Background Patient reported experience measures are contemporary quality indicators that focus on evaluation of healthcare delivery processes. While surgical arteriovenous fistulas (otherAVF) are preferred for haemodialysis vascular access, fears about surgery and complications often result in refusal/delays. A new technique of endovascular arteriovenous fistula creation (EndoAVF) has been developed and as part of it’s ongoing introduction into our unit, the patient perspective was felt critical to its evaluation. The Vascular Access Questionnaire (VAQ) provides a mechanism for identifying and scoring perceptions in this setting. Method Patients who had previously undergone EndoAVF formation were approached to undertake the VAQ as part of a service evaluation of their experience. In addition to the components of the VAQ, data questions relating to the patient’s perception of their access were gathered. Results were compared with a matched historical cohort of surgically created fistulas (otherAVF) patients. Results Patient satisfaction and self-reported ease of use with EndoAVF were high. Overall VAQ scores were similar between the EndoAVF and the surgically created cohort. Functionally, there was no significant difference in perception of their fistula by patients, irrespective of them being created surgically or radiologically. Conclusion Although numbers in this report are small limiting exploration of preserved inherent heterogeneity, we provide a useful initial patient reported experience and perspectives on comparative functional use of radiologically and surgically created AVFs. As real world experience gathers, future larger cohorts with adequate sampling may allow exploration of patient reported experiences and outcome measures.

Clinically-oriented outcome measures are increasingly being recognized as lacking in consideration of factors important to patients. There is an emerging move of guideline bodies advocating a more patient-centred approach. Aneurysms in autogenous arteriovenous fistula (AVF) can be considered unsightly and a constant reminder for patients of their dependence on dialysis. However, their impact on patient’s perception has not previously been reported. Between April 2017–18, the Vascular Access Questionnaire (VAQ) was administered to prevalent haemodialysis patients across ten dialysis units via structured interviews, as part of a quality improvement project. Data for the subgroup of patients with aneurysmal AVF (categorised as per classification by Valenti et al.), were retrospectively evaluated and compared to the wider cohort. Data were collected for 539 patients (median age: 66 years; 59

Background: The aims of this study were to assess the utility of using the Kidney Failure Risk Equation (KFRE) as an indicator to guide timing of vascular access creation in pre-dialysis patients. Materials and methods: Patients referred for vascular access creation had KFRE calculated at the time of assessment and compared to standard criteria for referral. Receiver operating characteristic curves were produced for each parameter. The outcomes at 3 months, 6 months, and 1 year were used as time points for analysis. Results: Two hundred and three patients were assessed, and full data sets were available on 190 (94.6%). Access was created in 156 patients (82.1%) with a fistula in 153 (98.7%). Only 65.7% initiated dialysis within the follow up period. Those patients with an AV access created (n = 156) 37 (23.7%) did not reach end stage over the entire follow up period. Of the remaining patients (n = 119) that reached end stage 72.2% (n = 86) started on an AVF/AVG and 27.7% (n = 33) on a CVC. Using ROC analysis for referral eGFR, ACR and KFRE predicting dialysis initiation predictors resulted in C statistics for eGFR, ACR, and KFRE2 of 0.68 (0.58-0.79), 0.75 (0.65-0.84), and 0.72 (0.62-0.81) at 3 months; 0.73 (0.65-0.81), 0.70 (0.62-0.78), and 0.75 (0.67-0.81) at 6 months; and 0.65 (0.57-0.72); 0.67 (0.59-0.75), and 0.68 (0.61-0.77) at 12 months. Conclusions: In a group of patients referred for vascular access creation the predictive models are relatively poor when applied to initiation of dialysis. The application of current guidelines to fistula creation appears to result in a high rate of unnecessary fistula formation and non-use. The study requires further evaluation in a test set of patients to confirm these findings and also identify where such risk based approaches may need modification.

