Preservation of upper extremity vasculature in patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) is essential to maintain future arteriovenous fistula (AVF) creation options. Despite Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations, inappropriate device and vein selection persists. This study evaluated adherence to KDOQI vessel preservation guidelines over a 5-year period at a single academic institution. A total of 3505 patients underwent placement of peripherally inserted central catheters (PICCs), centrally inserted central catheters (CICCs), femorally inserted central catheters (FICCs), acute dialysis catheters with venous ports (ADCwVPs), or centrally inserted tunneled catheters (CITCs) between January 2020 and January 2025, including 1433 PICCs, 1574 CICC/FICC/ADCwVP devices, and 498 CITCs. Nephrology consultation was obtained in 1464 patients (41.8%), of whom 647 (44.2%) had CKD stage 3b-ESKD. KDOQI compliance was achieved in 585 patients (90.4%); 62 patients (9.6%) were non-compliant, including 33 PICCs, 9 CICC/FICC/ADCwVPs, and 20 CITCs. Sensitivity analysis identified 22.6% (14/62) of non-compliant cases as clinically unavoidable, yielding an adjusted avoidable non-compliance rate of 7.4%. Axillary and femoral vein utilization differed significantly between renal cohorts (p < 0.001). Twenty-five CRBSIs were identified: 13 in patients without nephrology consultation and 12 within the consultation subgroup (6 CICC/FICC/ADCwVP, 5 CITC, 1 PICC); patients with renal impairment accounted for 48% of all CRBSIs. Two-year follow-up of 33 PICC recipients with CKD stage 3b-ESKD showed progression to hemodialysis in four patients, mortality in 13, and one case of upper extremity DVT managed with anticoagulation, with removal of the PICC and placement of a CITC. A multidisciplinary bedside vascular access model achieved high adherence to KDOQI vessel preservation recommendations while maintaining low complication rates. Strategic device and vein selection may support safe vascular access management in patients with advanced kidney disease, though downstream outcomes such as AVF creation and central venous stenosis were not directly assessed.
OBJECTIVE:This study aimed to develop and implement an evidence-based nursing intervention program for vascular catheter-related infection prevention and control within a specialized nursing alliance network, guided by the Ottawa Model of Research Use. METHODS:A quasi-experimental implementation study with historical controls was conducted from January 2023 to December 2024 in 12 departments of a specialized nursing alliance. Consecutive eligible adults with central venous catheters or PICCs were enrolled (control, n = 160; intervention, n = 164). Outcomes were analyzed using crude incidence densities, exact Poisson tests, and multilevel models adjusted for clustering and calendar period. Implementation included evidence translation, barrier assessment, bundle delivery, audit and feedback, and mixed-methods evaluation. RESULTS:Observed CLABSI events were fewer in the intervention phase (4/4468 vs 10/4136 catheter-days; 0.90 vs 2.42/1000 catheter-days). The univariate exact Poisson comparison showed a non-confirmatory trend (IRR = 0.37, 95% CI: 0.08-1.28; p = 0.108), while the adjusted model suggested a lower rate (IRR = 0.41, 95% CI: 0.23-0.73; p = 0.002) but was interpreted cautiously due to sparse-event overfitting risk. In 118 paired nurses, knowledge increased from 68.6 ± 12.1 to 86.7 ± 8.7, and overall bundle adherence increased from 60.1% to 90.2% (both p < 0.001). The adherence-infection model was exploratory (per 10% adherence increase: IRR = 0.82, 95% CI: 0.73-0.93; p = 0.001). CONCLUSION:The program produced robust process improvements and a promising downward trend in catheter-related infections. Rare-event infection estimates should be interpreted as hypothesis-generating, whereas the process findings support multilevel implementation strategies for catheter-care quality.
