Background and Aims Functioning vascular access is an essential element for life-saving hemodialysis therapy. Surgical creation of a radiocephalic arteriovenous fistula (AVF) is the gold standard of vascular access for hemodialysis. However an endovascular approach to arteriovenous fistula creation (endoAVF) has increasingly gained acceptance over the last years as an alternative to the conventional surgical method. It offers a minimally invasive method for the formation of arteriovenous shunts and allows the creation of fistulas with minimal vessel trauma. There are currently two technologies available for this purpose, the Ellipsys Vascular Access System (Medtronic, Avenu Medical, San Juan Capistrano, Calif) and the Wavelinq endoAVF System (BD Medical, Franklin Lakes, NJ). At our centre (Careggi University Hospital, Florence), we developed an integrated service, based on a multidisciplinary approach between Interventional Radiology and Interventional Nephrology for percutaneous arteriovenous fistulas utilizing both Ellipsys and Wavelinq. We describe our experience with a case series of 39 patients, showing feasibility and outcome of this treatment option. Method Between December 2020 and January 2023 we created an endoAVF in 39 patients. Patients were suitable for the procedure after a pre-therapeutic ultrasound vascular mapping showed adequate brachial, radial and ulnar vessels and no ipsilateral central venous stenosis. After procedure, we performed a regular clinical and ultrasound monitoring. Therefore, we collected data regarding patient characteristics, initial technical success rate, number of access lost and number of endoAVF meeting primary and secondary patency. Results Of the total of 39 patients treated with endoAVF, 29 (74.3%) were male, with a mean age of 60.1 ± 33.9 years. The Wavelinq procedure was performed in 32 patients (82.0%) and the Ellipsys procedure in 7 patients (17.9%). Initial technical success was achieved in 38 (97.4%) cases, while in 1 case we had a primary failure of the fistula (Figure 1). Among these 38 patients, 4 (10.5%) were lost to follow-up because of death from other causes (3 patients) and because of kidney transplantation (1 patient), while 2 other patients (5.2%) have not required hemodialysys yet. Of the remaining 32 patients, we had 2 fistulas lost because of complications and a cumulative functional patency of 93.7% (30 fistulas), with a primary patency rate of 76% (23 fistulas). Conclusion The endoAVF appears to be feasible and safe for the creation of arteriovenous fistula suitable for hemodialysis access. Our data show an high functional cumulative patency of the endoAVF and a good primary patency, reducing the necessity of further interventions. Furthermore, in the prevalent hemodialysis population, the minimally invasive endovascular arteriovenous fistula procedure should help improving long wait times for vascular access creation. Further studies with more patients and multicentric data are needed to assess long-term outcomes.
BACKGROUND AND AIMS A complex interplay lies between COVID-19 infection and kidney disease. Patients with COVID-19 are at an increased risk of acute kidney injury (AKI), while CKD patients represent a population at a high risk of mortality from COVID-19 [1]. For 3 years, our hospital has been running an intradyalitic vaccination project (HBV, Haemophylus, Pneumococcus, Influenza) for haemodialysis patients. No data regarding the anti-COVID-19 vaccination administered during the dialysis session are available yet. This is a safety study aimed at defining the feasibility of this vaccination protocol. METHOD A total of 186 haemodialysis patients from 3 centres were vaccinated with the Spikevax-Moderna vaccine (Fig. 1). According to Italian law, patients with a COVID-19 infection in the previous 12 months received only one dose. The administration was performed between 1 and 2 h after the start of the dialysis session. Data regarding mild adverse events were collected. In 117 patients, a titration of the anti-RBD S1 antibodies of the virus spike antigen was performed 1 month after the completion of the vaccination [2]. Therefore, a new titration was obtained after 3 months in 50 patients. RESULTS Of the 117 patients, 65 (55.5%) were male, with a mean age of 69.2 ± 13.1 years. Of these, 25 patients (21.3%) showed mild adverse events without compromising dialysis administration. No serious adverse events took place. Seroconversion was noticed in 111 patients (94.9%) after 1 month, with a mean anti-RBD S1 antibody titer of 751.1 ± 610.5 BAU/mL. When a new titration was performed after 3 months, the titer decreased to 203.1 ± 134.3 BAU/mL (t-test; P = 0.005). CONCLUSION Intradialytic vaccination is a procedure with an excellent safety profile that may be implemented in dialysis settings. Further studies should be permormed to confirm these results.
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