RESUMO
OBJECTIVE: To investigate the prevalence and predictors of hereditary hemorrhagic telangiectasia (HHT) and capillary-malformation arteriovenous malformation (CM-AVM) syndrome among children with no prior personal or family history of these diseases who presented with an arteriovenous shunt lesion. STUDY DESIGN: A retrospective chart review was completed on patients aged 0 through 21 years with arteriovenous shunt lesions evaluated at our Cerebrovascular Center. Diagnosis of definite or suspected HHT or CM-AVM was based on clinical features and genetic testing. Associations between final diagnosis and type and number of lesions, epistaxis, telangiectasias, CM, and pulmonary AVMs were assessed. RESULTS: Eighty-nine patients were included. Thirteen (14.6%) had definite HHT, 11 (12.4%) suspected HHT, and 4 (4.5%) definite CM-AVM. Having ≥2 episodes of epistaxis/year and ≥ 2 sites with telangiectasias were each associated with definite HHT (P < .001). Having ≥ 2 CM was associated with definite CM-AVM (P < .001). Pulmonary AVM was associated with increased odds of having definite HHT (OR = 6.3, 95% CI: 1.2-33.4). Multiple lesions (OR = 24.5, 95% CI: 4.5-134.8) and arteriovenous fistulas (OR = 6.2, 95% CI: 1.9-20.3) each increased the likelihood of having definite HHT or CM-AVM. Genetic testing was positive in 31% of patients tested. CONCLUSIONS: We recommend that children with neurovascular shunt lesions be offered genetic testing and undergo further evaluation for HHT and CM-AVM. Awareness and early diagnosis of these conditions is a critical step toward improving long-term outcomes and preventing disease-associated complications.
Assuntos
Fístula Arteriovenosa , Malformações Arteriovenosas Intracranianas , Telangiectasia Hemorrágica Hereditária , Criança , Humanos , Telangiectasia Hemorrágica Hereditária/complicações , Telangiectasia Hemorrágica Hereditária/diagnóstico , Telangiectasia Hemorrágica Hereditária/epidemiologia , Prevalência , Estudos Retrospectivos , Epistaxe , Malformações Arteriovenosas Intracranianas/complicações , Malformações Arteriovenosas Intracranianas/epidemiologia , Fístula Arteriovenosa/complicações , Fístula Arteriovenosa/epidemiologiaRESUMO
Introducción: La fístula arteriovenosa por vía quirúrgica para hemodiálisis constituye el acceso vascular de elección, para ese proceder depurador, no obstante, repercute negativamente sobre el aparato cardiovascular. Objetivo: Actualizar aspectos conceptuales y conductuales relativos a la permanencia de la fístula arteriovenosa para hemodiálisis posterior al trasplante renal. Métodos: Se revisó la literatura publicada en los últimos cinco años en las bases de datos; PubMed/Medline y Scopus y las fuentes de información; Cochrane Library y Ebsco. Resultados: La repercusión de la fístula arteriovenosa sobre el sistema cardiovascular tiene una marcada incidencia en diferentes alteraciones estructurales y funcionales del corazón que requieren de la adopción de una conducta destinada a evitar el riesgo. Se examinan puntos de vista convergentes y divergentes relacionados con la pertinencia de la fístula arteriovenosa como acceso vascular creado para hemodiálisis y la posibilidad de mantenerla luego del trasplante renal. Conclusiones: La fístula arteriovenosa supone el acceso vascular de apropiado para la supervivencia en hemodiálisis, sin embargo, las consecuencias de su permanencia sobre el aparato cardiovascular implican riesgo añadido de morbilidad y mortalidad(AU)
Introduction: Surgical arteriovenous fistula for hemodialysis is the vascular access of choice, this purifying procedure, however, has negative impact on the cardiovascular system. Objective: To bring up-to-date conceptual and behavioral aspects related to the permanence of the arteriovenous fistula for hemodialysis after renal transplantation. Methods: The literature published in the last five years was reviewed in PubMed/Medline and Scopus and information sources; Cochrane Library and Ebsco databases. Results: The repercussion of the arteriovenous fistula on the cardiovascular system has a marked incidence in different structural and functional alterations of the heart that require the adoption of a behavior to avoid risks. Convergent and divergent points of view related to the relevance of the arteriovenous fistula as a vascular access created for hemodialysis and the possibility of maintaining it after renal transplantation are examined. Conclusions: The arteriovenous fistula is the appropriate vascular access for survival in hemodialysis, however, the consequences of its permanence on the cardiovascular system imply an added risk of morbidity and mortality(AU)
