Vascular dialysis access created in a paretic arm of a patient with a history of cerebral stroke: A case report.

A patent vascular access is of crucial importance for patients on dialysis. There is no literature describing the success rate and complications of creating dialysis fistulae in a paretic arm. In addition, the risk for non-maturation of dialysis fistula is thought to be high due to the inactivity, muscle atrophy, vascular changes, and higher risk of thrombosis in paretic limbs. Here we describe a case of a successful creation and maturation of a native dialysis fistula.

Long-term results of cryopreserved allografts in aortoiliac graft infections.

OBJECTIVE: Different graft materials have been proposed for in situ reconstruction in the setting of vascular graft infection (VGI). We analyzed the long-term outcomes after in situ aortoiliac reconstruction with cryopreserved allografts. METHODS: We performed a retrospective analysis of patients who had undergone in situ aortoiliac reconstruction with cryopreserved arterial allografts for VGI from 2000 to 2015. The end points were the perioperative and long-term mortality and graft-related complications, including stenosis, occlusion, pseudoaneurysm, and reinfection. RESULTS: A total of 33 patients (91% male) with a median age of 67 years (range, 53-83 years) had undergone in situ aortoiliac reconstruction with cryopreserved allografts. The 30-day mortality was 6% (n = 2); both deaths were related to the allograft (one early allograft-enteric fistula and one graft rupture). Another two patients had experienced early (≤30 days) graft-related events (one allograft-enteric fistula and one graft limb occlusion), for an early graft-related complication rate of 12% (n = 4). Of the 31 discharged patients, 13 (42%) had died after a median of 47 months (range, 2-97 months). The median follow-up for the 18 remaining patients was 96 months (range, 10-146 months). The estimated survival at 1, 3, and 5 years was 88%, 81%, and 66%, respectively. Nine patients (29%) had experienced at least one of the following graft-related events during follow-up, including graft stenosis requiring intervention in five (16%), graft occlusion in four (13%), pseudoaneurysm in three (10%), and reinfection in two patients (6%). The estimated freedom from any first graft-related event at 1, 3, and 5 years was 78%, 71%, and 62%, respectively. The estimated primary patency and primary assisted patency at 1 and 3 years was 87% and 79%, and 90% and 83%, respectively. CONCLUSIONS: In situ aortoiliac reconstruction with cryopreserved allografts to treat VGI was associated with relevant perioperative graft-related complications. Although the reinfection rate was acceptable, other graft-related complications were frequent in the long term, in particular, graft occlusion and stenosis.

A novel retroauricular fixed port for hemodialysis: surgical procedure and preliminary results of the clinical investigation.

BACKGROUND: Inspired by bone conduction implants, which have a low infection rate, a bone-anchored port (BAP) system for hemodialysis was designed. OBJECTIVES: To demonstrate the surgical procedure for the BAP and to present preliminary results of the clinical investigation. MATERIALS AND METHODS: Patients with end-stage renal disease and contraindications for an arteriovenous forearm fistula were recruited for BAP implantation. A workflow specifically developed for implantation was followed. Postoperative evolution, the dialysis procedure, the functionality of the implant, and signs of infection were monitored. RESULTS: So far, five patients have been implanted with the BAP system. Hemodialysis with the BAP was unproblematic in all five patients, on average starting from the 9th day after implantation (range 2 to 15 days). Up to now, 1789 cumulative patient days (average 355 days, range 154 to 448 days) have been recorded. One patient died 14 months after implantation, from a cardiac arrest unrelated to the system. Dialysis was painless, and no catheter-related infections have occurred. CONCLUSION: BAP implantation can be safely performed but requires an interdisciplinary team. No infections related to the device have occurred. SIGNIFICANCE: The presented system is a promising addition to the choices of vascular accesses for hemodialysis patients.

Influences on the implementation of Mini-CEX and DOPS for postgraduate medical trainees' learning: A grounded theory study.

