Skip Navigation LinksResearch-Documents-

​Ladenheim Dialysis Access Centers performs continual research into better and more efficient ways to provide reliable Dialysis Access. On this page you can download some of our research findngs on various subjects and procedures.

  
  
  
  
Brief Description
JVA-D-16-00234 Hero Grafts and Thigh Fistulas.pdfJVA-D-16-00234 Hero Grafts and Thigh FistulasJournal of Vascular Access4/25/2017
ABSTRACT
Introduction: For access-challenged patients with bilateral upper extremity central venous stenosis, solutions include the Hemodialysis Reliable Outflow (HeRO) device or an autogenous AV fistula in the lower limb. We evalu- ated HeRO grafts and transpositions of the femoral vein in maintaining primary and secondary patency. Methods: We retrospectively analyzed 40 patients with a HeRO device and 18 patients with superficial femoral artery to transposed femoral vein autogenous arteriovenous fistula (SFA-tFV). All patients had bilateral central venous obstruction. All procedures were outpatient performed by a single surgeon at one center between 2009- 2015. Operative details, intraoperative flows, and flows at the first-week postoperative visit were analyzed, as were primary and secondary patency and intervention rates. Complications were compared between groups. Results: The one-year cumulative primary patency was 30% for HeRO grafts and 79% for SFA-tFV fistulas (p = 0.0001); secondary patency was 71% for HeRO grafts and 93% for SFA-tFV fistulas (p = 0.03). To maintain patency, HeRO patients required a mean 2.1 interventions per year and thigh fistula patients required a mean 0.4 interventions per year. Thirty-seven percent of thigh fistula patients had a hematoma or seroma versus 5% of HeRO patients and 17% of thigh fistula patients experienced delayed wound healing versus 2.5% of HeRO patients (p<0.05). None of the thigh fistula patients had distal ischemia. Conclusions: HeRO patients had lower primary and secondary patency rates versus thigh fistula patients and HeRO grafts required five-fold more interventions to maintain secondary patency. However, patients with thigh fistulas had significantly more wound healing problems. Thus, the SFA-tFV has become our access of choice for patients with bilateral central venous stenosis.
Keywords:
101_Online PDF.PDF101_Online PDF2016 Edition of "Liposuction: Principles and Practice"7/1/2016
The 2016 Edition of "Liposuction" Principles and Practice" will contain a chapter by Dr. Ladenheim on Liposuciton for Superficialization of Deep Veins after Creation of Arteriovenous Fistulas.
Double fistulas.pdfDouble fistulasVascular Access Society of the Americas, Chicago IL5/14/2016
When a primary AV access is failing, sometimes the best option for a secondary AV access is on the ipsilateral extremity.

Retrospective review of operations from 2008 to 2015  involving 4 surgeons at one practice.
Inclusion Criteria: All patients undergoing secondary access formation without ligation of failing ipsilateral primary access.

We found 7/11(64%) of the patients were able to tolerate the presence of two ipsilateral accesses without symptomatic arterial steal and only 3/11 (27%) needed ligation of the primary access because of steal(a 4th patient also developed steal, but expired before ligation could be done). 

4 patients (36%) were able to avoid placement of bridging catheters by cannulating their primary failing fistulas during maturation of the secondary access

