Dialysis access | ScienceGate

We discuss a case of a 58 year old male who presented for left upper extremity steal syndrome including ischemic monomelic neuropathy (IMN) 1.5 months after arteriovenous fistula creation. He presented after three surgical attempts to salvage his fistula with rest pain, complete loss of function with contracture of the 4th and 5th digits, and loss of sensation in the ulnar distribution for more than three weeks. At our institution, he underwent surgical ligation of the distal fistula and creation of a new fistula proximally, resulting in complete resolution of his vascular steal symptoms almost immediately despite the chronicity prior to surgical presentation. Our patient provides a unique perspective regarding dialysis access salvage versus patient quality of life. The patients’ functional status and pain levels should take precedence over salvage of an arteriovenous access site, and early ligation of the access should be completed prior to chronic IMN development. However, if a patient presents late along the IMN course, we recommend strong consideration of access ligation in order to attempt to regain the full neurovascular function of the extremity as we experienced in our patient.

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Subclavian vein and dialysis access planning.

American Journal of Roentgenology ◽

10.2214/ajr.157.5.1927801 ◽

1991 ◽

Vol 157 (5) ◽

pp. 1125-1126 ◽

Cited By ~ 1

Author(s):

N K Barrett ◽

E Brown ◽

J McIvor

Keyword(s):

Subclavian Vein ◽

Dialysis Access

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Current status of vascular access in Japan—from Dialysis Access Symposium 2017

The Journal of Vascular Access ◽

10.1177/1129729818762982 ◽

2019 ◽

Vol 20 (1_suppl) ◽

pp. 38-44

Author(s):

Mizuya Fukasawa

Keyword(s):

Vascular Access ◽

Current Status ◽

Good Survival ◽

Chronic Glomerulonephritis ◽

Dialysis Access ◽

Dialysis Patients ◽

Survival Prognosis ◽

Access Methods ◽

Number Of Patients ◽

Wide Range

At the second Dialysis Access Symposium held in Nagoya, Japan, a proposal was made to investigate the differences in vascular access methods used in different countries. In this article, we describe the management of vascular access in Japan. The Japanese population is rapidly aging, and the proportion of elderly patients on dialysis is also increasing. There were 325,000 dialysis patients in Japan at the end of 2015, of whom 65.1% were aged 65 years or above. The number of patients with diabetic nephropathy or nephrosclerosis as the underlying condition is also increasing, whereas the number with chronic glomerulonephritis is steadily decreasing. The Japanese health insurance system enables patients to undergo medical treatment at almost no out-of-pocket cost. Percutaneous transluminal angioplasty suffers from a severe device lag compared with other countries, but although there are limitations on permitted devices, the use of those that have been authorized is covered by medical insurance. One important point that is unique to Japan is that vascular access is performed and managed by doctors involved in dialysis across a wide range of disciplines, including nephrologists, surgeons, and urologists. This may be one factor contributing to the good survival prognosis of Japanese dialysis patients.

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Age is just a number: Is frailty being ignored in vascular access planning for dialysis?

The Journal of Vascular Access ◽

10.1177/1129729821989902 ◽

2021 ◽

pp. 112972982198990

Author(s):

Kulli Kuningas ◽

Nicholas Inston

Keyword(s):

Decision Making ◽

Kidney Disease ◽

Vascular Access ◽

Clinical Condition ◽

The Elderly ◽

Dialysis Access ◽

Adverse Health Outcomes ◽

Risk Of Mortality ◽

Increased Risk ◽

First Choice

Current international guidelines advocate fistula creation as first choice for vascular access in haemodialysis patients, however, there have been suggestions that in certain groups of patients, in particular the elderly, a more tailored approach is needed. The prevalence of more senior individuals receiving renal replacement therapy has increased in recent years and therefore including patient age in decision making regarding choice of vascular access for dialysis has gained more relevance. However, it seems that age is being used as a surrogate for overall clinical condition and it can be proposed that frailty may be a better basis to considering when advising and counselling patients with regard to vascular access for dialysis. Frailty is a clinical condition in which the person is in a vulnerable state with reduced functional capacity and has a higher risk of adverse health outcomes when exposed to stress inducing events. Prevalence of frailty increases with age and has been associated with an increased risk of mortality, hospitalisation, disability and falls. Chronic kidney disease is associated with premature ageing and therefore patients with kidney disease are prone to be frailer irrespective of age and the risk increases further with declining kidney function. Limited data exists on the relationship between frailty and vascular access, but it appears that frailty may have an association with poorer outcomes from vascular access. However, further research is warranted. Due to complexity in decision making in dialysis access, frailty assessment could be a key element in providing patient-centred approach in planning and maintaining vascular access for dialysis.

