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Richard P Stevenson,1 Christos Tolias,1 Keith Hussey,2 David B Kingsmore2 1Department of Surgery, Glasgow Royal Infirmary, Glasgow G4 0SF, UK; 2Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK Abstract: Mycotic pseudoaneurysms are rare, but potentially life threatening. They are challenging both from a diagnostic and surgical perspective. It is an area lacking in robust trial data, and current knowledge and evidence is represented only by retrospective case series. This review will summarize the current literature with regard to mycotic pseudoaneurysms consequent to illicit drug misuse. Keywords: IVDU, mycotic, pseudoaneurysm

Background: Patients with advanced chronic kidney disease requiring initiation of kidney replacement therapy (KRT) are frequently asked to enact complex management plans. Treatment burden has been defined as the effect of healthcare workload and the capacity a person has to manage this workload has on wellbeing. The aim of this review is to examine the experience of healthcare workload and the factors that affect capacity to meet that workload for people transitioning onto KRT for the first time, using a framework synthesis of published literature informed by normalisation process theory (NPT) and theory of patient capacity (TPC)., Methods: Medline, Scopus and CINAHL were systematically searched with manual citation and reference searching. Studies were included if meeting the criteria of adults aged 18 or over transitioning for the first time onto any modality of KRT (haemodialysis, peritoneal dialysis or kidney transplantation), using qualitative methodologies to describe any aspect of experiences of healthcare workload or any factors that affect capacity to manage workload were included. Abstracts and full papers were independently screened by two reviewers and data extraction and quality appraisal were also independently conducted by two reviewers. Qualitative data were analysed using framework synthesis informed by NPT and TPC., Results: A total of 24,380 studies were screened, 406 full texts were reviewed and 18 studies were included. There were four broad categories of workload described: making sense of KRT, working out what to do and how to do it, meeting the challenges of KRT, and reflecting on work done. Patient capacity influenced the experience of all types of workload and the treatment burden generated by the work., Conclusions: Transitioning onto KRT is a period of very high healthcare workload and potentially high treatment burden. The relationship between healthcare workload and capacity to handle workload is complex, multifactorial and changes over time. By better understanding workload, capacity and burden during transition, we can develop better ways of measuring these important aspects of care and develop interventions to reduce treatment burden in those transitioning onto KRT., Competing Interests: Declarations. Ethics approval and consent to participate: As this is a systematic review, we had no direct participants; therefore, neither consent to participate nor ethics approval was sought for this work. Consent for publication: This manuscript is a systematic review that does not include any identifiable individual data and did not collect or analyse any direct patient data; therefore, participant consent for publication was not sought. Competing interests: PBM reports consultancy or speaker fees from Boehringer Ingelheim, Astrazeneca, Pharmacosmos, GSK, Bayer, and Vifor Fresenius Medical Care Renal Pharma outside this work. KS reports honoraria for vascular access course teaching from WL Gore., (© 2025. The Author(s).)

Background: The information and decision support needs required to embed a patient-centred strategy are challenging, as several haemodialysis vascular access strategies are possible with significant differences in short- and long-term outcomes of potential treatment options. We aimed to explore and describe stakeholder perspectives on information needs when making decisions about vascular access (VA) for haemodialysis., Methods: We performed thematic analysis of seven (six online, one in person) focus group discussions including transcripts, post-it phrases and text responses with 14 patients and 12 vascular access professionals (four nephrologists, three surgeons and five nurses - Vascular access nurse specialists/Education and dialysis nurses) who participated in at total of six online and one in person focus group., Results: All patients had experience of haemodialysis and 50% had experience with at least one other modality of RRT. Ten patients had experience of more than one VA modality and 4/14 had experience of AVG, 13/14 had experience of AVF and 8/14 had experience of TCVC. We identified four semantic themes and two latent themes. The themes and their subthemes reflected information needs of patients when making vascular access decisions: Knowledge, Risks and Benefits of Relevant options, long-term treatment strategy and Personal Impact of VA. The latent themes, identified across all stakeholders, were of the need for consistent and trustworthy information., Discussion: All recent vascular access guidelines propose a shared decision-making approach to vascular access. The ability to implement this in practice carries an information need for both patients and clinicians. This study describes a framework model which can be applied during co-design and assessment of vascular access educational resources to facilitate a patient centred perspective., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Karen Stevenson has received honoraria for teaching on a cadaveric AV Graft Course from WL Gore. Prof David Kingsmore has received speaking honoraria and for running a cadaveric AVG course from WL Gore. Peter Thomson has received honoraria for speaking and teaching on cadaveric AV Graft Course from WL Gore.

Although randomised controlled trials (RCT) are considered the optimal form of evidence, there are relatively few in surgery. Surgical RCT are particularly likely to be discontinued with poor recruitment cited as a leading reason. Surgical RCT present challenges over and above those seen in drug trials as the treatment under study may vary between procedures, between surgeons in one unit, and between units in multi-centred RCT. The most contentious and debated area of vascular access remains the role of arteriovenous grafts, and thus the quality of the data that is used to support opinions, guidelines and recommendations is critical. The aim of this review was to determine the extent of variation in the planning and recruitment in all RCT involving AVG. The findings of this are stark: there have been only 31 RCT performed in 31 years, the vast majority of which exhibited major limitations severe enough to undermine the results. This underlines the need for better quality RCT and data, and further inform the design of future studies. Perhaps most fundamental is the planning for a RCT that accounts for the intended population, the uptake of a RCT and the attrition for the significant co-morbidity in this population., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Arteriovenous grafts (AVGs) are used for patients deemed unsuitable for the creation of an autogenous arteriovenous fistula (AVF) or unable to await maturation of the AVF before starting hemodialysis. However, AVGs are prone to infection and thrombosis resulting in low long-term patency rates. The novel aXess Hemodialysis Graft consists of porous polymeric biomaterial allowing the infiltration by cells and the growth of neotissue, while the graft itself is gradually absorbed, ultimately resulting in a fully functional natural blood vessel. The Pivotal Study will examine the long-term effectiveness and safety of the aXess Hemodialysis Graft., Methods: The Pivotal Study is a prospective, single-arm, multicenter study that will be conducted in 110 subjects with end-stage renal disease who are not deemed suitable for the creation of an autogenous vascular access. The primary efficacy endpoint will be the primary patency rate at 6 months. The primary safety endpoint will be the freedom from device-related serious adverse events at 6 months. The secondary endpoints will include the procedural success rate, time to first cannulation, patency rates, the rate of access-related interventions to maintain patency, the freedom from device-related serious adverse events and the rate of access site infections. Patients will be followed for 60 months. An exploratory Health Economic and Outcomes Research sub-study will determine potential additional benefits of the aXess graft to patients, health care institutions, and reimbursement programs., Discussion: The Pivotal study will examine the long-term performance and safety of the aXess Hemodialysis Graft and compare the outcome measures with historical data obtained with other graft types and autogenous AVFs. Potential advantages may include superior long-term patency rates and lower infection rates versus currently available AVGs and a shorter time to first cannulation compared to an autologous AVF. As such, the aXess Hemodialysis Graft may fulfill an unmet clinical need in the field of hemodialysis access., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Frans Moll is a consultant to Xeltis B.V. All other authors declare no conflict of interest.

