Femoral arteriovenous fistula 3 months after removal of catheter for hemodialysis

A 56‐year‐old Asian woman was admitted to hospital for the consideration of hemodialysis (HD). A right femoral dialysis catheter was inserted for HD. Three months after removal of catheter, she was admitted because of right inguinal swelling. A thrill and bruit were felt and heard at the inguinal area. Color Doppler detected a fistula between right superficial femoral artery and right common femoral vein and subsequently confirmed by contrast enhanced computed tomography scan and 3‐dimensional reconstruction with computed tomography. At surgery, a 4‐mm–diameter fistula was found between the right superficial femoral artery and right common femoral vein. A primary closure of both defects in the artery and vein was then carried out. A follow‐up digital vascular study 3 months after surgical repair was normal. In conclusion, nephrologist should have a heightened awareness to the potential of this complication and should at least document a normal exam following the removal of femoral catheters.     

Improving arteriovenous fistula rate: Effect on hemodialysis quality

Vascular access (VA) is the lifeline for patients with end‐stage renal disease on regular hemodialysis (HD). Tunneled catheters have been associated with increased risk of luminal thrombosis, infection, hospitalization, and high cost. Our aims were to follow the “Fistula First Initiative,” avoid or reduce the rate of catheter insertion, improve the rate of arteriovenous fistula (AVF) use, and study the effect of increased AVF use on quality of dialysis and patient's outcome. A VA program has been established in collaboration with an enthusiastic and professional vascular surgery team to manage 358 patients who have been on regular HD treatment for a period ranging from 1 to 252 months. The mean ± standard deviation age of patients was 52 ± 15 years with 62% male patients. Over a period of 2 years, 408 procedures were performed. These include 293 AVFs and 56 arteriovenous grafts (AVGs). Other procedures include 39 permanent catheter insertions, 8 AVF aneurysmectomy, removal of 6 AVGs, embolectomy of 4 AVGs, excision of 1 AVG lymphocele, and ligation of 1 AVF. This program resulted in significant increase in AVF rate from 35% to 82%; reduction in catheter rate from 62% to 10.9%; infection rate down from 6.6% to 0.6%; VA clotting down from 5.1% to 1.0%; and increase in average blood flow rate from 214 ± 32 to 298 ± 37 mL/min (P < 0.01). These results have been associated with improved average single pool Kt/V from 0.88 ± 0.19 to 1.28 ± 0.2 (P < 0.01); increased hemoglobin from 9.2 ± 1.2 to 10.9 ± 0.9 g/dL (P < 0.01); improved serum albumin from 3.2 ± 0.5 to 3.7 ± 0.4 g/dL (P < 0.05); reduction in administered erythropoietin dose by 19%; and significant drop in hospitalization rate from 6.1% to 3.8%. These results confirm the great benefits of AVF on quality of HD and patient outcome, and clearly affirm that AVF should always be considered first.     

Carotid-jugular arteriovenous fistula: a case report of an iatrogenic complication following internal jugular vein catheterization for hemodialysis access

We report a case of diabetic end-stage renal disease patient who presented with a right common carotid artery jugular arteriovenous fistula as a complication of the insertion of a polyurethane double-lumen hemodialysis catheter into the right internal jugular vein .On physical examination of the neck, a pulsating mass with a palpable thrill and a bruit was noted in the right subclavicular region. The diagnosis was confirmed by color doppler ultrasonography of the neck and carotid angiography. The review of the literature suggests the occurrence of this complication as rather rare. The fistula was successfully repaired surgically. It is emphasized that while securing the access, a thorough physical examination with a special emphasis on seeking any neck swellings, thrill, and bruit along with routine use of vascular doppler for securing dialysis access is recommended.     

