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Mulaney-Topkar B, Ho VT, Sgroi MD, Garcia-Toca M, George EL. Cost-effectiveness analysis of endovascular vs surgical arteriovenous fistula creation in the United States. J Vasc Surg 2024; 79:366-381.e1. [PMID: 37952783 DOI: 10.1016/j.jvs.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE In the United States, an estimated $2.8 billion annually is spent on vascular access and its complications. Endovascular arteriovenous fistula (endoAVF) creation is a novel, minimally invasive alternative to traditional surgical AV fistula (sAVF) creation in ≤60% of patients. Although cost effective in single-payer systems, the clinical and financial impact of endoAVF in the United States remains uncertain. METHODS We constructed a decision tree followed by a probabilistic cohort state-transition model to study the cost effectiveness of endoAVF vs sAVF creation. We conducted a systematic review to obtain input parameters including technical success, maturation, patency, and utility values. We derived costs from the Medicare 2022 fee schedule and from the literature. We used a 5-year time horizon, an annual discount rate of 3% for costs and utilities (measured in quality-adjusted life-years [QALYs]), and the common willingness-to-pay threshold of $50,000. One-way and Monte Carlo probabilistic sensitivity analyses were performed varying technical success, patency, reintervention, cost, and utility parameters. RESULTS In the base-case scenario, endoAVF ($30,129 average per-person costs, 2.19 QALYs gained, 65% patent at 5 years) was not cost effective compared with sAVF ($12.987 average per-person costs, 2.11 QALYs gained, 66% patent at 5 years), generating an incremental cost-effectiveness ratio of $227,504 per QALY gained. In one-way sensitivity analyses, endoAVF becomes cost effective when the initial cost of sAVF creation exceeds endoAVF by ≥$600 (eg, if endoAVF creation costs ≤$3000 relative to the base-case sAVF cost of $3600), the additional QALYs gained from endoAVF exceeds 0.12 QALYs/year (eg, 0.81 QALYs gained/year from endoAVF compared with base-case sAVF 0.69 QALYs/year), the endoAVF maturation rate is >90% (base case 78%), or the sAVF maturation rate is <65% (base case 78%). Probabilistic sensitivity analysis demonstrated that sAVF remained the optimal strategy in 71% of iterations. CONCLUSIONS EndoAVF is not cost effective compared with sAVF when modeling 5-year outcomes. The main driver of sAVF remaining cost effective is the four times higher up-front cost for endoAVF creation, as well as a relatively low additional increase in quality of life for endoAVF. It will be important to establish how the endoAVF learning curve contributes to upfront costs and, given the annual cost attributed to vascular access nationally, a randomized controlled trial is warranted.
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Affiliation(s)
- Bianca Mulaney-Topkar
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Vy T Ho
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Michael D Sgroi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Manuel Garcia-Toca
- Division of Vascular and Endovascular Surgery, Emory University, Atlanta, GA
| | - Elizabeth L George
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
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Ng JH, Yang W, Dember LM. Performance Characteristics of Candidate Criteria for Hemodialysis Arteriovenous Fistula Maturation. Clin J Am Soc Nephrol 2023; 18:1321-1332. [PMID: 37553865 PMCID: PMC10578636 DOI: 10.2215/cjn.0000000000000248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 07/31/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Twenty to 60% of newly created hemodialysis arteriovenous fistulas do not mature adequately for use. One barrier to developing interventions to improve fistula outcomes is a lack of standardized criteria for maturation. METHODS Using data from the multicenter, prospective Hemodialysis Fistula Maturation (HFM) Study, we determined sensitivities, specificities, and positive and negative predictive values of multiple candidate maturation criteria using the HFM Study maturation criteria as the reference. We also compared, across the maturation criteria, relationships between maturation and fistula survival using Cox proportional hazards models. RESULTS We included 535 of the 602 HFM Study participants. The median (interquartile range) age was 57 (47-65) years, 70% were men, and 45% were Black participants. Depending on the criterion and time frame for ascertainment (3, 4, 5, 6, or 9 months), sensitivities ranged from 57% to 100%, specificities ranged from 85% to 100%, positive predictive values ranged from 88% to 100%, and negative predictive values ranged from 65% to 100%. For all criteria, areas under the curve for the 6-month (0.90-0.97 for unassisted maturation and 0.89-0.95 for overall maturation) and 9-month time frames were similar. Attainment of unassisted maturation was associated with lower risks of fistula abandonment, with hazard ratios ranging from 0.10 to 0.40 depending on the criterion and time frame. Eliminating dialysis adequacy indicators, or simplifying the criteria in other ways, had little effect on performance characteristics. CONCLUSIONS High performance characteristics are maintained with maturation criteria that are simpler and less burdensome to ascertain than the HFM Study outcome measure.