A definitive randomised controlled trial of arteriovenous fistula (AVF) versus arteriovenous grafts (AVG) has been advocated for more than a decade, but as yet, none has been completed. The aim of this article is to summarise the theoretical barriers, review the difficulties in trial design and practicalities that have thus far prevented this from occurring., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Chronic kidney disease (CKD) affects 10% of the global population costing over a hundred billion dollars per annum and leading to increased risk of cardiovascular disease. Many patients with CKD require regular haemodialyses. Synthetic arteriovenous grafts (AVG) are increasingly used to provide rapid vascular connection for dialysis. Initially, they have excellent patency rates but are critically limited by neointimal hyperplasia at the venous anastomosis, which drives subsequent thrombosis, graft failure and death., Methods: Here, we describe a system in which electrical impedance spectroscopy sensors are incorporated circumferentially into the wall of a synthetic arteriovenous graft. This is combined with an implantable radiotelemetry system for data transmission outside the patient. The system was tested using monolayers of endothelial and smooth muscle cells as well as swine blood and clots with explanted human carotid artery plaques. Sensor testing was then performed in vitro and the device was implanted in vivo in female swine., Results: The device can wirelessly report the accumulation of biological material, both cells and blood. Differences are also detected when comparing controls with pathological atheroma. In swine differences between blockage formation in a graft were remotely obtained and wireless reported., Conclusions: Combining electrical impedance spectroscopy and an implantable radiotelemetry system enables graft surveillance. This has the potential to be used for early detection of venous stenosis and blood clot formation in real-time in vivo. In principle, the concept could apply to other cardiovascular diseases and vascular implantable devices., (© 2024. The Author(s).)

Introduction: A central component in the introduction of a novel surgical procedure or technique is an evaluation of its cost efficiency when compared with a benchmark standard of care. Accurate assessment of costs is thus essential in ensuring appropriate allocation of resources within a healthcare system. The treatment of kidney failure requires a significant volume of resources, and vascular access provision is the main modifiable cost. The costs of providing this service are obscured by generic NHS reference costs, which lack adequate granularity to allow meaningful comparisons between treatments. The aim of this systematic review will be to assess the reporting of procedural costs in all published economic analyses of vascular access surgery and perform a comparison of the reported procedural costs involved in arteriovenous fistula (AVF) and arteriovenous graft (AVG) creation. This will provide an estimate as to the accuracy of the NHS reference costs in this field., Methods and Analysis: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines will be followed. A systematic search will be performed of the MEDLINE, Embase and Cochrane databases to identify full-text economic analyses of vascular access for haemodialysis in which the procedural cost of AVF or AVG creation is reported. Publications in English from 1 January 2000 to 30 August 2023, will be eligible for inclusion. Studies will be selected by title and abstract review, followed by a full-text review using inclusion and exclusion criteria. Studies not reporting the procedural costs of surgery will be excluded. Data collected will pertain to procedural costs of AVF and AVG creation. Costs will be adjusted to a common currency using a gross domestic product (GDP) deflator index and conversion rates based on purchasing power parities for GDP. Comparison with NHS reference costs will indicate their reliability for use in future economic analyses in this field., Ethics and Dissemination: Ethical approval is not required for this systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations., Prospero Registration Number: CRD42023458779., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This study provides an overview of recent efforts to develop technology-based interventions for patients with high treatment burden. Adoption of a technological intervention for high treatment burden will depend on a range of factors, including: the reliability and accessibility of the technology, patient factors including age, socio-economic factors, technology literacy, overall health status and personal priorities - as well as the perceived benefits provided by the technology intervention, from the perspectives of both patients and clinicians.

Background: Cephalic arch stenoses (CAS) occur in near 70% of elbow arteriovenous fistulas. Percutaneous transluminal angioplasty (PTA) remains first-line treatment despite documented stent-grafts (SG) efficacy. The study aim is to report long-term outcomes based on initial treatment of CAS., Methods: Retrospective review of 12-year data in single tertiary centre. Outcomes included technical success, rupture rate, primary patency (PP), dialysis performance; categorical variables assessed via χ 2 or Fisher's; nonparametric tests used for skewed data. Kaplan-Meier analysis used for PP and cumulative patency. Cox proportional hazard regression model to assess explanatory variables in PP., Results: One hundred one brachio- and radiocephalic fistulas with CAS were included. SG as first intervention had higher success than PTA (85% vs 61%, p = 0.003). Rupture occurred in 9/85 (10.6%) PTA vs 0% in SG (p = 0.046). In a subgroup with poor urea reduction rate (URR), both PTA and SG improved dialysis performance post-intervention (p = 0.002). SG demonstrated better PP than PTA (79,73,60% patency at 3, 6, 9 months; versus 71,51,47%; p = 0.195) and cumulative patency (73,61,61% at 1, 2, 3 years; versus 60,34,26%; p < 0.001). Of the variables analyzed, technical success of PTA was the only discriminating factor (coeff.-1.01; RR 35%, p = 0.035). Accesses that underwent secondary stenting performed better than primarily stented CAS (p = 0.01)., Conclusions: SG superiority is confirmed in CAS, particularly when angioplasty is unsuccessful. While PTA has short-lived benefits, it can improve dialysis performance. Other than higher success rate, primary CAS stenting did not have advantages compared to post-PTA stenting in our study. Other factors related to inflow, outflow, conduit characteristics are presumed to be involved in access longevity., (© 2024. The Author(s).)

