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Glowczwski A, Hohmann S, Ross J, Peden E, Gowda A, Lovelady A, Glowczwski J, Fridley J, Simon BT. Effect of a novel cannulation device for vascular access on AVF maturation in a goat carotid-jugular fistula model. J Vasc Access 2024:11297298241286554. [PMID: 39370632 DOI: 10.1177/11297298241286554] [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: 10/08/2024] Open
Abstract
OBJECTIVE The Ark is a 3-D printed titanium device designed to be implanted around the draining vein of an arteriovenous fistula (AVF) to facilitate vascular access. The purpose of this study was to assess AVF maturation after Ark implantation in a large animal model. METHODOLOGY End-to-side AVFs were created between the carotid artery and jugular vein in nine pygmy goats that included three control (AVF only) and six experimental (AVF and Ark device) animals. For experimental animals, an Ark device was implanted approximately 10 cm downstream of the anastomosis at the time of AVF creation. Postoperative ultrasounds and cannulations of the jugular vein fistula were performed over 12 months. At the conclusion of the study, the AVF was ligated and Ark devices along with a segment of the arterialized vein and surrounding tissues were explanted for gross and histological assessment. RESULTS The control and experimental Ark groups exhibited increased dilation and flow as well as diminished depth underscoring the parallel developments in vascular attributes and AVF maturation between the two groups. Gross pathology, histology, and micro-CT imaging revealed intact endothelium, mature tissue integration throughout the porous Ark device, and no underlying stenosis. No adverse events such as foreign body reaction, skin or vessel erosion were identified. CONCLUSION The study showed maturation without stenosis of the fistula in all animals. This study confirmed that the Ark device functions as a scaffold around the access vein, allows fistula maturation, and can be consistently cannulated without infiltrations over a 12-month period in a large animal model.
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Affiliation(s)
- Alan Glowczwski
- Voyager Biomedical, Inc., Houston, TX, USA
- Veterinary Medical Park, Texas A&M University, College Station, TX, USA
| | | | - John Ross
- Voyager Biomedical, Inc., Houston, TX, USA
- Vascular Surgery, Regional Medical Center, Orangeburg, SC, USA
| | - Eric Peden
- Vascular Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Ashok Gowda
- Voyager Biomedical, Inc., Houston, TX, USA
- Biotex Inc. Houston, TX, USA
| | - April Lovelady
- Voyager Biomedical, Inc., Houston, TX, USA
- School of Engineering Medicine, Texas A&M University, Houston, TX, USA
| | | | - Jennifer Fridley
- Veterinary Medical Park, Texas A&M University, College Station, TX, USA
| | - Bradley T Simon
- Department of Clinical Sciences, Texas A&M University, College Station, TX, USA
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Zhao B, Wang H, Wang Y, Fu G, Guo S, Yu P. Type 2 diabetes increase the risk of arteriovenous fistula non-maturation, mediated by postoperative vascular hemodynamics. Int Urol Nephrol 2024:10.1007/s11255-024-04150-1. [PMID: 38995525 DOI: 10.1007/s11255-024-04150-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 07/05/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND The progression of atherosclerosis in small and medium-sized vessels has been associated with Type 2 diabetes (T2D). However, the influence of T2D on postoperative vascular remodeling and arteriovenous fistula (AVF) maturation is inconclusive. Besides, hemodynamic changes of postoperative vessel are also associated with AVF maturation. This study is intended to investigate the link between T2D and the occurrence of AVF non-maturation, as well as to delve into the impact of postoperative vascular hemodynamic parameters in this process. METHODS A total of 477 hemodialysis patients, with or without type 2 diabetes, underwent AVF creation at Beijing Haidian Hospital (Haidian Section of Pecking University Third Hospital) from August 2018 to March 2022 were collected, and were followed for 1-5 years. Logistic regression was applied to analyze the association of T2D, postoperative vascular hemodynamic parameters with the risk of AVF non-maturation. To verify the stability of the results, the sensitivity analyses were performed using propensity scores to match patients. We further investigated the regulatory role of the postoperative vascular hemodynamics. RESULTS There were 173 patients with T2D and 304 patients without T2D in this study. The maturation rate in T2D and non-T2D group was 47.977% and 63.816%, respectively. The findings of logistic regression analysis suggested that T2D significantly increased the risk of AVF immaturity [OR 1.716 (1.019-2.890), P = 0.042]. Besides, T2D was associated with the restriction of postoperative vascular hemodynamic parameters changes, including with decreased diameter of forearm cephalic radial artery and dilation rate of radial artery. The result of logistic regression analysis indicated that cephalic vein diameter at 1-month [0.402 (0.237-0.681), P = 0.001] and cephalic vein diameter at 2-month [0.501 (0.355-0.708), P < 0.001] were independently correlated with AVF maturation. Besides, the results of sensitivity analysis were consistent with that of logistic regression analysis. Moreover, the mediating effects of cephalic vein diameter were significant. CONCLUSION Our findings discovered that T2D significantly increased the risk of arteriovenous fistula non-maturation, which was mainly mediated by the changes of cephalic vein diameter.
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Affiliation(s)
- Bin Zhao
- NHC Key Laboratory of Hormones and Development, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, No. 6 North Huanrui Road, Beichen District, Tianjin, 300134, China
- Tianjin Key Laboratory of Metabolic Diseases, Tianjin Medical University, Tianjin, China
- Department of Nephrology, Beijing Haidian Hospital (Haidian Section of Pecking University Third Hospital), Beijing, 100080, China
| | - Hui Wang
- NHC Key Laboratory of Hormones and Development, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, No. 6 North Huanrui Road, Beichen District, Tianjin, 300134, China
- Tianjin Key Laboratory of Metabolic Diseases, Tianjin Medical University, Tianjin, China
| | - Yuzhu Wang
- Department of Nephrology, Beijing Haidian Hospital (Haidian Section of Pecking University Third Hospital), Beijing, 100080, China
| | - Gang Fu
- Department of Nephrology, Beijing Haidian Hospital (Haidian Section of Pecking University Third Hospital), Beijing, 100080, China
| | - Shanshan Guo
- Department of Nephrology, Beijing Haidian Hospital (Haidian Section of Pecking University Third Hospital), Beijing, 100080, China
| | - Pei Yu
- NHC Key Laboratory of Hormones and Development, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, No. 6 North Huanrui Road, Beichen District, Tianjin, 300134, China.
- Tianjin Key Laboratory of Metabolic Diseases, Tianjin Medical University, Tianjin, China.
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Pinto R, Barros J, Ferreira R, Alves P, Sousa R, Oliveira L, Pereira L, Correia AL, Silva AR, Henriques A, Magda Guerra, Mata F, Salgueiro A, Fernandes I, Alves R, Sousa C. Advancing arteriovenous fistula needling: The role of physical exam and doppler ultrasound. J Ren Care 2024. [PMID: 38850083 DOI: 10.1111/jorc.12505] [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: 02/02/2024] [Revised: 05/22/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND The success of haemodialysis (HD) critically depends on the effective use of arteriovenous fistulas (AVFs). The precise needling technique is vital to minimise complications and ensure functional vascular access. OBJECTIVE This study assesses the effectiveness of a nursing consultation protocol, which integrates physical examination (PE) with Doppler Ultrasound (DUS), in preparing patients for the first AVF needling. DESIGN/PARTICIPANTS A cross-sectional analysis at a Portuguese National Health Service Hospital engaged thirty new HD patients, four HD needling experienced nurses and one HD vascular access nurse. This study examines the accuracy of PE in assessing the matured AVF by the four nurses compared to a trained vascular access nurse encompassing systematic PE and DUS. MEASUREMENTS The primary data incorporated AVF characteristics derived from PE (inspection, palpation, and auscultation) and DUS findings (vein depth, diameter, and blood flow). A secondary focus was evaluating the change in nurses' perceived needling complexity following the nursing consultation. RESULTS The nursing consultation significantly enhanced the identification of crucial AVF features, such as accessory veins (p = 0.002), and improved the accuracy of AVF morphology assessments. This led to identifying longer needling tracks (p = 0.031) and a higher number of safe needling points (p = 0.016). Nurses reported a notable reduction in perceived complexity and potential adverse events following this method (p = 0.027). CONCLUSIONS Integrating structured PE with DUS in a nursing consultation framework significantly improves the preparation for AVF needling. This approach enhances the efficiency and safety of AVF needling and boosts nurse confidence and patient care in HD settings.
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Affiliation(s)
- Rui Pinto
- Unidade Local de Saúde de Coimbra. Dialysis Unit-Nephrology, University Hospital Centre, Coimbra, Portugal
| | | | - Ricardo Ferreira
- Unidade Local de Saúde de Coimbra. Dialysis Unit-Nephrology, University Hospital Centre, Coimbra, Portugal
| | - Pedro Alves
- Unidade Local de Saúde de Coimbra. Dialysis Unit-Nephrology, University Hospital Centre, Coimbra, Portugal
| | | | | | - Lénia Pereira
- Portuguese Red Cross North Health School, Oliveira de Azeméis, Portugal
| | - Ana Luísa Correia
- Unidade Local de Saúde de Coimbra. Dialysis Unit-Nephrology, University Hospital Centre, Coimbra, Portugal
| | - Ana Rita Silva
- Unidade Local de Saúde de Coimbra. Dialysis Unit-Nephrology, University Hospital Centre, Coimbra, Portugal
| | - Andreia Henriques
- Unidade Local de Saúde de Coimbra. Dialysis Unit-Nephrology, University Hospital Centre, Coimbra, Portugal
| | - Magda Guerra
- Centre for Interdisciplinary Research in Health-Hospital Centre Tondela and Viseu, Viseu, Portugal
| | - Fernando Mata
- Unidade Local de Saúde de Coimbra. Dialysis Unit-Nephrology, University Hospital Centre, Coimbra, Portugal
| | - Anabela Salgueiro
- Health Sciences Research Unit: Nursing-Nursing School Coimbra, Coimbra, Portugal
- Portuguese Vascular Access Association, Coimbra, Portugal
| | - Isabel Fernandes
- Health Sciences Research Unit: Nursing-Nursing School Coimbra, Coimbra, Portugal
| | - Rui Alves
- Unidade Local de Saúde de Coimbra. Dialysis Unit-Nephrology, University Hospital Centre, Coimbra, Portugal
| | - Clemente Sousa
- Centre Health Technology Services Research, Faculty of Medicine, Porto University, Porto, Portugal
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Giannikouris IE, Spiliopoulos S, Giannakopoulos T, Katsanos K, Passadakis P, Georgiadis G. Evaluation of arteriovenous fistula maturation and early prediction of clinical eligibility, using ultrasound: The Fistula Maturation Evaluation (FAME) Study. J Vasc Access 2024:11297298241255519. [PMID: 38801003 DOI: 10.1177/11297298241255519] [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: 05/29/2024] Open
Abstract
INTRODUCTION The study of time-related alterations of ultrasound-determined parameters during maturation, and the assessment of time to hemodynamic maturation, enabling early prediction of clinical eligibility, of hemodialysis autologous arteriovenous fistulae (AVF). METHODS This is an observational, prospective, study of only AVF-eligible patients referred for access creation, from 02/2019 to 02/2022 (ClinicalTrials.gov identifier: NCT0473687). Brachial artery diameter (dBA), access flow volume (FV), non-augmented efferent vein diameter (dEV), resistivity index (RI), and efferent vein total wall thickness (tEV), were assessed by ultrasound. Measurements were conducted daily in the first week and repeated on days 14, 21, 30, 60, and 90, postoperatively. The primary endpoint included the documentation of serial changes of flow and structural parameters related to AVF maturation in the first 90 days of the post-operative period and maturation early prediction. Secondary endpoints included the determination of factors affecting maturation. RESULTS One hundred one participants (mean age, 67 ± 6 years; 76 males) were enrolled. Average dBA and FV reached maximum on day 60 (5.64 ± 0.85 mm) and 90 (1.172 ± 617 mL/min), respectively. Day 7 values of dBA (5.48 ± 0.73 mm) and FV (1.039 ± 531 mL/min) did not alter significantly during the follow-up period. Parameters indicative of clinical functionality, dEV (5.82 ± 0.90 mm) and tEV (0.493 ± 0.10 mm), reached approximately 90% of maximum (6.66 ± 1.42 mm and 0.526 ± 0.11 mm), by day 14. RI reached minimum on day 30 (0.46 ± 0.09), without significant changes after day 2 (0.48 ± 0.09, p = 0.284). A significant correlation was identified, between day 7 FV and day 60 dEV (r = 0.40, p = 0.0002). A FV cut-off value ⩾657.51 mL/min, on day 7, predicted successful fistula maturation with 85% sensitivity and 100% specificity. Multivariate analysis identified female gender, age >75, diabetes, and wrist access as independent predictors of decreased values of maturation parameters. CONCLUSION Hemodynamic maturation is completed by the first postoperative week, while AVF is clinically functional, by the second. FV can be used for early prediction of maturation.
