Description

Publisher details

Wichtig Editore

Publications in this journal

• Use of bovine mesenteric vein in rescue vascular access surgery.

  Authors: Filippo Benedetto, Giuseppe Carella, Salvatore Lentini, David Barillà, Francesco Stilo, Giovanni De Caridi, Francesco Spinelli

  The journal of vascular access. 11(2):112-4.

  We describe a technique for rescue surgery of autologous arterovenous fistula (AVF), using bovine mesenteric vein (BMV), which may be used in patients with autologous AVF malfunction caused byWe describe a technique for rescue surgery of autologous arterovenous fistula (AVF), using bovine mesenteric vein (BMV), which may be used in patients with autologous AVF malfunction caused by steno-occlusion on the arterial side or by fibrosis of the first portion of the vein. To preserve the autologous AVF, we replaced the diseased portion of the artery, or the first centimeters of the vein, by a segment of BMV, with the aim of saving the patency and functionality of the access. We used this technique in 16 cases. All patients underwent hemodialysis treatment immediately after the procedure. Infection or aneurismal dilatation of the graft in implanted BMV was never observed.

• Frequency of central venous thrombosis symptoms and signs in patients who have history of catheter insertion via internal jugular and subclavian veins.

  Authors: Morteza Khavanin Zadeh, Mahdi Alemrajabi, Fatemeh Alemrajabi

  The journal of vascular access.

• Occluded arteriovenous graft puncturing for backup access.

  Authors: Akashi Togawa, Satoko Uyama, Seiko Takanohashi, Megumi Shimasaki, Takehiko Miyaji, Hiroyuki Endo

  The journal of vascular access.

• Endovascular salvage of a right brachial artery-right atrium hemodialysis graft using a covered endoprosthesis.

  Authors: Javier E Anaya-Ayala, Nyla Ismail, Michael J Reardon, Eric K Peden

  The journal of vascular access.

  Creation of a functional hemodialysis access in patients with exhausted peripheral access sites and concomitant central venous occlusive disease (CVOD) is a multifaceted challenge; often requiringCreation of a functional hemodialysis access in patients with exhausted peripheral access sites and concomitant central venous occlusive disease (CVOD) is a multifaceted challenge; often requiring complex, innovative solutions, not without their own complications. We present a 57-year-old hemodialysis patient with a history of hypercoagulable disorder and multiple failed arteriovenous accesses. Because of inadequate peripheral access sites and chronic occlusions in superior vena cava, brachiocephalic veins and inferior vena cava, in addition to multiple transhepatic catheter related issues; we decided to perform a right brachial artery to right atrium (RA) hemodialysis graft. The access was used without complications for 18 months at which point he had his first episode of thrombosis; open thrombectomy and percutaneous balloon angioplasty (PTA) at the atrial anastomosis were done with success. The following three months, he endured two more thrombectomies and PTAs. During the last intervention we performed an intravascular Ultrasound (IVUS) through the atrial anastomosis, which demonstrated stenosis; and the decision was made to extend the outflow anastomosis with a covered stent into the atrium. Therefore a 10 cm x 10 mm Viabahn stent-graft (W. L. Gore and Associates, Flagstaff, Ariz.) was deployed and post dilated with 8 mm balloon within the graft component. Repeat injection and Intravascular Ultrasound (IVUS) demonstrated significant improvement and free outflow. The brachial-RA hemodialysis graft could be use immediately and at 5 months has remained fully functional and no reinterventions have been necessary.

• The effect of peripherally inserted central catheter (PICC) valve technology on catheter occlusion rates - The 'ELeCTRiC' study.

  Authors: Andrew J Johnston, Carmel T Streater, Remy Noorani, Joanne L Crofts, Aldwin B Del Mundo, Richard A Parker

  The journal of vascular access.