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Affiliation(s)
- Jia Hwei Ng
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
| | - Wei Yang
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura M. Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Habib SG, Jano A, Ali AA, Phillips A, Pinter J, Yuo TH. Early clinical experience and comparison between percutaneous and surgical arteriovenous fistula. J Vasc Surg 2023; 78:766-773. [PMID: 37230183 DOI: 10.1016/j.jvs.2023.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Percutaneous arteriovenous fistula (pAVF) has been recently developed as an alternative to surgical AVF (sAVF). We report our experience with pAVF in comparison with a contemporaneous sAVF group. METHODS Charts of all 51 patients with pAVF performed at our institution were analyzed retrospectively, in addition to 51 randomly selected contemporaneous patients with sAVF (2018-2022) with available follow-up. Outcomes of interest were (i) procedural success rate, (ii) number of maturation procedures required, (iii) fistula maturation rates, and (iv) rates of tunneled dialysis catheter (TDC) removal. For patients on hemodialysis (HD), sAVF and pAVF were considered mature when the AVF was used for HD. For patients not on HD, pAVF were considered mature if flow rates of ≥500 mL/min were documented in superficial venous outflow; for sAVF, documentation of maturity based on clinical criteria was required. RESULTS Compared patients with sAVF, patients with pAVF were more likely to be male (78% vs 57%; P = .033) and less likely to have congestive heart failure (10% vs 43%; P < .001) and coronary artery disease (18% vs 43%; P = .009). Procedural success was achieved in 50 patients with pAVF (98%). Fistula angioplasties (60% vs 29%; P = .002) and ligation (24% vs 2%; P = .001) or embolization (22% vs 2%; P = .002) of competing outflow veins were more frequently performed on patients with pAVF. The surgical cohort had more planned transpositions (39% vs 6%; P < .001). When all maturation interventions were combined, pAVF required more maturation procedures, but this was not statistically significant (76% vs 53%; P = .692). When planned second-stage transpositions were excluded, pAVF had a statistically significant higher rate of maturation procedures (74% vs 24%; P < .001). Overall, 36 pAVF (72%) and 29 sAVF (57%) developed mature fistulas. This difference, however, was not statistically significant (P = .112). At the time of AVF creation, 26 patients with pAVF and 40 patients with sAVF were on HD, all through use of a TDC. Catheter removal was recorded in 15 patients with pAVF (58%) and 18 patients with sAVF (45%) (P = .314). The mean time until TDC removal in pAVF group was 146 ± 74 days, compared with 175 ± 99 in the sAVF group (P = .341). CONCLUSIONS Compared with sAVF, rates of maturation after pAVF seem to be similar, but this result may be related to the higher intensity of maturation procedures and patient selection. An analysis of appropriately matched patients will assist in elucidating the possible role of pAVF vis-a-vis sAVF.
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Affiliation(s)
- Salim G Habib
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Antalya Jano
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Adham Abou Ali
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amanda Phillips
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Joshua Pinter
- Division of Interventional Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Theodore H Yuo
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Bontinis A, Bontinis V, Koutsoumpelis A, Wilmink T, Giannopoulos A, Rafailidis V, Chorti A, Ktenidis K. A systematic review aggregated data and individual participant data meta-analysis of percutaneous endovascular arteriovenous fistula. J Vasc Surg 2023; 77:1252-1261.e3. [PMID: 36328141 DOI: 10.1016/j.jvs.2022.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/16/2022] [Accepted: 10/25/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the short-term and mid-term safety and efficacy of percutaneous endovascular arteriovenous fistula (pAVF) creation. METHODS A systematic search was implemented corresponding to the PRISMA 2020 and the PRISMA for individual participant data (IPD) systematic reviews 2015. Aggregated data from the included studies were obtained and meta-analyzed regarding both the overall pAVF efficacy and the comparison of pAVF with surgical AVF (sAVF). We performed a two-stage IPD meta-analysis for studies comparing pAVF and sAVF regarding primary and secondary patency. Primary end points included primary patency, secondary patency, and functional cannulation. RESULTS Eighteen studies with 1863 patients were included. The overall pAVF, primary patency, secondary patency, functional cannulation and abandonment rates were 54.01% (95% confidence interval [CI], 40.69-66.79), 87.27% (95% CI, 81.53-91.42), 79.94% (95% CI, 65.94-89.13), and 15.58% (95% CI, 7.77-28.79), respectively. The overall pAVF, technical success, maturation, reintervention per person-years and mean time to maturation rates were 97.08% (95% CI, 95.66-98.04), 82.13% (95% CI, 71.64-89.32), 0.80 (95% CI, 0.34-1.47), and 58 days (95% CI, 36.64-92.82), respectively. Secondary patency and pAVF abandonment rates where the only end points were WavelinQ and Ellipsys displayed statistically significant differences of 81.36% (95% CI, 76.15-85.65) versus 92.12% (95% CI, 87.94-94.93) and 32.54% (95% CI, 22.23-44.87) versus 11.13% (95% CI, 4.82-23.65). An IPD meta-analysis of hazard ratios for primary and secondary patency between pAVF and sAVF were 1.27 (95% CI, 0.61-2.67) and 1.25 (95% CI, 0.87-1.80), favoring sAVF. Statistically significant difference between pAVF and sAVF were solely depicted for steal syndrome relative risk of 5.91 (95% CI, 1.12-31.12) and wound infections relative risk of 4.19 (95% CI, 1.04-16.88). Plotting of pAVF smoothed hazard estimate displayed an upsurge in the probability of primary patency failure at 1 month after the intervention. CONCLUSIONS Although we failed to identify statistically significant differences between pAVF and sAVF regarding any of the primary end points, pAVF displayed a decreased risk for steal syndrome and wound infection. Although both the Ellipsys and WavelinQ devices displayed satisfactory secondary patency rates, Ellipsys demonstrated a statistically significant improved rate compared with WavelinQ. Additionally, and despite the borderline statistically insignificant inferior reintervention rate displayed by WavelinQ, one in three WavelinQ pAVFs resulted in abandonment. The introduction of pAVF as a treatment modality calls for standardized definition adjustment and improvement.
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Affiliation(s)
- Alkis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Vangelis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece.
| | - Andreas Koutsoumpelis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Teun Wilmink
- Department of Vascular Surgery, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Argirios Giannopoulos
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Vasileios Rafailidis
- Department of Radiology, School of Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Angeliki Chorti
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Kiriakos Ktenidis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
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Satchithanantham V, Rajahram D. An unusual cause of venous hypertension. VEINS AND LYMPHATICS 2022. [DOI: 10.4081/vl.2022.10753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The gold standard vascular access for hemodialysis is the arteriovenous fistula (AVF). Venous hypertension (VH) is an unusual complication of AVF, which can be misdiagnosed as cellulitis due to the similarities in clinical presentation. Here we present a case of venous hypertension in a 40-years-old gentleman, who presented with progressive pain and swelling of three lateral fingers of his left hand without other inflammatory signs after a year of AVF creation. Further evaluation with a duplex scan supported the clinical diagnosis of VH. He had undergone a surgical ligation of AVF and completely recovered from the symptoms.