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Affiliation(s)
- Ioannis E Giannikouris
- Department of Nephrology and Hemodialysis Unit, Mediterraneo Hospital, Glyfada, Athens, Attika, Greece
| | - Stavros Spiliopoulos
- 2nd Radiology Department, Division of Interventional Radiology, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Chaidari, Athens, Attika, Greece
| | - Triantafyllos Giannakopoulos
- Department of Vascular and Endovascular Surgery, Mediterranean Hospital of Cyprus, Limassol, Limassol (Lemesos), Cyprus
| | - Konstantinos Katsanos
- Department of Radiology, Health Sciences Division, School of Medicine, University of Patras, Patra, Achaia, Greece
| | - Ploumis Passadakis
- Department of Nephrology, Democritus University of Thrace School of Health Sciences, Alexandroupolis, Thrace, Greece
| | - George Georgiadis
- Department of Vascular Surgery, Democritus University of Thrace School of Health Sciences, Alexandroupolis, Thrace, Greece
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Wong TS, Chen Q, Zhong Q, Hu B, Feng G, Huang F, Lu J, Yin L, Yu Z, Akinwunmi BO, Huang J, Zhang CJ, Ming WK. Cost-effectiveness analysis of autogenous arteriovenous fistula, arteriovenous graft, and tunneled-cuffed catheter for hemodialysis in patients with end-stage kidney disease in Southern China. J Vasc Access 2024; 25:953-962. [PMID: 36540049 DOI: 10.1177/11297298221143010] [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] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To evaluate the cost-effectiveness of three permanent vascular accesses for maintenance hemodialysis patients from a hospital perspective throughout 5 years, which is the average life expectancy of patients with end-stage kidney disease. SUBJECTS AND METHODS We conducted a EuroQol(EQ-5D) questionnaire survey between January 2021 and March 2021 with 250 patients to estimate the health utility of various states in patients under different hemodialysis vascular access. We designed a Markov model and conducted a cost-effectiveness analysis to compare the cost-effectiveness of three hemodialysis vascular access in Guangzhou throughout 5 years. RESULTS The mean costs were US$44,481 with tunneled-cuffed catheter (TCC), and US$68,952 and US$59,247 with arteriovenous graft (AVG) and autogenous arteriovenous fistula (AVF), respectively. The mean quality-adjusted life-years (QALYs) was 1.41 with TCC, and 2.37 and 2.73 with AVG and AVF, respectively. AVG had an incremental cost-effectiveness ratio (ICER) of US$25,491 per QALY over TCC; AVF had an ICER of -US$26,958 per QALY over AVG. At a willingness to pay below US$10,633.8 per QALY, TCC is likely the most cost-effective vascular access. At any willingness to pay between US$10,633.8 and US$30,901.4 per QALY, AVF is likely the most cost-effective vascular access. CONCLUSION These findings illustrate the value of AVF given its relative cost-effectiveness to other hemodialysis modalities. Although AVG costs much more than TCC for slightly higher QALYs than TCC, AVG still has a greater advantage over TCC for patients with longer life expectancy due to its lower probability of death.
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Affiliation(s)
- Tak-Sui Wong
- Division of Nephrology, Department of Medicine, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Qian Chen
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, Guangdong, China
| | - Qiongqiong Zhong
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, Guangdong, China
| | - Bo Hu
- Division of Nephrology, Department of Medicine, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Guanrui Feng
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, Guangdong, China
| | - Fengqiu Huang
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, Guangdong, China
| | - Jian Lu
- Division of Nephrology, Department of Medicine, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Lianghong Yin
- Division of Nephrology, Department of Medicine, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | - Zongchao Yu
- Division of Nephrology, Department of Medicine, The First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
| | | | - Jian Huang
- MRC Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Casper Jp Zhang
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Wai-Kit Ming
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, Guangdong, China
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong
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Hafeez MS, Eslami MH, Chaer RA, Yuo TH. Comparing post-maturation outcomes of arteriovenous grafts and fistulae. J Vasc Access 2024; 25:779-789. [PMID: 36847168 DOI: 10.1177/11297298231151365] [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: 03/01/2023] Open
Abstract
BACKGROUND Though arteriovenous grafts (AVG) mature more reliably than arteriovenous fistulae (AVF) and require fewer maturation procedures (MP) to obtain functional patency, AVG are thought to have worse function after maturation. We explored differences in post-maturation outcomes between the following groups: AVF patients who did (AS-AVF) and did not (unAS-AVF) require assisted maturation and AVG patients who did (AS-AVG) and did not (unAS-AVG) require assisted maturation. METHODS Using the US Renal Data System (2012-2017), we retrospectively identified patients who initiated dialysis with a central venous catheter, underwent AVF or AVG placement and achieved successful two-needle cannulation. Primary patency and access abandonment after maturation were compared across groups using competing risks regression methods, generating sub-hazards ratios (sHR). RESULTS We identified 42,664 AVF and 12,335 AVG that met inclusion criteria. A larger proportion of AVFs required interventions: 18,408 AVF (43.2%) versus 2594 AVG (21.0%; p < 0.01). Both AS-AVG and AS-AVF patients experienced patency loss at 1 year more frequently compared with unAS-AVG (67.5% & 57.5% vs 55.2% respectively). Patency loss was lowest in unAS-AVF (38.9%). These trends were robust on adjusted analysis (unAS-AVG reference, AS-AVG sHR = 1.44, p < 0.01; AS-AVF sHR = 1.08, p < 0.01, unAS-AVF sHR = 0.67, p < 0.01). AS-AVGs were more likely to be abandoned than unAS-AVGs (11.7% unAS-AVG vs 17.2% AS-AVG). Fistulae, assisted or not, had lower unadjusted rates of 1-year abandonment than grafts (8.9% AS-AVF vs 7.3% unAS-AVF). On adjusted analysis, AVF usage was protective against abandonment (unAS-AVG, reference; AS-AVF sHR = 0.67, p < 0.01; unAS-AVF sHR = 0.59, p < 0.01) while AS-AVG was not (AS-AVG sHR = 1.32, p < 0.01). CONCLUSIONS unAS-AVF have the best long-term outcomes. AS-AVF lose primary patency at a higher rate than unAS-AVG. AVGs may be a better choice than AVFs if veins are marginal and likely to require assisted maturation. Further research is needed to identify anatomic and physiologic factors that affect long-term performance and influence conduit choice.
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Affiliation(s)
- Muhammad Saad Hafeez
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mohammad H Eslami
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Theodore H Yuo
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Field M, Khawaja AZ, Ellis J, Jones RG, Inston NG. Evaluating patient perspectives of endovascular created arteriovenous fistulas for dialysis access (EndoAVF). BMC Nephrol 2024; 25:38. [PMID: 38279146 PMCID: PMC10811914 DOI: 10.1186/s12882-024-03475-4] [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: 10/03/2023] [Accepted: 01/20/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Patient reported experience measures are contemporary quality indicators that focus on evaluation of healthcare delivery processes. While surgical arteriovenous fistulas (otherAVF) are preferred for haemodialysis vascular access, fears about surgery and complications often result in refusal/delays. A new technique of endovascular arteriovenous fistula creation (EndoAVF) has been developed and as part of it's ongoing introduction into our unit, the patient perspective was felt critical to its evaluation. The Vascular Access Questionnaire (VAQ) provides a mechanism for identifying and scoring perceptions in this setting. METHOD Patients who had previously undergone EndoAVF formation were approached to undertake the VAQ as part of a service evaluation of their experience. In addition to the components of the VAQ, data questions relating to the patient's perception of their access were gathered. Results were compared with a matched historical cohort of surgically created fistulas (otherAVF) patients. RESULTS Patient satisfaction and self-reported ease of use with EndoAVF were high. Overall VAQ scores were similar between the EndoAVF and the surgically created cohort. Functionally, there was no significant difference in perception of their fistula by patients, irrespective of them being created surgically or radiologically. CONCLUSION Although numbers in this report are small limiting exploration of preserved inherent heterogeneity, we provide a useful initial patient reported experience and perspectives on comparative functional use of radiologically and surgically created AVFs. As real world experience gathers, future larger cohorts with adequate sampling may allow exploration of patient reported experiences and outcome measures.
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Affiliation(s)
- Melanie Field
- Department of Renal Transplantation and Dialysis Access Surgery, Queen Elizabeth Hospital, Edgbaston, University Hospitals Birmingham, Birmingham, West Midlands, B15 2TH, UK.
| | - A Z Khawaja
- Department of Renal Transplantation and Dialysis Access Surgery, Queen Elizabeth Hospital, Edgbaston, University Hospitals Birmingham, Birmingham, West Midlands, B15 2TH, UK
| | - J Ellis
- Department of Renal Transplantation and Dialysis Access Surgery, Queen Elizabeth Hospital, Edgbaston, University Hospitals Birmingham, Birmingham, West Midlands, B15 2TH, UK
| | - R G Jones
- Department of Diagnostic and Interventional Radiology, Queen Elizabeth Hospital, Edgbaston, University Hospitals Birmingham, Birmingham, West Midlands, UK
| | - N G Inston
- Department of Renal Transplantation and Dialysis Access Surgery, Queen Elizabeth Hospital, Edgbaston, University Hospitals Birmingham, Birmingham, West Midlands, B15 2TH, UK
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Allon M, Al-Balas A, Young CJ, Cutter GR, Lee T. Predialysis Vascular Access Placement and Catheter Use at Hemodialysis Initiation. Clin J Am Soc Nephrol 2024; 19:67-75. [PMID: 37843844 PMCID: PMC10843203 DOI: 10.2215/cjn.0000000000000317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Current guidelines encourage placement of an arteriovenous (AV) fistula in patients with advanced CKD to avoid initiation of hemodialysis with a central venous catheter. However, the relative merits of predialysis placement of an AV fistula or graft have been poorly studied. METHODS This study included 380 patients (mean age 59±14 years, 73% Black patients, 51% male) from a large academic medical center who underwent predialysis placement of an AV fistula (286) or AV graft (94). The study quantified three end points: time from access placement to initiation of dialysis, likelihood of starting hemodialysis without a catheter, and number of vascular access procedures before dialysis initiation. RESULTS The eGFR at access surgery was <10, 10-14, and ≥15 ml/min per 1.73 m 2 in 87 (23%), 179 (47%), and 114 (30%) patients, respectively. The median time from access surgery to hemodialysis initiation was 69, 156, and 429 days in patients with an eGFR of <10, 10-14, and ≥15 ml/min per 1.73 m 2 , respectively ( P < 0.001). Hemodialysis was initiated within 2 years of access surgery in 298 (78%) of the patients. Catheter-free hemodialysis initiation was higher in patients with an AV graft versus an AV fistula when the eGFR was <10 ml/min per 1.73 m 2 (88% versus 43%; odds ratio [OR], 9.10 [95% confidence interval, 2.74 to 26.4]) and when the eGFR was 10-14 ml/min per 1.73 m 2 (88% versus 54%; OR, 6.05 [2.35 to 15.0]) but similar when the eGFR was ≥15 ml/min per 1.73 m 2 (90% versus 75%; OR, 3.00 [0.48 to 34.9]). Patients undergoing an AV fistula were more likely to undergo an angioplasty (11% versus 0%, P < 0.001), surgical access revision (26% versus 8%, P < 0.001), a second access placement (16% versus 6%, P = 0.02), and a catheter insertion (32% versus 11%, P < 0.001). CONCLUSIONS Among patients with CKD undergoing vascular access surgery when their eGFR was <15 ml/min per 1.73 m 2 , catheter use at dialysis initiation was much less likely when an AV graft, rather than an AV fistula, was placed.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alian Al-Balas
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carlton J. Young
- Division of Transplant Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gary R. Cutter
- Department of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timmy Lee
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
- Veterans Affairs Medical Center, University of Alabama at Birmingham, Birmingham, Alabama
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Ibáñez Pallarès S, Esteve Simó V, Tapia González I, Clará Velasco A, Ramírez de Arellano Serna M, Yeste Campos M. Clinical characteristics and preoperative ultrasound parameters related to low patency in radio-cephalic arteriovenous fistulas. J Vasc Access 2023:11297298231207125. [PMID: 37936382 DOI: 10.1177/11297298231207125] [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: 11/09/2023] Open
Abstract
INTRODUCTION Our objective is to describe the clinical characteristics and preoperative ultrasound mapping parameters associated with primary and secondary patency of radio-cephalic arteriovenous fistulas (RCF). METHODS A retrospective, single-center, descriptive study, including patients undergoing a RCF creation between 2015 and 2019. Socio-demographic data and ultrasound parameters were collected and an analysis of primary and secondary patency was performed. RESULTS Eighty-four patients were included in this study. Mean age was 65.6 (±13.9) years; 76.6% were male. Mean preoperative ultrasound parameters: forearm cephalic vein diameter was 2.8 (±0.57) mm, radial artery diameter was 2.6 (±0.42) mm, radial artery systolic peak velocity was 68 (±14.3) cm/s radial artery resistance index was 0.76 (±0.9). At the end of the 4 years the follow-up, the mean primary and secondary patency were 47.2% and 80% respectively. Only female sex was significantly associated with a decrease in both primary patency (p = 0.043, HR = 0.48) and secondary patency (p = 0.021, HR = 0.023). Furthermore, radial artery systolic peak velocity (p = 0.007, HR = 2.6) showed a significant association with decreased primary patency and forearm cephalic vein diameter showed a borderline significant association with decreased secondary patency (p = 0.046, HR = 8.2). CONCLUSIONS A standardized evaluation by a vascular surgeon or nephrologist represent a key in the preoperative assessment of AVF candidates. Based on our results, we will consider to avoid distal vascular access in both female patients with lower radial artery systolic peak velocity (less than 68 cm/s) and borderline forearm cephalic vein diameter (less than 2.8 mm) after initial assessment in our clinical practice. Our results could encourage new studies in order to stablish the potential role of these parameters in the RCFs patency rates.
