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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">A radiocephalic AVF &#40;RC-AVF&#41; is the vascular access &#40;VA&#41; of choice for haemodialysis &#40;HD&#41; patients&#44; but it has a high rate of primary failure &#40;20&#37;&#8211;50&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">1&#44;2</span></a> Primary failure includes thrombosis and failure to mature&#46; Maturation is a complex process that depends on the interplay of patient-dependent and surgical factors&#46; The fundamental lesion that leads to failure to mature is stenosis wherein the pathological substrate is neointimal hyperplasia&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">3</span></a> In predialysis&#44; a diagnosis of maturity tends to be made clinically&#44; although the importance of ultrasound as a complementary method to have objective quantitative criteria is being increasingly emphasised&#46; However&#44; there are not many systematic ultrasound follow-up studies of maturation&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">4&#8211;7</span></a> There is effective treatment for failure to mature&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">8&#8211;12</span></a> Nonetheless&#44; achieving a RC-AVF suitable for starting HD remains a significant challenge&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">For this reason&#44; we studied RC-AVFs placed in predialysis that had clinical and ultrasound follow-up of their maturation&#46; The objectives of this study were to determine the characteristics of RC-AVFs by ultrasound&#44; also the causes and frequency of failure as well as the treatment for a failure to mature and&#44; finally&#44; the percentage that was suitable for use at the start of HD&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Patients and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">In this retrospective study&#44; we analysed the 127 RC-AVFs that were placed from January 2009 to March 2013 in 117 consecutive patients with G4 and G5 chronic kidney disease &#40;CKD&#41; without dialysis&#46; By protocol&#44; all patients had recent presurgical vascular mapping that consisted of a colour-Doppler duplex ultrasound scan &#40;Siemens Acuson 150&#215;&#41; and a CO<span class="elsevierStyleInf">2</span> venogram &#40;Phillips Ayura&#41; of the upper limb&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">13</span></a> All patients signed the informed consent form&#46; None of the patients had nephrotoxicity associated with the limited quantity &#40;3<span class="elsevierStyleHsp" style=""></span>ml&#41; of non-ionic contrast material to as complement to CO<span class="elsevierStyleInf">2</span>&#46; The radial&#44; cubital and humeral artery were studied&#44; as well as the superficial and deep venous system&#44; including the central veins&#46; The placement of a RC-AVF was not advised if any of the following conditions were present&#58; if the vessels &#40;radial artery and cephalic vein&#41; were &#60;1&#46;6<span class="elsevierStyleHsp" style=""></span>mm&#44; if there were irreparable venous lesions or if there was central ipsilateral stenosis&#46; The surgical procedure was performed under the same conditions in all the patients and by the same surgical team&#46; The type of VA ultimately created by the surgeon was decided according to the indication of the presurgical mapping and the intraoperative findings&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Monitoring of the maturation of the RC-AVFs was performed in 2 ways&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall">A physical examination&#44; within the first 72<span class="elsevierStyleHsp" style=""></span>h post-surgery&#44; at the time of ultrasound examination and at each follow-up visit&#46; This included inspection&#44; palpation and auscultation of the body and the anastomosis of the RC-AVF following the previously published protocol&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">14&#44;15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Colour-Doppler duplex ultrasound scan 1&#8211;4 months post-surgery by the same vascular radiology team&#46;</p></li></ul></p><p id="par0035" class="elsevierStylePara elsevierViewall">The RC-AVF was considered to be mature if the flow rate in the humeral artery was &#8805;500<span class="elsevierStyleHsp" style=""></span>ml&#47;min and the cephalic vein in the forearm had a diameter &#8805;0&#46;4<span class="elsevierStyleHsp" style=""></span>cm&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">4</span></a> A pseudo-delay of maturation was diagnosed when the above characteristics were present and the depth of the cephalic vein was &#62;0&#46;5<span class="elsevierStyleHsp" style=""></span>cm from the skin surface&#46; Stenosis was considered to be significant if it was &#62;50&#37; of the vascular lumen&#46; The juxta-anastomotic segment was considered to be the segment between the anastomosis and the first 5<span class="elsevierStyleHsp" style=""></span>cm of the artery or vein &#40;post-anastomotic segment&#41;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Maturation follow-up protocol and therapeutic approach</span><p id="par0040" class="elsevierStylePara elsevierViewall">Immature RC-AVFs were evaluated using fistulography and were treated radiologically or surgically depending on the type of lesion found&#46; Radiological treatment consisted of a percutaneous transluminal angioplasty &#40;PTA&#41; associated or not associated to permeabilisation of thrombotic venous occlusion using thromboaspiration&#46; Surgical treatment was either proximal reanastomosis or the creation of a new vascular access&#46; They were subsequently monitored using serial ultrasound until the start of HD&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Mature RC-AVFs with associated lesions &#40;stenosis with or without thrombotic occlusion&#41; were followed up with ultrasound and if at any time there was a decrease in the blood flow&#44; an increase in the resistive index or both&#44; then the appropriate treatment&#44; radiological or surgical&#44; was pursued as previously described&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Mature RC-AVFs without associated lesions were monitored clinically without standardised ultrasound monitoring until the start of HD&#46; During follow-up an imaging study was performed only if it was indicated by the clinical examination&#46; However&#44; in all cases an ultrasound study was performed prior to the first AVF puncture to rule out a complication that would render its use inadvisable&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The RC-AVF was considered to be suitable if it was the VA both at the start of HD and throughout the first 3 months of dialysis&#44; without requiring another VA or a central venous catheter &#40;CVC&#41;&#44; even if radiological treatment was required during this time&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Statistics</span><p id="par0060" class="elsevierStylePara elsevierViewall">Qualitative variables were expressed in percentages and quantitative variables were expressed in means and standard deviations&#46; The qualitative variables were compared using the chi-squared test&#44; and the quantitative variables were compared using comparison of means with Student&#39;s <span class="elsevierStyleItalic">t</span> test for independent data&#46; We performed a multivariate logistic regression study in which the dependent variable was an immature FC-AVF and some of the variables described in the literature were included as independent variables &#40;sex&#44; age&#44; obesity&#44; cardiovascular disease and diabetes mellitus&#41;&#46; Kaplan&#8211;Meier survival curves were used to study the primary and secondary permeability of the 127 FC-AVFs in predialysis&#46; Primary permeability was defined as the time elapsed from the placement of the AVF to the first therapeutic intervention or thrombosis&#46; Secondary permeability was defined as the time elapsed from the creation of the AVF to its abandonment due to irreparable dysfunction&#44; or to the start of HD or end of the follow-up period in patients who did not start HD during that time&#46; Finally&#44; we prepared a ROC curve to predict the required arterial flow rate that would determine the clinical sign of non-collapsible hyperpulsatility in immature RC-AVFs with significant post-anastomotic stenosis&#46; A <span class="elsevierStyleItalic">p</span> value &#60;0&#46;05 was considered to be statistically significant&#46; The data were analysed using SPSS version 20&#46;0&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">Of the 127 RC-AVFs&#44; 21 &#40;16&#37;&#41; had thrombosis in the first 72<span class="elsevierStyleHsp" style=""></span>h&#46; In the remaining 106 RC-AVFs&#44; after the ultrasound study&#44; 72 &#40;68&#37;&#41; were mature and 34 &#40;32&#37;&#41; were immature&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Mean patient age was 68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 years&#44; 38&#37; were diabetic and 33&#37; had clinical evidence of cardiovascular disease &#40;ischaemic cardiomyopathy&#44; ischaemic cerebrovascular accident&#44; intermittent claudication or peripheral ischaemic lesions&#41;&#46; clinical manifestation of cardiovascular disease was present in 47&#37; of patients with an immature RC-AVF and 26&#37; of patients with a mature RC-AVF &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;035&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In the logistic regression study the only variable of those studied that was associated with an immature RC-AVF was cardiovascular disease