The Snuffbox Arteriovenous Fistula for Vascular Access

AbstractObjectives to determine the applicability, patency rates and factors influencing patency of snuffbox arteriovenous fistulae for haemodialysis access. Design retrospective non-randomised study. Materials and methods patency was determined by reference to an ongoing database and dialysis records of 645 vascular access procedures between 1985 and 1997, including 210 snuffbox fistulae in 201 patients. Results snuffbox fistulae comprised 189/376 (50%) primary procedures. Records of 208 snuffbox fistulae were available for patency analysis by the life-table method. Twenty-two (11%) thrombosed within 24 hours of operation. After six weeks 80% were used for dialysis. Cumulative patency was 65% at 1 year and 45% at 5 years. After thrombosis of snuffbox fistulae, ipsilateral wrist fistulae could be constructed in 45%. Fistula patency was significantly better in men than women (p<0.001) and for left- than right-sided fistulae (p<0.001). Diabetes, age >70 years, and the prior commencement of haemodialysis did not significantly affect fistula survival. Conclusions the snuffbox AV fistula gives a long segment of arterialised vein for needling and preserves proximal vessels. It is feasible in 50% of patients requiring primary access and has good long-term patency, especially in men. A more proximal fistula may be preferable in women with smaller vessels

Saphenofemoral arteriovenous fistula as hemodialysis access

<p>Abstract</p> <p>Background</p> <p>An upper limb arteriovenous (AV) fistula is the access of choice for haemodialysis (HD). There have been few reports of saphenofemoral AV fistulas (SFAVF) over the last 10-20 years because of previous suggestions of poor patencies and needling difficulties. Here, we describe our clinical experience with SFAVF.</p> <p>Methods</p> <p>SFAVFs were evaluated using the following variables: immediate results, early and late complications, intraoperative and postoperative complications (up to day 30), efficiency of the fistula after the onset of needling and complications associated to its use.</p> <p>Results</p> <p>Fifty-six SFAVF fistulas were created in 48 patients. Eight patients had two fistulas: 8 patent (16%), 10 transplanted (20%), 12 deaths (24%), 1 low flow (2%) and 20 thrombosis (39%) (first two months of preparation). One patient had severe hypotension during surgery, which caused thrombosis of the fistula, which was successfully thrombectomised, four thrombosed fistulae were successfully thrombectomised and revised on the first postoperative day. After 59 months of follow-up, primary patency was 44%.</p> <p>Conclusion</p> <p>SFAVF is an adequate alternative for patients without the possibility for other access in the upper limbs, allowing efficient dialysis with good long-term patency with a low complication rate.</p

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme