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",isbn:"978-1-80356-201-8",printIsbn:"978-1-80356-200-1",pdfIsbn:"978-1-80356-202-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,hash:"528a15fa0d821fb8bf4ffac5c3cc19f4",bookSignature:"Dr. Courtney Marsh",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11705.jpg",keywords:"Anatomy, Physiology, Reproduction, Fertility, Contraception, Metabolism, Food, Appetite, Obesity, Mood, Cognition, Behaviour",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 4th 2022",dateEndSecondStepPublish:"April 7th 2022",dateEndThirdStepPublish:"June 6th 2022",dateEndFourthStepPublish:"August 25th 2022",dateEndFifthStepPublish:"October 24th 2022",remainingDaysToSecondStep:"2 months",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Courtney Marsh is a reproductive endocrinology and infertility division director at the University of Kansas School of Medicine. She is the research chair for the department of obstetrics and gynecology and is active in many research activities.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"255491",title:"Dr.",name:"Courtney",middleName:null,surname:"Marsh",slug:"courtney-marsh",fullName:"Courtney Marsh",profilePictureURL:"https://mts.intechopen.com/storage/users/255491/images/system/255491.jpg",biography:"After graduating from the University of Kansas School of Medicine (KUMC), Dr. Marsh went on to complete her obstetrics and gynecology residency at Emory University, Atlanta, Georgia. For fellowship, Dr. Marsh trained in reproductive endocrinology and infertility at the University of Michigan.\n\nAs a fellow, she researched hypothalamic feedback of estrogen as related to the pubertal onset and menstrual cyclicity. She also completed research using neuroimaging techniques to better understand polycystic ovary syndrome (PCOS). She has several publications in the scientific literature and is also a member of many medical associations.\n\n Dr. Marsh specializes in treating women with infertility and PCOS. She is proud to provide both medical and surgical options in treating infertility including assisted reproductive technology.",institutionString:"University of Kansas Medical Center",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"University of Kansas Medical Center",institutionURL:null,country:{name:"United States of America"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"440204",firstName:"Ana",lastName:"Cink",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/440204/images/20006_n.jpg",email:"ana.c@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"40903",title:"Vascular Access for Hemodialysis - Overview and Emphasis on Complications",doi:"10.5772/53220",slug:"vascular-access-for-hemodialysis-overview-and-emphasis-on-complications",body:'\n\t\t\n\t\t\t
A functioning vascular access (VA) represents a key issue in the management of patients needing acute or chronic hemodialysis (HD). However, VA surgeons, interventionists and all involved in VA creation and preservation are facing an everyday challenge, a huge one: How to meet their HD patients’ VA needs. Most centers over the world are currently taking care of a steadily increasing and aging HD population, with more and more comorbidities, particularly diabetes mellitus, as well as of a growing proportion of prevalent patients with history of multiple access failures. With help of both autogenic and graft materials it has been possible to develop up to the present a wide armamentarium of VA options. However, all access alternatives are plagued with the same problems as in the past decades: thrombosis, infection, steal, etc, all of which limit their time span. In addition, anatomic sites for access creation are limited and may become exhausted. Every VA that fails brings the patient one step closer to a terminal access problem, a point where all roads seem closed. To avoid reaching this point, every VA team should be able, through careful planning and systematic application of adequate techniques for VA creation and preservation, to reduce VA-related complications to a minimum. In this chapter, a general overview of the field of VA for chronic hemodialysis in adult patients is offered where the most relevant topics are mentioned and briefly discussed. It is by no means an exhaustive review but we hope this way to convey an idea of the magnitude and complexity of the VA-related problematic and their possible solutions. We have dispensed with including details of VA history since a lot of well documented work on this issue is available in the literature.
\n\t\t\n\t\t
Temporary access in current nephrological praxis is synonymous with double lumen catheters whose main goal is to serve as interim VA. Emergent HD in a patient with chronic kidney disease (CKD) is the commonest indication for HD catheter insertion. It is a known fact that in most countries over the world a significant proportion, if not the majority of CKD patients starting HD do not have a functioning PVA [1]. Some of the reasons for this trend are:
\n\t\t\tmany patients seek specialized medical care for the first time when frank uremic symptoms are present,
late referral to either a nephrologist or
to the access surgeon, etc, which do not allow for a permanent VA to be timely created.
Two types of double-lumen catheters are used for emergent acute or chronic HD:
\n\t\t\tnon-tunneled, uncuffed (NTC) also called acute or temporary catheters, and
Tunneled, cuffed catheters (TC, called “permanent” catheters).
NTC are still the most commonly used catheter type for emergent HD and can be readily inserted, exchanged and withdrawn either at bedside or in a procedure at any center or outpatient dialysis facility. Although NTC are deemed to be used for a short dwell times (< 3 weeks), in some centers they are used for extended periods. Eventually, they are even exchanged for up to 2 times in case of malfunction [2].
\n\t\t\t\tTypical NTC insertion method is the Seldinger technique, which consists in placing a catheter percutaneously through a guidewire [3]. Once inserted, the NTC should be firmly fixed to the skin by means of a monofilament nonabsorbable synthetic suture (polyproplylene or nylon). Multifilament, also called “braided” sutures like silk, should not be used because bacteria may hide within the interstices of the braids and this way the catheter entry site may become secondarily infected. A loose fixation of the catheter to skin causes a constant in- and outward movement of the catheter through entry site which favors bacterial colonization and infection. Dehiscent sutures lead to partial or total catheter extrusion. In case of partial extrusion, no attempt should be done to reintroduce the catheter but rather, if deemed safe, it may be exchanged over a guidewire.
\n\t\t\t\tThe preferred insertion site is the right internal jugular vein (IJV) mainly because in a great majority of cases it does not interfere with ulterior AV access creation on the ipsilateral upper extremity [4]. On the contrary, catheterization of the left IJV is not equally safe as the right one and is associated with left innominate vein stenosis or thrombosis [2,5]. Femoral veins are safer vein accesses in emergency settings particularly in patients with high risk of bleeding [6]. However, when left in place for extended periods, femoral catheters may lead to stenosis and thrombosis of the external and/or common iliac veins causing significant impairment of venous drainage of the lower limbs with mild to severe, painful edema. In transplantation candidates, external iliac vein thrombosis, which can extend up to common iliac vein may preclude ulterior renal graft placement on the affected side. With respect to subclavian vein approach, the KDOQI guidelines [7] strongly recommend its avoidance unless:
\n\t\t\t\t\tpermanent access creation on the ipsilateral extremity is not possible because of severe arterial occlusive disease,
all potential access sites on the side are exhausted, or
when there is no other option.
Subclavian vein stenosis or thrombosis are a sequelae of 20 to 50% of subclavian vein catheters, which usually preclude ulterior use of ipsilateral arm for PVA creation [4]. Endovascular procedures like balloon angioplasty or stenting have proved useful in restoring central vein patency [8].
\n\t\t\t\tReal-time ultrasound guidance decreases significantly the rate of puncture-related complications in the case of IJV cannulation [9]. Landmark-guided puncture may be an acceptable alternative in experienced hands. Regardless of the employed insertion technique, in patients with history of previous IJV catheterization, checking sonographically for IJV patency (Figure 1) before making any catheter insertion attempt is strongly advised.
\n\t\t\t\t\tA) Normal ultrasound appearance of the right internal jugular vein (RIJV). (B) RIJV damage after catheterization.
(for superior vena cava catheters) or an abdominal plain film ( for femoral catheters) should be done to verify catheter tip position. Ideally, both posteroanterior and lateral thorax views may be needed to better assess catheter location. Normally, catheter tip should lie at the junction of the vena cava with the right atrium so that the catheter side openings are located into the caval lumen (Figure 2). Catheter malposition (Figure 3) and puncture-related complications can also be readily diagnosed with chest radiographs in two views.
\n\t\t\t\t\tA) Posteroanterior chest X-ray showing normally located right-sided internal jugular vein catheter. (B) Normal lateral view of the catheter (arrows).
A) Abnormal location of a left-sided internal jugular vein catheter. Lateral thorax view (B) shows catheter tip (arrow) and side openings into the azygus vein.
The distance from insertion site to venoatrial junction may vary according to patients anatomy (height, obesity), thorax length and shape, central vein configuration and insertion route. However, as a rule of thumb, a catheter of 15-16 cm in length catheters may be adequate when placing right-sided internal jugular veins in adults. A 17.5-20 cm long catheters is required for either left internal jugular or left subclavian vein approach [10]. Femoral catheters should be 20-25 cm in length depending on insertion point and patient’s physiognomy (i.e. obesity).