Background: Increasing options for vascular access have increased the need for more effective communication to optimize patient engagement and ensure effective consent. An advanced prototype of the mobile application (VA App) was developed over 3 years as a patient decision aid. For the first time, entry to the 2021 UK Kidney Week was opened to all professions and patients and was held online. The VA App was presented in an inter-active session. This report summarizes the findings., Methods: A 30-min interactive session was allocated with the session delivered in four sections: (1) demographic data was collected; (2) an overall opinion was obtained about current patient information sources and satisfaction with these; (3) the participants were asked a series of eight questions regarding the main problem areas previously identified; (4) following a 6-min demonstration video, the participants were then re-asked the same questions to determine if the VA App would improve/worsen these areas., Results: Completed data from 30 participants showed great variation in all demographics. The most cited source was verbal and rated the best, whilst all other sources were felt to be poor by 90%. All eight aspects of current information sources rated poorly. There was a unanimous agreement that the VA App could make this better. Interestingly, when the eight aspects were ranked by order of the worst to best, this matched the order of the benefits of the VA App., Discussion: This is the first report of an on-line, multi-professional co-design workshop. With a unanimous view that current systems are very limited and that better patient information systems are required, the VA App was found to be a potential solution as a patient decision aid. Interestingly, paper leaflets were widely viewed as the least used and the least effective mechanism for communicating information to patients. Funding for a commercially produced mobile application has been secured and will be further tested in the near future., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: D.B.K., K.S.S., RK and P.C.T. have received honoraria for speaking from W.L. Gore & Associates. D.B.K. and P.C.T. have received an investigator research grant from Proteon Therapeutics. D.B.K. has received an investigator-led small research grant from W.L. Gore & Associates.

Renal artery stenosis manifests as poorly-controlled hypertension, impaired renal function or pulmonary oedema, therefore the success of treatment is dependent on indication. This study aims to determine the outcomes of patients undergoing renal artery stenting (RASt) based on therapeutic aim compared to criteria used in the largest randomised trial. Retrospective case-note review of patients undergoing RASt between 2008-2021 (n = 74). The cohort was stratified by indication for intervention (renal dysfunction, hypertension, pulmonary oedema) and criteria employed in the CORAL trial, with outcomes and adverse consequences reported. Intervention for hypertension achieved significant reduction in systolic blood pressure and antihypertensive agents at 1 year (median 43 mmHg, 1 drug), without detrimental impact on renal function. Intervention for renal dysfunction reduced serum creatinine by a median 124 μmol/L, sustained after 6 months. Intervention for pulmonary oedema was universally successful with significant reduction in SBP and serum creatinine sustained at 1 year. Patients who would have been excluded from the CORAL trial achieved greater reduction in serum creatinine than patients meeting the inclusion criteria, with equivalent blood pressure reduction. There were 2 procedure-related mortalities and 5 procedural complications requiring further intervention. 5 patients had reduction in renal function following intervention and 7 failed to achieve the intended therapeutic benefit. Renal artery stenting is effective in treating the indication for which it has been performed. Previous trials may have underestimated the clinical benefits by analysis of a heterogenous population undergoing a procedure rather than considering the indication, and excluding patients who would maximally benefit., (© 2022. The Author(s).)

Advanced chronic kidney disease is a serious and common medical condition with significant treatment choices incurring varying high treatment burdens. Better understanding on how to best collect quality of life (QoL) in this unique situation may help guide critical decisions. This study investigates the acceptability of digital QoL questionnaires completed during routine haemodialysis sessions. Qualitative data was collected from patient (n=23) and clinical researcher (n=2) interviews alongside analysis of data from questionnaires completed by patients (n=101) during a 6-week validation study. Interviews refined the content and format of digital QoL questionnaires and provided novel insights regarding how patients assessed and completed QoL questions. This study suggests collecting QoL data using digital tablet technology during routine haemodialysis clinics is both feasible and acceptable to patients and has provided novel insights that are not routinely available with traditional methods.

Introduction: The perception that arteriovenous graft infection (AVGi) is frequent and severe is not based on contemporary data from large units using modern AVG. Furthermore, older reports compounded misperceptions by using non-standardised reporting that prevents easy comparison against the alternative modalities. The aim of this article is to use a recently published reporting scheme to analyse the frequency, management and outcome of AVGi in a large series of sequential early-cannulation AVG with long-term follow-up., Methods: A single-center series analysis was performed of 277 early-cannulation AVG with minimum 1-year follow-up (total 120,082 days). Infections relating to the AVG were classified, root-cause analysed and the outcomes presented., Results: Sixteen percent of all AVG implanted (51 episodes) developed infection related to the AVG. Primary AVGi (related to the insertion procedure or within 28 days) occurred in 9 (3%); secondary AVGi (related to AVG in use) occurred 33 times (rate 0.27/1000 haemodialysis days), at a mean of 382 days, and tertiary AVGi (in AVG no longer in use) occurred nine times. Only 1/3 of all AVGi led to bacteraemia, and ½ did not lead to loss of functional access., Summary: AVG infection is not common, caused a systemic infection in only one-third, did not lead to metastatic infection, and importantly, was treatable without loss of access in one-half of all cases. Using an objective system that discriminates between aetiology and outcome allows a more complete objective understanding of relative infection risks and outcomes for AVG that can inform discussions with patients requiring vascular access for haemodialysis.

