bluuebunny/crossref_metadata_2025 huggingface dataset:
Creation of Native Arteriovenous Fistulas with Interrupted Anastomoses Using a Self-Closing Clip Device - One Clinic's Experience
Authors: Ross John R.
Published: January 2018

The nitinol U-CLIP™ Anastomotic Device (Coalescent Surgical, Inc., Sunnyvale, CA) is a self-closing penetrating vascular clip that reduces suture management and eliminates knot tying, thus enabling rapid and precise interrupted suture placement and facilitating creation of an optimal vascular anastomosis. This report describes the use of U-CLIP devices in the surgical creation of native arteriovenous fistulas in 68 chronic hemodialysis patients. Overall, 61 of the 65 fistulas created matured successfully within 8–9 weeks. Radial cephalic fistulas: 93% were mature at 8 weeks. Brachiocephalic fistulas: 69% were mature at 8 weeks. One-stage basilic vein transposition: 100% were mature at 9 weeks. Two-stage basilic vein transposition: 100% were mature at 8 weeks after second stage. The results in this report show the excellent performance of U-CLIP vascular clips in the creation of several types of native arteriovenous fistulas in chronic hemodialysis patients. The fistulas created using the U-CLIP devices had a high maturation rate within a relatively short time period, and provided uniformly high flow rates. The patients in this study were a challenging population, with a high incidence of diabetes mellitus (81% of the patients) and vein sizes that were smaller than typically used for fistula creation. The U-CLIP™ Anastomotic Device offers the opportunity to create superior interrupted anastomoses for AV fistulas, even in patients who would otherwise be considered poor candidates for fistula creation.
Central Venous Catheters in Hemodialysis: An Actual Conundrum without Solutions
Authors: Di Iorio B.
Published: January 2018

Vascular access maintenance is a major problem for adequate care of End Stage Renal Disease. An ideal access delivers an adequate flow rate for the HD prescription, remains usable for an indefinitely long period of time, and has a low complication rate. The native arteriovenous fistula (AVF) remains the best access, but this option may be impraticable in many conditions. This paper describes why to use CVC, where CVC can be positioned and how CVC infections can be prevented. Also today, vascular access in hemodialysis remains the conundrum without solution, but it is often necessary and remains the only possible venous access in a particular category of patients.
Emerging Role of Enterococcus Spp in Catheter-Related Infections: Biofilm Formation and Novel Mechanisms of Antibiotic Resistance
Authors: Donelli G. , Guaglianone E.
Published: January 2018

Enterococci are gram-positive bacteria that are part of the normal human intestinal flora and can colonize the upper respiratory tract, biliary tract and vagina of otherwise healthy people. Although their virulence is relatively low, recently enterococci have emerged as significant nosocomial pathogens and are currently the 4th leading cause of hospital-acquired infections, including those associated with intravascular catheter and biliary stent implants. The frequent use of these medical devices is often associated with severe complications, including catheter-related bloodstream infections (CRBSIs) and biliary stent occlusions, because of microbial biofilm formation on the device surface.

Furthermore, other than a high level of resistance to penicillin, ampicillin and aminoglycosides, a dramatic increase in vancomycin resistance of enterococci has been recently observed in most clinical settings. Clinical strains exhibiting novel mechanisms of acquired resistance to antimicrobials are frequently isolated. In addition, enterococci have a great ability to transmit these resistance traits to other species and even to other genera. Due to their associated morbidity and mortality, enterococcal infections related to medical devices currently represent a major challenge for clinicians, especially for the management of critically ill patients, resulting in prolonged hospitalization and additional health costs.
Old and New Tools in the Diagnosis of Central Venous Catheter-Related Bloodstream Infections: Is there a Role for Brushing?
Authors: Citton R. , Pittiruti M. , Cauda R. , Tacconelli E.
Published: January 2018

Bloodstream infections (BSIs) are the third most common nosocomial infections. Catheters and other medical devices are the first exogenous causes of preventable infections in hospital. The estimated attributable mortality for catheter-associated BSI ranges from 1–35%, mainly depending on etiological agents and underlying disease. In considering this, it is necessary to reduce central venous catheter- (CVC)-related BSI prevalence and to obtain a rapid and accurate method for an early diagnosis. This review indicates the advantages and the disadvantages of old and new tools for the early diagnosis of CVC-related BSIs.
Bridge Graft to a Small Distal Artery after Fistula Ligation for Angioaccess-Induced Ischemia: Report of Two Cases
Authors: Andrade J.L. , Paschôa A.F. , Van Bellen B.
Published: January 2018

Angioaccess-induced ischemia is an infrequent but cumbersome problem, because both limb ischemia correction and access salvage should be undertaken during the same procedure. This paper reports two cases that we successfully managed with a bridge graft to a small distal artery after fistula ligation.
Early Rupture of Subclavian Vein Catheter: A Case Report and Literature Review
Authors: Sarzo G. , Finco C. , Zustovich F. , Parise P. , Savastano S. , Degregori S. , Vecchiato M. , Merigliano S.
Published: January 2018