Assuntos
Humanos , Masculino , Feminino , Sistema Cardiovascular , Fístula Arteriovenosa/epidemiologia , Diálise Renal/métodos , Transplante de Rim , Anormalidades Cardiovasculares/complicaçõesRESUMO
Introducción: Existe un incremento anual de pacientes con insuficiencia renal crónica tributarios a hemodiálisis. Para la realización de esta se requiere de la correcta inserción de accesos vasculares que sean duraderos y funcionales. Objetivo: Caracterizar la durabilidad y funcionabilidad de las fístulas arterio-venosas en pacientes no diabéticos con enfermedad renal crónica. Métodos: Se realizó un estudio ambispectivo en 60 pacientes no diabéticos, con enfermedad renal crónica, portadores de una fístula arterio-venosa interna autóloga. Se describieron las variables: edad, sexo, grado de la enfermedad, lugar de confección, durabilidad, funcionabilidad, intentos, superficialización, uso de prótesis de poli-tetra-fluoro-etileno y complicaciones. Resultados: La edad media de los pacientes fue de 55,7 ± 12,7 años y la mitad estuvo entre 40 y 59 años. Los del sexo masculino ocuparon el 71,7 por ciento. Las fístulas duraderas (66,7 por ciento) y las funcionales (71,7 por ciento) se mostraron como las de mayor aparición. Los pacientes con la enfermedad en grado 4 ocuparon el 51,7 por ciento. Las fístulas en zonas radio-cefálica (43,3 por ciento) y húmero-cefálica (45 por ciento) primaron. Solo el 71,7 por ciento tuvo un intento de cirugía. Únicamente en el 20 por ciento se realizó superficialización y cuatro pacientes (6,4 por ciento) recibieron prótesis de poli-tetra-fluoro-etileno. La trombosis representó la complicación más frecuente (25 por ciento). Conclusiones: La durabilidad y la funcionabilidad de las fístulas elaboradas se asociaron con factores como el grado de la enfermedad, el número de intentos, el uso de prótesis vasculares y las complicaciones(AU)
Introduction: There is an annual increase of patients with chronic renal impairment who need haemodialysis. The correct insertion of vascular accesses that are durable and functional is required to perform haemodialysis. Objective: Characterize the durability and functionability of arterio-venous fistulas in non-diabetic patients with chronic kidney disease. Methods: An ambispective study was conducted in 60 non-diabetic patients, with chronic kidney disease carrying an autologous internal arterio-venous fistula. The described variables were: age, sex, stage of the disease, place of manufacture, durability, workability, attempts, superficialization, use of polytetrafluoroethylene prostheses, and complications. Results: The average age of patients was 55.7 ± 12.7 years and half were between 40 and 59 years old. Males were 71.7 percent. Durable (66.7 percent) and functional (71.7 percent) fistulas were shown as the most common ones. Patients with a grade 4 disease represented the 51.7 percent. Fistulas in radio-cephalic zones (43.3 percent) and humerus-cephalic zone (45 percent) prevailed. Only 71.7 percent had an attempt of surgery. Only 20 percent had superficialization and four patients (6.4 percent) received polytetrafluoroethylene prostheses. Thrombosis was the most common complication (25 percent). Conclusions: The durability and functionability of the prepared fistulas were associated with factors such as the stage of the disease, the number of attempts, the use of vascular prostheses, and the complications(AU)
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Fístula Arteriovenosa/epidemiologia , Diálise Renal/métodos , Insuficiência Renal Crônica/etiologia , Trombose/complicaçõesRESUMO