\n\t\t\t\tNTC malfunction may be due to non-thrombotic causes like catheter misplacement, kinking, use of inappropriate catheter length and formation of pericatheter fibrin sleeve [11]. Thrombotic catheter occlusion is usually due to either intraluminal and/or mural thrombus formation. Malfunctioning catheters, except those having a fibrin sheath, mural thrombus or some evidence of infection can be exchanged over a guidewire. Biofilm formation begins immediately after catheter insertion by bacteria that has being carried by the catheter surface from skin entry site. With time, biofilm turns into a fibrin sheath o sleeve that covers side openings and adheres to the entire external surface of most catheters [12]. In advanced stage, a total extraluminal encasement of the catheter occurs causing backflow of blood which goes out through the catheter insertion orifice when dialysis pump is started. Thus, bleeding through catheter entry site only during HD indicates the presence of a fibrin sleeve and, the catheter should be removed. However, much of the fibrin sleeve may remain adhered to the vein wall after catheter removal [13] (Figure 4).
\n\t\t\t\t\tCatheter tip with adhered fibrin sheath.
Catheter exchange after balloon disruption of the sleeve has been reported to be a successful procedure in such cases [12]. Too short left-sided IJV or subclavian catheters may cause catheter malfunctioning as tip and side openings will lie within the lumen of the left innominate vein whose caliber and flow are lower than that of the vena cava [8].
\n\t\t\t\tCentral vein catheterization in patients with ESRD bears a higher risk of bleeding because of disturbances in platelet adhesion and aggregation. Carotid artery puncture can lead, if unadvertent, to formation of a big hematoma which can further extend in the neck and upper mediastinum causing external airway compression [14]. Mediastinal hematoma is a rare but feared complication after unadvertent arterial puncture. Pneumothorax, hemothorax and chylothorax are complications more related to subclavian than to IJV cannulation. Femoral artery puncture can also lead to formation of huge hematomas at the groin. Retroperitoneal hematoma is also an extremely rare complication and results from inadequate puncture technique.
\n\t\t\t\tBleeding around catheter entry site is most commonly due to a wide skin opening. Applying compression at entry site with sterile dressing may suffice to stop bleeding. Otherwise, the orifice can be reduced by stitching with 6x0 nylon suture which is usually effective to achieve local hemostasis. To prevent this complication, the size of the skin incision must be tailored as small as possible so that the catheter, once in place, fits tightly in the orifice. Persisting bleeding with bulging at puncture site points at a more serious cause of the bleeding and the patient should be immediately evaluated by a vascular surgeon. As mentioned before, bleeding only during HD is highly suggestive of encasement of the catheter by a fibrin sheath.
\n\t\t\t\tEarly infection of a new inserted catheter indicates poor aseptic conditions at the time of placement or inadequate catheter handling during HD or at home. Infected catheters may be the starting point of bacteremia and sepsis and there is an increased risk of metastatic complications, including endocarditis, septic arthritis, and epidural abscess. The relative risk of bacteremia is 7-fold higher in CKD patients with catheters than in those with an autogenous PVA [15]. Staph aureus and other grampositive bacteria like coagulase-negative staphylococcus and enteroccocus are the most commonly isolated agents in infected catheters [16]. Cultures of blood, entry site exudate and catheter tip play a key role in identifying the causative agent. Sensitivity tests to different antimicrobials with determination of minimal inhibitory concentration (MIC) are the basis for an effective antibiotic treatment.
\n\t\t\t\tDespite improved catheter technology and better biomaterials, central vein stenosis continues to be the most serious middle- and long-term complication of HD catheters. Central vein stenosis may preclude permanent VA creation on the ipsilateral upper or lower extremity. Clinically, the development of superficial vein collaterals on the affected side or the development of limb swelling after ipsilateral arteriovenous access creation shoul raise the suspicion of central vein occlusion. This diagnosis can be confirmed by imaging procedures like angiotomography or MRI. In the past decades, endovascular procedures like percutaneous transluminal angioplasty (PTA) or percutaneous transluminal stenting (PTS) has proven useful and safe to recanalize occluded central veins with low rates of technical failure. However, multiple additional interventions are the rule with both treatment modalities since neither of them offer truly durable outcomes nor add to the longevity of the ipsilateral access [17]. Superior vena cava syndrome is an extreme manifestation of central vein stenosis and results from multiple catheter insertions [18]. Femoral vein catheters may cause stenosis and thrombosis in the femoro-iliac axis precluding kidney graft placement on the affected side.
\n\t\t\t\tare usually of iatrogenic origin. Some of them can close spontaneously. US guided compression has proven effective some cases. If ineffective, a more invasive treatment should be attempted. The standard approach has been surgical but currently, percutaneous endovascular implantation of covered stents has been reported to yield similar results while being less invasive [19].
\n\t\t\t\tTC are made either of polyurethane, carbothane (polycarbonate-based polyurethane) or silicone. They are available in many shapes (straight or pre-curved), sizes (12-16 Fr), lengths (16-50 cm from tip to cuff) and tip forms (rounded, stepped or splitted). In addition, they may consist of either two single lumen catheters as the original Tesio catheter, which has 2 independent 10F catheters [20], or a double lumen device. All are provided with a polyester cuff favoring tissue in-growth for fixation of the catheter into the subcutaneous tunnel. TC can be either placed de novo or in exchange for a nontunneled catheter using the same insertion site without increased risk of infection [21,22].
\n\t\t\t\tA detailed description of all technical aspects of TC implantation are beyond the scope of this chapter. In principle, TC implantation technique is similar to that of NTC but a subcutaneous tunnel is additionally created to lodge the external segment or extension of the catheter. Catheter placement can also be done at a procedure room within the HD unit. TC offer some advantages over NTC. Tunneling from the neck to an exit site at the right or left upper chest quadrant below the clavicle brings greater comfort to patients, catheter extensions can easily be covered by dressings, concealed by clothing and, in addition, TC are suitable for outpatient management and care [23]. However, their disadvanges are many and far outweigh their advantanges [24]. In this regard, it should be underscored that tunneling does neither prevent nor make less severe central vein occlusion, which is the most feared middle- and long –term complication of all HD catheters.
\n\t\t\t\tTC have been found to reduce the incidence of catheter-related bloodstream infection particularly when antibiotic lock is additionally used [25]. However, contrary to NTC, TC are not routinely withdrawn as first move in case of infection. Removal is only done in case of persistent infection or infection recurrence nonresponsive to antimicrobial therapy. Therefore, a major concern in such cases is the emergence of multidrug-resistant bacteria. Long-term indwelling TC are associated with five- to ten-fold increased risk of bacteremia and sepsis, significantly higher mortality risk, decreased likelihood of adequate dialysis, more frequent hospital admissions and more frequent need for access surgeries [26,27]. It is essential to have cultures with blood drawn from catheter lumen as well as from a peripheral vein. Catheter infection can be confirmed by isolation of the same agent in both samples, particularly if the UFC count is 4-fold higher in the luminal sample than in the peripheral blood sample. Initial empirical administration of broad spectrum antibiotics should be followed by specific antibiotics when sensibility tests with minimum inhibitory concentration (MIC) data are available.
\n\t\t\t\tDysfunctional TC due to thrombotic occlusion requires administration of thrombolytic therapy to restore flow, decrease venous dialysis pressure and increase dialysis delivery. Tissue-type plasminogen activator (tPA, alteplase), is currently the only recommended antithrombotic agent for failing TC [28]. Single intraluminal instillation (in 30- 60 minutes) of low-dose (1 mg/ml) alteplase has been shown to increase catheter flow with significantly more patients achieving Qb=300 ml/min than with urokinase (5000 U/ml) (70%
A) Tunneled catheter placed into the inferior vena cava. (B) Catheter being used for HD.
Preserving peripheral veins at both upper extremities (not only at the non-dominant side) as well as both subclavian veins is the mainstay for an ulterior successful PVA creation. The major veins of the upper extremity like the cephalic and basilic, eventually also the cephalic accessory, are the only appropriate vessels for creation of a fistula or graft and should not be routinely used for administration of fluid or medication, especially when irritating, because they may cause irreversible endothelial injury. Indiscriminate peripheral venipuncture is the first cause of loss of adequate veins for VA creation. Nursing personnel should be advised to use alternative veins like hand dorsum veins (Figure 6), the median or intermediate antebrachial vein and other minor forearm veins for intravenous fluids and medications. If there is some compelling need to use any of the major arm veins, cannulation should be done only for short periods of time, using small gauge needles, and rotating puncture sites to prevent phlebitis and thrombosis. Patients should ideally receive education about the importance of vein preservation.
\n\t\t\t\t\tPreventing damage of peripheral veins. Venous cannula in the cephalic vein of a CKD patient (A) is removed and placed in a hand dorsum vein ( B).
The exact timing of placement of VA should be determined in each particular case by the rate of decline of renal function, presence of co-morbidities (i.e. diabetes, obesity), estimated time from referral to surgeon until access creation and degree of difficulty for VA creation. Avorn et al [29] found that patients referred to a nephrologist 90 days before the initiation of dialysis were approximately 40% more likely to undergo catheter placement compared with those who were seen 90 days before the initiation of dialysis.