Prolonged venous access devices (PVADs) have become indispensable in antiblastic protocols for the treatment of cancer patients, in anti-infection protocols for acquired immunodeficiency syndrome (AIDS) patients and in the management of chronic malabsorption syndromes. Using these catheters carries the risk of several complications, and some are potentially lethal, for example, cardiac embolization of catheter fragments. Rupture is a complication almost exclusive to catheters positioned percutaneously: after using this technique, device malfunction can occur due to catheter kinking after its excessively medial introduction in the subclavian vein. The early recognition of any pinch-off sign (POS) is fundamental in preventing catheter rupture that frequently follows this complication. Other factors can be involved in early rupture, for example, excessive force on a syringe used to clear a catheter that shows early signs of malfunction, or a strength defect in the materials used in the catheter construction. This report describes an early rupture case of an initially correctly positioned catheter and reviews 20 such cases in the recent literature.
Steal Syndrome of the Hemodialysis Vascular Access: Diagnosis and Treatment
Authors: Henriksson A.E. , Bergqvist D.
Published: January 2018

Purpose

Steal syndrome is an uncommon but serious condition of arterial insufficiency distal to a permanent hemodialysis fistula. The management of the condition is a great challenge to the surgeon because of the conflicting goals of preserving the fistula and treat the ischemia. In this review the purpose was to analyze the clinical problem and treatment possibilities.

Methods

Medline and Embase databases were searched for studies relevant to diagnosis and management of steal syndrome of the hemodialysis vascular access.

Results

The diagnosis of steal syndrome is largely based on clinical features and non-invasive studies. In same cases angiography may be necessary to find out the real causes of the steal syndrome. The cause is usually high fistula flow but other causes as steal phenomenon, inflow, outflow or anastomotic stenosis have to be considered and even combination of causes. The main treatment options are some form of flow reducing procedure or the distal revascularization interval ligation method. In some cases simple distal arterial ligation is the method of choice. Furthermore, in some patients a stenosis has to be treated as the first treatment option.

Conclusion

For an appropriate treatment of a steal syndrome a careful analysis of the cause is important.
Evaluation of Vascular Access Complications in Acute and Chronic Hemodialysis
Authors: El Minshawy O. , Abd El Aziz T. , Abd El Ghani H.
Published: January 2018

Purpose

This work aimed to determine the incidence of vascular access (VA)-related complications of temporary venous catheters in acute hemodialysis (HD) prescription, to study the survival rate of chronic HD patients who began HD with a catheter insertion and to evaluate associated complications.

Methods

The patients were classified into two groups. Group I, patients in whom venous catheters were inserted (652 patients). Group II, 80 patients with end-stage renal disease (ESRD) in whom an arteriovenous fistula (AVF) was established.

Results

Complications in the femoral approach were bleeding from a femoral artery wall laceration in only 6/600 patients (1%), successfully repaired in all patients, bleeding from a punctured femoral artery in 30 patients (5%), the incidence of infection and removal was 40%. Other complications included groin hematoma in 3 patients (0.5%) and catheter thrombosis in 45 patients (7.5%). In the jugular vein approach, infection occurred in 6/30 patients (20%), thrombosis in 9 patients (30%), and accidental withdrawal in 2 patients (6.7%). In the subclavian vein approach, catheter dysfunction was found in 7/22 patients (32%), infection in 10 patients (45.5%), and failure to cannulate the vein in 3 patients (13.6%). In group II, limb edema was found in 14/80 patients (17.5%), hematoma in 5 patients (6.3%), accidental trauma to the fistula in 2 patients (2.5%) and fistula stenosis in 15 patients (18.8%). Patients who began HD with a catheter had higher mortality than those who began with an AVF (12 months survival, respectively, 60 vs. 83%).

Conclusion

Patients who began HD with a catheter had more complications and higher mortality. Routine quality assessment of AVF by Doppler ultrasound is recommended.
Treatment of dialysis catheter infections in 2004
Authors: Gersch M.S.
Published: January 2018

Hemodialysis catheter associated infections are a major source of morbidity and mortality in end stage renal disease patients. There is disagreement about the management of catheter infections, particularly concerning the removal of potentially infected tunneled dialysis catheters. A dialysis catheter should generally be removed when an infection involves a temporary hemodialysis catheter, a septic patient, a patient with a tunnel tract infection, or a patient with evidence of a metastatic infectious complication. In treating stable patients with clinically mild catheter associated bacteremia, parenteral antibiotics alone have a low success rate in eliminating the infection. Antibiotic locks are an emerging strategy for treating these patients, but at present higher rates of success and lower costs are achieved by exchanging the catheter over a guidewire. Antibiotic lock solutions, antibiotic coated catheters, and totally implantable dialysis access systems may play a large role in prevention of catheter associated infections in the future; however, further randomized controlled trials of these strategies are needed. Future efforts should concentrate on limiting the use of traditional tunneled cuffed hemodialysis catheters by early referral to vascular surgery for the creation of an arterio-venous fistula.
Arterio-arterial prosthetic duct (AAD) as a vascular access in hemodialysis
Authors: Talaiezadeh A.H. , Haghighi K. Ehtesham
Published: January 2018