OBJECTIVES:Arteriovenous fistula is the preferred form of hemodialysis access. Positive remodeling may result in high flow vascular access (HFVA), leading to elevated right heart pressures, cardiomyopathy and in advanced presentation-high-output heart failure (HOHF). Noninvasive duplex ultrasound (DUS) is the most commonly accepted mode of surveillance for HFVA. The reliability of DUS compared to the gold standard modality of right heart catheterization (RHC) to quantify access circuit volume flow (Qa) has not been reported. Our aim is to analyze a cohort of patients with suspected HOHF who underwent both studies and evaluate the concordance between Qa measurements. METHODS:We identified a consecutive cohort of eight patients with suspected HFVA and HOHF requiring diagnostic RHC. Qa was calculated by DUS and RHC. The association between the two measures was calculated using Pearson correlation, and agreement was assessed with Lin's concordance correlation coefficient. We evaluate the association between brachial artery (BA) diameter and the Qa agreement. RESULTS:The mean Qa measured by DUS was 2623 ml/min, compared to a mean of 1538 ml/min measured by RHC. On average, the Qa measured by the DUS was 1086 ml/min greater than the RHC measurement, representing a 104% incremental difference. Only two of the eight cases (25%) had Qa measures within 500 ml/min. This discordance was greatest with a larger BA diameter, where a lower agreement measure of 0.39 and a moderate range correlation of 0.55 was found between Qa measured with RHC and DUS. CONCLUSION:Although DUS is the most utilized modality to monitor Qa, low correlation is observed compared to RHC, discrepancy that is directly associated with BA diameter and may reflect true overestimation of Qa by DUS or result from measurements obtained under differing hemodynamic conditions (e.g. heart rate variability). RHC should be used more liberally for the diagnosis and management of HFVA, particularly when HOHF is suspected.
Nontunneled central venous catheters (CVCs) are widely used for urgent and short-term vascular access in blood purification therapy, but catheter-related thrombosis remains a frequent and clinically important complication. It may cause catheter dysfunction, treatment interruption, premature catheter removal, additional interventions, pulmonary embolism, and increased mortality risk. This consensus summarizes current evidence on the epidemiology, classification, risk factors, prevention, evaluation, and management of thrombosis associated with nontunneled CVCs in blood purification therapy. Key preventive strategies include appropriate catheter indications, minimized dwell time, preference for the right internal jugular vein, ultrasound-guided insertion, standardized catheter care, and appropriate locking solutions. Evaluation should combine clinical recognition with stepwise imaging, with color Doppler ultrasonography as the first-line modality. Management should be individualized according to thrombus location and severity, including thrombolysis, anticoagulation, catheter removal, and selective interventional or surgical treatment.
BACKGROUND:Central venous hemodialysis catheters are widely used in critically ill patients, but conventional double-lumen designs have limited functionality and are associated with high recirculation rates and thrombotic risk. Triple-lumen catheters can potentially meet the needs of simultaneous hemodialysis and intravenous therapy, yet their hemodynamic performance has not been systematically evaluated. METHODS:A simplified superior vena cava (SVC)-catheter model was constructed. The Carreau non-Newtonian blood model was employed, and the Navier-Stokes equations were solved under mixed boundary conditions, including pulsatile SVC inflow and constant dialysis flow. A catheter flow rate of 400 mL/min was selected to represent a high-flow intermittent hemodialysis condition and to evaluate the catheter under a relatively demanding hemodynamic setting. Recirculation rate (RR) was calculated using Lagrangian particle tracking with 32,000 particles. Blood damage index (BDI) was calculated using the Grigioni power-law damage accumulation model with 1,400 platelet-sized particles. Wall shear stress (WSS) distribution was analyzed, and standard versus reversed connection configurations were compared. RESULTS:In standard connection, RR was 0.13%, mean BDI was 9.72 × 10⁻4, and high WSS (>10 Pa) areas accounted for 1.22% of the total catheter wall surface. In reversed connection, RR was 0.10%, mean BDI was 8.16 × 10⁻4, and high WSS areas accounted for 1.71%. High shear stress was predominantly localized at side-hole edges and the distal tip. CONCLUSION:A computational fluid dynamics (CFD) assessment framework was established for an acute, short-term, non-tunneled triple-lumen hemodialysis catheter for critically ill patients requiring temporary renal replacement therapy and an additional venous route. Under the single high-flow intermittent hemodialysis condition studied, the catheter demonstrated low recirculation, low BDI, and localized high WSS at side-hole edges and the distal tip. As comparator catheters were not simulated within the same framework, comparisons with prior literature are indirect and exploratory only. Direct comparator simulations and experimental validation are needed.