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Affiliation(s)
- Sara Ibáñez Pallarès
- Funtional Unit Vascular Access (FUVA), Consorci Sanitari Terrassa (CST), Terrassa, Barcelona, Spain
- Vascular Surgery Department, Consorci Sanitari Terrassa (CST), Terrassa, Barcelona, Spain
- Surgery and Morphologic Sciences Department, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Vicent Esteve Simó
- Funtional Unit Vascular Access (FUVA), Consorci Sanitari Terrassa (CST), Terrassa, Barcelona, Spain
- Nephrology Department, Consorci Sanitari Terrassa (CST), Terrassa, Barcelona, Spain
| | - Irati Tapia González
- Funtional Unit Vascular Access (FUVA), Consorci Sanitari Terrassa (CST), Terrassa, Barcelona, Spain
- Nephrology Department, Consorci Sanitari Terrassa (CST), Terrassa, Barcelona, Spain
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Dillavou ED, Lucas JF, Woodside K, Burgess J, Farber A, Hentschel D, Ozaki CK. VasQ U.S. pivotal study demonstrates the safety and effectiveness of an external vascular support for arteriovenous fistula creation. J Vasc Surg 2023; 78:1302-1312.e3. [PMID: 37527689 DOI: 10.1016/j.jvs.2023.07.054] [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: 05/20/2023] [Revised: 07/11/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE Arteriovenous fistula (AVF) creation is a commonly performed vascular operation that reports 6-month functional success rates as low as 50%. Recently, a nitinol external vascular support device, VasQ, has shown potential in studies outside the United States (U.S.) to improve AVF outcomes when implanted at creation. Here, the pivotal study results of this novel technology in treating patients in the U.S. are described. METHODS VasQ was implanted in 144 patients at 16 centers across the U.S. who were referred for creation of a new AVF and consented for enrollment in a 2-year, prospective, multicenter, single-arm, open-label study. Brachiocephalic (n = 129) and radiocephalic (n = 15) AVFs were analyzed. The primary endpoint was primary patency at 6 months compared against a performance goal of 55% derived from a systematic literature search. Safety endpoints included device-related events, ischemic steal, infection, aneurysm, and seroma at up to 6 months. Minimum arterial size was 2.0 mm; target veins were required to measure 2.5 to 6 mm. Key exclusion criteria were patients <18 or >80 years, those with known ipsilateral central venous occlusion, target cannulation zone venous depth greater than 8 mm, and New York Heart Association class 3 or 4. RESULTS Patients were 61% male, 53% White, 35% African American, and 14% Hispanic. Mean age was 60 years, and median body mass index was 30.4. Of the patients, 69% were diabetic, 66% were on dialysis at the time of creation, and 70% had a prior access surgery. At 6 months, steal was observed in 2.1%, infection in 0.7%, and no aneurysms or seromas were seen. Primary patency at 6 months was 66% (P < .021 vs performance goal). Physiological maturation was achieved in 92.4% of patients. Successful two-needle cannulation for patients that entered the study on dialysis was achieved in 88% of VasQ AVFs at a median of 56 days. Pre-dialysis patients who initiated dialysis during the study achieved two-needle cannulation in 81.6% VasQ AVFs. Interventions were required at a rate of 1.07 per patient year over the entire study period. Two-year cumulative patency was 76.6% (95% confidence interval, 67.9%-83.4%) with no statistical difference between patients requiring interventions and those that did not. No patency differences were observed between brachiocephalic and radiocephalic AVFs. CONCLUSIONS The U.S. pivotal study results demonstrated improved AVF outcomes and an excellent safety profile with VasQ use relative to traditional AVFs. Under the conditions of this trial, VasQ shows great promise in expeditiously and efficiently enhancing AVF functional success.
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Affiliation(s)
- Ellen D Dillavou
- Division of Vascular Surgery, WakeMed Hospital System, Raleigh, NC.
| | | | | | | | | | - Dirk Hentschel
- Brigham and Women's Hospital/Harvard Medical School, Boston, MA
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11
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Wu CC, Hung HC, Kao TC, Hsin CH, Yu SY, Hsieh HC, Ko PJ. High pulse pressure predicts primary arteriovenous fistula failure within 1 year. J Vasc Access 2023; 24:1349-1357. [PMID: 35394390 DOI: 10.1177/11297298211054797] [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: 11/16/2022] Open
Abstract
BACKGROUND The arteriovenous fistula is the preferred access route for hemodialysis, although its high primary failure rate remains a clinical challenge. Multiple studies have attempted to determine the risk factors for primary arteriovenous fistula failure; however, none have identified pulse pressure as a potential predictive marker. High pulse pressure is a surrogate poor arterial compliance endpoint and leads to inferior cardiovascular outcomes. Our aim was to determine whether elevated pulse pressure indicates poor arteriovenous fistula maturation. METHODS We retrospectively reviewed 274 patients who underwent an arteriovenous fistula index operation between September 1, 2018 and May 31, 2019. Demographic, clinical data, and operative parameters were collected and analyzed. The maximum follow-up period was 365 days. Arteriovenous fistula failure was defined as the inability to achieve functional use during the follow-up period. We identified risk factors for arteriovenous fistula failure by performing a multivariate logistic regression analysis using backward elimination procedures. RESULTS A total of 274 patients were included in the study. The patients' average age was 61.3 ± 14.0 years, approximately half of the patients (n = 161, 58.8%) were male, and the majority had hypertension. At the end of the follow-up period, 68 (24.8%) had arteriovenous fistula failure. The proportion of patients with pulse pressure values of >60 mmHg was significantly higher in the failure group than in the maturation group (66.0% vs 80.9%; p = 0.021). A PP value of >60 mmHg (odds ratio = 2.25; 95% confidence interval = 1.14-4.42; p = 0.019) and coronary artery disease or myocardial infarction (odds ratio = 1.97; 95% confidence interval = 1.01-3.84; p = 0.045) were found to be independent risk factors for primary arteriovenous fistula failure. CONCLUSIONS High pulse pressure is an independent risk factor for primary arteriovenous fistula failure.
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Affiliation(s)
- Chung-Cheng Wu
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Hao-Chien Hung
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan
| | - Tsung-Chi Kao
- Division of Cardiovascular Surgery, Hwa Young Hospital, Taoyuan
| | - Chun-Hsien Hsin
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Sheng-Yueh Yu
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Hung-Chang Hsieh
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Po-Jen Ko
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
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12
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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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13
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He Y, Anderson B, Hu Q, Hayes RB, Huff K, Isaacson J, Warner KS, Hauser H, Greenberg M, Chandra V, Kauser K, Berceli SA. Photochemically Aided Arteriovenous Fistula Creation to Accelerate Fistula Maturation. Int J Mol Sci 2023; 24:ijms24087571. [PMID: 37108733 PMCID: PMC10142855 DOI: 10.3390/ijms24087571] [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: 02/23/2023] [Revised: 04/10/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Rates of arteriovenous fistula maturation failure are still high, especially when suboptimal size veins are used. During successful maturation, the vein undergoes lumen dilatation and medial thickening, adapting to the increased hemodynamic forces. The vascular extracellular matrix plays an important role in regulating these adaptive changes and may be a target for promoting fistula maturation. In this study, we tested whether a device-enabled photochemical treatment of the vein prior to fistula creation facilitates maturation. Sheep cephalic veins were treated using a balloon catheter coated by a photoactivatable molecule (10-8-10 Dimer) and carrying an internal light fiber. As a result of the photochemical reaction, new covalent bonds were created during light activation among oxidizable amino acids of the vein wall matrix proteins. The treated vein lumen diameter and media area became significantly larger than the contralateral control fistula vein at 1 week (p = 0.035 and p = 0.034, respectively). There was also a higher percentage of proliferating smooth muscle cells in the treated veins than in the control veins (p = 0.029), without noticeable intimal hyperplasia. To prepare for the clinical testing of this treatment, we performed balloon over-dilatation of isolated human veins and found that veins can tolerate up to 66% overstretch without notable histological damage.
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Affiliation(s)
- Yong He
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL 32611, USA
| | | | - Qiongyao Hu
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL 32611, USA
| | - R B Hayes
- Alucent Biomedical Inc., Salt Lake City, UT 84108, USA
| | - Kenji Huff
- Alucent Biomedical Inc., Salt Lake City, UT 84108, USA
| | - Jim Isaacson
- Alucent Biomedical Inc., Salt Lake City, UT 84108, USA
| | | | - Hank Hauser
- Alucent Biomedical Inc., Salt Lake City, UT 84108, USA
| | | | - Venita Chandra
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA 94305, USA
| | | | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL 32611, USA
- North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA
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14
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Sharma M, Tong WL, Thompson D, Vachharajani TJ. Placing an appropriate tunneled dialysis catheter in an appropriate patient including the nonconventional sites. Cardiovasc Diagn Ther 2023; 13:281-290. [PMID: 36864971 PMCID: PMC9971288 DOI: 10.21037/cdt-22-426] [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] [Received: 08/26/2022] [Accepted: 12/19/2022] [Indexed: 02/21/2023]
Abstract
Hemodialysis remains the most frequently chosen kidney replacement modality across the world. A well-functioning dialysis vascular access is critical to providing successful dialysis therapy. Despite its drawbacks, central venous catheter is commonly used as a vascular access to initiate hemodialysis therapy in acute and chronic settings. The growing recognition of providing patient centric care and per recommendations from the recently published Kidney Disease Outcome Quality Initiative (KDOQI) Vascular Access Guidelines, selecting the appropriate patient population for a central venous catheter placement involves implementing the End Stage Kidney Disease (ESKD) Life-Plan strategy. The current review examines the circumstances and challenges that increasingly lead to the hemodialysis catheter being the default and the only available choice for patients. The current review outlines the clinical scenarios for selecting an appropriate patient for hemodialysis catheter use for short-term or long-term needs. The review further discusses clinical pointers to assist with the decision-making process on estimation on prospective catheter length selection, particularly in the intensive care unit setting without the aid of conventional fluoroscopic guidance. A hierarchy of conventional and non-conventional access sites is proposed based on KDOQI guidance and multi-disciplinary author experience. Non-conventional sites are reviewed, including complications and technical guidance, for trans-lumbar IVC, trans-hepatic, trans-renal, and other exotic sites.
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Affiliation(s)
- Mukesh Sharma
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, Nevada, USA
| | - Wei Lue Tong
- Department of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Dustin Thompson
- Department of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tushar J. Vachharajani
- Department of Kidney Medicine, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
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15
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Tello-Díaz C, Palau M, Muñoz E, Gomis X, Gavaldà J, Fernández-Hidalgo N, Bellmunt-Montoya S. Methicillin-Susceptible Staphylococcus aureus Biofilm Formation on Vascular Grafts: an In Vitro Study. Microbiol Spectr 2023; 11:e0393122. [PMID: 36749062 PMCID: PMC10100994 DOI: 10.1128/spectrum.03931-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/06/2023] [Indexed: 02/08/2023] Open
Abstract
The aim of this study was to quantify in vitro biofilm formation by methicillin-susceptible Staphylococcus aureus (MSSA) on the surfaces of different types of commonly used vascular grafts. We performed an in vitro study with two clinical strains of MSSA (MSSA2 and MSSA6) and nine vascular grafts: Dacron (Hemagard), Dacron-heparin (Intergard heparin), Dacron-silver (Intergard Silver), Dacron-silver-triclosan (Intergard Synergy), Dacron-gelatin (Gelsoft Plus), Dacron plus polytetrafluoroethylene (Fusion), polytetrafluoroethylene (Propaten; Gore), Omniflow II, and bovine pericardium (XenoSure). Biofilm formation was induced in two phases: an initial 90-minute adherence phase and a 24-hour growth phase. Quantitative cultures were performed, and the results were expressed as log10 CFU per milliliter. The Dacron-silver-triclosan graft and Omniflow II were associated with the least biofilm formation by both MSSA2 and MSSA6. MSSA2 did not form a biofilm on the Dacron-silver-triclosan graft (0 CFU/mL), and the mean count on the Omniflow II graft was 3.89 CFU/mL (standard deviation [SD] 2.10). The mean count for the other grafts was 7.01 CFU/mL (SD 0.82). MSSA6 formed a biofilm on both grafts, with 2.42 CFU/mL (SD 2.44) on the Dacron-silver-triclosan graft and 3.62 CFU/mL (SD 2.21) on the Omniflow II. The mean biofilm growth on the remaining grafts was 7.33 CFU/mL (SD 0.28). The differences in biofilm formation on the Dacron-silver-triclosan and Omniflow II grafts compared to the other tested grafts were statistically significant. Our findings suggest that of the vascular grafts we studied, the Dacron-silver-triclosan and Omniflow II grafts might prevent biofilm formation by MSSA. Although further studies are needed, these grafts seem to be good candidates for clinical use in vascular surgeries at high risk of infections due to this microorganism. IMPORTANCE The Dacron silver-triclosan and Omniflow II vascular grafts showed the greatest resistance to in vitro methicillin-susceptible Staphylococcus aureus biofilm formation compared to other vascular grafts. These findings could allow us to choose the most resistant to infection prosthetic graft.