It is possible for patients to have two ipsilateral hemodialysis accesses and not need a bridging catheter.
Pitfalls in Distal Radial Artery Ligation.pdfPitfalls in Distal Radial Artery LigationVascular Access Society of the Americas5/13/2016
Ligation of the distal radial artgery for dialysis access related steal syndrome should be performed close o the anastamosis. Without ligation close to the anastamosis, recurrent symptomas can develop over time due to persisten flow through an un-ligated branch.
HeRO grafts compared with thigh fistulas.pdfHeRO grafts compared with thigh fistulasVascular Access Society of the Americas5/13/2016
We found the primary patency and secondary of Femoral Vein transposition fistulas to be significantly greater than that of the HeRO graft.  Five times as many interventions were required to maintain patency of the HeRO graft compared with the thigh fistula.  The Femoral vein tranpsition has become our access of choice when a lower extremity AV access is required
Hemodialysis and Peritoneal Dialysis Access.pdfHemodialysis and Peritoneal Dialysis AccessGrand Rounds, Kaweah Delta Medical Center, Visalia California4/28/2016
This was a presentation to a nonspecialist audience of the following:
1. The rising prevalence and declining incidence of end stage renal disease
2. Common configurations of Hemodialysis and Peritoneal Dialysis Accesses
3. Commonly seen complications of hemodialysis and peritoneal dialysis access
JVA-D-15-00174 First week flow.pdfJVA-D-15-00174 First week flowJournal of Vascular Access4/5/2016
Abstrac t
Purpose: This study was conducted to determine whether volume flow rate at the first postoperative visit could
predict early failure of radiocephalic arteriovenous fistulas (RCAVFs).
Methods: We retrospectively studied the records of 264 patients who received a RCAVF between 2007 and 2013
at our centers. Data collected included patient demographics, medical history, arterial and venous mapping, and
volume flow rate intraoperatively after fistula creation but before closing the surgical incision. An intraoperative
flow rate >100 mL/minute was targeted. We measured volume flow at the first postoperative visit 1 week after
surgery and thereafter as needed.
Results: Intraoperative flow was not a significant predictor of primary patency (p = 0.44) but flow at the first
postoperative visit was a statistically significant predictor of fistula primary patency (p = 0.002). No fistula with a
blood flow <200 mL/minute at the 1-week postoperative visit reached maturity without receiving a maturation
procedure. The hazard ratio for the first follow-up flow (mL/min) was 0.9973 (95% CI 0.9956, 0 .9989), indicating
that for every 100 mL increase in blood flow the primary patency increases by 10%.
Conclusions: Flow rate at the 1-week postoperative visit was the most important predictor of RCAVF patency.
Thus, it should be possible to identify patients who would benefit from early intervention or closer follow-up as
soon as the first postoperative visit. This should help reduce the use of bridging hemodialysis catheters and minimize
the risks of catheter dependency.
Keywords: Arteriovenous fistula, Fistula flow rate, Primary patency
1 week postop flows.pdf1 week postop flowsPublished April 2016 Journal of Vascular Surgery  4/1/2016
We  studied 264 patients who received a RCAVF between 2007 and 2013. Flow at the first postoperative visit was a highly statistically significant predictor of fistula survival
SAVE Follow-up Study - 18 mth 7-31-15 + Figures+edl.pdfSAVE Follow-up Study - 18 mth 7-31-15 + Figures+edlUnpublished. Awaiting Decis by Journal of Vascular Surgery11/13/2015
The fistula secondary patency rate of 91% at 18 months compares favorably to reported fistula patency rates.  56% of devices implanted were continually used without intervention over the 18-month duration of the study. 
Ladenheim-2015-Seminars_in_Dialysis.pdfLadenheim-2015-Seminars_in_DialysisSeminars in Dialysis2/1/2015
We present a case in which Minimally Invasive Limited
Ligation Endoluminal-assisted Revision (MILLER) banding
was complicated by the development of a pseudoaneurysm
at the site of attempted banding
VWING.pdfVWINGJournal of Vascular Surgery3/4/2014
The VWING was safe and effective in facilitating AVF cannulation for patients with an otherwise mature but noncannulatable fistula.
Application of human type I pancreatic elastase (PRT-201).pdfApplication of human type I pancreatic elastase (PRT-201)Journal of Vascular Access2/13/2014
PRT-201 was well tolerated and increased AVG intraoperative outflow vein diameter and blood flow. Low dose tended to increase secondary patency and decrease the rate of procedures to restore or maintain patency.
Liposuction for Superficialization of Deep Veins after Creation of Arteriovenous Fistulas-Published.pdfLiposuction for Superficialization of Deep Veins after Creation of Arteriovenous Fistulas-PublishedJournal of Vascular Access1/13/2014
We conclude that liposuction is an effective
method of enabling cannulation of excessively deep
vein fistulas but because of the substantial risk of serious
surgical site complications, it may not be the ideal
method.
An Interesting Clinical Case Variant of the Cephalic Vein Emptying into the Internal Jugular Vein.pdfAn Interesting Clinical Case Variant of the Cephalic Vein Emptying into the Internal Jugular VeinSeminars in Dialysis8/1/2013