  Purpose: Peripherally Inserted Central Catheters (PICCs) are increasingly being used to provide short to medium-term central venous access. The current study was designed to test the hypothesis thatPurpose: Peripherally Inserted Central Catheters (PICCs) are increasingly being used to provide short to medium-term central venous access. The current study was designed to test the hypothesis that PICC valve technology does not influence PICC occlusion rates. Methods: Intensive care unit (ICU) patients who required a PICC were randomized to one of three types of dual lumen PICC (open ended non-valved, Groshong valve, PASV valve). PICC occlusions were recorded and managed with a protocol that used urokinase. Results: A total of 102 patients were recruited to the study. The overall risk of occlusion per catheter was 35% (95% CI 26% to 44%). The overall rate of occlusion was 76 occlusions per 1000 catheter days (95% CI 61 to 95). Presence or type of valve did not significantly influence this rate (open-ended non-valved PICC 38% of catheters, 79 occlusions per 1000 catheter days; Groshong 38% of catheters, 60 occlusions per 1000 catheter days; PASV 27% of catheters, 99 occlusions per 1000 catheter days). The dose of urokinase required to treat PICC occlusions did not significantly differ between PICC types. Conclusions: Valved PICCs do not appear to influence PICC occlusion rates.

• Relationship between the outcomes of stent placement and the properties of arteriovenous graft outflow vein stenotic lesions.

  Authors: Yuya Yamamoto, Junichi Nakamura, Yuji Nakayama, Hiroko Hino, Hiroki Kobayashi, Toshihiro Sugiura

  The journal of vascular access.

  Purpose: The mechanisms of venous stenosis in vascular access include vascular constriction and neointimal hyperplasia. One purpose of this study was to examine the properties of stenotic lesions inPurpose: The mechanisms of venous stenosis in vascular access include vascular constriction and neointimal hyperplasia. One purpose of this study was to examine the properties of stenotic lesions in arteriovenous graft outflow veins and the association with the results of treatment using stent placement.Subjects and Methods. The study involved 46 patients who underwent stent placement to treat arteriovenous graft outflow vein stenosis. The properties of stenotic lesions before stent placement were observed by ultrasonography and were classified into three groups: vascular constriction types, neointimal proliferation types, and mixed types. Stent placement was performed when elastic recoil occurred or when restenosis occurred at the same site within three months. The primary patency results for each group were then compared. The primary endpoint included patency of the treatment area.Results. The primary patency rate of the treatment area at 6, 12, 18 and 24 months post-stent placement for the vascular constriction type was 100.0%, 92.3%, 84.6% and 75.2%, respectively. Those rates were 66.7%, 33.3%, 33.3% and 25.0% for the neointimal proliferation type, and 90.5%, 52.4%, 38.1% and 27.2% with the mixed type. The vascular constriction type displayed excellent primary patency rates after stent placement.Conclusions. It is possible to define the types of stenotic lesions for which stent therapy is effective through morphological diagnosis of those lesions using ultrasound tomography.

• Safety and efficacy of StarClose SE Vascular Closure System in high-risk liver interventional oncology patients.

  Authors: Ron C Gaba, Ahmad Parvinian, Estrellita M Trinos, Suzanne V Padayao, Rechel M Francisco, Felix Y Yap, M Grace Knuttinen, Charles A Owens, James T Bui

  The journal of vascular access.

