Guidelines 3
📘 GuidelineCh 9 · Vascular & Venous Surgery⏳ Pending verification
UKKA Clinical Practice Guideline: Vascular Access for Haemodialysis (April 2023)
UKKA's vascular access guideline for haemodialysis: early education and vein preservation, referral and fistula formation for people likely to start haemodialysis within 12 months (2C), combined clinical and ultrasound assessment, and treatment of clinically significant stenosis with dysfunction (1B).
April 2023 · UK Kidney Association (UKKA)
📘 GuidelineCh 9 · Vascular & Venous Surgery⏳ Pending verification
Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery (20 October 2023)
The SBACV guideline on vascular access for hemodialysis, answering fourteen practical questions: native arteriovenous fistula generally preferred but selection individualised, duplex mapping when examination cannot predict anatomy, and no evidence-supported universal minimum vessel diameter (2C).
2023 · Sociedade Brasileira de Angiologia e de Cirurgia Vascular (SBACV)
📘 GuidelineCh 9 · Vascular & Venous Surgery⏳ Pending verification
Expert consensus on the establishment and maintenance of native arteriovenous fistula (16 June 2021)
The Chinese expert consensus on native arteriovenous fistula: after evaluation and planning, native AVF should generally be the first choice — covering preoperative assessment, vessel planning, operative technique, perioperative drugs and postoperative maintenance, with decisions individualised to local circumstances.
2021 · Expert Group of the Nephrology Branch of the China Academy of Chronic Disease Urology Nephrology and Blood Purification Commission of the China Medical Education Association
Live book 7
Practice Shift — Acute Limb Ischemia: Heparin Now, Rutherford Class Decides the Route (Addendum §11.1, Row 3)Heparinise acute limb ischemia immediately and let the Rutherford class drive the route: CTA and catheter therapy for Classes I–IIa, emergency operating-room thromboembolectomy for IIb, primary amputation for irreversible Class III.Practice Shift — CLTI: Map the Vein First — Bypass With Good GSV, Endovascular Otherwise (Addendum §11.1, Row 4)Map the saphenous vein before choosing the CLTI strategy: fit patients with an adequate single-segment GSV get open bypass first (BEST-CLI); patients without a usable vein, high-risk patients, and isolated infrapopliteal disease get endovascular-first (BASIL-2) — all on full medical therapy.Practice Shift — Dialysis Access: Fistula-First Life-Plan, Salvage Steal Without Ligation (Addendum §11.1, Row 6)Plan dialysis access by the ESKD Life-Plan — mapped autogenous fistula first, distal to proximal, prosthetic graft only when veins are exhausted — and salvage a stealing fistula with DRIL, RUDI or PAI instead of ligating it.Practice Shift — Extremity Arterial Trauma: Hard/Soft Signs and ABI Triage, Shunt Before Fixation (Addendum §11.1, Row 5)Triage extremity arterial trauma by hard and soft signs plus the injured extremity index: hard signs go straight to the operating room — and when bone and vessel are both injured and ischemia time is running, shunt first and graft definitively after stabilisation.Practice Shift — Saphenous Reflux: Endovenous Ablation First, Stripping Reserved (Addendum §11.1, Row 1)Ablate symptomatic saphenous reflux endovenously first — outpatient EVLA or RFA under duplex guidance and tumescent local anesthesia — and reserve open high ligation and stripping for when endovenous treatment is unavailable or the anatomy is extreme.Practice Shift — Venous Leg Ulcer: Early Ablation Within 2 Weeks, Not Compression Alone (Addendum §11.1, Row 2)Ablate early in active venous leg ulceration — within 2 weeks, on top of multilayer compression, after checking arterial inflow — instead of compressing alone and deferring ablation until the ulcer has completely healed.Stepwise Clinical Decision Pathway — Vascular, Endovascular & Venous Surgery (§11.2)Work the vascular pathway in four steps: duplex-map and arterially screen before any compression, ablate superficial reflux early in active ulceration, triage acute limb ischemia by Rutherford class under immediate heparin, and choose CLTI revascularization by conduit and anatomy.