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Affiliation(s)
- Cristina Tello-Díaz
- Department of Vascular and Endovascular Surgery, Hospital de la Santa Creu i Sant Pau, Institute of Biomedical Research (II-B Sant Pau), CIBER CV, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Departament de Cirurgia i Ciències Morfològiques, Barcelona, Spain
| | - Marta Palau
- Antimicrobial Resistance Laboratory, Vall d'Hebron Research Institute (VHIR), Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Estela Muñoz
- Antimicrobial Resistance Laboratory, Vall d'Hebron Research Institute (VHIR), Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Xavier Gomis
- Antimicrobial Resistance Laboratory, Vall d'Hebron Research Institute (VHIR), Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Joan Gavaldà
- Antimicrobial Resistance Laboratory, Vall d'Hebron Research Institute (VHIR), Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Nuria Fernández-Hidalgo
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Infectious Diseases Department, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI RD16/0016/0003), Instituto de Salud Carlos III, Madrid, Spain
| | - Sergi Bellmunt-Montoya
- Universitat Autònoma de Barcelona (UAB), Departament de Cirurgia i Ciències Morfològiques, Barcelona, Spain
- Antimicrobial Resistance Laboratory, Vall d'Hebron Research Institute (VHIR), Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Angiology, Vascular and Endovascular Surgery, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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Sharbidre KG, Alexander LF, Al-Balas A, Robbin ML. Percutaneous Creation of Dialysis Arteriovenous Fistula: Patient Selection and Ultrasound Mapping. Semin Intervent Radiol 2023; 40:87-99. [PMID: 37152789 PMCID: PMC10159719 DOI: 10.1055/s-0043-1764430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Affiliation(s)
- Kedar G. Sharbidre
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Alian Al-Balas
- Department of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle L. Robbin
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
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17
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Shahverdyan R, Konner K, Matoussevitch V. Gracz fistula is a feasible option after two failed percutaneous arteriovenous fistulae. J Vasc Access 2023; 24:145-148. [PMID: 34121500 DOI: 10.1177/11297298211021339] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Two devices for the creation of an endovascular percutaneous (pAVF) endovascular (endoAVF) arteriovenous fistulae (AVF) are available: the Ellipsys and the WavelinQ-4F systems. The main difference is the location of the anastomosis, making it feasible to use both pAVFs and surgical Gracz-type AVF in an algorithm sequence. A 66-year-old male patient with end-stage kidney disease and HIV was referred for a creation of a dialysis access after failed peritoneal dialysis. A radial-radial WavelinQ-pAVF with simultaneous coil embolization of a brachial vein was created but failed within 4 weeks. Therefore, an Ellipsys-pAVF was successfully created between the proximal radial artery and perforating vein on the same arm. After 2 days, however, the Ellipsys-pAVF anastomosis occluded. The ipsilateral Gracz-AVF was created, anastomosing perforating vein with the antecubital brachial artery. Cannulations were started 28 days later. During the follow up of 807 days, the AVF remained patent with last known volume flow of 1500 ml/min and no need for secondary interventions. We report a successful creation of a Gracz-AVF after primary failed pAVFs created with both pAVF-systems in a single patient and in the same arm. Thus, based on that case we recommend creation of pAVF prior to Gracz-AVF as integral part of Vascular Access creation algorithm, based on each patient's life plan.
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Affiliation(s)
| | - Klaus Konner
- Vascular Access Unit, Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Vladimir Matoussevitch
- Vascular Access Unit, Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Nordrhein-Westfalen, Germany
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Roetker NS, Guo H, Ramey DR, McMullan CJ, Atkins GB, Wetmore JB. Hemodialysis Access Type and Access Patency Loss: An Observational Cohort Study. Kidney Med 2022; 5:100567. [PMID: 36636202 PMCID: PMC9829958 DOI: 10.1016/j.xkme.2022.100567] [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: 11/08/2022] Open
Abstract
Rationale & Objective Access patency outcomes for arteriovenous fistulas (AVFs) as compared with arteriovenous grafts (AVGs) in patients receiving hemodialysis (HD) who have achieved a functioning permanent access are not fully explored. Study Design Observational cohort study. Setting & Population Fee-for-service Medicare beneficiaries aged ≥18 years with kidney failure who were newly using a permanent access for maintenance HD from the United States Renal Data System (2010-2015). Patients using an oral anticoagulant were excluded. Exposure AVG or AVF. Outcomes Loss of primary unassisted, primary assisted, and secondary patency. Analytical Approach Outcomes were characterized using cumulative incidence curves, and HRs adjusted for sociodemographic and clinical factors were estimated for the comparison of AVF versus AVG. Results The cohort included 60,329 and 17,763 patients newly using an AVF and AVG, respectively, for HD. Over 3 years of follow-up, AVG users, compared to AVF users, had a higher cumulative incidence of loss of primary unassisted patency (87% vs 69%; HR, 1.56; 95% CI, 1.52-1.60), loss of primary assisted patency (69% vs 25%; HR, 3.79; 95% CI, 3.67-3.92), and loss of secondary patency (22% vs 10%; HR, 2.03; 95% CI, 1.92-2.16). Stratified analyses revealed differences by subgroups; in particular, incidence of patency loss was higher among patients who underwent prior interventions to maintain prefunctional access patency and Black patients. Limitations This analysis focused on outcomes occurring after first successful use of a permanent access and thus does not inform about risk of patency loss during access maturation. Conclusions Among patients with kidney failure who successfully used a permanent access for HD, patency loss was consistently substantially higher in those using AVGs compared with AVFs. New interventions, such as prophylactic drugs, are needed to improve access longevity and reduce the need for invasive interventions, particularly among patients unable to receive a fistula.
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Affiliation(s)
- Nicholas S. Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Address for Correspondence: Nicholas S. Roetker, PhD, MS, Chronic Disease Research Group, Hennepin Healthcare Research Institute, 701 Park Ave, Suite S2.100, Minneapolis, MN 55415.
| | - Haifeng Guo
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | | | | | | | - James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Division of Nephrology, Hennepin County Medical Center and Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Sun JB, Liu CC, Shen X, Chen Q, Xu CL, Cui TL. Percutaneous endovascular arteriovenous fistula: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:978285. [PMID: 36148078 PMCID: PMC9486211 DOI: 10.3389/fcvm.2022.978285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/15/2022] [Indexed: 12/04/2022] Open
Abstract
Objective Currently, percutaneous endovascular creation of arteriovenous fistula (AVF) shows excellent outcomes. However, few systematic research evidence to support clinical decision making on the benefit of endovascular AVF is available. The purpose of this study was to evaluate the efficacy and safety of endovascular AVF (endoAVF) in patients with renal failure. Methods We searched the Medline, Embase, Cochrane Library, and ClinicalTrials.gov databases for studies on endovascular or endovascular versus surgery for the creation of AVF. Two reviewers independently selected studies and extracted data. A systematic review and meta-analysis were performed by Review Manager 5.4 software (Revman, The Cochrane Collaboration, Oxford, United Kingdom) and Stata 15.0 (Stata Corp, College Station, TX, United States). Results A total of 14 case series and 5 cohort studies, with 1,929 patients, were included in this study. The technique success was 98.00% for endoAVF (95% CI, 0.97–0.99; I2 = 16.25%). There was no statistically significant difference in 3 cohort studies between endovascular and surgical AVF for procedural success (OR = 0.69; 95% CI, 0.04–11.98; P = 0.80; I2 = 53%). The maturation rates of endoAVF were 87.00% (95% CI, 0.79–0.93; I2 = 83.96%), and no significant difference was observed in 3 cohort studies between the 2 groups (OR = 0.73; 95% CI, 0.20–2.63; P = 0.63; I2 = 88%). Procedure-related complications for endoAVF was 7% (95% CI, 0.04–0.17; I2 = 78.31%), and it did not show significant difference in 4 cohort studies between the 2 groups (OR = 1.85; 95% CI, 0.37–9.16; P = 0.45; I2 = 59%). Conclusion The endovascular creation of AVF is potentially effective and safe. These important data may provide evidence to support clinicians and patients in making decisions with endovascular AVF. But further research is great necessary due to lack of randomized controlled studies.
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Radiocephalic Arteriovenous Fistula Patency and Use. ANNALS OF SURGERY OPEN 2022; 3:e199. [PMID: 36199486 PMCID: PMC9508986 DOI: 10.1097/as9.0000000000000199] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/21/2022] [Indexed: 01/05/2023] Open
Abstract
We sought to confirm and extend the understanding of clinical outcomes following creation of a common distal autogenous access, the radiocephalic arteriovenous fistula (RCAVF). Mini-abstract: In this post hoc analysis of randomized clinical trial data including 914 adults with chronic kidney disease, the most robust predictors of radiocephalic arteriovenous fistula patency were larger cephalic vein diameter and access creation prior to a chronic hemodialysis requirement. Successful use occurred at increased rates in men, patients with larger diameter cephalic veins, smaller diameter arteries (albeit ≥2 mm), and when accesses were created using regional anesthesia and at higher volume centers.
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21
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Rosado-Toro JA, Philip RC, Dunn ST, Celdran-Bonafonte D, He Y, Berceli SA, Roy-Chaudhury P, Tubaldi E. Functional analysis of arteriovenous fistulae in non-contrast magnetic resonance images. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 222:106938. [PMID: 35738094 DOI: 10.1016/j.cmpb.2022.106938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 05/09/2022] [Accepted: 06/07/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Arteriovenous fistulae (AVF) are the preferred mode of hemodialysis vascular access and their successful maturation is critical to reduce patient morbidity, mortality, cost, and improve quality of life. Peri-anastomotic venous segment stenosis is the primary cause of AVF maturation failure. The objective is to develop a software protocol for the functional analysis of arteriovenous fistula. METHOD We have developed a standard protocol for the anatomical analysis of the AVF to better understand the mechanisms involved in AVF stenosis and to identify future imaging biomarkers for AVF success or failure using non-contrast magnetic resonance imaging (MRI). The 3D model of the AVF is created using a polar dynamic programming technique. Analysis has been performed on six Yorkshire cross domestic swine, but techniques can be applied into clinical settings. RESULTS Differences in AVF angles and vein curvature are associated with significant variability of venous cross-sectional area. This suggests that the pattern of stenosis is likely to be dependent upon hemodynamic profiles which are largely determined by AVF anatomical features and could play an important role in AVF maturation. CONCLUSIONS This protocol enables us to visualize and study the hemodynamic profiles indirectly allowing early stratification of patients into high and low risk groups for AVF maturation failure. High risk patients could then be targeted with an enhanced process of care or future maturation enhancing therapies resulting in a much-needed precision-medicine approach to dialysis vascular access.
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Affiliation(s)
| | - Rohit C Philip
- BIO5 Institute, University of Arizona, Tucson, AZ, USA; Department of Electrical and Computer Engineering, College of Engineering, University of Arizona, Tucson, AZ, USA
| | - Samuel Thomas Dunn
- BIO5 Institute, University of Arizona, Tucson, AZ, USA; Department of Aerospace and Mechanical Engineering, College of Engineering, University of Arizona, Tucson, AZ, USA
| | | | - Yong He
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Scott A Berceli
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Prabir Roy-Chaudhury
- UNC Kidney Center, College of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Eleonora Tubaldi
- Department of Mechanical Engineering, University of Maryland, College Park, MD, USA.
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22
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Snuff-Box Versus Wrist Radiocephalic Arteriovenous Fistulas for Hemodialysis: Maturation Tend and its Affecting Factors. Ann Vasc Surg 2022; 87:495-501. [PMID: 35780948 DOI: 10.1016/j.avsg.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Thanks to its well proved long-term patency rates, native radiocephalic arteriovenous fistula remains the most commonly used vascular access type. Many articles had approached the criteria leading to a mature fistula. The aims of this work are to evaluate variables that may affect the maturation of distal fistulas and to determine if wrist fistulas have less risk of maturation failure than the snuff-box fistulas. METHODS We recorded all distal radiocephalic fistulas that had been created from January 2018 to February 2021. Epidemiological and clinical profile of patients, characteristics of performed fistulas and per and post-operative data were recorded and analyzed. RESULTS From January 2018 to February 2021, 165 upper limb vascular accesses for hemodialysis had been created including 47 (28.5%) distal radiocephalic fistulas. Among the latter, 39 (83%) fistulas were performed at the wrist and 8 (17%) at snuff-box area. There were 34 men (72.3%). Mean age was 67 years (37-87). Both types of fistulas had approximately an identic frequency of primary maturation failure (50% for radiocephalic versus 47.2% for snuff-box fistulas). Secondary maturation had been achieved in 9 fistulas. Patients with medical history of dyslipidemia, peripheral arterial disease (PAD), central catheter placement, and bad quality of vessels tend to develop an immature fistula. CONCLUSIONS No significant differences in maturation tend between snuff-box and wrist fistulas had been demonstrated. Thus, it seems reasonable to privilege the creation of the most distal fistulas allowing preservation of wrist fistulas as a second option in case of snuff-box fistulas maturation failure. However, selection of the most suitable cases for snuff-box fistulas creation, based on clinical and duplex ultrasound data, remains primordial.