  Purpose: To assess the safety and efficacy of the StarClose SE Vascular Closure System (Abbott Vascular, Abbott Park IL, USA) in high-risk thrombocytopenic and coagulopathic interventional oncologyPurpose: To assess the safety and efficacy of the StarClose SE Vascular Closure System (Abbott Vascular, Abbott Park IL, USA) in high-risk thrombocytopenic and coagulopathic interventional oncology (IO) patients.Methods: In this single institution retrospective study, 63 high-risk thrombocytopenic or coagulopathic IO patients (M:F=51:12, mean age 58 years, range 31-88 years) who underwent 83 common femoral arteriotomy closures using the StarClose device were identified among all IO patients (n=131) undergoing StarClose closure (n=177) between 2008-2011. High-risk thrombocytopenia and coagulopathy were defined as platelet count =100 103/mL and international normalized ratio (INR) =1.5. Procedures included chemoembolization (n=67), radioembolization (n=8), and hepatic arterial mapping with technetium-99m macroaggrated albumin administration (n=8) for treatment of hepatocellular carcinoma (n=79) or liver metastases (n=4). Measured outcomes included technical success of arterial closure and closure-related adverse events, graded according to the Society of Interventional Radiology classification. Results: In all cases, 5 French common femoral arterial access was used. Platelet count was =100 103/mL in 80/83 (96.4%) cases and INR was =1.5 in 35/83 (42.2%) cases. Mean pre-procedure platelet count was 71 (range 26-347) 103/mL and mean INR was 1.4 (range 1.0-2.1). The StarClose device effectively sealed the arteriotomy in 83/83 (100%) cases, 60/83 (72.3%) cases were first-time closures, and 20/83 (24.1%) cases were repeat closures. Small groin hematomas, graded as class A minor complications, developed in 3/83 (3.6%) cases. No other complications were encountered. Conclusions: The StarClose SE Vascular Closure System confers high technical success and safety in common femoral arteriotomy closure in high-risk IO patients.

• Video-assisted two-stage basilic vein transposition for creation of brachio-basilic arteriovenous fistulae.

  Authors: Attilio Ignazio Lo Monte, Giuseppe Damiano, Vincenzo Davide Palumbo, Gabriele Spinelli, Antonino Sammartano, Giuseppe Buscemi

  The journal of vascular access.

• Multi-Detector Computed Tomography Venography in the assessment of dysfunction of tunneled hemodialysis central vein catheters.

  Authors: Tianlei Cui, Zhenlin Li, Yingying Yang, Xiaoxi Zeng, Li Zhou, Lizhu Jin, Baihai Su, Ye Tao, Ping Fu

  The journal of vascular access.

  Purpose: To assess the value of Multi-Detector Computed Tomography Venography (MDCTV) in the assessment of tunneled hemodialysis central vein catheters (CVCs) dysfunction. Methods: Twenty-fivePurpose: To assess the value of Multi-Detector Computed Tomography Venography (MDCTV) in the assessment of tunneled hemodialysis central vein catheters (CVCs) dysfunction. Methods: Twenty-five patients who had tunneled CVC dysfunction without abnormality found by x-ray and ultrasound were enrolled. Anti-platelet agents, anticoagulants, and thrombolytic therapy with urokinase failed to resume normal catheter function. MDCTV was performed to observe the position of catheters and to detect central venous stenosis, thrombosis, and fibrin sheath formation. Correct intervention was given according to MDCTV results. Results: MDCTV revealed that the catheter was malpositioned in 10 cases; there were five cases of central venous stenosis, four cases of central venous thrombosis, one case of fibrin sheath formation, and the other five had no abnormalities found. Blood flow on hemodialysis had reached over 300 mL/min after correct intervention. Conclusions: MDCTV provided a new possible way to assess dysfunction of tunneled hemodialysis central venous catheters.

• What is happening in the world of vascular access? Research and innovations are flowing through.

  Authors: Eric S Chemla

  The journal of vascular access.

  Vascular access perfectly reproduces myointimal hyperplasia that can be found in coronary or peripheral arteries and has a major advantage that these other sites cannot match: it is quite superficialVascular access perfectly reproduces myointimal hyperplasia that can be found in coronary or peripheral arteries and has a major advantage that these other sites cannot match: it is quite superficial and not close to a major vital organ and also affects a population that will attend the hospital for dialysis on a very regular basis. It therefore appears obvious to try and develop a tool that will mitigate myointimal hyperplasia and that could later be tested on coronary or peripheral arteries. Over the past few years several trials have been organized and we are now at a stage where some results have become available.

• Outcomes of initial hemodialysis access surgery in an Asian population.

  Authors: Stephen E Thwaites, Peter A Robless

  The journal of vascular access.

