Showing papers in "Journal of Vascular Access in 2012"
TL;DR: The authors' multicenter study confirms that the intracavitary ECG method for real time verification of tip position is accurate, safe, feasible in all adult patients and applicable to any type of short-term or long-term central venous access device.
Abstract: Purpose: The aim of this multicenter study was to assess the feasibility, safety, and accuracy of the intracavitary ECG method for real-time positioning of the tip of different types of central venous catheters. Methods: A total of 1444 catheter insertions in adult patients were studied in eight Italian centers (539 ports, 245 PICCs, 325 tunneled CVCs, 335 non-tunneled CVCs). Patients with no visible P wave at the standard baseline ECG were excluded. Depending on the type of catheter and its purpose, the target was to position the tip either (a) at the cavo-atrial junction, or (b) in the lower third of the superior vena cava, or (c) in the upper part of the atrium. The final position was verified by a post-procedural chest x-ray. Results: The method was feasible in 99.3% of all cases. There were no complications potentially related to the method itself. At the final x-ray control, 83% of all tips were positioned exactly at the target; 12.4% were positioned within 1-2 cm from the target, but still in a correct central position; only 3.8% were malpositioned. The mismatch between intra-procedural ECG method and post-procedural x-ray was significantly lower when the x-ray was taken in supine position. Conclusions: Our multicenter study confirms that the intracavitary ECG method for real time verification of tip position is accurate, safe, feasible in all adult patients and applicable to any type of short-term or long-term central venous access device.
128 citations
TL;DR: Length of hospital stay and cost are markedly increased in patients who develop PICC-associated upper extremity venous thrombosis, and trauma, renal failure, left-sided catheters, basilic placement, TPN, and infusion with antibiotics, specifically vancomycin, were significant risk factors for UEVT associated with PICCs.
Abstract: PurposeTo identify clinically important risk factors associated with upper extremity venous thrombosis following peripherally inserted central venous catheters (PICC).MethodsA retrospective case co...
102 citations
Pennsylvania State University1, Vanderbilt University Medical Center2, University of Louisville3, University of Michigan4, Cleveland Clinic5, University of California, Los Angeles6, Detroit Medical Center7, Munson Medical Center8, Geisinger Medical Center9, Texas A&M Health Science Center College of Medicine10, Mercy Medical Center (Baltimore, Maryland)11
TL;DR: The Vessel Health and Preservation programme incorporates evidence-based practices focused on timely, intentional proactive device selection implemented within 24 hours of admission into any acute facility, allowing for the reduction of variations and roadblocks in care while increasing positive patient outcomes and satisfaction.
Abstract: Vascular access for the infusion of medications and solutions requires timely assessment, planning, insertion, and assessment. traditional vascular access is reactive, painful, and ineffective, often resulting in the exhaustion of peripheral veins prior to consideration of other access options. Evidence suggests clinical pathways improve outcomes by reducing variations and establishing processes to assess and coordinate care, minimizing fragmentation and cost. Implementation of a vascular access clinical pathway leads to the intentional selection of the best vascular access device for the patient specific to the individual diagnosis, treatment plan, current medical condition, and the patient’s vessel health (1). the Vessel Health and Preservation (VHP) programme incorporates evidence-based practices focused on timely, intentional proactive device selection implemented within 24 hours of admission into any acute facility. VHP is an all-inclusive clinical pathway, guiding clinicians from device selection through patient discharge, including daily assessment. Initiation of the VHP programme within a facility provides a systematic pathway to improve vascular access selection and patient care, allowing for the reduction of variations and roadblocks in care while increasing positive patient outcomes and satisfaction. Patient safety and preservation of vessel health is the ultimate goal.
84 citations
TL;DR: Not only does venous IH pre-exist, but inflammation and oxidation markers are present within veins used for the AVF conduit prior to its creation in CKD patients as early as one year before dialysis is commenced.
Abstract: PurposeIntimal hyperplasia (IH), a well-recognized cause of dialysis vascular access failure, is generally believed to be an acquired pathologic lesion. Recent data suggests that IH is present prio...