with an OR of 2&#46;6 &#40;95&#37; CI&#58; 1&#46;1&#8211;6&#46;1&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ultrasound characteristics of functioning radiocephalic arteriovenous fistulas</span><p id="par0075" class="elsevierStylePara elsevierViewall">Mean flow rate in the humeral artery was 805<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>479<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46; Flow rate exceeded one litre per minute in 27&#37; of cases and 1&#46;5<span class="elsevierStyleHsp" style=""></span>l&#47;min in 11&#37; of cases&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In mature RC-AVFs&#44; mean flow rate in the humeral artery was 1014<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>434<span class="elsevierStyleHsp" style=""></span>ml&#47;min and internal diameters in the different thirds of the cephalic vein&#44; from distal to proximal&#44; were 5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;6&#59; 5&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;1 and 5&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;9<span class="elsevierStyleHsp" style=""></span>mm&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; We found no lesions in 69&#37; of RC-AVFs&#44; at least one lesion &#40;stenosis with or without thrombotic occlusion&#41; in 31&#37; of them&#44; and of these&#44; we found more than one lesion in 18&#37;&#46; In 28&#37; of cases&#44; the lesion was post-anastomotic venous stenosis &#40;in 10&#37; it was significant and in 18&#37; it was not significant&#41;&#44; and in 8&#37; of cases&#44; it was located in the proximal vein &#40;1&#37; significant&#44; 3&#37; not significant and 4&#37; occlusion&#41;&#46; Among mature RC-AVFs&#44; 17&#37; had a maturation pseudo-delay&#46; We found an aneurysm without stenosis in 6&#37;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">In immature RC-AVFs&#44; mean flow rate in the humeral artery was 362<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>164<span class="elsevierStyleHsp" style=""></span>ml&#47;min and internal diameters in the different thirds of the cephalic vein&#44; from distal to proximal&#44; were 3&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;6&#59; 4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;6 and 4&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7<span class="elsevierStyleHsp" style=""></span>mm&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In 97&#37; of cases&#44; significant stenosis was found&#44; and of these cases&#44; 42&#37; had more than one lesion&#46; It was located in the post-anastomotic vein in 76&#37; of cases&#44; in the proximal vein in 42&#37; of cases &#40;of these&#44; half were thrombotic occlusion&#41;&#44; in the anastomosis in 6&#37; of cases and in the artery in 18&#37; of cases &#40;11&#37; juxta-anastomotic and 7&#37; diffuse&#41;&#46; Only 3&#37; of immature RC-AVFs did not have underlying lesions&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Therefore&#44; the most common cause of failure to mature was significant stenosis in the post-anastomotic vein&#46; This lesion often presents a non-collapsible hyperpulsatility on raising the arm&#46; In our case&#44; this sign was present in 60&#37; of immature RC-AVFs with significant post-anastomotic venous stenosis&#46; We found a significant difference &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;049&#41; in the flow rate of the humeral artery between those with the sign &#40;flow rate 443<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>182<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; and those without it &#40;flow rate 307<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>114<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46; In our population&#44; hyperpulsatility as a sign of significant post-anastomotic venous stenosis in immature RC-AVFs was present when the flow rate was &#8805;385<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;sensitivity&#58; 73&#37; and specificity&#58; 90&#37;&#41; &#40;AUC&#58; 0&#46;76&#59; 95&#37; CI&#58; 0&#46;56&#8211;0&#46;96&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Treatment of radiocephalic arteriovenous fistulas</span><p id="par0095" class="elsevierStylePara elsevierViewall">Of the 127 RC-AVFs studied&#44; 58 &#40;46&#37;&#41; received some type of treatment in predialysis&#46; The causes were&#58; 11&#37; post-surgical thrombosis&#44; 24&#37; failure to mature&#44; 6&#37; lesions that progressed in mature RC-AVFs and 5&#37; a maturation pseudo-delay&#46; The type of treatment was&#58; in 20 &#40;16&#37;&#41; a new VA &#40;12 contralateral RC-AVFs&#44; 4 humeral&#8211;cephalic RC-AVFs&#44; 2 cubital&#8211;basilic RC-AVFs&#44; one humeral&#8211;basilic RC-AVF and one humeral&#8211;axillary graft&#41;&#44; in 24 &#40;19&#37;&#41; radiological&#44; in 8 &#40;6&#37;&#41; proximal reanastomosis&#44; and in 6 &#40;5&#37;&#41; vein superficialisation&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Among mature RC-AVFs&#44; 18&#37; required treatment&#46; In immature RC-AVFs&#44; 88&#37; require treatment&#44; and only 12&#37; were not treated &#40;one case due to the absence of an underlying lesion&#44; 2 cases due death and another case due to patient&#39;s refusal&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the treatment performed in each type of AVF &#40;mature with or without lesions&#44; and immature with or without lesions&#41;&#46; Among mature RC-AVFs without lesions&#44; 10&#37; required surgical treatment &#40;cephalic vein superficialisation&#41;&#46; Regarding mature RC-AVFs with associated lesions&#44; 36&#37; required treatment&#58; surgical in 37&#46;5&#37; of cases and radiological in 62&#46;5&#37; of cases&#46; Finally&#44; in the case of immature RC-AVFs&#44; 56&#37; were treated radiologically&#44; 32&#37; were treated surgically and 12&#37; received no treatment for the above-mentioned reasons&#46; Therefore&#44; the most common treatment in immature and mature RC-AVFs with lesions was radiological&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">A total of 28 PTAs were performed in 24 RC-AVFs &#40;19 immature and 5 mature with lesions that progressed&#41;&#46; A PTA of one lesion was performed in 20 patients&#44; and a PTA of 2 lesions was performed in the same procedure in 4 patients&#46; In 3 cases&#44; in addition to a PTA&#44; the vein was repermeabilised owing to associated thrombotic occlusion&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the location of the lesions treated using a PTA&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Post-anastomotic venous stenosis was treated with a PTA in 19 cases &#40;68&#37;&#41;&#44; a new VA in 5 cases &#40;18&#37;&#41; and proximal reanastomosis in 4 cases &#40;14&#37;&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Clinical course of the arteriovenous fistulas treated</span><p id="par0120" class="elsevierStylePara elsevierViewall">Of the patients who were treated radiologically&#44; 17 started HD during the study&#44; and in these patients the mean number of predialysis PTAs was 1&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&#46; One PTA was required in 77&#37; and 2 PTAs were required in 23&#37; prior to the start of HD&#46; Mean time between the first PTA and the start of HD was 6&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8 months &#40;1&#8211;32 months&#41;&#46; In 94&#37; of RC-AVFs treated radiologically&#44; this AVF was the VA at the start of HD&#44; and in 6&#37;&#44; another type of AVF had to be placed &#40;one patient required a humeral&#8211;axillary graft since that patient had previously had a contralateral RC-AVF placed and it too had failed&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In the subgroup of patients with significant post-anastomotic venous stenosis the AVF worked at the commencement of HD in 93&#37; of those treated with a PTA &#40;14 of 15&#41; and 100&#37; &#40;2 of 2&#41; who underwent proximal reanastomosis&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The primary and secondary permeability curves of all the RC-AVFs in predialysis are shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; Primary and secondary permeability were 59&#37; and 78&#37; at 6 months&#44; 48&#37; and 77&#37; at 12 months&#44; and 43&#37; and 75&#37; at 24 months&#44; respectively&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Characteristics of the vascular access at the start of haemodialysis</span><p id="par0135" class="elsevierStylePara elsevierViewall">Of the 58 patients who started HD at the time of the study&#44; 76&#37; did so with a RC-AVF&#44; 10&#37; with another AVF &#40;5&#37; humeral&#8211;cephalic&#44; 4&#37; cubital&#8211;basilic and 1&#37; humeral&#8211;axillary graft&#41; and 14&#37; with a CVC&#46; Mean time between surgery and the start of HD was 12&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;7 months&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Of the 44 RC-AVFs that were suitable at the start of HD&#44; 43&#37; of them were treated in predialysis &#40;36&#37; radiologically and 7&#37; surgically&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> schematically represents the type of VA used to start HD according to RC-AVF&#44; whether it was immature&#44; immature specifically treated in predialysis or mature&#46; Of the 58 patients who started HD&#44; 23 had an immature RC-AVF and 35 had a mature AVF with or without lesions&#46; Of the 23 patients with an immature RC-AVF&#44; 5 &#40;22&#37;&#41; required a CVC since the start of HD was unexpected and&#44; as a result&#44; there was not time enough to perform a treatment in predialysis&#46; One out of the 5 patients with