  Purpose: Access-related morbidity contributes substantially to the costs of hemodialysis. The aim of this study was to examine the outcomes of initial hemodialysis access surgery at a single centerPurpose: Access-related morbidity contributes substantially to the costs of hemodialysis. The aim of this study was to examine the outcomes of initial hemodialysis access surgery at a single center in Singapore and to analyze factors which might influence survival of the surgically-created access. Methods: Patients undergoing their first hemodialysis access operations between January 2003 and December 2007 were retrospectively identified. Primary and assisted primary patency rates were determined by the Kaplan-Meier method. Data on age, sex, diabetic status, and prior tunneled central venous catheter (CVC) use were analyzed against the outcome of arteriovenous fistulas (AVF). Results: During the study period, 410 primary upper limb access operations were performed: 297 forearm AVF (72.4%), 91 upper arm AVF (22.2%), and 22 arteriovenous grafts (AVG; 5.4%). Men comprised 55.4%, 271 (66.1%) had diabetes, and 316 patients (77.1%) came to surgery with pre-existing CVC. Sixty-two percent of forearm AVF and 67% of arm AVF were used successfully. Age, sex, diabetes, and prior use of a CVC did not significantly affect the ability to use an AVF. Only in the female diabetic subgroup was an earlier loss of primary assisted patency of AVF recorded. Conclusions: In our Asian population, we have demonstrated AVF patency rates equivalent to those of international centers. We now face the challenge of achieving a higher rate of pre-emptive AVF placement with a subsequent reduction in CVC use.

• Intra-cavitary ECG is an effective method for correct positioning the tip of tunneled Groshong catheters.

  Authors: Giuseppe Capozzoli, Gino Accinelli, Loris Fabbro, Roberta Pedrazzoli, Franco Auricchio

  The journal of vascular access.

  Background: Intra-cavitary electrocardiography (ECG) is a well-known method for correct positioning of the tip of central venous catheters (CVC). A significant increase in the P wave, as registeredBackground: Intra-cavitary electrocardiography (ECG) is a well-known method for correct positioning of the tip of central venous catheters (CVC). A significant increase in the P wave, as registered by the intra-cavitary electrode, signals the entrance of the catheter into the right atrium. Methods: In this prospective observational study, 155 consecutive oncologic patients were enrolled for cannulation of the right or left internal jugular vein for insertion of a tunneled Groshong catheter. In 150 patients the tip was positioned by means of intracavitary ECG. Five patients with atrial fibrillation (N=4) or pacemaker in place (N=1) were excluded from the study. As the P-wave amplitude began to increase, the catheter was secured in that position and the insertion depth was registered. Results: Intra-cavitary ECG was always apt to detect the increase in the P wave. On the post-operative chest x-ray all Groshong catheters except two were in the correct position. Conclusions: The need for chest x-ray or fluoroscopy may be virtually eliminated by using the ECG technique.

• Percutaneous approach in the maintenance and salvage of dysfunctional autologous vascular access for dialysis.

  Authors: Paola De Rango, Basso Parente, Enrico Cieri, Paolo Bonanno, Luca Farchioni, Alessandra Manzone, Fabio Verzini

  The journal of vascular access.

  Purpose: Endovascular procedures have been increasingly used for salvage of failing vascular access with conflicting results. The aim of this study was to assess the mid-term patency and complicationPurpose: Endovascular procedures have been increasingly used for salvage of failing vascular access with conflicting results. The aim of this study was to assess the mid-term patency and complication rates of angioplasty procedures performed in a single center for treatment of stenosis compromising vascular accesses. Methods: A prospective database of vascular accesses performed in 2006-2010 was investigated. The endovascular approach was applied following a standardized protocol by a dedicated team. A total of 531 consecutive procedures were reviewed (326 men; mean age 70.94 years). Patency rates were estimated using the Kaplan-Meier method. Results: There were 199 procedures for failing access: 135 were surgical and 64 angioplasties performed for anastomosis (n=27), venous (n=45) or arterial (n=7) stenosis. Immediate technical success of endovascular procedures was 95.3%(61/64); complication rate was 6.3% (4/64). Primary patency rates were 55% at six months, 49% at 12 months, and 21% at 24 months. In the concurrent group of 135 open procedures, primary patency rates were 80% at six months and 67% at 12 months (P=.002); nevertheless, at 24 months, patency was as low as 49%. Cost estimates for angioplasty revealed additional fees ranging from 411.34 to 446.34 Euro with respect to open surgical procedures. Conclusions: Most dysfunctional vascular accesses can be successfully and safely treated by the endovascular route. In spite of poor mid-term durability, the angioplasty balloon might be considered as a bridge, effective, and repeatable solution with reasonable costs to prolong access survival avoiding additional surgery. The failure rate in the mid-term for dysfunctional vascular access may also be high after surgical reintervention.

