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Cheun TJ, Hart JP, Davies MG. Management of depth to achieve timely arteriovenous fistula utilization. J Vasc Surg 2024; 80:545-553.e3. [PMID: 38604320 DOI: 10.1016/j.jvs.2024.03.445] [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: 01/11/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Failure to achieve timely arteriovenous fistulae (AVFs) utilization due to excessive depth (>6 mm) remains an ongoing concern for dialysis access. This study evaluates the outcomes of radiocephalic (RCF) and brachiocephalic (BCF) fistula elevation required for access utilization. METHODS A retrospective review of all patients undergoing first-time autologous access over 10 years was undertaken. RCF and BCF were analyzed, and cases of initial access failure due to depth alone were selected for study. Primary and staged brachio-basilic AVF were excluded. Outcomes of early thrombosis, line placement, maturation (successful progression to hemodialysis [HD), reintervention, and functional dialysis (continuous HD for 3 consecutive months) were examined. RESULTS From January 2012 to December 2022, 1733 patients (67% female; mean age, 61 ± 14 years) underwent autologous AVF placement. Of these, 298 patients (17%) had depth-related AVF access issues (BCF, 71% and RCF, 29%). Nineteen percent of these AVFs underwent a primary balloon-assisted maturation (BAM), and 2% had side branch coil embolization before consideration for elevation. The average time to intervention for depth was 11 ± 4 weeks after primary creation. During elevation, side branch ligation occurred in 38% of cases, and 15% underwent intraoperative BAM, The pre-elevation depth was 8.2 ± 3.1 mm, and the mean post-elevation depth was 4.7 ± 2.9 mm (P = .002). Early thrombosis (<18 days) occurred in 4% of cases. There was no mortality, and the 30-day major adverse cardiac event rate was 2%, with a 30-day morbidity of 5%, which was driven by wound issues. Six percent of the AVFs underwent follow-up BAM within 3 months. Mean maturation of the AVFs was 74% ± 3% vs 72% ± 3% (P = .58) for the elevation vs no-elevation groups at 24 weeks, respectively. However, there was an increase in tunneled central line placement in pre-emptive fistula patients due to the delay in maturation (elevation, 17% vs no-elevation, 8%; P = .008). There was a mean successful access time of 6 ± 3 weeks after elevation (16 ± 4 weeks after access creation). There was a median of 2.4 secondary interventions per year after elevation compared with a median of 2.7 secondary interventions per year without elevation. Mean access functionality was 68% ± 8% vs 75% ± 8% at 3 years for the elevation vs no-elevation groups, respectively (P = .25). CONCLUSIONS Elevation of deep BCF and RCF occurs late after placement but can be successfully achieved with low morbidity and satisfactory long-term functionality. It results in an increase in tunneled central line placement in pre-emptive fistula patients. Elevation is a valuable adjunct to AVF maturation and enhances an autologous access policy.
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Affiliation(s)
- Tracy J Cheun
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular Surgery, Long School of Medicine, San Antonio, TX
| | - Joseph P Hart
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular/Endovascular Surgery, Ascension Health, Waco, TX.
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2
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Kobzeva-Herzog AJ, Levin SR, Young S, McNamara TE, Alonso AG, Farber A, King EG, Siracuse JJ. Assessing Time to Removal of Tunneled Dialysis Catheters after Arteriovenous Access Creation. Ann Vasc Surg 2024; 102:35-41. [PMID: 38377711 DOI: 10.1016/j.avsg.2023.12.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 02/22/2024]
Abstract
BACKGROUND Tunneled dialysis catheters (TDCs) are a temporary bridge until definitive arteriovenous (AV) access is established. Our objective was to evaluate the time to TDC removal in patients who underwent AV access creations with TDCs already in place. METHODS A single-center analysis of all AV access creations in patients with TDCs was performed (2014-2020). Primary outcome was time to TDC removal after access creation. RESULTS There were 364 AV access creations with TDCs in place. The average age was 58 years, 44% of patients were female, and 64% were Black. The median time to TDC removal was 113 days (range, 22-931 days) with 71.4% having a TDC >90 days after access creation. Patients with TDC >90 days were often older (60 vs. 54.7), had hypertension (98.1% vs. 93.3%), were diabetic (65.4% vs. 47.1%), and had longer average time to maturation (107.1 vs. 55.4 days, P < 0.001) and first access (114 vs. 59.4 days, P < 0.001). Multivariable analysis showed that older age was associated with prolonged TDC placement (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005) and prosthetic graft use was associated with shorter TDC indwelling time (OR 0.09, 95% CI 0.04-0.23, P ≤ 0.001). Kaplan-Meier analysis showed that 87% of TDCs were removed at 1 year. CONCLUSIONS The majority of patients with TDCs who underwent AV access creation had prolonged TDC placement. Prosthetic graft use was associated with shorter catheter times. Close follow-up after access placement, improving maturation times, and access type selection should be considered to shortened TDC times.
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Affiliation(s)
- Anna J Kobzeva-Herzog
- Division of Vascular and Endovascular Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA
| | - Sara Young
- Division of Vascular and Endovascular Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA
| | - Thomas E McNamara
- Division of Vascular and Endovascular Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA
| | - Andrea G Alonso
- Division of Vascular and Endovascular Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA.