Vascular access (VA) is mainly a problem confronting patients undergoing hemodialysis (HD). In some cases, peripheral veins are damaged or thrombosed because of repeated vein punctures and subsequent thrombophlebitis or accompanying ailments like diabetes or other kinds of vasculitis, making the use of conventional VA methods unsuitable. In this study, we present our experience using a synthetic vascular graft as an arterio-arterial duct (AAD) in the upper arm of patients undergoing HD, in whom other procedures had failed. In this procedure, we used a synthetic vascular prosthesis of polytetrafluoroethylene(ePTFE) (Gore-Tex®) or Vasculink® as an AAD, subcutaneous in the media aspect of the upper arm. HD was performed for this duct. Twenty patients were selected in whom all other VA means had failed. Patient age ranged from 33–83 yrs. In two patients (12%), early graft thrombosis was the cause of failure. In the remaining 14 patients (87%), a suitable flow was established. In another two patients, after several dialysis sessions the duct stopped functioning. We believe the reason for this malfunction was too much pressure on the graft to control bleeding due to the inadequate training of the HD personnel. The remaining 12 patients (75%) used the duct for >6 months. With this method, because we used only the artery for placing the conduit, complications relating to the vein such as limb ischemia, edema and venous hypertension did not prevail. On the other hand, because the conduit is an accessory duct, should it have become thrombosed, arterial flow to the limb would be unhindered. Therefore, we believe when all other conventional VA methods have failed, AAD is a suitable technique.
Experience with the use of uncuffed double-lumen silicone hemodialysis catheters
Authors: Sombolos K.I. , Christidou F.N. , Bamichas G.I. , Anagnostopoulos T.C. , Megalopoulos A.A. , Kalpakidis V.I. , Natse T.A.
Published: January 2018

Aim

This study aimed to describe our experience with the use of uncuffed double-lumen silicone hemodialysis catheters (USHDCs) that were used in 54 cases as a temporary vascular access (VA). Subjects and methods: We recorded, retrospectively, all the USHDCs (size 13.5 French (F), length 15, 20 and 24 cm) that were inserted in our dialysis unit from July 2003 to September 2004. Catheter and patient characteristics, as well as catheter related complications, were recorded.

Results

There were 88 catheters used in 54 cases (44 patients). The catheters remained in place for a total of 2537 days (range 8–127 days, mean 46.9 ± 31.1). For catheter placement, the internal jugular veins (group A) or the femoral veins (group B) were used in a non-randomized manner. In group A, in 17 cases, 31 catheters were used for a total of 1169 days (mean 68.7 ± 28.5), while in group B, in 37 cases, 57 catheters were used for a total of 1368 days (mean 36.9 ± 27.1; p<0.001). In group B, 81% of cases (30/37) were ambulatory from the time of insertion. Mean urea reduction ratio (URR) in well functioning catheters (blood flow ≥200 ml/min) was 65.5 ± 4.6% in group A and 56.9 ± 6.2% in group B; p<0.001. Catheter-related bacteremia was observed in five group A cases and in seven group B cases (p=ns). Three cases of minor bleeding at the insertion site and three cases of ipsilateral leg edema were recorded in group B patients. In group A, only one case of bleeding at the insertion site was recorded.

Conclusion

Uncuffed double-lumen silicone hemodialysis catheters (USHDCs), 13.5 F in size, provided a very efficient temporary VA when placed in the jugular vein. Femoral placement of these catheters can also be used successfully in non bed-ridden patients, but delivering a lower dialysis dose.
Preserving the left arm vein in cases of hemodialysis access generating left internal mammary artery steal syndrome
Authors: Ginzburg V. , Margulis G. , Greenberg G. , Mayzler O. , Wolak T. , Tovbin D. , Ilya R. , Szendro G.
Published: January 2018

In patients undergoing chronic hemodialysis (HD) through an arm arteriovenous fistula (AVF), coronary insufficiency can occur if the patient undergoes a coronary artery bypass graft (CABG) using the ipsilateral internal mammary artery (1–4). Therefore, the creation of a new AVF after CABG should avoid using the arm ipsilateral to the side where the internal thoracic artery was used. In cases where coronary syndrome appears when this advice is not followed, treatment should be offered aimed at overcoming the hemodynamic interference between the diminished coronary supply through the left or right internal mammary artery by closure of the existing fistula, with or without temporary central venous line insertion until the maturation of a new fistula. We suggest a different approach by moving only the arterial inflow site of the AVF to the controlateral subclavian artery, but in addition, leaving the well functioning venous outflow tract intact. In cases of left internal mammary steal it is achieved by creating a conduit running from the right subclavian artery to the left cephalic vein; therefore, creating a new arterial inflow source, connected to the existing functioning old venous outflow tract to maintain an immediately functioning new fistula without a coronary steal.
Incidence of Sepsis in Central Venous Catheter-Bearing Patients with Hematologic Malignancies: Preliminary Results
Authors: Nosari A. , Nichelatti M. , De Gasperi A. , Nador G. , Anghilieri M. , Mazza E. , Cozzi P. , Mancini V. , Miqueleiz S. , Bettinelli L. , Lucchesini C. , Baraté C. , Ricci F. , Ciapanna D. , Ravelli E. , Morra E.
Published: January 2018

Background

Indwelling central venous catheters (CVCs) are essential devices in the management of patients with hematological disorders treated with chemotherapy. However, their nature predisposes patients to unwanted complications.

Methods

CVC-related complications were retrospectively analyzed in 227 hematologic patients who were consecutively admitted to our hematology department between May 2002 and April 2004. Patients’ diagnoses comprised acute myeloid leukemia (36.8%), acute lymphoid leukemia (7.3%), lymphoproliferative disorders (28.3%), multiple myeloma (19.5%), myeloproliferative syndromes (5%) and others (3.1%). The CVCs used were polyurethane three lumen 7-Fr (111 patients) for chemotherapy and 12-Fr (114 patients) for chemotherapy and peripheral blood stem cell apheresis, plus two tunneled catheters.