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23
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Liu Z, Bible J, Petersen L, Roy-Chaudhury P, Geissler J, Brouwer-Maier D, Singapogu R. Measuring Cannulation Skills for Hemodialysis: Objective Versus Subjective Assessment. Front Med (Lausanne) 2021; 8:777186. [PMID: 34917637 PMCID: PMC8669158 DOI: 10.3389/fmed.2021.777186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/27/2021] [Indexed: 11/13/2022] Open
Abstract
Lack of cannulation skill during hemodialysis treatments results in poor clinical outcomes due to infiltration and other cannulation-related trauma. Unfortunately, training of patient care technicians and nurses, specifically on the "technical" aspects of cannulation, has traditionally not received much attention. Simulators have been successfully deployed in many medical specialties for assessment and training of clinical skills. However, simulators have not been as widely used in nursing, especially in the context of training clinical personnel in the dialysis unit. We designed a state-of-the-art simulator for quantifying skill for hemodialysis cannulation. In this study, 52 nurses and patient care technicians with varying levels of clinical experience performed 16 cannulations on the simulator with different fistula properties. We formulated a composite metric for objectively measuring overall success of cannulation and compared this metric with subjective assessment by experts. In addition, we examined if years of clinical experience correlated with objective and subjective scores for cannulation skill. Results indicated that, while subjective and objective metrics generally correlated with each other, the objective metric was more precise and better suited for quantifying cannulation skill. Further, the simulator-based objective metric provides several advantages over subjective ratings, including providing fine-grained assessment of skill, consistency in measurement unaffected by subjective biases, and basing assessment on a more complete evaluation of performance. Years of clinical experience, however, demonstrated little correlation with either method of skill assessment. The methods presented for cannulation skill assessment in this study, if widely applied, could result in improved cannulation skill among our PCTs and nurses, which could positively impact patient outcomes in a tangible way.
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Affiliation(s)
- Zhanhe Liu
- Department of Bioengineering, Clemson University, Clemson, SC, United States
| | - Joe Bible
- School of Mathematical and Statistical Sciences, Clemson University, Clemson, SC, United States
| | - Lydia Petersen
- Department of Bioengineering, Clemson University, Clemson, SC, United States
| | - Prabir Roy-Chaudhury
- UNC Kidney Center, University of North Carolina, Chapel Hill, NC, United States.,(Bill Hefner) VA Medical Center, Salisbury, NC, United States
| | - Judy Geissler
- Williams S Middleton Memorial Veterans Hospital, Madison, WI, United States
| | | | - Ravikiran Singapogu
- Department of Bioengineering, Clemson University, Clemson, SC, United States
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Nakaya I, Goto T, Nakamura Y, Yoshikawa K, Oyama J, Tamayama Y, Morooka M, Ito S, Ishioka H, Matsuura Y, Soma J. Temporary central venous catheter at hemodialysis initiation and reasons for use: a cross-sectional study. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00318-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Creating permanent vascular access (VA) is recommended before hemodialysis initiation in patients with end-stage renal disease (ESRD). Although many patients are still introduced to hemodialysis with temporary central venous catheters (CVCs), the reasons for their use remain unclear. We aimed to clarify the characteristics of Japanese patients introduced to hemodialysis using temporary CVCs, the reasons for their use, and whether this rate can be reduced in the future.
Methods
We conducted this cross-sectional study in an acute care general hospital in Japan. We enrolled 393 patients aged ≥ 18 years who received a permanent VA creation for initiating hemodialysis. We classified participants into the temporary CVC group or the permanent VA group according to the VA type at hemodialysis initiation and compared their backgrounds. We identified why permanent VA could not be used at hemodialysis initiation for patients in the temporary CVC group.
Results
Of the 393 patients, 137 (35%) initiated hemodialysis with a temporary CVC, and arteriovenous fistulas (AVFs) were created as the first VA in all patients during hospitalization following hemodialysis initiation. The remaining 256 patients (65%) initiated hemodialysis via AVF cannulation. The duration of predialysis nephrology care was significantly shorter in the temporary CVC group than that in the permanent VA group. The median time from AVF creation to the first successful cannulation was also shorter in the temporary CVC group (8 vs. 66 days, P < 0.001), but the estimated glomerular filtration rate values at hemodialysis initiation did not differ. Reasons for temporary CVC use were varied and complex. Problems on the part of healthcare providers, patient behavioral issues, and characteristics of causative kidney disease itself were underlying reasons. Delayed referral to a nephrologist was less frequent than expected (16%) and the most commonly reported reason (20%) was that a nephrologist was unable to predict the timing of hemodialysis initiation.
Conclusions
Patients with ESRD should be referred to a nephrologist earlier for AVF creation. However, given the already relatively high rate of hemodialysis initiation with permanent VA in Japan, we considered it surprisingly difficult to further reduce the temporary CVC usage rate in Japan.
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25
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Huber TS, Berceli SA, Scali ST, Neal D, Anderson EM, Allon M, Cheung AK, Dember LM, Himmelfarb J, Roy-Chaudhury P, Vazquez MA, Alpers CE, Robbin ML, Imrey PB, Beck GJ, Farber AM, Kaufman JS, Kraiss LW, Vongpatanasin W, Kusek JW, Feldman HI. Arteriovenous Fistula Maturation, Functional Patency, and Intervention Rates. JAMA Surg 2021; 156:1111-1118. [PMID: 34550312 DOI: 10.1001/jamasurg.2021.4527] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance National initiatives have emphasized the use of autogenous arteriovenous fistulas (AVFs) for hemodialysis, but their purported benefits have been questioned. Objective To examine AVF usability, longer-term functional patency, and remedial procedures to facilitate maturation, manage complications, or maintain patency in the Hemodialysis Fistula Maturation (HFM) Study. Design, Setting, and Participants The HFM Study was a multicenter (n = 7) prospective National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases cohort study performed to identify factors associated with AVF maturation. A total of 602 participants were enrolled (dialysis, kidney failure: 380; predialysis, chronic kidney disease [CKD]: 222) with AVF maturation ascertained for 535 (kidney failure, 353; CKD, 182) participants. Interventions All clinical decisions regarding AVF management were deferred to the individual centers, but remedial interventions were discouraged within 6 weeks of creation. Main Outcomes and Measures In this case series analysis, the primary outcome was unassisted maturation. Functional patency, freedom from intervention, and participant survival were summarized using Kaplan-Meier analysis. Results Most participants evaluated (n = 535) were men (372 [69.5%]) and had diabetes (311 [58.1%]); mean (SD) age was 54.6 (13.6) years. Almost two-thirds of the AVFs created (342 of 535 [64%]) were in the upper arm. The AVF maturation rates for the kidney failure vs CKD participants were 29% vs 10% at 3 months, 67% vs 38% at 6 months, and 76% vs 58% at 12 months. Several participants with kidney failure (133 [37.7%]) and CKD (63 [34.6%]) underwent interventions to facilitate maturation or manage complications before maturation. The median time from access creation to maturation was 115 days (interquartile range [IQR], 86-171 days) but differed by initial indication (CKD, 170 days; IQR, 113-269 days; kidney failure, 105 days; IQR, 81-137 days). The functional patency for the AVFs that matured at 1 year was 87% (95% CI, 83.2%-90.2%) and at 2 years, 75% (95% CI, 69.7%-79.7%), and there was no significant difference for those receiving interventions before maturation. Almost half (188 [47.5%]) of the AVFs that matured had further intervention to maintain patency or treat complications. Conclusions and Relevance The findings of this study suggest that AVF remains an accepted hemodialysis access option, although both its maturation and continued use require a moderate number of interventions to maintain patency and treat the associated complications.
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Affiliation(s)
- Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Erik M Anderson
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham
| | - Alfred K Cheung
- Nephrology and Hypertension Division, University of Utah School of Medicine, Salt Lake City
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle
| | | | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern, Dallas
| | | | | | - Peter B Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Alik M Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, Massachusetts
| | - James S Kaufman
- Renal Section, Veterans Affairs New York Harbor Healthcare System, New York
| | - Larry W Kraiss
- Division of Vascular Surgery, University of Utah, Salt Lake City
| | | | - John W Kusek
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Harold I Feldman
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia
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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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27
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Lyu B, Chan MR, Yevzlin AS, Gardezi A, Astor BC. Arteriovenous Access Type and Risk of Mortality, Hospitalization, and Sepsis Among Elderly Hemodialysis Patients: A Target Trial Emulation Approach. Am J Kidney Dis 2021; 79:69-78. [PMID: 34118301 DOI: 10.1053/j.ajkd.2021.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/29/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Evidence is mixed regarding the optimal choice of the first permanent vascular access for elderly patients receiving hemodialysis (HD). Lacking data from randomized controlled trials, we used a target trial emulation approach to compare arteriovenous fistula (AVF) versus arteriovenous graft (AVG) creation among elderly patients receiving HD. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Elderly patients included in the US Renal Data System who initiated HD with a catheter and had an AVF or AVG created within 6 months of starting HD. EXPOSURE Creation of an AVF versus an AVG as the incident arteriovenous access. OUTCOMES All-cause mortality, all-cause and cause-specific hospitalization, and sepsis. ANALYTICAL APPROACH Target trial emulation approach, high-dimensional propensity score and inverse probability of treatment weighting, and instrumental variable analysis using the proclivity of the operating physician to create a fistula as the instrumental variable. RESULTS A total of 19,867 patients were included, with 80.1% receiving an AVF and 19.9% an AVG. In unweighted analysis, AVF creation was associated with significantly lower risks of mortality and hospitalization, especially within 6 months after vascular access creation. In inverse probability of treatment weighting analysis, AVF creation was associated with lower incidences of mortality and hospitalization within 6 months after creation (hazard ratios of 0.82 [95% CI, 0.75-0.91] and 0.82 [95% CI, 0.78-0.87] for mortality and all-cause hospitalization, respectively), but not between 6 months and 3 years after access creation. No association between AVF creation and mortality, sepsis, or all-cause, cardiovascular disease-related, or infection-related hospitalization was found in instrumental variable analyses. However, AVF creation was associated with a lower risk of access-related hospitalization not due to infection. LIMITATIONS Potential for unmeasured confounding, analyses limited to elderly patients, and absence of data on actual access use during follow-up. CONCLUSIONS Using observational data to emulate a target randomized controlled trial, the type of initial arteriovenous access created was not associated with the risks of mortality, sepsis, or all-cause, cardiovascular disease-related, or infection-related hospitalization among elderly patients who initiated HD with a catheter.
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Affiliation(s)
- Beini Lyu
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Micah R Chan
- Department of Medicine, University of Wisconsin School of Medicine and Public Health; Madison, Wisconsin
| | | | - Ali Gardezi
- Department of Medicine, University of Wisconsin School of Medicine and Public Health; Madison, Wisconsin
| | - Brad C Astor
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Medicine, University of Wisconsin School of Medicine and Public Health; Madison, Wisconsin.
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28
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Trerotola SO, Roy-Chaudhury P, Saad TF. Drug-Coated Balloon Angioplasty in Failing Arteriovenous Fistulas: More Data, Less Clarity. Am J Kidney Dis 2021; 78:13-15. [PMID: 33975757 DOI: 10.1053/j.ajkd.2021.02.331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 02/22/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Scott O Trerotola
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Prabir Roy-Chaudhury
- University of North Carolina Kidney Center, Chapel Hill, NC, WG (Bill) Hefner VA Medical Center, Salisbury, NC
| | - Theodore F Saad
- Section of Renal and Hypertensive Diseases, Christiana Care Health System, Newark, DE
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29
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Shahverdyan R, Meyer T, Matoussevitch V. Patency and functionality of radiocephalic arteriovenous fistulas with an external support device (VasQ™): Real-world single-center experience. J Vasc Access 2021; 22:166-172. [PMID: 32026749 PMCID: PMC7983332 DOI: 10.1177/1129729820904599] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 12/02/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The VasQTM device was designed to improve the outcome of arteriovenous fistulae by optimizing the hemodynamics of the flow in the juxta-anastomotic region of the arteriovenous fistulae through tailored external support. The aim of the study was to evaluate the impact of the VasQ on outcome of radiocephalic arteriovenous fistulae in a real-world setting. METHODS This was a single-center, retrospective analysis of patients with either fistula creation before or after dialysis initiation with implantation of the VasQ device during creation of end-to-side radiocephalic arteriovenous fistulae between June 2018 and May 2019. The flow rate and vein diameter were evaluated intraoperatively, at discharge within 48 h postprocedure and at a follow-up of 1, 3, 6, 9, and 12 months. RESULTS Thirty-three VasQ devices were implanted during 33 radiocephalic arteriovenous fistula procedures. The study population comprised mostly of men, with an average age of 66 years. Mean intraoperative flow was 428 mL/min (range: 130-945). All patients were discharged with patent arteriovenous fistulae and mean fistula flow of 740 mL/min (range: 230-1300 mL/min). The primary patency was 100% and 79% at 3 and 6 months, respectively. Cumulative/secondary patency was 100% and 90% at 3 and 6 months, respectively. CONCLUSION Data presented here suggest that the VasQ device has the potential to provide benefit to the functionality of radiocephalic arteriovenous fistulae.
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Affiliation(s)
| | - Tobias Meyer
- Department of Nephrology, Asklepios Clinic Barmbek, Hamburg, Germany
| | - Vladimir Matoussevitch
- Vascular Access Unit, Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
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30
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Singapogu R, Chowdhury A, Roy-Chaudhury P, Brouwer-Maier D. Simulator-based hemodialysis cannulation skills training: a new horizon? Clin Kidney J 2021; 14:465-470. [PMID: 33623670 PMCID: PMC7886575 DOI: 10.1093/ckj/sfaa206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 08/27/2020] [Indexed: 12/24/2022] Open
Abstract
In accordance with the recently released Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, there is a significant need for focused efforts on improving hemodialysis cannulation outcomes. Toward this, structured and meaningful training of our clinical personnel who cannulate in dialysis clinics is a priority. With the availability of advanced sensors and computing methods, simulators could be indispensable tools for standardized skills assessment and training. In this article we present ways in which sensor data could be used to quantify cannulation skill. As with many other medical specialties, implementation of simulator-based training holds the promise of much-needed improvement in end-stage kidney disease patient outcomes.