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Kingsmore D, Edgar B, Stevenson K, Greenlaw N, Aitken E, Jackson A, Thomson P. A practical review of barriers and challenges to a definitive randomised trial of grafts versus fistula. J Vasc Access 2024:11297298241234610. [PMID: 38436199 DOI: 10.1177/11297298241234610] [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: 03/05/2024] Open
Abstract
A definitive randomised controlled trial of arteriovenous fistula (AVF) versus arteriovenous grafts (AVG) has been advocated for more than a decade, but as yet, none has been completed. The aim of this article is to summarise the theoretical barriers, review the difficulties in trial design and practicalities that have thus far prevented this from occurring.
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Affiliation(s)
- David Kingsmore
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ben Edgar
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Karen Stevenson
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nicola Greenlaw
- Glasgow Clinical Trials Unit, Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Emma Aitken
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Andrew Jackson
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter Thomson
- Department of Renal Medicine, Queen Elizabeth University Hospital, Glasgow, UK
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Abdo EM, Abouelgreed TA, Elshinawy WE, Farouk N, Abdelaal MA, Ismail H, Ibrahim AH, Kasem SA, Aboomar AA. Use of Basilic vein in arteriovenous fistulas construction for hemodialysis access. Is it a good option alternative to prosthetic arteriovenous grafts? Arch Ital Urol Androl 2023; 95:11455. [PMID: 37435737 DOI: 10.4081/aiua.2023.11455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/08/2023] [Indexed: 07/13/2023] Open
Abstract
PURPOSE For patients with a failed forearm autogenous fistula (AF) and an exhausted cephalic vein, there is controversy about whether a brachial basilic AF with transposition or an arteriovenous prosthetic bridging graft (BG) must be the second vascular access option. This work measured and compared these two modalities according to patency rates, complications, and revisions. PATIENTS AND METHODS A retrospective study of 104 cases that had either a brachial basilic AF (72) or an Arteriovenous BG (32). Technical success, operative complications, procedurerelated mortality, maturation time, functional primary, secondary, and overall patency rates were all assessed. RESULTS Technical success was obtained in all participants. No procedure-linked mortality. Maturation time for BGs was significantly shorter than AFs. The complication rate was significantly higher in BGs than in AFs. The most prevalent complication was access thrombosis. The functional primary patency rate was significantly higher in AF than in BG at 12-month followup: 77.7% vs 53.1% (p < 0.012). secondary patency rate was higher in AF than in BG at 1-year follow-up 62.5% vs 42.8% (p = 0.063), respectively. In addition, BGs required more interventions to preserve patency. CONCLUSIONS AF had higher primary, secondary and overall functional patency rates and needed fewer procedures to keep patency than BGs. Cases that need early vascular access as a result of central venous catheter complications or who have a reduced life expectancy may benefit from BGs.
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Affiliation(s)
- Ehab M Abdo
- Department of Vascular Surgery, Faculty of Medicine, Al-Azhar University, Cairo.
| | | | - Waleed E Elshinawy
- Department of Vascular Surgery, Faculty of Medicine, Al-Azhar University, Cairo.
| | - Nehal Farouk
- Department of Vascular Surgery, Faculty of Medicine, Al-Azhar University, Cairo.
| | | | - Hassan Ismail
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo.
| | - Amal H Ibrahim
- Department of Internal Medicine, Nephrology Unit, Faculty Medicine, Al-Azhar University, Cairo.
| | - Samar A Kasem
- Department of Internal Medicine, Nephrology Unit, Faculty Medicine, Al-Azhar University, Cairo.
| | - Ahmed A Aboomar
- Department of Internal Medicine, Nephrology Unit, Faculty Medicine, Tanta University, Tanta.
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Kim H, Nelson PR, Mushtaq N, Mallios A, Kempe K, Zamor K, Pandit V, Vang S, Jennings WC. Creating reverse flow arteriovenous fistulas with a forearm cannulation target. J Vasc Access 2023; 24:552-558. [PMID: 34423671 DOI: 10.1177/11297298211039654] [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] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Establishing a forearm arteriovenous fistula (AVF) offers preferred cannulation sites and preserves proximal access opportunities. When a radiocephalic AVF at the wrist is not feasible and the upper arm cephalic and median cubital veins are inadequate, an AV graft or more complex access procedure is often required. Creating a retrograde flow forearm AVF (RF-AVF) is a valuable alternative where the mid-forearm median antebrachial or cephalic vein is adequate, offering forearm cannulation zones with AVF outflow through deep and superficial collaterals. We report our technique and results. METHODS We retrospectively reviewed our vascular access data base of consecutive patients during an 11-year study period where a RF-AVF established the only available cannulation target in the forearm. In addition to physical examination, all patients had ultrasound vessel mapping. RESULTS A forearm access was established with a RF-AVF as the only opportunity for cannulation in 48 patients. Ages were 14-86 years (median = 62 years). Forty-four percent female, 63% diabetic, 13% obese, and 29% had previous access operations. Inflow was proximal radial artery in 47 individuals and one proximal ulnar. Nine AVFs (19%) failed at 2-66 months (median 14 months). One RF-AVF was ligated due to arm edema. Follow-up was 2-111 months (median = 23.5 months). Primary and cumulative patency rates were 62% and 91% at 12 months, and 46% and 85% at 24 months. Five patients were lost to follow-up with functioning RF-AVFs (mean 41 months). Twenty-three patients (48%) died during F/U of causes unrelated to access procedures (mean 25 months). CONCLUSIONS Establishing a reverse flow forearm AVF offers a successful autogenous access option in the forearm for selected patients with an inadequate distal radial artery and/or cephalic vein at the wrist, avoiding more complex or staged procedures and preserving upper arm sites for future use. A proximal radial artery inflow procedure is recommended.
