Multi-center investigation of intial hemodialysis vascular access in end-stage renal disease patients

Objective To investigate vascular access modalities at initiation of hemodialysis for end stage renal disease (ESRD) patients in hospitals of different levels, and to analyze the reasons contributing to the absence of arteriovenous fistula (AVF) during initial hemodialysis. Methods A pre-designed questionnaire was used to collect the information of patients that entered hemodialysis within five years, including basic information and their first vascular access types, and analyze the factors that influence patients' AVF use. Results (1) According to the 203 questionnaires returned from 5 hospitals, central venous catheter (CVC) was chosen by 122 (60.1%) patients, direct arteriovenous puncture by 44 (21.7%) patients, AVF by only 35 (17.2%) patients, and long-term cuffed catheter by 2 (1.0%) patients. For patients in different hospitals, 61.7% of patients in Jiamusi Hospital used direct arteriovenous puncture, while CVC were used most in the other four hospitals. The leading reason contributing to the absence of AVF was patient's refusal [75 cases (44.6%)], among which patients regarding AVF psychologically unacceptable accounted for the most [44 cases (26.2%)]. Following that were 45 cases (26.8%), in which patients were uninformed of AVF and 38 cases (22.6%) caused by time limitation. (3) Logistic regression showed well-educated, female, and urban residential patients were more likely to choose AVF at initiation of hemodialysis. Conclusion The percentage of AVF utility at the start of hemodialysis remains low, with situation varying in different hospitals and regions. Multiple factors are associated with vascular access modalities, among which the influence of doctors cannot be ignored. More efforts should be spared on patient education to improve the dialysis quality of ESRD patients in China.     

Vascular access for hemodialysis in the elderly

Objective

The objective of this study was to compare the outcomes of arteriovenous fistulas (AVFs) with arteriovenous grafts (AVGs) in a large population-based cohort of elderly patients in the United States.

Vascular access and patient outcomes in hemodialysis: questions answered in recent literature

Hemodialysis is not possible without access to the vascular system to provide an adequate and reliable source of blood flow through the hemodialyzer. Since maintenance hemodialysis therapy became a reality in the latter half of the twentieth century, no vascular access has exceeded the success and reliability of arteriovenous fistulae (AVF). They have the lowest infection and thrombosis rates, have the longest patency rates, and are associated with the best morbidity and mortality outcomes of any access modality. In the United States, the majority of patients starting hemodialysis do not have a primary AVF, which may explain why vascular access complications represent almost 20% of the total spending for hemodialysis. In addition, as much as 50% of hospitalization costs for end-stage renal disease are related to access issues. Every effort must be directed in the U.S. as well as elsewhere to promote the use of AVF whenever possible. In some European countries, more than 90% of patients have AVF as their hemodialysis access when nephrologists perform placement of vascular access. Already, some programs in the U.S. have recognized the need for trained nephrologists to provide these services. U.S. interventional nephrologists should be given the opportunity to learn AVF placement procedures to emulate their European counterparts, and thus improve U.S. dialysis outcomes.     

疑难血液透析通路的建立

目的总结疑难血液透析通路的建立经验,为提高患者生存率提供一定的临床依据。方法回顾性分析上海交通大学医学院附属仁济医院血管外科收治的7例疑难病例的病史及血液透析通路的设计。结果收集2008年4月至2014年1月收治的7例病例,男3例,女4例,年龄46~79岁,平均年龄(66.6±13.4)岁,其共同特点是由于插管及其他原因,造成中心静脉资源的耗竭,缺乏常规血液透析通路的建立手段及后续手段匮乏,远期通畅率不高,同时部分患者还存在急诊透析通路的建立困难。最终这7例患者根据各自病情分别施行了左股静脉带隧道带涤纶套导管置管1例,右头臂静脉支架植入术1例,股动脉-股总静脉人工血管袢式动静脉内瘘术2例,股动脉-髂总静脉人工血管袢式动静脉内瘘术1例,股浅动脉-股浅动脉人工血管通路1例,肱动脉-肱动脉人工血管通路1例,以维持透析。7例患者随访时间11~56个月,维持规律性血液透析,有5例因其他原因死亡,1例随访2年后失访,1例维持透析。结论中心静脉耗竭是造成血液透析通路建立困难的主要原因,尽量减少和避免中心静脉插管,有助于保护静脉资源。下肢血管通路是维持血液透析通路的一种选择,而当所有静脉资源耗竭时,可采用动脉-动脉的血管通路。     