immature RC-AVF was not treated owing to the patient&#39;s refusal and the AVF was irreparable at the time of the start of dialysis&#46; The 4 remaining patients received a treatment during the first week of dialysis session&#58; one case with a PTA&#44; 2 cases with proximal reanastomosis and one case with a contralateral RC-AVF&#46; In patients with an immature RC-AVF specifically treated in predialysis &#40;18 patients&#41;&#44; none of them required a CVC and 78&#37; did so with this RC-AVF&#46; Finally&#44; all the patients with a mature RC-AVF with or without associated lesions started HD using their RC-AVF&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">The patients who started HD using a CVC &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41; and those who did so with an AVF &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&#44; had no significant differences in relation to age&#44; sex&#44; diabetes mellitus&#44; cardiovascular disease&#44; obesity or CKD aetiology&#46; The only difference observed was the time elapsed between surgery and the start of HD &#40;5 months versus 13 months&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0155" class="elsevierStylePara elsevierViewall">Consistent with the literature&#44; 43&#37; of our RC-AVFs had a primary failure that required a treatment in predialysis to avoid the use of CVC at the start of HD&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">1&#44;2</span></a> In 16&#37;&#44; thrombosis occurred in the first 72<span class="elsevierStyleHsp" style=""></span>h&#44; and 32&#37; of non-thrombosed RC-AVFs had a failure to mature&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Maturation is a very complex process that makes a RC-AVF becomes suitable for HD&#46; It starts at when the anastomosis is created and is followed by vascular remodelling that includes an increase in the diameter and arterial and venous blood flow&#44; as well as a thickening of the venous wall that will allow repeated venipuncture and a sufficient flow rate for HD&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">16&#44;17</span></a> The complexity of this process reflects the fact that it is a result of the interplay of multiple factors&#46; Some are patient-dependent factors that will determine the capacity for vascular remodelling&#46; Others are surgical factors that will create the intra-FAV shear pressure required for vascular remodelling&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">18</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Presurgical factors reported to be associated with a failure to mature include female sex&#44; obesity&#44; diabetes&#44; age and cardiovascular disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">12&#44;18&#44;19</span></a> In our case&#44; the only one of the above variables associated with a failure to mature was clinically manifestation of cardiovascular disease&#46; The many traditional and non-traditional factors &#40;oxidative stress&#44; inflammation&#44; calcium and phosphorus metabolism&#44; nutrition&#44; and endothelial dysfunction&#41; associated with CKD that determine a greater cardiovascular risk in these patients may contribute to a VA&#39;s failure to mature&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">20</span></a> CKD is known to accelerate venous neointimal hyperplasia in animal models&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">21</span></a> Moreover&#44; 83&#37; of patients with advanced CKD have venous neointimal hyperplasia at the time of surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">3</span></a> Finally&#44; the potential contribution to a failure to mature of the abnormal capacity for arterial and venous vasodilatation in patients with CKD should be taken into consideration&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">22&#44;23</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Currently&#44; we do not have vascular anatomical and functional able to define the risk for a failure to mature of a fistula<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">7</span></a>&#59; however presurgical mapping in all patients&#44; as well as a good surgical technique&#44; may contribute to obviate the negative effect of the above-mentioned factors on a failure to mature&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">24&#8211;27</span></a> Multiple studies have demonstrated similar results in these populations at risk when preoperative ultrasound is used&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">28&#8211;33</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">It is known that systematic preoperative ultrasound evaluation increases the percentage of RC-AVFs performed&#44; although it also increases the number of immature RC-AVFs&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">33</span></a> However&#44; if