Results

The pathological events were: bacteriaemias (n=46); occlusions (n=10); exit tunnel infections (n=8); thrombosis (n=6); lung emboli (n=2). Among febrile patients the bacteriemia frequency was 20%, of which 13.6% were CVC-related (with a higher incidence in leukemia patients (p=0.027). Among the isolates, gram-positive bacteria were found in 29 cases (23 CVC-related cases), and gram-negative bacteria in 16 cases (8 CVC-related cases). Only one patient had Candida albicans sepsis. At univariate and multivariate analysis significant risk factors for infection (p<0.0001) were only the number of days/catheters and neutropenia duration.

Conclusions

In our hematologic patients, the CVC complications were mainly septic, with only 10.1% of CVC-related bacteriemias, despite prolonged catheterization duration. Acute leukemia patients were at major risk for sepsis, probably due to a more severe neutropenia and prolonged catheterization duration.
AV Fistula Rates: Changing the Culture of Vascular Access
Authors: Mcgill R.L. , Marcus R.J. , Healy D.A. , Brouwer D.J. , Smith B.C. , Sandroni S.E.
Published: January 2018

Purpose

Data from the United States Renal Data System show about 30% of prevailing hemodialysis (HD) patients use arteriovenous fistulae (AVF), which falls far short of the Kidney Disease Outcomes Quality Initiative (K/DOQI) goals of 40–50%. Recent initiatives to increase the use of AVF in HD patients have been criticized as unachievable under realistic practice conditions.

Methods

A multidisciplinary effort to increase AVF use was undertaken at an outpatient HD center beginning in 1998. Strategies focused on education and recruitment of patients in both inpatient and outpatient settings, preservation of veins, pre-operative vein mapping, and education of staff.

Results

AVF rates increased from 32%, to 72% over 6 years. The percentage of prosthetic grafts decreased from 40% to 13%. Central venous catheters fell from 28% to 15%. Among residual patients with catheters, 77% had maturing fistulae, as well. Infection rates in the dialysis unit decreased by 39%. Bacteremia declined by 47%. These improvements have been sustainable over the past 12 months.

Conclusions

Adherence to a strategic program similar to the Fistula First Initiative can increase fistula rates under ordinary practice conditions. High fistula rates can be achieved in male and female patients. Unanimous commitment among all members of the health care team is needed. Reduction in the risks of infection, bacteremia, endocarditis, and death may be derived from achievable changes in practice.
Clopidogrel Diminishes Hemodialysis access Graft Thrombosis
Authors: Trimarchi H. , Young P. , Forrester M. , Schropp J. , Pereyra H. , Freixas E.
Published: January 2018

Background

The most common complication of hemodialysis access graft is thrombosis. Clopidogrel, an inhibitor of platelet aggregation, was assessed to prevent this serious complication.

Methods

Nineteen patients on chronic hemodialysis whose vascular accesses were grafts were divided into two groups: Group A (n=11, 58%) consisted of patients who did not receive anti-thrombotic therapy after graft placement; Group B (n=8, 42%) received clopidogrel 75 mg/day from two days after surgery onwards. Both groups were well matched with respect to age, gender, cause of renal failure, hematocrit, platelet count and Kt/V. All patients’ thrombotic episodes were followed up from the day of graft surgery until thrombosis was diagnosed. Finally, the survival difference between both groups was determined.

Results

Ten thrombotic episodes were diagnosed in Group A while no events were reported in Group B (p<0.001). Graft access days of patency were significantly more in Group B than in Group A (350.8±166 vs 86.8±69, p<0.001). The time elapsed from dialysis initiation to graft placement was not different (Group A: 18±12 days; Group B: 20±10 days). Days in hemodialysis were different between both groups (Group A: 195.9±96; Group B: 545.5±291, p<0.001) and all patients of Group A (n=11, 57.9%) and two patients of Group B (25%) died (p=0.001). No major bleeding events were reported.

Conclusions

Clopidogrel significantly decreased thrombotic graft episodes. Patients on clopidogrel had a prolonged vascular access patency, longer time on hemodialysis and longer survival.
Vascular access in Cystic Fibrosis - Does Size Matter?
Authors: Carroll W.D. , Anderson M. , Reddy R.V. , Pantin C. , Lenney W.
Published: January 2018

Vascular access is an important part of patient management in cystic fibrosis. In most instances, vascular access is straightforward. However, a single bad experience with venepuncture has a lasting impact. Clinical experience suggested that for some individuals a smaller, shorter intravenous catheter (Leaderflex 22G, 0.7 mm × 8.0 cm, Vygon) might be a suitable alternative to standard vascular access via a standard long-line (2 Fr or 3 Fr Nutriline, Vygon).

Methods

Between September 2002 and May 2004 we offered a free, fully informed choice between a standard 30 cm long line or a shorter (8 cm) Leaderflex line and audited this change in practice.

Results

A total of 56 lines were inserted over the study period. Data were available for 54 of these (22 Leaderflex and 32 standard long lines). Mean and median line survival was comparable. Leaderflex lines survived for a mean of 12.2 days and median of 14 days. Standard long lines survived for a mean of 12.6 days and median of 14 days.