Racial differences in utilization and outcomes of hemodialysis access in the Unites States

ObjectiveTo evaluate patterns of use and outcomes of arteriovenous fistulas and prosthetic grafts within racial categories in a large population based cohort of hemodialysis (HD) patients in the United States.MethodsA retrospective analysis of white, black, and Hispanic patients in the prospectively maintained United States Renal Database System who had an autogenous fistula or prosthetic graft placed for HD access between January 2007 and December 2014 was performed. Analysis of variance, χ², t-tests, Kaplan-Meier, log-rank tests, multivariable logistic, and Cox regression analyses were used to evaluate maturation, patency, infection, and mortality.ResultsThis study of 359,942 patients, composed of 285,781 autogenous fistulas (79.4%) and 74,161 prosthetic grafts (20.6%) placed in 213,877 white (59.4%), 115,727 black (32.2%), and 30,338 Hispanic (8.4%) patients. There was a 11% increase in the risk-adjusted odds of HD catheter use as bridge to autogenous fistula placement in blacks (adjusted odds ratio, 1.11; 95% confidence interval [CI], 1.08-1.14; P < .001) and a 9% increase in Hispanics (adjusted odds ratio, 1.09; 95% CI, 1.05-1.14; P < .001) compared with whites. Fistula maturation for HD access for whites vs blacks vs Hispanics was 77.0% vs 76.3% vs 77.8% (P = .35). After adjusting for covariates, fistula maturation was higher for blacks (adjusted hazard ratio, 1.09; 95% CI, 1.06-1.13; P < .001) and Hispanics (adjusted hazard ratio, 1.13; 95% CI, 1.06-1.20; P < .001) compared with whites. There was no significant difference in prosthetic graft maturation for blacks and Hispanics compared with whites. Primary, primary-assisted, and secondary patency were highest for Hispanic and least for black autogenous fistula recipients. Primary, primary-assisted, and secondary patency was also highest for Hispanic patients who received prosthetic grafts. Prosthetic grafts were associated with a decrease in patency and patient survival compared with fistulas in all racial categories. Mortality was lower for blacks and Hispanics relative to white patients. Initiation of HD with a catheter and conversion to autogenous fistula was associated with decrease in patency and patient survival compared with initiation with a fistula in all racial groups.ConclusionsAutogenous fistulas are associated with better patency and patient survival compared with prosthetic grafts for all races studied. The use of HD catheter before fistula placement is more prevalent in Hispanic and black patients and is associated with worse patency and patient survival irrespective of race. Fistula and graft patency is highest for Hispanic patients. Patient survival is higher for Hispanic and black patients relative to whites. These associations suggest potential benefit with initiation of HD via autogenous fistula and minimizing temporizing catheter use, irrespective of race.     

Steal in Hemodialysis Patients Depends on Type of Vascular Access

OBJECTIVES: To study incidence and severity of steal phenomena in hemodialysis patients and to investigate possible methods for its detection. METHODS: A questionnaire was composed based on a literature search. A subgroup of patients having steal as identified by the questionnaire was studied using physical examination, arterial blood pressure, skin temperature, digital oxygenation, grip strength and plethysmography. Contralateral arms served as controls. RESULTS: A cold hand was present in 50% of the patients with a brachiocephalic (BC) arteriovenous fistula (AVF, n = 28) compared to 25% of prosthetic forearm loops (loop, n = 27) and 12% of the radiocephalic (RC, n = 65, p < 0.05) fistulas. Diabetics were at risk for steal (p < 0.001). Intensity of steal was not related to magnitude of access flow. Digital skin temperatures and grip strength were lower in steal hands (p < 0.02). Manual compression of the AVF normalised low digital pressures in steal hands (106 +/- 33 vs 154 +/- 25 mmHg, p < 0.001, contralateral side 155 +/- 21 mmHg). CONCLUSIONS: Mild to moderate steal symptoms are common in a hemodialysis patient. Individuals with a BC are at a higher risk for developing complaints associated with reduced hand circulation compared to patients with a RC or loop. Low finger pressures in the presence of steal symptoms are usually reversible.     