Geographic disparities in arteriovenous fistula placement in patients approaching hemodialysis in the United States

Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD). Several factors associated with AVF placement have been identified (e.g., age, sex, race, comorbidities). We hypothesized that geographic location of patient residence might be associated with the probability of AVF placement as the initial access. We used the data from the United States Renal Data System (USRDS) database (2005–2008) linked to Medicare claims (2003–2008). Logistic regression was used to estimate specific characteristics of population associated with the AVF as first access placed or attempted for HD initiation. Our primary variable of interest was the geographic location, and the multivariate model was adjusted for age, sex, race, body mass index, primary cause of end‐stage renal disease (ESRD), duration of pre‐ESRD nephrology care, comorbidities, employment status, substance abuse, and income. Geographic location was determined using the data collected by the RUCA project and divided population into metropolitan, micropolitan, and rural categories. Patients (n = 111,953) identified from the USRDS database with linked Medicare claims were examined. Rates of fistula placement in the metropolitan, micropolitan, and rural population were 18.5%, 22.4%, and 21.6%, respectively. In comparison, patients who received catheter as the first access were 81.5%, 77.6% and 78.4%, respectively. The odds ratio of AVF placement as a first HD access in the rural and metropolitan population compared with the micropolitan population were 0.96 (0.90–1.03; P = 0.26) and 0.80 (0.76–0.84; P < 0.001), respectively. Our results indicate the presence of geographic disparities in AVF placement with decreased rates of AVF as the first access created in the metropolitan (but not rural) populations compared with the micropolitan communities.     

The impact of arteriovenous fistula creation in pulmonary hypertension: Measurement of pulmonary pressures by right heart catheterization in a patient with respiratory failure following arteriovenous fistula creation

Pulmonary hypertension (PHT) is frequent in patients receiving hemodialysis (HD) and carries a high mortality. While it has been suggested that arteriovenous fistulae (AVF) may exacerbate PHT in HD patients, it has also been observed that creating AVF in patients with chronic lung disease and normal renal function may lead to improved exercise tolerance. Most of the observations regarding HD patients using echocardiography demonstrated that temporary closure of AVF improved pulmonary pressures. We present the case of a 45‐year‐old patient with chronic obstructive pulmonary disease on HD who experienced respiratory failure following AVF formation and underwent right heart catheterization. Severe PHT was diagnosed but transient occlusion of the fistula failed to improve the PHT. This case supports the theory that fistula creation does not exacerbate pre‐existing PHT and that AVF can be the access of choice in patients with known chronic lung disease and pulmonary hypertension.     

The long‐term effects of arteriovenous fistula creation on the development of pulmonary hypertension in hemodialysis patients

The aim of this prospective study was to evaluate long‐term effects of arteriovenous fistula (AVF) on the development of pulmonary arterial hypertension (PAH) and the relationship between blood flow rate of AVF and pulmonary artery pressure (PAP) in the patients with end‐stage renal disease (ESRD). This prospective study was performed in 20 patients with ESRD. Before an AVF was surgically created for hemodialysis, the patients were evaluated by echocardiography. Then, an AVF was surgically created in all patients. After mean 23.50 ± 2.25 months, the second evaluation was performed by echocardiography. Also, the blood flow rate of AVF was measured at the second echocardiographic evaluation. Pulmonary arterial hypertension was defined as a systolic PAP above 35 mmHg at rest. Mean age of 20 patients with ESRD was 55.05 ± 13.64 years; 11 of 20 patients were males. Pulmonary arterial hypertension was detected in 6 (30%) patients before AVF creation and in 4 (20%) patients after AVF creation. Systolic PAP value was meaningfully lower after AVF creation than before AVF creation (29.95 ± 10.26 mmHg vs. 35.35 ± 7.86 mmHg, respectively, P: 0.047). However, there was no significant difference between 2 time periods in terms of presence of PAH (P>0.05). Pulmonary artery pressure did not correlate with blood flow rate of AVF and duration after AVF creation (P>0.05). In hemodialysis patients, a surgically created AVF has no significant effect on the development of PAH within a long‐term period. Similarly, blood flow rate of AVF also did not affect remarkably systolic PAP within the long‐term period.     

Iatrogenic or congenital arteriovenous fistula of left upper arm used for hemodialysis after venous superficialization

The authors report a case of iatrogenic brachial arteriovenous fistula (AVF) on the left arm in a 20‐year‐old man with a history of autosomal dominant polycystic kidney and failing kidney transplant. An attempt to create vascular access for hemodialysis by utilization of an existing iatrogenic brachial AVF was undertaken. The patient underwent surgical superficialization of a concomitant enlarged and deeply located vein. Four weeks after the procedure, the AVF was successfully cannulated for hemodialysis. In this case, iatrogenic/congenital AVF was successfully converted to vascular access for hemodialysis.     