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Affiliation(s)
| | - Aniqa Chowdhury
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Prabir Roy-Chaudhury
- University of North Carolina Kidney Center, Chapel Hill, NC.; and, WG (Bill) Hefner VA Medical Center, Salisbury, NC, USA
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Pisoni RL, Zepel L, Zhao J, Burke S, Lok CE, Woodside KJ, Wasse H, Kawanishi H, Schaubel DE, Zee J, Robinson BM. International Comparisons of Native Arteriovenous Fistula Patency and Time to Becoming Catheter-Free: Findings From the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2021; 77:245-254. [DOI: 10.1053/j.ajkd.2020.06.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 06/30/2020] [Indexed: 11/11/2022]
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Vyahalkar S, Chaudhari A, Binnani P, Kulkarni A, Nagarik A, Jawade K, Chandrashekhar S. Comparative study of the effects of two suturing techniques of End-to-side arteriovenous anastomosis on early outcomes of radio-cephalic fistulas. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_58_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Vrtovsnik F, Brunet P, Chauveau P, Juillard L, Lasseur C, Mercadal L. [Clinical practice guideline on peri- and postoperative care of arteriovenous fistulas and grafts for haemodialysis in adults]. Nephrol Ther 2020; 16:376-386. [PMID: 33139227 DOI: 10.1016/j.nephro.2020.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/04/2020] [Indexed: 11/16/2022]
Affiliation(s)
- François Vrtovsnik
- Service de néphrologie, Nord-université de Paris, Inserm U1149, hôpital Bichat, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France.
| | - Philippe Brunet
- Service de néphrologie, centre de néphrologie et transplantation rénale, université Aix-Marseille, hôpital de la Conception, AP-HM, 147, boulevard Baille, 13385 Marseille cedex 05, France
| | - Philippe Chauveau
- Aurad-Aquitaine, 2, allée des Demoiselles, 33171 Gradignan cedex, France
| | - Laurent Juillard
- Service de néphrologie, Inserm U1060, université de Lyon, hôpital Herriot, place d'Arsonval, Lyon cedex 03, France
| | - Catherine Lasseur
- Aurad-Aquitaine, 2, allée des Demoiselles, 33171 Gradignan cedex, France
| | - Lucile Mercadal
- Département uro-néphrologie transplantation rénale, Sorbonne université, Inserm U1018, hôpital Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
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See YP, Cho Y, Pascoe EM, Cass A, Irish A, Voss D, Polkinghorne KR, Hooi LS, Ong LM, Paul-Brent PA, Kerr PG, Mori TA, Hawley CM, Johnson DW, Viecelli AK. Predictors of Arteriovenous Fistula Failure: A Post Hoc Analysis of the FAVOURED Study. ACTA ACUST UNITED AC 2020; 1:1259-1269. [DOI: 10.34067/kid.0002732020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/27/2020] [Indexed: 11/27/2022]
Abstract
BackgroundAn autologous arteriovenous fistula (AVF) is the preferred hemodialysis vascular access, but successful creation is hampered by high rates of AVF failure. This study aimed to evaluate patient and surgical factors associated with AVF failure to improve vascular access selection and outcomes.MethodsThis is a post hoc analysis of all participants of FAVOURED, a multicenter, double-blind, multinational, randomized, placebo-controlled trial evaluating the effect of fish oil and/or aspirin in preventing AVF failure in patients receiving hemodialysis. The primary outcome of AVF failure was a composite of fistula thrombosis and/or abandonment and/or cannulation failure at 12 months post-AVF creation, and secondary outcomes included individual outcome components. Patient data (demographics, comorbidities, medications, and laboratory data) and surgical factors (surgical expertise, anesthetic, intraoperative heparin use) were examined using multivariable logistic regression analyses to evaluate associations with AVF failure.ResultsOf 536 participants, 253 patients (47%) experienced AVF failure during the study period. The mean age was 55±14.4 years, 64% were male, 45% were diabetic, and 4% had peripheral vascular disease. Factors associated with AVF failure included female sex (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.20 to 2.68), lower diastolic BP (OR for higher DBP, 0.85; 95% CI, 0.74 to 0.99), presence of central venous catheter (OR, 1.49; 95% CI, 1.02 to 2.20; P=0.04), and aspirin requirement (OR, 1.60; 95% CI, 1.00 to 2.56).ConclusionsFemale sex, requirement for aspirin therapy, requiring hemodialysis via a central venous catheter, and lower diastolic BP were factors associated with higher odds of AVF failure. These associations have potential implications for vascular access planning and warrant further studies.
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Hill K, Xu Q, Jaensch A, Esterman A, Le Leu R, Childs J, Juneja R, Jesudason S. "Outcomes of arteriovenous fistulae cannulation in the first 6 weeks of use: A retrospective multicenter observational study". J Vasc Access 2020; 22:726-732. [PMID: 32912057 DOI: 10.1177/1129729820954717] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Arteriovenous fistula (AVF) management for haemodialysis (HD) is one of the most challenging aspects of clinical care. A successful cannulation outcome when an AVF or arteriovenous graft (AVG) is used for the first time can be influenced by many factors, including access maturity, staff skill, and patient factors. This study examined AVF/AVG outcomes at initiation of HD across two major metropolitan public hospitals. METHODS Electronic medical records were reviewed to collect data retrospectively for a cohort of all newly commencing ESRD HD starts during 2018 to identify cannulation outcomes in the first 6 weeks. RESULTS Of the 117 patients included, AVG use was low (5%). Twenty-four percent of patients required a surgical intervention to salvage a poorly functioning AVF prior to commencing HD. About 32.5% of the cohort had an uneventful start with all successful cannulations. For the remainder of the cohort the number of treatments with unsuccessful cannulation ranged from 1 to 4 or more. About 36% required a surgical intervention for a poorly functioning AVF after commencing HD. Commencing HD with a CVC is associated with a lower likelihood of subsequent successful cannulation (p < 0.001). CONCLUSION Even in experienced centres, a subset of patients experienced complicated cannulation in the first 6 weeks of HD. Several areas of improvement could be considered for these patients; timely referral for access creation, post-operative surveillance to ensure AVF maturation inclusive of duplex ultrasonography, gentle induction using small gauge needles and low blood flows, and consideration of a single needle HD initiation pathway.
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Affiliation(s)
- Kathleen Hill
- University of South Australia, Adelaide, South Australia, Australia
| | - Qunyan Xu
- University of South Australia, Adelaide, South Australia, Australia
| | - Ashleigh Jaensch
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adrian Esterman
- University of South Australia, Adelaide, South Australia, Australia
| | - Richard Le Leu
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Jessie Childs
- University of South Australia, Adelaide, South Australia, Australia
| | - Rajiv Juneja
- Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Shilpanjali Jesudason
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Gage SM, Reichert H. Determining the incidence of needle-related complications in hemodialysis access: We need a better system. J Vasc Access 2020; 22:521-532. [PMID: 32811335 DOI: 10.1177/1129729820946917] [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] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Hemodialysis access complications are common. We hypothesize that many of these complications can be traced back to needle-related injury from routine cannulation practices or inadvertent cannulation injuries. We set out to compare the rates of hemodialysis access complications under prior and current diagnosis coding systems, determine the incidence of needle-related complications for hemodialysis access, and describe the association of needle-related complications and resulting interventions. METHODS Arteriovenous graft and arteriovenous fistula placements occurring in the first 6 months of 2014 and 2016 were identified in the United States Renal Data System Medicare claims data. Placements were followed until end of hemodialysis access life or end of the calendar year. Diagnoses and resulting interventions occurring during placement life were identified and mapped to needle-related complication terms. RESULTS Almost 30,000 placements for 27,000 patients were followed in each year, with 67% of all accesses placed being arteriovenous fistula and 33% arteriovenous graft. In both years, 75% of arteriovenous fistulae and arteriovenous grafts required one or more interventions. Stenosis and thrombosis were the most common complications diagnosed and treated (41% and 16%, respectively); however, potential needle-related complications accounted for 6% of this dataset. DISCUSSION International Classification of Diseases, 9th Revision, was inadequate for determining the incidence of specific hemodialysis access complications or needle-related complications. International Classification of Diseases, 10th Revision, introduced several more hemodialysis access diagnoses but is still subject to coding confusion and catch-all coding for a variety of common and otherwise well-defined complications, suggesting that the true incidence of needle-related complications is buried in the non-specific diagnosis codes. These findings mark the clear need for an improved diagnosis coding system that consistently represents all common hemodialysis access complications.
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Affiliation(s)
- Shawn M Gage
- InnAVasc Medical, Inc., Durham, NC, USA.,Duke University, Durham, NC, USA
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Packer D, Kaufman JS. Catheter First: The Reality of Incident Hemodialysis Patients in the United States. Kidney Med 2020; 2:242-244. [PMID: 32734964 PMCID: PMC7380429 DOI: 10.1016/j.xkme.2020.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- David Packer
- Division of Nephrology, New York University School of Medicine, New York, NY
| | - James S. Kaufman
- Division of Nephrology, New York University School of Medicine, New York, NY
- VA New York Harbor Healthcare System, New York, NY
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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 1001] [Impact Index Per Article: 250.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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Onder AM, Flynn JT, Billings AA, Deng F, DeFreitas M, Katsoufis C, Grinsell MM, Patterson L, Jetton J, Fathallah-Shaykh S, Ranch D, Aviles D, Copelovitch L, Ellis E, Chadha V, Elmaghrabi A, Lin JJ, Butani L, Haddad M, Marsenic O, Brakeman P, Quigley R, Shin HS, Garro R, Liu H, Rahimikollu J, Raina R, Langman CB, Wood E. Predictors of time to first cannulation for arteriovenous fistula in pediatric hemodialysis patients: Midwest Pediatric Nephrology Consortium study. Pediatr Nephrol 2020; 35:287-295. [PMID: 31696356 DOI: 10.1007/s00467-019-04396-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/16/2019] [Accepted: 10/07/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Permanent vascular access (PVA) is preferred for long-term hemodialysis. Arteriovenous fistulae (AVF) have the best patency and the lowest complication rates compared to arteriovenous grafts (AVG) and tunneled cuffed catheters (TCC). However, AVF need time to mature. This study aimed to investigate predictors of time to first cannulation for AVF in pediatric hemodialysis patients. METHODS Data on first AVF and AVG of patients at 20 pediatric dialysis centers were collected retrospectively, including demographics, clinical information, dialysis markers, and surgical data. Statistical modeling was used to investigate predictors of outcome. RESULTS First PVA was created in 117 children: 103 (88%) AVF and 14 (12%) AVG. Mean age at AVF creation was 15.0 ± 3.3 years. AVF successfully matured in 89 children (86.4%), and mean time to first cannulation was 3.6 ± 2.5 months. In a multivariable regression model, study center, age, duration of non-permanent vascular access (NPVA), and Kt/V at AVF creation predicted time to first cannulation, with study center as the strongest predictor (p < 0.01). Time to first cannulation decreased with increasing age (p = 0.03) and with increasing Kt/V (p = 0.01), and increased with duration of NPVA (p = 0.03). Secondary failure occurred in 10 AVF (11.8%). Time to first cannulation did not predict secondary failure (p = 0.29), but longer time to first cannulation tended towards longer secondary patency (p = 0.06). CONCLUSIONS Study center is the strongest predictor of time to first cannulation for AVF and deserves further investigation. Time to first cannulation is significantly shorter in older children, with more efficient dialysis treatments, and increases with longer NPVA duration.
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Affiliation(s)
- Ali Mirza Onder
- Division of Pediatric Nephrology, Le Bonheur Children's Hospital, University of Tennessee, School of Medicine, Memphis, TN, USA.