INTRODUCTION:Peripherally inserted central catheter ports (PICC-ports) are a recent alternative to traditional chest ports for long-term vascular access in oncology. While associated with easier insertion and improved patient comfort, comparative safety data remain limited. Prior meta-analyses were not conclusive as they included patients from older cohorts in whom outdated brachial or arm ports were used. This warrants further studies evaluating the safety profile of PICC-ports in a general cancer population. MATERIALS AND METHODS:We conducted a retrospective, single-center study comparing safety of PICC-ports and chest ports in adult oncology patients implanted between August 2022 and November 2024. Patients with contraindications to PICC-ports or receiving continuous infusion chemotherapy were excluded to minimize indication bias. All catheters were placed by a trained vascular access team using the ultrasound-guided micro-Seldinger technique and standardized protocols (SIP-Port and ISALT3). The primary outcome was the rate of severe adverse events (SAE) per 1000 catheter-days (CD), defined as complications requiring device removal, hospitalization, or resulting in death. Secondary outcomes included transient adverse events (TAE). RESULTS:A total of 329 patients were included (172 chest ports, 157 PICC-ports). Baseline characteristics were broadly comparable between groups. SAE incidence was comparable between groups (0.47 vs 0.55 per 1000 CD, p = 0.672). Similarly, TAE rates showed no significant difference (1.05 vs 0.79 per 1000 CD, p = 0.331). However, PICC-ports had more frequent placement failures, while chest ports had significantly more catheter occlusions requiring urokinase (p < 0.01). CONCLUSION:In this retrospective cohort, PICC-ports demonstrated a safety profile comparable to chest ports, with fewer occlusions but more placement failures. These results support the routine clinical use of PICC-ports in eligible patients, though further randomized trials are needed to confirm long-term outcomes.
PURPOSE:The aim of this study was to evaluate the effectiveness of the use of antimicrobial-impregnated neonatal peripherally inserted central catheters (AI n-PICC) compared to the use of standard n-PICC (S n-PICC). METHODS:The study was planned as prospective randomized controlled trial (open-label). Babies with a birth weight of less than 1500 g in a 4-year period were included in the study. Newborns who needed a n-PICC were allocated randomly (1:1) to receive either an AI n-PICC (impregnated with miconazole and rifampicin) or a S n-PICC. The primary outcome was the incidence of central line-associated bloodstream infection (CLABSI), and secondarily, to assess reasons for catheter removal, and catheter duration times in these two groups. RESULTS:There were a total of 254 infants from both groups during the study. The mean gestational age were 27.6 ± 2.8 week in S group and 27.5 ± 2.8 week in AI group. No significant differences observed in gestational age, birth weight, enteral feeding parameters, hospital stay, or antibiotic use duration (p > 0.05). The mean dwelling time was 14.2 ± 8.5 day in S group and 15.4 ± 9.7 day in AI group (p:0.293). The frequency of catheter withdrawal due to complications were 29.9% in the S group and 19.7% in the AI group (p:0.081). CLABSI rate (per 1000 catheter days) were found 9.44 in S group and 3.07 in AI group (p:0.013). The use of AI n-PICCs were associated with a 74% reduction in the hazard of catheter-related infection (HR = 0.26, 95% CI [0.09, 0.70], p = 0.008). CONCLUSIONS:Our study demonstrates that the use of AI n-PICCs was associated with a reduction in the rate of infection development in premature infants requiring n-PICC. The use of AI n-PICC may be effective especially in premature infants with a high risk of developing catheter-related infection.