\n\t\t\t\tThe initial evaluation of peripheral veins is done on clinical grounds. Past access failure should be analyzed and a careful history of previous catheterizations, particularly of central outflow veins, like subclavian and innominate veins. Previous right IJV cannulation in most cases do not preclude ipsilateral access creation, except in patients developing arm edema during catheter dwell time or when enlarged superficial vein collaterals are observed on the chest wall or the neck, which is highly suspicious for significant central vein stenosis or occlusion. Evaluation of the arm veins should be done by palpation with a proximal tourniquet or inflatable pressure cuff in place. This way, stenotic or thombotic segments can be easily detected. The explored outflow vein walls should be distensible all along its course with uninterrupted lumen. Collecting past history of venipuncture, presence of edema, especially if unilateral, is extremely important. Palpation of the arteries should include assessment of pulse amplitude and rhythm, as well as texture of the arterial wall all along its course. Evaluation should detect wall hardening, plaques or absence of pulse. Allen’s test should be routinely done in all cases.
\n\t\t\t\tColor Doppler ultrasound (CDU) is usually a complementary diagnostic tool in the setting of VA planning. It should be used to further assess pathologic findings obtained at clinical evaluation. CDU can corroborate or exclude underlying vein stenosis and thombosis, arterial plaques, etc. Hemodynamic parameters like vessel diameter, arterial flow pattern and flow measurement can also be readily assessed. Minimum artery diameter for successful autogenous AV access creation at forearm ranges from 1.5 mm and 2.0 mm although 2.0 mm seems to be a more acceptable limit in adults [30,31]. In addition to measuring arterial diameter, it is of utmost importance to exclude calcification of the media, which precludes surgical opening of the artery, or the presence of proximal atheromas which would reduce inflow. Typical arterial flow pattern is shown in Figure 7.
\n\t\t\t\t\tDoppler ultrasound of the radial artery (A) showing nomal triphasic flow pattern (B).
Venous system can be evaluated sonographically for continuity and absence of strictures. To this end, CDU scans should be done with a distal tourniquet in place to distend the outflow vein. Evaluation of the basilic vein at upper arm is only possible with CDU since this vein is located below the brachial fascia in most of its upper arm course. Arm diameter in obese patients may limit access site selection. CDU may also dictate the need for primary or staged vein elevation in case of too deep lying outflow veins.
\n\t\t\t\tA central vein imaging procedure is necessary to exclude subclavian or innominate vein stenosis or thrombosis in patients with history of subclavian or left internal jugular vein cannulation, especially if catheter infection occurred or when vein collaterals are visible on skin over the chest. To circumvent the need for central imaging procedure, it is advisable to select in first instance the contralateral upper extremity for access creation, if the vessels are appropriate, in those patients with history of subclavian vein cannulation only on one side. Likewise, former left IJV cannulation requires that innominate vein stenosis or occlusion be excluded before ipsilateral VA creation.
\n\t\t\t\tThe sequence of VA creation should, ideally, be individually tailored with clear preference for native vessels, exhausting first more distal VA options bilaterally before considering creating a proximal one. The sequence of preference is:
\n\t\t\t\t\tradiocephalic fistula (RCF),
ulnarbasilic fistula (UBF),
brachiocephalic fistula (BCF)
brachiobasilic (BBF) or brachiobrachial fistula and
brachioaxillary straight graft (BASG).
Eventually, placement of a forearm graft, in preference in straight configuration, may be evaluated before moving to an autogenous upper arm access [32]. If graft placement is decided, the graft/vein anastomosis should be performed below the elbow crease in order that both cephalic and basilic vein at upper arm remain intact for ulterior access procedures.
\n\t\t\t\tSome basic clinical, hemodynamic and laboratory parameters should be systematically evaluated in patients scheduled for VA surgery [32]. Patients should be in their dry weight, afebrile without evidence of catheter infection or elsewhere, no signs of cardiac insufficiency nor pericardial effusion, normal range heart rate and rhythm, minimal BP 110/70 without orthostatic hypotension. Regarding laboratory data, normal WBC and platelet count with Hb levels above 8 g/dl are essential. Too high hematocrit levels can make the patient more prone to access thrombosis. In such cases, transient epoetin reduction should be considered. Coagulation tests like bleeding time, TP and TPT should be within normal range. Serum albumin should be 3.0 mg/dl or higher. Prothrombotic medication (methilprednisolone) should be tapered to 10-15 mg daily before performing access surgery. It is very important that antithrombotic agents (ASA, clopidogrel, davigatran), anticoagulants (low-weight heparin, warfarin) are stopped at least 5 to 8 days before surgery.
\n\t\t\t\tA detailed operative technique for each access type would be beyond the scope of this chapter. However, It can be never stressed enough that, for successful VA creation, surgical procedures should be done under stringent aseptic conditions, using appropriate surgical instruments, sutures and a meticulous technique. AVF not requiring general anesthesia, like forearm fistulas and BCF, may be performed on an outpatient basis in a procedure room located within a renal unit, Access procedures requiring axillary nerve block or general anesthesia should be performed in a conventional operating room keeping the patient hospitalized for a short observation period. Vein collaterals should be ligated to allow for better maturation. Ligation of tributary veins like hand dorsum veins in case of RCF and cephalic accessory vein in case of BCF may prevent retrograde flow once the runoff vein has enlarged and increased its flow. The recommended anastomosis technique for arm fistulas is side-to-end. However, for forearm fistulas, side-to-side anastomosis, turned into a functional side-to-end anastamosis by juxta-anastomotic ligation of the distal venous limb (Figure 8), may be an equivalent alternative which has an additional advantage: the anastomosis size can be tailored regardless of the diameter of the vessels.
\n\t\t\t\t\tSide-to-side anastomosis turned into a functional side-to-end by juxta-anastomotic ligation of the distal venous limb.
In case of BBF creation, subcutaneous transposition of the arterialized basilic vein is mandatory since it runs in most of its upper arm course beneath the deep fascia and would otherwise not be amenable to safe cannulation except in its short distal postanastomotic segment [33]. In addition, the basilic vein is crossed in part of its upper arm course by branches and filaments of the medial antebrachial cutaneous nerve. Aneurysmatic dilation of the postanostomic segment of BBF is commonly observed when superficialization is not performed owing to the fact that the arterialized vein is being “clamped” proximally by the deep fascia. Superficialization of the vein usually requires either a long incision or multiple short incisions in the medial aspect of the upper arm. However, a new endoscopically performed superficializacion technique has been described recently [34]. Some authors recommend doing superficialization as a two-stage procedure [35].
\n\t\t\t\t\tRCF (A) and BCF (B) with staged superficialization of the cephalic vein.
RCF, also called Cimino or Brescia-Cimino fistula, is by far the best type of HD access. It offers the longest and easiest to puncture vein segment, lowest venous dialysis pressures, higher primary function rates, as well as better long-term survival. Snuff box fistula, a distal variant of RCF which may be created at the basis of the thumb, can be performed if the caliber of the vessels at this location is appropriate. UBF, another autogenic VA type in the forearm, was first described by Hanson et al as early as 1967 [36]. UBF is an optimal VA alternative with good survival rates [37] which has not yet been included in the KDOQI recommendations probably under the argument that the posteromedial course of the basilic vein along the forearm is inconvenient for cannulation. However, in our experience, UBF does not need transposition to be successfully cannulated (Figure 10).
\n\t\t\t\t\tUlnarbasilic fistula being used for HD. Note that transposition of the arterialized basilic vein is not necessary for safe cannulation.
BCF and BBF with vein superficialization are the the two basic autogenic fistula variants at upper arm. If the basilic vein is found to be inadequate, one of the brachial veins may be used instead [34]. Other access options like Gracz fistula, or bidirectional (reverse) fistulas offer no additional advantages over other conventional fistulas [38].
\n\t\t\t\tIn the forearm, arteriovenous grafts (AVG) are placed in either straight or loop configuration [39]. Inflow artery of straight grafts may be either the radial or the ulnar artery. Inflow artery of forearm loop grafts is the brachial artery. Outflow veins are usually antecubital veins. As stated earlier, the graft/vein anastomosis should be located in preference below the elbow crease. At upper arm, the most common AVG variant is the brachioaxillary graft. Since adhesion between the graft and subcutaneous tissue may last up to 3 weeks, it is advisable waiting until after that time has elapsed to start cannulation. The shorter waiting time for starting cannulation is one of the advantages of AVG over AVF. The expanded PTFE (ePTFE) remains still the most commonly used graft material. Biological prostheses are of limited availability, usually more expensive and of variable size and quantity [39].
\n\t\t\t\tThey should be attempted only when all options in the upper extremity are exhausted.
\n\t\t\t\tIt is an autogenous AV access in the thigh which is created between the femoral artery and the transposed common femoral vein. It has good patency rates but a higher risk of distal ischemia [40].
\n\t\t\t\tIt is created by anastomosis of the distal femoral artery and the great saphenous vein (Figure 11) which is subcutanously transposed to allow cannulation. Access survival is acceptable [41].
