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Parker M, Bennett PC, Dhillon B, Al-Thaher A, Al-Alwani Z, Elzubeir L, Cetin T, Elkhawad M, Ali T. Influence of balloon type and lesion location on outcomes following fistuloplasty. Vascular 2024:17085381241273126. [PMID: 39129056 DOI: 10.1177/17085381241273126] [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: 08/13/2024]
Abstract
BACKGROUND There is limited evidence supporting the optimal use of fistuloplasty to maintain vascular access at various lesion sites, despite its critical role in facilitating renal replacement therapy and the overall high failure rates of arteriovenous fistulas (AVFs). This study aims to identify covariates affecting primary and secondary patency following fistuloplasty of native upper limb vascular access AVFs. METHODS This retrospective study included all patients who underwent fistuloplasty at a tertiary vascular centre over 4 years. Baseline characteristics were recorded, and factors associated with primary and secondary patency rates were analysed. RESULTS A total of 206 patients (88 male, 118 female) with a mean age of 68 (±14) years underwent fistuloplasty during the study period. The prevalence of diabetes, ischaemic heart disease and antiplatelet usage were 33%, 21% and 70%, respectively. The median number of fistuloplasties per access during the follow-up period was 2 [1-3]. Fistulas were classified as radiocephalic (65), brachiocephalic (102) and brachiobasilic transposition (39). Recurrent stenosis (RS) was identified in 60 patients who had previous fistuloplasty before the study period, while 146 patients had de novo stenoses (DNS). Stenosis location significantly differed between RS and DNS (p = .03), with DNS primarily being anastomotic and RS predominantly in central and mixed locations. Younger fistulas were more likely to have anastomotic stenoses compared to those older than 1 year (p = .001). While no significant differences in primary patency (PP) were observed, secondary patency (SP) varied by stenosis location: Central 32 [13-42] months, Fistula vein 20 [12.5-35.5] months, Mixed 25 [13.5-37.5] months and Anastomotic 19 [7-29.5] months (p = .012). CONCLUSION Stenosis location in AVFs is associated with the age and type of the fistula. Younger fistulas often fail due to anastomotic stenoses, which have lower secondary patency compared to stenoses at other sites. Preliminary data suggest that central stenoses, primarily occurring in older fistulas, exhibit better secondary patency following fistuloplasty than stenoses at other locations.
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Affiliation(s)
- Michael Parker
- Norfolk Centre for Interventional Radiology, Norfolk & Norwich University Hospital, Norwich, UK
| | - Philip C Bennett
- Norfolk and Norwich Vascular Unit, Norfolk & Norwich University Hospital, Norwich, UK
| | - Baljeet Dhillon
- Norfolk Centre for Interventional Radiology, Norfolk & Norwich University Hospital, Norwich, UK
| | - Ahmad Al-Thaher
- Department of Medical Statistics, Kellogg College, University of Oxford, Oxford, UK
| | - Zahra Al-Alwani
- Department of Medical Statistics, Kellogg College, University of Oxford, Oxford, UK
| | - Lee Elzubeir
- Norfolk Centre for Interventional Radiology, Norfolk & Norwich University Hospital, Norwich, UK
| | - Tugce Cetin
- Norfolk Centre for Interventional Radiology, Norfolk & Norwich University Hospital, Norwich, UK
| | - Maysoon Elkhawad
- Norfolk and Norwich Vascular Unit, Norfolk & Norwich University Hospital, Norwich, UK
| | - Tariq Ali
- Norfolk Centre for Interventional Radiology, Norfolk & Norwich University Hospital, Norwich, UK
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Shahverdyan R, Lessne ML, Mehta TI. Comparison of Outcomes of Drug-Coated Balloons versus Plain Balloons in Secondary Interventions on Percutaneous Arteriovenous Fistulae. J Vasc Interv Radiol 2024; 35:1176-1186.e1. [PMID: 38685469 DOI: 10.1016/j.jvir.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/24/2024] [Accepted: 04/21/2024] [Indexed: 05/02/2024] Open
Abstract
PURPOSE To compare patency and reintervention outcomes after either plain old balloon angioplasty (POBA) or drug-coated balloon angioplasty (DCBA) for venous stenoses after percutaneous arteriovenous fistula (pAVF) creation. MATERIALS AND METHODS One-hundred ninety-five pAVFs were successfully created during the study period, 141 using Ellipsys and 54 using Wavelinq. After pAVF creation, 95 patients (48.7%) required secondary percutaneous transluminal angioplasty (PTA) with either POBA (n = 55, 58%) or DCBA (n = 40, 42.1%). The most common site for PTA was the juxta-anastomotic segment (75.5%; 74/98). Univariate and multivariate Cox regression analyses were used to compare target lesion primary patency, access circuit primary