80 citations
TL;DR: The symptoms of hemodialysis vascular access patients associated with non-correctable central venous lesions resolved successfully and their access was maintained using a precision inflow banding procedure.
Abstract: Purpose: Vascular access patients with central vein (CV) stenosis or occlusion may have significant symptoms. Treatment is generally by balloon angioplasty, with or without stenting. However, CV lesions may not be correctable and when treated, tend to recur. Surgical bypass of CV obstruction is a major procedure and ligation of the access may leave the patient dependent on catheter dialysis. We review a precision inflow banding procedure to limit vascular access flow and pressure for symptomatic patients with CV obstruction while preserving access functionality. Materials and Methods: All individuals with symptomatic CV occlusive disease who underwent an autogenous vascular access inflow restriction procedure by the two senior authors were identified. All had failed attempts to correct CV lesions by angioplasty and stent placement. A precision banding procedure was used for access inflow reduction with the addition of real-time intravascular flow monitoring. Results: Twenty-two patients were identified. Ages were 22-72 years (mean=43 years). Nine patients (40.9%) were women, and 8 (36.4%) obese. Mean access flow was 1640 mL/minute before banding decreased to 820 mL/minute after banding (P< .01). All patients had access salvage. Swelling resolved promptly in 20 patients and was markedly improved in two individuals. Three patients underwent aneurysm repair with simultaneous inflow banding and decreased intra-access pressure after flow restriction. Two fistulas failed at eight and 13 months. Mean follow-up was 8 months. Conclusions: The symptoms of hemodialysis vascular access patients associated with non-correctable central venous lesions resolved successfully and their access was maintained using a precision inflow banding procedure.
58 citations
TL;DR: It is concluded that hydrodynamics has a determinant effect on the efficacy of pulsed and continuous infusion for flushing IVADs and that the adjunction of an intermittent component in the flow increases it.
Abstract: PurposeTo compare, under controlled conditions similar to practical situations, the efficacy of pulsed and continuous infusion for flushing IVADs. For both of them different flow rates, flushing vo...
48 citations
TL;DR: Laterality of PICC placement is not significantly associated with symptomatic VTE formation, and the overall rate of thrombosis in this study is comparable to that of previous studies.
Abstract: PurposeThe use of peripherally inserted central venous catheters (PICCs) has become widespread in hospital medicine. PICCs are preferentially placed on the right side due to anatomic ease of insert...
35 citations
TL;DR: DRIL procedure is effective at relieving symptoms in carefully selected patients, but does have potential complications such as bypass failure and worsened ischemia, and deserves further study.
Abstract: PurposeThe Distal Revascularization Interval-Ligation (DRIL) procedure has demonstrated efficacy in the management of Dialysis Access-associated Steal Syndrome (DASS); however, this has not been wi...
31 citations
TL;DR: In this article, a percutaneous balloon angioplastic angioploin (PLA) was used for hemodialysis patients with acute access thrombosis.
Abstract: PurposePatency of mature vascular access for hemodialysis is mostly limited by the growing stenoses leading to acute access thrombosis. The therapy of choice is usually percutaneous balloon angiopl...
29 citations
TL;DR: Although selection bias cannot be excluded in this retrospective study, heparin-bonded AVGs did not perform better than conventional AVGs and co-morbid conditions did not affect the cumulative patency or complication rates of brachiocephalic AVF or AVG.
Abstract: PurposeArteriovenous fistulae (AVF) are the preferred vascular access for hemodialysis patients. However, patients who do not have suitable veins require prosthetic arteriovenous graft (AVG) placem...
27 citations
TL;DR: Valved PICCs do not appear to influence PICC occlusion rates, and the dose of urokinase required to treat PICc occlusions did not significantly differ between PICS types.
Abstract: Purpose: Peripherally Inserted Central Catheters (PICCs) are increasingly being used to provide short to medium-term central venous access. The current study was designed to test the hypothesis that PICC valve technology does not influence PICC occlusion rates. Methods: Intensive care unit (ICU) patients who required a PICC were randomized to one of three types of dual lumen PICC (open ended non-valved, Groshong valve, PASV valve). PICC occlusions were recorded and managed with a protocol that used urokinase. Results: A total of 102 patients were recruited to the study. The overall risk of occlusion per catheter was 35% (95% CI 26% to 44%). The overall rate of occlusion was 76 occlusions per 1000 catheter days (95% CI 61 to 95). Presence or type of valve did not significantly influence this rate (open-ended non-valved PICC 38% of catheters, 79 occlusions per 1000 catheter days; Groshong 38% of catheters, 60 occlusions per 1000 catheter days; PASV 27% of catheters, 99 occlusions per 1000 catheter days). The dose of urokinase required to treat PICC occlusions did not significantly differ between PICC types. Conclusions: Valved PICCs do not appear to influence PICC occlusion rates.
TL;DR: The genius and the perseverance of the three physicians paved the way towards peripheral and central catheter vein placement, one of the most frequently performed maneuvers in hospitals.
Abstract: Sir William Harvey (1578-1657), who had many precursors, discovered blood circulation in 1628 after a significant number of anatomic dissection of cadavers; his studies were continued by Sir Christopher Wren and Daniel Johann Major. The first central vein catheterization was performed on a horse by Stephen Hales, an English Vicar. In 1844, a century later, the French biologist Claude Bernard attempted the first carotid artery cannulation and repeated the procedure in the jugular vein, again on a horse. He was first to report the complications now well known to be associated with this maneuver. In 1929 Werner Forssmann tried cardiac catheterization on himself, but could not investigate the procedure further since his findings were rejected and ridiculed by colleagues. His work was continued by Andre Frederic Cournand and Dickinson Woodruff Richards Jr in the United States. In 1956 the three physicians shared the Nobel Prize for Medicine for their studies on vascular and cardiac systems. The genius and the perseverance of the three physicians paved the way towards peripheral and central catheter vein placement, one of the most frequently performed maneuvers in hospitals. Its history still remains unknown to most and deserves a short description.
TL;DR: Having a CVC may negatively influence HRQOL in HD patients andVascular access type does not seem to be related to depressed mood in HD.
Abstract: Purpose Arteriovenous fistulas (AVF) are the vascular access of choice for hemodialysis (HD) compared with arteriovenous grafts (AVG) and central venous catheters (CVC). In spite of increasing recognition of importance of a patient's perception of health-related quality of life (HRQOL) and depression, few studies have assessed the association of vascular access type with HRQOL and depression. The purpose of our study was to examine HRQOL and depression among patients with different vascular access. Methods Severity of symptoms of depression and HRQOL were assessed by Beck Depression Inventory (BDI) and Short Form-36 (SF-36), respectively. Vascular access was reported as one of three options; AVF, AVG, and CVC. Results In total, 136 patients were included; 104 had AVF, 15 had AVG, and 17 had CVC. BDI and HRQOL parameters differed among patients with different vascular access types. In post hoc analysis, BDI and HRQOL subscales were not different between patients with AVF and AVG. Patients with CVC had lower physical functioning (P:.001), role-physical limitation (P:.015), general health perception (P:.017), vitality (P:.010), social functioning (P:.004), role-emotional (P:.008), mental health (P:.001), physical component summary score (P:.017), and mental component summary score (P:.006) when compared to patients with AVF. Patients with CVC had lower physical functioning (P:.044), role-emotional (P:.044) and mental health scores (P:.04) when compared to patients with AVG. Conclusions Having a CVC may negatively influence HRQOL in HD patients. Vascular access type does not seem to be related to depressed mood in HD.
TL;DR: It is indicated that cancer patients are more vulnerable to CVC-related infections during Home Parenteral Nutrition and that a safer protocol should be adopted in order to contain C VC-related complications.