\n\t\t\t\tIt is also an autogenous alternative whose inflow is provided by the proximal femoral artery at groin level. It requires frequent endovascular procedures owing to vein stenosis. Only 70% of all new created saphenous loop are functional with a 16-months survival rate [42].
\n\t\t\t\tThis AVG type is created at the groin using the common femoral artery as inflow, or at mid-thigh level using the superficial femoral artery instead [39,43]. Infection rate of thigh graft is higher than that of upper arm accesses.
\n\t\t\t\t\tA) Saphenofemoral arteriovenous fistula. (B) Arterioarterial HD through a superficialized femoral artery.
Ideally, mature AVF should have the following characteristics to be safely punctured: discernible vein margins, flow greater than 600 mL/min, vein diameter at least 0.6 cm and should be located no more than 0.6 cm deep [8]. Too deep lying arterialized cephalic veins, particularly in obese patients, can be superficialized either along its forearm course in case of RCF or along its upper arm course as in the case of BCF. (Figure 9). Since superficialization is an extensive, surgically complex and time-consuming procedure, we recommend to perform it as staged procedure on a case-by-case basis once the impossibility to cannulate the new access has been established. Superficialization of the vein can be done by surgical transposition [44], by single lipectomy [45] (or suction-assisted lipectomy [46]. Maturation time of BBF is about 8 weeks. Adequate puncture technique and care is the clue to prolonged VA survival. Cannulations can help to widen the caliber of the arterialized vein on condition that puncture sites are rotated. Lack of needle rotation may favor the development of aneurysms at neddling sites. However, some authors recommend the buttonhole cannulation and report less complications and interventions using this technique [47].
\n\t\t\tComplications in the immediate and early postoperative access complication are bleeding, thrombosis and infection. CKD patients are more prone to bleeding, but this complication is totally preventable with careful surgical technique. Significant bleeding associated with skin bulging at the operative site always requires surgical revision.
\n\t\t\t\tis the commonest complication of PVA in the immediate and early postoperative period. Even using an impeccable surgical technique and in the presence of both adequate vessel anatomy and optimal hemodynamic parameters, the risk of thrombosis remains high in the first minutes or hours after access surgery. Arterial wall incision done for anastomosis is in principle an arterial injury causing exposure of subendothelial elements as collagen and laminin which initiates a cascade of cytochemical and cellular events leading to platelet recruiting, adhesion and activation at the anastomosis site. Platelet activation together with thrombin generation results in thrombus formation [48]. In addition, chronic renal failure per se is a procoagulant state with multiple concurrent hemostatic abnormalities [49]. Some comorbidities like old age, obesity, diabetes, atrial fibrillation and hypertension could also contribute to enhance prothrombotic conditions. Therefore
in a new created VA needs aggressive therapy particularly because the anastomosis site is almost always involved and may rupture leading to acute, eventually life-threatening bleeding requiring urgent VA ligation. Infection is more common in AVG than in AVF [50]. Factors favoring infection are intraoperative contamination, poor wound care, diabetes, steroids, etc. Similarly as in NTC and TC, most episodes of infection are due to gram positive bacteria in particular, S. aureus. Infection at the anastomosis site may lead to fistula ligation or graft excision.
\n\t\t\t\tThrombosis in this period is most commonly due to hypotension after HD. The nursing staff should be strongly advised to always measure standing blood pressure (BP) before allowing a patient going back home after finishing HD session. If BP is found to be less than 110/70, the patient should be placed immediately in recumbent position until BP improvement. Tight circular bandages or dressings should be avoided. Since a new created AVF or AVG may cause a variable decrease in peripheral vascular resistance, antihypertensive drug dosing may eventually need to be adjusted. A bit higher median arterial pressure than usual (100-110 mmHg) should be tolerated in the first 10 days after surgery. Patients should be advised to keep their arm elevated to reduce local edema and decreased wound suture tension. Mild to moderate edema is not uncommon but it normally subsides within the first 3 weeks after surgery. In case of persistent or worsening edema, venous hypertension syndrome owing to an underlying central or peripheral vein occlusion should be suspected. Arterial steal is another complication that may also become clinically apparent during this period. Both the latter complications will be addressed in detail later in this chapter.
\n\t\t\tAs mentioned earlier a mature autogenous access requires
\n\t\t\t\tan adequate diameter (> 6 mm),
discernible margins,
adequate access flow rate (>500 ml/min) and
it must be sufficiently superficial (<0.6 cm deep) to permit accurate, safe cannulation.
Blood acces flow increases dramatically within 24 hours of autogenous access placement and reaches most of its maximum flow within 3 to 6 weeks [51,52]. Average flow rates vary according to access site and type. Mean forearm fistula fistula flow is 784 ± 623 ml/min, upper arm fistula 1400 ± 850 and prosthetic graft 1270 ± 604 [53]. Similarly, most of the increase in access diameter is achieved within 4 to 8 weeks of autogenous access placement [54]. It has been estimated that about one quarter to one third of AVF fail to mature [55]. Causes of lack of maturation are poor arterial inflow (inadequate vessel diameter, proximal atheroma, juxta-anastomotic occlusion of the proximal arterial limb, anastomosis of small size, chronic hypotension), juxta-anastomotic vein stenosis (probably resulting from intraoperative prolonged venous clamping), lack of ligation of tributary and collateral veins, venous intimal or media fibrosis not allowing vein diameter to enlarge. The usefulness of endovascular or surgical procedures to improve flow and promote AVF maturation should be evaluated in each particular case.
\n\t\t\tInfiltration are common complications. They may be confined to subcutaneous tissue looking like ecchymotic lesions or be the result of subaponeurotic bleeding, when the needle crosses the vein lumen leaving an orifice in the posterior vein wall [56]. In the latter case, skin bulging is seen without significant ecchymosis. Hematomas may eventually either become secondarily infected, cause significant stenosis or turn into pseudoaneurisms.
\n\t\t\t\tPA are typical puncture-related complications of both AVF and AVG. The trigger event is usually a wall laceration due to a traumatic cannulation with subsequent hematoma formation around the vessel or a leak at the anastomosis site leading to hematoma formation [57]. The size of the hematoma may vary widely and is one of the determinants of final PA size. Inadequate compression at puncture site favors further hematoma grow. PA may be located either subcutaneously or subfascially depending on where the hematoma was located. Once hematoma is formed around the fistula vein or graft, it will be progressively eroded in the course of few days by the pressure of a blood jet going out through the wall defect, which will later become the PA neck. Finally, a cavity or sac can be observed within the hematoma, connected to the fistula vein or graft lumen by the PA neck (Figure 12). PA can develop in both AVG and AVF. US guided compression of the PA for 30 minutes [58], or US guided direct thrombin injection into the PA sac have been used as primary options [59]. However, in case the latter measures fail or when PA is rapidly enlarging, revision is required. Surgical revision has been the standard approach to treat PA. However, endovascular treatment using covered stents insertion to exclude PA has been successfully used to treat such complications [57,60]. This method has proven safe and effective and the results has been encouraging, however it requires a specialized institution and the procedure-related costs are high. Surgery should be used in preference in case of wide-neck PA or when a significant skin bulge or mass is observed. Infection is a contraindication for endovascular procedures. In case of secondarily infected PA, the best way of action is to ligate the access in a definite manner.
\n\t\t\t\t\tA) Perigraft hematoma. (B) Doppler ultrasound show formation of pseudoaneurysm following hematoma cavitation.
Different than pseudoaneursyms, aneurysms are widened or enlarged segments of the arterialized vein that may develop at puncture site or at the anastomosis. Aneurysms may reach significant sizes and exhibit small saccular areas with thin wall which may cause, if ruptured, serious bleeding, Aneurysms usually limit puncture sites and can be the starting point of infections and thrombus formation. In selected cases, surgical plication may be attempted to reduce aneurysm size on condition that a proximal stenosis of the vein is excluded [61]. Otherwise, ligation of the access is the only option.
\n\t\t\t\tInfection can develop at puncture sites, poor aseepsia, hematoma formation or infiltrations being predisponent factors. Most commonly isolated agents are grampositive bacteria, particularly S. aureus and coagulase-negative staphylococci [62]. AVF or AVG infection should be always viewed as an emergency condition that require hospitalization since it may ultimately lead to access rupture with bleeding, sepsis, endocarditis and other metastatic infections. Aggressive empirical antibiotic therapy should be started until culture results are available. Strict adherence to aseptic and antiseptic protocols by the nursing staff and patient’s education are instrumental in preventing access-related infections.