Codes 26
PER-DFU-COMP-01 — Infection58% · ≈50–60% — (a) Infected at presentation to specialist centres; (b) ulcers becoming infected over their course — two labelled metricsPER-DFU-COMP-02 — HospitalisationUp to ~20% — DFU patients requiring hospital admissionPER-DFU-CTX-01 — DFU precedes ~80% of diabetes-related amputations; 5-year mortality ~30% (context)CONTEXT ONLY: DFU precedes ~80% of diabetes-related amputations; 5-yr mortality ~30% — This is the reason prevention matters, quoted once.PER-DFU-PREV-01 — Lifetime incidence of DFU19–34% — Proportion of people with diabetes who develop ≥1 foot ulcer during their lifetimePER-DFU-PREV-02 — Annual incidence of DFU~2% per year (2.2% in the UK community study) — New ulcers per year among people with diabetesPER-DFU-PREV-03 — Point prevalence of active DFU6.3% (95% CI 5.4–7.3) — Proportion of people with diabetes with an active foot ulcer at a given timePER-DFU-PREV-04 — Diabetic peripheral neuropathy — prevalencePoint prevalence ≈30% · and · ~50% develop DPN over a lifetime — DPN by clinical/neurophysiological criteria — two different metrics, published split, never blended (Dispute D4)PER-DFU-PREV-05 — PAD among people with a DFU49% — PAD diagnosed (ABI <0.9 in EURODIALE) in patients presenting with a new DFUPER-DFU-PREV-06 — Ulcer composition by perfusion statusNo PAD: 51% · PAD present: 49% · majority · purely ischaemic ulcers are a small minority — EURODIALE 4-stage classification by PAD ± infection at presentationPER-DFU-PROT-01 — Pressure-relieving therapeutic footwear (custom-made / demonstrated pressure relief, worn indoors + outdoors)13.3% vs 25.4% · RR 0.49 (95% CI 0.28–0.84) · halves — Ulcer recurrence with usual footwear — , i.e. roughly recurrencePER-DFU-PROT-02 — The footwear effect is conditional on pressure relief + adherenceOR 2.33 · neither · and — Recurrence when condition was met (in-shoe peak pressure <200 kPa device adherence >80% of steps). Wearing the device is not enough — it must actually offload, and actually be wornPER-DFU-PROT-03 — Home foot-temperature monitoring (daily plantar temperature; act if >2.2 °C difference vs the other foot on 2 consecutive days)Disputed — see D2. · 0.51 · RR 0.78 (0.57–1.08), p=0.133 — not significant · Adopted position: a real but adherence-dependent adjunct — never headline "halves your risk" unqualified — 🔴 Pooled MA of 4 early RCTs: effect ≈ (95% CI 0.31–0.84; absolute recurrence 18.7% vs 30.8%). Largest pragmatic RCT (DIATEMP, n=304, 18 months): primary endpoint ; any-site recurrence RR 0.76 (0.58–1.00), p=0.046; the subgroup who actually reduced activity on a hotspot: RR 0.34 (0.11–0.99).PER-DFU-PROT-04 — Structured foot-care education aloneNo adoptable protective number. · insufficient and inconsistent · Low — Cochrane (12 RCTs): education improves knowledge and short-term self-care behaviour, but evidence that *limited education alone* reduces ulcer incidence is — the one positive ulcer result (RR 0.31) came from a high-bias-risk trial, while the lower-bias-risk trial found RR 1.00 (0.70–1.44). IWGDF nonetheless recommends structured education as a component of care (Strong recommendation, certainty)PER-DFU-PROT-05 — Risk stratification + scheduled foot screeningRisk 0 · yearly · Risk 1 · 6–12-monthly · Risk 2 · 3–6-monthly · Risk 3 · 1–3-monthly · Honesty note: no RCT isolates screening itself as the intervention that reduces ulcer incidence — IWGDF system: (no LOPS/PAD) → screen ; (LOPS or PAD) → ; (LOPS+PAD, or either + deformity) → ; (LOPS or PAD + prior ulcer/amputation/end-stage renal disease) → . Population distribution of categories (JAMA, adapted from Stang & Leese): risk 0 ≈78.6%, risk 1 ≈14.2%, risk 2 ≈4.3%, risk 3 ≈1.8%. — screening works by triggering footwear, education and care intensity; IWGDF grades the stratification/prognosis evidence High, the downstream pathway is what carries the effectPER-DFU-PROT-06 — Integrated foot care (professional foot care + adequate footwear + structured education, repeated: 1–3-monthly if high risk, 3–6-monthly if moderate)No single pooled ulcer-incidence figure verified · amputation · outside this dossier's scope and not quoted — recommended as a package by IWGDF (Strong; Low certainty). The components with numbers are carded separately above (footwear PROT-01; education PROT-04). The multidisciplinary-care effect most often quoted is an outcome and is thereforePER-DFU-REC-01 — Recurrence after healing42% at 1 year · 58% at 3 years · 65% at 5 years — Any new ulcer after complete healing of the index ulcer (same or different site)PER-DFU-RISK-01 — Loss of protective sensation (LOPS)Likelihood ratio 11–16 · OR 3.68 — (a) Future ulceration — positive monofilament test; (b) ulcer recurrencePER-DFU-RISK-02 — PADOR 3.10 (95% CI 2.43–3.95) — Ulcer recurrence after healingPER-DFU-RISK-03 — Foot deformityOR 2.51 (95% CI 1.85–3.40) — Ulcer recurrencePER-DFU-RISK-04 — Diabetic peripheral neuropathyOR 1.78 (95% CI 1.45–2.19) — Ulcer recurrencePER-DFU-RISK-05 — Plantar location of the index ulcerOR 2.44 (95% CI 1.41–4.23) — Ulcer recurrencePER-DFU-RISK-06 — Previous foot ulcer (or amputation)The strongest single predictor of ulceration · risk category 3 · remission, not cure — Future ulcerationPER-DFU-RISK-07 — Poor glycaemic control (HbA1c)1.24 (1.05–1.46) · 1.98 (1.65–2.39) · 2.68 (2.13–3.37) · 4.52 (3.62–5.65) — First lower-limb ulcer incidence (dose–response)PER-DFU-SUC-01 — Healing of neuropathic ulcers with good standard careSplit by population (Dispute D3): · 24.2% healed by 12 weeks (95% CI 19.5–28.8) · 30.9% by 20 weeks (26.6–35.1) · ≈30–40% healed at 12 weeks — Complete healing by 12 and 20 weeks; standard care = debridement, dressings, pressure offloading, infection treatment as needed — no advanced adjuncts (trial control arms)PER-DFU-SUC-02 — Healing by 1 year — and the PAD penalty≈77% heal within 1 year · 84% without PAD vs 69% with PAD — Any healing within 1 year of presentation at specialist centresPER-DFU-SUC-03 — Offloading device type and healing81.9% vs 66.1% · RR 1.24 (95% CI 1.09–1.41) · 80–90% — Complete healing of plantar neuropathic ulcers; non-removable (TCC / irremovable walker) vs removable devices