BACKGROUND: In 2014, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) concluded that medical management alone for cranial arteriovenous malformations (AVMs) had better clinical outcomes than interventional treatment. The impact of the ARUBA study on changes in the rates of intervention and outcomes is unknown. Thus, we investigated whether the conclusions from ARUBA may have influenced treatment modalities and outcomes of unruptured AVMs. METHODS: The National Inpatient Sample (NIS) was queried between 2006 and 2018, for adult patients with an AVM who were admitted on an elective basis. Interventions included open, endovascular, and stereotactic surgeries. Join-point regression was used to assess differences in slopes of treatment rate for each modality before and after the time-point. Logistic regression was used to assess the odds of non-routine discharge and hemorrhage between the two time-points for each treatment modality. Linear regression was used to assess the mean length of stay (LOS) for each treatment modality between the two time-points. RESULTS: A total of 40,285 elective admissions for AVMs were identified between 2006 and 2018. The rate of intervention was higher pre-ARUBA (n = 15,848; 63.8%) compared to post-ARUBA (n = 6985; 45.2%; difference in slope - 8.24%, p < 0.001). The rate of open surgery decreased, while endovascular and stereotactic surgeries remained the same, after the ARUBA trial time-point (difference in slopes - 8.24%, p < 0.001; - 1.74%, p = 0.055; 0.20%, p = 0.22, respectively). For admissions involving interventions, the odds of non-routine discharge were higher post-ARUBA (OR 1.24; p = 0.043); the odds of hemorrhage were lower post-ARUBA (OR 0.69; p = 0.025). There was no statistical difference in length of stay between the two time-points (p = 0.22). CONCLUSION: The rate of intervention decreased, the rate of non-routine discharge increased, and rate of hemorrhage decreased post-ARUBA, suggesting that it may have influenced treatment practices for unruptured AVMs.
Assuntos
Fístula Arteriovenosa , Malformações Arteriovenosas Intracranianas , Radiocirurgia , Adulto , Fístula Arteriovenosa/epidemiologia , Fístula Arteriovenosa/cirurgia , Humanos , Pacientes Internados , Malformações Arteriovenosas Intracranianas/epidemiologia , Malformações Arteriovenosas Intracranianas/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Introducción: La hemobilia es por definición una causa de hemorragia digestiva alta, donde existe una comunicación de la vía biliar en cualquiera de sus segmentos con vasos sanguíneos que desembocan a través de la ampolla de Vater. Su presentación es infrecuente y no sospechada en la práctica clínica diaria de gastroenterólogos, cirujanos, hepatólogos, clínicos e intensivistas, con un difícil manejo diagnóstico-terapéutico y una elevada morbi-mortalidad. Objetivo: Describir tres casos de pacientes con diagnóstico de hemobilia. Desarrollo: Se presentan tres casos con hemobilia que tuvieron una elevada mortalidad y con diferente etiología; en el primer caso por trombosis de la arteria hepática postrasplante hepático, el segundo secundario a un colangiocarcinoma de la unión hepatocística y el tercero con diagnóstico de un aneurisma de la arteria hepática derecha confirmado y parcialmente tratado por angiotomografía, posteriormente intervenido quirúrgicamente y único sobreviviente. Conclusiones: Resultaron tres casos con hemobilia de diferentes causas, con una elevada mortalidad por la intensidad de la hemorragia digestiva alta y las comorbilidades asociadas, además de señalar que ninguno de ellos presentó la tríada clásica reportada por Quincke(AU)
Introduction: Hemobilia is, by definition, a cause of upper gastrointestinal bleeding, where there is a communication of the bile duct in any of its segments with blood vessels that flow through the ampulla of Vater. It is rare and it is not suspected in the daily clinical practice of gastroenterologists, surgeons, hepatologists, clinicians and intensivists, hence the diagnostic-therapeutic management is difficult and it has high morbidity and mortality. Objective: To report three cases of patients with a diagnosis of hemobilia. Case report: We report three cases of hemobilia of high mortality and different etiology. The first case had post-liver transplantation hepatic artery thrombosis, the second had asecondary cholangiocarcinoma of the hepatocystic junction and the third had diagnosis of confirmed right hepatic artery aneurysm partially treated by CT angiography, subsequently operated on and the only survivor. Conclusions: These three hemobilia cases had different causes, and high mortality due to the intensity of the upper gastrointestinal bleeding and the associated comorbidities, in addition to noting that none of them exhibited the classic triad reported by Quincke(AU)