Introduction: In order for Mini-Clinical Evaluation Exercise (Mini-CEX) and Direct Observation of Procedural Skills (DOPS) to actually have a positive effect on trainees' learning, the way in which the tools are implemented is of key importance. However, there are many factors influencing their implementation. In this study, we aim to develop a comprehensive model of such factors. Methods: Using a constructivist grounded theory approach, we performed eight focus groups. Participants were postgraduate trainees and supervisors from three different specialties; all were experienced with Mini-CEX and/or DOPS. Data were analyzed for recurring themes, underlying concepts and their interactions using constant comparison. Results: We developed a model demonstrating how the implementation of Mini-CEX and DOPS for trainees' learning is influenced by 13 factors relating to four categories: organizational culture (e.g. value of teaching and feedback), work structure (e.g. time for Mini-CEX and DOPS, faculty development), instruments (e.g. content of assessment), and users (e.g. relationship between trainees and supervisors), and their interaction. Conclusions: We developed a complex model of influencing factors relating to four categories. Consideration of this model might support successful implementation and trainees' learning with Mini-CEX and DOPS.

Reality check: primary vascular access creation today.

INTRODUCTION: In Switzerland, the outcome of vascular access creation in the 4500 current dialysis patients is unknown, mainly because there is no prospective registry for patients undergoing vascular access surgery for renal replacement therapy. The aim of the study was to assess the quality of vascular access creation and to compare it with the current literature and guidelines, in order to define strategies to improve clinical outcome. METHODS: Retrospective single-centre study in a tertiary referral centre. All consecutive patients over 18 years of age undergoing primary vascular access creation between January 2013 and December 2014 were included. Follow-up data for at least 12 months were collected. RESULTS: During the study period, 365 patients had a surgical intervention for renal replacement therapy. A primary vascular access was created in 74 patients (20%), who were further analysed in our study: 63 (85%) had an arteriovenous fistula (AVF) and 11 (15%) an arteriovenous graft (AVG). The intervention-free survival (primary patency rate) of the primary vascular access at 1 year was 46% (95% confidence interval [CI] 33-58%) for AVF and 30% (95% CI 7-58%) for AVG, with a secondary patency rate at 1 year of 75% (95% CI 63-84%) for AVF and 50% (95% CI 18-75%) for AVG. Twenty-seven patients (36%) with primary vascular access underwent central venous catheter (CVC) placement (tunnelled or non-tunnelled) before the access creation. Thirty-seven (50%) patients had their first dialysis through a CVC. Thirty-one patients (42%) never received a CVC. CONCLUSIONS: The primary patency of vascular access was unexpectedly low, and the number of CVC requests unexpectedly high. In light of this, we consider it essential that centres creating vascular access should register their activities and compare their outcomes with current guidelines to check and improve clinical management. To facilitate this, there is an initiative starting in 2018 encouraging all Swiss vascular surgeons to provide data on vascular access interventions, including 1-year follow-up, in the national online registry "SwissVasc 2.0".

Arteriovenous access ischemic steal (AVAIS) in haemodialysis: a consensus from the Charing Cross Vascular Access Masterclass 2016.

Arteriovenous access ischaemic steal (AVAIS) is a serious and not infrequent complication of vascular access. Pathophysiology is key to diagnosis, investigation and management. Ischaemia distal to an AV access is due to multiple factors. Clinical steal is not simply blood diversion but pressure changes within the adapted vasculature with distal hypoperfusion and resultant poor perfusion pressures in the distal extremity. Reversal of flow within the artery distal to the AV access may be seen but this is not associated with ischaemia in most cases.Terminology is varied and it is suggested that arteriovenous access ischemic steal (AVAIS) is the preferred term. In all cases AVAIS should be carefully classified on clinical symptoms as these determine management options and allow standardisation for studies.Diabetes and peripheral arterial occlusive disease are risk factors but a 'high risk patient' profile is not clear and definitive vascular access should not be automatically avoided in these patient groups.Multiple treatment modalities have been described and their use should be directed by appropriate assessment, investigation and treatment of the underlying pathophysiology. Comparison of treatment options is difficult as published studies are heavily biased. Whilst no single technique is suitable for all cases of AVAIS there are some that suit particular scenarios and mild AVAIS may benefit from observation whilst more severe steal mandates surgical intervention.

Novel Bone-Anchored Vascular Access on the Mastoid for Hemodialysis: Concept and Preclinical Trials.