Discussion

Leaderflex lines offer a well-tolerated alternative to standard long lines for the administration of a 14-day course of intravenous antibiotics. Their reduced size and cost offer advantages to patients and doctors.
Efficacy of Low-Dose Alteplase for Treatment of Hemodialysis Catheter Occlusions
Authors: Haymond J. , Shalansky K. , Jastrzebski J.
Published: January 2018

Background

Traditionally, alteplase 2 mg/lumen doses have been used to treat central venous catheter (CVC) occlusions. On January 20, 2004, our hemodialysis (HD) unit implemented a new protocol to utilize alteplase 1 mg/lumen doses for catheter occlusion.

Objectives

The objectives were to 1) assess the efficacy of low-dose alteplase in restoring HD catheter patency; 2) determine the duration of CVC patency as determined by need for further alteplase doses, or radiological or surgical line interventions; and 3) evaluate the financial implications of the new protocol.

Methods

The study was a prospective, open-label trial of 50 consecutive HD patients with permanent, tunnelled CVC lines. A treatment course consisted of 1 or 2 doses of alteplase instilled for 60 minutes then aspirated or as an overnight (48–72 hour) dwell until the next HD. The patient's first alteplase dose following implementation of the new protocol was evaluated. Patients were followed for two months to record need for further alteplase treatment courses, and four months to document radiological or surgical line interventions. The primary outcome was to assess successful restoration of catheter patency defined as the ability of alteplase to restore or maintain HD blood flow rate at or above 300 mL/minute. A financial analysis compared alteplase costs for 11 months prior to and after implementation of the new protocol.

Results

Alteplase 1 mg/lumen doses restored catheter patency in 72% of HD patients with one dose, increasing to 83% with a second dose. Sixty-two percent of patients required a subsequent alteplase course with a median time to next treatment of 14 days and a median of 2 courses/patient. Radiological interventions were ordered in 38% of patients resulting in 8 lines replacements and 7 line strippings. Financial savings with the new low-dose protocol were ~CDN$22,000.

Conclusion

Low dose alteplase 1 mg/lumen successfully treated occlusion of permanent hemodialysis catheters, with a resulting cost reduction.
Arteriovenous Fistulas for Hemodialysis Created using a Long-Term Absorbable Suture: A Safe Solution and a Measure to Minimize Myointimal Hyperplasia
Authors: Occhionorelli S. , De Tullio D. , Pellegrini D. , Ascanelli S. , Resta G. , Stano R. , Messina F. , Azzena G.
Published: January 2018

Background/aims

The goal of the therapeutic management of patients affected by end-stage renal disease (ESRD) is to maintain the vascular access (VA) as long as possible. Myointimal hyperplasia development in the vascular walls of arteriovenous fistulas (AVFs) is considered one of the most important factors responsible for procedure failure. These alterations could be linked to hemodynamic changes in the anastomosis and to the presence of the surgical suture itself. We report our preliminary experience, discussing the use and the possible benefits of an absorbable suture in polyglycolide trimethylene carbonate (PTC) in AVF creation.

Methods

Seventy-four AVFs were created as primary access for hemodialysis (HD), using PTC, over 4 years. Age, gender, ESRD etiology, artery and vein preoperative diameters, AVF survival outcome, and the number of AVFs created per year were recorded. The Kaplan-Meier method was used to analyze AVF survival rates.

Results

No dehiscences, pseudoaneurysms, or failures in the “critical” period related to PTC absorption were recorded. Kaplan-Meier analysis was used to evaluate AVF survival; 12-month primary AVF survival (74.33%) and AVF failure (25.67%) rates, 9 “early” (8.22%) and 10 “late” failures (13.51%), and a 360-day mean survival were found.

Conclusions

Our data indicate that PTC, a well known and widely used material for sutures in vascular surgery, is safe and effective in AVF creation. Potential advantages of PTC sutures are represented by a reduced myointimal hyperplasia formation in the AVF vascular walls, prolonging the AVF lifespan and avoiding re-interventions.
Axillary to Common Iliac Arteriovenous Graft for Hemodialysis Access: Case Report and Review of “Exotic” Axillary-Based Grafts
Authors: Evans D.C. , Upton E.C. , Lawson J.H.
Published: January 2018

A 58-year-old Caucasian male with end-stage renal disease and peripheral arterial disease was referred to us for management of his complex vascular access. His vascular access history included a left wrist primary fistula, a left upper arm access graft, a left leg loop graft, and multiple PermCaths in his jugular veins with recurrent infections. Magnetic resonance venography (MRV) of his chest revealed extensive bilateral venous occlusions due to numerous past hemodialysis access catheters. The patient was scheduled for right lower extremity arteriovenous graft placement, but intraoperatively was found to have severe peripheral arterial disease and a thromboendarterectomy was performed instead. Lower body venous imaging demonstrated patent iliac veins. Based on these anatomic considerations a right axillary artery to right common iliac vein polytetrafluoroethylene (PTFE) graft was placed. The graft required revision twice – once for graft ultrafiltration at the arterial end of the graft and once for needle stick infection – but continues to serve as sufficient access after 15 months. Grafts based off the axillary artery have become increasingly popular in recent years and several venous outflow options have been considered, each with distinct advantages. The common iliac vein offers a central location with high flow rate and low probability of infection. Axillary artery to iliac vein arteriovenous grafting may have a place in the vascular surgeon's armamentarium for complex vascular access cases.
Cancer chemotherapy administered via hemodialysis fistulas
Authors: Harney J. , Ahmed S. , Faccini K. , Raymond J. , Lind P. , Nye S. , Mcgill R.L.
Published: January 2018