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Lie G, Ahmed N, Shah N, Eleti S, Lam S, Elsaadany A, Akhtar MR, Egan T, White W, Sivaprakasam R, Jaffer O. Adapting a Dialysis Service for Delivery of Percutaneous Arteriovenous Fistulas. Radiographics 2022; 42:1795-1811. [PMID: 36190866 DOI: 10.1148/rg.220010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The percutaneous arteriovenous fistula (pAVF) is an exciting and novel addition to the vascular access options available to patients with end-stage kidney disease who require dialysis. Early clinical results have been promising, with high rates of maturation and low rates of reintervention. To successfully adapt an existing hemodialysis service to include the provision of pAVF formation, it is essential to identify and align the interests of key clinical and nonclinical stakeholders. Only through strong collaboration can the service be supported. The authors provide a comprehensive overview of the planning fundamentals required, including the referral pathway, screening and clinical assessment, and practical procedural elements and considerations, as well as follow-up requirements such as cannulation, fistula surveillance, and maintenance. Key staffing requirements are highlighted, including those pertaining to vascular US screening and dialysis nurse training. A broad and structured planning approach ensures that the entire network of key stakeholder interests is included and provides a strong foundation for a compelling business plan to attract the necessary funding and managerial support for the service. The authors present a systematic framework of the essential considerations necessary to facilitate the planning, funding, and ultimately delivery of a successful pAVF service. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Geoffrey Lie
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
| | - Niaz Ahmed
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
| | - Nimesh Shah
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
| | - Saigeet Eleti
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
| | - Stefan Lam
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
| | - Amr Elsaadany
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
| | - Mohammed Rashid Akhtar
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
| | - Timothy Egan
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
| | - William White
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
| | - Rajesh Sivaprakasam
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
| | - Ounali Jaffer
- From the Departments of Interventional Radiology (G.L., N.A., N.S., S.E., A.E., M.R.A., O.J.), Anaesthesia (T.E.), Renal Medicine and Transplantation (W.W.), and Transplant Surgery (R.S.), The Royal London Hospital, Whitechapel Road, London E1 1FR, United Kingdom; and Department of Gastroenterology, West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom (S.L.)
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Sánchez-Villar I, García-González Z, Pestana-Rodríguez R, García-Ruiz A. Sistema percutáneo de creación de fistulas arteriovenosas en pacientes con hemodiálisis: nuestra experiencia inicial. ENFERMERÍA NEFROLÓGICA 2022. [DOI: 10.37551/52254-28842022026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introducción: La fístula arteriovenosa es considerada el acceso de elección para los pacientes en hemodiálisis; en los últimos años emerge una alternativa a la creación quirúrgica de esta: la fístula arteriovenosa endovascular. Esta nueva tecnología conlleva un método menos agresivo y sin cirugía.Objetivo: Describir los datos preliminares de nuestra unidad tras la implantación de este sistema novedoso, así como su implicación para enfermería.Material y Método: Análisis descriptivo retrospectivo de las FAV-endovasculares realizadas a cinco pacientes mediante técnica percutánea. Se consideraron las características de los pacientes, de las FAV-endovasculares realizadas y la dificultad para su punción (escala EVA).Resultados: La edad media fue de 63 (47-77) años, 100% hombres, dializándose con catéter tunelizado, a 4 de los pacientes se les había realizado al menos una fístula arteriovenosa quirúrgica sin éxito. La creación de la FAV-endovascular fue exitosa en 4 de los 5 pacientes, todas con localización radio-radial. No hubo complicaciones durante el procedimiento. De las 4 FAV-endovasculares 3 precisaron intervención endovascular posterior para su maduración. La media de tiempo de maduración 4,5 (4-5) meses; las 4 continuaron permeables al año.Puntuada por 9 enfermeras experimentadas, la mediana de dificultad fue: punción inicial: 7, a partir del mes: 5 y comparada con las FAV quirúrgicas: 5.Conclusiones: La FAV-endovascular supuso un procedimiento mínimamente invasivo con menor impacto para los pacientes, elevado éxito inicial, pero precisó intervención endovascular posterior para su maduración. La dificultad para la punción fue más elevada inicialmente. La ausencia de cicatriz supuso realizar una exploración más exhaustiva.
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Abdel Aal AK, Jefferson X, Klusman C, Garcia L, Hassanein H, Abdel Aal T, Shahin MM. Devices and Techniques for Percutaneous Creation of Dialysis Arteriovenous Fistulas. Semin Intervent Radiol 2022; 39:66-74. [PMID: 35210735 PMCID: PMC8856769 DOI: 10.1055/s-0042-1742381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Dialysis treatment for chronic kidney disease was first developed by Dr. Willem Kolff in 1943, and its availability began to grow in 1962 after which it has become a mainstay treatment for patients with chronic kidney disease. It is estimated that, in 2021, 15% of adults in the United States (∼37 million people) have chronic kidney disease, of which 661,000 individuals have renal failure, and 468,000 individuals require dialysis. There have been several advancements in dialysis treatment since its advent, most notably the creation of arteriovenous fistulas (AVFs) for venous access in 1966. In recent years, the U.S. Food and Drug Administration approved two new devices for AVF creation using a percutaneous approach. These are the WavelinQ (Becton Dickinson, New Jersey) and the Ellipsys (Avenu Medical, California) endovascular AVF (endoAVF) devices that use radiofrequency and thermal technologies, respectively, to create the AVF. Since the introduction of these technologies, several studies have shown that they are safe and effective, with favorable durability and low rate of serious adverse events. In this article, we will discuss these two devices and the techniques used for percutaneous creation of dialysis AVF as an alternative to traditional open surgical techniques.