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Affiliation(s)
- Hyein Kim
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Peter R Nelson
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Nasir Mushtaq
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Tulsa, OK, USA
| | | | - Kelly Kempe
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Kimberly Zamor
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Viraj Pandit
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Steven Vang
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - William C Jennings
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, USA
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6
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Kempe K, Nelson PR, Mushtaq N, Kim H, Zamor K, Vang S, Pandit V, Randel M, Christie R, Jennings W. Autogenous Vascular Access in American Indians. Ann Vasc Surg 2022; 83:108-116. [PMID: 34954040 DOI: 10.1016/j.avsg.2021.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND American Indians (AI) or Alaska Natives, or in combination with another race, comprised 6.8 million individuals in 2010 and the population is expected to exceed 10 million in the current census. Diabetes is more common in AIs than in other races in the United States and is responsible for 69% of new onset end stage renal disease in AI patients. The incidence of obesity is also higher among AIs. As both diabetes and obesity make creating a successful autogenous vascular access more challenging, we reviewed our experience creating arteriovenous fistulas in AI patients. METHODS Our vascular access database was reviewed for consecutive new AI patients undergoing creation of a hemodialysis vascular access during a 10-year period. Each patient underwent ultrasound vessel mapping by the operating surgeon in addition to history and physical examination. The goal for initial cannulation was 4-6 weeks after access creation. Minimal AVF flow volume for cannulation was 500 mL/min with an outflow vein diameter of 6 mm. RESULTS 235 consecutive new AI patients were identified. All patients had an autogenous access constructed. The median age was 56 years (range, 15-89 years). Diabetes was present in 85% and 42% were female. Obesity was noted in 27% of the patients and 37% had previous vascular access operations. Primary patency at 12 and 24 months was 62% and 46%, respectively. Cumulative patency at 12 and 24 months was 96% and 94%, respectively. Female gender and previous access operations were associated with lower primary (P = 0.002 and 0.02, respectively) and cumulative patency (P = 0.01 and 0.04, respectively). Obesity was associated with lower cumulative access patency (P = 0.02). Overall, 74% of the access operations used the radial or ulnar artery for AVF inflow. Distal radial artery inflow AVFs were associated with longer patient survival (P = 0.01) and individuals with proximal radial inflow had longer survival when compared to brachial artery AVFs. Previous access operations were associated with shorter patient survival (P = 0.04). CONCLUSIONS Safe and functional arteriovenous fistulas can be created for American Indians despite a higher prevalence of vascular access risk factors such as diabetes and obesity.
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Affiliation(s)
- Kelly Kempe
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Peter R Nelson
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Nasir Mushtaq
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Tulsa, OK
| | - Hyein Kim
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Kimberly Zamor
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Steven Vang
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Viraj Pandit
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Mark Randel
- Eastern Oklahoma VA Health Care System, Department of Surgery, OK
| | - Ryan Christie
- University of Oklahoma School of Community Medicine, Tulsa, OK
| | - William Jennings
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community, Medicine, Tulsa, OK.
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7
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Nelson PR, Mallios A, Randel M, Jennings WC. Percutaneous arteriovenous fistula creation. Semin Vasc Surg 2021; 34:195-204. [PMID: 34911625 DOI: 10.1053/j.semvascsurg.2021.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/09/2021] [Accepted: 10/10/2021] [Indexed: 11/11/2022]
Abstract
The first percutaneous systems used to create an arteriovenous fistula for hemodialysis were approved by the US Food and Drug Administration in 2018 and included the Ellipsys and WavelinQ devices. Early results and longer-term studies of these catheter-based devices suggest that they offer important benefits and potentially improved outcomes in patients with appropriate anatomy. The deep communicating vein in the cubital fossa and its relationship to the proximal radial artery or proximal ulnar artery are key vascular elements of both systems. The devices differ significantly in technical design, energy source, imaging requirements, procedure times, catheters, access vessel sites, and techniques. We review the two approved percutaneous arteriovenous fistula devices, including technical considerations, selecting the appropriate patient, postoperative evaluation, interventions, outcomes, potential complications, and cannulation issues.
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Affiliation(s)
- Peter R Nelson
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, 1919 S. Wheeling Avenue, Suite 600, Tulsa, OK 74104
| | | | - Mark Randel
- Department of Surgery, Eastern Oklahoma Veterans Affairs Health Care System, Tulsa and Muskogee, Oklahoma
| | - William C Jennings
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, 1919 S. Wheeling Avenue, Suite 600, Tulsa, OK 74104; Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK.
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Mobley D, Kalloo SD, Baskin KM, Koh E, McLennan G, Narayan R, Towbin R, White S, Weintraub JL. Research Priorities for Percutaneous Arteriovenous Fistula Creation in Patients with End-Stage Renal Disease: Proceedings and Recommendations from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol 2021; 32:1240.e1-1240.e8. [PMID: 34332723 DOI: 10.1016/j.jvir.2021.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/29/2021] [Indexed: 11/19/2022] Open
Abstract
Recently developed endovascular techniques to create percutaneous arteriovenous fistulas are an alternative to surgical arteriovenous fistula creation, although there is currently a lack of high-level evidence regarding their creation, maturation, utilization, and long-term function. Recognizing this, the Society of Interventional Radiology Foundation sponsored a Research Consensus Panel and Summit for the prioritization of a research agenda to identify and address the gaps in current knowledge.