Preoperative assessment prior to surgical arteriovenous fistulas (AVFs) including ultrasound-guided mapping has been shown to have beneficial effects on their immediate success as well as early outcomes. This has led to their wide acceptance and adoption however clinical practice criteria is variable and is reflected in variabilities in practice. When transposing this to percutaneously created endovascular AVFs (endoAVFs), variable preoperative assessment criteria could equally result in variable practice and potentially subsequent and expectant outcomes. We aimed to review literature on reported validated methodologies and workflows of preoperative assessment for surgical AVF creation as reported in highest levels of available evidence, specifically randomized controlled trials. Published practice recommendations and guidelines on best clinical practice as well as systematic reviews and meta-analyses of published studies were also reviewed. Data on practice methodology from identified trial publications and protocols was collated and a summative narrative synthesis was carried out which compared these methodologies to additional assessments that may be required when targeting assessment for percutaneous endoAVF formation, based on our units experience as part of an international multicentre trial. In this review we present a brief overview of published literature and guidelines and propose a unified and uniform workflow for preoperative assessment for surgical AVFs and endoAVFs to aide clinical and imaging practice.

Vascular access remains one of the most challenging aspects of renal replacement therapy. New European Renal Best Practice (ERBP) Clinical practice guideline on peri- and postoperative care of arteriovenous fistulas and grafts for haemodialysis was published in 2019 (https://doi.org/10.1093/ndt/gfz072). During Advisory Board meeting of ERBP, the official guidance providing body of ERA-EDTA, it was decided that ERBP will stimulate the translation of the short version of the guidelines into different languages (www.european-renal-best-practice.org/sites/default/files/u33/ERBP_006-VASCAC_Short-Version.pdf).