Assuntos
Humanos , Masculino , Fístula Arteriovenosa/epidemiologia , Colangiocarcinoma/epidemiologia , Hemobilia/diagnóstico , Hemobilia/etiologiaRESUMO
Las fístulas arteriovenosas durales medulares son malformaciones vasculares adquiridas que constituyen una causa muy infrecuente de mielopatía progresiva (5-10 casos por millón de habitantes por año). La resonancia magnética es el estudio por imágenes de elección para su diagnóstico. A continuación presentamos el caso de una paciente femenina de 89 años, que consultó a la guardia de nuestra institución por un cuadro de paraparesia moderada asociada a parestesias e incontinencia urinaria posterior a esfuerzo físico. Se le diagnosticó una fístula arteriovenosa dural medular como causante de su cuadro. (AU)
Spinal dural arteriovenous fistulas (SDAVF) are acquired spinal vascular malformations and a rare cause of progressive myelopathy (5-10 new cases per year and per 1 million inhabitants). Magnetic resonance imaging is the diagnosis modality of choice. We present a case of a 89-year-old female patient who consulted the emergency department of our institution because of paraparesis and lower extremities paresthesias associated with urinary incontinence post physical effort. With the final diagnosis of spinal dural arteriovenous fistula, as a cause of the clinical symptoms. (AU)
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Fístula Arteriovenosa/diagnóstico por imagem , Dura-Máter/anormalidades , Parestesia , Fibrilação Atrial/complicações , Doenças da Medula Espinal/diagnóstico por imagem , Tabagismo/complicações , Incontinência Urinária , Fístula Arteriovenosa/etiologia , Fístula Arteriovenosa/epidemiologia , Dor Lombar/complicações , Aneurisma da Aorta Abdominal/complicações , Paraparesia , Incontinência Fecal , Hipertensão/complicações , Hipestesia , Disfunção Erétil , Anticoagulantes/uso terapêuticoRESUMO
OBJECTIVE: The A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial has received fierce criticism, including considerable selection bias, poor generalizability, questionable clinical practices (only 15.8% underwent surgical resection, the gold standard for arteriovenous malformation [AVM] treatment), and short follow-up (33 months) for a disease process that carries a life-long risk. In this study, we sought to present our own experience treating unruptured brain AVMs to provide supporting evidence of the ARUBA trial criticism. METHODS: All cases of treated brain AVMs from 2004 to 2017 at our institution were retrospectively reviewed and included in the analysis if they met ARUBA trial inclusion criteria. The primary outcome was symptomatic stroke or death. Secondary outcomes included AVM obliteration, long-term clinical impairment (modified Rankin Scale score >1), and new major or minor postoperative deficit. RESULTS: Of the 245 reviewed cases, 86 met the ARUBA trial criteria. Treatment included microsurgical resection alone (2.3%), preoperative embolization followed by microsurgical resection (62.8%), stereotactic radiosurgery alone (10.5%), embolization followed by stereotactic radiosurgery (15.1%), and embolization alone (9.3%). The primary outcome was met in 8.3%, new perioperative major and minor complications occurred in 5.8% and 12.8%, and long-term clinical impairment in 4.5%. AVM obliteration was observed in 92.4% overall and in 100% of patients who underwent surgical resection. CONCLUSIONS: The criticism of the ARUBA trial is warranted, as our study found that treatment of unruptured brain AVMs has an acceptable safety profile when approached in a multidisciplinary manner at an experienced institution, using surgical resection as the primary treatment modality when applicable.