PURPOSE:Repeated interventions for arteriovenous (AV) access dysfunction in hemodialysis patients are costly, burdensome, and detrimental to quality of life. The FLEX Vessel Preparation (VP) system utilizes a technique termed kinetic endovascular micro-incision creation (KEMIC) to improve vessel compliance and durability prior to angioplasty. This study compares real-world procedural and specifically the economic outcomes from matched U.S. and European cohorts. MATERIALS AND METHODS:This is a retrospective, quality-improvement (QI)-exempt comparative study from two high-volume centers. Twelve FLEX patients managed by a single U.S. vascular surgeon were compared to 60 matched PTA controls via propensity matching. The European cohort included 74 patients treated with FLEX at a single center and compared to 80 matched PTA controls in Germany. FLEX-VP was performed using three to eight passes with a balloon-free, microblade catheter, typically via a 6 F sheath and followed by low-pressure angioplasty and/or drug-coated balloon. RESULTS:U.S. FLEX patients underwent 1.5 fewer interventions per patient-year than PTA controls (0.7 vs 2.2, p < 0.01). In Germany, FLEX reduced reinterventions by 0.4 per patient-year compared to PTA (0.6 vs 1.0, p < 0.001). Depending on local procedure costs, these reductions translate to estimated per-patient annual savings of $1451-$2902 in the U.S. and €426-€767 in Germany. Kaplan-Meier analyses demonstrated superior reintervention-free survival at 12 months in both cohorts (U.S.: 70.7% vs 46.1%; Germany: 67.4% vs 44.3%). CONCLUSIONS:KEMIC is a reproducible, low-risk, stent-sparing approach that improves access durability while potentially delivering substantial savings to payers and systems.
BACKGROUND:Literature describing the characteristics and outcomes of peripherally inserted central catheter (PICC) in middle-income countries remained limited. The primary objective of this study was to determine the incidence of catheter failure. The secondary objectives were to describe the characteristics and complications of PICC placement, and to identify risk factors associated with catheter failure. METHODS:This retrospective study was conducted at a tertiary care center in Thailand. Patients who underwent PICC placement by the Anesthesiology Line Service Team between January 2023 and August 2024, were included. Data collection included patient characteristics, procedural details, and post-insertion care. Reasons for removal were considered appropriate if the catheter remained functional until the end of treatment or the patient's death; otherwise, removal due to complications was classified as catheter failure. RESULTS:A total of 905 patients received 1038 PICCs, accounting for 43,925 catheter-days. The median catheter dwell time was 21 days (IQR 11-45). The incidence of catheter failure was 22.4% (232 catheters; 95% CI, 19.9%-24.9%). The most common complications leading to catheter removal were central line-associated blood stream infection (7.7%), catheter breakage (3.7%), and catheter dislodgement (3.6%). The most frequent complication during PICC maintenance was catheter occlusion (22.2%). Independent risk factors for catheter failure included pediatric patients (adjusted odds ratio (aOR) 2.312; 95% CI 1.2105-4.436), prolonged intravenous medication (aOR 1.717; 95% CI 1.083-2.720), chemotherapy (aOR 1.846; 95% CI 1.107-3.078), procedural time >60 min (aOR 2.037; 95% CI 1.081-3.841), and catheter duration >3 weeks (aOR 1.626; 95% CI 1.172-2.254). CONCLUSIONS:The incidence of catheter failure (22.4%) and other complications during PICC maintenance (28.0%) was higher than modern optimized vascular access program. Recognition of common complications and risk factors leading to PICC removal highlights the need for targeted surveillance and post-insertion care to improve PICC outcomes.
BACKGROUND AND AIM:Catheter-associated thrombosis is a frequent cause of tunneled catheter dysfunction, and evidence for prophylactic anticoagulation with direct oral anticoagulants is limited. This study evaluated the efficacy and safety of apixaban and rivaroxaban in preventing catheter-associated thrombosis and improving catheter survival. METHODS:A prospective randomized controlled trial was conducted at a tertiary referral center from January 2022 to December 2024. A total of 477 patients requiring permanent venous catheters were randomized into three groups: Group A (Apixaban 2.5 mg twice daily), Group B (Rivaroxaban 10 mg once daily), and Group C (placebo). Patients were followed by duplex ultrasonography at 1 week, 1-, 3-, 6-, and 12-months post-catheterization. The primary outcome was the incidence of tunneled catheter-associated thrombosis (CAT). Secondary outcomes included catheter survival and complication rates. RESULTS:Catheter-associated thrombosis occurred significantly less frequently in the apixaban (8.6%) and rivaroxaban (11.9%) groups than in the placebo group (33.3%) (p < 0.001). Both DOAC groups demonstrated significantly improved catheter survival compared with placebo on Kaplan-Meier analysis (log-rank p < 0.001), with no significant difference between apixaban and rivaroxaban. On multivariable logistic and Cox regression analyses, DOAC use was independently associated with a reduced risk of catheter-associated thrombosis and loss of catheter access, whereas chemotherapy was associated with higher risk. Catheter-related complications, including malfunction, infection, and limb deep venous thrombosis, occurred more frequently in the placebo group. No major or clinically relevant non-major bleeding events were observed during follow-up. CONCLUSION:Prophylactic use of apixaban or rivaroxaban significantly reduces catheter-associated thrombosis and prolongs catheter survival compared with placebo, without an increased risk of bleeding. These findings support the efficacy and safety of selective prophylactic DOAC use in patients with tunneled central venous catheters and warrant further multicenter studies to confirm their role in routine clinical practice.
