Creating reverse flow arteriovenous fistulas with a forearm cannulation target

Background: Establishing a forearm arteriovenous fistula (AVF) offers preferred cannulation sites and preserves proximal access opportunities. When a radiocephalic AVF at the wrist is not feasible and the upper arm cephalic and median cubital veins are inadequate, an AV graft or more complex access procedure is often required. Creating a retrograde flow forearm AVF (RF-AVF) is a valuable alternative where the mid-forearm median antebrachial or cephalic vein is adequate, offering forearm cannulation zones with AVF outflow through deep and superficial collaterals. We report our technique and results. Methods: We retrospectively reviewed our vascular access data base of consecutive patients during an 11-year study period where a RF-AVF established the only available cannulation target in the forearm. In addition to physical examination, all patients had ultrasound vessel mapping. Results: A forearm access was established with a RF-AVF as the only opportunity for cannulation in 48 patients. Ages were 14–86 years (median = 62 years). Forty-four percent female, 63% diabetic, 13% obese, and 29% had previous access operations. Inflow was proximal radial artery in 47 individuals and one proximal ulnar. Nine AVFs (19%) failed at 2–66 months (median 14 months). One RF-AVF was ligated due to arm edema. Follow-up was 2–111 months (median = 23.5 months). Primary and cumulative patency rates were 62% and 91% at 12 months, and 46% and 85% at 24 months. Five patients were lost to follow-up with functioning RF-AVFs (mean 41 months). Twenty-three patients (48%) died during F/U of causes unrelated to access procedures (mean 25 months). Conclusions: Establishing a reverse flow forearm AVF offers a successful autogenous access option in the forearm for selected patients with an inadequate distal radial artery and/or cephalic vein at the wrist, avoiding more complex or staged procedures and preserving upper arm sites for future use. A proximal radial artery inflow procedure is recommended.

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Results of combined stereotactic radiosurgery and transarterial embolization for dural arteriovenous fistulas of the transverse and sigmoid sinuses

Journal of Neurosurgery ◽

10.3171/jns.2001.94.6.0886 ◽

2001 ◽

Vol 94 (6) ◽

pp. 886-891 ◽

Cited By ~ 81

Author(s):

Jonathan A. Friedman ◽

Bruce E. Pollock ◽

Douglas A. Nichols ◽

Deborah A. Gorman ◽

Robert L. Foote ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Transarterial Embolization ◽

Symptom Relief ◽

Related Complication ◽

Content Type ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Lost To Follow Up ◽

Fine Print

Object. Most dural arteriovenous fistulas (DAVFs) of the transverse and sigmoid sinuses do not have angiographically demonstrated features associated with intracranial hemorrhage and, therefore, may be treated nonsurgically. The authors report their experience using a staged combination of radiosurgery and transarterial embolization for treating DAVFs involving the transverse and sigmoid sinuses. Methods. Between 1991 and 1998, 25 patients with DAVFs of the transverse and/or sigmoid sinuses were treated using stereotactic radiosurgery; 22 of these patients also underwent transarterial embolization. Two patients were lost to follow-up review. Clinical data, angiographic findings, and follow-up records for the remaining 23 patients were collected prospectively. The mean duration of clinical follow up after radiosurgery was 50 months (range 20–99 months). The 18 women and five men included in this series had a mean age of 57 years (range 33–79 years). Twenty-two (96%) of 23 patients presented with pulsatile tinnitus as the primary symptom; two patients had experienced an earlier intracerebral hemorrhage (ICH). Cognard classifications of the DAVFs included the following: I in 12 patients (52%), IIa in seven patients (30%), and III in four patients (17%). After treatment, symptoms resolved (20 patients) or improved significantly (two patients) in 96% of patients. One patient was clinically unchanged. No patient sustained an ICH or irradiation-related complication during the follow-up period. Seventeen patients underwent follow-up angiographic studies at a mean of 21 months after radiosurgery (range 11–38 months). Total or near-total obliteration (> 90%) was seen in 11 patients (65%), and more than a 50% reduction in six patients (35%). Two patients experienced recurrent tinnitus and underwent repeated radiosurgery and embolization at 21 and 38 months, respectively, after the first procedure. Conclusions. A staged combination of radiosurgery and transarterial embolization provides excellent symptom relief and a good angiographically verified cure rate for patients harboring low-risk DAVFs of the transverse and sigmoid sinuses. This combined approach is a safe and effective treatment strategy for patients without angiographically determined risk factors for hemorrhage and for elderly patients with significant comorbidities.