Assuntos
Fístula Arteriovenosa/terapia , Malformações Arteriovenosas Intracranianas/terapia , Adulto , Fístula Arteriovenosa/epidemiologia , Embolização Terapêutica , Feminino , Humanos , Malformações Arteriovenosas Intracranianas/epidemiologia , Masculino , Microcirurgia , Procedimentos Neurocirúrgicos , Complicações Pós-Operatórias/epidemiologia , Radiocirurgia , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: Cryoballoon pulmonary vein isolation (PVI) has emerged as an alternative to radiofrequency PVI for atrial fibrillation (AF). Data are lacking to define the rates and predictors of complications, particularly phrenic nerve injury (PNI). METHODS AND RESULTS: We evaluated a single-center prospective registry of 450 consecutive patients undergoing cryoballoon PVI between 2011 and 2015. Patients were 59±10 years old, 26% were women, 58% had hypertension, their mean CHA2DS2VASc score was 1.7±1.3, 30% had persistent atrial fibrillation, and 92% received a second-generation 28-mm balloon. Predefined major complications were persistent PNI, pericardial effusion, deep vein thrombosis, arteriovenous fistula, atrioesophageal fistula, bleeding requiring transfusion, stroke, and death. PNI was categorized as persistent if it persisted after discharge from the laboratory. Logistic regression was performed to identify predictors of complications and specifically PNI. We identified a major complication in 10 (2.2%) patients. In 49 (10.8%) patients, at least transient PNI was observed; only 5 persisted beyond the procedure (1.1%). All cases of PNI resolved eventually, with the longest time to resolution being 48 days. We also describe 2 cases of PNI manifesting after the index hospitalization. Regression analysis identified 23-mm balloon use (16.3% versus 5.2%, odds ratio 2.94, P=0.011) and increased age (62.8±7.7 versus 58.7±0.12 years, odds ratio 1.058, P=0.014) as independent significant predictors of PNI. There were no significant predictors of major complications. CONCLUSIONS: In a large contemporary cohort, cryoballoon PVI is associated with low procedural risk, including lower rates of PNI than previously reported. Older age and 23-mm balloon use were associated with PNI. Our low rate of PNI may reflect more sensitive detection methods, including compound motor action potential monitoring and forced double-deflation.
Assuntos
Fibrilação Atrial/cirurgia , Criocirurgia , Complicações Pós-Operatórias/epidemiologia , Veias Pulmonares/cirurgia , Sistema de Registros , Idoso , Fístula Arteriovenosa/epidemiologia , Transfusão de Sangue , Estudos de Coortes , Fístula Esofágica/epidemiologia , Feminino , Hemorragia/epidemiologia , Hemorragia/terapia , Mortalidade Hospitalar , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/epidemiologia , Traumatismos dos Nervos Periféricos/epidemiologia , Nervo Frênico/lesões , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Trombose Venosa/epidemiologiaRESUMO
Post-embolization hemorrhage is the most severe, dramatic and morbidity-mortality-related complication in the treatment of endovascular arteriovenous malformations (AVMs). The objective of this study was to determine predictive factors of post-embolization hemorrhage. This is a retrospective study in 71 patients with cerebral AVMs having undergone 147 embolization sessions with n-butyl cyanoacrylate (n-BCA), carried out between 2006 and 2011. Clinical-demographic, morphological and treatment data as well as results were recorded. The relationship of post-procedure hemorrhage with demographic and morphological factors, percentage devascularization per session, venous drainage and whether or not post-procedure hypotension had been induced was investigated. Six post-embolization hemorrhages occurred, all in sessions characterized by extensive devascularization without the induction of post-procedure hypotension; which disappeared after a limit to the extent of devascularization per session and post-procedure hypotension were introduced. In the multivariate analysis, hemorrhage predictors were: nidus diameter < 3 cm (OR= 45.02; CI=95%:1.17-203.79; P=0.005); devascularization > 40% (OR=32.4; CI=95%: 3.142- 518.6; P=0.009) per session; intranidal aneurysms (OR=7.5; CI=95%:1.19-341.3; P=0.041) and lack of post-procedure hypotension (OR=16.51; CI=95%:1.81-324.4; P=0.049) and the association of sessions with devascularization exceeding 40% with lack of post-procedure hypotension, showed an increase in the risk of hemorrhage (OR=36.4; CI=95%:3.67-362.4; P=0.002). Extensive devascularization and the absence of post-procedure hypotension increase the risk of hemorrhage. We suggest partial, 25-30%, devascularization per session and the induction of post-procedure hypotension, which produces a 20% decrease of the basal mean arterial pressure (MAP).