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Affiliation(s)
- David Mobley
- Division of Vascular and Interventional Radiology, Department of Radiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY.
| | - Sean D Kalloo
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Kevin M Baskin
- Interventional Radiology, Sharon Regional Medical Center, Sharon, PA
| | - Elsie Koh
- American Endovascular Care, New York, NY
| | - Gordon McLennan
- Interventional Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Rajeev Narayan
- Interventional Nephrology, San Antonio Kidney Disease Center, San Antonio, TX
| | - Richard Towbin
- Department of Interventional and Pediatric Radiology, Phoenix Children's Hospital, Phoenix, AZ
| | - Sarah White
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, WI
| | - Joshua L Weintraub
- Department of Radiology (in Surgery), Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY
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Voto C, Panetta T. Salvage of Suboptimal or Occluded Arteriovenous Fistulas Using a 4 French System From the Radial Artery for Initial Balloon Angioplasty Maturations. Cureus 2021; 13:e13446. [PMID: 33767930 PMCID: PMC7982301 DOI: 10.7759/cureus.13446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction End-stage renal disease (ESRD) is a condition that has seen a large increase in prevalence in recent decades. Paralleling this increase in prevalence is the increasing number of patients requiring vascular access for hemodialysis. Arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) are considered the procedures of choice for hemodialysis access. However, due to the suboptimal venous anatomy (<2 mm diameter, sclerotic vascular walls) and chronic medical conditions (diabetes mellitus) seen in many ESRD patients, successful AVF creation and maturation is not always possible using standard procedures. In this study, we performed primary balloon angioplasty (PBA) at the time of AVF creation with subsequent balloon angioplasty maturation (BAM) procedures in a group of patients with a large proportion of diabetes and suboptimal venous anatomy. The purpose of this study was to compare the assisted patency and survival rates in patients with suboptimal veins used to create AVFs to patients with standard vein AVFs and AVGs. Methods Over a nine-year period, PBA during AVF creation was performed 682 times. Of these, 551 AVFs were matured in optimally sized veins using standard BAM procedures, and 131 AVFs were matured in suboptimal veins utilizing a modified approach. In the subset of patients with suboptimal venous anatomy, we performed the initial BAM procedure via the radial artery utilizing a 4 French system. Additionally, routine clinical surveillance was scheduled throughout the study period for all patients. Suboptimal veins included small (<2 mm diameter), sclerotic, accessory, or recanalized veins. During the study period, 69 AVGs were created and matured using standard graft-gram procedures. A Kaplan-Meier analysis of survival and assisted patency rates comparing the three groups were calculated utilizing data from a retrospective database and medical records. A hazard ratio and a log-rank test were calculated to assess statistical significance. Results The mean time of follow-up for all three groups (n=703) was 43.2 months. Among patients requiring hemodialysis access in the study, the fistula creation rate was 90.8%. Patients with suitable venous anatomy who underwent AVF creation with PBA and standard BAM procedures experienced higher primary assisted patency rates relative to the suboptimal vein AVF and AVG groups (p<0.0001). No difference was seen between the suboptimal vein AVF and AVG groups. Patient survival and the percentage of diabetics were comparable amongst all three groups. Conclusion Using our approach, we were able to achieve a high AVF creation rate amongst a group of patients with a large proportion of suboptimal veins and diabetes. Despite not performing as well as standard vein AVFs in regards to primary assisted patency, the patients with suboptimal vein AVFs experienced similar patency and survival rates as compared to patients receiving AVGs. This new approach enhances the ability to create AVFs in patients who would otherwise not be amenable to fistulas and may contribute to reduced complication risk and improved overall survival.
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Affiliation(s)
- Christian Voto
- College of Osteopathic Medicine, University of New England, Biddeford, USA
| | - Thomas Panetta
- Vascular Surgery, Mercy Medical Center, Rockville Centre, USA
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10
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Jasty VS, Haddad D, Mohan B, Zhou W, Siracuse JJ, Tan TW. Tapered and non-tapered prosthetic grafts in upper extremity dialysis access: A systematic review and meta-analysis. J Vasc Access 2020; 23:42-49. [PMID: 33213273 DOI: 10.1177/1129729820974177] [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: 11/15/2022] Open
Abstract
OBJECTIVE It is unclear whether tapered arteriovenous grafts (AVGs) are superior to non-tapered AVGs when it comes to preventing upper extremity ischemic steal syndrome. We aimed to evaluate the outcomes of tapered and non-tapered AVGs using systematic review and meta-analysis. METHODS A literature search was systemically performed to identify all English publications from 1999 to 2019 that directly compared the outcomes of upper extremity tapered and non-tapered AVGs. Outcomes evaluated were the primary patency at 1-year (number of studies (n) = 4), secondary patency at 1-year (n = 3), and risk of ischemic steal (n = 5) and infection (n = 4). Effect sizes of individual studies were pooled using random-effects model, and between-study variability was assessed using the I2 statistic. RESULTS Of 5808 studies screened, five studies involving 4397 patients have met the inclusion criteria and included in the analysis. Meta-analyses revealed no significant difference for the risk of ischemic steal syndrome (pooled odds ratio (OR) 0.92, 95% Confidence Incidence (CI) 0.29-2.91, p = 0.89, I2 = 48%) between the tapered and non-tapered upper extremity AVG. The primary patency (OR 1.33, 95% CI 0.93-1.90, p = 0.12, I2 = 10%) and secondary patency at 1-year (OR 1.49, 95% CI 0.84-2.63, p = 0.17, I2 = 13%), and rate of infection (OR 0.62, 95% CI 0.30-1.27, p = 0.19, I2 = 29%) were also similar between the tapered and non-tapered AVG. CONCLUSIONS The risk of ischemic steal syndrome and patency rate are comparable for upper extremity tapered and non-tapered AVGs. This meta-analysis does not support the routine use of tapered graft over non-tapered graft to prevent ischemic steal syndrome in upper extremity dialysis access. However, due to small number of studies and sample sizes as well as limited stratification of outcomes based on risk factors, future studies should take such limitations into account while designing more robust protocols to elucidate this issue.
