Objective Arterio-arterial synthetic loop graft (AASLG), also known as arterio-arterial prosthetic loop, is an alternative hemodialysis (HD) option in a specific group of patients where other HD conventional arteriovenous (AV) access and tunneled central venous catheters are not technically feasible (type 3 end-stage vascular access). The aim of this study is to report our experience with AASLG in this cohort of fragile patients and contrast the outcomes and risks with other artificial dialysis access solutions. Patients and methods A prospective study was conducted on patients who underwent axillary or femoral AASLG using polytetrafluoroethylene graft after exhaustion of all conventional AV access options in these patients with end-stage renal disease undergoing HD. The patients were prospectively observed for graft primary and secondary patency and graft-related complications. Outcomes were reported according to the recommended standards for reporting AV HD accesses. Results Between January 2018 and July 2020, 16 patients (median age, 58.76 years; range, 52-68 years) underwent 19 AASLG access placements. Procedures were done under general anesthesia in 18 occasions, whereas one was done under local anesthesia. A total of 15 patients had 18 axillary AASLG, whereas one had femoral AASLG. Central vein occlusion was present in all patients. Patients were followed up for 3-24 months (mean, 16 months). The technical success of the procedure was 100% despite two cases of postoperative hematoma development, and there were no 30-day perioperative mortalities. Primary patency at 6 months was 78.9%, and the achieved secondary patency rate was 89.5%. At 12 months, the primary and secondary patency rates were 42.2 and 68.4%, respectively. Two procedures were complicated with early postoperative bleeding that required surgical intervention, but no blood transfusion was required. Three procedures were complicated with pseudoaneurysm formation at puncture sites that were repaired surgically by interposition grafts. During follow-up, five AASLGs were thrombosed, three of which had a successful graft thrombectomy and one had a contralateral axillary AASLG done. Two patients developed graft infection, and the graft was excised and replaced by a contralateral axillary AASLG. Conclusion Our early experience with AASLG showed that this procedure has a high early success rate with a considerable risk of complications. This procedure could be offered to patients with end-stage renal disease when other AV access options are not feasible. For long-term outcome assessment, further follow-up is needed.

Arterio-arterial synthetic loop graft as a reliable alternative for type 3 end-stage vascular access

The number of patients with end-stage renal disease (ESRD) requiring hemodialysis is constantly rising worldwide. Vascular hemodialysis access is considered the lifeline for patients with end-stage renal disease, and arteriovenous fistula (AVF) has been the golden standard access for hemodialysis. In Europe, over 25% of all hospital admissions for ESRD are for the construction or maintenance of a patent vascular hemodialysis access.

Axillary artery loop interposition graft (AALG) as unusual access for hemodialysis

Background Vascular access has always been the Achilles repair of hemodialysis. Developments in health care have carried forward patients requiring management who have no veins appropriate for formation of arteriovenous fistula or insert of central venous catheters. This study reports arterioarterial prosthetic loop (AAPL) graft as an effective access for hemodialysis patients with venous occlusion. Objective To assess AAPL graft regarding primary and secondary patency rates and incidence of complications. Patients and methods This study was performed on 20 patients with the end-stage renal diseases. The age of the patients ranged between 47 and 72 years, with a mean age of 57.9 years. Results The primary patency rates were 100, 100, 95, 90, and 80%, respectively, and the secondary patency rates were 100, 100, 100, 95.0, and 95.0% at 1, 3, 6, 9, and 12 months, respectively. Conclusion AAPL can offer an efficient access for hemodialysis in such special group of patients with unsuitable arteriovenous access or having cardiac insufficiency.