Introduction: Arteriovenous fistulae (AVF) are the 'gold standard' vascular access for haemodialysis. Universal usage is limited, however, by a high early failure rate. Several small, single-centre studies have demonstrated better early patency rates for AVF created under regional anaesthesia (RA) compared with local anaesthesia (LA). The mechanistic hypothesis is that the sympathetic blockade associated with RA causes vasodilatation and increased blood flow through the new AVF. Despite this, considerable variation in practice exists in the UK. A high-quality, adequately powered, multicentre randomised controlled trial (RCT) is required to definitively inform practice., Methods and Analysis: The Anaesthesia Choice for Creation of Arteriovenous Fistula (ACCess) study is a multicentre, observer-blinded RCT comparing primary radiocephalic/brachiocephalic AVF created under regional versus LA. The primary outcome is primary unassisted AVF patency at 1 year. Access-specific (eg, stenosis/thrombosis), patient-specific (including health-related quality of life) and safety secondary outcomes will be evaluated. Health economic analysis will also be undertaken., Ethics and Dissemination: The ACCess study has been approved by the West of Scotland Research and ethics committee number 3 (20/WS/0178). Results will be published in open-access peer-reviewed journals within 12 months of completion of the trial. We will also present our findings at key national and international renal and anaesthetic meetings, and support dissemination of trial outcomes via renal patient groups., Trial Registration Number: ISRCTN14153938., Sponsor: NHS Greater Glasgow and Clyde GN19RE456, Protocol V.1.3 (8 May 2021), REC/IRAS ID: 290482., Competing Interests: Competing interests: AJRM is currently president of Regional Anaesthesia UK (RA-UK). RA-UK has reviewed and endorsed the trial protocol, but has not been involved in the design or development in any way. AJRM has received consulting fees from Heron therapeutics and Intelligent US. RH has received honoraria from GE., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Purpose: This prospective, observational first in human study evaluated the safety and effectiveness of WRAPSODY TM Cell-impermeable Endoprosthesis (Merit Medical Systems, Inc.) in the treatment of arteriovenous fistula and arteriovenous graft access circuit stenosis., Materials and Methods: Investigators conducted a prospective analysis of 46 patients with access circuit stenosis from three centres. Treatment sites included the peripheral outflow veins (e.g. cephalic arch, basilic vein swing point; 16 fistula and 10 graft patients); the graft-vein anastomosis (9 patients); and the central veins (up to, but not including the SVC; 11 patients). Primary outcome measures included 30-day freedom from access circuit-related safety events and 30-day target lesion primary patency. Secondary outcome measures included procedural success; device- and procedure-related adverse events; target lesion primary patency; access circuit primary patency; and secondary patency. In-person follow-up was scheduled at 1, 3, 6, and 12 months. An independent data monitoring/clinical event committee adjudicated all reinterventions and device/procedure-relatedness for adverse events., Results: All initial procedures were successful. All but one patient was free from safety events through the first 30 days (97.8% (45/46)). This event was not device-related. Over the remainder of the study, one adverse event was adjudicated as possibly device-related. Six- and 12-month target lesion primary patency rates were 97.7% (42/43) and 84.6.% (33/39), respectively. Six- and 12-month access circuit primary patency rates were 84.4% (38/45) and 65.9% (29/44), respectively., Conclusion: Results suggest that the study device is safe and effective for treatment of stenoses in the peripheral and central veins of arteriovenous access circuits., Level of Evidence: Level 2b, cohort study., (© 2021. The Author(s).)

It is inevitable that complications arising from surgical procedures are ascribed to surgical technique, and this applies to venous stenosis (VS) in arteriovenous grafts. However, despite a wide range of cellular studies, computer modelling, observational series and clinical trials, there remains uncertainty on whether surgical technique contributes to VS. This article reviews evidence from basic science, fluid dynamics and clinical data to try and rationalise the main surgical options to modify the occurrence of venous stenosis. There is sufficient data from diverse sources to make recommendations on clinical practice (size of target vein, shape of anastomosis, angle of approach, distance from venous needling, trauma to the target vein) whilst at the same time this emphasises the need to carefully report the practical aspects of surgical technique in future clinical trials.