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Affiliation(s)
| | - David Haddad
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Babu Mohan
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Wei Zhou
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Jeffrey J Siracuse
- Department of Vascular Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Tze-Woei Tan
- College of Medicine, University of Arizona, Tucson, AZ, USA
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11
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Lee SYD, Xiang J, Kshirsagar AV, Steffick D, Saran R, Wang V. Supply and Distribution of Vascular Access Physicians in the United States: A Cross-Sectional Study. ACTA ACUST UNITED AC 2020; 1:763-771. [PMID: 34355198 DOI: 10.34067/kid.0002722020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Because functioning permanent vascular access (arteriovenous fistula [AVF] or arteriovenous graft [AVG]) is crucial for optimizing patient outcomes for those on hemodialysis, the supply of physicians placing vascular access is key. We investigated whether area-level demographic and healthcare market attributes were associated with the distribution and supply of AVF/AVG access physicians in the United States. Methods A nationwide registry of physicians placing AVFs/AVGs in 2015 was created using data from the United States Renal Data System and the American Physician Association's Physician Masterfile. We linked the registry information to the Area Health Resource File to assess the supply of AVF/AVG access physicians and their professional attributes by hospital referral region (HRR). Bivariate analysis and Poisson regression were performed to examine the relationship between AVF/AVG access physician supply and demographic, socioeconomic, and health resource conditions of HRRs. The setting included all 50 states. The main outcome was supply of AVF/AVG access physicians, defined as the number of physicians performing AVF and/or AVG placement per 1000 prevalent patients with ESKD. Results The majority of vascular access physicians were aged 45-64 (average age, 51.6), male (91%), trained in the United States (76%), and registered in a surgical specialty (74%). The supply of physicians varied substantially across HRRs. The supply was higher in HRRs with a higher percentage white population (β=0.44; SEM=0.14; P=0.002), lower unemployment rates (β=-10.74; SEM=3.41; P=0.002), and greater supply of primary care physicians (β=0.18; SEM=0.05; P=0.001) and nephrologists (β=15.89; SEM=1.22; P<0.001). Conclusions Geographic variation was observed in the supply of vascular access physicians. Higher supply of such specialist physicians in socially and economically advantaged areas may explain disparities in vascular access and outcomes in the United States and should be the subject of further study and improvement.
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Affiliation(s)
- Shoou-Yih D Lee
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan.,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Jie Xiang
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Abhijit V Kshirsagar
- University of North Carolina Kidney Center and Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Diane Steffick
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Virginia Wang
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
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12
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Horst VD, Nelson PR, Mallios A, Kempe K, Pandit V, Kim H, Jennings WC. Avoiding hemodialysis access-induced distal ischemia. J Vasc Access 2020; 22:786-794. [PMID: 32715859 DOI: 10.1177/1129729820943464] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Timely creation and maintenance of a safe and reliable vascular access is essential for hemodialysis patients with end-stage renal disease. Hemodialysis access-induced distal ischemia (HAIDI) is a recognized complication of arteriovenous fistulas and grafts that may result in serious or even devastating consequences. Avoiding such complications is clearly preferred over treatment of HAIDI once established. Proper recognition of patients at increased risk of HAIDI includes careful pre-operative evaluation of the patient's medical and surgical history along with physical examination and imaging to determine a plan for creating a functional permanent access while minimizing the risk of distal ischemia. Our aim is to review identifying characteristics of individuals at risk of HAIDI and provide recommendations regarding pre-operative assessment. Vascular access options and techniques are suggested for establishing a functional vascular access without distal ischemia for such patients.