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Transcranial Doppler Ultrasound Screening in Urban Pediatric Sickle Cell Center - Better Charting Improves Compliance over Published Rates

Blood ◽

10.1182/blood.v128.22.4749.4749 ◽

2016 ◽

Vol 128 (22) ◽

pp. 4749-4749

Author(s):

Ariel Gliksberg ◽

Christopher McCauley ◽

Lewis L. Hsu

Keyword(s):

Medical Record ◽

Electronic Medical Record ◽

Sickle Cell ◽

Research Funding ◽

Chart Review ◽

Ultrasound Screening ◽

Patients Âgés ◽

Lost To Follow Up

Abstract Background: TranscranialDoppler ultrasound (TCD) screening for stroke risk is one of the major advances in pediatric sickle cell disease, since the landmark STOP study. TCD screening is among the measures for quality of pediatric sickle cell care proposed by expert consensus (Wang 2011, NHLBI guidelines 2014). Reeves et al 2016 shows that TCD screening rates are low but still improving (22% in 2006 -44% in 2010). To improve the quality-of-care provided to pediatric sickle cell patients at University of Illinois Hospital, we conducted chart review in 2014 to establish a baseline report of UI Hospitalsadherence to the expert care standards. At that time TCD screening rates were much lower than immunization rates. We then introduced a reminder table in the electronic medical record. 18 months since this change in EMR we re-evaluated our compliance with TCDs. Objectives: To evaluate the improvement atUIHealthpediatric sickle cell clinic compliance with annual TCD. Methods: A manual chart review of these pediatric sickle cell patients was employed to determine adherence to TCD screening standards. All patients ages 2-16yowith SCD-SS and SCD-S/Beta-0-thalassemia that were seen in pediatric sickle cell clinic and adolescent-adult transition clinics two times over 15 months from 2/1/15-5/1/16 were included in study. TCD compliance was determined if patient had TCD between 5/1/2015 through 5/31/16. 5-15 minutes per patient was spent evaluating EMR for TCD compliance Data from the 2014 previous study was also re-evaluated using the same criteria of 2 visits within 15 months of original study date and TCD within 1 year of study. Results: In this work, the charts of 91 pediatric SCD-SS and SCD-S/Beta0 patients were reviewed (ages 2-16 years; M: 34 F 28, 5 ineligible [2 on chronic transfusion, 1 high hemoglobin, 1 yearly MRI, 1 last visit before 2yo]. Lost to follow-up (Seen in clinic since 2014 but not 2 visits from 2/1/15-5/1/16): 24 The rate of TCD screening among these eligible children was 53 out of 62, or 85.5% in 2016. Comparable figures from the 2014 chart review were 17 out of 27, or 63% in 2014. Fishers exact test indicates that this was a significant improvement, p=0.05. Conclusions: We focused our quality-improvement efforts onTranscranialDoppler screening, adding a reminder table in the Electronic Medical Record then re-assessing 18 months later. The rate of TCD screening significantly improved from 63% to 85%. Although less than 100%, these compare favorably to other published TCD rates (Table). The next step is to improve clinic attendance and tracking, to reduce the rate of patients who are "lost to follow-up." To facilitate future chart reviews we have incorporated the key parameters into our "Screening & Management Table" as a component of the electronic medical record. Table Table. Disclosures Hsu: Purdue Pharma: Research Funding; Mast Therapeutics: Research Funding; Eli Lilly: Research Funding; Sancilio: Research Funding; Centers for Medicare and Medicaid Innovation: Research Funding; Pfizer: Consultancy, Research Funding; EMMI Solutions: Consultancy; Gerson Lehman Group: Consultancy; Astra Zeneca: Consultancy, Research Funding; Hilton Publishing: Consultancy, Research Funding.

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Creating Arteriovenous Fistulas in 132 Consecutive Patients: Exploiting the Proximal Radial Artery Arteriovenous Fistula: Reliable, Safe, and Simple Forearm and Upper Arm Hemodialysis Access

Yearbook of Vascular Surgery ◽

10.1016/s0749-4041(08)70622-5 ◽

2007 ◽

Vol 2007 ◽

pp. 369-370

Author(s):

G.L. Moneta

Keyword(s):

Arteriovenous Fistula ◽

Radial Artery ◽

Hemodialysis Access ◽

Upper Arm ◽

Arteriovenous Fistulas

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Efficacy and comparison of elevation transposition and lipectomy for superficialization of cephalic arteriovenous fistula veins

The Journal of Vascular Access ◽

10.1177/1129729818757709 ◽

2018 ◽

Vol 19 (4) ◽

pp. 350-357 ◽

Cited By ~ 1

Author(s):

Michele S Wang ◽

Shouwen Wang

Keyword(s):