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The Impact of Clinical Presentation on Survival in Patients Requiring Hemodialysis Catheters for Acute and Unplanned Dialysis: A Prospective Observational Study

Canadian Journal of Kidney Health and Disease ◽

10.1177/20543581211009986 ◽

2021 ◽

Vol 8 ◽

pp. 205435812110099

Author(s):

Benjamin Talbot ◽

Ray Lin ◽

Qiang Li ◽

Min Jun ◽

Sradha Kotwal ◽

...

Keyword(s):

Observational Study ◽

Clinical Presentation ◽

High Risk Patient ◽

Renal Unit ◽

Dialysis Access ◽

Hemodialysis Access ◽

All Cause Mortality ◽

Maintenance Dialysis ◽

The Impact ◽

Unplanned Dialysis

Background: Most studies addressing hemodialysis initiation with a dialysis catheter focus on patients entering maintenance dialysis programs and exclude other patients, such as those with acute kidney injury (AKI), making interpretation and application of the results difficult for clinicians managing patients at the time of dialysis commencement. Objective: To compare the survival of all patients requiring a catheter for hemodialysis access according to the nature of clinical presentation. Design: Prospective observational. Setting: An Australian tertiary renal unit. Patients: All patients requiring a central venous catheter (CVC) for hemodialysis access between 2005 and 2015. Measurements: Baseline comorbidities, demographics, and nature of clinical presentation. Data regarding each episode of dialysis access insufficiency and each CVC were collected. The primary outcome was all-cause mortality. Methods: Patients were classified into 1 of 3 groups based on physician assessment at the time of presentation: patients believed to have AKI with expected renal recovery (AKI), patients considered to be entering the maintenance dialysis program without a functioning dialysis access (Maintenance Dialysis), patients unable to perform peritoneal dialysis, or use their existing hemodialysis access (Access Failure). Time-split multivariable Cox regression analyses were used to compare survival between groups. Results: A total of 557 eligible patients had complete prospective data regarding CVC use and were included in the analyses. The majority of patients were in the AKI (246/557, 44%) and Maintenance Dialysis groups (182/557, 33%) compared with the Access Failure group (129/557, 23%). During a median follow-up of 3 years, 302 (54%) of the 557 patients died. Following adjustment, risk of all-cause mortality was higher in the AKI group (hazard ratio [HR]: 2.01, 95% confidence interval [CI]: 1.31-3.60, P = .001) during the first 2 years after catheter insertion and lower in years 2 to 4 (HR: 0.42, 95% CI: 0.20-0.88, P = .02) than in the reference Maintenance Dialysis group. No difference in mortality risk between the Access Failure and reference group was found. Limitations: Single-center study. Possible residual confounding owing to the observational study design. Conclusions: Patients requiring acute or unplanned hemodialysis experience high mortality, and the nature of clinical presentation does influence outcomes. Most notable is the greater early mortality experienced by patients with AKI compared to other patient groups. Prospective definition of the nature of unplanned dialysis initiation is important to accurately measure and improve outcomes in this high-risk patient population. Human Research Ethics Committee Approval Number CH62/6/2017-042.

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Giant brachial artery aneurysm as a rare complication of a dialysis shunt

The Journal of Vascular Access ◽

10.1177/1129729819886746 ◽

2019 ◽

Vol 21 (5) ◽

pp. 799-802 ◽

Cited By ~ 1

Author(s):

Elisa Maria Schilling ◽

Malte Weinrich ◽

Thomas Heller ◽

Sebastian Koball ◽

Andreas Neumann

Keyword(s):

Brachial Artery ◽

Rare Complication ◽

Artery Aneurysm ◽

Giant Aneurysm ◽

Magnetic Resonance Imaging Scan ◽

Dialysis Access ◽

Large Tumor ◽

Arteriovenous Fistulas ◽

Arteriovenous Shunts ◽

Ongoing Care

Our patient exhibited a large tumor on his right upper arm where his former dialysis access site had been. X-ray, Doppler ultrasound, and magnetic resonance imaging scan could not fully reveal the nature of that tumor. Eventually, a surgical approach showed a giant aneurysm of the inflowing brachial artery to a partially obliterated arteriovenous fistula. This case highlights the importance of ongoing care for patients with arteriovenous shunts. Even arteriovenous fistulas, that are obliterated or no longer in use, can, especially when immunosuppressant therapy and other vascular risk factors are added to the overall cardiovascular risk, transform and endanger the health of our patients.

