512 - Ultrasound-Guided Sheath Reversal: A Novel and Simplified Technique for Dialysis Access Interventions

Purpose: Many AV access interventions require bidirectional access to treat antegrade and retrograde segments, traditionally requiring two separate sheath insertions. Sheath reversal can minimize the need for multiple access points, reducing access-related challenges and risks. While fluoroscopy-guided reversal has been described, a purely US-guided technique has not. Our group has simplified this approach for broader adoption.

Materials and Methods: This retrospective, single-center study included AV access interventions performed between 1/01/2021, and 5/31/2025, in which a single-sheath US-guided reversal technique was used. Eligible cases were identified through the mPower search engine. Inclusion criteria were fistula or graft interventions using a singular access site and sheath reversal. Unidirectional interventions and those involving multiple access sites, including declots, were excluded.

Initial needle access was obtained as vertically as possible under real-time US to minimize tissue tract length. A woggle purse-string suture was placed before sheath manipulation for hemostasis in case access was lost. After treating one direction, the sheath was pulled back under US guidance until the tip was 5–10 mm within the AV access lumen. The sheath was then flipped and redirected, and US was used on the opposite side to confirm tip position before treating the second direction.

Results: A total of 38 procedures met inclusion criteria. Technical success was achieved in 100% of cases, and none required a second access. The mean procedure time was 35.1 ± 19.6 minutes, with an average fluoroscopy time of 4.6 ± 3.6 minutes and sedation time of 33.6 ± 17.7 minutes. No instances of access loss, hematoma, or major bleeding events. Stents were deployed in 10.5% of cases.

Conclusion: This US-guided sheath reversal technique is fast, safe, and effective, with no recorded instances of access loss or complications. The simplicity and reproducibility of this technique make it easy for broad adoption.