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Affiliation(s)
- Ahmed Kamel Abdel Aal
- University of Texas Health Science Center at Houston, Department of Radiology, Houston, Texas,Address for correspondence Ahmed Kamel Abdel Aal, MD, PhD, FSIR Department of Radiology, University of Texas Health Science Center at HoustonHouston, TX 77030
| | | | | | | | | | | | - Mohamed M. Shahin
- University of Texas Health Science Center at Houston, Department of Radiology, Houston, Texas
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Tyagi R, Ahmed SS, Navuluri R, Ahmed O. Endovascular Arteriovenous Fistula Creation: A Review. Semin Intervent Radiol 2021; 38:518-522. [PMID: 34853497 DOI: 10.1055/s-0041-1736531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Endovascular arteriovenous fistula (endoAVF) creation offers a minimally invasive method for the formation of arteriovenous shunts utilized for hemodialysis. Currently, there exist two similar yet unique devices: WavelinQ and Ellipsys. This review analyzes the anatomy, pre- and postoperative considerations, fistula creation methods, and outcomes associated with endoAVF. Currently, data are limited with regard to clinical efficacy of endoAVFs when compared to surgical AVFs. However, early data suggest endoAVFs are a useful technique in the creation of AVFs.
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Affiliation(s)
- Ravi Tyagi
- University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - S Samaduddin Ahmed
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois
| | - Rakesh Navuluri
- Section of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, Illinois
| | - Osman Ahmed
- Section of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, Illinois
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Al-Balas A, Varma R, Sharbidre K, Al-Balas H, Almehmi A, Abdel Aal AK, Robbin ML, Allon M. Feasibility of Creation of an Endovascular Arteriovenous Fistula in Patients Undergoing Preoperative Vascular Mapping. KIDNEY360 2021; 3:287-292. [PMID: 35373141 PMCID: PMC8967643 DOI: 10.34067/kid.0004242021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/14/2021] [Indexed: 01/10/2023]
Abstract
Background The first endovascular arteriovenous fistula (endoAVF) device (WavelinQ), a novel percutaneous technique of AVF creation, was approved by the Food and Drug Administration in 2018 and has been placed in a small number of United States patients on hemodialysis. It is unknown how often patients with advanced CKD have vascular anatomy suitable for WavelinQ creation. The goal of this study was to determine the proportion of patients with vascular anatomy suitable for WavelinQ creation and to assess patient characteristics associated with such suitability. Methods All patients referred for vascular access placement at a large academic medical center underwent standardized preoperative sonographic vascular mapping to assess suitability for an AVF. During a 2-year period (March 2019 to March 2021), we assessed the suitability of the vessels for creation of WavelinQ. We then compared the demographic characteristics, comorbidities, and vascular mapping measurements between patients who were or were not suitable for WavelinQ. Results During the study period, 437 patients underwent vessel mapping. Of these, 51% of patients were eligible for a surgical AVF, and 32% were eligible for a WavelinQ AVF; 63% of those suitable for a surgical AVF were also suitable for a WavelinQ AVF. Patients with a vascular anatomy suitable for WavelinQ were younger (age 55±15 versus 60±14 years, P=0.01) but similar in sex, race, diabetes, hypertension, coronary artery disease, and peripheral artery disease. Conclusions Among patients with CKD with vascular anatomy suitable for a surgical AVF, 63% are also suitable for a WavelinQ endoAVF. Older patients are less frequently suitable for WavelinQ.
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Affiliation(s)
- Alian Al-Balas
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama,Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rakesh Varma
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kedar Sharbidre
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hassan Al-Balas
- Division of Interventional Radiology, Baylor College of Medicine, Houston, Texas,Division of Radiology, Jordan University of Science & Technology, Irbid, Jordan
| | - Ammar Almehmi
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama,Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ahmed Kamel Abdel Aal
- Division of Interventional Radiology, University of Texas at Houston, Houston, Texas
| | - Michelle L. Robbin
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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11
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Percutaneous Arteriovenous Fistula Creation with the WavelinQ 4-French EndoAVF System: A Single-Center Retrospective Analysis of 30 Patients. J Vasc Interv Radiol 2021; 33:33-40. [PMID: 34610421 DOI: 10.1016/j.jvir.2021.09.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 09/15/2021] [Accepted: 09/24/2021] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To retrospectively assess the safety and efficacy of percutaneous arteriovenous fistula (pAVF) creation with the WavelinQ 4-F EndoAVF System. MATERIALS AND METHODS From February 2018 to June 2020, 30 pAVFs were created in 30 consecutive patients (men; age, 55.3 years ± 13.6). Of the 30 patients, 21 (70%) were already on hemodialysis using a central venous catheter. The primary outcome measures were technical success, complications, and cannulation rate. The secondary outcome measures included the number of secondary procedures needed for cannulation, maintenance time to cannulation, and pAVF survival. RESULTS Technical success was 100%. The adverse event rate was 6.7% (2/30), including a pseudoaneurysm of the brachial artery that developed immediately after sheath removal and an aneurysm of the anastomosis 17 days after the procedure, which was treated with a covered stent placed in the arterial side. The mean follow-up was 547 days ± 315.7 (range, 14-1,071 days). The cannulation rate was 86.7% (26/30). The mean time to cannulation was 61.3 days ± 32.5 (range, 15-135 days). The mean follow-up after cannulation was 566.2 days ± 252.7 (range, 35-1,041 days). Four pAVFs were thrombosed after cannulation, with 2 of them successfully declotted. Sixteen interventions were needed to achieve cannulation after the index procedure in 15 patients (overall, 0.53 procedures/patient). Seven maintenance endovascular interventions (following cannulation) were performed during the follow-up period in 6 patients (overall, 0.27 procedures/patient, 0.17 procedures/patient-years). For the pAVFs that were cannulated, patency was 96% at 1 year, and 82% at 2 and 3 years, according to the Kaplan-Meier survival analysis. CONCLUSIONS This initial experience suggests that pAVF creation is safe and can be successfully performed with high maturation and long-term patency rates. Larger-scale prospective studies are needed to validate the results.