Hemodialysis vascular access options in pediatrics: considerations for patients and practitioners

Recent data indicate that the incidence of end-stage renal disease (ESRD) in pediatric patients (age 0–19 years) has increased over the past two decades. Similarly, the prevalence of ESRD has increased threefold over the same period. Hemodialysis (HD) continues to be the most frequently utilized modality for renal replacement therapy in incident pediatric ESRD patients. The number of children on HD exceeded the sum total of those on peritoneal dialysis and those undergoing pre-emptive renal transplantation. Choosing the best vascular access option for pediatric HD patients remains challenging. Despite a national initiative for fistula first in the adult hemodialysis population, the pediatric nephrology community in the United States of America utilizes central venous catheters as the primary dialysis access for most patients. Vascular access management requires proper advance planning to assure that the best permanent access is placed, seamless communication involving a multidisciplinary team of nephrologists, nurses, surgeons, and interventional radiologists, and ongoing monitoring to ensure a long life of use. It is imperative that practitioners have a long-term vision to decrease morbidity in this unique patient population. This article reviews the various types of pediatric vascular accesses used worldwide and the benefits and disadvantages of these various forms of access.     

不同动静脉内瘘重建手术方式比较

目的 探讨终末期肾脏病血液透析患者动静脉内瘘失功后3种重建自体血管通路手术的优缺点,为临床选择做参考.方法 针对终末期肾脏病维持性3种液透析动静脉内瘘失功患者(241例),根据其自身血管条件、原有内瘘情况、血管彩超等检查结果,施行以下3种之其中一种重建自体血管通路的手术:原有内瘘近心端重新吻合血管(92例)、使用取栓管球囊行经皮血管成形术(包括内瘘取栓术和血管扩张术,87例),另选血管建立动静脉内瘘(62例).随访2年,比较3种手术方式的成功率、通畅率、平均血流量、并发症发生率等情况.结果 3种手术方式的手术成功率分别为93.5％、94.2％、96.8％,2年通畅率分别为80.4％、82.7％、80.6％,2年平均内瘘血流量分别为(250±24) ml/min、(240±21)ml/min、(230±16)ml/min,均无统计学差异.3组患者均无充血性心力衰竭、窃血综合征等严重并发症发生.结论 针对动静脉内瘘失功的血液透析患者,应依据血管条件选择手术方式来重建血管通路.经皮血管成形术(包括内瘘取栓术和血管扩张术)作为一种微创有效的手术方式,能最大限度地保留患者的血管资源,可予临床推广.     

上臂侧侧吻合动-静脉内瘘20例临床分析

目的 探索一种血液透析血管通路新式的动-静脉内瘘方法.方法 对前臂无法建立血液透析血管通路的内瘘患者,经彩超评估上臂血管情况后,采用肱动脉与头静脉或正中静脉或贵要静脉做侧侧吻合.使用连续性缝合完成的技术要求.结果 20例患者上臂侧侧吻合动-静脉内瘘手术一次性成功,无明显内瘘术后相关严重的并发症发生,患者使用情况良好.血...     

Arteriovenous fistulas for hemodialysis access in children and adolescents using the proximal radial artery inflow site

Introduction

Hemodialysis (HD) for children and adolescents with renal failure is increasingly common in the United States. Consensus opinion views an arteriovenous fistula (AVF) as the best long-term access option, although catheter-based HD remains the most common vascular access in children and has greater risks of complications and higher mortality rates than AVF access. This report reviews our experience with children and adolescents undergoing vascular access operations.

Methods

We reviewed 721 consecutive vascular access patients who had vascular access surgery by a single surgeon during the previous 5 years. Ten patients 20 years or younger were included in this study. In addition to physical examination, each patient had preoperative vascular ultrasound mapping by the operating surgeon. A radiocephalic AVF (RC-AVF) at the wrist was the first choice for dialysis access when feasible; however, the patients in this report were generally seen after years of intravenous access and venipunctures that necessitated more proximal AVF constructions. A proximal radial artery AVF (PRA-AVF) was our most common choice for vascular access when an RC-AVF was not suitable.

Results

Patient ages were 9 to 20 years (mean, 16). Seven were male. Renal failure was caused by glomerulnephitis in 4 patients, 3 had a history of obstuctive uropathy, 2 were diabetic and one had congenital nephrotic syndrome. Eight patients had PRA-AVFs created, 1 had an RC-AVF, and 1 patient required a transposition AVF. Follow-up was 4 to 56 months (mean, 32 months). Primary, primary-assisted, and cumulative patencies were 77.8%, 100%, and 100% at 24 months. No prosthetic grafts were used in any vascular access patient during the study period.

Conclusion

We found HD access in children and adolescents was reliably established through use of a PRA-AVF when an RC-AVF was not feasible. Access sites were often possible through the upper arm cephalic veins and/or with retrograde flow into the forearm. Cumulative (secondary) patency was 100% at 24 months.     