Ex vivo normothermic perfusion (EVNP) is increasingly recognised as a viability tool to increase organ utilisation in deceased donor transplantation. We report the use of EVNP to assess graft perfusion quality following indication nephrectomy and back-bench arterial reconstruction in a case of renal artery stenosis, unamenable to endovascular treatment. Once explanted, it was not possible to effectively cold perfuse the graft through the main renal artery or collaterals. An arterial reconstruction was performed with patch angioplasty using the largest collateral creating a single common stem. EVNP was used to assess organ perfusion and, therefore, viability. Excellent global perfusion was evident alongside urine production, demonstrating that the arterial reconstruction was satisfactory. A patient with end-stage renal disease was consented with particular attention to the uncertainty of the underlying donor disease process and long-term outcome of the reconstruction. Primary function was achieved and recipient estimated glomerular filtration rate (eGFR) remains stable at 58 mL/min/1.73 m² at 6 months., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Tunneled central venous catheter infection (TCVCi) is a common complication that often necessitates removal of the TCVC and replacement by a further TCVC. Theoretically, insertion of an early - cannulation graft (ecAVG) early after TCVC infection is possible but not widely practiced with concerns over safety and infection in the ecAVG. With 8 years of ecAVG experience, the aim of this study was to compare the outcomes following TCVC infection, comparing replacement with TCVC (TCVCr) versus immediate ecAVG (ecAVGr)., Design: Retrospective comparison of 2 cohorts, who underwent replacement of an infected TCVC either by an early cannulation graft (n = 18) or by a further central catheter (n = 39)., Methods: Data were abstracted from a prospectively completed electronic patient record and collected on patient demographics, TCVC insertion, duration and infection, including culture proven bacteriaemia and subsequent access interventions., Results: Eighteen of 299 patients identified from 2012 to 2020 had an ecAVG implanted as treatment for a TCVCi. In a 1-year time-period (January 1, 2015-December 31, 2015) out of 222 TCVC inserted, 39 were as a replacement following a TCVCi. No patient with an ecAVGr developed an immediate infection, nor complication from the procedure. The rate of subsequent vascular access infection was significantly more frequent for those with a TCVCr than with an ecAVGr (0.6 vs. 0.1/patient/1000 HD days, P< 0.000). The number of further TCVC required was significantly higher in the TCVCr group (7.1 vs. 0.4/patient/1000 HD days, P= 0.000)., Conclusions: An ecAVG early following a TCVC infection is safe, reduces the incidence of subsequent infectious complications and reduces the number of TCVC required, with a better functional patency., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Infection is the second highest cause of mortality in end-stage renal disease, with a significant proportion relating to haemodialysis (HD) vascular access-related infection (VARI)., Aim: To report the rate and antimicrobial resistance (AMR) of all-source bloodstream infections (BSIs) by vascular access type in a Scottish HD cohort., Methods: Retrospective analysis was undertaken of data on adult patients attending seven HD units during 2017. Total HD days for each vascular access type were calculated. BSIs were analysed with rates expressed per 1000 HD days. AMR was verified using health board microbiology databases., Findings: Excluding contaminant organisms, there was an overall BSI rate of 0.57 per 1000 HD days. The highest all-source and vascular access-related infection (VARI) BSI rates per 1000 HD days were in the non-tunnelled central venous catheter (CVC) group (3.11 and 2.07 respectively), followed by tunnelled CVC (1.10 and 0.67), arteriovenous graft (0.51 and 0.31), and finally arteriovenous fistula (0.29 and 0.02). The non-VARI BSI rates were lowest in the arteriovenous graft group. Staphylococci comprised the majority of events, with Staphylococcus aureus implicated in 29%. Gram-negative BSIs were prevalent, particularly in CVC groups, and associated with higher mortality. Multidrug-resistant (MDR) S. aureus and carbapenem resistance were relatively low. MDR Gram-negatives were high compared with the Scottish population., Conclusion: Arteriovenous fistula access is confirmed as having lowest all-source and VARI BSI rates, and arteriovenous graft access the lowest non-VARI BSI rates. Staphylococci remain the prevailing genus; however, the contributions of Gram-negative BSIs, the higher mortality, and proportion of MDR organisms in this group are notable., (Copyright © 2021 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Purpose: To describe a novel endovascular technique for intracaval cement retrieval after spinal surgery., Technique: We produced a replica of the intracaval cement fragment and a 3D print to plan the endovascular procedure. A woven caval filter was modified with two drawstring sutures to be used as fishing net. We used a 10F sheath in the right internal jugular vein to place the caval filter proximal to the floating fragment, and a 24F sheath in the right femoral vein was the working access. After the deployment of the caval filter, the following steps were performed through the 24F sheath: (A) The drawstring sutures were snared and retrieved to the skin surface in the groin; (B) the fragment was secured with two snare catheters from the femoral access and one through the lumen of the caval filter; (C) the fragment was broken off with a snared guide wire at the base; (D) the smallest fragment was removed directly with the snare; (E) the larger dislodged fragment was controlled within the periprocedural caval filter by tightening the drawstring and removed through the 24F sheath., Conclusion: Cement fragments located in the inferior vena cava after cement-augmented spinal surgery procedures can be safely removed by the described fishing net technique.

Objectives: There has been considerable change in the practice of deceased kidney transplantation in the past 15 years, with more extreme phenotypes implanted. The aim of this study was to determine whether increased use of expanded criteria donors (extended criteria donors and donors after circulatory death) affected clinical outcomes, including the incidence and pattern of delayed graft function., Methods and Materials: A retrospective analysis of 1359 renal transplants was performed over 15 years. The first 10 years of data (group 1) were compared with the subsequent 5 years (group 2). Outcomes were analyzed at 6 months and 12 months in addition to serum creatinine and patterns of delayed graft function (posttransplant times: on hemodialysis, to peak creatinine, for creatinine to half, and for creatinine to fall within 10% of baseline)., Results: There was a significant increase in the percentage of expanded criteria donor allografts used in group 2 with a significant increase in the incidence of delayed graft function. Despite this, serum creatinine and the incidence of biopsy-proven acute rejection had both improved in group 2. Group 2 expanded criteria donor kidneys had a significantly lower incidence of type 1 delayed graft function and a significantly higher incidence of types 3 and 4 delayed graft function. Time for creatinine to half in both groups was the best predictor of a serum creatinine <180 μmol/L at 1 year., Conclusion: The increased use of expanded criteria donor kidneys has led to a higher incidence of delayed graft function, but the pattern has shown that the requirement for hemodialysis has significantly reduced., (Copyright © 2018 Elsevier Inc. All rights reserved.)

A master class was held at the Vascular Access at Charing Cross (VA@CX2017) conference in April 2017 with invited experts and active audience participation to discuss arteriovenous (AV) vascular access aneurysms, a serious and common complication of vascular access (VA). The natural history of aneurysms in VA is poorly defined, and although classifications exist they are not uniformly applied in studies or clinical practice. True and pseudo aneurysms of AV access occur. Whilst an AV fistula by definition is an abnormal dilatation of a blood vessel, an agreed definition of 18 mm, or 3 times accepted maturation diameter, is proposed. The mechanism of aneurysmal dilatation is unknown but appears to be a combination of excessive external remodeling, wall changes due to injury, and obstruction of outflow. Diagnosis of AV aneurysms is based on physical examination and ultrasound. Venography and cross-sectional imaging may assist and be required for the investigation of outflow stenosis. Treatment of pseudo aneurysms and true aneurysms of VA (AVA) is not evidence-based, but relies on clinical experience and available facilities. In many AVA, a conservative approach with surveillance is suitable, although intervals and modalities are unclear. Avoidance of rupture is imperative and preemptive treatment should aim for access preservation, ideally with avoidance of prosthetic materials. Different techniques of aneurysmorrhaphy are described with good results in published series. Although endovascular approaches and stenting are described with good short-term results, issues with cannulation of stented areas occur and, while possible, this is not recommended, and long-term access revision is recommended.