2 The Journal of Vascular Access 22(6) 1Interventional Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; 2Interventional Radiology, Manchester Royal Infirmary, Manchester, United Kingdom; 3Interventional Nephrology, Salford Hospital, Manchester, United Kingdom; 4Renal Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; 5Renal Research, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom Introduction: A UK multicentre, prospective, randomised controlled trial examining the efficacy of paclitaxel eluting (DCB) vs standard angioplasty balloons in native haemodialysis fistulas was conducted between 2016 18. The trial was terminated prematurely amid the paclitaxel mortality controversy reported in peripheral vascular disease application in late 2018. Preliminary results of the recruited cohort are presented. Materials and Methods: Patients with dysfunctional, stenotic native fistulas were randomised to receive either a Ranger DCB or a standard angioplasty balloon. No pre-dilatation was required but post-dilatation with a high-pressure balloon was permitted in cases of residual stenosis >30%. The primary objective was to determine target lesion and access circuit primary patency as per standard definitions. Primary end-point was a composite of one or more of the following: >50% re-stenosis of index lesion requiring intervention, re-intervention on index lesion due to clinical or paraclinical indication, fistula failure. Clinical follow up was to 12 months with fistulography at 12, 25 and 52 weeks. Adverse events were recorded. results: A total of 92 patients were recruited, 45 in the DCB arm and 47 in the standard arm. There was a total of 54 de novo and 38 recurrent stenoses, across 36 forearm and 56 above elbow fistulas (48 brachiocephalic). Overall, primary patency at 12 months was 51.1% and 46.8% in the DCB and standard balloon arms respectively (p=0.41). Mean time to event was 273 days and 249 days, respectively. In subset analysis of the brachiocephalic fistula group (24 in DCB arm, 24 in standard arm), primary patency at 12 months was 42% vs 29% (p=0.04) with mean time to event of 266 days and 193 days respectively. conclusion: Although this trial was terminated prematurely, the Ranger DCB appears to prolong time to fistula re-stenosis compared to standard balloons, with significance demonstrated in brachiocephalic fistulas. ID:22 best paper award certificate of merit Presentation form: Poster double guide wire technique (dgt): optimization of iuxta-anastomotic stenosis endoVascular trEatMEnt Nicola Pirozzi1, Jacopo Scrivano1, Roberto Pirozzi2 1Interventional Nephrology Unit, Nuova ITOR, Rome, Italy; 2Endovascular Unit, Nuova ITOR, Roma, Italy background: Treatment options for juxta-anastomotic stenosis (JAS) of radio-cephalic arteriovenous fistula (RCAVF) are surgical bypass or angioplasty. As to endovascular treatment data from literature show a higher rate of recurrence (0.5 procedure/AVF/year). We describe the refinement of endovascular “double guide technique” (DGT) as to TurmelRodrigues original description. Patient and Methods: A 65y patients underwent DGT for a low flow (Qb) RCAVF due to JAS. By means of retrograde access through the outflow vein by a 6F introducer, two guide wire were navigated: the first one into proximal radial artery (GW1), the other into the distal artery (GW2). The introducer was removed and repositioned over the GW2, the GW1 left aside. A noncompliant balloon 6x40mm were inserted, the distal mark pushed at the curve the GW1 drowned trans-anastomotically. Inflations at 30atm were performed. After a check for rupture, balloon, GW2 and the introducer were removed, the GW1 being left in place. The introducer was repositioned over the GW1 and a semi-compliant 4x40 mm balloon, pushed trans-anastomotically, inflated at 18 atm. The final angiographic control was performed, the GW1 and balloon being removed after check for rupture. The RACVF was used as to the usual dialysis schedule. The RCAVF Qb improved from 350ml/min to 1100 and 1300 ml/min at 1 and 12-month respectively postoperatively. Discussion: DGT is effective in treating JAS, it allow a complete effacement of the stenosis by the use of two different balloon tailored for the different target: effluent vein and anastomotic area. The navigation is eased into different zones before dilatation. GW1 allow for treatment of artery spasm and serve as a secure device in case of rupture. In a previous series of DGT we described a recurrence rate of 0.28 procedure/patients/year. conlusion: DGT allow for a minimally invasive and long-term proficient treatment of juxta-anastomotic stenosis of RCAVF. ID:29 Presentation form: Poster controlateral endoVascular recanalization of the left brachio-cephalic Vein in patient wIth uPPEr arM artErIovEnous fIstula for hemodialysis Alessia Pini1, Raffaella Mauro1, Gianluca Faggioli1, Maria Letizia Soverini2, Annalisa Zucchelli2, Cristina Rocchi1, Mauro Gargiulo1 1Vascular Surgery, Univeristy of Bologna, Bologna, Italy; 2Nephrology, Dialysis and Hypertension, University of Bologna, Bologna, Italy Due to the widespread central venous catheters use, central venous occlusive disease (CVOD) had become extremely common in hemodialysis patients. It is often asymptomatic and incidentally diagnosed during imaging investigations; however, after an ipsilateral vascular access placement, it can lead to significant symptoms and to an ineffective dialysis. The CVOD is conventionally managed with antegrade endovascular recanalization, including angioplasty and stent placement. However, the treatment of long stenosis or tight obstructions can be extremely complex and require alternative technical strategies. We report a challenging case of brachiocephalic vein obstruction, successfully recanalized and stented from a contralateral approach; different other options could have been considered in this case but this technical strategy led not only to an excellent perioperative results, but also made it possible to preserve the ipsilateral and contralateral venous bed for future vascular accesses. This technique may be useful in patients in whom the standard antegrade approach fail. ID:47 Presentation form: Oral aV fistula maturation delay pta knows the way Rui Filipe Nogueira, Nuno Afonso Oliveira, Emanuel Ferreira, Luís Rodrigues, Ana Belmira, Rui Alves Nephrology, Coimbra University Hospital Centre, Coimbra, Portugal background: Arteriovenous fistula is the optimal vascular access for hemodialysis as it has the best long-term patency rate and the lowest complication rate. Although we are still lacking consensus, surgery has

. Int J Clin Pract 2010; 64: 1239–1244 94. Kaufman JS, Connor TZ, Zhang JH et al. Randomized controlled trial of clopidogrel plus aspirin to prevent hemodialysis access graft thrombosis. J Am Soc Nephrol 2003; 14: 2313–2321 95. Kooistra MP, van Es A, Marx JJ et al. Low-dose aspirin does not prevent thrombovascular accidents in low-risk haemodialysis patients during treatment with recombinant human erythropoietin. Nephrol Dial Transplant