End-stage renal failure (ESRF) patients can develop cancer before or after kidney disease occurs. Cancer chemotherapy often needs to be administered via the sort of central venous catheter that is normally avoided in ESRF care. Three cases are presented in which ESRF patients received chemotherapy for cancer via existing hemodialysis fistulas, and the consequences of central venous access in a fourth patient are discussed.
How to avoid and manage a pneumothorax
Authors: Giacomini M. , Iapichino G. , Armani S. , Cozzolino M. , Brancaccio D. , Gallieni M.
Published: January 2018

Pneumothorax is one of the most frequent complications during percutaneous central vascular cannulation. When choosing a site for central vascular access, the internal jugular vein is preferable to other vessels, for the lower frequency of related complications, including pneumothorax. This review intends to summarize the current state of the art on how to avoid and, if it occurs, to manage this rare but relevant complication. In order to prevent pneumothorax, as well as other relevant complications of central vein cannulation, it is advisable to use ultrasound guidance whenever possible. If pneumothorax occurs, it is important to recognize its signs and symptoms. To exclude the presence of asymptomatic pneumothorax, in the normal clinical routine a chest X-ray should be obtained within 4 hours from the procedure of central vein cannulation of subclavian and internal jugular veins. If promptly recognized, pneumothorax can be managed quickly and in a relatively easy way. Depending on its size and symptoms, and in particular when a tension pneumothorax is supected, treatment can vary from simple observation to a chest tube insertion or, in the latter case, to an emergency thoracentesis needle insertion in the pleural space.
Blood flow study of arteriovenous grafts with homologous and autologous veins in canine femoral vessels
Authors: Galego S.J. , Miranda F. , Ortiz J. Pinto , De Lima Bessa K. , De Carvalho Fürst R. Vilhena , Fujii E. Yumi , Ramacciotti O.
Published: January 2018

Purpose

The objective of this study was to assess the blood flow in arteriovenous (AV) communications comparing autologous and homologous veins, in the femoral vessels of dogs.

Methods

Ten mongrel dogs were used for the blood flow analysis, and two AV grafts (AVG) were placed in each of them. The grafts were made with an autologous vein in one side, and a homologous vein, kept in a 0.25% glutaraldehyde solution, in the other side. The volumetric flow was measured before and after AVG placement. Fifteen minutes after surgery, the volumetric flow was measured in the cranial artery, in the caudal artery, in the graft and in the vein, and the same procedure was repeated 15 days after surgery. Measurements were done using an eletromagnetic flowmeter calibrated previously. For data analysis, the Wilcoxon test was used (to compare the difference in the results between the times and the techniques used) (CK0.05).

Results

An increase of about 5.3 times was observed in the femoral artery cranial portion flow of these accesses during the first operation and an increase of 6.8 times in the re-operation for both techniques. In the femoral artery caudal portion of the AVGs there was a blood flow inversion of about 1.6 times for both techniques during the first operation and about 4.1 and 3.7 times for the autologous and homologous veins, respectively. There was a significant increase in the autologous grafts. In the cranial portion of the femoral vein, there was an increase in the flow in relation to the femoral artery flow before graft placement. There was an increase of 5.3 and 7.4 times for the autologous and homologous grafts, respectively, in the first operation and from 8–9.6 times in the re-operation. There was also a significant increase in the autologous graft in relation to the two procedures. A significant difference among the grafts placed during the first surgery was observed, which was not observed after 15 days. In the graft blood flow analysis, a flow increase of 5.1 times for the autologous vein and 6.6 times for the homologous vein and from 7.5–8.2 times in the re-operation was found in relation to the femoral artery flow. There was a significant increase in autologous vein flow between the first operation and the re-operation.

Conclusion

The mean blood flow of the homologous AVG was greater during the first operation and similar to the autologous grafts during the re-operation. Therefore, the homologous AVG could be considered a possible alternative to vascular access for hemodialysis.
Collateralization of the palmar arch by a failing radiocephalic fistula: An underappreciated complication of Cimino fistula anatomy
Authors: Mcgill R.L. , Marcus R.J. , Healy D.A. , Kiproff P.M. , Nye S.
Published: January 2018

Stenosis at the anastomosis of an arteriovenous dialysis fistula can cause fistula failure due to venous thrombosis. Three cases are presented in which anastomotic stenosis in radiocephalic fistulas resulted in radial artery occlusion with collateralization of ulnar artery flow across the palmar arch. Hand ischemia did not occur, and reductions in fistula efficiency were clinically subtle. Urea kinetics were compromised, and a characteristic palmar bruit was heard.
Azygos arch cannulation by central venous catheters for hemodialysis
Authors: Granata A. , Figuera M. , Castellino S. , Logias F. , Basile A.
Published: January 2018

Cannulation of central veins and placement of catheters for temporary haemodialysis is a common procedure in the management of patients with end stage renal failure. The internal jugular vein is the site of choice for central venous catheter placement, being associated with the lowest complication rate. This procedure can be associated with a variety of malpositions of the catheter and rarely, can lead to significant morbidity and even mortality, if this is not recognised and corrected early. For anatomical reasons, the risk of azygos arch cannulation is substantially increased if catheters are inserted via left-sided veins. We report a case with a rare complication associated with the insertion of a catheter for temporary haemodialysis.
Unusual Long-Term Complication of Permanent Central venous Catheter for Hemodialysis. Review of the Literature on Mechanical Complications
Authors: Di Iorio B.R. , Mondillo F. , Bortone S. , Nargi P. , Capozzi M. , Spagnuolo T. , Cucciniello E. , Bellizzi V.
Published: January 2018