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Affiliation(s)
- Vernon D Horst
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - Peter R Nelson
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | | | - Kelly Kempe
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - Viraj Pandit
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - Hyein Kim
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - William C Jennings
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
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13
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Tayebi P, Kazemzadeh G, Modaghegh MHS, Kamyar MM, Ravari H. Brachio-basilic upper arm transposition fistulas vs. prosthetic brachio-axillary vascular access grafts-Which one is preferred for hemodialysis? Hemodial Int 2020; 24:182-187. [PMID: 32052592 DOI: 10.1111/hdi.12817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 12/20/2019] [Accepted: 01/12/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION There is still controversy on the use of brachio-basilic upper arm transposition fistula (BBAVF) and prosthetic brachio-axillary vascular access grafts (BAPTFE) in patients with no suitable cephalic veins for creating an autogenous brachio-cephalic fistula. METHODS In a randomized controlled clinical trial, 60 hemodialysis patients who were not a suitable candidate for BCAVF were randomly assigned into two groups: BBAVF and BAPTFE. The patients were clinically followed up to 1 year and the patency rate and access-related complications were compared between the two groups. FINDINGS Access failure rate in the BBAVF and BAPTFE groups was 30.0% and 36.6%, respectively. The primary patency time was 232.73 ± 113.36 and 261.53 ± 147.37 days, respectively (P = 0.40). Thrombosis formation and infection were the two main causes for access failure, yet indicating no significant difference between the two groups (P > 0.05). DISCUSSION BBAVF and BAPTFE have comparable clinical outcomes in short-term follow-up. Therefore, BAPTFE can be used as an alternative vascular access for hemodialysis in patients who are not a suitable candidate for BBAVF.
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Affiliation(s)
- Pouya Tayebi
- Department of Vascular and Endovascular Surgery, Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran.,Vascular and Endovascular Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Gholamhossein Kazemzadeh
- Vascular and Endovascular Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mohammad Mahdi Kamyar
- Vascular and Endovascular Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Ravari
- Vascular and Endovascular Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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14
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Dougherty MJ, Troutman DA, Maloni KC. Management of Difficult Dialysis Access Issues for Dialysis Patients. Adv Surg 2019; 53:83-101. [PMID: 31327458 DOI: 10.1016/j.yasu.2019.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Matthew J Dougherty
- Section of Vascular Surgery, Pennsylvania Hospital, University of Pennsylvania, 700 Spruce Street, Suite 101, Philadelphia, PA 19106, USA.
| | - Douglas A Troutman
- Section of Vascular Surgery, Pennsylvania Hospital, University of Pennsylvania, 700 Spruce Street, Suite 101, Philadelphia, PA 19106, USA
| | - Krystal C Maloni
- Pennsylvania Hospital, University of Pennsylvania, 700 Spruce Street, Suite 101, Philadelphia, PA 19106, USA
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15
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Cheng TW, Farber A, Eslami MH, Kalish JA, Jones DW, Rybin D, Siracuse JJ. Removal of infected arteriovenous grafts is morbid and many patients do not receive a new access within 1 year. J Vasc Surg 2019; 70:193-198. [DOI: 10.1016/j.jvs.2018.10.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 10/09/2018] [Indexed: 11/24/2022]
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16
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Roberts L, Farber A, Jones DW, Woo K, Eslami MH, Simons J, Malas M, Tan TW, Rybin D, Siracuse JJ. Tapered arteriovenous grafts do not provide significant advantage over nontapered grafts in upper extremity dialysis access. J Vasc Surg 2019; 69:1552-1558. [DOI: 10.1016/j.jvs.2018.08.181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/23/2018] [Indexed: 11/29/2022]
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17
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Comparative outcomes of vascular access in patients older than 70 years with end-stage renal disease. J Vasc Surg 2019; 69:1196-1206.e5. [DOI: 10.1016/j.jvs.2018.07.061] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 07/22/2018] [Indexed: 11/19/2022]
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18
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Spanish Clinical Guidelines on Vascular Access for Haemodialysis. Nefrologia 2018; 37 Suppl 1:1-191. [PMID: 29248052 DOI: 10.1016/j.nefro.2017.11.004] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/21/2017] [Indexed: 12/26/2022] Open
Abstract
Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.
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19
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Woo K, Ulloa J, Allon M, Carsten CG, Chemla ES, Henry ML, Huber TS, Lawson JH, Lok CE, Peden EK, Scher L, Sidawy A, Maggard-Gibbons M, Cull D. Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure. J Vasc Surg 2017; 65:1089-1103.e1. [PMID: 28222990 DOI: 10.1016/j.jvs.2016.10.099] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes. METHODS The RAND/UCLA Appropriateness Method was used. Accordingly, a comprehensive literature search was performed and a synthesis of results compiled. The RAND/UCLA Appropriateness Method was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts rated the appropriateness of each scenario in two rounds. On the basis of the distribution of the panelists' scores, each scenario was determined to be appropriate, inappropriate, or indeterminate. RESULTS Panelists achieved agreement in 2964 (77.7%) scenarios; 860 (41%) AVF and 588 (34%) AVG scenarios were scored appropriate, 686 (33%) AVF and 480 (28%) AVG scenarios were scored inappropriate, and 542 (26%) AVF and 660 (38%) AVG scenarios were indeterminate. Younger age, larger outflow vein diameter, normal or obese body mass index (vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with AVF or AVG appropriateness. Dialysis status was not associated with AVF appropriateness. Body mass index and functional status were not associated with AVG appropriateness. To simulate the surgeon's decision-making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. Of these 864 clinical situations, 311 (36%) were rated appropriate for AVG but inappropriate or indeterminate for AVF. CONCLUSIONS The results of this study indicate that patient-specific situations exist wherein AVG is as appropriate as or more appropriate than AVF. These results provide patient-specific recommendations for clinicians to optimize vascular access selection criteria, to standardize care, and to inform payers and policy. Indeterminate scenarios will guide future research.