Effect of needle orientation during arteriovenous access puncture on needed compression time after hemodialysis: A randomized controlled trial

Background

There are two techniques for puncturing an arteriovenous fistula: one where the needle is inserted bevel up and then rotated to a bevel down position, and another where the needle is inserted bevel down. The aim of this study was to compare these two methods of needle insertion on minimum compression time required for hemostasis after needle removal.

Methods

This was a prospective, randomized, cross-over, blinded, single-center, routine care study. Each patient's average post-dialysis puncture site compression time was determined during a 2-week baseline period while using bevel-up access puncture. Subsequently, minimum post-dialysis puncture-site compression time was determined during each of two sequential follow-up periods, during which fistula puncture was done with needles inserted bevel up or down, respectively. The order of treatments (bevel up or bevel down insertion) was randomized. During each follow-up period, the minimum compression time necessary to avoid bleeding on needle removal was determined by progressively shortening the compression time. Puncture-associated pain was also assessed as prepump and venous pressures and ability to achieve desired blood flow rate during the dialysis session.

Results

Forty-two patients were recruited. The baseline compression time after needle removal averaged 9.99 ± 2.7 min During the intervention periods, the minimum compression time was on average 10.8 min (9.23–12.4) when the access needles had been inserted bevel down versus 11.1 min (9.61–12.5) when the access needles had been inserted bevel up (p = 0.72). There was no difference in puncture-associated pain between the two insertion techniques, and no difference in prepump or venous pressures or ability to achieve the desired blood flow rate during the dialysis session.

Conclusion

Bevel-up and bevel-down needle orientation during arteriovenous fistula puncture are equivalent techniques in terms of achieving hemostasis on needle removal, and puncture-associated pain.     

High‐output heart failure secondary to arteriovenous fistula

In the hemodialysis patient population, a surgically created arteriovenous fistula is the preferred vascular access option. Development of high‐output heart failure may be an underappreciated complication in patients who have undergone this procedure. When a large proportion of arterial blood is shunted from the left‐sided circulation to the right‐sided circulation via the fistula, the increase in preload can lead to increased cardiac output. Over time, the demands of an increased workload may lead to cardiac hypertrophy and eventual heart failure. Patients may present with the usual signs of high‐output heart failure including tachycardia, elevated pulse pressure, hyperkinetic precordium, and jugular venous distension. Typically, the AV fistula is quite large and is likely located in the upper arm, more proximal to the heart. Routine access flow monitoring should demonstrate blood flows (Qa) >2000 ML/min. Echocardiogram may reveal either a low or high left ventricular ejection fraction, and right‐heart catheterization demonstrates an elevated cardiac output with a low to normal systemic vascular resistance. When addressing the problem of high‐output heart failure, the nephrologist is faced with the dilemma of preventing progression of heart failure at the expense of loss of vascular access. Nevertheless, treatment should be directed at correcting the underlying problem by surgical banding or ligation of the fistula.     

Long-term patency of arteriovenous fistulas for hemodialysis: A decade's experience in a transplant unit

Background

The heterogeneous quality of studies on arteriovenous fistulas outcome, with variable clinical settings and large variations in definitions of patency and failure rates, leads to frequent misinterpretations and overestimation of arteriovenous fistula patency. Hence, this study aimed to provide realistic and clinically relevant long-term arteriovenous fistula outcomes.

Methods

We retrospectively analyzed all autologous arteriovenous fistulas at our center over a 10-year period (2012–2022). Primary and secondary patency analysis was conducted using the Kaplan–Meier method; multivariate analysis of variance was used to detect outcome predictors. Vascular access-specific endpoints were defined according to the European guidelines on vascular access formation.

