Hemodialysis (HD) access failure is a frequent problem encountered by vascular surgeons. As treatment of end-stage renal disease improves and patients live longer on HD, eventual exhaustion of traditional upper extremity...Hemodialysis (HD) access failure is a frequent problem encountered by vascular surgeons. As treatment of end-stage renal disease improves and patients live longer on HD, eventual exhaustion of traditional upper extremity HD access is common. Efforts to preserve and maintain these accesses are essential. However, when they fail, alternative surgical access options should be pursued prior to destination-tunneled dialysis catheters. Hemodialysis Reliable Outflow grafts as well as various configurations of lower extremity arteriovenous fistulae and grafts can be utilized. For most alternative HD access options, there is a paucity of data for long-term patency, cost, and risk of infectious or ischemic complications compared to traditional options. However, smaller studies examining Hemodialysis Reliable Outflow grafts, femoral vein transposition, and lower extremity grafts show acceptable safety and efficacy. Depending on the cause of traditional access failure and patient-specific anatomic constraints, we recommend a systematic approach to alternative access creation, with destination-tunneled dialysis catheters reserved as a last resort. The most common cause of HD access failure is venous outflow obstruction. As such, we have structured this manuscript around a meta-analysis of retrospective studies describing nontraditional access options that can be utilized with escalating degrees of central venous stenosis or occlusion.
Hemodialysis (HD) access for patients with end-stage renal disease is a steadily increasing necessity, and maintaining patency of native or synthetic fistulas can be challenging. The main physiologic changes of an HD acc...Hemodialysis (HD) access for patients with end-stage renal disease is a steadily increasing necessity, and maintaining patency of native or synthetic fistulas can be challenging. The main physiologic changes of an HD access that cause it to fail are inflow or outflow vessel stenosis or access thrombosis. These are propagated by factors intrinsic to end-stage renal disease, altered hemodynamics from a fistula, and typically further exacerbated by associated comorbidities. Diagnosis of fistula dysfunction can be made with a combination of history, physical examination, HD dynamic measurements, laboratory findings, and invasive or noninvasive imaging. Stenoses can be managed with endovascular interventions, including angioplasty with or without stenting, or open operations. Thrombosis of HD access, which is most often a result of an underlying stenosis, can be managed similarly with either endovascular or surgical thrombectomy with adjunctive treatment. Our goal was to review the pathophysiology of the most common forms of fistula failure, diagnosis, and endovascular and surgical options for flow restoration.
Vascular access is an essential component of the Patient Life-Plan, Access Needs for patients with end-stage kidney disease requiring kidney replacement therapy with hemodialysis. Central venous catheter use is associate...Vascular access is an essential component of the Patient Life-Plan, Access Needs for patients with end-stage kidney disease requiring kidney replacement therapy with hemodialysis. Central venous catheter use is associated with high morbidity and mortality. As such, arteriovenous access (AVA) is the preferred modality for hemodialysis. Although AVA is preferred, maturation and functional patency after creation can be a challenge to achieve. A significant proportion of AVAs fail to mature, require reinterventions to achieve maturation, or cannot be successfully cannulated and used reliably for hemodialysis, despite physiologic maturation. Thus, most patients on hemodialysis require multiple AVA procedures throughout their lifetime. A thoughtful and deliberate strategy to create, maintain, survey, and troubleshoot AVA is required. In this review, autogenous AVA maturation, maintenance, and surveillance strategies to prolong the life of AVA for patients requiring hemodialysis are discussed.
The treatment of end-stage kidney disease (ESKD with peritoneal dialysis (PD) continues to increase. Timely initiation of PD is dependent on successful PD catheter placement, which can be performed using open or laparosc...The treatment of end-stage kidney disease (ESKD with peritoneal dialysis (PD) continues to increase. Timely initiation of PD is dependent on successful PD catheter placement, which can be performed using open or laparoscopic surgical or percutaneous techniques. Dialysis access surgeons who incorporate PD catheter insertion in their practice can uniquely offer comprehensive access services to their patients. This review discusses the various methods of PD catheter insertion, patient conditions that impact surgical decision-making, and the management of catheter-related complications.