Arterioarterial prosthetic loop: a new approach for hemodialysis access as an unusual vascular access

Objective: Diagnosis of lower limb lymphedema depends on clinical signs in most health organization. One of the recent investigational tools for lymphedema diagnosis is near infrared fluoroscopy lymphangiogram. The aim of our study was to evaluate the accuracy of clinical signs in lymphedema diagnosis in comparison to fluoroscopic lymphangiography. Also, to know the value of immediate and delayed lymphangiography in clinically diagnosed lymphedema patients. Patients and methods: Prospective Cohort study of 44 patients with 73 lower limbs swelling. All patients assessed by history, clinical examination. Body mass index has been measured. Immediate and delayed findings (After 24 hours) of near infrared lymphography of subcutaneous injection of Indocyanine Green has been documented. Results: The sensitivity and specificity of clinical signs in predicting fluoroscopic -confirmed lymphedema were 77% and 58% respectively. The overall accuracy was 69 %. Forty six out of 73 limb swellings showed the classical clinical signs of lymphedema. Twenty five of them showed normal lymphatic pattern by immediate fluoroscopy. One half of this group showed changes of images of fluorescent lymphangiography after 24 hours of injection into dermal backflow pattern. The sensitivity of clinical signs in predicting lymphedema was 77%, specificity was 58%. The overall accuracy was 69%. Conclusions: These results would suggest clinical signs of lymphedema unreliable in making a correct diagnosis of lymphedema in about one third of pateints. Also, we cannot rely on immediate lymphangiographic fluoroscopy to exclude lymphedema.

Reliability of Clinical Signs to Diagnose Lower Limb Lymphedema in Comparison to Immediate and Delayed Near Infrared Fluoroscopic Lymphangiography

Fluorescence Mapping of Greater Omentum Lymphatic Flow and Changing the Concept of Lymphedema Surgical Treatment: A Novel Experimental Study

INTRODUCTION
Chronic kidney disease (CKD) affects 13% of the global population and requires renal replacement therapy due to ESRD. Hemodialysis (HD) is the most common dialysis modality for ESRD patients, but establishing vascular access is challenging due to high morbidity and mortality rates. Arteriovenous fistulas (AVFs) are the gold standard for vascular access, but many fail due to anastomotic hemodynamics, vein diameter, and anastomatic suture technique. A prospective study was conducted to evaluate the impact of two continuous suturing techniques, the anchor technique and the parachute technique, on AVFs' initial outcomes.


METHODS
This randomized, controlled study involved adult patients who presented for AVF creation at our center. We divided the patients into two groups: anchors and parachutes. Four skilled vascular access surgeons performed the procedures. The primary goal was functional maturation of the AVF, defined as an AVF fistula ready to be cannulated with a cannulating vein length of at least 10 cm, a diameter of more than 6 mm, a depth of less than 6 mm, and a flow rate of 600 mL/min. Secondary goals included patency and complications such as bleeding, infection, steal syndrome, and aneurysmal dilatation at the anastomosis site. AVFs were evaluated immediately after surgery and during follow-up visits at the outpatient clinic. A duplex scan was performed to measure flow at various intervals. All patients provided appropriate written consent.


RESULT
The study involved 186 patients, with 86 excluded. 100 were randomized, with 5 cases losing follow-up and 3 deaths within 12 months. The follow-up continued until January 2024, with a mean of 8.6 months. The Parachute technique shows higher technical success (p value = 0.046) and primary patency at 30 days (p value = 0.014) compared to Anchor, but there is no statistical significance between both groups regarding functional maturation at 6 weeks (p value = 0.352). The parachute technique has a higher hematoma rate than the anchor technique (p value = 0.025), while other complications like intra-operative bleeding, postoperative bleeding, pseudoaneurysm formation, thrombosis, steal syndrome, and seroma formation show no significant differences. Nine patients, five of whom were diabetic and underwent conservative management, exhibited mild to moderate steal syndrome. This suggests an increased risk of steal syndrome among diabetic patients.


CONCLUSION
The parachute technique for AVF creation offers better technical success and short-term primary patency outcomes, while both parachute and anchor techniques are equally effective for long-term functional maturation and overall complication rates.

Anchor versus parachute suturing technique in arteriovenous fistula creation for hemodialysis.

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Arterioarterial prosthetic loop: a new approach for hemodialysis access as an unusual vascular access

Reliability of Clinical Signs to Diagnose Lower Limb Lymphedema in Comparison to Immediate and Delayed Near Infrared Fluoroscopic Lymphangiography

Fluorescence Mapping of Greater Omentum Lymphatic Flow and Changing the Concept of Lymphedema Surgical Treatment: A Novel Experimental Study

Anchor versus parachute suturing technique in arteriovenous fistula creation for hemodialysis.