The radial artery (RA), a branch of the brachial artery, is frequently utilized in a variety of medical procedures: by cardiologists for cardiac catheterization, by nephrologists for arteriovenous fistula creation, by interventional radiologists, and by plastic surgeons for free flap reconstruction. Knowledge of RA anatomical variants is particularly important in patients with end-stage renal disease, as they often require fistula creation for hemodialysis. Failure to recognize such variants may lead to procedural complications. We describe the case of a 35-year-old man with diabetes whose preoperative ultrasound examination, performed before the creation of an arteriovenous fistula, revealed a high division of the radial artery into the superficial radial artery and the deep branch of the radial artery. The deep palmar branch of the radial artery was successfully used for anastomosis in the wrist. In this publication, we provide the data regarding this rare anomaly and indicate that such a finding should not lead to abandoning the creation of a radial-cephalic fistula.
OBJECTIVE:This study aims to assess changes in radial artery elastic function among patients with end-stage renal disease (ESRD) using velocity vector imaging (VVI). METHODS:A retrospective analysis was conducted on 68 pre-hemodialysis ESRD patients and 30 healthy individuals admitted to the Affiliated Hospital of Yanbian University between January 2022 and June 2024. The patients with ESRD were divided into the nondiabetic kidney disease (NDKD) group and the diabetic kidney disease (DKD) group, while the healthy individuals were assigned to the control group (CG). The off-line VVI analysis was performed on the long axis of the radial artery. The following parameters were assessed: peak systolic strain (Ss; %), peak diastolic strain (Sd; %), peak systolic strain rate (SRs; 1/s), and peak diastolic strain rate (SRd; 1/s). Receiver operating characteristic curve analysis evaluated the significance of VVI parameters in differentiating DKD. RESULTS:The levels of Ss, SRs, Sd, and SRd in the anterior wall and the posterior wall of the radial artery were significantly lower in the DKD group compared to both the CG and NDKD groups (p < 0.01). Moreover, there was a decreasing trend in the VVI parameter levels of both the anterior and posterior radial artery among the CG, NDKD, and DKD groups, and these differences were statistically significant (ptrend < 0.001). Receiver operating characteristic curve analysis revealed that the area under the curve for the Ss, SRs, Sd, and SRd in the anterior wall and the posterior wall were 0.990, 0.915, 0.896, 0.920, 0.928, 0.849, 0.829, and 0.848, respectively. CONCLUSION:The VVI technique provides a new method for accurately quantifying the elastic function of the radial artery and an important basis for evaluating the therapeutic effect of arterial stiffness, reflecting the disease course, and assessing the vascular conditions before arteriovenous fistula.
