Magda van Loon

Buttonhole needling of haemodialysis arteriovenous fistulae results in less complications and interventions compared to the rope-ladder technique

BACKGROUND The rope-ladder puncture technique, with cannulation along the whole length of the vessel traject, has been very common in haemodialysis patients with autogenous arterio-venous fistula (AVF). Todays dialysis population with AVF may exhibit difficult cannulation, because of a short vein length or a complicated cannulation route. An alternative needling possibility is the buttonhole (BH) technique, which inserts needles at exactly the same location during every dialysis session. The present study was conducted to investigate the effect of both cannulation techniques on the incidence of vascular access (VA) complications. METHODS A total of 75 prevalent haemodialysis patients with autogenous AVF using the BH technique were compared with 70 patients using the rope-ladder technique. The following parameters were registered: haematoma occurrence, redness, swelling, aneurysm formation, the use of sharp or dull needles, miscannulations, and interventions. Needling pain and fear of puncture were assessed using a verbal rating scale (VRS). The duration of the follow-up was 9 months. RESULTS Patients in the BH group had more unsuccessful cannulations, compared with the rope-ladder method (P < 0.0001), but the frequency of haematoma (P < 0.0001) and aneurysm formation (P < 0.0001) was less. In addition, intervention such as angioplasty (P < 0.0001) was higher in patients using the rope-ladder technique. A negative outcome of the BH technique was the higher incidence of access infections compared to the rope-ladder method. CONCLUSION This study showed that the BH method is a valuable technique with few complications like haematoma, aneurysm formation and the need for interventions. However, the infections induced by the BH method should not be underestimated. This underlines the importance of an aseptic and correct technique of the buttonhole procedure.

Cannulation and vascular access-related complications in hemodialysis: Factors determining successful cannulation

Little is known about cannulation of the vascular access (VA), such as the number of successful cannulation procedures, frequency of complications caused by cannulation, and VA failure. Incident patients were followed for 6 months, from the first successful cannulation with 2 needles—both used for the hemodialysis treatment. Data included patient characteristics, comorbidities, and medication. Vascular access characteristics included: type of VA and location, vein diameter assessed by Duplex ultrasound, length of the cannulation route, and maturation period. Longitudinal data were collected by dialysis nurses, using identical questionnaires, and a standardized method to register data from each dialysis session. Among 10 Dutch dialysis facilities, clinical data from 120 patients were collected from June 2005 to March 2007. The use of autogenous arteriovenous fistulae (P<0.001) and limited length of the cannulation route (P<0.003) negatively affect the outcome of cannulation and complications such as use of single‐needle (SN) dialysis and central vein catheters (CVC). Previous use of CVC and SN hemodialysis were significant predictors for VA failure (P<0.0001). The present study demonstrated that during the first 6 months of a newly placed VA, a huge number of cannulation‐related complications such as miscannulation, use of CVC, and SN dialysis are encountered. Despite the fact that guidelines recommended the arteriovenous fistulae as the preferred VA, cannulation‐related complications can lead to increased morbidity. The length of the cannulation route positively correlates with successful cannulation. Therefore, adjusted cannulation techniques might be indicated to improve VA outcome.

CANNULATION PRACTICE PATTERNS IN HAEMODIALYSIS VASCULAR ACCESS: PREDICTORS FOR UNSUCCESSFUL CANNULATION

BACKGROUND Little is known about the relationship of cannulation practices in dialysis facilities with the frequency of failed cannulations, complications and subsequent vascular access (VA) failure. METHODS In an observational study the incidence of mis-cannulations and related complications were observed. Patient characteristics, comorbidities and VA characteristics like type of VA were correlated with occurrence of cannulation-related complications. In addition, the cannulation technique and practice patterns like needle direction, tourniquet use and years of experience of dialysis nurses were registered. RESULTS During the study period, 37% of patients with autogenous arteriovenous fistulae (AVF), and 19% of patients with arteriovenous grafts (AVG) had more than 10 miscannulations. Cannulation-induced haematoma resulted into single-needle (SN) and catheter dialysis in 40% of the patients. The use of central venous catheters (CVC) and SN dialysis were significant predictors of VA failure (p <0.0001). CONCLUSION This study demonstrated a high incidence of unsuccessful cannulation procedures and cannulation-related complications necessitating catheter and SN dialysis. The type and location of the VA is significantly related to occurrence of unsuccessful and complicated cannulation.