The difficult hemodialysis access extremity: proximal radial arteriovenous fistulas and the role of angioscopy and valvulotomes

BACKGROUND: Native arteriovenous (AV) fistulas (NAVF) offer significantly lower risks than grafts or catheters. Individuals with a difficult access extremity (DAE) are often viewed as unsuitable for NAVFs. The proximal radial artery (PRA) NAVF offers a safe and reliable opportunity for a direct fistula in most patients, and we find it an important surgical option in the DAE. METHODS: Consecutive vascular access operations were reviewed to find individuals with DAE. We defined the DAE patient group as those individuals where a wrist (Cimino) or upper arm brachiocephalic NAVF was not possible or was predicted to fail. RESULTS: Preoperative physical and ultrasound examinations identified 58 individuals with DAE. Mean age was 56 years (range 11 to 87), 34 were female, 29 were diabetic, and 27 had previous access surgery. NAVFs were constructed in all patients. No grafts were utilized. Forty-six patients had a PRA NAVF constructed. NAVF patency was 91%. Twenty-three patients required retrograde angioscopy or passage of a valvulotome to gain forearm access. Twenty-one of these 23 individuals maintained an open NAVF segment in the forearm. CONCLUSION: NAVFs were constructed in all patients. PRA NAVFs play an important role in extending hemodialysis by NAVF for this difficult patient group. Forearm access is often possible in these patients and may be successfully augmented by angioscopy or valvulotomes.     

A national study of autogenous arteriovenous access use and patency in a contemporary hemodialysis population

ObjectiveThe predicted outcomes of autogenous arteriovenous (AV) hemodialysis access creation are predominantly based on historical data; however, both the hemodialysis population and clinical practices have changed significantly during the last decade. This study examined contemporary AV access clinical use and patencies.MethodsA multicenter observational cohort study was performed of all new AV accesses created in Scotland in 2015. The primary end point was efficacy assessed by successful AV access use for a minimum of 30 days and primary, primary assisted, and secondary patency at 1 year. Data obtained included all interventions to maintain or to restore patency. Predictors of patency loss including demographics, comorbid conditions, dialysis status, AV access location, duplex ultrasound surveillance, procedures, prior access, and antiplatelets were assessed. Kaplan-Meier and competing risks analyses were performed to estimate the probability of AV access failure. All patients were followed up for at least 1 year or had a censoring event.ResultsA total of 582 AV accesses were created in 537 patients (mean age, 60 [standard deviation, 14] years; 60% men; 42% with diabetes) in nine adult renal centers. Mean follow-up was 11.8 (standard deviation, 7.6) months. By the end of the follow-up, 322 (55.3%) AV accesses were successfully used for dialysis. At 1 year, 48% (95% confidence interval [CI], 44-52) of AV accesses had primary patency, (95% CI, 63-71) had primary assisted patency, and 69% (95% CI, 65-73) had secondary patency. The leading cause of primary patency loss was primary failure (30%). An average of 0.48 intervention per patient-year was required to maintain patency. On multivariable analysis, patency was better for an upper arm than for a forearm AV access (1-year secondary patency of upper arm vs forearm AV accesses, 74% vs 58%). The cumulative hazard and incident functions for AV access failure were 31% (95% CI, 27-35) and 23% (95% CI, 20-27) at 1 year, respectively.ConclusionsDespite advances in recent years with preoperative vessel assessment and surveillance, patency rates have not improved, with primary failure remaining the major obstacle. Competing events should be taken into consideration; otherwise, biases may occur with overestimation of the probability of AV access failure.     

应用假性桡动脉瘤建立永久性血液透析通道

由专人用内瘘穿刺针直接在桡动脉上定点定向穿刺，使形成动脉瘤，以后在动脉瘤上穿刺进行血液透析，２５例患中，成功２１例，血流量可达２００－３５０ｍｌ／ｍｉｎ。迄今已进行５０１次透析，最长１例２０９次，未发生并发症。本方法是建立血管通道的一种新方法，其优点是不需手术，减轻患者的痉和经济负担；克服了其它方法制作的动静脉内、外瘘的缺点；可满足紧急血液透析的需要；穿刺简单易行，容易推广。     