The ideal dialysis access ensures adequate blood flow for dialysis, has a long life, and is associated with a low complication rate. Although no current type of access fulfills all these criteria, the native arteriovenous fistula (AVF) is close to doing so. Unfortunately, various kinds of vascular access (VA) are becoming more and more necessary to enable hemodialysis (HD). The central venous catheter (CVC), which is associated with higher morbidity and mortality, could be the only viable option to maintain permanent VA. We report an unusual complication in a patient, a 74-year-old female, who had been undergoing HD via a CVC for 14 yrs. A polyurethane CVC with a double lumen was inserted into the right internal jugular vein because an AVF was not feasible, and a polytetrafluoroethylene (PTFE) prosthesis was obstructed. In 2003, the CVC was removed due to stenosis and occlusion of the superior vena cava. A new CVC, also made of polyurethane and with a double lumen, was inserted into the left femoral vein. In January 2005, the patient reported a small rupture of about 3–4 mm located under the cuff of the CVC. For this reason, the left femoral vein had to be used, replacing the Optiflow one with a 40-cm long Tesio CVC, and the second catheter was inserted into the right femoral artery by conventional surgery. After 10 months, the patient returned once more, after the CVC in the left femoral vein had been removed because of malfunction and that the attempts to cannulate the same vein again had failed. Currently, two 70-cm long Tesio catheters implanted in the right femoral vein (whose tips almost reach the diaphragm) are used for dialysis sessions. The number of CVC implants has progressively increased amongst HD patients who are elderly, diabetic or who have been on long-term HD. The patient described in this case report is currently using a 70-cm long double Tesio catheter (single Tesio CVC in SPI silicon) placed in the right femoral vein. She has resumed therapy with dicumarol anticoagulants, maintaining INR within the 2.5–3.5 range. In conclusion, both the increase in the use of venous catheters for HD and in the survival of dialysis patients contribute towards the observation of rare complications associated with CVC use.
Catheter induced superior vena cava syndrome aggravated by shunt placement
Authors: Verbeek W.H.M. , Riezebos R.K. , Siegert C.E.H. , Weijmer M.C.
Published: January 2018

A case is presented of a dialysis catheter induced SVC syndrome aggravated by a recently surgically created AV fistula. Conventional angiography as well as computed tomography showed a catheter induced stenosis in the SVC. Removal of the catheter and treatment with anticoagulants resulted in resolution of the syndrome without the need for invasive endovascular intervention.
The endless history of vascular access: a surgeon's perspective
Authors: Berardinelli L.
Published: January 2018

Gaining access to blood circulation has been a major breakthrough of modern medical care and, despite the evolution of dialysis technology, vascular access (VA) remains the main impediment in providing quantity as well as quality of life to the end-stage renal disease (ESRD) patient. The external Scribner shunt and the internal Brescia/Cimino arteriovenous fistula (AVF) opened the way for further advancements such as graft angioaccess and other sophisticated devices. Forty years later, the radio-cephalic fistula remains the VA with the longest patency and the lowest complications. Although various technical solutions can be adopted for constructing access to the patient's vessels, the nephrologist must bear in mind that every VA in the upper limb, lower limb or body wall needs a run-in and a run-off: currently, thrombosis of the central vessels due to the excessive widespread use of central venous catheters (CVCs) emerge as a substantial cause of hemodialysis (HD) morbidity and mortality. Moreover, as there is a risk of central vein stenosis, even 2 weeks after catheter placement, and an impaired venous outflow precludes the creation of any VA and sometimes the placement of a kidney transplant in the iliac fossa for many years, we agree with McGill et al, who in 2005 said that “expansion of catheter access may contribute to the reduced survival of hemodialysis patients in the United States”.
Anticoagulation therapy for the prevention of hemodialysis tunneled cuffed catheter (TCC) thrombosis
Authors: Colì L. , Donati G. , Cianciolo G. , Raimondi C. , Comai G. , Panicali L. , Nastasi V. , Cannarile D.C. , Gozzetti F. , Piccari M. , Stefoni S.
Published: January 2018

Background

Chronic oral anticoagulation is currently used to avoid thrombosis and the malfunction of tunneled cuffed catheters (TCCs) for hemodialysis (HD). The aim of the study was to assess the efficacy of early warfarin administration, after TCC placement, in comparison to its administration after the first thrombosis or malfunction event of the TCC.

Patients and methods

One hundred and forty-four chronic dialysis patients, who underwent TCC placement between June 2001 and June 2005, were randomized into two groups: 81 patients, group A, started oral anticoagulation 12 hr after the TCC placement (target international normalized ratio (INR) 1.8–2.5), in association with ticlopidine 250 mg/die; 63 patients, group B, started warfarin after the first thrombosis/malfunction episode (target INR 1.8–2.5) in association with ticlopidine 250 mg/die. The efficacy of oral anticoagulation therapy in preventing TCC thrombotic complications was evaluated in a 12-month follow-up period, after TCC placement, in terms of: a) the number of patients with thrombotic-malfunction events; b) the number of thrombotic-malfunction events with urokinase infusion (events/patient/year); c) intradialytic blood flow rate (BFR, ml/min); d) negative blood pressure (BP) from the arterial line of the TCC (AP, mmHg); e) positive BP, in the extracorporeal circuit from the venous line (VP, mmHg); and f) bleeding complications.