GOAL: We present the development of a bone-anchored port for the painless long-term hemodialytic treatment of patients with renal failure. This port is implanted behind the ear. METHODS: The port was developed based on knowledge obtained from long-term experience with implantable hearing devices, which are firmly anchored to the bone behind the ear. This concept of bone anchoring was adapted to the requirements for a vascular access during hemodialysis. The investigational device is comprised of a base plate that is firmly fixed with bone screws to the bone behind the ear (temporal bone). A catheter leads from the base plate valve block through the internal jugular vein and into the right atrium. The valves are opened using a special disposable adapter, without any need to puncture the blood vessels. Between hemodialysis sessions, the port is protected with a disposable cover. RESULTS: Flow rate, leak tightness, and purification were tested on mockups. Preoperative planning and the surgical procedure were verified in 15 anatomical human whole head specimens. CONCLUSION: Preclinical evaluations demonstrated the technical feasibility and safety of the investigational device. SIGNIFICANCE: Approximately 1.5 million people are treated with hemodialysis worldwide, and 25% of the overall cost of dialysis therapy results from vascular access problems. New approaches toward enhancing vascular access could potentially reduce the costs and complications of hemodialytic therapy.

[A new bone anchored hemodialysis access]. / Neuartiger knochenverankerter Hämodialysezugang.

When classic arteriovenous fistulas or grafts fail, dialysis patients have a vital requirement for a catheter to ensure vascular access. Permanent central venous catheters penetrate the cervical and thoracic soft tissues and the skin without rigid fixation. The infection rate for such devices is high, often requiring explantation. Bone anchored hearing aids are an established treatment in patients with conductive hearing loss. The implant is firmly fixed on the temporal bone and the abutment permanently penetrates the skin. Severe infections requiring explantation are very rare. We suppose that one of the main reasons for the low complication rate is the firm fixation of the implant to the temporal bone, which minimizes the movement of the skin relative to the underlying bone. Based on the experience with implantable hearing devices we developed a percutaneous bone anchored port fixed to the skull in the region of the temporal bone. Such a bone anchored port could be a beneficial alternative to conventional central venous catheters for patients undergoing hemodialysis. In the course of the development process we investigated the individual anatomy to locate the correct implantation site with sufficient bone thickness; we studied screw stability in bone; we developed the titanium implant that houses the port system as well as the surgical tools and procedure for save implantation; we tested flow rate, leak tightness and purification on mockups; we defined the Seldinger-insertion of the catheter into the internal jugular vein via a small neck incision. Our results show the technical feasibility of a temporal bone anchored port and form the basis of a now-approved clinical pilot study.

Key points for patient safety in dialysis access.

For more than 15 years, patient safety has been an issue in different domains of medicine. There is evidence for this subject and also a great need for information. First, we should be familiar with the basic terminology such as the relationship between adverse events and errors, and understand the variations of error. In patient management, besides skills and knowledge (evidence-based medicine), the ability (competence) of healthcare professionals to act and react in unexpected situations is key to prevent and treat adverse events. Not only healthcare professionals should be involved in the process but also healthy people in a way that they understand and patients in a way that they are actively involved. This paper will show how a more general view of patient safety can and should be implemented in the daily work of caregivers dealing with dialysis access in different aspects. A key factor to advance in this subject is to be open-minded and sensualized for this topic. The reader should get an idea of how an institution can create a culture of safety.

Simulation in vascular access surgery training.

Rapidly growing technical developments and working time constraints call for changes in trainee formation. In reality, trainees spend fewer hours in the hospital and face more difficulties in acquiring the required qualifications in order to work independently as a specialist. Simulation-based training is a potential solution. It offers the possibility to learn basic technical skills, repeatedly perform key steps in procedures and simulate challenging scenarios in team training. Patients are not at risk and learning curves can be shortened. Advanced learners are able to train rare complications. Senior faculty member's presence is key to assess and debrief effective simulation training. In the field of vascular access surgery, simulation models are available for open as well as endovascular procedures. In this narrative review, we describe the theory of simulation, present simulation models in vascular (access) surgery, discuss the possible benefits for patient safety and the difficulties of implementing simulation in training.

Simulation in vascular access surgery.