球囊辅助下血透用桡动静脉内瘘术

目的 评价球囊辅助下血透用桡动静脉内瘘术的手术方法和初步疗效。方法回顾性总结2005年8～12月复旦大学附属中山医院血管外科收治的12例诊断明确的尿毒症病人行球囊辅助下桡动静脉瘘术。选择非主利手，游离头静脉和桡动脉，分别结扎头静脉和桡动脉的远端，向头静脉和（或）桡动脉近端插入Fogarty取栓导管，用1mL的注射器向球囊注入肝素盐水0．1—0．3mL，充起球囊，持续、均匀扩张头静脉和（或）桡动脉及其狭窄段，以7-0无损伤血管缝线吻合血管。结果术后即时、回病房当天、术后1d、3d和7d听诊吻合口杂音，扪及血管震颤。平均随访3个月，手术通畅率100％。已有5例病人内瘘成熟，内瘘血流量大于150mL／min，满足血透流量。结论球囊辅助下桡动静脉内瘘术成功率高，可以纠正头静脉狭窄，内瘘成熟快。短期临床效果好，中远期临床效果在进一步观察中。     

Recirculation Measures with Urea and Mannitol During Hemodialysis

Abstract: A simple, accurate, and reproducible method of measuring recirculation in grafts during hemodialysis is essential for improving the efficiency of dialysis. In our studies, plasma samples for plasma urea nitrogen (PUN) were taken from the arterial line of the dialyzer at blood flows (A) of 200, 300, and 400 ml/min, preceded by a 5–min period of equilibration, and at 15 s and 2 min after turning the flow down to 100 ml/min (S), the latter serving as systemic samples. Recirculation was calculated as (S – A)/(S – V). Total blood flow (Q_b) through the grafts was measured by color Doppler ultrasound. We found a significant, inverse relationship between recirculation and total flow through the graft at dialyzer Q_b of 400 but not 300 or 200 ml/min. The magnitude and prevalence of recirculation was always greater when the 2 min sample was used as S compared to the 15 s sample and as dialyzer Q_b increased. As a qualitative, urea–independent measure of recirculation, we assayed the appearance of mannitol in the arterial line in blood drawn 15 s after initiating a mannitol push into the venous line. Blood obtained just prior to the mannitol push was used as the zero blank. Thirteen of 18 patients had a measurable, but low, level of mannitol, 5 did not, and 2 had inconsistent results in studies done on separate days. We conclude that the majority of patients receiving chronic hemodialysis have a low degree of recirculation and that methods relying on urea must be suspected of exaggerating the true degree of recirculation.     

Double-Blind Randomized Trial of the Effect of Ticlopidine in Arteriovenous Fistulas for Hemodialysis

Abstract: The antiplatelet drug ticlopidine was assessed as an agent for improving the patency of Brescia-Cimino arteriovenous fistulas as access for hemodialysis. In a double-blind randomized study over 1 month, two of six fistulas in the ticlopidine group and five of nine in the placebo group failed. A further one placebo and two ticlopidine patients still had functioning fistulas at the time of withdrawal for technical reasons from the trial. Ticlopidine appears, therefore, to enhance the efficacy of Brescia-Cimino fistulas, at least in the short term.     

Investigation of vascular access in maintenance hemodialysis patients in Shanxi province

Objective To understand the current situation of vascular access selection in maintenance hemodialysis (MHD) patients in Shanxi Province, and analyze the factors affecting vascular access selection and risk factors of death in MHD patients. Methods MHD patients with clear vascular access information in Shanxi Province from January 2014 to December 2018 were enrolled in this study. The clinical data of patients were collected. The vascular access information of the selected candidates was clear. Multivariate logistic regression equation method was used to analyze the influencing factors of vascular access and the risk factors of death in MHD patients. Results Among the 10.236 patients with MHD, 9.130 patients (89.2%) selected autologous arteriovenous fistula (AVF) as vascular access, and 5.138 patients (50.2%) chose tunnel-free and non-polyester sheath central venous catheter (NCC) for the first dialysis. Multivariate logistic regression analysis showed that the primary disease of diabetic nephropathy (OR=0.517, 95%CI 0.281-0.796, P＜0.001) and dialysis age＜1 year (OR=0.483, 95%CI 0.219-0.811, P＜0.001) were the influencing factors of patients with MHD who did not to choose AVF. Primary disease of diabetic nephropathy (OR=2.242, 95% CI 1.816-2.828, P＜0.001), and using of central vein catheter (OR=1.785, 95% CI 1.237-2.579, P＜0.001) were independent risk factors of death in MHD patients. Conclusions AVF is the first choice for MHD patients in Shanxi Province. There is higher proportion of the use of NCC as the first dialysis vascular access. Primary disease of diabetic nephropathy and dialysis age＜1 year are the influencing factors for MHD patients not to choose AVF. Primary disease of diabetic nephropathy and use of central vein catheter may increase the risk of death in MHD patients.     