Results

Ten patients (12%) in group A showed TCC thrombosis/malfunction vs. 33 patients (52%) in group B (p<0.01). In group A, 0.16 events of thrombosis/malfunction per patient/year vs. 1.65 in group B (p<0.001) were observed. BFR was respectively 305 ± 34 vs. 246 ± 42 ml/min (p<0.001). AP was –124 ± 13 in group A vs. –174 ± 21 mmHg in group B (p<0.05). VP was 112 ± 28 in group A vs. 168 ± 41 mmHg in group B (p<0.05). No patient showed any bleeding events.

Conclusions

Early warfarin therapy allows a significant reduction in TCC thrombotic complications and an improvement in both arterial and venous fluxes in comparison with the same therapy administered after the first TCC thrombotic/malfunction event. This therapy did not induce any bleeding complications in the patients included in the study.
Follow-up of an age-period-cohort analysis on alcohol-related mortality trends in Sweden 1970–2015 with predictions to 2025
Authors: Rosén Måns , Haglund Bengt
Published: January 2018

Background and aims: Several studies have indicated that birth cohorts are important in explaining trends in alcohol-related mortality. An earlier study from Sweden with data up to 2002 showed that birth cohorts that grew up under periods of more liberal alcohol policies had higher alcohol-related mortality than those cohorts growing up under more restrictive time periods. In spite of increasing alcohol consumption, predictions in 2002 also indicated lower alcohol-related mortality in the future. The aim of this study is to follow-up whether the effects of birth cohorts and the predictions made for Sweden still holds using data up to 2015. Method: The study comprised an age-period-cohort analysis and predictions based on population predictions from Statistics Sweden. The analysis was based on all alcohol-related deaths in the Swedish population between 1969 and 2015 for the cohorts born in the decades 1920 through 1990. Data were restricted to people 15–84 years of age. In total, the analysis covered 68,341 deaths and more than 284 million person-years. Results: Male and female cohorts born in the 1940s to 1950s exhibited the highest alcohol-related mortality, while those born in the 1970s continued to have the lowest alcohol-related mortality rates. The predicted mortality rates for males are still anticipated to decrease somewhat through 2025. Conclusions: The updated age-period-cohort analysis further supports the importance of focusing on restrictive alcohol policies targeting adolescents.
Police and Crime Commissioners
Authors: Loveday Barry
Published: January 2018

This article considers the progress of the new system of police governance in England and Wales. It assesses the responsibilities and powers of Police and Crime Commissioners (PCCs) and examines local initiatives undertaken by some PCCs that have proved to have national ramifications. It evaluates the accountability of PCCs between elections and highlights the limited powers of Police and Crime Panels. It considers the convention of police operational independence in light of two controversial police investigations, and the potential need for PCC oversight of future publicly high-profile investigations. It provides an initial assessment of an important and recent High Court ruling (R v Police and Crime Commissioner for South Yorkshire, 2017) which, by making the PCC responsible for all police operational activity, questions the tradition of constabulary operational independence. It is argued that enabling the PCC to bring a chief officer to account for all police operations might mean that potentially challenging and fruitless investigations can be avoided in the future.
Vibration analysis of air-bearing work-stage under micro-scale effect
Authors: Chen Dongju , Dong Lihua , Pan Ri , Fan Jinwei , An Chenhui
Published: January 2018

Vibration is one of the key factors that influences the ultra-precision machining. Taking the air-bearing work-stage for an example, the vertical vibration of the slide plate will directly affect the surface accuracy of machined parts. There are many factors that affect the vibration of precision machine tools, for example, the fluctuation of gas source, noise, environment, and so on. It will affect the machining accuracy and machining efficiency and cannot work in severe cases. Where the lubrication of the gas film in the air-bearing work-stage is in the micro scale category, its flow characteristics are different from the macroscopic gas flow, and it will also affect the stability of the sliding plate. This paper analyzed the vertical vibration characteristics of the air-bearing work-stage by considering the characteristics of gas film in micro scale when the velocity of the slide plate is 0. Based on the Reynolds equation and the characteristics of gas flow, the stiffness ( K) and the damping ( C) of the gas film are obtained by considering different micro factors. The gas film is assumed as the spring system. Then the stiffness and damping of the gas film are taken into the vibration equation of the slide plate. Through solving the vibration equations, the influence of the micro factor of the fluid on the vibration of the slide plate is researched. The results show that when considering the micro factors of the lubrication gas film, the vibration amplitude of slide plate and the frequency at the maximum amplitude are different from the one in macroscopic without considering any micro factors. At the same thickness of the gas film, the influence of the micro factors on the amplitude of slide plate is largest when three micro scale factors (the first order velocity slip, the flow factor Q and the effective viscosity) are considered. With the increase of the film thickness, the micro scale factors have the little effect on the frequency at the maximum amplitude. By analyzing the dimensionless parameters of the experimental signals and the different simulation signals, we found that when the micro-scale factors are considered at the same time, the vibration amplitude of the slide plate and the frequency at the maximum amplitude are closest to the experimental result. It is proved that combined with the micro scale factor, the analysis of dynamic characteristics of air-bearing work-stage is more accurate.