Findings

Of 312 arteriovenous fistulas, 57.5% (n = 181) were radio-cephalic (RC_AVF), 35.2% (n = 111) brachio-cephalic (BC_AVF), and 6.3% (n = 20) brachio-basilic (BB_AVF). 6, 12, and 24 months follow-up was available in 290 (92.1%), 282 (89.5%), and 259 (82.2%) patients, respectively. Primary patency rates at 6, 12, and 24 months were 39.5%, 34.8%, and 27.2% for RC_AVF, 58.3%, 44.4%, and 27.8% for BC_AVF, and 40.0%, 42.1%, and 22.2% for BB_AVF (p = 0.15). Secondary patency rates at 6, 12, and 24 months were 65.7%, 63.8%, and 59.0% for RC_AVF, 77.7%, 72.0%, and 59.6% for BC_AVF, and 65.0%, 68.4%, and 61.1% for BB_AVF (p = 0.29). Factors associated with lower primary and secondary patency were hemodialysis at time of arteriovenous fistula formation (p = 0.037 and p = 0.024, respectively) and higher Charlson Comorbidity Index (p = 0.036 and p < 0.001, respectively). Previous kidney transplant showed inferior primary patency (p = 0.005); higher age inferior secondary patency (p < 0.001).

Discussion

Vascular access care remains challenging and salvage interventions are often needed to achieve maturation or maintain patency. Strict adherence to standardized outcome reporting in vascular access surgery paints a more realistic picture of arteriovenous fistula patency and enables reliable intercenter comparison.     

Digital infarction in a hemodialysis patient due to embolism from a thrombosed brachial arteriovenous fistula

Acute onset of digital ischemia and infarction is an unusual complication in patients undergoing hemodialysis. This is a report of a patient on regular hemodialysis who presented with acute distal extremity ischemia, progressing to digital infarction and on evaluation was found to have thrombosis of brachial arteriovenous fistula with embolization to the distal arteries causing digital artery occlusion.     

Effects of secondary amyloidosis on arteriovenous hemodialysis fistula outcomes and intradialytic hypotension: a case-control study

Amyloid fibrils can affect vascular structure through deposition and by causing nitric oxide depletion and increase of asymmetric dimethyl arginine. Patients with amyloidosis are prone to development of hypotension. Hypotension may also affect the maturation of arteriovenous fistula (AVF) and may set the stage for formation of thrombosis and fistula failure. Thus, we aimed to evaluate effects of secondary amyloidosis on AVF outcomes and intradialytic hypotension. This is a case‐control study which included 20 hemodialysis patients with amyloidosis and 20 hemodialysis patients without amyloidosis as control group. All patients underwent Doppler ultrasound of AVF. A thorough fistula history and baseline laboratory values along with episodes of intradialytic hypotension and blood pressure measurements were recorded. There was no difference between the groups regarding age, gender, body mass index, presence of comorbidities, hypertension, and drug use. Systolic and diastolic blood pressures were similar (119 ± 28/75 ± 17 and 120 ± 14/75 ± 10 mmHg for patients with and without amyloidosis, respectively). Intradialytic hypotension episodes were also similar. Patients with amyloidosis had significantly lower serum albumin and higher C‐reactive protein values compared to control hemodialysis patients. AVF sites and total number of created fistulas were similar in both groups. Flow rates of current functional AVFs were not different between the groups (1084 ± 875 and 845 ± 466 mL/minute for patients with and without amyloidosis, respectively, p:0.67). Patency duration of first AVF was not different between the groups. Clinical fistula outcomes and rate of intradialytic hypotension episodes were not significantly different between patients with and without secondary systemic amyloidosis.     

