Complications of vascular access are an important cause of morbidity and mortality in hemodialysis patients. 1 It is widely accepted that an arteriovenous fistula (AVF) is the optimal form of vascular access, with better patency and lower infection rates than arteriovenous grafts and central

Acute gastrointestinal bleeding is a common medical emergency, which carries a significant mortality. CT Angiography is an important non-invasive diagnostic tool, which can be used to plan subsequent endovascular or surgical management. The cases presented demonstrate that a meticulous and systematic approach to image interpretation is necessary, in particular, to detect focal sites of contrast extravasation and small pseudoaneurysms.

BackgroundThe initial therapy for a stenosis in an arteriovenous fistula used for haemodialysis is radiological balloon dilatation or angioplasty. The benefit of angioplasty is often short-lived, intervention-free survival is reported to be 40–50 % at 1 year. Previous small studies and observational data suggest that paclitaxel-coated balloons may be of benefit in improving outcomes after fistuloplasty of stenotic arteriovenous fistulae.Methods/designWe have designed a multicentre, double-blind randomised controlled trial to test the superiority of paclitaxel-coated balloons for preventing restenosis after fistuloplasty in patients with a native arteriovenous fistula. Two hundred and eleven patients will be followed up for a minimum of 1 year. Inclusion criteria include a clinical indication for a fistuloplasty, an access circuit that is free of synthetic graft material or stents, and a residual stenosis of 30 % or less after plain balloon fistuloplasty. Exclusion criteria include a synchronous venous lesion in the same access circuit, location of the stenosis central to the thoracic inlet or a thrombosed access circuit at the time of treatment. The primary endpoint is time to end of target lesion primary patency. This is defined as a clinically-driven radiological or surgical re-intervention at the treatment segment, thrombosis that includes the treatment segment, or abandonment of the access circuit due to an inability to re-treat the treatment segment. Secondary endpoints include angiographic late lumen loss, time to end of access circuit cumulative patency, the total number of interventions, and quality of life. The trial is funded by the National Institute for Health Research.DiscussionWe anticipate that this trial will provide rigorous data that will determine the efficacy of additional paclitaxel-coated balloon fistuloplasty versus plain balloon fistuloplasty only to preserve the patency of arteriovenous fistulae used for haemodialysis.Trial registrationISRCTN14284759. Registered on 28 October 2015.

Failure of maturation of native autologous arteriovenous fistulae (AVFs), fistula thrombosis and dialysis access dysfunction are most often caused by arteriovenous (AV) access stenosis. 1 The pathophysiology of AVF stenosis and mechanisms of restenosis are not yet fully understood.Venous neointimal hyperplasia is a recognised cause of vascular access stenosis and fistula failure. 2 Failure of fistula maturation and early fistula failure have been shown to be due to both neointimal hyperplasia and adverse adventitial remodelling or a failure of venous dilatation resulting in AVF stenosis. 2 Ultrasound is a non-invasive, readily available diagnostic tool used in the assessment of AVF dysfunction and failure of fistula maturation. Doppler ultrasound has a high sensitivity and specificity in the diagnosis of vascular access stenosis. 3,4 The technique, in the hands of an experienced operator, has high accuracy and reproducibility in detecting more than 90% of significant stenosis. 4 Ultrasound can also be used to assess neointimal hyperplasia by measuring intimal-medial thickness (IMT) at the site of a stenosis. 5 Carotid intima-media thickness (CIMT) measurements are made