a protocol is applied for early and effective treatment of a failure to mature&#44; the final result will be an increase in the number RC-AVFs that ready to be use at the start of HD&#46; Our protocol for approaching a VA in predialysis is an example of this concept&#44; such that 78&#37; of the patients with an immature RC-AVF that is treated in predialysis will start HD with this AVF and none with a CVC&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In immature RC-AVFs&#44; we found an underlying lesion in almost 100&#37; of cases&#46; As in other series&#44; the most common location of the lesion was the post-anastomotic vein&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">8</span></a> There were different reasons to explain this&#44; but essentially&#44; the configuration of the AVF itself is contributing factor due the abnormal stress generated shear pressure exerted on the endothelium and also the potential injury due to surgical manipulation&#46; Both of these factors would stimulate neointimal hyperplasia and vasoconstriction resulting in stenosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">16&#44;34&#8211;38</span></a> In our case&#44; this lesion was treated radiologically in the majority of cases with a good outcome and required re-interventiont in a relatively low percentage of cases &#40;20&#37;&#41;&#46; Currently&#44; the superiority of surgical vs radiological treatment in this type of lesion has not been established&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">39</span></a> Availability at each centre will determine the type of treatment used&#46; In our department&#44; the most common treatment is radiological&#59; surgical treatment is reserved for certain lesions that would not benefit from PTA &#40;long or multiple lesions&#41;&#46; Therefore&#44; in our case&#44; we cannot compare the outcomes of the two treatments&#46; Another fact of interest supporting ultrasound follow-up in immature RC-AVFs is that only 60&#37; of cases with significant post-anastomotic stenosis had non-collapsible hyperpulsatility&#44; and so a clinical examination would have a limitation their diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">14</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">It should be noted that mature RC-AVFs had lesions in 31&#37; of cases and that 18&#37; of cases will progress and will require treatment in predialysis&#46; This highlight the fact that ultrasound follow-up of the maturation offers advantages over exclusively clinical follow-up&#59; this had already been published in other series but with a lower number of RC-AVFs&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">5&#44;6</span></a> Moreover&#44; ultrasound was essential for the diagnosis of a maturation pseudo-delay &#40;which affected 17&#37; of our mature AVFs&#41;&#46; Finally&#44; it should be noted that a high percentage of our AVFs had high flow rates&#44; which alert about the potential deleterious cardiological effect in the mid- to long term&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">40&#44;41</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In our patients the most common type of treatment of failure to mature was radiological&#46; The difference between the primary and secondary permeability curves&#44; which is very similar to those previously published&#44;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">8&#44;12</span></a> illustrate the efficacy of the treatment of failure to mature in our patients&#46; Overall&#44; 94&#37; of immature RC-AVFs treated radiologically will be suitable at the start of HD&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Finally&#44; the most determining factor for avoiding a CVC was placement of RC-AVF with enough time in advance sp the diagnose and treatment of primary failure before can be made before commencenment of HD&#46; The time to place a VA in predialysis is very difficult to determine&#46; In our case&#44; it seems that VA should be placed at least 6&#8211;12 months prior to the start of HD&#44; which would be in line with the recommendations of the different guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">42&#8211;44</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">In summary&#44; ultrasound was very useful in the study of maturation of VA in predialysis since it allowed us&#58; A&#41; To determine the patient&#39;s vascular status regardless of his or her potential comorbidities&#46; B&#41; To diagnose an immature AVF and its potential causes and guide its treatment&#46; C&#41; To diagnose&#44; in mature AVFs&#44; potential associated lesions&#44; which may initially have no functional repercussions but may progress and require treatment&#46; D&#41; To diagnose a maturation pseudo-delay&#46; E&#41; To quantify the vascular flow rate&#46; F&#41; To diagnose in