Effectiveness of surgical banding for high flow in brachial artery-based hemodialysis vascular access

OBJECTIVE Autogenous arteriovenous hemodialysis (HD) access may develop high flow (>2 L/min) over time. Reducing flow volume of a high-flow access (HFA) using a surgical banding technique has been reported to be successful in the short-term. The aim of this study was to evaluate the efficacy of banding in HFAs in terms of freedom from recurrence of high flow during a 1-year follow-up. METHODS All HD patients undergoing surgical banding of an HFA during an 8-year period in three hospitals were retrospectively studied. Access flow data, freedom of recurrent high flow, and complications were analyzed during a 12-month postoperative observation period. RESULTS A total of 50 patients (30 males; age, 51 ± 2 years) were available for analysis. Banding was performed 30 ± 6 months after arteriovenous access construction. Most of the HFA patients (56%) required medication for hypertension, but diabetes mellitus and peripheral arterial obstructive disease were seldom observed (6% and 12%, respectively). Most HFAs (96%) were brachial artery-based fistulas (brachiocephalic: 56%, basilic vein transposition: 40%, radiocephalic: 4%). Banding initially reduced access flow by >50% (3070 ± 95 vs 1490 ± 105 mL/min, P < .001). Recurrent high flow (>2 L/min) developed in 52% of the patients during the observation period. Young age (45 ± 3 vs 57 ± 3 years; P = .02) and an access flow >1 L/min immediately after banding (P = .03) were risk factors for recurrent high flow. CONCLUSIONS An immediate postbanding access flow >1 L/min and young age are risk factors for recurrent high flow in a banded brachial artery-based HD access during a 1-year follow-up.

One-year efficacy of the RUDI technique for flow reduction in high-flow autologous brachial artery-based hemodialysis vascular access

Purpose Flow reduction is advised in hemodialysis (HD) patients with a high-flow (>2 L/min) arteriovenous fistula (AVF). The revision using distal inflow (RUDI) technique is based on the premise that access flow is attenuated once inflow is provided by a smaller caliber forearm artery. Aim of the study was to evaluate the efficacy of RUDI during a 1-year follow-up. Methods All HD patients undergoing a RUDI operation using a greater saphenous vein (GSV) or a basilic vein (BaV) interposition for a high-flow access (HFA, >2 L/min) during a 3.5-year time period were included. Serial access flow, percentage of freedom from recurrent high flow and complications were determined. Results A total of 19 HFA patients were studied (11 males, age 55 ± 3 years). All AVFs were brachial artery based (brachiocephalic, n = 14; brachiobasilic, n = 5). RUDI immediately reduced access flow by almost 2 L/min (3,080 ± 200 to 1,170 ± 160 mL/min (p = 0.001)). Access flows at 1, 6 and 12 months were 1,150 ± 160, 1,460 ± 200 and 1,580 ± 260 mL/min, respectively. Postoperative complications included insufficient flow reduction (n = 1, BaV) and occlusion requiring revision (n = 1, GSV). Recurrent HFA occurred three times (n = 2 BaV, n = 1 GSV). Access flows were significantly (p<0.05) higher in the BaV group compared to the GSV group. Conclusions RUDI effectively reduces access flow in a brachial artery-based high-flow HD vascular access. A flow-reducing effect is sustained at 1-year follow-up in most patients. GSV is preferred as an interposition graft compared to a BaV.

Editor's Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

The European Society for Vascular Surgery (ESVS), in line with its mission, appointed the Vascular Access (VA) Writing Committee (WC) to write the current clinical practice guidelines document for surgeons and physicians who are involved in the care of patients with haemodialysis (HD) and VA. The goal of these Guidelines is to summarise and evaluate all the currently available evidence to assist physicians in selecting the best management strategies for all patients needing VA or for pathologies derived from a VA.

Preoperative computer simulation for planning of vascular access surgery in hemodialysis patients

Introduction The arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis patients. Unfortunately, 20-40% of all constructed AVFs fail to mature (FTM), and are therefore not usable for hemodialysis. AVF maturation importantly depends on postoperative blood volume flow. Predicting patient-specific immediate postoperative flow could therefore support surgical planning. A computational model predicting blood volume flow is available, but the effect of blood flow predictions on the clinical endpoint of maturation (at least 500 mL/min blood volume flow, diameter of the venous cannulation segment ≥4 mm) remains undetermined. Methods A multicenter randomized clinical trial will be conducted in which 372 patients will be randomized (1:1 allocation ratio) between conventional healthcare and computational model-aided decision making. All patients are extensively examined using duplex ultrasonography (DUS) during preoperative assessment (12 venous and 11 arterial diameter measurements; 3 arterial volume flow measurements). The computational model will predict patient-specific immediate postoperative blood volume flows based on this DUS examination. Using these predictions, the preferred AVF configuration is recommended for the individual patient (radiocephalic, brachiocephalic, or brachiobasilic). The primary endpoint is FTM rate at six weeks in both groups, secondary endpoints include AVF functionality and patency rates at 6 and 12 months postoperatively. Trial registration ClinicalTrials.gov (NCT02453412), and ToetsingOnline.nl (NL51610.068.14).

The value of intravascular ultrasound in the treatment of central venous obstructions in hemodialysis patients.