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12
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Mordhorst A, Clement J, Kiaii M, Faulds J, Hsiang Y, Misskey J. A Comparison of Outcomes Between Open and Endovascular Arteriovenous Access Creation for Hemodialysis. J Vasc Surg 2021; 75:238-247.e1. [PMID: 34303803 DOI: 10.1016/j.jvs.2021.07.104] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Preliminary outcomes for percutaneous endovascular autogenous access (endoAVF) have shown promising results; however, comparisons with surgical cohorts in dialysis populations are lacking. This study compares autogenous arteriovenous access created with the EverlinQ endoAVF system with accesses created by conventional surgical technique with respect to functional and patency related outcomes. METHODS This is a multicenter, retrospective review of autogenous arteriovenous accesses entered into a prospective database. Patients receiving radiocephalic, brachiocephalic, or endoAVF arteriovenous accesses between 2014 -2019 were included. Autogenous access maturation, primary patency, secondary patency, steal syndrome, and re-interventions were collected and analyzed using standard statistical and survival analyses. RESULTS A total of 369 accesses were created during the study period, including 61 endovascular accesses, 171 radiocephalic accesses, and 137 brachiocephalic accesses (median follow-up 17 months; range 1 - 71 months). Maturation failure at the end of follow-up was 27±6%, 27±5%, and 18±4% for endovascular, radiocephalic, and brachiocephalic accesses, respectively (p =.049 for brachiocephalic vs. endovascular accesses). Primary patencies at 12 and 24 months were 42±5% and 32±7% for endovascular accesses, 43±4% and 24±4% for radiocephalic accesses, and 42±4% and 29±4% for brachiocephalic accesses (p=.906). Secondary patencies at 12 and 24 months were 68±6% and 60±7% for endovascular accesses, 75±3% and 67±4% for radiocephalic accesses, and 91±3% and 81±4% for brachiocephalic accesses (p=.006 for brachiocephalic vs. endovascular accesses). There were no statistically significant differences in ischemic steal syndrome (3.3%, 4.1% and 8.0%; p=.229) or total reinterventions/year (1.0±3.1, 0.9±1.8, and 1.2±1.8; p=.289) for endovascular, radiocephalic, or brachiocephalic arteriovenous accesses, respectively. CONCLUSIONS EndoAVF compare favorably with respect to maturation and patency compared with surgically created accesses in a real-world cohort. Outcomes and reintervention rates are similar to conventional radiocephalic arteriovenous accesses, but are inferior with respect to patency and maturation to brachiocephalic accesses.
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Affiliation(s)
- Alexa Mordhorst
- Division of Vascular Surgery, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada.
| | - Jason Clement
- Department of Radiology, St. Paul's Hospital, Vancouver, BC, Canada
| | - Mercedeh Kiaii
- Department of Nephrology, St. Paul's Hospital, Vancouver, BC, Canada
| | - Jason Faulds
- Division of Vascular Surgery, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - York Hsiang
- Division of Vascular Surgery, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Jonathan Misskey
- Division of Vascular Surgery, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
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13
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Huo C, Wang L, Wang Q, Yang Y, Chen B. Hydroxysafflor Yellow A inhibits the viability and migration of vascular smooth muscle cells induced by serum from rats with chronic renal failure via inactivation of the PI3K/Akt signaling pathway. Exp Ther Med 2021; 22:850. [PMID: 34149896 PMCID: PMC8210222 DOI: 10.3892/etm.2021.10282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/19/2021] [Indexed: 12/15/2022] Open
Abstract
It has been reported that the viability and migration of vascular smooth muscle cells contributes to arteriovenous fistula stenosis. Hydroxysafflor Yellow A (HSYA) has been demonstrated to inhibit the viability and migration of VSMCs by regulating Akt signaling. The present study aimed to investigate the role of HSYA on the viability and migration of human umbilical vein smooth muscle cells (HUVSMCs) following stimulation using serum from rats with chronic renal failure (CRF), and to determine the effects of HSYA on PI3K/Akt signaling. Wistar rats were randomly divided into two groups, control and CRF groups. Serum from each group was collected to stimulate the HUVSMCs. Cell Counting Kit-8 and wound healing assays were performed to assess cell viability and migration, respectively. Flow cytometry analysis was performed to assess apoptosis, and western blot analysis was performed to detect protein expression levels of PI3K and Akt. Nitric oxide (NO) production was measured using the Nitrate/Nitrite assay kit. The results demonstrated that serum from CRF rats significantly enhanced cell viability, migration and apoptosis, the effects of which were reversed following treatment with HSYA. In addition, CRF serum decreased NO and endothelial NO synthase expression, whilst increasing the protein expression levels of PI3K and phosphorylated-Akt in HUVSMCs. Notably, treatment with HSYA markedly restored NO production and inactivated the PI3K/Akt signaling pathway. Furthermore, the PI3K/Akt inhibitor, AMG511, exerted similar effects to HSYA. Taken together, the results of the present study suggest that HSYA suppresses cell viability and migration in the presence of CRF serum by inactivating the PI3K/Akt signaling pathway.