\n\t\t\t\tLuminal stenosis may range from mild to severe and can develop at any site along the AVF or graft (anastomotic stenosis, peri or postanastomotic stenosis, puncture-related stenosis, stenosis at the site of former venipunctures and venous outflow stenosis). While anastomotic or puncture-related stenosis point at surgical failure or inadequate puncture technique, perianastomotic stenosis in AVF and venous outflow stenosis at the graft-vein anastomosis are due primarily to neointimal hyperplasia [63]. Other possible causes of postanastomotic stenosis might be venous wall damage induced by clamping and excessive denudation of the vein. The diagnosis of luminal vein stenosis can be accurately done in a great majority of arteriovenous fistulas by physical examination alone [64]. CDU or other vascular imaging techniques should be used to confirm the clinical diagnosis of stenosis. Treatment of stenosis is either surgical or endovascular (balloon dilatation or stent placement) and the results depend largely on the size and type of the stenosis. The KDOQI Guidelines [7] recommend that stenoses in prosthetic or autogenous accesses should be treated prophylactically with percutaneous transluminal angioplasty or surgical revision if the stenosis is 50% of the lumen diameter and is associated with clinical abnormalities. Early detection of fistula vein stenosis can be achieved by applying the KDOQI static intra-access pressure surveillance protocol which consists of serial calculations of the normalized arterial and venous segment static intra-access pressure ratios or indexes. Arterial index values > 0.43 in AVF or > 0.75 in AVG are suggestive of significant stenosis [65]. Index calculations and normal range values are described in detail in the respective KDOQI recommendation [7].
\n\t\t\t\tof the runoff vein is a special type of stenosis which has been subject of extensive research. Cumulative patency of AVG largely depends on the development of neointimal hyperplasia at the graft/venous anastomosis. Therefore, prevention of this complication would contribute to prolong AVG survival [63]. Research has been focused on how to eliminate or inhibit the two main pathogenetic factors involved in the development of this complication: Shear stress and the subsequent endothelial cell proliferation. Shear stress has long been pointed as the main cause of neointimal proliferation as proved in experimental flow models. Some modifications in graft configuration have been shown to reduce shear stress, particularly on the bed of graft-vein junction, like helical ePTFE grafts which swirl blood flow across the graft-venous anastomosis reducing endothelial stress [66]. Another way to limit neointimal hyperplasia is reducing venous outflow turbulence either by modifying the graft-vein anastomotic angle inserting grafts with angled \nvenous end [67] or with the so called Y-Split AVG (Prolong™) that bifurcates shortly after arterial end and reunite just before the runoff vein anastomosis [68].
Access recirculation occurs when dialized blood having already passed through the dialyzer, instead of returning to circulation via the proximal “venous” needle, is redirected toward the distally placed arterial needle and reenters the extracorporeal circuit. The explanation is that flow of the extracorporeal circuit exceeds that of the VA whose minimal range should be between 300 to 450 mL/min [72]. Recirculation results in dialysis delivery being less than that prescribed. The most common cause is stenosis of the outflow vein which can ultimately lead to access thrombosis owing to significant intraaccess flow reduction. Other causes to be excluded are poor arterial inflow, close proximity of the needles and inverted lines. Complementary imaging methods like Doppler ultrasound, venography, angioresonance, etc, can locate site and determine degree and extension of the stenotic segment, measuring access recirculation is a valuable tool to estimate the percentage of recirculation and help to establish the indication for surgical or endovascular interventions. Recirculation may be measured either by urea-based or non-urea based methods like ultrasound dilution, potassium dilution, ionic dialysance, glucose infusion and thermal dilution [73]. Percentage recirculation can be calculated by the traditional urea-based method according to the following equation: [Systemic BUN-arterial blood line BUN/Systemic BUN-venous blood line BUN] x 100. Consistency of the urea-based methods is poor for surveillance for access stenosis, in part because of arteriovenous (cardiopulmonary recirculation) and venovenous disequilibrium [74,75] but if the percentage recirculation is >10% stenosis should be suspected. Other methods which eliminate the effect of disequilibrium have different thresholds, such as > 5% for ultrasound dilution [76].
\n\t\t\t\tAlso referred to as HD access-induced distal ischaemia (HAIDI), ASS is a rather uncommon complication and occurs in 2.7–4.3% of AVG and 1% of AVF [77,78]. It may appear early after surgery or in the postcannulation period. Symptoms range from only pain and coldness during dialysis to digital necrosis. It may develop shortly after surgery or years afterwards. Patients at risk are diabetic and those with severe peripheral occlusive disease. ASS may be classified in 4 stages [79]:
\n\t\t\t\t\tStage 1: Retrograde diastolic flow without complaints; steal phenomenon;
Stage 2: Pain on exertion and/or during HD;
Stage 3: Rest pain and
Stage 4: Ulceration/necrosis/gangrene.
The diagnosis of steal syndrome is made clinically, color Doppler US and complementary imaging procedures. Measuring finger pressure before and after fistula vein or graft compression is a very helpful diagnostic manoever in patients with steal syndrome. Using the digital brachial index (DBI), Goff et al [80] identified patients with a DBI of <0.45 as having a significant risk for ASS. Treatment of ASS is surgical and has two main objectives: increasing or restoring distal limb flow and maintaining access patent. Surgical interventions to obtain symptoms relief in SS are of two kinds:
\n\t\t\t\t\tRevascularization and
Banding.
The more severe forms require excision or removal of the affected tissue.
\n\t\t\t\t\tA) Steal syndrome with painful necrotic ulceration of the middle finger. (B) Stage 4 steal syndrome.
Distal revascularization with interval ligation (DRIL) was first described by Shanzer et al [81] as early as 1988 and consists in placing an arterioarterial bridge that bypasses the anastomosis site. In addition, a juxta anastomotic ligation of the distal limb of the artery is done. It has been long viewed as the gold standard procedure.
Proximalization of the arterial inflow: First, the distal original arteriovenous anastomosis is closed and the artery repaired using an interposition graft. Secondly, the outflow vein is anastomosed to a bridge graft (autologous or else) which is in turn anastomosed to a more proximal site of the artery. This procedure is useful in cases with low fistula flow [82].
Revision Using Distal Inflow (RUDI). In this technique the original anastomosis at the brachial artery is ligated and the outflow vein is anastomosed more distally to either the radial or ulnar artery just below the bifurcation using a bridge graft (autologous or ePTFE). The basic principle is that the distal artery has both lower diameter and flow [83].
The main objective of banding is to increase postanastomotic outflow resistance by narrowing the lumen of the outflow vein or graft so as to reduce outflow and increase distal arterial flow. Banding may be achieved either by placing a
It is a rather uncommon complication which can easily be overseen [89]. Excessive shunting of the access, anemia and underlying heart disease are triggering factors. Surgical banding [90] may relieve symptoms, but in case of persistent manifestations, definite ligation is the only remaning option.
\n\t\t\t\tVHS is a relatively common complication of AV accesses, particularly AVF and consists of a painful edema, redness and warmth of the affected skin area that appear after VA creation that may affect, depending on the site of the outflow stenosis or occlusion, either the entire upper extremity or may be circumscribed to forearm, hand, or skin segments overlying the fistula. The stenotic site represents a formidable barrier against arteriovenous flow originating a steady rise of the intraluminal pressure distally to the stenosis. The increased intraluminal pressure is in turn transmitted backward to the superficial or subcutaneous vein system producing the typical symptoms of VHS (Figure 14). In patients with longstanding VHS skin pigmentation occurs as well as other manifestations observed in chronic venous insufficiency like vein collaterals, small varicosities and even ulcerative lesions. The mechanism of hyperpigmentation is possibly similar to that of chronic venous insufficiency where both a moderate hypermelanosis and dermal hemosiderin deposits can be seen microscopically, derived from the breakdown of red blood cells that have extravasated through damaged capillaries and smaller vessels are [91]. Diagnosis of VHS is made clinically and should be complemented by imaging procedures like ultrasound, flebography, angiotomography or angioresonance. The main advantage of the two latter procedures is that small dosis of contrast media are used. Treatment options are: Ligation of retrograde veins, endovascular or surgical procedures or definite access ligation.
\n\t\t\t\tThe purpose is to perform an arterioarterial hemodialysis. The arteries reported to be used this way are: the superficial femoral [91], the brachial [92] and radial artery [93].
\n\t\t\tDesperate case access option that has been performed as axillary-axillary chest loop (preferred type) or femorofemoral loop. Reported primary and secondary patency at 3 years were 54% and 87%, respectively [94].
\n\t\t\tThese are a particular type of VA. The axillary artery is anastomosed by means of an ePTFE graft to either the ipsitaleral axillary vein, internal jugular or femoral vein. Loop configuration of the graft at the upper chest is the typical configuration when either the axillary or the ipsilateral internal jugular vein is used [95]. If the contralateral axillary vein is used as outflow, ePTFE configuration in the form of a collar or necklace is placed. Mickley et al [96] described a novel AVG using the axillary artery as inflow and the right atrium as outflow in cases with superior vena cava occlusion.
\n\t\t\t\tA) Venous hypertension syndrome developing after a brachiocephalic fistula creation (B) Angiotomography showing right innominate vein occlusion.
Xenografts are more expensive than PTFE grafts, a fact which limits their use in spite of their proven better patency rates and lesser frequency of complications compared to PTFE graft [97-99]. Two types xenografs are commercially available:
\n\t\t\t\tThe bioingeneered bovine carotid artery (Artegraft™) which has been in use since 1970 and
the bioengineered bovine mesenteric vein (Procol™).
