Aneurysms are a common and often difficult complication seen with arteriovenous vascular access for haemodialysis. The purpose of this narrative review is to define and describe the scale of the problem and suggested therapeutic strategies. A narrative review of the published literature illustrated by individual cases is presented with the aim of summarising the relevant literature. The definitions of aneurysm are inconsistent throughout the literature and therefore systematic review is impossible. They vary from qualitative descriptions to quantitative definitions using absolute size, relative size and also size plus characteristics. The incidence and aetiology are also ill defined but separation into true aneurysms and false, or pseudoaneurysms may be helpful in planning treatment, which may be conservative, surgical or radiological. The lack of useful definitions and classification along with the multitude of management strategies proposed make firm evidence based conclusions difficult to draw. Further robust well designed studies are required to define best practice for this common problem.

Crossed fused renal ectopia is a rare congenital anomaly, and is mostly detected incidentally. A 45-year-old man, during investigation for recurrent abdominal pain, was found to have an empty left renal fossa and right crossed renal ectopia with fusion on ultrasonography. In the present case, there were no abnormalities and/or alteration of the renal function. Abdominal tomography scan with contrast medium confirmed the diagnosis. Ectopic kidney is often associated with other abnormal situations such as agenesis, vascular malformation, incontinence, a palpable abdominal mass, urinary tract infection, high incidence of stone formation, and genital anomalies. Through this case report, we emphasize the importance of adequate imaging.

A functioning vascular access is a critical requirement to improve the quality of life in hemodialysis patients, so monitoring and surveillance of vascular access play key roles in identifying all dysfunctions and reducing the huge economic cost as well as adequacy of dialysis.In our five-year experience, a study protocol has been used and improved with the help of ultrasonography.Doppler ultrasound is an excellent and sensitive modality for hemodialysis access evaluation, one of techniques employed for arteriovenous fistulae (AVF) study, not only as a preoperative tool, but also in post-operative monitoring of AVF maturation. In addition, the current guidelines recommend AVF surveillance by access blood flow measurement and the correction of hemodynamic stenosis in order to prolong access survival. Doppler ultrasound is readily available, directly used by nephrologists, non-invasive, safe, inexpensive, reproducible, although it requires more clinical skill and time to perform and proper equipment. Ultrasonography imaging can substantially reduce the number of subsequent invasive angiographic procedures. In our opinion, Doppler ultrasound should have a crucial place in the interdisciplinary cooperation in AVF monitoring and it should be included as part of an integrated vascular access management program.

Pulmonary hypertension is defined as an increased systolic pulmonary pressure of >30 mm Hg, and it shows a 40% prevalence in hemodialysis patients due to vascular access (both central venous catheter and arteriovenous fistula). Secondary pulmonary hypertension in chronic kidney disease patients is strictly related to pulmonary circulation impairment together with chronic volume overload and increased levels of cytokines and growth factors, such as FGF, PDGF, and TGF-β, leading to fibrosis. Endothelial dysfunction, together with lower activation of NOS, increased levels of serum endothelin and fibrin storages, involves an extensive growth of endothelial cells leading to complete obliteration of pulmonary vessels. Pulmonary hypertension has no pathognomonic and distinctive symptoms and signs; standard transthoracic echocardiography allows easy assessment of compliance of the right heart chambers. The therapeutic approach is based on traditional drugs such as digitalis-derived drugs, vasodilatory agents (calcium channel blockers), and oral anticoagulants. New pharmacological agents are under investigation, such as prostaglandin analogues, endothelin receptor blockers, and phosphodiesterase-5 inhibitors.

As a consequence of the central role of the arteriovenous fistula for dialysis (AVF) in the clinical management of the dialysis patient the necessity to limit the puncture-related complications to extend as much as possible the life of the vascular access. Accordingly, the AVF needling technique has gained growing attention. Alongside the traditional rope ladder (RL) puncture method, the buttonhole technique (BH) is increasingly popular; this technique employs the same cannulation sites of AVF in every dialysis associated with the use of dull needles to minimize vessels damage. The BH technique, utilized only for native AVF, is considered an appropriate alternative to the RL and is now recommended by several scientific societies for its reported benefits such as: AVF greater ease of cannulation, less pain, faster hemostasis and less tendency to the creation of aneurysms and hematomas. The use of BH is especially recommended in cases in which the RL is problematic with short or winding venous sections and in home dialysis in which the patient performs the needling. However recent evidence in literature, countering these theoretical advantages, indicates that the BH technique appears to be closely related to an increased risk of local and systemic infections. Furthermore, the purported benefits of BH have not held up under closer examination.