The most recent National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines shifted emphasis to kidney replacement modality selection and vascular access planning and creation of the Endstage Kidney...The most recent National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines shifted emphasis to kidney replacement modality selection and vascular access planning and creation of the Endstage Kidney Disease Life-Plan, which promotes a patient-centered approach. The Life-Plan is intended to be created through discussions between the patient and their multidisciplinary care team to ultimately develop a lifelong kidney replacement therapy strategy. The focus of the Life-Plan is to engage the patient in a multidisciplinary patient-centered approach. The Life-Plan includes selection of the most suitable treatment modality (eg, hemodialysis, peritoneal dialysis, or transplantation), setting (home or center), and type of vascular access. Ultimately, this approach considers overall patient health, preferences, and anatomic factors. Patients choose between hemodialysis, which can be performed either in center or at home, and peritoneal dialysis. When considering vascular access, options consist of tunneled dialysis catheter, arteriovenous fistula, and arteriovenous graft. Each modality and vascular access type has benefits and disadvantages that should be weighed carefully with the patient and their supportive team to arrive at a decision that aligns as closely as possible with each individual patient's circumstances.
Preparing a dialysis patient for access placement is a process that should ideally begin well before the need for access use. Unfortunately, this is often not the case and patients are often seen well after dialysis has...Preparing a dialysis patient for access placement is a process that should ideally begin well before the need for access use. Unfortunately, this is often not the case and patients are often seen well after dialysis has been initiated with a catheter. The process should include a detail-oriented history and a thorough vascular oriented physical examination. A complete history and physical exam will help tailor access options in individual patients. The KDOQI guideline structures the selection and timing of dialysis access, ensuring each patient's medical circumstances and preferences are taken into account. The preparation of a dialysis patient should also include discussion with the patient in regard to their values and expectations before coming to a life-long plan for the patient. This holistic approach aims to achieve reliable and functioning access while preserving future options and improving patient outcomes. This following review will cover the elements of both as well as adjunctive imaging modalities and their indications to allow for successful access placement.
Tunneled dialysis catheter (TDC) placement plays an essential role in hemodialysis patients. These catheters are inserted in a significant number of patients prior to establishing permanent dialysis access. Insertion is...Tunneled dialysis catheter (TDC) placement plays an essential role in hemodialysis patients. These catheters are inserted in a significant number of patients prior to establishing permanent dialysis access. Insertion is often simple and straightforward, and the preference is to use the right internal jugular vein due to fewer chances of long-term complications. However, significant obstacles exist including upper body central venous occlusions making catheter insertion complicated. In this report, we describe the technique of TDC insertion in the upper body, known complications from long-term TDC insertion, upper body central venous occlusion as an obstacle for TDC placement as well as the solutions available to mitigate this problem. Additionally, we will review techniques to convert TDC into long-term hemodialysis access.
e-Health, defined as "the use of new information and communication technologies (ICT) to improve or support health and health care," has grown in popularity over recent years as a cost-efficient, rapidly adaptable tool t...e-Health, defined as "the use of new information and communication technologies (ICT) to improve or support health and health care," has grown in popularity over recent years as a cost-efficient, rapidly adaptable tool to deliver health care education to a wide audience. In the field of vascular disease, for which early detection and risk factor management may greatly influence patient outcomes, application of e-Health educational resources may provide innovative solutions to facilitate evidence-based and patient-centered care provision of care; to enable patients to take a more active role in the management of their long-term vascular health conditions; and to augment their preparation for, and recovery from, surgical procedures.
Virtual assistants, broadly defined as digital services designed to simulate human conversation and provide personalized responses based on user input, have the potential to improve health care by supporting clinicians a...Virtual assistants, broadly defined as digital services designed to simulate human conversation and provide personalized responses based on user input, have the potential to improve health care by supporting clinicians and patients in terms of diagnosing and managing disease, performing administrative tasks, and supporting medical research and education. These tasks are particularly helpful in vascular surgery, where the clinical and administrative burden is high due to the rising incidence of vascular disease, the medical complexity of the patients, and the potential for innovation and care advancement. The rapid development of artificial intelligence, machine learning, and natural language processing techniques have facilitated the training of large language models, such as GPT-4 (OpenAI), which can support the development of increasingly powerful virtual assistants. These tools may support holistic, multidisciplinary, and high-quality vascular care delivery throughout the pre-, intra-, and postoperative stages. Importantly, it is critical to consider the design, safety, and challenges related to virtual assistants, including data security, ethical, and equity concerns. By combining the perspectives of patients, clinicians, data scientists, and other stakeholders when developing, implementing, and monitoring virtual assistants, there is potential to harness the power of this technology to care for vascular surgery patients more effectively. In this comprehensive review article, we introduce the concept of virtual assistants, describe potential applications of virtual assistants in vascular surgery for clinicians and patients, highlight the benefits and drawbacks of large language models, such as GPT-4, and discuss considerations around the design, safety, and challenges associated with virtual assistants in vascular surgery.