Objective: Early cannulation arteriovenous grafts (ecAVGs) are proposed as an alternative to tunneled central venous catheters (TCVCs) in patients requiring immediate vascular access for hemodialysis (HD). We compared bacteremia rates in patients treated with ecAVG and TCVC., Methods: The study randomized 121 adult patients requiring urgent vascular access for HD in a 1:1 fashion to receive an ecAVG with or without (+/-) an arteriovenous fistula (AVF; n = 60) or TCVC+/-AVF (n = 61). Patients were excluded if they had active systemic sepsis, no anatomically suitable vessels, or an anticipated life expectancy <3 months. The primary end point was the culture-proven bacteremia rate at 6 months, with the trial powered to detect a reduction in bacteremia from 24% to 5% (α = .05, β = .8). Secondary end points included thrombosis, reintervention, and mortality. A cost-effectiveness analysis was also performed., Results: Culture-proven bacteremia developed in 10 patients (16.4%) in the TCVC arm ≤6 months compared with two (3.3%) in the ecAVG+/-AVF arm (risk ratio, 0.2; 95% confidence interval, 0.12-0.56; P = .02). Mortality was also higher in the TCVC+/-AVF cohort (16% [n = 10] vs 5% [n = 3]; risk ratio, 0.3; 95% CI, 0.08-0.45; P = .04). The difference in treatment cost between the two arms was not significant (£11,393 vs £9692; P = .24)., Conclusions: Compared with TCVC+/-AVF, a strategy of ecAVG+/-AVF reduced the rate of culture-proven bacteremia and mortality in patients requiring urgent vascular access for HD. The strategy also proved to be cost-neutral., (Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.)

Objective: Current treatment strategies for painful critical ischemia in patients with end-stage renal disease (ESRD) are suboptimal. A drug that is non-renally excreted has minimal systemic absorption and does not require dose adjustment in renal failure is attractive. The aim of this study was to evaluate the safety and efficacy of Qutenza® (topical capsaicin 8%) for chronic neuropathic pain from critical ischemia in patients with ESRD., Design and Setting: A prospective cohort study was conducted in a single-center, university teaching hospital., Patients: Twenty patients with ESRD were treated with Qutenza® for neuropathic pain from critical limb ischemia., Methods: Patients were followed-up at 1, 6 and 12 weeks post-treatment. The primary end point was the difference in visual analog scale (VAS) between baseline and week 12. Secondary end points were Brief Pain Inventory questionnaire (BPI) scores, quality of life assessment (EQ-5D) and patient global impression of change (PGIC). Safety and tolerability data were also collected. The trial was prospectively registered with clinical trials databases (EudraCT: 2012-001586-32; NCT01704313)., Results: There was significant reduction in VAS from baseline to week 12 (-20+/-7%; P = 0.02). There was a significant reduction in all seven domains of the BPI. Quality of life also improved at 12 weeks following treatment in two of the EQ-5D domains (mobility and pain). Qutenza® was well tolerated with no significant side effects in this patient cohort, which included 20% diabetics., Conclusions: In this small, observational study Qutenza® treatment has been shown to be effective and well-tolerated to treat neuropathic pain from critical ischemia in patients with ESRD.

Background: Early cannulation arteriovenous grafts (ecAVGs) are advocated as an alternative to tunnelled central venous catheters (TCVCs). A real-time observational "virtual study" and budget impact model was performed to evaluate a strategy of ecAVG as a replacement to TCVC as a bridge to definitive access creation., Methodology: Data on complications and access-related bed days was collected prospectively for all TCVCs inserted over a six-month period (n = 101). The feasibility and acceptability of an alternative strategy (ecAVGs) was also evaluated. A budget impact model comparing the two strategies was performed. Autologous access in the form of native fistula was the goal wherever possible., Results: We found 34.7% (n = 35) of TCVCs developed significant complications (including 17 culture-proven bacteraemia and one death from line sepsis). Patients spent an average of 11.9 days/patient/year in hospital as a result of access-related complications. The wait for TCVC insertion delayed discharge in 35 patients (median: 6 days). The ecAVGs were a practical and acceptable alternative to TCVCs in over 80% of patients. Over a 6-month period, total treatment costs per patient wereGBP5882 in the TCVC strategy and GBP4954 in the ecAVG strategy, delivering potential savings ofGBP927 per patient. The ecAVGs had higher procedure and re-intervention costs (GBP3014 vs. GBP1836); however, these were offset by significant reductions in septicaemia treatment costs (GBP1322 vs. GBP2176) and in-patient waiting time bed costs (GBP619 vs. GBP1870)., Conclusions: Adopting ecAVGs as an alternative to TCVCs in patients requiring immediate access for haemodialysis may provide better individual patient care and deliver cost savings to the hospital.

