As demonstrated by the results of our study, after renal transplantation the possibility of spontaneous AVF closure caused by a thrombosis is not a rare event. The dilemma is whether to preserve a fistula that could be useful in case of restarting HD or to perform a systematic fistula closure because of cardiac output and cardiac failure risks. Concerning this question there is no consensus between different authors in the literature. In reviewing the literature and analyzing our data, we conclude that the definite indications for AVF closure in well functioning renal transplanted patients are heart failure, high flow fistula, VA complications and important aesthetic reasons. Routine AVF closure is not indicated until prospective and randomized studies can demonstrate the ability of this procedure to reduce the high incidence of cardiac morbidity and mortality that is present, even after renal transplantation.
Frequently patients are started on hemodialysis after the placement of a central venous catheter (temporary or tunneled) in the internal jugular vein (IJV). Currenty this procedure is facilitated by ultrasound probes that improve the rate of success of catheter placement in vessels and diminishes the possible complications, minimizing the gap between nephrologists with wide surgical expertise and those with limited surgical experience. Stenosis and thrombosis of the subclavia vein are well documented complications derived from the placement of the venous catheter. Internal jugular vein thrombosis is not seen very often due to scarce clinical evidence. In our paper we have been able to systematically document various extrinsic thrombotic complications outside the central venous catheter, by use of ultrasound (periluminar or related to the vessel).
The choice of vascular access in hemodialysis pediatric patients can be challenging, due to the small diameter of vessels. In the last 19 years, 38 arteriovenous fistulas (AVF) for hemodialysis have been created on 21 patients; 25 of them were radio-cephalic AVF. The evaluation of the vessels was, in the majority of cases, done by clinical criteria. A local anesthesia was used in all surgical procedures. The percentage of early AVF failure was 24%. Long-term AVF survival was 97%, 65% and 55% at respectively 1, 3 and 5 years. Our data indicate that even in pediatric patients the radio-cephalic fistula is the first choice surgical procedure.
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