深静脉长期留置导管与动静脉内瘘在血液透析患者中的应用比较

目的比较深静脉长期留置导管与自体动静脉内瘘作为血管通路的透析充分性及并发症,探讨深静脉长期留置导管在血液透析中的意义。方法选择徐州市中心医院肾脏内科新建立长期留置导管患者24例（导管组）,新建立自体动静脉内瘘患者30例（内瘘组）,随访36-40个月,比较2组患者年龄、最大血流量及观察终点前1个月内射血分数（EF）、尿素清除指数（Kt／V）以及观察期间2组感染、血栓、死亡发生情况。结果导管组使用时间（30．2±7．0）个月,内瘘组使用时间（37．9±2．4）个月;导管组最大血流量、通路使用时间、Kt／V值均低于内瘘组,但差异无统计学意义（P〉0．05）;导管组年龄、EF值高于内瘘组,差异无统计学意义（P〉0．05）;导管组感染率、血栓发生率及病死率均高于内瘘组（P〈0．05）。结论导管组与内瘘组均可达到充分透析,虽然导管组感染率和血栓发生率较高,深静脉长期导管仍为维持性血液透析患者建立血管通路的良好替代。     

Axillary Artery to Contralateral Axillary Vein Graft Fistula in Chronic Hemodialysis Patients

Background.?Vascular access failure is a severe and common complication for hemodialysis patients. The possible vascular access sites are limited in dialysis patients. Axillary artery to contralateral axillary vein arteriovenous fistula (AVF) is one of the possibilities. However, the clinical outcome of this procedure is still un-defined. Object.?The purpose of this study is to review the clinical outcome of axillary artery to contralateral axillary vein AVF as a hemodialysis vascular access. Patients and Methods.?We retrospectively reviewed native or graft arteriovenous fistula records for chronic hemodialysis patients at Chang Gung Memorial Hospital in Kaohsiung, Taiwan, from 01 1986 to 03 2001. Records were reviewed for all chronic hemodialysis patients, with more than 2000 individuals receiving more than 10,000 fistulas. Eight patients received axillary artery to contralateral axillary vein AVF. Results.?The mean age for these patients was 61.7 ± 16.3 year-old at time of surgery. All patients had received multiple native or graft arteriovenous fistula creation. The 2-year and 4-year AVF graft survival is 87.5% and 43.8% respectively. One patients developed brachial plexopathy after operation. Another patient had venous hypertension distal to the AVF site. Both patients were managed conservatively. There is no AVF-related mortality in these patients. Conclusion. We conclude that axillary artery to contralateral axillary vein graft fistula may be a feasible alternative choice for chronic hemodialysis access.     

The Hemodynamic Effects of Hemodialysis Needle Rotation and Orientation in an Idealized Computational Model

Maintaining the patency of vascular access is essential for performing efficient hemodialysis. Appropriate cannulation technique is critical in maintaining the integrity of vascular access. This study focused on analyzing the hemodynamic effect of needle rotation, which is performed to alleviate the pressure if the needle becomes attached to the blood vessel wall. The hemodynamic benefits (normal wall shear stress [WSS] and smooth flow with no oscillatory motion) of this technique are investigated in an idealized model of the cephalic vein in order to determine a needle position that will reduce conditions known to contribute to vascular access failure. A computational fluid dynamics study was conducted, with antegrade and retrograde orientations simulated on the arterial needle, whereas the venous needle is placed in the antegrade orientation. In every case, needle rotation offered no hemodynamic benefit in minimizing the conditions known to cause endothelial damage, a precursor to vascular access failure. Venous needle rotation reduced the maximum WSS by 30%. However, the WSS was above the range, which may damage the endothelial layer. The arterial needle in the antegrade orientation produced a large region of oscillatory shear, whereas a retrograde orientation produced a region of smooth flow in the vicinity of the needle with only a small region of oscillatory shear. The flow through the venous needle back eye was negligible, whereas the arterial needle back eye was more efficient in the retrograde orientation. Therefore, the venous needle should not be rotated, whereas the arterial needle may be rotated to alleviate pressure with consideration given to the orientation of the needle.