e-Health technology holds great promise for improving the management of patients with vascular diseases and offers a unique opportunity to mitigate the environmental impact of vascular care, which remains an under-invest...e-Health technology holds great promise for improving the management of patients with vascular diseases and offers a unique opportunity to mitigate the environmental impact of vascular care, which remains an under-investigated field. The innovative potential of e-Health operates in a complex environment with finite resources. As the expansion of digital health will increase demand for devices, contributing to the environmental burden of electronics and energy use, the sustainability of e-Health technology is of crucial importance, especially in the context of increasing prevalence of cardiovascular diseases. This review discusses the environmental impact of care related to vascular surgery and e-Health innovation, the potential of e-Health technology to mitigate greenhouse gas emissions generated by the health care sector, and to provide leads to research promoting e-Heath technology sustainability. A multifaceted approach, including ethical design, validated eco-audits methodology and reporting standards, technological refinement, electronic and medical devices reuse and recycling, and effective policies is required to provide a sustainable and optimal level of care to vascular patients.
Three-dimensional (3D) printing has been used in medicine with applications in many different fields. 3D printing allows patient education, interventionalists training, preprocedural planning, and assists the interventio...Three-dimensional (3D) printing has been used in medicine with applications in many different fields. 3D printing allows patient education, interventionalists training, preprocedural planning, and assists the interventionalist to improve treatment outcomes. 3D printing represents a potential advancement by allowing the printing of flexible vascular models. In this article, the authors report a clinical case using 3D printing to perform a physician-modified fenestrated endograft. An overview of 3D printing in vascular and endovascular surgery is provided, focusing on its potential applications for training, education, preprocedural planning, and current clinical applications.
Extended reality has brought new opportunities for medical imaging visualization and analysis. It regroups various subfields, including virtual reality, augmented reality, and mixed reality. Various applications have bee...Extended reality has brought new opportunities for medical imaging visualization and analysis. It regroups various subfields, including virtual reality, augmented reality, and mixed reality. Various applications have been proposed for surgical practice, as well as education and training. The aim of this review was to summarize current applications of extended reality and augmented reality in vascular surgery, highlighting potential benefits, pitfalls, limitations, and perspectives on improvement.
Natural language processing is a subfield of artificial intelligence that aims to analyze human oral or written language. The development of large language models has brought innovative perspectives in medicine, includin...Natural language processing is a subfield of artificial intelligence that aims to analyze human oral or written language. The development of large language models has brought innovative perspectives in medicine, including the potential use of chatbots and virtual assistants. Nevertheless, the benefits and pitfalls of such technology need to be carefully evaluated before their use in health care. The aim of this narrative review was to provide an overview of potential applications of large language models and artificial intelligence chatbots in the field of vascular surgery, including clinical practice, research, and education. In light of the results, we discuss current limits and future directions.
Current planning of aortic and peripheral endovascular procedures is based largely on manual measurements performed from the 3-dimensional reconstruction of preoperative computed tomography scans. Assessment of device be...Current planning of aortic and peripheral endovascular procedures is based largely on manual measurements performed from the 3-dimensional reconstruction of preoperative computed tomography scans. Assessment of device behavior inside patient anatomy is often difficult, and available tools, such as 3-dimensional-printed models, have several limitations. Digital twin (DT) technology has been used successfully in automotive and aerospace industries and applied recently to endovascular aortic aneurysm repair. Artificial intelligence allows the treatment of large amounts of data, and its use in medicine is increasing rapidly. The aim of this review was to present the current status of DTs combined with artificial intelligence for planning endovascular procedures. Patient-specific DTs of the aorta are generated from preoperative computed tomography and integrate aorta mechanical properties using finite element analysis. The same methodology is used to generate 3-dimensional models of aortic stent-grafts and simulate their deployment. Post processing of DT models is then performed to generate multiple parameters related to stent-graft oversizing and apposition. Machine learning algorithms allow parameters to be computed into a synthetic index to predict Type 1A endoleak risk. Other planning and sizing applications include custom-made fenestrated and branched stent-grafts for complex aneurysms. DT technology is also being investigated for planning peripheral endovascular procedures, such as carotid artery stenting. DT provides detailed information on endovascular device behavior. Analysis of DT-derived parameters with machine learning algorithms may improve accuracy in predicting complications, such as Type 1A endoleaks.