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Affiliation(s)
- Changliang Huo
- Department of Nephrology, Lianyungang Hospital of Traditional Chinese Medicine, Lianyungang, Jiangsu 222000, P.R. China
| | - Li Wang
- Department of Nephrology, Lianyungang Hospital of Traditional Chinese Medicine, Lianyungang, Jiangsu 222000, P.R. China
| | - Qiuli Wang
- Department of Nephrology, Lianyungang Hospital of Traditional Chinese Medicine, Lianyungang, Jiangsu 222000, P.R. China
| | - Yanbo Yang
- Department of Nephrology, Lianyungang Hospital of Traditional Chinese Medicine, Lianyungang, Jiangsu 222000, P.R. China
| | - Bo Chen
- Department of Nephrology, Lianyungang Hospital of Traditional Chinese Medicine, Lianyungang, Jiangsu 222000, P.R. China
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Sandhu B, Hill C, Hossain MA. Endovascular arteriovenous fistulas- are they the answer we haven't been looking for? Expert Rev Med Devices 2021; 18:273-280. [PMID: 33688779 DOI: 10.1080/17434440.2021.1899806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Surgically created arteriovenous fistulas are the accepted gold standard for the establishment of hemodialysis access in patients requiring dialysis. However, primary and maturation failures may limit their usage. Recent advances in endovascular technology have resulted in the creation of devices for endovascular arteriovenous fistula formation. These devices may offer an additional or alternative approach to fistula formation in patients with end-stage kidney disease. AREAS COVERED This review describes the limitations of surgical arteriovenous fistulas and the endovascular devices currently available. The review covers initial trial data and subsequent studies examining their use. EXPERT OPINION Early results achieved with endovascular fistula formation are encouraging. Current limitations of this technology include anatomic suitability and a high rate of re-interventions required to establish maturity. Greater uptake of the technology will also require a review of long-term outcomes in larger patient cohorts.
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Affiliation(s)
- Bynvant Sandhu
- Department of Renal Transplant and Vascular Access Surgery, Royal Free Hospital, London, UK
| | - Charlie Hill
- Department of Renal Transplant and Vascular Access Surgery, Royal Free Hospital, London, UK
| | - Mohammad Ayaz Hossain
- Department of Renal Transplant and Vascular Access Surgery, Royal Free Hospital, London, UK
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15
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Osofsky R, Byrd D, Reagor J, Das Gupta J, Clark R, Argyropoulos C, Fabre A, Owen J, Marek J, Rana MA, Langsfeld M, Chavez L. Initial Outcomes Following Introduction of Percutaneous Arteriovenous Fistula Program with Comparison to Historical Surgically Created Fistulas. Ann Vasc Surg 2021; 74:271-280. [PMID: 33549799 DOI: 10.1016/j.avsg.2020.12.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/30/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Recently, there has been an abundance of encouraging data regarding the creation of percutaneous arteriovenous fistulas. Despite promising data regarding their clinical maturation, a paucity of data exists which provides direct comparison between percutaneously created AVFs (pAVF) and open surgically created AVFs (sAVF). This study has 2 primary objectives: First, to compare clinical outcomes of pAVFs to sAVFs, with emphasis on clinical maturation and frequency of postoperative interventions to facilitate maturation. Second, to contribute toward the evidence-based incorporation of the pAVF procedure into the hemodialysis access algorithm. METHODS A single-center retrospective review was performed on all consecutive patients undergoing surgically created brachiocephalic arteriovenous fistula (BC-AVF, sAVF group) from January 1, 2018 to December 31, 2018 and Ellipsys-created percutaneous arteriovenous fistula (pAVF group) from January 1, 2019 to December 31, 2019. Comparative analysis between groups was performed. RESULTS A total of 24 patients underwent Ellipsys-created pAVF with mean age of 56.7 ± 22.6 years (12 males [50%], 12 females [50%]) and 62 patients underwent surgically created BC-AVF with mean age of 62.5 ± 13.2 years (32 males [52%], 30 females [48%]). Both the pAVF and sAVF groups had comparable mean operating times (60 ± 40 vs. 56 ± 25 min, P = 0.67) and frequency of procedural technical success (23 [96%] vs. 62 [100%], P = 0.28), respectively. The pAVF group had a lower clinical maturation rate (12 [52%] vs. 54 [87%], P = 0.003) and a higher primary failure rate (9 [39%] vs. 6 [10%], P = 0.003) when compared to the sAVF group. The pAVF group had an increased overall rate of undergoing a postoperative intervention (18 [78%] vs. 13 [21%], P< 0.001), as well as an increased number of total postoperative interventions (1.1 ± 0.9 vs. 0.3 ± 0.6 interventions, P< 0.001) compared to the sAVF group. Percutaneous transluminal angioplasty of the juxta anastomotic segment was the most prevalent postoperative intervention performed in the pAVF group and occurred at a significantly increased frequency when compared to the sAVF group rate (13 [57%] vs. 5 [8%], P< 0.001). CONCLUSIONS In our single-center retrospective review, patients undergoing Ellipsys-created pAVF in the first year following introduction of percutaneous endovascular had inferior rates of clinical maturation and underwent more postoperative interventions when compared to historical patients undergoing surgically created BC-AVF. Outcome discrepancies compared to previously reported Ellipsys data demonstrate a need for further studies examining the practical translatability of the pAVF.
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Affiliation(s)
- Robin Osofsky
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Dominick Byrd
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Jason Reagor
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Jaideep Das Gupta
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Ross Clark
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Christos Argyropoulos
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Anna Fabre
- Division of Interventional Radiology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Jonathan Owen
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM
| | - John Marek
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Muhammad Ali Rana
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - Mark Langsfeld
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM
| | - LeAnn Chavez
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM.
