Indications for vascular grafts as hemodialysis access: consensus from experience in Italy.

INTRODUCTION: In Italy, the use of arteriovenous grafts (AVG) is limited (1-5 %) due to different approaches to vascular access (VA) management as compared to other countries, where guidelines (which may not apply to the Italian setting) have been produced. Therefore, the Study Group (GdS) on VA of the Italian Society of Nephrology produced this position paper, providing a list of 8 recommendations built upon current guidelines. METHODS: The most controversial and innovative issues of existing guidelines have been summed up in 12 different statements. We selected 60 Italian dialysis graft experts, nephrologists and vascular surgeons (PP1SIN Study Investigators). They were asked to express their agreement/disagreement on each issue, thus creating a new method to share and exchange information. RESULTS: Most of them agreed (consensus > 90%) on specific criteria set to choose AVG over native AVF (nAVF) and tunnelled venous catheter (tVC) and on the necessary conditions to implant them. They did not fully agree on the use of AVG in obese patients, in patients at risk of developing ischemia, on the priority of AVG as an alternative to brachial-basilic fistula with vein transposition, and in case of a poorly organized setting regarding graft maintenance. Keeping in mind that the nAVF should be preferred whenever is feasible, AVGs are indicated when superficial veins are unavailable or to repair a nAVF (bridge graft). An AVG is an alternative to tVC if the expected patient survival is long enough to guarantee its clinical benefits.

Developing recommendations for vascular access for hemodialysis: Vascular Access Working Group of the Italian Society of Nephrology.

This paper presents an overview of the project carried out by the Vascular Access (VA) Working Group of the Italian Society of Nephrology with the aim of developing 4 position papers at the national level on how to choose, use, and implant the different, possible types of vascular access. The topics of the project are: 1) recommendations on the use of prosthetic arteriovenous fistulas for vascular access in hemodialysis, 2) recommendations on the use of venous catheters for hemodialysis, 3) infections induced by a venous catheter for hemodialysis, and 4) how to create and maintain a vascular access for hemodialysis. This paper also gives an explanation of the difficulties existing in Italy in the implementation of international guidelines, mostly due to significant differences in the procedures for the creation of VA, compared with the countries where most of the literature on the subject has been published. Individual position papers were drafted for each of the different topics. A list of recommendations was produced based on existing guidelines. Then these recommendations were critically reviewed by experts working in Italy, who expressed their opinion on their inclusion in position papers. The working method used to gather the opinions of the various experts is described. The final target is to provide clinicians interested in VA with updated documents on selected topics. Such documents will be updated periodically, and they will present a thorough overview of expert opinions.

[Indications for vascular grafts as dialysis access; consensus from the Italian experience]. / Indicazioni all'uso delle protesi vascolari per l'accesso emodialitico: un'esperienza Italiana basata sul consenso.

In Italy, the use of arteriovenous grafts (AVGs) is limited (1-4%) due to different approaches to vascular access management compared to other countries, where guidelines that may not apply to the Italian setting have been produced. Therefore, the Vascular Access Study Group of the Italian Society of Nephrology produced this position paper, providing a list of 8 recommendations built upon current guidelines. The most controversial and innovative issues of the existing guidelines have been summed up in 12 different topics. We selected 60 Italian dialysis graft experts, nephrologists and vascular surgeons (PP1SIN Study Investigators). They were asked to express their approval or disapproval on each issue, thus creating a new method to share and exchange information. Almost all agreed on specific criteria for the choice of AVG over native arteriovenous fistulas (AVF) and tunneled venous catheters (tVC) and on the necessary conditions to implant them. They did not fully agree on the use of AVG in obese patients and patients at risk of developing ischemia, as an alternative to brachiobasilic fistula with vein transposition, and in case of a poorly organized setting. When AVF is feasible, it should be preferred. AVGs are indicated when superficial veins are unavailable or to repair an AVF (bridge graft). An AVG is an alternative to tVC if the expected patient survival is long enough to allow clinical benefits. The ultimate choice of the graft type is made by the physician in charge of the surgical intervention. Antithrombotic prophylaxis may be justified in some cases.

[Vascular access for hemodialysis: recommendations of the Vascular Access Study Group of the Italian Society of Nephrology]. / Gli accessi vascolari per emodialisi: le raccomandazioni del Gruppo di Studio della Società Italiana di Nefrologia.