BACKGROUND:Tunneled hemodialysis catheters are frequently required when permanent vascular access is unavailable or urgent dialysis initiation is necessary. Although fluoroscopy is commonly used to guide catheter placement, access to fluoroscopic facilities may be limited. This study reports a single‑center experience with tunneled hemodialysis catheter placement using anatomical landmarks, with ultrasound guidance, without routine immediate fluoroscopy. METHODS:A retrospective observational study was conducted including all consecutive tunneled hemodialysis catheter placements performed between February 2022 and February 2026 at a tertiary vascular surgery center. Catheters were inserted by vascular surgeons using ultrasound‑guided venous access and anatomical landmarks to estimate catheter length and tip position. Immediate fluoroscopy was used selectively in technically challenging cases. Outcomes included technical success, catheter tip position on post‑procedural imaging, need for reintervention, and peri‑procedural complications. RESULTS:A total of 447 catheter-related procedures were performed in 384 patients (mean age 73.8 years). Catheter placement was completed without immediate fluoroscopy in 429 procedures (96.0%; 95% CI: 94.2-97.8). The right internal jugular vein was the most frequently used access site (72%). Overall technical success was achieved in 406 procedures (90.8%; 95% CI: 88.1-93.5). Post-procedural imaging demonstrated right atrial tip positioning in 86.0% of right internal jugular placements (95% CI: 82.2-89.8) and 66.7% of left internal jugular placements (95% CI: 56.1-77.3). Reintervention due to catheter dysfunction occurred in 41 procedures (9.2%; 95% CI: 6.5-11.9) and was more frequent following left internal jugular access (18.7% vs 7.1%; RR 2.61, 95% CI: 1.41-4.83). Periprocedural complications were infrequent and predominantly minor, with no mortality. CONCLUSIONS:In this retrospective descriptive series, tunneled CVC insertion without fluoroscopic guidance was feasible and demonstrated an acceptable safety profile. These findings support the potential role of this approach in selected clinical settings; however, comparative studies are required to further evaluate its relative effectiveness.
OBJECTIVE:Central line-associated bloodstream infection (CLABSI) is a major cause of morbidity in pediatric cardiac intensive care units. Closed vascular access systems are modern devices used to prevent both needle-stick injuries and CLABSI. This study aimed to compare CLABSI rates between three-way stopcock (TWS) systems and closed vascular access systems (CVAS) in a pediatric cardiovascular surgery intensive care unit (PCSICU). METHODS:This study included patients with central venous catheters (CVC) between September 1, 2024, and October 31, 2025. CVC bundle practices were used in this study. The study included 2 time periods: the 7-month TWS period before the initiation of the CVAS, and the 7-month CVAS period. RESULTS:A total of 111 patients were included. In the 7-month TWS period, 48 patients were admitted to the PCSICU, 334 patient days, and 312 CVC days were recorded. During the CVAS period, 63 patients were admitted to the PCSICU, and 277 patient days and 274 CVC days were recorded. The CLABSI rate decreased from 12.8 per 1000 catheter-days in the TWS period to 0 per 1000 catheter-days in the CVAS period [Poisson comparison, p = 0.17]Conclusions:The CLABSI was not observed in the CVAS period. These findings suggest that closed systems, which may reduce line manipulation, could contribute to lowering CLABSI risk, warranting further investigation in larger studies.
BACKGROUND:PICC-ports are emerging as an alternative long-term vascular access device in oncology. However, real-world outcome data remain limited. We evaluated device survival and complication rates in a tertiary center using a standardized bundle for PICC-port insertion. METHODS:We conducted a retrospective cohort study at a tertiary vascular access center in France including 295 PICC-ports implanted in adult oncology patients between November 2023 and October 2025. Devices were inserted by anesthesiologists and specialized vascular access nurses according to the SIP-Port protocol. Data collected included demographics, cancer type, catheter dwell time, early and late complications, and device failures defined as removals due to device-related complications. Device survival was evaluated using Kaplan-Meier analysis. RESULTS:A total of 72,344 catheter-days were recorded. Mean and median device dwell times were 245.2 and 280 days respectively. The cohort consisted of 138 men (46.8%) and 157 women (53.2%), with a mean age of 64.4 years. The most common malignancies were breast cancer (28.1%), lung cancer (23.7%), and head and neck cancer (16.9%). Infection incidence was 0.15 per 1000 catheter-days and symptomatic catheter-related thrombosis occurred at 0.16 per 1000 catheter-days. Twenty-four devices (8.1%) were removed due to serious adverse events. Device survival free from serious adverse events at 365 days was 91.2%. CONCLUSION:PICC-ports implanted by trained vascular access specialists demonstrated excellent device survival and low complication rates. These findings support the safety and reliability of PICC-ports as long-term vascular access devices for oncology patients when inserted and maintained using standardized protocols.