some cases lesions that did not have clinical expressivity&#46; Therefore&#44; all the above contingencies show that ultrasound in the follow-up of maturation offers advantages over exclusively clinical follow-up&#44; such that they should complement each other&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">In conclusion&#44; with our approach to the VA in predialysis we have achieved that 80&#37; of our patients were able to start HD using a distal AVF &#40;76&#37; radiocephalic and 4&#37; cubital&#8211;basilic&#41;&#44; potential complications of more proximal VA have been prevented and therefore we have saved venous resources that may be vital for our patients&#8217; future&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Patients and methods"
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              "titulo" => "Maturation follow-up protocol and therapeutic approach"
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              "titulo" => "Statistics"
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              "titulo" => "Ultrasound characteristics of functioning radiocephalic arteriovenous fistulas"
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              "identificador" => "sec0035"
              "titulo" => "Treatment of radiocephalic arteriovenous fistulas"
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              "titulo" => "Clinical course of the arteriovenous fistulas treated"
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              "identificador" => "sec0045"
              "titulo" => "Characteristics of the vascular access at the start of haemodialysis"
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          "titulo" => "Discussion"
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    "fechaRecibido" => "2015-05-14"
    "fechaAceptado" => "2015-10-28"
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            0 => "Radiocephalic arteriovenous fistula"
            1 => "Predialysis"
            2 => "Failure of maturation"
            3 => "Ultrasonography"
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            0 => "F&#237;stula arteriovenosa radio-cef&#225;lica"
            1 => "Predi&#225;lisis"
            2 => "Fracaso de maduraci&#243;n"
            3 => "Ecograf&#237;a"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of the study was to analyse outcomes of AVF-RC in predialysis stage in which a clinical and radiological follow up of its maturation had been done and primary failure had been treated&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We studied 127 RC-AVF in 117 predialysis patients&#46; All cases had a preoperative map&#46; The RC-AVF was considered mature if it had a brachial artery flow &#8805;500<span class="elsevierStyleHsp" style=""></span>ml&#47;min and a cephalic vein diameter of &#8805;4<span class="elsevierStyleHsp" style=""></span>mm&#46; Primary failure was treated radiologically or surgically depending on the type of lesion&#46; Fifty-eight patients started dialysis at the time of the study&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In 106 RC-AVF without thrombosis&#44; 72 &#40;68&#37;&#41; were mature and 34 &#40;32&#37;&#41; were immature&#46; A total of 97&#37; of the immature had at least one lesion&#44; and the most common site was the post-anastomotic vein&#46; Lesions were found in 31&#37; of mature RC-AVF&#44; and 18&#37; of patients required treatment&#46; Radiological treatment was the most frequent for maturation failure&#46; After 6 months&#44; primary and secondary patency were 59&#37; and 78&#37;&#44; while after 12 months they were 48&#37; and 77&#37;&#44; respectively&#46; The 80&#37; of patients started dialysis with a distal AVF &#40;76&#37; RC-AVF and 4&#37; ulnar basilic&#41;&#46; None of the patients with treated immature RC-AVF started dialysis with CVC&#44; while 78&#37; of the patients started with said AVF&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ultrasonography for monitoring maturation provides advantages over clinical monitoring&#46; With our management of RC-AVF in predialysis&#44; 80&#37; of patients start dialysis with an adequate distal AVF&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo del estudio fue analizar las FAV-RC en predi&#225;lisis en las que se hizo un seguimiento cl&#237;nico y ecogr&#225;fico de la maduraci&#243;n y cuyo fracaso se trat&#243;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudiamos 127 FAV-RC en 117 pacientes predi&#225;lisis&#46; Todos dispon&#237;an de un mapa preoperatorio&#46; La FAV-RC era madura si ten&#237;a un flujo en la arteria humeral &#8805;500<span class="elsevierStyleHsp" style=""></span>ml&#47;min y un di&#225;metro en la vena cef&#225;lica &#8805;4<span class="elsevierStyleHsp" style=""></span>mm&#46; Se trat&#243; el fracaso de maduraci&#243;n seg&#250;n