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16
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Kamiyama H, Kitama M, Shimizu HO, Yamashita M, Kojima Y, Shimizu K. Fundamental Study for Optical Transillumination Imaging of Arteriovenous Fistula. ADVANCED BIOMEDICAL ENGINEERING 2021. [DOI: 10.14326/abe.10.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Hideaki Kamiyama
- Graduate School of Engineering, Division of Engineering, Hokkaido University of Science
| | - Masataka Kitama
- Department of Radiological Technology, Faculty of Health Sciences, Hokkaido University of Science
| | - Hisae O. Shimizu
- Department of Clinical Engineering, Faculty of Health Sciences, Hokkaido University of Science
| | - Masaji Yamashita
- Department of Clinical Engineering, Faculty of Health Sciences, Hokkaido University of Science
| | - Yohichiro Kojima
- Department of Electrical and Electronic Engineering, Faculty of Engineering, Hokkaido University of Science
| | - Koichi Shimizu
- Graduate School of Information, Production and Systems, Waseda University
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17
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Sultan S, Langsfeld M, Chavez L, Fabre A, Osofsky R, Argyropoulos C, Owen JG. Initial 6-month quality review of a percutaneous endovascular arteriovenous fistula program. J Vasc Access 2020; 22:540-546. [DOI: 10.1177/1129729820948692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Percutaneous arteriovenous fistulas have recently proven successful alternatives to surgical arteriovenous fistulas with encouraging initial results. The Ellipsys Endovascular Arteriovenous Fistula System utilizing ultrasound and thermal energy has recently received approval for use in the United States. At the University of New Mexico, we developed an integrated service between Vascular Surgery, Interventional Radiology, and Interventional Nephrology for percutaneous arteriovenous fistulas utilizing Ellipsys. Methods: We performed a retrospective chart review of the initial 6 months (January 1st 2019 to July 1st 2019) of 18 percutaneous arteriovenous fistula placements to evaluate our initial technical success rate, the number of arteriovenous fistulas meeting maturation characteristics or use in dialysis, and to identify areas for quality improvement. Results: Initial technical success was achieved in 17 out of 18 arteriovenous fistulas (94.4%). Three patients did not report for any follow-up at the end of the initial 6 months. Of the remaining patients, 7 out of 15 were using their arteriovenous fistulas or meeting maturation characteristics at the end of the study (46.7%). Patient loss to follow-up/no-show (16.7%), patient not yet requiring hemodialysis (27.8%), and poor post-surgical maturation and/or need for additional maturation procedures (55.6%) were the predominate reasons for non-use. We identified improved coordination of care, early intervention, and outpatient dialysis center education as the primary areas of focus for quality improvement. Conclusion: Initial technical success rate of percutaneous arteriovenous fistulas placement was comparable to published studies. Early and aggressive secondary angiographic interventions of arteriovenous fistulas failing to meet cannulation requirements, improved coordination of post-operative care, and outpatient dialysis center education appear to be the primary targets for quality improvement.
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Affiliation(s)
- Sulaiman Sultan
- Division of Nephrology, The University of New Mexico, Albuquerque, NM, USA
| | - Mark Langsfeld
- Division of Vascular Surgery, The University of New Mexico, Albuquerque, NM, USA
| | - LeAnn Chavez
- Division of Vascular Surgery, The University of New Mexico, Albuquerque, NM, USA
| | - Anna Fabre
- Division of Interventional Radiology, The University of New Mexico, Albuquerque, NM, USA
| | - Robin Osofsky
- Division of Vascular Surgery, The University of New Mexico, Albuquerque, NM, USA
| | | | - Jonathan G Owen
- Division of Nephrology, The University of New Mexico, Albuquerque, NM, USA
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18
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Rognoni C, Tozzi M, Tarricone R. Endovascular versus surgical creation of arteriovenous fistula in hemodialysis patients: Cost-effectiveness and budget impact analyses. J Vasc Access 2020; 22:48-57. [PMID: 32425096 PMCID: PMC7897778 DOI: 10.1177/1129729820921021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives: The aim of the present study was to perform cost-effectiveness and budget impact analyses comparing endovascular arteriovenous fistula creation to surgical arteriovenous fistula creation in hemodialysis patients from the National Healthcare Service (NHS) perspective in Italy. Methods: A systematic literature review has been conducted to retrieve complications’ rates after arteriovenous fistula creation procedures. One study comparing endovascular arteriovenous fistula creation, performed with WavelinQ device, to the surgical approach through propensity score matching was preferred to single-arm investigations to execute the economic evaluations. This study was chosen to populate a Markov model to project, on a time horizon of 1 year, quality adjusted life years and costs associated with endovascular arteriovenous fistula (WavelinQ) and surgical arteriovenous fistula options for both cohorts of incident and prevalent hemodialysis patients. Results: For both incident and prevalent hemodialysis patients, endovascular arteriovenous fistula creation, performed with WavelinQ, was the dominant strategy over surgical arteriovenous fistula approach, showing less cost and better patients’ quality of life. Compared to the current scenario, progressively increasing utilization rates of WavelinQ over surgical arteriovenous fistula creation in the next 5 years in incident hemodialysis patients are expected to save globally 30–36 million euros to the NHS. Conclusion: Endovascular arteriovenous fistula creation performed with WavelinQ could be a cost-saving strategy in comparison with the surgical approach for patients in hemodialysis. Future studies comparing different devices for endovascular arteriovenous fistula creation versus the surgical option would be needed to confirm or reject the validity of this preliminary evaluation. In the meantime, decision-makers can use these results to take decisions on the diffusion of endovascular procedures in Italy.