Assuntos
Fístula Arteriovenosa/epidemiologia , Fístula Arteriovenosa/terapia , Hemorragia Cerebral/epidemiologia , Embolização Terapêutica/estatística & dados numéricos , Embucrilato/uso terapêutico , Malformações Arteriovenosas Intracranianas/epidemiologia , Malformações Arteriovenosas Intracranianas/terapia , Adolescente , Adulto , Idoso , Causalidade , Hemorragia Cerebral/prevenção & controle , Criança , Comorbidade , Cuba/epidemiologia , Feminino , Hemostáticos/uso terapêutico , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
Introducción: el tratamiento sustitutivo de la insuficiencia renal crónica en su estadio terminal requiere la creación previa de un acceso vascular permanente cuando se elige como método depurador la hemodiálisis, siendo la fístula arteriovenosa autóloga el angioacceso más usado por las ventajas que ofrece. El objetivo de este estudio fue conocer las características generales de esta población de pacientes y cómo ellas se relacionaron con la supervivencia anual de las fístulas arteriovenosas realizadas en este grupo de enfermos. Métodos: se llevó a cabo un estudio prospectivo, descriptivo y longitudinal para el que se tomaron 109 pacientes en los que se realizaron 115 fístulas arteriovenosas. Estos pacientes asistieron al Instituto de Nefrología de La Habana para realizarse un acceso vascular para hemodiálisis, estos accesos vasculares fueron construidos por el Grupo Básico de Trabajo de Cirugía de dicha institución, en el período comprendido de marzo de 2005 a marzo de 2007. Se analizaron los factores de riesgo que podían influir en la supervivencia de las fístulas. Resultados: en el estudio realizado se observó un ligero predominio del sexo maculino (59 hombres y 50 mujeres), con una edad media de 52,5 años, y en los que predominaron como causa de insuficiencia renal crónica la nefroangioesclerosis seguida de la nefropatía diabética y la enfermedad renal poliquística autosómica dominante. La cifra promedio de filtrado glomerular con que se enviaron los pacientes a realizarse la fístula fue de 18,73 ml/min. De nuestros pacientes, 59 presentaban algún tipo de acceso vascular previo. Encontramos una menor supervivencia o tasa de permeabilidad primaria en los pacientes diabéticos y en las fístulas de localización braquial, fundamentalmente las humerobasílicas, sin presentar una relación estadísticamente significativa este último aspecto (p < 0,05). El 35 por ciento de nuestros pacientes se encontraba en régimen de hemodiálisis al realizarse la fístula arteriovenosa. Conclusiones: la fístula arteriovenosa autóloga continúa siendo el acceso vascular preferido por su menor índice de complicaciones. Es importante la selección previa del sitio adecuado para su creación. La diabetes mellitus es un importante factor de riesgo que influye significativamente en una menor supervivencia de los angioaccesos(AU)
Introduction: in the replacement therapy of end-stage renal disease, the previous creation of a permanent vascular access is required when hemodialysis is chosen as a depurative method. Autologous arteriovenous fistula is the most widely used angioaccess because of its advantages. The objective of the present study was to assess the demographic data of this population and their relationship with the annual survival of arteriovenous fistulae in this group. Methods: a longitudinal prospective and descriptive study was conducted in 109 patients in whom 115 arteriovenous fistulae were created. They had been referred to the Department of Surgery of the Nephrology Institute of Havana in order to create vascular access for hemodialysis in the period from March 2005 through March 2007. The risk factors in the fistula survival were analyzed. Results: males slightly predominated (59 males and 50 females). The average age was 52.5 years. Nephroangiosclerosis followed by diabetic nephropathy and polycystic kidney disease were the predominant causes of end-stage renal disease. Glomerular filtration average for these patients was 18.73 ml/min. Fifty nine had a previous vascular access. A lower survival or primary patency rate was found in diabetic patients and in cases of humerobasilic fistulae, without any statistically significant relation in this last aspect (p>0.05). Thirty five percent of the patients were under hemodialysis therapy at the time of arteriovenous fistula placement. Conclusions: autologous arteriovenous fistula remains as a preferred vascular access due to its lower rate of complications. The selection of the correct placement site prior to the procedure is critical. Diabetes mellitus is an important risk factor which may have a significant effect on lower survival rates of vascular accesses