Background: Running out of vascular access for dialysis is thankfully rare, but despite this, most units will have a number of patients with few options and in a precarious state. The increasing longevity of dialysis patients portends more patients will reach minimal access options. End stage vascular access is poorly defined but classification may enable assessment and comparison of treatment options. Three options for patients with end stage access are a central venous catheter through a translumbar or transhepatic route, arterial-arterial prosthetic loop or a right atrial graft. Aims: The aims of this study are to provide a structured review of evidence for these procedures to allow application and guide practice for patients with end stage vascular access. Methods: A standardised search of published literature was performed of relevant studies. In addition, the references cited in those papers were assessed for any further available articles. All study types were included and reviewed by two authors independently. Primary outcomes were patient survival and secondary patency rate at 3 and 12 months. Secondary outcomes were long-term patency rates, mean time to cannulation and complications such as access dysfunction, thrombosis and infection. Summary: Based on the available evidence, it would appear that arterial-arterial prosthetic loop is a definitive option for maintaining dialysis access in patients with no more arteriovenous access options. Translumbar and transhepatic dialysis catheters may offer short- and medium-term options and right atrial grafts may also be suitable as an option where arterial-arterial prosthetic loop is unsuitable.

Quality improvement initiatives should be aimed to enhance clinical outcomes, service delivery and quality of life for patients. For patients reliant on haemodialysis, vascular access is a lifeline. Survival differences relating to the type of vascular access are evident and many initiatives have focussed on increasing absolute rates of arteriovenous fistulas and/or decreasing central venous catheter use. While these have achieved some success quantitatively, the qualitative effects are less obvious. The aims of this review article are to explore the concepts of quality of care in vascular access. There is a paucity of studies into the effects of vascular access on the quality of life of dialysis patients, and where studies have been performed, generalised patient-reported outcome measures have been used. To facilitate the implementation of quality improvement programmes specifically for vascular access requires suitable tools. While existing patient-reported outcome measures may be applicable to vascular access, it is likely that these will require further evaluation, and the development of vascular access-specific patient-reported outcome measures may be required.

Purpose: Devices to permit percutaneous endovascular arteriovenous fistula formation have recently been introduced into clinical practice with promising initial evidence. As guidelines support a distal fistula first policy, the question of whether an endovascular arteriovenous fistula should be performed as an initial option is introduced. The aims of this study were to compare a matched cohort of endovascular arteriovenous fistula with surgical radiocephalic arteriovenous fistulas. Materials and methods: Using data from a prospectively collected database over a 3-year period, a matched comparative analysis was performed. Results: WavelinQ arteriovenous fistulas (group W, n = 30) were compared with radiocephalic arteriovenous fistulas (group RC; n = 40). Procedural success was high with 96.7% for group W and 92.6% for group RC. Primary patency at 6 and 12 months was greater in group W (65.5% 6mo and 56.5% 12mo) compared to group RC (53.4% 6mo and 44% 12mo) (p = 0.69 and 0.63). Mean primary patency was significantly lower for RC (235 +/- 210 days) vs W (362 +/- 240 days) (p < 0.05). Secondary patency for group W was 75.8% and 69.5% at 6 and 12 months, respectively. Secondary patency for RC was lower at 66.7% and 57.6% at 6 and 12 months, respectively. Conclusion: Outcomes of WavelinQ arteriovenous fistulas in this series are similar to published results. When compared to a contemporaneously created group of surgical fistulas, WavelinQ demonstrated superior outcomes. These data would support that WavelinQ endovascular arteriovenous fistulas may be considered as a first option in the access pathway particularly if vessels at the wrist are absent or less than ideal.

In recent years, new emerging technology has allowed the endovascular creation of dialysis fistulas in the proximal forearm without the need for open surgery. Two such systems currently exist, and evidence to date has demonstrated high rates of technical success in fistula creation, high rates of dialysis functionality, and low rates of re-intervention using both systems. Whilst early trial data has demonstrated lower rates of re-intervention to maintain patency compared to surgical fistulas, endovascular re-interventions are still required to maintain functionality. The endovascular fistula (endoAVF) typically exhibits a shared drainage pattern and is morphologically distinct from the surgical fistula and patterns of failure observed often differ to what has been traditionally encountered. A fresh approach and understanding is therefore required and here we share our observations and experience of endovascular re-intervention in endoAVF created with the Wavelinq system.