- Division of Pediatric Nephrology, Batson Children's Hospital of Mississippi , University of Mississippi Medical Center, Jackson, MS, USA.
| | - Joseph T Flynn
- Division of Nephrology, Seattle Children's Hospital, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Fang Deng
- Kidney Diseases Division, Feinberg School of Medicine, Northwestern University and the Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Marissa DeFreitas
- Department of Pediatrics, Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami Leonard M Miller School of Medicine, Miami, FL, USA
| | - Chryso Katsoufis
- Department of Pediatrics, Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami Leonard M Miller School of Medicine, Miami, FL, USA
| | - Matthew M Grinsell
- Division of Pediatric Nephrology, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Larry Patterson
- Division of Pediatric Nephrology, Children's National Health System, Washington, DC, USA
| | - Jennifer Jetton
- Division of Nephrology, Dialysis and Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Sahar Fathallah-Shaykh
- Division of Pediatric Nephrology, Children's of Alabama, University of Alabama, Birmingham, AL, USA
| | - Daniel Ranch
- Division of Pediatric Nephrology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Diego Aviles
- Division of Pediatric Nephrology, Children's Hospital New Orleans, LSU Heath School of Medicine, New Orleans, LA, USA
| | - Lawrence Copelovitch
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eileen Ellis
- Division of Pediatric Nephrology, Arkansas Children's Hospital, Little Rock, AR, 72202, USA
| | - Vimal Chadha
- Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Ayah Elmaghrabi
- Division of Pediatric Nephrology, Children's Medical Center Dallas, UT Southwestern, Dallas, TX, USA
| | - Jen-Jar Lin
- Division of Pediatric Nephrology, Brenner Children's Hospital, Wake Forest University, Winston Salem, NC, USA
| | - Lavjay Butani
- Division of Pediatric Nephrology, UC Davis Children's Hospital, Sacramento, CA, USA
| | - Maha Haddad
- Division of Pediatric Nephrology, UC Davis Children's Hospital, Sacramento, CA, USA
| | - Olivera Marsenic
- Division of Pediatric Nephrology, Yale New Haven Children's Hospital, Yale University School of Medicine, New Haven, CT, 06504, USA
| | - Paul Brakeman
- Division of Pediatric Nephrology, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Raymond Quigley
- Division of Pediatric Nephrology, Children's Medical Center Dallas, UT Southwestern, Dallas, TX, USA
| | - H Stella Shin
- Division of Pediatric Nephrology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Rouba Garro
- Division of Pediatric Nephrology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Hui Liu
- Division of General Academic Pediatrics, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Javad Rahimikollu
- Department of Statistics, West Virginia University, Morgantown, WV, USA
| | - Rupesh Raina
- Division of Pediatric Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Craig B Langman
- Kidney Diseases Division, Feinberg School of Medicine, Northwestern University and the Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Ellen Wood
- Department of Pediatrics, Division of Pediatric Nephrology, SSM Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, MO, USA
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Karydis N, Bevis P, Beckitt T, Silverberg D, Halak M, Calder F. An Implanted Blood Vessel Support Device for Arteriovenous Fistulas: A Randomized Controlled Trial. Am J Kidney Dis 2020; 75:45-53. [DOI: 10.1053/j.ajkd.2019.05.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 05/16/2019] [Indexed: 11/11/2022]
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Lee T, Qian JZ, Zhang Y, Thamer M, Allon M. Long-Term Outcomes of Arteriovenous Fistulas with Unassisted versus Assisted Maturation: A Retrospective National Hemodialysis Cohort Study. J Am Soc Nephrol 2019; 30:2209-2218. [PMID: 31611240 DOI: 10.1681/asn.2019030318] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/29/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND About half of arteriovenous fistulas (AVFs) require one or more interventions before successful dialysis use, a process called assisted maturation. Previous research suggested that AVF abandonment and interventions to maintain patency after maturation may be more frequent with assisted maturation versus unassisted maturation. METHODS Using the US Renal Data System, we retrospectively compared patients with assisted versus unassisted AVF maturation for postmaturation AVF outcomes, including functional primary patency loss (requiring intervention after achieving AVF maturation), AVF abandonment, and frequency of interventions. RESULTS We included 7301 patients ≥67 years who initiated hemodialysis from July 2010 to June 2012 with a catheter and no prior AVF; all had an AVF created within 6 months of starting hemodialysis and used for dialysis (matured) within 6 months of creation, with 2-year postmaturation follow-up. AVFs matured without prior intervention for 56% of the patients. Assisted AVF maturation with one, two, three, or four or more prematuration interventions occurred in 23%, 12%, 5%, and 4% of patients, respectively. Patients with prematuration interventions had significantly increased risk of functional primary patency loss compared with patients who had unassisted AVF maturation, and the risk increased with the number of interventions. Although the likelihood of AVF abandonment was not higher among patients with up to three prematuration interventions compared with patients with unassisted AVF maturation, it was significantly higher among those with four or more interventions. CONCLUSIONS For this cohort of patients undergoing assisted AVF maturation, we observed a positive association between the number of prematuration AVF interventions and the likelihood of functional primary patency loss and frequency of postmaturation interventions.
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Affiliation(s)
- Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; .,Veterans Affairs Medical Center, Birmingham, Alabama; and
| | - Joyce Zhang Qian
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Yi Zhang
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Hoggard JG, Blair RD, Montero M, Moustafa MA, Newman J, Pergola PE, Saucier N, Wheeler CJ, Mermel LA, Ross JR, Beserab AD. Clinical outcomes associated with the use of the NexSite hemodialysis catheter with new exit barrier technology: Results from a prospective, observational multi-center registry study. PLoS One 2019; 14:e0223285. [PMID: 31589644 PMCID: PMC6779244 DOI: 10.1371/journal.pone.0223285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/17/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Decreasing the risk of catheter related bloodstream infections (CRBSIs) remains a key focus for improving outcomes and reducing cost of care for hemodialysis (HD) patients. Recent studies demonstrate CRBSI rates can be improved by managing bacterial colonization at the catheter exit site. Herein we present the results of a study documenting the clinical performance of the NexSite HD catheter, a new tunneled central venous catheter which incorporates Exit Site Management (ESM) technology. Methods We conducted an observational study using a prospective, multi-center registry of HD patients implanted with the NexSite HD catheter. The primary endpoint for the study was CRBSI rate for a period up to 180-days following catheter placement. Secondary endpoints included device placement success rate, exit site healing, development of an exit site or tunnel infection, and early or late non-infectious catheter-related complications. All reasons for early non-elective catheter removal were recorded. Results A total of 115 HD patients at 6 sites were included in the final analysis. Cumulative catheter use was 10,924 days with a mean duration of 95 days. Seven patients experienced CRBSIs during the study period resulting in a CRBSI rate of 0.64 per 1,000 catheter-days. Seventy-four patients (64.3%) had either elective catheter removal (n = 56) or utilized the catheter for the entire 180-day observation period (n = 18). Thirty-five patients (30%) underwent non-elective device removal either due to CRBSI (n = 5), low flow (n = 16), exit site issues (n = 7), or for other causes (n = 7). Six patients died during the observation period with 1 death due to CRBSI-associated complications and the remaining 5 deaths attributed to non-device related causes. Conclusion Our findings demonstrate that the NexSite HD catheter equipped with ESM technology can achieve a CRBSI rate in compliance with the NKF KDOQI (National Kidney Foundation Kidney Disease Outcome Quality Initiatives) Clinical Performance Guidelines stated goal of less than 1.0/1,000 catheter-days when used in hemodialysis patients using current standard of care nursing protocols.
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Affiliation(s)
- Jeffrey G. Hoggard
- Capital Nephrology Associates, Raleigh, North Carolina, United States of America
- * E-mail:
| | - Richard D. Blair
- Eastern Nephrology, New Bern, North Carolina, United States of America
| | - Manuel Montero
- Eastern Nephrology, New Bern, North Carolina, United States of America
| | - Moustafa A. Moustafa
- South Carolina Nephrology and Hypertension Center, Orangeburg, South Carolina, United States of America
| | - Joseph Newman
- Eastern Nephrology, Greenville, North Carolina, United States of America
| | - Pablo E. Pergola
- Renal Associates PA, San Antonio, Texas, United States of America
| | - Nathan Saucier
- Eastern Nephrology, New Bern, North Carolina, United States of America
| | - Clarence J. Wheeler
- Kidney and Blood Pressure Clinic of Lubbock, Lubbock, Texas, United States of America
| | - Leonard A. Mermel
- Division of Infectious Diseases, Rhode Island Hospital and Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - John R. Ross
- Access Connections LLC, Orangeburg, South Carolina, United States of America
| | - Anatole D. Beserab
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America
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Shahinian VB, Zhang X, Tilea AM, He K, Schaubel DE, Wu W, Pisoni R, Robinson B, Saran R, Woodside KJ. Surgeon Characteristics and Dialysis Vascular Access Outcomes in the United States: A Retrospective Cohort Study. Am J Kidney Dis 2019; 75:158-166. [PMID: 31585684 DOI: 10.1053/j.ajkd.2019.08.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022]
Abstract
RATIONALE & OBJECTIVE An arteriovenous fistula (AVF) is the preferred access for most patients receiving maintenance hemodialysis, but maturation failure remains a challenge. Surgeon characteristics have been proposed as contributors to AVF success. We examined variation in AVF placement and AVF outcomes by surgeon and surgeon characteristics. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS National Medicare claims and web-based data submitted by dialysis facilities on maintenance hemodialysis patients from 2009 through 2015. EXPOSURES Patient characteristics, including demographics and comorbid conditions; surgeon characteristics, including specialty, prior volume of AVF placements, and years since medical school graduation. OUTCOMES Percent of access placements that were an AVF from 2009 to 2015 (designated AVF placement), and percent of AVFs with successful use within 6 months of placement (maturation) from 2013 to 2014. ANALYTICAL APPROACH Multilevel logistic regression models examining the association of surgeon characteristics with the outcomes, adjusted for patient characteristics and dialysis facilities as random effects. RESULTS Among 4,959 surgeons placing 467,827 accesses, median AVF placement was 71% (IQR, 59%-84%). More recent year of medical school graduation and general surgery specialty (vs vascular, cardiothoracic, or transplantation surgery) were associated with higher odds of AVF placement. Among 2,770 surgeons placing 49,826 AVFs, the median AVF maturation rate was 59% (IQR, 44%-71%). More recent year of medical school graduation, but not surgical specialty, was associated with higher odds of AVF maturation. Greater prior volume of AVF placement was associated with higher odds of AVF maturation: OR of 1.46 (95% CI, 1.37-1.57) for highest (>84 AVF placements in 2years) versus lowest (<14) volume quintile. LIMITATIONS The study relied on administrative data, limiting capture of some factors affecting access outcomes. CONCLUSIONS There is substantial surgeon-level variation in AVF placements and AVF maturation. Surgeons' prior volume of AVF placements is strongly associated with AVF maturation.
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Affiliation(s)
- Vahakn B Shahinian
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Xiaosong Zhang
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Anca M Tilea
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Kevin He
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
| | - Douglas E Schaubel
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
| | - Wenbo Wu
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI.
| | - Kenneth J Woodside
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
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Hill K, Sharp R, Childs J, Esterman A, Le Leu R, Juneja R, Jesudason S. Cannulation practices at haemodialysis initiation via an arteriovenous fistula or arteriovenous graft. J Vasc Access 2019; 21:573-581. [PMID: 31423945 DOI: 10.1177/1129729819869093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION A functioning long-term vascular access is required for haemodialysis therapy; however, establishing this can be challenging in the setting of advanced age and vessels damaged by diabetes. Complications include the inability to insert two needles for the treatment resulting in miscannulation trauma and in some cases insertion of a temporary central venous access device. The broad objective of this review is to define the evidence base regarding cannulation practices in the initiation of haemodialysis via an arteriovenous fistula or an arteriovenous graft. METHODS This review uses the framework recommended by the Joanna Briggs Institute and the process by which papers were included or excluded followed the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses group approach. A total of 20 primary research studies met the inclusion criteria. RESULTS Cannulation in the 10- to 15-week period rather than delaying past this time frame is associated with the best outcomes. New vascular access given time to mature through single-needle haemodialysis treatments may improve long-term patency. Duplex ultrasound mapping prior to initiation of cannulation supports the clinical decision-making process on timing of and selection of cannulation sites. CONCLUSION Cannulation trauma at the initiation of haemodialysis could potentially be reduced with a strategy of incremental haemodialysis using single-needle treatment supported with duplex ultrasonography assessment to 'map' the vascular access as a guide for clinicians prior to cannulation initiation.
