergoing hemodialysis, regardless of age.

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Brachial artery aneurysm as a late complication of arteriovenous fistula

The Journal of Vascular Access ◽

10.1177/11297298211059326 ◽

2021 ◽

pp. 112972982110593

Author(s):

Jana Janeckova ◽

Petr Bachleda ◽

Marketa Koleckova ◽

Petr Utikal

Keyword(s):

Kidney Transplantation ◽

Arteriovenous Fistula ◽

Brachial Artery ◽

Late Complication ◽

Artery Aneurysm ◽

Primary Patency ◽

Arterial Diameter ◽

Distal Embolization ◽

Brachial Artery Diameter ◽

Arteriovenous Fistulas

Introduction: Brachial artery aneurysm (BAA) is a rare late complication of arteriovenous fistula (AVF). It brings the risk of peripheral embolism and hand ischemia and is defined by brachial artery diameter above 10 mm or by regional dilatation by >50%. BAA is described in the literature in closed radiocephalic arteriovenous fistulas after kidney transplantation. The aim of the study was to analyze the prevalence of BAA and of their more dangerous forms. Method: A observational one center study performed on patients after kidney transplantation with AVF or arteriovenous graft (AVG). We invited all patients followed up for kidney transplantation in our center. Arterial diameter greater than 10 mm was considered as a brachial artery aneurysm to simplify the detection and evaluation of aneurysms. Results: About 162 patients with AVF after kidney transplantation were examined between 4/2018 and 4/2020. Brachial artery aneurysm was detected in 34 patients (21%) with AVF or AVG, of them 7 had confirmed wall thrombi. AVF flow volume of more than 1500 ml/min increased the risk of BAA development by 4.54x. Eight aneurysms were treated surgically. After this surgery, the primary patency was 87.5% in 12 months. Conclusion: Brachial artery aneurysm was relatively frequent in our study compare to the literature. Aneurysm or dilatation of the brachial artery is more frequent in functional AVFs. Surgical correction is necessary in cases of complicated aneurysms to prevent distal embolization.

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Haemodynamics of Brachial Arteriovenous Fistula Development

The Journal of Vascular Access ◽

10.1177/112972980000100205 ◽

2000 ◽

Vol 1 (2) ◽

pp. 54-59 ◽

Cited By ~ 10

Author(s):

A.G. Martin ◽

M. Grasty ◽

P.A. Lear

Keyword(s):

Blood Flow ◽

Arteriovenous Fistula ◽

Brachial Artery ◽

Cephalic Vein ◽

Fistula Formation ◽

Post Exercise ◽

Digital Pressure ◽

Clinical Measurements ◽

A Prospective Study ◽

Artery Flow

This study observes the development of brachial arteriovenous fistulae, and assesses methods of predicting potential usefulness for haemodialysis. Creation of an adequate brachial fistula causes significant changes in blood flow to the forearm and hand. A prospective study of fifteen consecutive patients undergoing brachial arteriovenous fistula formation for haemodialysis was undertaken. Clinical measurements and coloured flow Doppler measurements were performed pre operatively, immediately post operatively and at two and eight weeks after surgery. The morphology of the fistula was studied and the volume flow was measured. Digital pressure was measured pre and post exercise at each visit. Fourteen fistulae worked well by eight weeks. There was an immediate large increase in brachial artery blood flow and by two weeks all fistulae that went on to develop well had a brachial artery flow of more than 700 mls/minute. The cephalic vein mean diameter pre operatively was 2.39 mm and increased to 5.4 mm by two weeks post operatively. Fistulae with flows over 400 mls/minute at two weeks had a good outcome. There were significant differences in digital pressure after fistula formation (P ≤ 0.05). Digital mean arterial pressure dropped from 118 mm Hg pre-operatively to 98 mm Hg post operatively, at rest, and 89 mm Hg after exercise. Four patients developed forearm/hand claudication on exercise or signs of distal ischaemia. Three of these were diabetic with calcified vessels. All patients with a suitable cephalic vein should have attempted fistula formation rather than recourse to use of a synthetic graft. In diabetics creating a shunt in an already marginally competent vascular tree exposes the patient to risk of significant hand ischaemia.

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Sonographic Evaluation of an Immature Brescia-Cimino Fistula

Journal of Diagnostic Medical Sonography ◽

10.1177/8756479317696792 ◽

2017 ◽

Vol 33 (3) ◽

pp. 240-244

Author(s):

Clare Chappell

Keyword(s):

Renal Disease ◽

Arteriovenous Fistula ◽

End Stage Renal Disease ◽

Common Cause ◽

Arteriovenous Fistulas ◽

Sonographic Evaluation ◽

Stage Renal Disease ◽

End Stage ◽

Vein Stenosis

Arteriovenous fistulas are known to be traumatic, congenital, or created for hemodialysis purposes in patients diagnosed with end-stage renal disease. In this case study of an immature Brescia-Cimino fistula, an outflow vein stenosis was assessed solely using sonography. This type of stenosis has been found to be the most common cause of fistula failure. This case study demonstrates how the use of sonography identified an immature arteriovenous fistula as well as assisted in further treatment planning and outcomes.

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