el tipo de lesi&#243;n&#46; Un total de 58 pacientes iniciaron hemodi&#225;lisis durante el seguimiento&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En las 106 FAV-RC funcionantes&#44; 72 &#40;68&#37;&#41; fueron maduras y 34 &#40;32&#37;&#41; inmaduras&#46; El 97&#37; de las inmaduras presentaron al menos una lesi&#243;n y la localizaci&#243;n m&#225;s frecuente fue la vena postanastom&#243;tica&#46; El 31&#37; de las FAV-RC maduras ten&#237;an lesiones y en el 18&#37; precisaron tratamiento&#46; El tratamiento m&#225;s frecuente del fracaso de maduraci&#243;n fue radiol&#243;gico&#46; A los 6 meses la permeabilidad primaria y secundaria fue del 59 y del 78&#37;&#59; a los 12 meses del 48 y del 77&#37;&#44; respectivamente&#46; El 80&#37; de los pacientes iniciaron hemodi&#225;lisis con una FAV distal &#40;76&#37; radio-cef&#225;licas y 4&#37; cubitobas&#237;licas&#41;&#46; Ning&#250;n paciente con una FAV-RC inmadura tratada lo hizo con CVC y un 78&#37; lo hizo con dicha FAV&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La ecograf&#237;a en el seguimiento de la maduraci&#243;n aporta ventajas frente al seguimiento cl&#237;nico&#46; Con nuestro abordaje del AV en predi&#225;lisis conseguimos que el 80&#37; de nuestros pacientes inicien hemodi&#225;lisis mediante una FAV distal&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Muray Cases S&#44; Garc&#237;a Medina J&#44; P&#233;rez Abad JM&#44; Andreu Mu&#241;oz AJ&#44; Ramos Carrasco F&#44; P&#233;rez P&#233;rez A&#44; et al&#46; Importancia del seguimiento y tratamiento del fracaso de maduraci&#243;n en la f&#237;stula arteriovenosa radio-cef&#225;lica en predi&#225;lisis&#46; Papel de la ecograf&#237;a&#46; Nefrologia&#46; 2016&#59;36&#58;410&#8211;417&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ultrasound characteristics of mature and immature RC-AVFs&#46; A&#41; Flow rate in the humeral artery&#46; Significant differences in flow rate &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#46; B&#41; Diameters of the cephalic vein in the forearm in its distal&#44; medial and proximal third&#46; Significant difference in diameters &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Total population &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>117&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Immature RC-AVF &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mature RC-AVF &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;mean &#91;SD&#93;&#41; &#40;years&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Men&#47;women &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#47;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#47;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#47;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Left&#47;right RC-AVFs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">102&#47;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Diabetes mellitus&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Cardiovascular disease n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;035&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Obesity &#40;BMI</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">33&#41;&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">CKD aetiology&#44; &#37;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Glomerular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Polycystitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics of the population&#46; Comparison of these characteristics between mature and immature RC-AVFs&#46;</p>"
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        "etiqueta" => "Table 2"
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                0 => """
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of AVF&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Without lesion &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 superficialisations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">With lesion &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 superficialisation<br>1 reanastomosis<br>1 new VA<br>5 PTAs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Immature AVF &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Without lesion &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">With lesion &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 PTAs<br>5 reanastomosis<br>6 new VAs<br>3 no&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Type of treatment according to type of RC-AVF&#46;</p>"
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
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            2 => array:3 [
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            3 => array:3 [
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            5 => array:3 [
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