Purpose: Autologous arteriovenous fistulae (AVF) are the vascular access option of choice. However, Brachiobasilic fistula (BBF) are complex procedures with variable outcomes reported in the literature. Our aim was to evaluate outcomes and morbidity associated with BBF in our population., Methods: Retrospective analysis of prospectively collected data was undertaken for all 51 BBF created in our institution between January 2010 and March 2013. These were compared to an age and sex-matched group of brachiocephalic fistula (BCF) created over a similar time period. Demographic, operative and outcome data was collected for all patients. The primary end points were primary functional patency, primary-assisted patency and secondary patency at 3, 6 and 12 months. Continuous data was compared using Student's t-test and categorical data using chi-squared test (p < 0.05 is significant)., Results: Mean patient age was 57 years (range: 21-82). About 45% were male. About 73% of patients were already on hemodialysis (HD) at the time of BBF creation. BBF was the secondary or tertiary access procedure in 60.8% of patients (n = 31). BBF were associated with significant operative burden with 82% of patients requiring a general anaesthetic and median hospital admission of 2 days (range: 1-4). About 75% had a single-stage procedure. About 23.5% (n = 12) required operative revision (superficialization or anastomotic revision for stenosis). Patients with BBF spent an additional 3.45 days/year in hospital as a result of access related complications compared to 0.56 days/year in the BCF group. Primary-assisted patency at 3, 6 and 12 months was better in the BCF group than BBF group (86%, 72% and 48% vs. 71%, 59%, 33%, respectively; p < 0.01) Primary functional and secondary patency rates at 3, 6 and 12 months were 74%, 58% and 32% and 78%, 63% and 41%, respectively, with an average of 0.33 procedures per AVF to maintain patency (10 fistuloplasties, 4 IR thrombectomy and 3 surgical thrombectomy). About 32% (n = 17) of BBF were never used for HD (seven patients had a patent AVF but did not require HD >18 months following creation; nine failed to adequately mature and one patient refused second stage superficialization)., Conclusions: BBF are associated with a significant initial operative burden and higher complication and poorer patency rates than BCF. About one-third of BBF created in this series were never used. Given the morbidity associated with this procedure, careful consideration should be given to creation of BBF in pre-dialysis patients particularly those in whom the rate of decline in renal function is slow.

Objective: Continuous suturing techniques have conventionally been used for the end-to-side anastomoses of radiocephalic fistulas (RCFs); however, primary patency rates are poor. Only 50% to 60% of RCFs ever achieve functional patency. We hypothesized that a hybrid interrupted-continuous suturing technique (as used in many microsurgical procedures) may improve outcomes in fistulas constructed from small vessels., Methods: A randomized controlled trial comparing hybrid interrupted-continuous (n = 42) with continuous (n = 36) suturing techniques for RCF was undertaken. Patients were excluded if vessels were <1.8 mm in diameter or if previous ipsilateral fistula had been attempted. A priori power calculation indicated that a sample size of 78 patients was required to detect an improvement in patency from 50% to 80% (α = .05, β = .8). The primary end point was primary patency at 6 weeks (assessed by a blinded observer for the presence of thrill and bruit). Secondary end points were immediate patency, functional patency (assessed clinically and by ultrasound) at 6 weeks, and presence of anastomotic stenosis., Results: Groups were comparable for basic patient demographics, operating surgeon, and vessel diameter as measured on preoperative ultrasound (mean age, 58.9 ± 13 years; 68% male). Primary patency at 6 weeks was higher in the hybrid interrupted-continuous suturing technique group (71% vs 47%; P = .01). Immediate patency was also higher in the hybrid interrupted-continuous suturing technique group (93% vs 67%; P < .001). There was no significant difference in functional patency at 6 weeks (52% vs 36%; P = .18). Three patients developed an anastomotic stenosis. All were in the hybrid interrupted-continuous suturing technique group. One patient from the interrupted suturing technique cohort required re-exploration for bleeding., Conclusions: A hybrid interrupted-continuous suturing technique yielded higher immediate and 6-week primary patency rates for RCF. The hybrid interrupted-continuous suturing technique may improve anastomotic compliance and reduce the narrowing and puckering that can occur on suture tightening in small-caliber vessels. Based on these findings, consideration should be given to performing hybrid interrupted-continuous anastomoses for RCFs., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate the relationship between Qa, cardiovascular parameters and symptomatic cardiac disease., Methods: A prospective cohort study of 100 patients dialysing via an arteriovenous fistula (AVF) was performed. Qa was measured using pulsed Doppler ultrasound. Cardiovascular parameters were measured using thoracic bioimpedance technique (Medis, GmbH). Measurement of cardiovascular parameters was undertaken pre- and post-occlusion of the AVF., Results: Mean age was 57.1 years (range: 19-83); 51% male. Mean values pre-occlusion: mean arterial blood pressure (MABP) 89.6 ± 16.9 mmHg; stroke volume index (SVI) 39.3 ± 4.6 mL; cardiac index (CI) 3.7 ± 0.8 L/min/m2 ; systemic vascular resistance index (SVRI) 585.5 ± 67.8 dyn/sec/cm-5/m2; oxygen delivery (DO2I) 607.1 ± 116.8 mL/min/m2. A total of 12% of patients had CI&gt;4.5 L/min/m2 pre-occlusion. There was no difference in heart rate (HR), MABP and SVI following occlusion of AVF. Mean CI reduced post-AVF occlusion (∆CI: -0.42 L/min/m2; p&lt;0.001), as did DO2I (∆ DO2I: 45.5 mL/min/m2; p&lt;0.001). SVRI increased (∆SVRI: 170.1 dyn/sec/cm-5/m2; p&lt;0.001). The drop in CI which occurred post-AVF occlusion was greater in patients with Qa &gt;2000 mL/min (-2.79 ± 0.34 vs. -0.24 ± 0.48 L/min/m2; p&lt;0.001). There was a non-significant trend towards symptomatic heart failure in those patients with a greater ∆CI following AVF occlusion (NYHA 1: -0.1 ± 0.1 L/min/m2; NHYA 2: -0.3 ± 0.7 L/min/m2; NYHA 3: -0.7 ± 1.0 L/min/m2; p = 0.06)., Conclusions: The relationship between AVF blood flow, cardiac output and symptomatic cardiac disease is complex. Occlusion of an AVF leads to reduced cardiac output and improved oxygen delivery, even in asymptomatic patients. This difference is most marked in patients with high-flow AVF (&gt;2000 mL/min). High-flow AVF with large ∆CI may lead to high cardiac output state, which is reversible on occlusion of the AVF.

