Use of chronically occluded fistula to establish access outflow

Maintaining a good quality vascular access in the long term can become particularly challenging especially in patients that are on dialysis for many years and present with exhausted venous capital and chronic access related complications. We present a 60-year-old female patient with multiple bilateral previous failed accesses, a previous distal revascularization interval ligation (DRIL) for hemodialysis access induced distal ischemia (HAIDI). Her chronically (more than a month) occluded arteriovenous fistula AVF was used to establish outflow and create a functioning forearm arteriovenous graft (AVG).

Dialysis Access-Associated Steal Syndrome with Percutaneous Endovascular Arteriovenous Fistula Creation.

Background: Dialysis access-associated steal syndrome is an infrequent complication after hemodialysis access creation. Clinical symptoms depend on the degree of steal. Mild symptoms include coldness, numbness and pain during dialysis. Severe steal can present with rest pain, cyanosis and ulcerations, and may require surgical ligation of the fistula. With recent advances in arteriovenous fistula creation, percutaneous endovascular arteriovenous fistula creation has demonstrated better maturation and patency rates with lower risk of wound healing and infection rates as compared to surgically created hemodialysis access. Percutaneous creation offers a minimally invasive alternative, though complications have been reported. The following presents the first described case of DASS following the use of percutaneous endovascular arteriovenous fistula creation, and discusses risk factors and management. Case Presentation: Our case is that of a 27-year-old male with end stage renal disease due to congenital renal dysplasia, who underwent left percutaneous arteriovenous fistula creation for initiation of dialysis. Two months after the procedure the patient complained of coldness, pain, tingling, and numbness in the left arm during dialysis, concerning for steal syndrome. The patient subsequently underwent brachial artery angiogram, which showed predominant flow through the fistula and minimal antegrade flow through the ulnar and interosseous arteries towards the hand, with a focal, severe stenosis in the distal ulnar artery. Angioplasty of the stenosis was performed, though steal symptoms continued. Conclusions: DASS, though rare, can be seen with percutaneous arteriovenous fistula creation. Identification of the risk factors prior to creation, especially in patients who are at higher risk of peripheral vascular disease, can help avoid this complication. Management is largely guided by clinical presentation. As long as there is adequate collateral supply to the extremity, single vessel occlusion is not a contraindication to percutaneous arteriovenous fistula creation with the use of WavelinQ technology. Careful patient selection with pre-creation angiogram may reduce the risk of symptomatic steal.

An Evaluation Of The Quality Of Patient-Oriented Online Resources For Hemodialysis Access (Preprint)

BACKGROUND Patients and families increasingly turn to the internet for information and resources regarding their medical conditions. These searches are conducted in an independent and unsupervised manner, often without guidance from providers. Multiple reports in the medical oncology literature have cast significant doubt on the accuracy and currency of the data found on patient-focused websites OBJECTIVE To critically appraise the quality of patient-focused online resources concerning hemodialysis access procedures. METHODS A recently validated search strategy using the meta-search engines Google, Dogpile, and Yippy with the query “hemodialysis access” was performed on a cleared-cache web browser during January 2020. Inclusion criteria for the study were websites intended for patient education in English. Exclusions criteria consisted of online monographs, academic journals, and sites requiring paid subscription. Three independent reviewers evaluated the websites using a validated, structured rating tool that scored the Affiliation, Accountability, Interactivity, Structure and Organization, Readability, and Content of the websites. Inter-rater reliability was quantified by calculated kappa coefficients for each element of the instrument. RESULTS Out of more than 27 million collective search results using the three meta-search engines, the first 269 hits were considered for analysis. Only 63 unique patient-oriented sites were acceptable for analysis. 46% were sponsored by commercial entities. Accountability and interactivity were weak across sites. Readability as determined by Flesch-Kincaid and SMOG indices ranged from 6th grade to post-graduate level. 19% were written at a college reading level or higher, however these sites had content quality comparable to those utilizing more elementary prose. 85% of non-commercial domain sites were free of inaccuracies compared to 59% of commercial sites (P=.02). Non-commercial domain sites trended toward more comprehensive content as well as superior readability (average 10th grade reading level compared to average 11th grade reading level, P=.08). The average composite score of all the websites was 2.8 out of a maximum possible weighted score of 7.8, indicating poor global quality of websites. Kappa coefficients were 0.7 or greater for a random sample of 10 websites. CONCLUSIONS This is the first report on the quality of online patient resources in vascular surgery. The study demonstrates that online patient education resources regarding hemodialysis access are poor and require input from the vascular surgery community. Providers need to be aware and understand this issue and seek to inform and mitigate misinformation and potential misguidance. The vascular surgery community should invest in more readable and comprehensive web resources. CLINICALTRIAL n.a