• A proposed management algorithm for fistulae between hemodialysis access circuits and adjacent veins.

  Authors: Hannah R Margoles, Richard D Shlansky-Goldberg, Michael C Soulen, Scott O Trerotola

  The journal of vascular access.

  Purpose: Fistulae between an arteriovenous hemodialysis graft (AVG) or fistula (AVF) and an adjacent vein are an unusual complication of hemodialysis access. Such fistulae may theoretically causePurpose: Fistulae between an arteriovenous hemodialysis graft (AVG) or fistula (AVF) and an adjacent vein are an unusual complication of hemodialysis access. Such fistulae may theoretically cause steal syndrome, extremity edema, or access dysfunction. We sought to use our experience and existing literature to develop a management algorithm for this access complication. Methods: Twelve patients with AVG/AVF to adjacent vein fistulae found on fistulography were identified using a quality assurance database. Indications for fistulography, treatment rendered for both the fistulae and access stenosis, and outcome of treatment were determined. AVG/AVF to adjacent vein fistulae, when identified and considered to be significant, were treated with embolization. Results: Five out of twelve patients had successful embolization of their AVG/AVF to adjacent vein fistulae. Reasons for treatment included partial thrombosis of the access to the level of the fistula (n=1), contribution to bleeding during dialysis (n=1), and concern for competing flow causing thrombosis (n=5). No recurrence was identified. Seven patients did not undergo embolization either because of failure to recognize the fistula (n=3) or determination that treatment was not indicated (n=4). Two untreated fistulae were found occluded at follow-up. Additional access treatment included angioplasty (n=11), covered stent (n=1), and mechanical thrombectomy (n=3). Conclusions: The significance of AVG/AVF to adjacent vein fistulae remains unclear; some resolve spontaneously, possibly related to PTA of outflow stenosis. Embolotherapy is an effective treatment for such fistulae when determined to be significant.

• Allogenous vein graft as vascular access for hemodialysis - lost battle?

  Authors: Karel Nedved, Theodor Suchý, Jarmila Hálová, Mojmír Malický, Petr Gorun, Pavel Vitvar

  The journal of vascular access.

  Purpose: The purpose of this paper is to assess a long-term outcome of allogenous vein grafts (ALVG) as vascular access for hemodialysis. Materials and methods: For nearly eight years (between 9/2002Purpose: The purpose of this paper is to assess a long-term outcome of allogenous vein grafts (ALVG) as vascular access for hemodialysis. Materials and methods: For nearly eight years (between 9/2002 and 9/2011) a total of 78 patients with 112 ALVGs were involved in the study. The register included 46 women and 32 men, mean age 66.1 ± 11.2 years; range 20-88 years. The patient database was retrospectively reviewed and statistical processing was performed. Results: Almost all ALVGs were treated by PTA or surgically, very often repeatedly. The number of radiologic interventions was 316, the number of surgical procedures 31. Mean follow-up time was 795 days, range 28-3522 days. Thirty-five patients died of unrelated causes, nineteen with functional graft, fourteen patients were lost to follow-up. Forty ALVGs failed for various reasons, mostly because of occlusion. Only one patient underwent successful renal transplantation, no patient converted to peritoneal dialysis. Thirty-seven ALVGs remain correctly functioning. Primary patency rates at 6, 12, and 24 months were 81 ± 5%, 63 ± 5%, and 34 ± 2% respectively. Secondary patency rates at 6, 12, and 24 months were 96 ± 2%, 82 ± 4%, and 65 ± 5% respectively. Conclusions: Allogenous vein grafts, in spite of the high number of necessary radiologic and surgical interventions and reinterventions, show acceptable clinical usability and durability, comparable with other types of prosthetic grafts.