BACKGROUND:Despite technically successful angioplasty of native arteriovenous fistula (AVF) stenoses, early luminal loss may occur before routine post-angiography surveillance. While elastic recoil is recognized intra-procedurally, delayed reduction in luminal diameter from early post-angioplasty recoil (EPR) remains poorly characterized. METHODS:We performed a retrospective secondary analysis of a multicenter randomized controlled trial comparing drug-eluting balloons (DEB) with sham balloons for recurrent AVF stenoses in 102 patients. Minimum luminal diameter on completion angiography (D0) was compared with the first post-angioplasty ultrasound performed within 14 days (D1). EPR was defined as >30% reduction in luminal diameter between D0 and D1. Baseline clinical, vascular access, and procedural variables were analyzed to identify predictors of EPR. Re-intervention rates and luminal changes at 6 months were assessed. RESULTS:Of 129 trial participants, 102 had complete angiographic and ultrasound datasets. EPR occurred in 42 patients (41%), with a mean diameter reduction of 43.7%. AVFs demonstrating EPR were significantly older than those without recoil (mean age 3.71 vs 2.33 years; p = 0.022). Patient age, access location, prior interventions, and stent use were not associated with EPR. Mean diameter reduction was 43.7% in the EPR group versus 11.5% in the non-EPR group (p < 0.001). Overall 6-month re-intervention rates were similar between groups; however, subgroup analysis demonstrated that EPR accounted for approximately 45% of total luminal loss in 27/102 patients requiring repeat intervention. DEB use did not influence EPR but was associated with reduced late restenosis. CONCLUSIONS:Early post-angioplasty luminal loss detected on ultrasound is common following AVF angioplasty and occurs more frequently in older fistulas. EPR contributes substantially to subsequent restenosis and may represent an under-recognized mechanism of early treatment failure. Selective early ultrasound surveillance may help identify patients at increased risk of early luminal compromise.
Endovascular arteriovenous fistula (eAVF) creation is a minimally invasive alternative to traditional surgical arteriovenous fistula (sAVF) for hemodialysis access. We conducted a systematic review and meta-analysis to evaluate the clinical outcomes of eAVF and compare them with those of sAVF. A total of 28 studies were included, comprising 20 single-arm eAVF studies and 8 comparative studies, identified through searches of PubMed, MEDLINE, Web of Science, ScienceDirect, Google Scholar, and Cochrane CENTRAL from inception to February 1, 2025. Outcomes assessed included technical success, maturation rate, primary patency, reintervention, and complications. The pooled technical success rate of eAVF was 97%, with a maturation rate of 77%. Primary patency rates were 64% at 6 months and 77% at 12 months. The overall complication rate was low (9%), although moderate to high heterogeneity was observed across several outcomes. Device subgroup analyses demonstrated numerical differences between Ellipsys and WavelinQ systems with overlapping confidence intervals. In comparative studies, no statistically significant differences were observed in maturation rate or primary patency; however, eAVF was associated with numerically higher reintervention rates and lower complication rates. These findings suggest that eAVF represents a safe and effective alternative to surgical AVF in appropriately selected patients, while highlighting the importance of careful patient selection and post-procedural surveillance given the heterogeneity of existing evidence.
BACKGROUND:Evidence for intracavitary electrocardiography (IC-ECG) to locate 1-Fr epicutaneous-cava catheter (ECC) tips in neonates remains limited. METHODS:We retrospectively analyzed 196 neonates (2019-2025) undergoing 1-Fr ECC insertion with IC-ECG guidance using either a conventional monitor-defibrillator (DEF) or a dedicated neonatal interface (Pilot™). Bedside echocardiography performed at the end of the procedure (within 2 h) served as the reference standard. Endpoints were applicability, feasibility, accuracy, malposition, and early complications (⩽24 h). RESULTS:IC-ECG correctly identified catheter-tip position in 94.9% of cases under an intention-to-diagnose framework (186/196) and showed complete concordance with echocardiography in all evaluable catheters. Applicability was 100% (196/196; 95% CI 98.1-100.0). Feasibility (interpretable tracing) was 94.9% (186/196; 95% CI 90.8-97.5). Diagnostic accuracy was 94.9% under intention-to-diagnose (186/196; 95% CI 90.8-97.5) and 100% among interpretable tracings (186/186; 95% CI 98.0-100.0). In 10 cases, the tracing was neither readable nor interpretable, likely due to electrical interference. In three cases, the tracing was readable but the P-wave never reached a maximal amplitude throughout catheter navigation; ultrasound verification confirmed malposition. No clinically significant arrhythmias or occlusions occurred within 24 h. CONCLUSIONS:IC-ECG provides excellent diagnostic performance for 1-Fr ECC tip location in neonates. A flat P-wave should prompt ultrasound confirmation. Multicenter studies are warranted.