Endophthalmitis: a rare complication of arteriovenous fistula infection

Vascular access infection is a frequent problem in patients undergoing maintenance hemodialysis. Infection of arteriovenous fistula (AVF) is less common than dialysis catheter-associated infection. Previous case reports described endophthalmitis secondary to hemodialysis catheter-related infection, but not secondary to native AVF infection. We report a rare patient of endophthalmitis as a metastatic infection of AVF cannulation site abscess. A 19-year-old girl on maintenance hemodialysis for the past 2 years has presented with a history of fever, chills, and rigor of 3-days duration and painful dimness of vision in the left eye of 1-night duration. It was followed by redness of the eye, photophobia, and ocular discharge. On examination, the patient was febrile with an abscess near cannulation site of AVF. There was no perception of light in the left eye, conjunctiva was congested, cornea was clear, hypopyon present, and pupil was mid-dilated, not reacting to light. Lens was clear. Vitreitis and exudative retinal detachment was present. Methicillin sensitive Staphylococcus aureus was isolated from blood, pus from AVF abscess and vitreous fluid. Diagnosis of endophthalmitis was confirmed by B-scan ultrasound. She was treated with both intravenous and intraocular antibiotics and drainage of pus from AVF abscess and therapeutic vitrectomy. Though arteriovenous abscess responded to sensitive antibiotics and drainage, vision has not improved much. Strict aseptic precautions during regular AVF cannulation are required. Lapses may lead to loss of vision apart from described complications like access closure, endocarditis, and osteomyelitis.     

Clinical hemodialysis experience with percutaneous arteriovenous fistulas created using the Ellipsys® vascular access system

Introduction: The aim of this study is to report our clinical hemodialysis experience using a percutaneous arteriovenous fistula (pAVF) created with the Ellipsys® vascular access system. This pAVF device creates a permanent AVF anastomosis between the proximal radial artery (PRA) and the deep communicating vein (DCV) in the proximal forearm. Methods: The medical records of all patients with a pAVF were retrospectively reviewed. The clinical data analyzed included reliability of pAVF use, quality of dialysis, rate and success of puncture, and pAVF related complications, along with incidence of subsequent interventions. Findings: Between May 2017 and November 2018, 34 patients had a pAVF created with technical success in 33 patients (97%). Twenty‐eight out of 34 (82%) patients had successful two‐needle cannulation within 10 days to 6 weeks after pAVF creation. The mean Kt/v was 1.6 (1.2‐2) and the average recirculation was 10%. Fifteen patients (44%) needed no further access intervention. Twelve patients (35%) required an additional procedure to assist maturation of the pAVF in order to facilitate puncture. The average blood flow measured at the brachial artery, before the first cannulation, was 850 ml/min. From causes unrelated to the procedure, four patients died during the follow‐up study. Two patients required revision to a surgical AVF. None of the pAVFs developed aneurysmal degeneration steal syndrome, or high access flow related issues. Discussion: The Ellipsys® pAVF offers a safe and functional vascular access for hemodialysis. Advantages included prompt access maturation, avoidance of high flow AVFs, and a simple nonsurgical procedure with high patient satisfaction. Functional outcomes are equivalent and likely better than surgical fistulas. There appears to be less aneurysmal degeneration and need for future re‐intervention. Objective dialysis parameters indicate excellent quality of hemodialysis for the patient.     

Hypoproteinemia as a prognostic risk factor for arteriovenous fistula failure

Introduction: Any vascular access is of limited duration with many factors which influence survival in patients on chronic hemodialysis (HD). Hypoproteinemia as a marker of chronic illness is common among chronic HD patients. Our aim was to analyze the survival of the primary arteriovenous fistula (AVFs) and the risk factors which influence their patency and to test the hypothesis that patients with normal values of serum proteins have lower risk of AVF failure compared to patients with hypoproteinemia. Methods: Seven hundred thirty‐four consecutive patients were included who underwent creation of an AVF. The patients were prospectively followed‐up for 2 years. Only patients with AVF function after a month from its creation were analyzed. The patients were divided into two subgroups, with normal and low serum protein levels (<65 g/L). Findings: At follow‐up 497 (67.7%) AVFs were still functional while 237 (32.3%) AVFs failed due to thrombosis or stenosis. Serum proteins and AVFs created on the forearm were positive predictors while diabetes was a negative predictor of longer AVF survival (P < 0.001; P = 0.003; P = 0.043). When comparing patients with normal and low serum protein levels (<65 g/L), mean survival time was significantly longer in patients with normal serum levels (P < 0.001). Discussion: In this study, hypoproteinemia was an independent prognostic marker for AVF failure at 2 years. Hypoproteinemia, based on our results, is an independent, more sensitive and prognostic marker of possible vascular access failure than the presence of other common factors which influence shorter AVF survival.