The Hemoaccess Reliable Outflow (HeRO™) Vascular Access Device (Hemosphere, Inc., Minneapolis, MN) has emerged as a valuable, innovative alternative to tunneled catheters (TC). Early results suggests that bacteremia was significantly less frequent for the HeRO device than for TC being its secondary patency (> 72.2%) quite close to that of PTFE grafts [100-102]. According to the description by Katzman et al [102], this device consists of a 6-mm straight ePTFE upper arm graft serving as cannulation segment, whose distal end is anastomosed to the brachial artery and the proximal one is attached by means of a titanium-made crimp ring to an also subcutaneously placed, 5 mm inner diameter, silicon catheter ( “outflow component”). The catheter may be introduced endovascularly or inserted into the internal jugular or subclavian vein utilizing the Seldinger technique The catheter tip should lie at the cavoatrial junction.
\n\t\t\tTheir main advantage is that they can be used 24 hours after placement and would avoid using NTC and TC preventing catheter-related morbidity and costs. Some of the ESG have resulted from modifications introduced to the original ePTFE like the
The creation of AVG using TEVG technology is really very promising. Some are created by seeding autologous bone marrow-derived mononuclear cells onto biodegradable tubular scaffolds constructed mainly from derivatives of the extracellular matrix or using allogeneic or canine smooth muscle cells grown on a tubular polyglycolic acid [108]. Other TEVG grafts are created from autologous fibroblasts and endothelial cells obtained from small skin and vein biopsies. The grafts are implanted without synthetic scaffolding [108].
\n\t\t\tAs stated in the introduction paragraph, during the past two decades, HD population has become increasingly composed of patients of advanced age and/or suffering from comordibities like diabetes, hypertension, chronic hypotension, dyslipidemias, occlusive artery peripheral disease, malnutrition, etc. In this population the risk of VA loss or malfunction is extremely high, particularly when two or more comorbid conditions coexist.
\n\t\t\tare prone to complications like occlusive arterial disease which limits their access options and, in a significant proportion of them, the primary access has to be created at upper arm due to severe atheromatous changes of distal arteries. The risk for development of arterial steal syndrome in patients of this group is elevated. In addition, a subset of diabetic patients suffer from chronic hypotension, orthostatic hypotension, etc., owing to autonomic neuropathy or cardiac failure. Access thrombosis is very common among those patients and, in many of them, a TC for chronic HD or CAPD are often the only remaining option.
\n\t\t\tdefined as interdialytic systolic pressure of less than 100 mmHg without cardiac function impairment, affects 5 to 10% of HD population. Its pathophysiology is not well understood but the mechanism of hypotension seems to be a reduction of the peripheral resistances with poor response to midodrine and other vassopresor agents [109]. In these patients frequent VA thrombosis are observed. The creation of upper arm fistulas has been recommend as primary access choice in such cases [110].
\n\t\t\thave been associated with AV access thrombosis [111]. In addition, serum albumin is a known marker of nutritional status in HD patients. Hypoalbuminamia is associated with malnutrition and the latter, in turn, may lead to poor wound healing, infection and subsequent VA loss [112]. Hyperhomocysteinemia has also been found by some authors to be a risk factor for VA thrombosis and suggest decreasing levels before performing any VA [113]. Others, on the contrary, found no association between risk for thrombosis and hyperhomocysteinemia [114]. Further studies are necessary to clarify whether lowering plasma homocysteine concentrations may prevent VA failure in HD patients.
\n\t\t\tPatients with SLE on HD are at increased risk of vascular access thrombosis as compared to non-SLE patients because of the high prevalence of the so called, antiphospholipid antibodies, namely, anticardiolipin antibodies and lupus anticoagulant among SLE patients. [115 - 117]. Lupus anticoagulant is actually a prothrombotic agent which precipitates the formation of thrombi in vivo. In addition, SLE patients on chronic HD receiving high dosis of oral steroids, may have an elevated risk of VA thrombosis and infection and, for this reason, steroid dosis should be reduced before performing VA surgery.
\n\t\t\tThe ideal AVG, which can be created with graft materials similar to the patient’s own vessels is yet to be invented. However, a lot of progress has been done. The best example is TEVG technology which are showing us a complete new world in the realm of HD accesses in the future. Likewise, early stick grafts are undoubtedly unvaluable developments which have raised special attention because they could obviate the need for a bridging NTC or TC. However, before resorting to all that panoply of innovative developments whose extensive use would otherwise represent a serious financial burden for any health care system, there is a lot that can still be done. Catheters have been a necessary evil but one step in the right direction is avoiding or minimizing their use in the years to come. To reach this goal, increasing pre-dialysis construction of autogenous fistulas is the only way out of the current trend. Applying autogenic-oriented VA plans is another crucial step that could help to substantially decrease the use of grafts. Additionally, but equally essential measures are complications prevention through patients’ education, continuous staff training and timely-performed VA preserving interventions. Certainly, we will continue finding patients with very difficult access who will benefit from all those innovative AV types described in this chapter. Yet, it would not be far from the truth to state that the VA needs of the overwhelming majority of our patients could be met with a simple autogenous fistula if timely done, adequately punctured and optimally cared.
\n\t\tThe author thanks NOVARTIS-NOVACID, Caracas, Venezuela, for their unvaluable bibliographic support.
Nematodes are microscopic roundworms live in soil, marine, freshwater. Plant parasitic nematodes cause economic damage to cultivated crops in the tropics and subtropics areas, estimated about 10 percent of world crop production is lost due to nematode [1]. More than 4100 species of plant-parasitic nematode of global food security [2] and damage caused by plant nematodes has been estimated at $US80 billion per year [3]. Presently 25 genera of plant parasitic nematodes, include species that are economic pests of crop plants. Ten most important nematode genera are significance at global level
Plant Parasitic nematodes are associated in agricultural crop in global food security. Agriculturally important root-knot nematodes and identified by Berkeley [13] (1855) who observed galls on cucumber roots. Plant-parasitic nematodes have a stylet, which is used for penetration of host plant tissue and release proteinaceous secretions from the glands to the host cell. These glandular secretions induce cellular metabolically active feeding cell [14]. Cellulose is the primary component of plant cell walls, cellulases (β-1,4-endoglucanases) are secreted to degrade the cell wall which allows nematode entry into host tissue. On the basis of their feeding habits, they are migratory ectoparasites, endoparasites, semi-endoparasitic. Ectoparasitic nematodes in the soil, feed at the root surface and Endoparasitic nematodes feed within the root. Endoparasitic nematodes are further divided into migratory and sedentary groups. Migratory endoparasitic nematodes include
The most economically important nematodes, the root-knot and cyst nematodes are wide range of species [16]. The potato (
Fruits are the most important rich in Vitamins A and C and minerals like Calcium and Iron, low caloric values and low in fats. The plant parasitic nematodes are economic importance in fruit production. Fruit crops are perennial in nature, harbor and build-up of nematode population. Roots damaged by the nematodes lose efficiency in the utilization of available soil moisture and nutrients and easy prey to many fungi and bacteria which cause root decay. Symptoms of nematode attack often include reduced growth, chlorosis, wilting and death of plants. These resulted in reduced yields and poor fruit quality of fruits viz., citrus, banana, grapevine, pineapple, pomegranate and papaya. Nematode management is important for high yields and quality of fruits production. The integrated Nematode Management is population reduction of plant parasitic nematodes and development of resistant varieties of crops.
Root-knot nematodes (
Root-knot of infected roots,
Cyst nematodes (
Cyst of
The genus
Lesions on roots caused by
Infected banana plan and lesion on roots.
The citrus nematode was first discovered in California, later described as a new species,
Infected roots by
Reniform nematodes (
Infected roots by
Stem and bulb nematodes (
Infected garlic and onion bulb by
Management practices should be effective, environmentally safe, and economical and must focus on reducing nematode populations to levels below the damage threshold. The common methods of nematodes management used resistant varieties, rotating of crops, soil amendments, soil solarization and applying pesticides. Soil solarization is very effective for control of many nematodes and soil-borne pathogens. Soil solarization of field to ensure adequate moisture, cover with plastic, to make it air tight, at least 45 days during June and July. Resistant plant cultivars is limited because few nematode very specific for specific resistance, correct identification of the nematode species and race before cultivar selected. Crop resistance cultivars with crop rotation is the best management practices.
In crop rotation, crops must be select carefully because some species of nematodes viz., root-knot, reniform, and burrowing are very wide host ranges. Crop rotation and cover cropping are often practices in integrated pest management to reduce plant-parasitic nematode incidence. Soil nematode effectively decreased by rotational cultivation of non-host cultivars of wide host range of
Green manuring as sudangrass and corn are excellent green manure crops that provide good nematode control. The organic agriculture for environmental welfare, biological controls are great interest for crop producers. The efficacy of nematophagous bacteria and fungi in the control of cyst and root-knot nematodes has been well-documented [82, 83]. Parasitic bacteria (
Most nematicides are highly toxic synthetic pesticides health risk. Limitations uses of chemical pesticides are alternative methods and great attention to nematode control. Chemical nematicides are often used in the management of root-knot nematodes, restrictions in some soil fumigants due to increased environmental toxicity expensive costs and risk to humans.