Abstract: Background Home Parenteral Nutrition is a therapeutic option to improve quality of life in chronic intestinal failure. Aims To describe frequency of complications both in cancer and noncancer patients. Methods This study was performed on 270 adult patients (52% with cancer, 48% without cancer) followed for a total of 371 years of treatment. Mean duration of therapy was 191±181 for cancer and 830±1168 days/patient for noncancer. The treatment was administered by a competent, dedicated provider. Patients received our prescribed "all-in-one admixtures" at their homes. Results Catheter-related complications/1000-days-catheter was 1.40; mechanical complications were comparable in cancer (0.82) and noncancer (0.91) patients while a statistically significant difference was observed between cancer (0.71) and noncancer (0.46) patients for sepsis. Bacterial infections were more frequent in noncancer, mycotic infections primarily affected cancer patients. In our experience 49% of the patients were readmitted, with a low incidence rate of 0.89/1000 days-catheter. The incidence of hepatobiliary complications in our population was 65%. The degree of liver damage was related to short bowel syndrome and to length of treatment. Conclusions This study indicated that cancer patients are more vulnerable to CVC-related infections during Home Parenteral Nutrition and that a safer Home Parenteral Nutrition protocol should be adopted in order to contain CVC-related complications.
TL;DR: This review article delineates the complicated interactions of upper limb vein aneurysms, delineates their complicated interactions and also highlights their utility in clinical decision-making and therapeutic management.
Abstract: Upper limb vein aneurysms complicate all types of autogenous arteriovenous fistulae (AVF) and comprise false aneurysms secondary to venipuncture trauma as well as true aneurysms, characterized by dilatation of native veins. The dilatation of a normal vein and the development of a true aneurysm are strongly influenced by local hemodynamic factors affecting the flow in the drainage venous system and are also the target of operative interventions. This review article focuses on the description of these hemodynamic aspects which all physicians involved in the management of dialysis patients should be aware of. Furthermore, it delineates their complicated interactions and also highlights their utility in clinical decision-making and therapeutic management.
TL;DR: The initial results suggest that single cannulation dual lumen venovenous ECMO catheter placement can be performed successfully and safely in an Interventional Radiology setting.
Abstract: PurposeTo report our initial results of venovenous ECMO placement of a novel bicaval dual lumen catheter in six consecutive patients with severe respiratory failure.MethodsThe dual lumen catheters ...
TL;DR: Reformative operations should be considered in cases of urgency and irresponsiveness to endovascular surgery rather than closing the fistulas directly, as it prolongs the duration of AVF patency.
Abstract: PurposeThis study was designed to determine the clinical presentation, characteristics, and management of aneurysm/pseudoaneurysm formation (APF) in dialysis access fistulas.MethodsThe treatment me...
TL;DR: Following successful renal transplantation, functioning AVFs should almost never be ligated and the physiologic impact of the patent AVF on patients does not strongly advocate routine ligation following transplant.
Abstract: PurposeThere is limited literature available to guide physicians on a course of action when they are approached by renal transplant recipients regarding the status of their vascular accesses. Howev...
TL;DR: Stent-grafts can be successfully used to improve freedom from re-intervention rates and overall patency rates of failing AVGs, according to a retrospective review of patients treated with percutaneous Viabahn® stents for failing hemodialysis arteriovenous grafts.
Abstract: PurposeFailing hemodialysis grafts continue to pose a challenge in the care of patients with end-stage renal disease (ESRD). We review our experience using percutaneous stent-grafts for the treatme...
TL;DR: Although thrombophlebitis frequently occurred in PVCs inserted in a prehospital setting, early removal of the device with complication was common and further studies are warranted to identify the optimal in situ time for PVCs Inserted by prehospital emergency teams.
Abstract: PurposeTo investigate prehospital peripheral venous catheters (PVCs) in relation to the frequency of thrombophlebitis.MethodData in this prospective study were collected using three types of data s...
TL;DR: Thrombo-embolic prophylaxis appears to be rather ineffective for prevention of CRT, and TIVAPs of the forearm may be associated with a certain rate of early and late CRT.