Left ventricular assist devices are used in heart failure patients as bridge to transplantation or increasingly as a destination therapy. These patients frequently have renal dysfunction and many reach end-stage renal failure. If haemodialysis is required, minimization of infection risk is essential. Arteriovenous grafts have been recommended for these patients due to hypothetical concerns regarding fistula maturation due to continuous flow. A case is described where a brachiocephalic arteriovenous fistula was successfully formed and used for dialysis without issue. This is one case of a small number in the literature where arteriovenous fistulas have been used in left ventricular assist device patients and it appears that concerns are unfounded and good outcomes have been reported. It would appear from this experience that approaches to vascular access for dialysis in patients with continuous-flow left ventricular assist devices are in accordance with vascular access guidelines and standard practice.

Haemodialysis is capable of prolonging life in patients with end stage renal disease, however this therapy comes with significant negative impact on quality of life. For patients requiring haemodialysis, the need for an adequately functioning vascular access (VA) is an everyday concern. The Vascular Access Questionnaire (VAQ) provides a mechanism for identifying and scoring factors in haemodialysis that impact on patients’ quality of life and perception of their therapy. Between April 2017–18 the VAQ was administered to prevalent haemodialysis patients at 10 units in the West Midlands via structured interviews. 749 of 920 potentially eligible patients completed the survey. The mean VAQ score was seen to improve significantly with age (7.7 in < 55 vs. 3.8 in 75+) and the duration of access (8.9 if less than 1 month old vs. 5.0 at a year). Better average scores were demonstrated for Arteriovenous fistulas (AVF) than other modalities (AVF 5.1 vs. AVG (arteriovenous grafts) 7.2 vs. CVC (central venous catheter) 6.6). There was no significant difference in scores between fistulas on non-dominant or dominant arms, with both having a mean of 5.2 (p = 0.341). Overall, better satisfaction scores were seen in AVF. The presence of an AVF on the non-dominant arm was not a concern for the majority of patients and did not affect the VAQ score. A number of factors were identified that can influence VAQ satisfaction score.

All types of vascular access, a necessity for haemodialysis, are prone to thrombosis and if untreated this results in failure. Thrombosis results from the combination of impaired blood flow, endothelial and vessel wall injury and a propensity towards pro-coagulative states, either intrinsic or aggravated by dialysis or dehydration. The treatment of access thrombosis relies on removal of the clot (thrombectomy) and treatment of the underlying problem. In most cases this is stenosis secondary to neointimal hyperplasia which can occur early (failure to mature) or later. Pharmacological approaches have largely been shown to be ineffective at prevention of thrombosis. The mainstay of preventing access failure may be in surveillance and detecting stenosis prior to occlusion although the optimal protocol to achieve this remains undefined. Management of thrombosed access is via either surgical and radiological approaches. Multiple techniques and devices are available for thrombectomy and the choice is usually based on local expertise and availability rather than evidence as few trials have been performed to allow robust comparisons. This paper outlines the basis of access thrombosis and discusses the currently available techniques for treatment.

Background: The fistula first initiative has promoted arteriovenous fistulas (AVFs) as the vascular access of choice. To preserve as many future access options as possible, multiple guidelines advocate that the most distal AVF possible should be created in the first place. Generally, snuff box and radiocephalic (RC) are accepted and well-described sites for AVFs; however, the forearm ulnar-basilic (UB) AVF is seldom used or recommended. The aim of this study is to assess and systematically review the evidence base for the creation of the UB fistula and to critically appraise whether more attention should be given to this site.Methods: Electronic databases Were searched for studies involving the creation of UB fistulas for dialysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes for this study were 1-year primary and secondary patency rates. Secondary outcomes were rates of hemodialysis access-induced distal ischemia (HAIDI) and infection.Results: After strict inclusion and/or exclusion criteria by 2 reviewers, 8 studies were included in our review. Weighted-pooled data reveal 1-year primary patency rate for UB AVFs of 53.0% (95% confidence interval [CI]: 40.1-65.8%) with a secondary patency rate of 72.0% (95% CI: 59.2-83.3). HAIDI and infection rates were low.Conclusions: Our review has shown that the UB AVF may be a viable alternative when a RC AVF is not possible, and dialysis is not required urgently. It has adequate 1-year primary and secondary patency rates and extremely low risk of HAIDI. While it may be more challenging for both surgeons and dialysis nurses to make it a successful vascular access it offers a further option of distal access which may be overlooked.