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Affiliation(s)
- Karen Woo
- Division of Vascular Surgery, David Geffen School of Medicine, University of California, Los Angeles, Calif.
| | - Jesus Ulloa
- Department of Surgery, UCSF School of Medicine, University of California, San Francisco, Calif
| | - Michael Allon
- Division of Nephrology, University of Alabama School of Medicine, University of Alabama, Birmingham, Ala
| | - Christopher G Carsten
- Division of Vascular Surgery, University of South Carolina School of Medicine, University of South Carolina, Greenville, SC
| | - Eric S Chemla
- St. George's University Hospitals NHS Foundation Trust Vascular Institute, St. George's University, London, United Kingdom
| | - Mitchell L Henry
- Division of Transplantation Surgery, The Ohio State University College of Medicine, The Ohio State University, Columbus, Ohio
| | - Thomas S Huber
- Division of Vascular Surgery, University of Florida College of Medicine, University of Florida, Gainesville, Fla
| | - Jeffrey H Lawson
- Division of Vascular Surgery, Duke University School of Medicine, Duke University, Durham, NC
| | - Charmaine E Lok
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eric K Peden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Tex
| | - Larry Scher
- Department of Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Anton Sidawy
- Division of Vascular Surgery, George Washington School of Medicine and Health Sciences, George Washington University, Washington, D.C
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Calif
| | - David Cull
- Division of Vascular Surgery, University of South Carolina School of Medicine, University of South Carolina, Greenville, SC
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20
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Greenberg J, Jayarajan S, Reddy S, Schmieder FA, Roberts AB, van Bemmelen PS, Lee J, Choi ET. Long-Term Outcomes of Fistula First Initiative in an Urban University Hospital-Is It Still Relevant? Vasc Endovascular Surg 2017; 51:125-130. [PMID: 28330437 DOI: 10.1177/1538574417692454] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Dialysis access failure is a major cause of morbidity in patients with end-stage renal disease. The Fistula First Breakthrough Initiative (FFBI) dictates arteriovenous fistulae (AVFs) should be preferred over arteriovenous grafts (AVGs) as first line for surgically placed accesses. The purpose of this study was to compare patency rates of surgical dialysis accesses in our mature, urban population after the FFBI. METHODS Current dialysis patients with accesses placed between 2006 and 2011 were included. Patient characteristics, access outcomes, interventions, and survival outcomes were analyzed. RESULTS We report outcomes of 220 patients undergoing dialysis access. Of those 220, 75 received numerous accesses. All outcomes are evaluated as per access itself, that is, a patient may have numerous access types, each individually analyzed. Of the accesses, 138 were AVF and 190 were AVG. The average age of patients was 59.8 years. The groups were evenly matched in distribution of race and prevalence of hypertension, diabetes, coronary artery disease, and Peripheral Vascular Disease (PVD). Average number of complications requiring intervention per access were fewer with AVF than AVG (1.21 vs 1.72, P = .02). The AVF had greater rates of stenosis (51.4% vs 40.6%, P = .0182), whereas AVG had greater thrombosis rates (14.6% vs 31.9%, P < .001). Both AVF and AVG had similar primary patency (median: 186 vs 142 days, P = .1774) and 3-year secondary patency (59.2% vs 49.2%, P = .0945). Arteriovenous fistula in patients aged <60 years was found to have the greatest primary ( P = .0078) and secondary patency ( P = .0400). Outcomes did not differ between AVF and AVG in those aged >60 years. CONCLUSIONS Although complications requiring intervention are greater with AVG, primary and secondary patency rates are similar between AVF and AVG, except when considering AVF in patients aged <60 years.
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Affiliation(s)
- Jacques Greenberg
- 1 Division of Vascular and Endovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Senthil Jayarajan
- 2 Section of Vascular Surgery, Washington University School of Medicine, MO, USA
| | - Sridhar Reddy
- 3 Division of Nephrology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Frank A Schmieder
- 1 Division of Vascular and Endovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Andrew B Roberts
- 1 Division of Vascular and Endovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Paul S van Bemmelen
- 1 Division of Vascular and Endovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Jean Lee
- 3 Division of Nephrology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Eric T Choi
- 1 Division of Vascular and Endovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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21
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Comprehensive Comparison of the Performance of Autogenous Brachial-Basilic Transposition Arteriovenous Fistula and Prosthetic Forearm Loop Arteriovenous Graft in a Multiethnic Asian Hemodialysis Population. BIOMED RESEARCH INTERNATIONAL 2016; 2016:8693278. [PMID: 27840832 PMCID: PMC5093232 DOI: 10.1155/2016/8693278] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/31/2016] [Accepted: 09/28/2016] [Indexed: 11/21/2022]
Abstract
Aim. For patients who have exhausted cephalic vein arteriovenous fistula (AVF) options, controversy exists on whether brachial-basilic AVF with transposition (BBTAVF) or a forearm arteriovenous graft (AVG) should be the next vascular access of choice. This study compared the outcomes of these two modalities. Methods. A retrospective study of 122 Asian multiethnic patients who underwent either a BBTAVF (81) or an AVG (41). Maturation time and intervention rates were analyzed. Functional primary, secondary, and overall patency rates were evaluated. Results. The maturation time for BBTAVFs was significantly longer than AVGs. There was also a longer deliberation time before surgeons abandon a failing BBTAVF compared to an AVG. Both functional primary and secondary patency rates were significantly higher in the BBTAVF group at 1-year follow-up: 73.2% versus 34.1% (p < 0.001) and 71.8% versus 54.3% (p = 0.022), respectively. AVGs also required more interventions to maintain patency. When maturation rates were considered, the overall patency of AVGs was initially superior in the first 25 weeks after creation and then became inferior afterwards. Conclusion. BBTAVFs had superior primary and functional patency and required less salvage interventions. The forearm AVG might have a role in patients who require early vascular access due to complications from central venous catheters or with limited life expectancy.