In the last years, simulation training has become widespread in different areas of medicine due to social expectations, political accountability and professional regulation. Different types of simulators allow to improve knowledge, skills, communication and team behavior. Simulation sessions have been proven to shorten the learning curve and allow education in a safe environment. Patients on dialysis are an expanding group. They often suffer from several comorbidities and need complex surgical procedures with regard to their dialysis access. Therefore, education in evidence-based algorithms is as important as teaching of practical skills. In this chapter, we are presenting an overview of available dialysis access training modalities. We are convinced that simulation will become more important in the near future and has a substantial impact on strategies to improve aspects of patient safety.

Team training to establish a safety culture in dialysis access surgery.

Operating room (OR) team safety training and learning in the field of dialysis access is well suited for the use of simulators, simulated case learning and root cause analysis of adverse outcomes. The objectives of OR team training are to improve communication and leadership skills, to use checklists and to prevent errors. Other objectives are to promote a change in the attitudes towards vascular access from learning through mistakes in a nonpunitive environment, to positively impact the employee performance and to increase staff retention by making the workplace safer, more efficient and user friendly.

Careful and safe vascular access creation.

Morbidity and mortality are significant in hemodialysis patients, and every vascular access (VA) is prone to complications - some more, some less. The risk of complications rises from arteriovenous fistulae to arteriovenous grafts and peaks in nontunneled central lines. Strategies to achieve complete evaluation of the patient and precise planning mark the start of successful VA creation. Furthermore, preoperative considerations include safety checklists, team time-out procedures, and antibiotic prophylaxis. Intraoperative technical features and postoperative aspects of documentation and surveillance schemes complete careful and safe VA creation.

Patient safety in dialysis access: education and research.

Today, a growing activity to improve patient safety in all domains of medicine is reality. This chapter deals with patient safety research in general, but is also about strategies to implement this evidence in the daily clinical work treating patients on dialysis. Good clinical research practice has been well established for some years. In the domain of dialysis access, further basic, clinical, epidemiological and health service research will be important to further improve patient safety as a whole.

Self-made pericardial tube graft: a new surgical concept for treatment of graft infections after thoracic and abdominal aortic procedures.

BACKGROUND: The aim of this study was to evaluate a new surgical concept for the treatment of graft infections after operation or endovascular treatment of thoracic, thoracoabdominal, and abdominal aortic diseases. METHODS: Between 2004 and 2011, 15 patients (mean age 72 ± 10 years, 87% men) with prosthetic graft or endovascular graft infection were treated with complete removal of the infected prosthetic material, extensive debridement of the surrounding tissues, and orthotopic vascular reconstruction with self-made xenopericardial tube grafts constructed from a patch. Perioperative and long-term outcomes were evaluated. RESULTS: Perioperative mortality was 27% (n = 4). All deaths were due to multiorgan failure resulting from uncontrolled septicemia from the local infectious process. Mean observational follow-up was 24 months (5 to 83 months). Control computed tomographic scans showed normal findings at the operative site in all patients. Antibiotic treatment was continued for a mean of 6 months. Freedom from reinfection was 100%. Freedom from reoperation was also 100%. CONCLUSIONS: Treatment of graft infections after operation or endovascular treatment of thoracic, thoracoabdominal, and abdominal aortic diseases by complete removal of the infected prosthetic material and extensive debridement as well as orthotopic vascular reconstruction using self-made xenopericardial tube grafts as neoaortic segments provides excellent results with regard to durability and freedom from reinfection and reoperation. This new concept is an additional alternative to cryopreserved homografts that extends the armamentarium for treating patients with these highly complex conditions.

[Surgical options in the treatment of chronic venous ulcers]. / Chirurgische Therapieoptionen beim chronisch venösen Ulcus cruris.

Surgery offers several options in prevention of chronic venous insufficiency and its sequelae. Both the operation on veins with valve dysfunction to reduce reflux and the elimination of obstruction in thrombosed veins aim for the reduction of venous hypertension. Elevated venous pressure, impairment of cutaneous capillaries and a chronic inflammatory process result in sclerosis of skin and subcutaneous tissue and might proceed to the fascia resulting in a chronic compartment syndrome. Non- healing chronic venous ulcers under conservative therapy for more than three months may be treated by vein-surgery, local wound care therapy like shaving and negative pressure treatment and if necessary by lowering of elevated intracompartimental pressure by fasciotomy or even fasciectomy.