Computational surgery (CS) is an interdisciplinary field that uses mathematical models and algorithms to focus specifically on operative planning, simulation, and outcomes analysis to improve surgical care provision. As...Computational surgery (CS) is an interdisciplinary field that uses mathematical models and algorithms to focus specifically on operative planning, simulation, and outcomes analysis to improve surgical care provision. As the digital revolution transforms the surgical work environment through broader adoption of artificial intelligence and machine learning, close collaboration between surgeons and computational scientists is not only unavoidable, but will become essential. In this review, the authors summarize the main advances, as well as ongoing challenges and prospects, that surround the implementation of CS techniques in vascular surgery, with a particular focus on the care of patients affected by abdominal aortic aneurysms (AAAs). Several key areas of AAA care delivery, including patient-specific modelling, virtual surgery simulation, intraoperative imaging-guided surgery, and predictive analytics, as well as biomechanical analysis and machine learning, will be discussed. The overarching goals of these CS applications is to improve the precision and accuracy of AAA repair procedures, while enhancing safety and long-term outcomes. Accordingly, CS has the potential to significantly enhance patient care across the entire surgical journey, from preoperative planning and intraoperative decision making to postoperative surveillance. Moreover, CS-based approaches offer promising opportunities to augment AAA repair quality by enabling precise preoperative simulations, real-time intraoperative navigation, and robust postoperative monitoring. However, integrating these advanced computer-based technologies into medical research and clinical practice presents new challenges. These include addressing technical limitations, ensuring accuracy and reliability, and managing unique ethical considerations associated with their use. Thorough evaluation of these aspects of advanced computation techniques in AAA management is crucial before widespread integration into health care systems can be achieved.
Technological advances over the past century have accelerated the pace and breadth of medical and surgical care. From the initial delivery of "telemedicine" over the radio in the 1920s, the delivery of medicine and surge...Technological advances over the past century have accelerated the pace and breadth of medical and surgical care. From the initial delivery of "telemedicine" over the radio in the 1920s, the delivery of medicine and surgery in the 21 century is no longer limited by connectivity. The COVID-19 pandemic hastened the uptake of telemedicine to ensure that health care can be maintained despite limited face-to-face contact. Like other areas of medicine, vascular surgery has adopted telemedicine, although its role is not well described in the literature. This narrative review explores how telemedicine has been delivered in vascular surgery. Specific themes of telemedicine are outlined with real-world examples, including consultation, triaging, collaboration, mentoring, monitoring and surveillance, mobile health, and education. This review also explores possible future advances in telemedicine and issues around equity of care. Finally, important ethical considerations and limitations related to the applications of telemedicine are outlined.
The COVID-19 pandemic exposed the vulnerabilities of global health care systems, underscoring the need for innovative solutions to meet the demands of an aging population, workforce shortages, and rising physician burnou...The COVID-19 pandemic exposed the vulnerabilities of global health care systems, underscoring the need for innovative solutions to meet the demands of an aging population, workforce shortages, and rising physician burnout. In recent years, wearable technology has helped segue various medical specialties into the digital era, yet its adoption in vascular surgery remains limited. This article explores the applications of wearable devices in vascular surgery and explores their potential outlets, such as enhancing primary and secondary prevention, optimizing perioperative care, and supporting surgical training. The integration of artificial intelligence and machine learning with wearable technology further expands its applications, enabling predictive analytics, personalized care, and remote monitoring. Despite the promising prospects, challenges such as regulatory complexities, data security, and interoperability must be addressed. As the digital health movement unfolds, wearable technology could play a pivotal role in reshaping vascular surgery while offering cost-effective, accessible, and patient-centered care.