• Dealing with vanishing central veins.

  Authors: Alexis Lacout, Mostafa El Hajjam, Juliette Thariat, Pierre Yves Marcy

  The journal of vascular access.

• The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study.

  Authors: Mauro Pittiruti, Daniele Bertollo, Ermanno Briglia, Massimo Buononato, Giuseppe Capozzoli, Luigi De Simone, Antonio La Greca, Cecilia Pelagatti, Piersandro Sette

  The journal of vascular access.

  Purpose: The aim of this multicenter study was to assess the feasibility, safety, and accuracy of the intracavitary ECG method for real-time positioning of the tip of different types of centralPurpose: The aim of this multicenter study was to assess the feasibility, safety, and accuracy of the intracavitary ECG method for real-time positioning of the tip of different types of central venous catheters. Methods: A total of 1444 catheter insertions in adult patients were studied in eight Italian centers (539 ports, 245 PICCs, 325 tunneled CVCs, 335 non-tunneled CVCs). Patients with no visible P wave at the standard baseline ECG were excluded. Depending on the type of catheter and its purpose, the target was to position the tip either (a) at the cavo-atrial junction, or (b) in the lower third of the superior vena cava, or (c) in the upper part of the atrium. The final position was verified by a post-procedural chest x-ray. Results: The method was feasible in 99.3% of all cases. There were no complications potentially related to the method itself. At the final x-ray control, 83% of all tips were positioned exactly at the target; 12.4% were positioned within 1-2 cm from the target, but still in a correct central position; only 3.8% were malpositioned. The mismatch between intra-procedural ECG method and post-procedural x-ray was significantly lower when the x-ray was taken in supine position.Conclusions: Our multicenter study confirms that the intracavitary ECG method for real time verification of tip position is accurate, safe, feasible in all adult patients and applicable to any type of short-term or long-term central venous access device.

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

  Authors: Luigi Tazza, Franco Galli, Salvatore Mandolfo, Giacomo Forneris, Michele Di Dio, Roberto Palumbo, Maurizio Gallieni, Giuseppe Bonforte, Antonio Carnabuci, Fosco Cavatorta, Mauro Aloisi, Luciano Carbonari

  The journal of vascular access.

  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 (whichIntroduction: 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.

• Vessel health and preservation (Part 1): A new evidence-based approach to vascular access selection and management.

  Authors: Nancy L Moureau, Nancy Trick, Thomas Nifong, Cathy Perry, Cheryl Kelley, Ruth Carrico, Michael Leavitt, Steven M Gordon, Jessica Wallace, Monte Harvill, Connie Biggar, Michael Doll, Loreli Papke, Lori Benton, Deborah A Phelan

  The journal of vascular access.

  Vascular access for the infusion of medications and solutions requires timely assessment, planning, insertion, and assessment. Traditional vascular access is reactive, painful, and ineffective, oftenVascular access for the infusion of medications and solutions requires timely assessment, planning, insertion, and assessment. Traditional vascular access is reactive, painful, and ineffective, often resulting in the exhaustion of peripheral veins prior to consideration of other access options. Evidence suggests clinical pathways improve outcomes by reducing variations and establishing processes to assess and coordinate care, minimizing fragmentation and cost. Implementation of a vascular access clinical pathway leads to the intentional selection of the best vascular access device for the patient specific to the individual diagnosis, treatment plan, current medical condition, and the patient's vessel health (1). The Vessel Health and Preservation (VHP) programme incorporates evidence-based practices focused on timely, intentional proactive device selection implemented within 24 hours of admission into any acute facility. VHP is an all-inclusive clinical pathway, guiding clinicians from device selection through patient discharge, including daily assessment. Initiation of the VHP programme within a facility provides a systematic pathway to improve vascular access selection and patient care, allowing for the reduction of variations and roadblocks in care while increasing positive patient outcomes and satisfaction. Patient safety and preservation of vessel health is the ultimate goal.