Introduction Digital subtraction angiography (DSA) is the gold standard in diagnosis and treatment of central venous obstructions (CVOs) in hemodialysis access. However, growing data suggest that DSA might underestimate the degree and morphology of venous outflow stenosis. This could lead to inappropriate CVO management. Intravascular ultrasound (IVUS) has been shown to identify lesion characteristics remaining obscure with angiography. With the current study we suggest IVUS as an eminent imaging modality in CVO management. Methods Twelve patients (8 male, mean age 62.4 ± 9 years) were analyzed for suspicion of symptomatic CVO. Both angiography and IVUS evaluation were performed to determine the degree of obstruction before and after PTA. Stent placement was indicated when significant residual stenosis (>50% lumen reduction) was suspected. Results Conventional plain angiography determined 8 out of 12 central venous lesions significant. Secondary signs of obstruction, i.e., collateral filling, was present in all 12 cases. After PTA, persistent significant stenosis was observed in 3 out of 12 patients. IVUS showed significant lumen reduction in all 12 cases. Additionally, IVUS showed a median cross-sectional area of 24 ± 12 mm2 before PTA and 37 ± 23 mm2 after PTA (NS). Furthermore, IVUS showed signs of intraluminal fibrotic trabeculations in 9 patients. Stenting was performed in 10 patients with >50% lumen reduction on IVUS after PTA. Conclusions Conventional angiography seems unreliable to identify all significant aspects of a central venous outflow obstruction. Additional use of IVUS might aid in the decision-making process and select the optimal treatment strategy.

Hemodialysis vascular access management in the Netherlands

Purpose In the Netherlands, 86% of patients start renal replacement therapy with chronic intermittent hemodialysis (HD). Guidelines do indicate predialysis care and maintenance of a well-functioning vascular access (VA) as critical issues in the management of the renal failure patient. Referral to the surgeon and time to VA creation are important determinants of the type and success of the VA and HD treatment. Methods and Results Data from a national questionnaire showed that time from referral to the surgeon and actual access creation is <4 weeks in 43%, 4 to 8 weeks in 30% and >8 weeks in 27% of the centers. Pre-Operative ultrasonography and postoperative access flowmetry are the diagnostic methods in the majority of centers (98%). Most facilities perform rope-ladder cannulation with occasionally the buttonhole technique for selected patients in 87% of the dialysis units. Endovascular intervention for thrombosis is practiced by 13%, surgical thrombectomy by 21% and either endovascular or surgery by 66% of the centers. Weekly multidisciplinary meetings are organized in 57% of the units. Central vein catheters are inserted by radiologists (36%), nephrologists and surgeons (32%). Conclusions We conclude that guidelines implementation has been successful in particular regarding issues as pre-operative patient assessment for VA creation and postoperative surveillance in combination with (preemptive) endovascular intervention, leading to very acceptable VA thrombosis rates.

Randomized Controlled Trial Comparing Open Versus Laparoscopic Placement of a Peritoneal Dialysis Catheter and Outcomes: The CAPD I Trial

Objective: To determine the best operation technique, open versus laparoscopic, for insertion of a peritoneal dialysis (PD) catheter with regard to clinical success. Clinical success was defined as an adequate function of the catheter 2 – 4 weeks after insertion. Methods: All patients with end-stage renal disease who were suitable for PD and gave informed consent were randomized for either open surgery or laparoscopic surgery. A previous laparotomy was not considered an exclusion criterion. Laparoscopic placement had the advantage of pre-peritoneal tunneling, the possibility for adhesiolysis, and placement of the catheter under direct vision. Catheter fixation techniques, omentopexy, or other adjunct procedures were not performed. Other measured parameters were in-hospital morbidity and mortality and post-operative infections. Results: Between 2010 and 2016, 95 patients were randomized to this study protocol. After exclusion of 5 patients for various reasons, 44 patients received an open procedure and 46 patients a laparoscopic procedure. Gender, age, body mass index (BMI), hypertension, current hemodialysis, severe heart failure, and previous an abdominal operation were not significantly different between the groups. However, in the open surgery group, fewer patients had a previous median laparotomy compared with the laparoscopic group (6 vs 16 patients; p = 0.027). There was no statistically significant difference in mean operation time (36 ± 24 vs 38 ± 15 minutes) and hospital stay (2.1 ± 2.7 vs 3.1 ± 7.3 days) between the groups. In the open surgery group 77% of the patients had an adequate functioning catheter 2 – 4 weeks after insertion compared with 70% of patients in the laparoscopic group (p = not significant [NS]). In the open surgery group there was 1 post-operative death (2%) compared with none in the laparoscopic group (p = NS). The morbidity in both groups was low and not significantly different. In the open surgery group, 2 patients had an exit-site infection and 1 patient had a paramedian wound infection. In the laparoscopic group, 1 patient had a transient cardiac event, 1 patient had intraabdominal bleeding requiring reoperation, and 1 patient had fluid leakage that could be managed conservatively. The survival curve demonstrated a good long-term function of PD. Conclusion: This randomized controlled trial (RCT) comparing open vs laparoscopic placement of PD catheters demonstrates equal clinical success rates between the 2 techniques. Advanced laparoscopic techniques such as catheter fixation techniques and omentopexy might further improve clinical outcome.