Creation of an autologous arteriovenous fistula (AVF) for vascular access in haemodialysis is the modality of choice. However neointimal hyperplasia and loss of the luminal compartment result in AVF patency rates of ~60% at 12months. The exact cause of neointimal hyperplasia in the AVF is poorly understood. Vascular trauma has long been associated with hyperplasia. With this in mind in our rabbit model of AVF we simulated cannulation autologous to that undertaken in vascular access procedures and observed significant neointimal hyperplasia as a direct consequence of cannulation. The neointimal hyperplasia was completely inhibited by topical transdermal delivery of the non-steroidal anti-inflammatory (NSAID) diclofenac. In addition to the well documented anti-inflammatory properties we have identified novel anti-proliferative mechanisms demonstrating diclofenac increases AMPK-dependent signalling and reduced expression of the cell cycle protein cyclin D1. In summary prophylactic transdermal delivery of diclofenac to the sight of AVF cannulation prevents adverse neointimal hyperplasic remodelling and potentially offers a novel treatment option that may help prolong AVF patency and flow rates., (Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Histopathological features on time-zero renal biopsies correlate with graft outcome after renal transplantation. With increasing numbers of marginal donors, assessment of pre-implantation graft quality is essential. The clinician's choice of wedge or core biopsy is performed without evidence of efficacy or safety. This study aims to compare the information derived from wedge biopsy versus core biopsy., Methods: Prospective evaluation of 37 wedge biopsies and 30 core biopsies was performed. Histopathological data were collected on number of glomeruli and arterioles observed, and Remuzzi scoring for glomerulosclerosis, tubular atrophy, interstitial fibrosis, and arteriolar narrowing was performed. Clinical data on delayed graft function (DGF) were also collated. Sensitivity, specificity, and positive and negative predictive values for DGF were compared., Results: Patient demographics between the two cohorts were comparable. No complications of biopsies occurred; 81% of wedge biopsies versus 50% of core biopsies had >10 glomeruli (P = .01), whereas 32% of wedge biopsies and 57% of core biopsies had >2 arterioles (P = .02). Wedge biopsies were more likely to identify pathology with more glomerulosclerosis, tubular atrophy (P < .01), and interstitial fibrosis (P < .01). There was a non-significant trend toward high Remuzzi scores in wedge biopsy (22% versus 7% with Remuzzi ≥ 4; P = .12). The sensitivity and positive predictive value of Remuzzi ≥ 4 for predicting DGF was better on wedge biopsy (45.5% versus 0%; P < .01 and 62.5% versus 0%; P < .01, respectively)., Conclusions: Wedge biopsies were safe and superior to core biopsies for identifying clinically significant histopathological findings on pre-implantation renal biopsy. We believe that the wedge biopsy is the method of choice for time-zero biopsies., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Autologous arteriovenous fistulae (AVF) are the optimal form of vascular access for haemodialysis. AVFs typically require 6 to 8 weeks to "mature" from the time of surgery before they can be cannulated. Patients with end-stage renal disease needing urgent vascular access therefore traditionally require insertion of a tunnelled central venous catheter (TCVC). TCVCs are associated with high infection rates and central venous stenosis. Early cannulation synthetic arteriovenous grafts (ecAVG) provide a novel alternative to TCVCs, permitting rapid access to the bloodstream and immediate needling for haemodialysis. Published rates of infection in small series are low. The aim of this study is to compare whether TCVC ± AVF or ecAVG ± AVF provide a better strategy for managing patients requiring immediate vascular access for haemodialysis., Methods/design: This is a prospective randomised controlled trial comparing the strategy of TCVC ± AVF to ecAVG ± AVF. Patients requiring urgent vascular access will receive a study information sheet and written consent will be obtained. Patients will be randomised to receive either: (i) TCVC (and native AVF if this is anatomically possible) or (ii) ecAVG (± AVF). 118 patients will be recruited. The primary outcome is systemic bacteraemia at 6 months. Secondary outcomes include culture-proven bacteraemia rates at 1 year and 2 years; primary and secondary patency rates at 3, 6, 12 and 24 months; stenoses; re-intervention rates; re-admission rate; mortality and quality of life. Additionally, treatment delays, impact on service provision and cost-effectiveness will be evaluated., Discussion: This is the first randomised controlled trial comparing TCVC to ecAVG for patients requiring urgent vascular access for haemodialysis. The complications of TCVC are considered an unfortunate necessity in patients requiring urgent haemodialysis who do not have autologous vascular access. If this study demonstrates that ecAVGs provide a safe and practical alternative to TCVC, this could instigate a paradigm shift in nephrology thinking and access planning., Trial Registration: This study has been approved by the West of Scotland Research Ethics Committee 4 (reference no. 13/WS/0087, 28 August 2013) and is registered with the International Standard Randomised Controlled Trial Number Register (reference no. ISRCTN80588541 , 27 May 2014).

Objectives: Delayed graft function is a significant prognostic indicator after renal transplantation. We hypothesized that delayed graft function is not a single entity, and different patterns of delayed graft function reflect various underlying pathological processes., Materials and Methods: An analysis of 762 renal transplants was performed, showing serum creatinine was charted serially for the first 30 days after transplant. Measurements were obtained: time on hemodialysis; time to peak creatinine; time for creatinine to half; time for creatinine to within 10% of baseline., Results: Four patterns of delayed graft function were identified. There was no association between pattern of delayed graft function, and 1-year graft survival or serum creatinine at 1 year. Time for creatinine to > 15 days was associated with a higher creatinine level at 1 year than it was with patients with time for creatinine to half < 5 days (300.6 ± 54.3 vs 211.3 ± 26.0 μmol/L; P < .01). Patients with 1-year creatinine concentrations > 180 μmol/L had longer time on hemodialysis and time for creatinine to half than did those with 1-year creatinine concentrations ≤ 180 μmol/L (9.2 ± 1.3 μmol/L vs 7.0 ± 0.7 μmol/L; P = .03; and 11.6 ± 1.7 μmol/L vs 6.0 ± 0.4 μmol/L; P < .001). Time for creatinine to half of 6.5 days (sensitivity 67.3%; specificity 79.4%; area under the curve, 0.70) was the best predictor of a 1-year creatinine concentration ≤ 180 μmol/L., Conclusions: Delayed graft function is not a single entity; rather; it is the most common presentation of a heterogeneous variety of pathologies. Its rate of resolution of renal function is the best predictor of long-term graft outcome.