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Effectiveness and safety of repeated percutaneous intervention in an office-based endovascular center in maintaining hemodialysis access

Vascular ◽

10.1177/17085381211004306 ◽

2021 ◽

pp. 170853812110043

Author(s):

Jay Patel ◽

Stephanie Chang ◽

Shaan Manawar ◽

John Munn ◽

Mark C Rummel ◽

...

Keyword(s):

Percutaneous Intervention ◽

Dialysis Access ◽

Arteriovenous Graft ◽

Hemodialysis Access ◽

Upper Arm ◽

Access Site ◽

Arteriovenous Fistulas ◽

Arteriovenous Grafts ◽

The Mean

Objectives Percutaneous dialysis access interventions are routinely used to maintain the patency of dialysis access despite the lack of data regarding their long-term effectiveness. This retrospective study was undertaken to study the effectiveness and safety of percutaneous dialysis access interventions in arm fistulas and bridge grafts in an office-based endovascular center. Methods Patients who had a percutaneous dialysis access intervention in their upper extremity access site, performed at a single office-based endovascular center over a nine-year period (2007–2016) were included in this study. The patients’ demographic factors, patency, and complications were analyzed. Patients were entered in the study after first percutaneous dialysis access intervention. Results A total of 298 limbs in 259 patients had 913 procedures carried out over a nine-year period. There were 190 access arteriovenous fistulas and 108 arteriovenous grafts. The two most common arteriovenous fistulas were the brachiocephalic fistula ( n = 74, 39%) and radio cephalic fistula ( n = 69, 36%). Arteriovenous grafts were most commonly placed in the upper arm ( n = 66, 61%) followed by the forearm ( n = 42, 39%). The mean overall patency for all limbs was 50.86 months. Arteriovenous fistulas had a significantly longer patency than arteriovenous grafts (51.65 vs. 42.09 months; P = 0.01). In addition, patients with two or more percutaneous dialysis access intervention in their arteriovenous fistula had significantly greater patency than those with only one percutaneous dialysis access intervention (58.5 vs. 7.6 months; hazard ratio 0.41; P = 0.0008). This was not true for the arteriovenous graft group. Women represented 49% of the patient group. Their accesses had shorter patency than men (39.8 vs. 60 months; P = 0.0007). Conclusions This data support the use of repeated percutaneous dialysis access intervention to maintain long-term patency of dialysis access sites in an office-based endovascular center. Overall, fistulas have longer patency than grafts and women have poorer outcomes as compared to men

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Ultrasound evaluation of dialysis access-related distal ischaemia

The Journal of Vascular Access ◽

10.1177/1129729820932420 ◽

2021 ◽

pp. 112972982093242

Author(s):

N Pirozzi ◽

L De Alexandris ◽

J Scrivano ◽

L Fazzari ◽

J Malik

Keyword(s):

Differential Diagnosis ◽

Ultrasound Examination ◽

Preoperative Evaluation ◽

Signs And Symptoms ◽

Central Vein ◽

Dialysis Access ◽

Needed Information ◽

Vein Catheter ◽

Ultrasound Evaluation ◽

Central Vein Catheter

Dialysis access-related distal ischaemia is a rare yet potentially rather risky complication of haemodialysis angioaccess. Timely diagnosis is crucial to target both the goals of the access team: first of all to preserve the function of the hand ideally along with angioaccess patency. Unfortunately for some patients, urgent access ligation and central vein catheter insertion would be needed to save the hand. After a first clinical examination to determine the diagnostic suspicion, the ultrasound evaluation would provide nearly all the needed information to confirm the diagnosis and to determine the most appropriate procedure to rescue the patient from distal ischaemia. In some cases, photoplethysmography would help in the differential diagnosis of other non-ischaemic causes of similar signs and symptoms. Angiography would complete the preoperative evaluation for some. Dialysis access-related distal ischaemia would be briefly reviewed, and a deep description of the ultrasound examination tools and findings would be provided for a tailored therapeutic approach.

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