This case report describes a 45 year old patient who was referred to our center for surgical creation of long term vascular access. Angiographic mapping revealed the left cephalic vein draining directly into the internal jugular vein rather than axillary vein. The pati3ent was received an ulnar artery to cephalic vein fistula
Our Technique for Upper Arm Lipectomy of AV Fistula Using the HemaClear® Surgical Exsanguination Tourniquet.pdfOur Technique for Upper Arm Lipectomy of AV Fistula Using the HemaClear® Surgical Exsanguination TourniquetVAS International Congress Prague, Czech Republic4/25/2013
The sterile ultra-narrow HemaClear tournequet
provides excellent exposure and hemostasis for upper arm Lipectomy surgery. Techniques are detailed
allen-ladenheim-hero grafts.pdfallen-ladenheim-hero graftsAmerican Nephrology Nurses Association4/21/2013
We reviewed 32 patients receiving the HeRO graft and noted complications. Nursing interventions which could help prevent them or mitigate harm are reviewed.
Ladenheim et al. - Unknown - High incidence of perigraft seroma formation with gelatin-coated polytetrafluoroethylene grafts(3).pdfLadenheim et al. - Unknown - High incidence of perigraft seroma formation with gelatin-coated polytetrafluoroethylene grafts(3)Seminars in Dialysis11/1/2012
We reviewed the effectiveness of a gelatin-coated PTFE graft designed to reduce graft weeping. 11 clinically significant seromas were detected in 30 sealed PTFE grafts.  It was concluded it was not the ideal prosthesis for hemodialysis access
A sterile elastic exsanguination tourniquet is effective in preventing blood loss during hemodialysis access surgery.pdfA sterile elastic exsanguination tourniquet is effective in preventing blood loss during hemodialysis access surgeryJournal of Vascular Access8/11/2012
We report the first use of a sterile elastic exsanguination tourniquet (SET) in performing hemodialysis vascular access
procedures in 27 patients.
HeRO vs THIGH FISTULA.pptxHeRO vs THIGH FISTULAVascular Access for Hemodialysis XIII Symposium, Orlando Florida5/9/2012
Objectives: A common dilemma in dialysis access surgery is obtaining a reliable arteriovenous access in patients with bilateral central venous stenosis secondary to prior central venous dialysis catheters. Often a choice must be made between a hemodialysis reliable outflow (HeRO) device in an upper extremity or an autogenous arteriovenous fistula of the lower extremity. We studied our results of managing this problem with the HeRO device and our recent change in approach to managing this condition. Methods: This was a retrospective review of all patients undergoing placement of a HeRO device or superficial femoral artery-transposed superficial femoral vein AV (SFA-tSFV) fistula for hemodialysis over a three year period by one surgeon. Intraoperative and postoperative intra-access flows were assessed by direct duplex measurement. For primary patency calculations, the endpoint was first episode of clotting, angioplasty, revision, or access removal. Data were censored at death or the end of the study period if the primary endpoint was not reached. Survival data were summarized by product limit method. Results: We implanted 33 HeRO devices and created 9 SFA/tSFV fistulas. The one year cumulative primary patency of the HeRO graft was 25%. 6 month primary patency was 40%. We implanted 12 HeRO devices in 2009, 14 in 2010, but in 2011 HeRO use decreased to only 6, with 5 thigh fistulas placed. In the first quarter of 2012 we have place 1 HeRO and and 4 thigh fistulas. Follow-up times on the thigh fistulas are 21-207 days. Our first two thigh fistulas suffered from inadequate runoff. The times to cannulation ranged from 19 days to 64 days. Conclusions: Our cumulative primary patency for the HeRO graft of 25% at one year was comparable to published patency rates for prosthetic arteriovenous grafts. Use of the HeRO graft has decreased by at least 50% as we are placing more thigh fistulas. Our learning curve for thigh fistulas has highlighted the need for documenting adequate outflow by thorough preoperative venography.
Coding of Procedures in Interventional Nephrology 2010.pdfCoding of Procedures in Interventional Nephrology 2010American Society of Diagnostic and Interventional Nephrology11/25/2009
Proper coding of interventional procedures is a difficult and daunting, but essential task. Each procedure
that is done is made up of a number of parts, each of which has its own code. This requires that a list of
component codes be created for each procedure based upon selections made from a long list of
alternatives. It is important that this be done correctly.
Ten Mistakes to Avoid in Dialysis Access Surgery.pdfTen Mistakes to Avoid in Dialysis Access SurgeryChapter in Vascular Access: Principles and Practice1/1/2009
10 Mistakes to avoid in dialysis access are described
Results of Managing Transtibial Amputations with a Prefabricated Polyethylene Rigid Removal Dressing.pdfResults of Managing Transtibial Amputations with a Prefabricated Polyethylene Rigid Removal Dressing
Ultrasound and Fluoroscopy guided Balloon angioplasty in patients with nonmaturing arteriovenous fistula.pdfUltrasound and Fluoroscopy guided Balloon angioplasty in patients with nonmaturing arteriovenous fistula
Use of the HemaClear® Exsanguination Tourniquet in Dialysis Access Surgery.pdfUse of the HemaClear® Exsanguination Tourniquet in Dialysis Access Surgery
Remembering the Good Old Days of Dialysis Access.pptRemembering the Good Old Days of Dialysis AccessCommunity Medical Centers, Fresno California