Nematode release β-1,4-endoglucanase and polygalacturonase during primary infection and feeding site and in plants growth proteins are secreted during processes to allow for cell enlargement [89]. Several root-knot resistance gene (
Management of nematodes is an integrated method of pest management system. Because of most commonly practiced methods including crop rotation, developing resistant and tolerant cultivars, using chemicals and cultural practices [24, 73]. Effective management practices are required accurate diagnosis, and proper effective management techniques.
There are several genera and species of nematodes that are of economic importance. Correct nematode diagnosis can developing management program. The nematodes must be eliminate minimize the damage to determine the appropriate method. Commonly practiced methods are including crop rotation, resistant and tolerant cultivars, cultural practices and chemicals. The ability to reduce yield losses caused by nematodes is need to understanding about pathogen biology and the application of appropriate control measures. Use of chemicals is impractical commercial and cultural methods fail to complete control. Breeding for resistance and tolerance is the major strategy for long-term and environmentally sound control. It is necessary to research particularly nematodes race and pathotype, and a great need for global collaborative research to control of these important pathogens.
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. 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After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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García\nHernández",authors:[{id:"77194",title:"Dr.",name:"José",middleName:"A.",surname:"Peláez",slug:"jose-pelaez",fullName:"José Peláez"},{id:"171273",title:"Dr.",name:"Rashad",middleName:null,surname:"Sawires",slug:"rashad-sawires",fullName:"Rashad Sawires"},{id:"171274",title:"Dr.",name:"María Teresa",middleName:null,surname:"García Hernández",slug:"maria-teresa-garcia-hernandez",fullName:"María Teresa García Hernández"},{id:"171275",title:"Dr.",name:"Raafat El-Shafey",middleName:null,surname:"Fat-Helbary",slug:"raafat-el-shafey-fat-helbary",fullName:"Raafat El-Shafey Fat-Helbary"},{id:"171276",title:"Dr.",name:"Hamza Ahmed",middleName:null,surname:"Ibrahim",slug:"hamza-ahmed-ibrahim",fullName:"Hamza Ahmed Ibrahim"}]},{id:"67102",doi:"10.5772/intechopen.85322",title:"Impacts of the 2015 Gorkha Earthquake: Lessons Learnt from Nepal",slug:"impacts-of-the-2015-gorkha-earthquake-lessons-learnt-from-nepal",totalDownloads:2213,totalCrossrefCites:5,totalDimensionsCites:9,abstract:"Nepal is highly vulnerable to a number of disasters for example: earthquakes, floods, landslides, fires, epidemics, avalanches, windstorms, hailstorms, lightning, glacier lake outburst floods, droughts and dangerous weather events. Among these disasters—earthquake is the most- scary and damaging. The effects of a disaster, whether natural or human induced, are often long lasting. The Gorkha earthquake of 25 April 2015 enormously affected human, socio-economic and other multiple sectors and left deep scars mainly in the economy, livelihood and infrastructure of the country. Besides the natural factors, the damages from disasters in Nepal are in increasing trend due to the human activities and inadequate proactive legislations. Fundamentally, the weak structures have been found as the major cause of damage in earthquakes. This underlines the need for strict compliance of building codes. Thus, proactive disaster management legislation focusing on disaster preparedness is necessary. This paper analyses and shows the critical gaps and responsible factors that would contribute towards seismic risk reduction to enable various stakeholders to enhance seismic safety in Nepal. Additionally, this chapter aims to pinpoint the deficiencies in disaster management system in Nepal with reference to the devastating Gorkha earthquake and suggest appropriate policy and advanced technical measures for improvement.",book:{id:"7660",slug:"earthquakes-impact-community-vulnerability-and-resilience",title:"Earthquakes",fullTitle:"Earthquakes - Impact, Community Vulnerability and Resilience"},signatures:"Shiva Subedi and Meen Bahadur Poudyal Chhetri",authors:[{id:"285969",title:"Mr.",name:"Shiva",middleName:null,surname:"Subedi",slug:"shiva-subedi",fullName:"Shiva Subedi"},{id:"293220",title:"Dr.",name:"Meen",middleName:null,surname:"Paudyal Chhetri",slug:"meen-paudyal-chhetri",fullName:"Meen Paudyal Chhetri"}]},{id:"47961",doi:"10.5772/59641",title:"Seismic Reliability-Based Design Optimization of Reinforced Concrete Structures Including Soil-Structure Interaction Effects",slug:"seismic-reliability-based-design-optimization-of-reinforced-concrete-structures-including-soil-struc",totalDownloads:1311,totalCrossrefCites:3,totalDimensionsCites:9,abstract:null,book:{id:"4488",slug:"earthquake-engineering-from-engineering-seismology-to-optimal-seismic-design-of-engineering-structures",title:"Earthquake Engineering",fullTitle:"Earthquake Engineering - From Engineering Seismology to Optimal Seismic Design of Engineering Structures"},signatures:"Mohsen Khatibinia, Sadjad Gharehbaghi and Abbas Moustafa",authors:[{id:"94191",title:"Prof.",name:"Abbas",middleName:null,surname:"Moustafa",slug:"abbas-moustafa",fullName:"Abbas Moustafa"},{id:"173876",title:"Dr.",name:"Sadjad",middleName:null,surname:"Gharehbaghi",slug:"sadjad-gharehbaghi",fullName:"Sadjad Gharehbaghi"}]},{id:"60778",doi:"10.5772/intechopen.76014",title:"The Earthquake Disaster Risk in Japan and Iran and the Necessity of Dynamic Learning from Large Earthquake Disasters over Time",slug:"the-earthquake-disaster-risk-in-japan-and-iran-and-the-necessity-of-dynamic-learning-from-large-eart",totalDownloads:1068,totalCrossrefCites:4,totalDimensionsCites:7,abstract:"This book chapter targets how learning from large earthquakes disasters occurred and developed in Japan and Iran in the last 100 years. As research case studies, large earthquake disasters in Japan and Iran were investigated and analyzed. Normal distribution was found to be a good estimate of the magnitude distribution for earthquakes, in both the countries. In Japan, there is almost a linear correlation between magnitude of earthquakes and number of dead people. However, such correlation is not present for Iran. This lack of correlation in Iran and existence of linear correlation in Japan highlights that the magnitude of earthquakes directly affects the number of fatalities and extent of destruction in Japan, while in Iran, there is an increased complexity with regard to the factors affecting earthquake consequences. A correlation is suggested between earthquake culture and learning from large earthquake disasters in both Japan and Iran. Learning from large earthquake disasters is impacted by a multitude of factors, but the rhythm of learning in Japan is much higher if compared with Iran. For both Japan and Iran, a reactive learning approach based on past earthquake disasters needs to be constantly backed up by a proactive approach and dynamic learning.",book:{id:"6564",slug:"earthquakes-forecast-prognosis-and-earthquake-resistant-construction",title:"Earthquakes",fullTitle:"Earthquakes - Forecast, Prognosis and Earthquake Resistant Construction"},signatures:"Michaela Ibrion and Nicola Paltrinieri",authors:[{id:"209369",title:"Ph.D.",name:"Michaela",middleName:null,surname:"Ibrion",slug:"michaela-ibrion",fullName:"Michaela Ibrion"},{id:"244752",title:"Dr.",name:"Nicola",middleName:null,surname:"Paltrinieri",slug:"nicola-paltrinieri",fullName:"Nicola Paltrinieri"}]},{id:"66486",doi:"10.5772/intechopen.85557",title:"The IDEA Model as a Conceptual Framework for Designing Earthquake Early Warning (EEW) Messages Distributed via Mobile Phone Apps",slug:"the-idea-model-as-a-conceptual-framework-for-designing-earthquake-early-warning-eew-messages-distrib",totalDownloads:857,totalCrossrefCites:3,totalDimensionsCites:6,abstract:"Short response time available in the event of a major earthquake poses unique challenges for earthquake early warning (EEW). Mobile phone apps may be one way to deliver such messages effectively. In this two-phase study, several hundred participants were first randomly assigned to one of eight experimental conditions. Results of phase one afforded researchers the ability to reduce the number of conditions to four. Phase two consisted of five experimental conditions. In each condition, a 10 second EEW was delivered via a phone app. The four treatment conditions were designed according to elements of the IDEA model. The control condition was based on the actual ShakeAlert EEW computer program message being used by emergency managers across the US west coast at the time. Results of