Arteriovenous fistula creation: should US nephrologists get involved?

Arteriovenous fistula creation by nephrologist and its outcomes: a prospective cohort study from Vietnam

BACKGROUND

Arteriovenous fistula (AVF) is the gold standard vascular access for effective hemodialysis. There is a growing interest in AVF creations performed by nephrologists to help reduce vascular surgeons' workload and enhance the timely treatment of patients with end-stage renal disease (ESRD). However, little is known about the feasibility and effectiveness of this approach in the low-resource settings. We examined the AVF surgical success and failure rates and associated predictors as well as early complications of AVF creations by a trained nephrologist with supports from vascular surgeons in Vietnam.

METHODS

A prospective cohort study was conducted on all adult ESRD patients at the Hemodialysis Department of Thong Nhat Hospital between April 2018 and October 2020. Information on demographic characteristics, comorbidities, and AVF creations was collected using a standardized questionnaire. All patients were followed up until 18 weeks post-surgery.

RESULTS

Among 100 patients with a mean age of 61.22 ± 17.11 years old, male accounted for 54%. Common causes of ESRD included hypertension (57%) and diabetes (32%). Just more than half (52%) of them reported having an AVF creation prior to ESRD. The successful first-time AVF creation rate was 98% (13/99, 95%CI: 8.74-21.18%). The primary and secondary AVF failure rates were 13.13% (13/99, 95%CI: 8.74-21.18%) and 16.87% (14/83, 95%CI: 10.32-26.25%), respectively. Early complications included bleeding (1%) and early thrombosis of the anastomosis (2%). There was a statistically significant association between age and primary AVF failure (P = 0.005) and between operation time and secondary AVF failure (P = 0.038).

CONCLUSIONS

AVF creations performed by well-trained and skilled interventional nephrologists with supports from vascular surgeons can result in favorable short- and long-term outcomes. It is important to follow up older patients and those with a long operation time to detect AVF failures. A standardized AVF creation training program and practice for nephrologists is needed to increase successful rates.

Are There Differences in Arteriovenous Fistulae Created for Hemodialysis between Nephrologists and Vascular Surgeons?

OBJECTIVE

Many studies have reported insufficient support from surgical services, resulting in nephrologists creating arteriovenous fistulas in many centers. The aim of this study was to compare risk factors of arteriovenous fistula dysfunction in patients whose fistulas were created by nephrologists versus vascular surgeons.

METHODS

This was a retrospective, analytical study of interventions by nephrologists and vascular surgeons during a period of 15 years. Out of a total of 1,048 fistulas, 764 (72.9%) were created by nephrologists patients, while vascular surgeons were responsible for 284 (27.1%) fistulae. Laboratory, demographic, and clinical parameters which might affect functioning of these arteriovenous fistulae were analyzed.

RESULTS

Patients whose arteriovenous fistula was formed by nephrologists differed significantly from those created by vascular surgeons in relation to the preventive character of the arteriovenous fistula (p = 0.011), lumen of the vein (p < 0.001) and systolic blood pressure (p = 0.047). Multivariate logistic regression of arteriovenous fistula dysfunction showed that risk factors were female gender (odds ratio [OR] = 1.56, 95% CI 1.16-2.07), whether the fistulae were created by vascular surgeons or nephrologists (OR = 1.38; 95% CI 1.01-1.89) and the site of the arteriovenous fistula (OR = 0.64; 95% CI 0.48-0.85).

CONCLUSIONS

Arteriovenous fistulae created by vascular surgeons, female gender, and the location are risk factors of dysfunction.

A Successful Scheme for Reducing Waiting Times for Arteriovenous Fistula Formation

Purpose

In a bid to reduce waiting times for arteriovenous fistula (AVF) formation we introduced a scheme whereby nephrologists were able to place patients directly on the waiting list for surgery. This study evaluated the quality of these direct referrals and assessed the reduction in waiting times.

Methods

Fifty consecutive patients referred directly to the waiting list were compared with 50 patients placed on the waiting list after being assessed in our vascular access clinic.

Results

Forty-nine patients from the direct group and 47 patients from the clinic group underwent surgery. In the direct group 39 patients (80%) underwent the same procedure as they had been originally listed for, compared with 39 patients (83%) in the clinic group (p=0.80). A fistula suitable for needling was created in 37 patients (76%) of the direct group and 38 patients (81%) of the clinic group (p=0.62). The median wait from referral to surgery in the direct group was significantly lower than in the clinic group (62 vs.141 days; p<0.0001).

Conclusion

This study demonstrates that nephrologists are able to effectively assess select patients for AVF formation. This significantly reduces waiting times for surgery, without an increase in cancelled operations, or a reduction in technical success.

Autologous arteriovenous fistula creation by nephrologists

In 1966, physicians from the Bronx Veterans Administration Hospital, New York City described the surgical creation of a distal radial artery to cephalic vein AV fistula. This novel configuration, for the first time, allowed effective and reproducible cannulation for hemodialysis access and has remained the gold standard for hemodialysis access since. More than 40 years later, vascular access remains the Achilles' heel of hemodialysis therapy. In this article, we will review the outcomes and techniques of the pre-eminent nephrologist-surgeons from around the world in an attempt to define those elements that are necessary for successful autologous fistula creation. The hope is that these elements may be employed by others in an effort to increase the numbers and durability of autologous fistulae in incident and prevalent hemodialysis patients, particularly in the United States.

Arteriovenous fistula surgery: an American perspective from Italy

Hemodialysis depends on durable, long-term vascular access for the patient. In the United States, arteriovenous fistula (AVF) creation rates are lower than they are in Europe. Excess morbidity and mortality has been attributed to reliance on catheters and prosthetic grafts. In Italy, there is a high rate of fistula creation, and they are predominantly created by nephrologists. As American interventional nephrologists become more involved in the procedural aspects of renal care, consideration should be given to replicating the Italian model of dialysis access creation. Specific aspects of the surgical technique, comparison to available literature, and potential reasons for higher fistula creation rates are explored from the vantage point of an American nephrologist visiting Italy. The pertinence to American dialysis access programs is discussed, as is the opportunity for interventional nephrologists in the United States to further expand and improve upon the successes of the Italian experience.