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22
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Creating Arteriovenous Fistulas using Surgeon-performed Ultrasound. J Vasc Access 2016; 17:333-9. [DOI: 10.5301/jva.5000569] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2016] [Indexed: 11/20/2022] Open
Abstract
Purpose An arteriovenous fistulas (AVF) is the preferred vascular access for hemodialysis and is associated with lower mortality, morbidity and cost when compared with grafts and particularly with central venous dialysis catheters. This study reviews a series of new patients where an autogenous access was constructed for each individual utilizing surgeon-performed ultrasound (SP-US). Methods Consecutive new patients referred for a permanent vascular access during an 11-year period were retrospectively reviewed. In addition to physical examination, each patient underwent SP-US evaluation for preoperative vessel mapping and post-operative evaluation for access maturation. SP-US was also used in the evaluation of access dysfunction in mature AVFs. Results We identified 1874 patients. Ages were 8-94 years (mean 60 years). Of these, 51% were female and 59% were diabetic; 33% had previous failed access operations. Follow-up was 3-127 months (mean 23 months). An autogenous access was constructed for each individual. No grafts were used. Direct AVFs were constructed in 1240 (66%) patients and 634 (34%) individuals required a transposition or translocation procedure. Primary and cumulative patency rates were 60.0% and 93.0% at 12 months and 47.3% and 90.2% at 24 months, respectively. AVF arterial inflow was most commonly supplied by the proximal radial artery (67%). Conclusions Creating a functional autogenous vascular access is possible for most patients. No grafts were used in this series of 1874 consecutive new patients. Important elements for success included SP-US evaluation, utilization of the many vascular access options available, establishing radial artery AVF inflow when feasible, and prompt intervention when indicated.
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23
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Korepta LM, Watson JJ, Elder EA, Davis AT, Mansour MA, Chambers CM, Cuff RF, Wong PY. Outcomes for forearm and upper arm arteriovenous fistula creation with the transposition technique. J Vasc Surg 2016; 63:764-71. [DOI: 10.1016/j.jvs.2015.09.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 09/25/2015] [Indexed: 11/25/2022]
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24
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Cowan D, Smith L, Chow J. Maintaining a viable vascular access for hemodialysis in an elderly person with diabetes: a journey to live, not just to stay alive. Clin Case Rep 2016; 4:203-8. [PMID: 26862425 PMCID: PMC4736524 DOI: 10.1002/ccr3.459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/02/2015] [Accepted: 10/26/2015] [Indexed: 12/03/2022] Open
Abstract
The longevity of a successful vascular access (VA) is enhanced when the care of the patient's VA is the responsibility of everyone involved, including the patient and their family. A family nursing perspective enhances VA care outcomes and increases quality of life and well‐being for patients requiring hemodialysis.
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Affiliation(s)
- Debi Cowan
- Renal Services Central Coast Local Health District (CCLHD) Holden Street Gosford New South Wales 2250 Australia; Nursing & Midwifery School of Health Sciences University of Tasmania Locked Bag 1322 Launceston Tasmania 7250 Australia
| | - Lindsay Smith
- Nursing & Midwifery School of Health Sciences University of Tasmania Locked Bag 1322 Launceston Tasmania 7250 Australia
| | - Josephine Chow
- Clinical Innovation & Business Unit South Western Sydney Local Health District Don Everett Building, Locked Bag 7103, BC 1871 Liverpool New South Wales 2170 Australia
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25
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Hemodialysis Access in the Elderly: Outcomes among Patients Older than Seventy. Ann Vasc Surg 2016; 31:77-84. [DOI: 10.1016/j.avsg.2015.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 07/17/2015] [Accepted: 08/10/2015] [Indexed: 11/17/2022]
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26
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Abstract
Effective hemodialysis requires a reliable vascular access. Clinical practice guidelines strongly recommend the fistula as the preferred option followed by arteriovenous (AV) grafts, with central venous catheters being least preferred. Recently, there has been a growing awareness of the limitations of the fistula, its high rate of primary failure and that a fistula may not be appropriate for all patients initiating or on hemodialysis. However, determinates for fistula eligibility have not been clearly defined. The creation and use of a fistula requires the complex integration of patient, biological, and surgical factors, none of which can be easily predicted or planned. There have been several successful initiatives over the last decade addressing patient suitability for AV access, but none have validated defined criteria for fistula eligibility. We discuss these initiatives by addressing: 1) process of care, 2) radiological and nonradiological tests and procedures, and 3) alternative surgical approaches. Careful clinical judgment, appropriate vascular access assessment and placement, and an individualized approach to the risks and benefits will optimize patient health outcomes while minimizing prolonged catheter dependence among hemodialysis patients.
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Affiliation(s)
- Ahmed A Al-Jaishi
- Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada; Kidney, Dialysis, Transplantation Program, Institute for Clinical Evaluative Sciences (ICES-KDT), London, Ontario, Canada
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