this experiment revealed that EEW messages designed according to the IDEA model were more effective in producing desired learning outcomes than the ShakeAlert control message. Thus, the IDEA model may provide an effective content framework for those choosing to develop such apps for EEW.",book:{id:"7660",slug:"earthquakes-impact-community-vulnerability-and-resilience",title:"Earthquakes",fullTitle:"Earthquakes - Impact, Community Vulnerability and Resilience"},signatures:"Deanna D. Sellnow, Lucile M. Jones, Timothy L. Sellnow, Patric Spence, Derek R. Lane and Nigel Haarstad",authors:[{id:"222937",title:"Ph.D.",name:"Deanna",middleName:null,surname:"Sellnow",slug:"deanna-sellnow",fullName:"Deanna Sellnow"}]}],mostDownloadedChaptersLast30Days:[{id:"47538",title:"An Updated Seismic Source Model for Egypt",slug:"an-updated-seismic-source-model-for-egypt",totalDownloads:3359,totalCrossrefCites:11,totalDimensionsCites:21,abstract:null,book:{id:"4488",slug:"earthquake-engineering-from-engineering-seismology-to-optimal-seismic-design-of-engineering-structures",title:"Earthquake Engineering",fullTitle:"Earthquake Engineering - From Engineering Seismology to Optimal Seismic Design of Engineering Structures"},signatures:"R. Sawires, J.A. Peláez, R.E. Fat-Helbary, H.A. Ibrahim and M.T. García\nHernández",authors:[{id:"77194",title:"Dr.",name:"José",middleName:"A.",surname:"Peláez",slug:"jose-pelaez",fullName:"José Peláez"},{id:"171273",title:"Dr.",name:"Rashad",middleName:null,surname:"Sawires",slug:"rashad-sawires",fullName:"Rashad Sawires"},{id:"171274",title:"Dr.",name:"María Teresa",middleName:null,surname:"García Hernández",slug:"maria-teresa-garcia-hernandez",fullName:"María Teresa García Hernández"},{id:"171275",title:"Dr.",name:"Raafat El-Shafey",middleName:null,surname:"Fat-Helbary",slug:"raafat-el-shafey-fat-helbary",fullName:"Raafat El-Shafey Fat-Helbary"},{id:"171276",title:"Dr.",name:"Hamza Ahmed",middleName:null,surname:"Ibrahim",slug:"hamza-ahmed-ibrahim",fullName:"Hamza Ahmed Ibrahim"}]},{id:"47738",title:"Earthquakes and Dams",slug:"earthquakes-and-dams",totalDownloads:3204,totalCrossrefCites:2,totalDimensionsCites:1,abstract:null,book:{id:"4488",slug:"earthquake-engineering-from-engineering-seismology-to-optimal-seismic-design-of-engineering-structures",title:"Earthquake Engineering",fullTitle:"Earthquake Engineering - From Engineering Seismology to Optimal Seismic Design of Engineering Structures"},signatures:"Hasan Tosun",authors:[{id:"79083",title:"Prof.",name:"Hasan",middleName:null,surname:"Tosun",slug:"hasan-tosun",fullName:"Hasan Tosun"}]},{id:"47881",title:"Simplified Multi-Block Constitutive Model Predicting the Seismic Displacement of Saturated Sands along Slip Surfaces with Strain Softening",slug:"simplified-multi-block-constitutive-model-predicting-the-seismic-displacement-of-saturated-sands-alo",totalDownloads:1137,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"4488",slug:"earthquake-engineering-from-engineering-seismology-to-optimal-seismic-design-of-engineering-structures",title:"Earthquake Engineering",fullTitle:"Earthquake Engineering - From Engineering Seismology to Optimal Seismic Design of Engineering Structures"},signatures:"Constantine A. Stamatopoulos",authors:[{id:"171228",title:"Dr.",name:"Constantine",middleName:null,surname:"Stamatopoulos",slug:"constantine-stamatopoulos",fullName:"Constantine Stamatopoulos"}]},{id:"67102",title:"Impacts of the 2015 Gorkha Earthquake: Lessons Learnt from Nepal",slug:"impacts-of-the-2015-gorkha-earthquake-lessons-learnt-from-nepal",totalDownloads:2212,totalCrossrefCites:5,totalDimensionsCites:9,abstract:"Nepal is highly vulnerable to a number of disasters for example: earthquakes, floods, landslides, fires, epidemics, avalanches, windstorms, hailstorms, lightning, glacier lake outburst floods, droughts and dangerous weather events. Among these disasters—earthquake is the most- scary and damaging. The effects of a disaster, whether natural or human induced, are often long lasting. The Gorkha earthquake of 25 April 2015 enormously affected human, socio-economic and other multiple sectors and left deep scars mainly in the economy, livelihood and infrastructure of the country. Besides the natural factors, the damages from disasters in Nepal are in increasing trend due to the human activities and inadequate proactive legislations. Fundamentally, the weak structures have been found as the major cause of damage in earthquakes. This underlines the need for strict compliance of building codes. Thus, proactive disaster management legislation focusing on disaster preparedness is necessary. This paper analyses and shows the critical gaps and responsible factors that would contribute towards seismic risk reduction to enable various stakeholders to enhance seismic safety in Nepal. Additionally, this chapter aims to pinpoint the deficiencies in disaster management system in Nepal with reference to the devastating Gorkha earthquake and suggest appropriate policy and advanced technical measures for improvement.",book:{id:"7660",slug:"earthquakes-impact-community-vulnerability-and-resilience",title:"Earthquakes",fullTitle:"Earthquakes - Impact, Community Vulnerability and Resilience"},signatures:"Shiva Subedi and Meen Bahadur Poudyal Chhetri",authors:[{id:"285969",title:"Mr.",name:"Shiva",middleName:null,surname:"Subedi",slug:"shiva-subedi",fullName:"Shiva Subedi"},{id:"293220",title:"Dr.",name:"Meen",middleName:null,surname:"Paudyal Chhetri",slug:"meen-paudyal-chhetri",fullName:"Meen Paudyal Chhetri"}]},{id:"63029",title:"An Estimation of “Energy” Magnitude Associated with a Possible Lithosphere-Atmosphere-Ionosphere Electromagnetic Coupling Before the Wenchuan MS8.0 Earthquake",slug:"an-estimation-of-energy-magnitude-associated-with-a-possible-lithosphere-atmosphere-ionosphere-elect",totalDownloads:1117,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"A large scale of abnormities from ground-based electromagnetic parameters to ionospheric parameters has been recorded during the Wenchuan MS8.0 earthquake. All these results present different anomalous periods, but there seems one common climax leading to a lithosphere-atmosphere-ionosphere electromagnetic coupling (LAIEC) right on May 9, 3 days prior to the Wenchuan main shock. Based on the electron-hole theory, this chapter attempts to estimate the “energy source” magnitude driving this obvious coupling with the Wenchuan focus zone parameters considered. The simulation results show that the total surface charges fall in ~107–108 C, and the related upward electric field is ~108–109 V/m. These corresponding parameters are up to 109 C and 1010 V/m when the main rupture happens, and the order of the output current is up to 107 A. The electric field increasing in the interface between the Earth’s surface and the atmosphere, on one hand, can cause electromagnetic parameter abnormities of ground-based observation, with the range beyond 1000 km. On the other hand, it can accumulate air ionization above pre-earthquake zone and lead to ionospheric anomaly recorded by some spatial seismic monitoring satellites.",book:{id:"6564",slug:"earthquakes-forecast-prognosis-and-earthquake-resistant-construction",title:"Earthquakes",fullTitle:"Earthquakes - Forecast, Prognosis and Earthquake Resistant Construction"},signatures:"Mei Li, Wenxin Kong, Chong Yue, Shu Song, Chen Yu, Tao Xie and\nXian Lu",authors:[{id:"236284",title:"Dr.",name:"Mei",middleName:null,surname:"Li",slug:"mei-li",fullName:"Mei Li"},{id:"243785",title:"MSc.",name:"Chen",middleName:null,surname:"Yu",slug:"chen-yu",fullName:"Chen Yu"},{id:"243786",title:"MSc.",name:"Chong",middleName:null,surname:"Yue",slug:"chong-yue",fullName:"Chong Yue"},{id:"243788",title:"Dr.",name:"Tao",middleName:null,surname:"Xie",slug:"tao-xie",fullName:"Tao Xie"},{id:"243789",title:"MSc.",name:"Wenxin",middleName:null,surname:"Kong",slug:"wenxin-kong",fullName:"Wenxin Kong"},{id:"243790",title:"BSc.",name:"Shu",middleName:null,surname:"Song",slug:"shu-song",fullName:"Shu Song"}]}],onlineFirstChaptersFilter:{topicId:"778",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:287,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:10,numberOfPublishedChapters:103,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"25",title:"Environmental Sciences",doi:"10.5772/intechopen.100362",issn:"2754-6713",scope:"\r\n\tScientists have long researched to understand the environment and man’s place in it. 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\r\n\tThe four topics of this book series - Pollution; Environmental Resilience and Management; Ecosystems and Biodiversity; and Water Science - will address important areas of advancement in the environmental sciences. They will represent an excellent initial grouping of published works on these critical topics.