Abstract: PurposeTo identify risk factors for the development of catheter-related thrombosis (CRT) in patients with totally implant-able venous access ports (TIVAP) in the forearm, and to analyze the effect of prophylaxis and treatment.MethodsWe retrospectively identified 200 patients (94 men, 106 women, mean age 57.7 +/-14 y) with TIVAP implantation in the forearm between 3/2010 and 11/2010. Type, number of punctures and sonographically defined diameter of the accessed vein were analyzed. Chemotherapy administered prior to the implantation procedure and history of thrombo-embolic events were assessed. Thrombo-embolic prophylaxis (TEP) following port implantation and treatment as well as course of CRT were analyzed.ResultsTwenty-one patients (10.5%) were diagnosed with CRT. Accessed vessels and mean diameter were basilic (n=150, 3.7 mm), brachial (n=39, 3.5 mm) and cephalic (n=11, 3.5 mm) vein. Neither type nor vessel diameter had effect on CRT development (P>.05). Implantation in the left forearm resulted in a sig...
TL;DR: Type of upper limb fistula did not impact on failure rates, and the presence of stenosis was the only variable found to have a significant impact on AVF failure in multivariate analysis.
Abstract: PurposeArterio-venous fistulae (AVF) for hemodialysis are prone to problems, ultimately leading to failure of the fistulae. Our aim was to determine the site and time to first stenosis and time to and factors influencing AVF failure for radio-cephalic (RC), brachio-cephalic (BC), and transposed brachio-basilic (BB) AVF.MethodsRetrospective analysis of native AVF constructed within a single vascular unit between January 2002–December 2008. Patients followed up to the end points of death, AVF failure or end of study period. Data collected included: age, sex, AVF type, time and site of first stenosis and time to failure. The relationship between fistula type, stenosis, and failure were examined.ResultsIn total, 398 native AVF were included in the study (91 RC, 208 BC, and 99 BB), with a mean age of 66 years. A total of 215 (54%) AVF developed a flow limiting stenosis, and over time 151 (40%) AVF failed. Stenoses developed significantly earlier in RC AVF (median 113 days) compared to BC (median 277 days), com...
TL;DR: Sharp needle recanalization is an effective percutaneous treatment for restoring function to hemodialysis accesses with chronically occluded venous outflow pathways.
Abstract: Purpose: To assess the effectiveness of sharp needle recanalization (SNR) for treatment of chronically occluded venous outflow in hemodialysis access. Methods: A retrospective analysis of patient records from January 2006 to March 2010 was conducted. Forty-four hemodialysis patients (31 fistulas, 13 grafts) were referred for arm swelling (18%), excessive bleeding after dialysis (29%), and thrombosis (53%). All patients had chronic occlusion of the outflow vein which failed conventional recanalization techniques. A new outflow pathway was established by advancing a 21g needle and dilating the subcutaneous tract to bridge the fistula body to a juxtaposed patent vein. If necessary, uncovered or covered stents were utilized to maintain patency of the newly formed subcutaneous tract. Results: Forty-four patients underwent 45 SNR procedures, with restoration of normal function and complete relief of symptoms in 40 (91%) patients. The average tract length was 15 mm (range, 1 to 32) and the average dilatation diameter was 8 mm. During the initial SNR procedure, bare metal (n=21) or covered (n=5) stents were inserted in 26 patients. The average follow-up was 18.4 months (range, 0.2 to 48 months). No major complications were observed with the procedure. At 12 months, the primary access, primary tract, and secondary access patencies were 10%, 51%, and 92%, respectively. Percutaneous thrombectomy procedures were performed at a rate of 1.16 per access-year and the number of interventions within the tract was 0.94 per access-year. Conclusions: Sharp needle recanalization is an effective percutaneous treatment for restoring function to hemodialysis accesses with chronically occluded venous outflow pathways.
TL;DR: The ulcerated autologous dialysis dialysis fistula is a life-threatening lesion that requires prompt surgical intervention to reduce mortality and should be utilized as a temporizing measure until surgical correction can be undertaken.
Abstract: PurposeThe incidence of ulcerated, bleeding, autologous, hemodialysis fistulas has been felt to be increasing in recent years. This review was undertaken to examine our experience with patients who...