Arteriovenous fistula (AVF) thrombosis remains the leading cause of vascular access failure in hemodialysis. Surveillance programs aim to detect significant stenosis before thrombosis occurs; however, preventive strategies have shown inconsistent outcomes. Both clinical examination and Doppler ultrasound (DUS) are operator-dependent, contributing to variability in surveillance effectiveness. We propose a physiology-based AVF surveillance strategy centered on DUS, integrating anatomical assessment with quantitative Doppler parameters. The approach combines residual diameter, peak systolic velocity (PSV) ratio, and access blood flow (Qa) to characterize stenosis severity and hemodynamic relevance. The complementary and emerging role of multiparametric ultrasound (mpUS) techniques is also described. Clinical examination provides early bedside information, while DUS enables simultaneous evaluation of vascular anatomy, flow velocities, and Qa in a single non-invasive assessment. Instrumental surveillance methods based on dilution or pressure monitoring increase objectivity but have not consistently improved long-term access patency. Variability in DUS acquisition and interpretation currently limits its clinical impact. A combined diagnostic model based on residual diameter, PSV ratio, and Qa allows differentiation between geometric (Venturi-effect) and hemodynamically significant stenosis, supporting appropriate timing of intervention. Emerging mpUS techniques, including shear-wave elastography and vector flow imaging, may further enhance early risk stratification by assessing vessel wall mechanics and flow shear patterns. The key issue in vascular access surveillance is not whether to monitor, but how to monitor effectively. A standardized, physiology-driven DUS strategy has the potential to shift AVF surveillance from reactive intervention to proactive management. When performed consistently by trained operators, DUS represents not a complement to clinical monitoring, but its natural extension.
OBJECTIVES:The maintenance of a functioning hemodialysis access (HA) is central to achieve optimal outcomes for the end stage kidney-disease population. Access thrombosis (AT) is the leading cause of permanent HA loss. Clinical examination (CE) provides 100% sensitivity and specificity for the diagnosis of AT. However, vascular ultrasound (VUS) is routinely used to confirm the diagnosis, despite rarely impacting clinical management decisions. In this study, we explore the trends of VUS usage to diagnose AT and the associated direct economic and indirect opportunity costs. METHODS:This single-center, retrospective study includes all patients who underwent VUS for AT between January 2014 and December 2024. A chart review was performed to determine the type of access, study setting, ordering physician, HA salvage attempts, and reasons for avoiding interventions. We used the average reported cost of VUS ($2520) and a 60-min meantime to perform the study. RESULTS:A total of 690 patients were included, with 47.8% arteriovenous grafts (AVG) and 52.2% arteriovenous fistulas (AVF) thrombosed. The annual number of VUS increased starting in 2019. The VUS was most frequently ordered in outpatient settings (72.1%) and by vascular surgeons (71.9%). After VUS, 71.5% underwent interventions to salvage or create new HA, with 40.4% receiving percutaneous thrombectomy (PCT). PCT was more common in AVG patients than AVF (54.4% vs 26.1%). The economic burden of VUS for the included patients was estimated to be 1,738,800 USD. CONCLUSIONS:The overutilization of VUS is associated with significant economic costs and lost opportunities for other patients, with minimal impact on clinical decision making. VUS devices and technician's time could be better utilized. Our study highlights the need to reassess the routine VUS use for diagnosing AT, and to socialize best practice for the diagnosis of this common condition across the multiple specialties involved in the care of this growing population.