The Vascular Access Study Group of the Italian Society of Nephrology has scheduled four national studies regarding the choice, implantation and use of vascular access. Study topics will include 1) utilization of vascular grafts for hemodialysis; 2) indications and use of venous catheters; 3) tunneled central venous catheter infection; 4) organization of the implantation and repair of vascular access. After examining the difficulties in implementing international guidelines on vascular access in Italy and the differences in practice patterns between our and other countries (where the most important studies were published), the Study Group set out to prepare four position papers based on discussion of controversial aspects of the international guidelines by nephrologists and surgeons experienced in the Italian practice. An innovative operative method for verifying the consensus on vascular access practice patterns was used. The final aim was to write a document addressed to vascular access operators (surgeons and nephrologists) based on the consensus of experts on controversial vascular-access- related issues. The project will include yearly updates of the documents.

Endovascular treatment of benign superior vena cava syndrome: venographic patterns and implications for treatment.

PURPOSE: We report our experience with the percutaneous treatment of superior vena cava syndromes of benign etiology. MATERIALS AND METHODS: From August 1994 to August 2003 a total of 14 superior vena cava syndromes of benign origin were treated. Previous use of a central venous catheter pending the development of a peripheral arteriovenous fistula for dialysis was believed to be the cause of the obstruction of the superior vena cava in 11 patients. In 2 other cases the cause was attributed to post-radiation mediastinal fibrosis and, in one case, to a previously implanted pacemaker. The superior vena cava syndrome was confirmed by venography. After negotiating the obstruction, a self-expanding stent was selected based on the CT and venographic data. At the end of the procedure, technical success was confirmed by venography, and haemodynamic success by pressure measurements. The follow-up allowed the assessment of the clinical success of the procedure. RESULTS: Technical success was achieved in 13 patients (92.8%); in one case the obstruction could not be negotiated with the wire guide, so the patient was referred for surgery. One self-expanding stent proved sufficient to resolve the central venous obstruction and restore superior vena cava diameter in all cases but one. In one young woman, whose central obstruction was resolved with PTA, was unable to complete the procedure with deployment of a self-expanding stent owing to a supervening asthma attack that could not be treated with the commonly-used drugs. No complications related to the procedure were reported. The symptoms cleared up within 2 weeks, and haemodynamic improvements were already seen within minutes of stent deployment. CONCLUSIONS: Percutaneous treatment is a valuable alternative to surgery as it is able to restore haemodynamic parameters and resolve the clinical picture, ensuring longer functionality to arteriovenous fistulae and an improved quality of life.

A therapeutic alternative in the treatment of epididymal cysts: percutaneous sclerotherapy.

PURPOSE: Epididymal cysts are benign structures commonly seen during urological or ultrasound testicular examinations. They are treated only if symptomatic. Surgery is the standard treatment, although it carries a high risk of complications. We report our experience with sclerotherapy of epididymal cysts with sonographic assistance, and present an analysis of costs. MATERIALS AND METHODS: Between January 1999 and December 2000 we examined 48 epididymal cysts in 45 patients during ultrasound examinations. Except one, all of the patients were symptomatic. We decided to treat 25 symptomatic cysts that were more than 5 cm. in diameter. All of the patients refused surgery as they knew of the existence of the percutaneous method. The procedures were performed on a out-patient basis with ultrasound assistance and using 3% Polidocanol for sclerosis. Follow-up was at 3/6 and 12 months after treatment. If we found persistence of symptoms and/or a cyst was more than 5 cm of diameter, a second session was proposed. RESULTS: Twenty-five epididymal cysts were treated, with a technical success of 100%. Mean fluid evacuation was 36 ml; mean sclerosing agent injected was 4.5 ml. There were no complications. After 3/6 months 17/25 patients were free of symptoms (68%) and the cysts had disappeared in 15 of them (60%). After the repeat procedure, performed on only 4 patients, the number of symptom-free patients was 21/25 (84%). DISCUSSION: Epididymal cysts are often solitary cystic fluid collections that are occasionally reported during physical or ultrasound urological clinical examinations. They present as painless testicular enlargements on palpation and are echo-free at ultrasound examination. Percutaneous sclerotherapy has gained wide acceptance in the therapeutic handling of other pathologies and it appears as an ideal solution for this benign clinical condition of the superficial structures. Polidocanol, widely used on varicose vein therapies for its local anaesthetic properties, is the ideal sclerosing agent for superficial and delicate structures, such as epididymal cysts. The results of the present study have shown that symptomatic cysts may be cured in 84% of cases without complications and with low costs. CONCLUSIONS: Percutaneous sclerotherapy is a valid therapeutic alternative to surgery in the management of epididymal cysts: it is safe, effective, free of complications, less costly and shows good results in the follow-up.