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Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milan, Italy
| | - Matteo Tozzi
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milan, Italy.,Department of Policy Analysis and Public Management, Bocconi University, Milan, Italy
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19
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Khawaja AZ, Tullett KAJ, Jones RG, Inston NG. Preoperative assessment for percutaneous and open surgical arteriovenous fistula creation in patients for haemodialysis. Clin Kidney J 2019; 14:408-417. [PMID: 33564445 PMCID: PMC7857810 DOI: 10.1093/ckj/sfz121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 08/07/2019] [Indexed: 11/14/2022] Open
Abstract
Preoperative assessment prior to surgical arteriovenous fistulas (AVFs) including ultrasound-guided mapping has been shown to have beneficial effects on their immediate success as well as early outcomes. This has led to their wide acceptance and adoption however clinical practice criteria is variable and is reflected in variabilities in practice. When transposing this to percutaneously created endovascular AVFs (endoAVFs), variable preoperative assessment criteria could equally result in variable practice and potentially subsequent and expectant outcomes. We aimed to review literature on reported validated methodologies and workflows of preoperative assessment for surgical AVF creation as reported in highest levels of available evidence, specifically randomized controlled trials. Published practice recommendations and guidelines on best clinical practice as well as systematic reviews and meta-analyses of published studies were also reviewed. Data on practice methodology from identified trial publications and protocols was collated and a summative narrative synthesis was carried out which compared these methodologies to additional assessments that may be required when targeting assessment for percutaneous endoAVF formation, based on our units experience as part of an international multicentre trial. In this review we present a brief overview of published literature and guidelines and propose a unified and uniform workflow for preoperative assessment for surgical AVFs and endoAVFs to aide clinical and imaging practice.
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Affiliation(s)
- Aurang Z Khawaja
- University Hospitals Birmingham NHS Foundation Trust, Renal Transplantation and Dialysis Access, Birmingham, UK
| | - Karen A J Tullett
- University Hospitals Birmingham NHS Foundation Trust, Renal Transplantation and Dialysis Access, Birmingham, UK
| | - Robert G Jones
- University Hospitals Birmingham NHS Foundation Trust, Diagnostic and Interventional Radiology, Birmingham, UK
| | - Nicholas G Inston
- University Hospitals Birmingham NHS Foundation Trust, Renal Transplantation and Dialysis Access, Birmingham, UK
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Endovascular Creation of Arteriovenous Fistulae for Hemodialysis Access with a 4 Fr Device: Clinical Experience from the EASE Study. Ann Vasc Surg 2019; 60:182-192. [DOI: 10.1016/j.avsg.2019.02.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 02/11/2019] [Accepted: 02/19/2019] [Indexed: 11/24/2022]
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21
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Yan Wee IJ, Yap HY, Tang TY, Chong TT. A systematic review, meta-analysis, and meta-regression of the efficacy and safety of endovascular arteriovenous fistula creation. J Vasc Surg 2019; 71:309-317.e5. [PMID: 31564584 DOI: 10.1016/j.jvs.2019.07.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 07/15/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The percutaneous endovascular approach to arteriovenous fistula (AVF) creation is a minimally invasive alternative to surgical AVF creation. This systematic review and meta-analysis aimed to investigate the efficacy and safety of endovascular AVF creation in patients with end-stage renal disease. METHODS This study conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search was performed on major databases to identify relevant articles. Meta-analysis of proportions and meta-regression were conducted. RESULTS Seven studies totaling 300 patients were included, of which four evaluated the everlinQ (TVA Medical, Austin, Tex) and three employed the Ellipsys (Avenu Medical, San Juan Capistrano, Calif) systems. The overall technical success rate was 97.50% (95% confidence interval [CI], 94.98-99.31%; I2 = 0.00%; P = .487). The 90-day maturation rate was 89.27% (95% CI, 84.00-93.66%; I2 = 21.29%; P = .283), and the 6-month patency and 12-month patency were 91.99% (95% CI, 87.98-95.35%; I2 = 0.00%; P = .780) and 85.71% (95% CI, 79.90-90.71%; I2 = 0.00%; P = NS), respectively. The overall procedure-related complication rate was 5.46% (95% CI, 0.310-14.42%; I2 = 81.21%; P = .000). Meta-regression was conducted on the pooled rates of technical success and complication, showing that age, diabetes, white race, hypertension, on dialysis, and body mass index were not significant sources of heterogeneity. CONCLUSIONS Current endovascular AVF systems appear to be effective and safe. However, given the lack of head-to-head comparative analyses with surgical AVF creation, superiority cannot be established.
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Affiliation(s)
- Ian Jun Yan Wee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hao Yun Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore.
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22
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Murea M, Geary RL, Davis RP, Moossavi S. Vascular access for hemodialysis: A perpetual challenge. Semin Dial 2019; 32:527-534. [PMID: 31209966 DOI: 10.1111/sdi.12828] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Vascular access for hemodialysis has a long and rich history. This article highlights major innovations and milestones in the history of angioaccess for hemodialysis. Advances in achievement of lasting hemodialysis access, swift access transition, immediate and sustaining access to vascular space built the momentum at different turning points of access history and shaped the current practice of vascular access strategy. In the present era, absent of large-scale clinical trials to validate practice, the ever-changing demographic and comorbidity makeup of the dialysis population pushes against stereotypical angioaccess goals. The future of hemodialysis vascular access would benefit from proper randomized clinical trials and acclimatization to clinical contexts.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Randolph L Geary
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Ross P Davis
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Shahriar Moossavi
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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23
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24
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Jones RG, Morgan RA. A Review of the Current Status of Percutaneous Endovascular Arteriovenous Fistula Creation for Haemodialysis Access. Cardiovasc Intervent Radiol 2018; 42:1-9. [DOI: 10.1007/s00270-018-2037-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022]
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