Novel Procedures

The topic of this section are some techniques in the field of vascular access surgery that we could call “hybrid techniques”, of which there are not many references in the literature. We talk about hybrid techniques when traditional surgery is combined with endovascular techniques to improve the success of the procedure (1, 2). Generally these are techniques used in other fields of medicine (heart disease and peripheral vascular diseases) imported and subsequently included in that of vascular access. The procedures are not performed before or after surgery, but during the creation of the fistula. The main advantage is that a percutaneous procedure is avoided for the patient. Take for example a stenotic radial artery candidate for distal radiocephalic fistula. We have several possibilities: 1. exclude the vessel and do the fistula in another district. 2. Perform an angioplasty of the artery before creating the fistula. 3. Create the fistula and then perform a PTA if immature. 4. Perform an intraoperative angioplasty. We have always been supporters of solution n. 4 (3-5) . Our first article on intraoperative angioplasties dates back to 2006 (probably the first work on the subject in the literature) (3). We have subsequently performed approximately 400 intraoperative angioplasties on more than 2000 surgical fistula creations. Recently, intraoperative endovascular lithotripsy has been added to traditional angioplasty for the treatment of calcified arterial stenoses (6). Finally, predilatation of the vessels is a technique improperly included in this section. In fact, it does not require the use of endovascular devices but is a system that dilates the vessels by injecting a saline solution into the vessel before proceeding with its incision. Excetpt four publication (5, 7), there is no trace of this technique in the literature, therefore we recommend its use only to expert surgeons.

1. Szewczyk D, Bojakowski K, Kasprzak D, Kaźmierczak S, Piasecki A, Andziak P. Ann Vasc Surg. 2019 Nov;61:356-362. doi: 10.1016/j.avsg.2019.04.047. Epub 2019 Jul 31.
2. Gora R, Bojacowsky K, Foroncewicz B, et al. Vascular. 2020 Dec;28(6):775-783. https://doi.org/10.1177/1708538120931626
3. Napoli M, Montinaro A, Russo F, et al. Ultrasound guided brachial arterial angioplasty during the creation of a radio-cephalic arteriovenous fistula: a case report. J Vasc Access. 2006 Jan-Mar;7(1):38-42. 
4. Napoli M, Montinaro A, Russo F, et al. Early experiences of intraoperative ultrasound guided angioplasty of the arterial stenosis during upper limb arteriovenous fistula creation. J Vasc Access. 2007; 8(2):97-102. 
5. Napoli M, Lefons ML, Mangione D, et al. Primary intraoperative transluminal angioplasty: a new approach to reduce the early failure of distal arteriovenous fistulas. J Vasc Access 2015;16(3):250–254.
6. Napoli M, Barbarini S, Ria P, et al. The intraoperative intravascular lithotripsy to recruit a calcified radial artery for creating a distal radio-cephalic fistula. J Vasc Access. 2021 Jul 2:11297298211017029. doi: 10.1177/11297298211017029.
7. Napoli M, Zito A, Lefons ML, et al. The Pre-dilatation of vessels: A simple method to recruit small caliber veins for creating distal fistulas. J Vasc Access. 2022 Mar;23(2):257-264. doi: 10.1177/1129729820983170. Epub 2021 Jan 22.