TL;DR: The data suggest that TIVADs represent a safe and effective device for the intermittent IV administration of drugs in people with CF, however, people with CFRD have a higher risk of developing TIVad-related infection.
Abstract: PurposeThe aim of this study was to assess the incidence of late onset complications of totally implantable venous access devices (TIVAD) in patients with cystic fibrosis (CF) and to investigate po...
TL;DR: Coil embolisation of ADVs is an effective treatment option for dysfunctional fistulae that can be performed at the same time as angioplasty and coiling with only 5% patients having coiling of ADV alone.
Abstract: PurposeArterio-venous fistulae (AVFs) are accepted as the best form of haemodialysis vascular access (VA) but are plagued by high primary failure. Accessory drainage veins (ADVs) may account for up...
TL;DR: AVGs are sometimes a better choice for those patients in which the time to and probability of successful fistula maturation may be a concern, and close monitoring of AVGs in patients with the identified risk factors associated with loss of primary patency may improve the life expectancy of the access.
Abstract: PurposeThe objective of this study was to explore the association between loss of primary functional patency within 6 months of first use and demographic and clinical characteristics in patients with arteriovenous grafts (AVGs) receiving chronic hemodialysis. The knowledge and management of these characteristics will minimize the proportion of catheter-dependent dialysis patients for whom AVGs are the best choice.MethodsThis was a retrospective study of all chronic hemodialysis patients with AVGs followed by the Southern Alberta Renal Program from January 2005 to June 2008. Demographic and clinical variables and initial intra-access blood flow (IABF) were compared between those with and without loss of primary functional patency. To determine the contribution of independent variables to the dependant variable of loss of primary functional patency, a multivariable analysis using logistic regression was performed.ResultsThe incidence of primary failure was 30% (107/359). Multivariable analysis found that lo...
TL;DR: It is shown that it is possible to define the types of stenotic lesions for which stent therapy is effective through morphological diagnosis of those lesions using ultrasound tomography and the vascular constriction type displayed excellent primary patency rates after stent placement.
Abstract: PurposeThe mechanisms of venous stenosis in vascular access include vascular constriction and neointimal hyperplasia. One purpose of this study was to examine the properties of stenotic lesions in ...
TL;DR: The study demonstrated the capability of the CFD framework to analyze patient a-v fistulas on a regular basis using both MRI and ultrasound-based approaches.
Abstract: Purpose A-v anastomosis entails dramatic changes in hemodynamic conditions, which may lead to major alterations to the vessels involved; primarily dilatations and devastating stenoses. Wall shear stress is thought to play a key role in the remodeling of the vessels exposed to abnormal levels and oscillating wall shear stress. In this study we sought to develop a framework suitable for thorough in vivo analyses of wall shear stress and vessel morphology of a-v fistulas in patients. Methods Using ultrasound and magnetic resonance imaging (MRI) transverse image stacks from six patient a-v fistulas were obtained. From the image stacks three-dimensional geometries of the patient fistulas were created using dedicated segmentation software. Geometries of three a-v fistulas were imported into finite element software in order to perform fluid flow simulations of blood flows and frictional forces on the vessel walls in the a-v fistulas. Boundary conditions for the simulations were obtained using both a MRI phase contrast and an ultrasound Doppler technique. Results The segmentation of the six fistulas of very different age and morphology (two end-to-side and four side-to-side) showed the ability of the approach to create geometries of various fistula morphologies. Simulations of the three fistulas showed an instant picture of the present status of the exposure to different levels of wall shear stress and the morphological status in the vessel remodeling process. Conclusion The study demonstrated the capability of the CFD framework to analyze patient a-v fistulas on a regular basis using both MRI and ultrasound-based approaches.
TL;DR: The need for chest x-ray or fluoroscopy may be virtually eliminated by using the ECG technique, which was always apt to detect the increase in the P wave.
Abstract: BackgroundIntra-cavitary electrocardiography (ECG) is a well-known method for correct positioning of the tip of central venous catheters (CVC). A significant increase in the P wave, as registered b...