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Affiliation(s)
- Kathleen Hill
- University of South Australia, Adelaide, SA, Australia
| | - Rebecca Sharp
- University of South Australia, Adelaide, SA, Australia
| | - Jessie Childs
- University of South Australia, Adelaide, SA, Australia
| | | | - Richard Le Leu
- Central and Northern Adelaide Renal and Transplantation Service, Adelaide, SA, Australia
| | - Rajiv Juneja
- Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Shilpa Jesudason
- Central and Northern Adelaide Renal and Transplantation Service, Adelaide, SA, Australia
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Gallieni M, Hollenbeck M, Inston N, Kumwenda M, Powell S, Tordoir J, Al Shakarchi J, Berger P, Bolignano D, Cassidy D, Chan TY, Dhondt A, Drechsler C, Ecder T, Finocchiaro P, Haller M, Hanko J, Heye S, Ibeas J, Jemcov T, Kershaw S, Khawaja A, Labriola L, Lomonte C, Malovrh M, Marti I Monros A, Matthew S, McGrogan D, Meyer T, Mikros S, Nistor I, Planken N, Roca-Tey R, Ross R, Troxler M, van der Veer S, Vanholder R, Vermassen F, Welander G, Wilmink T, Koobasi M, Fox J, Van Biesen W, Nagler E. Clinical practice guideline on peri- and postoperative care of arteriovenous fistulas and grafts for haemodialysis in adults. Nephrol Dial Transplant 2019; 34:ii1-ii42. [PMID: 31192372 DOI: 10.1093/ndt/gfz072] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Indexed: 01/02/2023] Open
Affiliation(s)
| | | | | | | | | | - Jan Tordoir
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Davide Bolignano
- Institute of Clinical Physiology of the Italian National Council of Research, Reggio Calabria, Italy.,ERBP, guideline development body of ERA-EDTA, London, UK
| | | | | | | | - Christiane Drechsler
- ERBP, guideline development body of ERA-EDTA, London, UK.,University of Würzburg, Würzburg, Germany
| | - Tevfik Ecder
- Istanbul Bilim University School of Medicine, Istanbul, Turkey
| | | | - Maria Haller
- ERBP, guideline development body of ERA-EDTA, London, UK.,Ordensklinikum Linz Elisabethinen, Linz, Austria
| | | | - Sam Heye
- Jessa Hospital, Hasselt, Belgium
| | - Jose Ibeas
- Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Aurangzaib Khawaja
- Queen Elisabeth Hospital, University Hospitals Birmingham, West Midlands Deanery, Birmingham, UK
| | | | - Carlo Lomonte
- Miulli General Hospital, Acquaviva delle Fonti, Italy
| | | | | | | | | | | | | | - Ionut Nistor
- ERBP, guideline development body of ERA-EDTA, London, UK.,University of Medicine and Pharmacy, Iasi, Romania
| | - Nils Planken
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ramon Roca-Tey
- Hospital de Mollet, Fundació Sanitària Mollet, Barcelona, Spain
| | - Rose Ross
- Ninewells Hospital Scotland, Dundee, UK
| | | | | | | | | | | | - Teun Wilmink
- Heart of England NHS foundation Trust, Birmingham, UK
| | - Muguet Koobasi
- ERBP, guideline development body of ERA-EDTA, London, UK
| | - Jonathan Fox
- ERBP, guideline development body of ERA-EDTA, London, UK.,University of Glasgow, UK
| | - Wim Van Biesen
- ERBP, guideline development body of ERA-EDTA, London, UK.,Ghent University Hospital, Ghent, Belgium
| | - Evi Nagler
- ERBP, guideline development body of ERA-EDTA, London, UK.,Ghent University Hospital, Ghent, Belgium
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Wang S, Wang MS. Intraoperative pneumatic tourniquet use may improve the clinical outcomes of arteriovenous fistula creations. J Vasc Access 2019; 20:706-715. [PMID: 31081478 DOI: 10.1177/1129729819845968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES A major pathology affecting the usability of arteriovenous fistulas for hemodialysis is juxta-anastomosis stenosis. Intraoperative pneumatic tourniquet eliminates the use of vascular clamps, reduces vascular trauma, and may then reduce the juxta-anastomosis stenosis. The aim of this study was to compare the outcomes of arteriovenous fistula creations using the tourniquet-assisted approach versus the clamp-assisted approach. METHODS This retrospective study analyzed the outcomes of primary arteriovenous fistulas created by the lead author from 2008 to 2017 and met the specified inclusion criteria applied to both groups. RESULTS A total of 575 patients were included. Upon comparing the tourniquet group (n = 411) with the clamp group (n = 164): the primary arteriovenous fistula failure rate was significantly lower (2.4% vs 7.3%, p = 0.01); the percentage of arteriovenous fistula used for hemodialysis without initial interventions was significantly higher (71.5% vs 45.1%, p < 0.001) and with initial interventions was conversely lower (26.0% vs 47.6%, p < 0.001); the primary patency rate of the whole fistula conduits was significantly higher (44.2% vs 23.0% at 1 year, p < 0.001) and so was the cumulative patency rate (97.2% vs 92.6% at 1 year, p < 0.001); and the juxta-anastomosis primary patency rate (free of interventions for the juxta-anastomosis region) was higher (71.0% vs 47.8% at 1 year, p < 0.001). Based on multivariate Cox proportional hazards regression analyses, the effect of tourniquet use on the juxta-anastomosis primary patency remained significant (hazard ratio = 2.24, 95% confidence interval = 1.72-2.93, p < 0.001) when other significant factors (fistula location, gender, and diabetes) were considered. CONCLUSION Intraoperative pneumatic tourniquet may significantly improve the clinical outcomes of arteriovenous fistula creations by reducing juxta-anastomosis trauma and subsequent stenosis.
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Affiliation(s)
- Shouwen Wang
- Ambulatory Surgery Center, Arizona Kidney Disease & Hypertension Center (AKDHC), Phoenix, AZ, USA
| | - Michele S Wang
- Ambulatory Surgery Center, Arizona Kidney Disease & Hypertension Center (AKDHC), Phoenix, AZ, USA
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47
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Shiu YT, Rotmans JI, Geelhoed WJ, Pike DB, Lee T. Arteriovenous conduits for hemodialysis: how to better modulate the pathophysiological vascular response to optimize vascular access durability. Am J Physiol Renal Physiol 2019; 316:F794-F806. [PMID: 30785348 PMCID: PMC6580244 DOI: 10.1152/ajprenal.00440.2018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 02/04/2019] [Accepted: 02/17/2019] [Indexed: 12/11/2022] Open
Abstract
Vascular access is the lifeline for patients on hemodialysis. Arteriovenous fistulas (AVFs) are the preferred vascular access, but AVF maturation failure remains a significant clinical problem. Currently, there are no effective therapies available to prevent or treat AVF maturation failure. AVF maturation failure frequently results from venous stenosis at the AVF anastomosis, which is secondary to poor outward vascular remodeling and excessive venous intimal hyperplasia that narrows the AVF lumen. Arteriovenous grafts (AVGs) are the next preferred vascular access when an AVF creation is not possible. AVG failure is primarily the result of venous stenosis at the vein-graft anastomosis, which originates from intimal hyperplasia development. Although there has been advancement in our knowledge of the pathophysiology of AVF maturation and AVG failure, this has not translated into effective therapies for these two important clinical problems. Further work will be required to dissect out the mechanisms of AVF maturation failure and AVG failure to develop more specific therapies. This review highlights the major recent advancements in AVF and AVG biology, reviews major clinical trials, and discusses new areas for future research.
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Affiliation(s)
- Yan-Ting Shiu
- Division of Nephrology, University of Utah , Salt Lake City, Utah
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center , Leiden , The Netherlands
| | - Wouter Jan Geelhoed
- Department of Internal Medicine, Leiden University Medical Center , Leiden , The Netherlands
| | - Daniel B Pike
- Division of Nephrology, University of Utah , Salt Lake City, Utah
| | - Timmy Lee
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham , Birmingham, Alabama
- Veterans Affairs Medical Center , Birmingham, Alabama
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48
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Allon M. Vascular Access for Hemodialysis Patients: New Data Should Guide Decision Making. Clin J Am Soc Nephrol 2019; 14:954-961. [PMID: 30975657 PMCID: PMC6556719 DOI: 10.2215/cjn.00490119] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This commentary critically examines key assumptions and recommendations in the 2006 Kidney Disease Outcomes Quality Initiative vascular access guidelines, and argues that several are not relevant to the contemporary United States hemodialysis population. First, the guidelines prefer arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs), on the basis of their superior secondary survival and lower frequency of interventions and infections. However, intent-to-treat analyses that incorporate the higher primary failure of AVFs, demonstrate equivalent secondary survival of both access types. Moreover, the lower rate of AVF versus AVG infections is counterbalanced by the higher rate of catheter-related bloodstream infections before AVF maturation. In addition, AVFs with assisted maturation (interventions before successful AVF use), which account for about 50% of new AVFs, are associated with inferior secondary patency compared with AVGs without intervention before successful use. Second, the guidelines posit lower access management costs for AVFs than AVGs. However, in patients who undergo AVF or AVG placement after starting dialysis with a central venous catheter (CVC), the overall cost of access management is actually higher in patients receiving an AVF. Third, the guidelines prefer forearm over upper arm AVFs. However, published data demonstrate superior maturation of upper arm versus forearm AVFs, likely explaining the progressive increase in upper arm AVFs in the United States. Fourth, AVFs are thought to fail primarily because of aggressive juxta-anastomotic stenosis. However, recent evidence suggests that many AVFs mature despite neointimal hyperplasia, and that suboptimal arterial vasodilation may be an equally important contributor to AVF nonmaturation. Finally, CVC use is believed to result in excess mortality in patients on hemodialysis. However, recent data suggest that CVC use is simply a surrogate marker of sicker patients who are more likely to die, rather than being a mediator of mortality.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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49
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Viecelli AK, Polkinghorne KR, Pascoe EM, Paul-Brent PA, Hawley CM, Badve SV, Cass A, Hooi LS, Kerr PG, Mori TA, Ong LM, Voss D, Johnson DW, Irish AB. Fish oil and aspirin effects on arteriovenous fistula function: Secondary outcomes of the randomised omega-3 fatty acids (Fish oils) and Aspirin in Vascular access OUtcomes in REnal Disease (FAVOURED) trial. PLoS One 2019; 14:e0213274. [PMID: 30913208 PMCID: PMC6435148 DOI: 10.1371/journal.pone.0213274] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 02/18/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Arteriovenous fistulas (AVF) for haemodialysis often experience early thrombosis and maturation failure requiring intervention and/or central venous catheter (CVC) placement. This secondary and exploratory analysis of the FAVOURED study determined whether omega-3 fatty acids (fish oils) or aspirin affected AVF usability, intervention rates and CVC requirements. METHODS In 567 adult participants planned for AVF creation, all were randomised to fish oil (4g/d) or placebo, and 406 to aspirin (100mg/d) or placebo, starting one day pre-surgery and continued for three months. Outcomes evaluated within 12 months included AVF intervention rates, CVC exposure, late dialysis suitability failure, and times to primary patency loss, abandonment and successful cannulation. RESULTS Final analyses included 536 participants randomised to fish oil or placebo (mean age 55 years, 64% male, 45% diabetic) and 388 randomised to aspirin or placebo. Compared with placebo, fish oil reduced intervention rates (0.82 vs 1.14/1000 patient-days, incidence rate ratio [IRR] 0.72, 95% confidence interval [CI] 0.54-0.97), particularly interventions for acute thrombosis (0.09 vs 0.17/1000 patient-days, IRR 0.53, 95% CI 0.34-0.84). Aspirin significantly reduced rescue intervention rates (IRR 0.45, 95% CI 0.27-0.78). Neither agent significantly affected CVC exposure, late dialysis suitability failure or time to primary patency loss, AVF abandonment or successful cannulation. CONCLUSION Although fish oil and low-dose aspirin given for 3 months reduced intervention rates in newly created AVF, they had no significant effects on CVC exposure, AVF usability and time to primary patency loss or access abandonment. Reduction in access interventions benefits patients, reduces costs and warrants further study.
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Affiliation(s)
- Andrea K. Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Kevan R. Polkinghorne
- Department of Nephrology, Monash Medical Centre, Melbourne, Australia
- Department of Medicine, Monash University, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Elaine M. Pascoe
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Peta-Anne Paul-Brent
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Carmel M. Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Sunil V. Badve
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Nephrology, St George Hospital, Sydney, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Lai-Seong Hooi
- Department of Medicine and Hemodialysis Unit, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - Peter G. Kerr
- Department of Nephrology, Monash Medical Centre, Melbourne, Australia
- Department of Medicine, Monash University, Melbourne, Australia
| | - Trevor A. Mori
- Medical School, University of Western Australia, Perth, Australia
| | - Loke-Meng Ong
- Department of Nephrology, Penang Hospital, Georgetown, Malaysia
| | - David Voss
- Middlemore Renal Services, Middlemore Hospital, Auckland, New Zealand
| | - David W. Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Ashley B. Irish
- The George Institute for Global Health, Sydney, Australia
- Department of Nephrology, Fiona Stanley Hospital, Perth, Australia
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50
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Pike D, Shiu YT, Cho YF, Le H, Somarathna M, Isayeva T, Guo L, Symons JD, Kevil CG, Totenhagen J, Lee T. The effect of endothelial nitric oxide synthase on the hemodynamics and wall mechanics in murine arteriovenous fistulas. Sci Rep 2019; 9:4299. [PMID: 30862797 PMCID: PMC6414641 DOI: 10.1038/s41598-019-40683-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 02/19/2019] [Indexed: 11/12/2022] Open
Abstract
Creation of a hemodialysis arteriovenous fistula (AVF) causes aberrant vascular mechanics at and near the AVF anastomosis. When inadequately regulated, these aberrant mechanical factors may impede AVF lumen expansion to cause AVF maturation failure, a significant clinical problem with no effective treatments. The endothelial nitric oxide synthase (NOS3) system is crucial for vascular health and function, but its effect on AVF maturation has not been fully characterized. We hypothesize that NOS3 promotes AVF maturation by regulating local vascular mechanics following AVF creation. Here we report the first MRI-based fluid-structure interaction (FSI) study in a murine AVF model using three mouse strains: NOS3 overexpression (NOS3 OE) and knockout (NOS3-/-) on C57BL/6 background, with C57BL/6 as the wild-type control (NOS3+/+). When compared to NOS3+/+ and NOS3-/-, AVFs in the OE mice had larger lumen area. AVFs in the OE mice also had smoother blood flow streamlines, as well as lower blood shear stress at the wall, blood vorticity, inner wall circumferential stretch, and radial wall thinning at the anastomosis. Our results demonstrate that overexpression of NOS3 resulted in distinct hemodynamic and wall mechanical profiles associated with favorable AVF remodeling. Enhancing NOS3 expression may be a potential therapeutic approach for promoting AVF maturation.
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Affiliation(s)
- Daniel Pike
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
- Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Yun-Fang Cho
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Ha Le
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Maheshika Somarathna
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tatyana Isayeva
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lingling Guo
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J David Symons
- Department of Nutrition and Integrative Physiology and Molecular Medicine Program, University of Utah, Salt Lake City, UT, USA
- Division of Endocrinology, Metabolism, and Diabetes, University of Utah, Salt Lake City, UT, USA
| | - Christopher G Kevil
- Departments of Pathology, Molecular and Cellular Physiology, and Cellular Biology and Anatomy, LSU Health Shreveport, Shreveport, LA, USA
| | - John Totenhagen
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Timmy Lee
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA.
- Veterans Affairs Medical Center, Birmingham, AL, USA.
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