Patients with chronic renal failure require long-term hemodialysis, and the establishment and maintenance of functional vascular access is a prerequisite for hemodialysis and a lifeline for patients who rely on dialysis for survival. Vascular access is the lifeline of hemodialysis patients with renal failure and is the cornerstone of hemodialysis. In recent years, with the vigorous development of hemodialysis, the establishment and maintenance of vascular access has become more and more important. On the one hand, with the increasing population of hemodialysis, hemodialysis equipment and quality improvement, the dialysis age of patients has been prolonged; on the other hand, with the increase of aging population, the proportion of comorbidities such as diabetes increases, and the increase of various invasive operations deteriorates the vascular conditions of patients, which increases the difficulty of establishing and maintaining vascular access. The establishment and maintenance of vascular access ranges from simple autologous arteriovenous fistulas to complex artificial vascular arteriovenous fistulas, from the establishment of access to the management of various stenoses, thrombosis, aneurysmal dilatation, blood theft and other complications, from open surgery to endovenous treatment; vascular access doctors are faced with more and more technical challenges. Vascular access surgery, a tertiary department under the Department of Vascular Surgery of our hospital, has carried out and standardized vascular access surgery for dialysis in accordance with domestic and international guidelines. With its professional vascular anastomosis techniques and standardized management, the Vascular Access Division has established an unobstructed lifeline for many patients with uremia; many patients who have failed to receive treatment in outside hospitals have also received the most appropriate repair here: minimally invasive repair or reconstruction of new autologous/artificial vascular arteriovenous fistulas. Arteriovenous fistula (vascular access) is the use of vascular surgery techniques to artificially create a short circuit between arteries and veins to provide long-term and effective extracorporeal circulation for hemodialysis. A direct anastomosis between the radial artery and the cephalic vein in the distal forearm is the preferred long-term vascular access for dialysis patients and is referred to as the “standard endovascular” or “first level vascular access”; however, in some cases, no suitable autologous vessel can be found for anastomosis in either forearm and a replacement vessel has to be used. However, in some cases, no suitable autologous vessel can be found for anastomosis in either forearm, and a replacement vessel has to be used to create a graft endovascular fistula, also known as a “second level vascular access. Graft endovascular fistulas are used to establish vascular access between distant arteries and veins by “bridging” them with other vessels. Autologous vessels are vessels harvested from other parts of the patient’s body, most commonly the saphenous vein of the lower extremity. Autologous vessels as vascular graft material have the advantages of high patency rate, low tissue reaction, less bleeding from puncture, and low cost; therefore, it is the material of choice for endovascular grafting. However, when autologous vessels are not applicable, artificial vessels should be chosen, which can also achieve better results. For a long time, the quality of arteriovenous endovascular fistulas for uremic patients has been uneven due to the lack of a special department for the implementation of arteriovenous endovascular fistulas for uremic patients, who are constantly worried about their “lifeline” while suffering from great pain. During the repeated use of hemodialysis, many patients suffer from various degrees of occlusion, thrombosis, local aneurysm formation and other complications, until they are unable to use the arteriovenous fistula, and then suffer the pain of surgery again and bear the burden of the associated treatment costs. How to establish this “lifeline”? The first step is to perform preoperative assessment of the autologous vessels, medical history, arterial assessment, venous assessment, and even venography depending on the specific condition; and the general order of establishing the endovascular fistula: non-dominant hand first, then dominant hand; forearm, then upper arm; upper extremity, then lower extremity. Each time vascular access is established, it is important to take into account how the next vascular access will be performed. If an adjacent angioplasty is not available, it can be replaced with an artificial vessel or an autologous/allogeneic saphenous vein. Artificial vessels are usually made of 6mm diameter PTFE material without rings. Once the autologous vessel meets the following requirements: ① The diameter of the access vein must be sufficiently dilated, at least 5-6 mm, and the length of the dilated vein segment must be at least 10-375 px; ② The available vein segment must be superficially located and easy to find and puncture. The vein wall must be arterialized and thickened enough to tolerate the trauma of repeated punctures; ③ The blood flow in the passageway must be at least 300-400 ml/min, preferably 500 ml/min. i.e., the fistula is considered mature enough to tolerate repeated punctures. After prolonged use of the endovascular fistula, more than 1/4 of patients will have stenosis or occlusion of the fistula (combined with thrombosis) due to stenosis around the venous anastomosis or anastomosis caused by the proliferation of neointima, followed by stenosis of the arterial anastomosis and the graft itself, which will require endoluminal or surgical repair, including: secondary surgical remedy (e.g. patchplasty, ligation of important branches of the vein, cephalic vein lift in obese patients). Minimally invasive endoluminal techniques i.e. local thrombectomy + balloon dilation/+ stenting. Postoperative follow-up: Patients are followed up on an outpatient basis 2 weeks after surgery and once a month thereafter until the access is available for dialysis. Anticoagulation to maintain low blood viscosity and prevent thrombosis. How to maintain the fistula in daily life? The limb with an arteriovenous endovascular fistula should not be weighted, do not compress it when sleeping, put a soft pillow on the operated limb to promote venous blood flow to reduce the degree of swelling, wear loose and comfortable sleeves, avoid wearing ornaments, learn to self-monitor the endovascular anastomosis for tremors and auscultate vascular murmurs, and do not measure blood pressure or draw blood from the limb with an arteriovenous endovascular fistula.
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