Ambulatory Surgery ◽

Primary Patency ◽

Secondary Patency ◽

Upper Arm ◽

Arteriovenous Fistulas ◽

Second Stage ◽

Ambulatory Surgery Center ◽

The Mean ◽

Surgery Center

Objective: Substantial percentages of cephalic arteriovenous fistulas are situated too deep and require superficialization before use for hemodialysis. The superficialization techniques are diverse: tunnel transposition, elevation, elevation transposition, and lipectomy. Since the fistula veins are not mobilized during lipectomy, it is believed that lipectomy produces better outcomes than other techniques. However, no available report directly compares lipectomy with other techniques. The objective of this report is to compare the outcomes of cephalic elevation transposition with lipectomy. Methods: The clinical data of patients who underwent second-stage cephalic elevation transposition or lipectomy at an ambulatory surgery center from 2009 to 2017 were analyzed ( n = 153). Results: Comparing the cephalic elevation transposition group ( n = 125) with the lipectomy group ( n = 28), the mean body mass index was 36.8 ± 7.6 versus 38.1 ± 7.2 ( p = 0.41); the percentage of upper arm fistulas was 84% versus 61% ( p < 0.01); the mean follow-up was 20.1 ± 17.5 versus 38.6 ± 24.4 months ( p < 0.01); the primary patency rates of the whole fistula conduits were 42% versus 50% at 1 year ( p = 0.08); the secondary patency rates were 99% versus 100% at 1 year ( p = 0.22); the primary patency rates of the superficialized vein segments were 73% versus 68% at 1 year ( p = 0.72); and the mean number of percutaneous interventions required for the superficialized vein segments was 0.49 ± 1.10 versus 0.43 ± 0.71 per access-year ( p = 0.74). Conclusion: Cephalic elevation transposition and lipectomy are both reliable techniques for superficialization of cephalic fistula veins and their outcomes are comparable.

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Untreated congenital hypothyroidism due to loss to follow-up: developing preventive strategies through quality improvement

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2018-0149 ◽

2018 ◽

Vol 31 (9) ◽

pp. 987-994

Author(s):

Kristal Anne Matlock ◽

Sarah Dawn Corathers ◽

Nana-Hawa Yayah Jones

Keyword(s):

At Risk ◽

Quality Improvement ◽

Congenital Hypothyroidism ◽

Practice Guidelines ◽

Provider Education ◽

Loss To Follow Up ◽

Patients Âgés ◽

Provider Adherence ◽

Lost To Follow Up

Abstract Background Children with congenital hypothyroidism (CH) are at risk for preventable intellectual disability without adequate medical management. The purpose of this manuscript is to discuss quality improvement (QI)-based processes for improving provider adherence to practice guidelines and ultimately identifying at-risk patients with chronic illness prior to the occurrence of adverse events. Methods Our study population included patients ages ≤3 years diagnosed with CH; lost to follow-up was defined as >180 days since last evaluation by an endocrinology provider. Iterative testing of interventions focused on establishing standardized care through (1) registry-based identification, (2) scheduling future appointments during current visits, (3) outreach to patients lost to follow-up and (4) provider and family education of current practice guidelines. Results A population-validated, electronic medical registry identified approximately 100 patients ages ≤3 years diagnosed with CH; initially, 12% of patients met criteria for lost to follow-up. Through serial testing of interventions, the rate of loss to follow-up declined to the goal of <5% within 8 months. Additional measures showed improvement in provider adherence to standard of care. All patients identified as lost to follow-up initially were seen within the first 3 months of intervention. Conclusions Applying QI methodology, a multidisciplinary team implemented a process to identify and contact high-risk CH patients with inadequate follow-up. Focused interventions targeting population management, scheduling and patient/provider education yield sustained improvement in the percentage of patients with a chronic condition who are lost to follow-up.

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Patency Outcomes of Arteriovenous Fistulas and Grafts for Hemodialysis Access: A Trade-Off between Nonmaturation and Long-Term Complications

Kidney360 ◽

10.34067/kid.0000462020 ◽

2020 ◽

Vol 1 (9) ◽

pp. 916-924

Author(s):

Bram M. Voorzaat ◽

Cynthia J. Janmaat ◽

Koen E.A. van der Bogt ◽

Friedo W. Dekker ◽

Joris I. Rotmans

Keyword(s):

Cohort Study ◽

Retrospective Cohort ◽

Hemodialysis Access ◽

Short Term ◽

Upper Arm ◽

Trade Off ◽

Arteriovenous Fistulas ◽

Arteriovenous Grafts

BackgroundArteriovenous fistulas (AVFs) for hemodialysis (HD) are often associated with better outcomes than arteriovenous grafts (AVGs). We aimed to investigate vascular access (VA) outcomes and assessed if AVF nonmaturation outweighs long-term complications of AVGs.MethodsIn this multicenter, retrospective cohort study in The Netherlands, 1- and 3-year primary, primary assisted, secondary, and functional patency rates were calculated, and the incidence of adverse events and procedures was assessed. Functional patency of RCAVFs, upper arm AVFs, and AVGs was compared using Cox analyses.ResultsIn total, 1041 patients who received their first VA were included, of whom 863 had VAs that successfully matured. These patients were analyzed with a median follow-up of 25 months. The 1-year functional patency rates were 67%±2.0% for RCAVFs, 83%±2.0% for upper arm AVFs, and 85%±3.5% for AVGs. Three-year functional patency rates were 62%±2.0% for RCAVFs, 74%±2.0% for upper arm AVFs, and 69%±5% for AVGs. AVGs required more procedures per year (3.3 per year) of functional patency when compared with upper arm AVFs (1.8 per year).ConclusionsThe functional patency of AVFs and AVGs is comparable, although AVGs required more interventions to maintain usability for HD. The choice of VA is a trade-off between short-term advantages, favoring AVGs, and long-term advantages, favoring AVFs. Which VA is most appropriate depends on the patient’s prognosis and preferences.

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