Access flow volume (Qa) and survival in a hemodialysis population: An analysis of 5208 Qa measurements over a 9-year period

A scoping review on surgical reduction of high flow arteriovenous haemodialysis access

Volume flow (Qa) > 1.5-2 l /minQa in arteriovenous accesses may be associated with high flow related systemic or locoregional complications. A variety of surgical techniques are advocated for Qa reduction. Aim of this scoping review is to provide an overview of available evidence regarding the efficacy of this broad spectrum of interventions for Qa reduction in patients with a high flow haemodialysis access. PubMed and Embase were searched according to PRISMA-guidelines. Studies on invasive management of HFA were selected. Inclusion required an English description of surgical techniques in human HFAs including pre- and postoperative access flow-values. Sixty-six studies on 940 patients (mean age 56 years (3-90 years), male 62%, diabetes mellitus 26%, brachial artery-based arteriovenous access 65%) fulfilled inclusion criteria. Performed techniques were banding (58%), revision using distal inflow (12%), plication/anastomoplasty (10%), graft interposition (5%), proximal radial artery ligation (3%), aneurysm repair (4%), or miscellaneous other techniques (8%). Definition of HFA, work-up, indication for surgery and intraoperative monitoring were diverse. All techniques reduced Qa on the short term (mean drop 0.9-1.7 l/min). Secondary access patency rates varied between 70% and 93% (mean follow-up 15 (0-189) months). Definitions of success and recurrence varied widely precluding a comparison of efficacy of techniques. Patient specific factors legitimizing invasive treatment for HFA are discussed. Recommendations on reporting standards when dealing with HFA surgery are provided. In conclusion, the present report on the current management of high flow access does not allow for drawing any definite conclusions due to a lack of standardization in definition, indications for surgical intervention and techniques. Randomized trials comparing different Qa reducing techniques in symptomatic patients are warranted, as are trials comparing a wait-and-see approach versus Qa reduction in asymptomatic patients. As an overview of the variety of techniques was lacking, this scoping review might serve as a map for future researchers.