• Cerebral air embolism after central dialysis line removal: the role of the fibrin sheath as portal (mechanism) of air entry.

  Authors: Giuseppe Capozzoli, Claudia Schenk, Norberto Vezzali

  The journal of vascular access.

  We report a case of cerebral air embolism after central dialysis line removal and the role of the fibrin sheath as portal (mechanism) of air entry. This case has been documented with computedWe report a case of cerebral air embolism after central dialysis line removal and the role of the fibrin sheath as portal (mechanism) of air entry. This case has been documented with computed tomographic (CT) images of the partially air-filled sheath tract.

• Spontaneous fracture and migration of distal segment of a peripherally inserted central venous catheter to heart in a neonate.

  Authors: Vaneet Kumar Kalra, Prem Arora, Jorge Lua

  The journal of vascular access.

• The effect of new clinical pathways on the outcome of vascular access surgery.

  Authors: Jacob A Akoh, James Powys-Lybbe

  The journal of vascular access.

  Purpose: Prior to 2007, the waiting time for vascular access surgery at our center was approximately 107 days compared to a UK average of 45 days. Two new pathways were developed; the rapid andPurpose: Prior to 2007, the waiting time for vascular access surgery at our center was approximately 107 days compared to a UK average of 45 days. Two new pathways were developed; the rapid and super-rapid pathways incorporating an access liaison nurse who organized vessel mapping and referred patients for surgery. This audit was to determine whether the pathways were effective in reducing the waiting times and improving vascular accesses outcomes. Methods: All 210 patients with established renal failure undergoing 232 vascular access procedures between January 2008 and March 2011 were studied. Detailed patient information including type of procedure and cause of access failure were stored in an Excel spreadsheet and analyzed using SPSS for Windows. Results: One hundred and twenty patients had a brachiocephalic fistula, 61 a radiocephalic fistula, 39 an access using the basilic vein ± transposition, and 11 a transposition of the long saphenous vein and one a brachio-axillary graft. Overall median waiting time from referral to access surgery was 23 days. Patients were followed up for a median of 248 days after surgery. The overall primary failure rate was 9.1% and 25 of 27 accesses failed because of thrombosis. The overall cumulative survival probability of accesses at one year was 61.4% with a mean survival of 621.2 days (SEM = 34.8). Conclusion: The clinical pathways have improved VA service to patients with a drastic reduction in waiting times, elimination of synthetic access, and maintenance of satisfactory results.

• Common and uncommon complications of totally implantable central venous ports: A pictorial essay.

  Authors: Evangelos Perdikakis, Elias Kehagias, Dimitrios Tsetis

  The journal of vascular access.

  Purpose: The purpose of this study is to present the characteristic radiologic features of common and uncommon complications in totally implantable central venous ports. Material and Methods: ThePurpose: The purpose of this study is to present the characteristic radiologic features of common and uncommon complications in totally implantable central venous ports. Material and Methods: The authors reviewed 138 implantations of central venous ports in oncologic patients during an 18-month period and present the characteristic imaging features of the complications detected. Results: All chest ports were placed via the internal jugular vein using both fluoroscopic and ultrasound guidance. The technical success rate was 99.3% (137/138). All catheter or port-related complications were retrospectively assessed. Sixteen complications were detected during the follow-up period, and catheter removal was required in 10 patients. Conclusions: Image-guided central venous port catheter implantation is a very safe procedure with a low rate of complications. The typical imaging features of common and uncommon complications are very helpful in establishing the correct diagnosis and thus tailoring the appropriate therapy.

• Venous hypertension due to outflow stenosis in a Gracz arteriovenous fistula: correction with distal cephalic transposition.

  Authors: Efstratios I Georgakarakos, Theodoros T Kostas

  The journal of vascular access.

• Phlegmasia cerulea dolens of the arm.

  Authors: Bernhard Petritsch, Frank Wendel, Dietbert Hahn, Jan P Goltz

  The journal of vascular access.

Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.