Objective: After carotid endarterectomy (CEA), patients have been regularly followed up by duplex ultrasound imaging. However, the evidence for long-term follow-up is not clear, especially if the results from an early duplex scan are normal. This study assessed and systematically reviewed the evidence base for long-term surveillance after CEA and a normal early scan.Methods: Electronic databases were searched for studies assessing duplex surveillance after CEA in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome for this study was the incidence of restenosis after a normal early scan. The secondary outcome was the number of reinterventions after a normal early scan.Results: The review included seven studies that reported 2317 procedures. Of those patients with a normal early scan, 2.8% (95% confidence interval, 0.7%-6%) developed a restenosis, and 0.4% (95% confidence interval, 0%-0.9%) underwent a reintervention for their restenosis during the follow-up period.Conclusions: This review confirms that routine postoperative duplex ultrasound surveillance after CEA is not necessary if the early duplex scan is normal.

Background Native or prosthetic arteriovenous (AV) fistulas are preferred for permanent haemodialysis (HD) access. These are marked with circuit steno-occlusive disease leading to dysfunction or even failure. Late failure rates have been reported as high as 50%. Standard angioplasty balloons are an established percutaneous intervention for HD access stenosis. Reported restenosis rates remain high and practice guidelines recommend a wide 6-month primary patency (PP) of at least 50% for any intervention. Neointimal hyperplasia is one of the main causes for access circuit stenosis. Drug eluting balloon (DeB) angioplasty has been proposed as an alternative intervention to reduce restenosis by local drug delivery and possible inhibition of this process. Purpose To systematically assess the reported efficacy and safety of DeB angioplasty in percutaneous management of prosthetic and autologous HD access stenosis. Methods Protocol for the review was developed following the PRISMA-P 2015 statement. An electronic database (Medline, EMBASE, Clinical Trials.gov and Cochrane CENTRAL) search was conducted to identify articles reporting on the use of DeB intervention in HD AV access. Backward and forward citation search as well as grey literature search was performed. The MOOSE statement and PRISMA 2009 statement were followed for the reporting of results. Data from the included studies comparing DeBs with non-DeBs were pooled using a random effects metaanalysis model and reported separately on randomised and non-randomised studies. Results Six studies reported on 254 interventions in 162 participants (mean 27 ± 10 SD). The pooled mean and median duration of follow-up was 12 and 13 months (range 6-24 months). These comprised two randomised control trials (RCTs) and four cohort studies. Participant's mean age was 64 ± 5 years and 61% were male. Target lesions (TLs) ranged from under 2 mm to 5.9 mm and 51 were reported as de novo stenosis. Device failure described as wasting of the DeB was reported in two studies (55% and 92.8%). At 6 months TL PP was reported between 70% to 97% for DeBs in the RCTs and cohort studies, and 0% to 26% for non-DeBs. TLs treated with DeBs were associated with a higher primary patency at 6 months as compared to non-DeB balloons (RCTs: odds ratio [OR] 0.25, 95% CI 0.08 to 0.77 and I 2 = 19%, cohort studies: OR 0.10, 95% CI 0.03 to 0.31 and an I 2 = 20%). No procedure-related major or minor complications were reported. Conclusions Current literature reports DeBs as being safe and may convey some benefit in terms of improved rate of restenosis when used to treat AV access disease. However, this body of evidence is small and clinically heterogeneous. A large multicentre RCT may help to clarify the role of DeBs in the percutaneous treatment of AV HD access stenosis.

It remains challenging to accurately predict whether an individual arteriovenous fistula (AVF) will mature and be useable for haemodialysis vascular access. Current best practice involves the use of routine clinical assessment and ultrasonography complemented by selective venography and magnetic resonance imaging. The purpose of this literature review is to describe current practices in relation to pre-operative assessment prior to AVF formation and highlight potential areas for future research to improve the clinical prediction of AVF outcomes.