patency, secondary patency, and reintervention rates in the POBA and DCBA cohorts. RESULTS Thirty-four of 55 (62%) patients in the POBA cohort and 14 of 40 (35%) patients in the DCBA cohort required reinterventions for pAVF restenosis. Mean number of follow-up days among patients treated with POBA was 1,030.4 (SD ± 342.9) and among those treated with DCBA was 744.4 (SD ± 403.5). The use of POBA compared with DCBA was not associated with target lesion and access circuit primary patency loss in multivariate analysis (hazard ratio [HR], 1.81; 95% CI, 0.93-3.51; P = .080; and HR, 1.77; 95% CI, 0.73-4.28; P = .210, respectively). However, time from fistula creation to the first PTA (days) was statistically significantly associated with both outcomes (HR, 0.997; 95% CI, 0.994-0.999; P = .009; and HR, 0.997; 95% CI, 0.992-0.999; P = .021, respectively). There were no major adverse events. CONCLUSIONS In this retrospective single-center analysis of pAVFs, considerably more patients who underwent PTA with POBA after pAVF creation required reinterventions compared with PTA using DCBA, although the follow-up time of POBA was longer. In multivariate analysis, no differences were noted in the hazard of patency loss between POBA and DCBA.
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Affiliation(s)
| | - Mark L Lessne
- Vascular & Interventional Specialists, Charlotte Radiology, Charlotte, North Carolina; Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Tej Ishaan Mehta
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
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Mirabella D, Dinoto E, Rodriquenz E, Bellomo M, Miccichè A, Annicchiarico P, Pecoraro F. Improved Ultrasound-Guided Balloon-Assisted Maturation Angioplasty Using Drug-Eluting Balloons in the First Autogenous Arteriovenous Fistula Procedure: Early Experience. Biomedicines 2024; 12:1005. [PMID: 38790967 PMCID: PMC11118221 DOI: 10.3390/biomedicines12051005] [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: 03/22/2024] [Revised: 04/21/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024] Open
Abstract
In patients with end-stage renal failure requiring hemodialysis, autogenous arteriovenous fistula (AVF) is preferred over tunneled dialysis catheters due to lower complications and costs. However, AVF maturation failure remains a common issue due to small vein size, multiple venipunctures, and other factors. Guidelines recommend using vessels of >2 mm for forearm AVFs and >3 mm for upper arm AVFs. This study investigates the use of intraoperative Doppler ultrasound (DUS)-guided Balloon-Assisted Maturation (BAM) with drug-eluting balloons (DEB) during initial AVF creation. Data from 114 AVF procedures, of which 27.2% underwent BAM, were analyzed. BAM was performed in 25 distal radio-cephalic and 6 proximal brachio-cephalic AVFs. With DUS guidance, vein stenosis was identified and treated using DEB. Technical success was achieved in all cases, with no early mortality. Early BAM-related complications were minimal, and no AVF thrombosis occurred. AVF maturation time was 15 days (SD: 3), and no further complications were reported during a mean follow-up of 10.38 months. Using BAM with DEB during AVF creation led to successful maturation and dialysis use without the need for secondary procedures. This study emphasizes the importance of identifying AVF failure risk early and utilizing DUS-guided procedures to enhance AVF outcomes. A more liberal use of intraoperative BAM could limit reinterventions in patients undergoing AVFs.
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Affiliation(s)
- Domenico Mirabella
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Ettore Dinoto
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Edoardo Rodriquenz
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Michele Bellomo
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Andrea Miccichè
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Paolo Annicchiarico
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Felice Pecoraro
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
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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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Sharbidre KG, Alexander LF, Varma RK, Al-Balas AA, Sella DM, Caserta MP, Clingan MJ, Zahid M, Aziz MU, Robbin ML. Hemodialysis Access: US for Preprocedural Mapping and Evaluation of Maturity and Access Dysfunction. Radiographics 2024; 44:e230053. [PMID: 38096113 PMCID: PMC10772307 DOI: 10.1148/rg.230053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 12/18/2023]
Abstract
Patients with kidney failure require kidney replacement therapy. While renal transplantation remains the treatment of choice for kidney failure, renal replacement therapy with hemodialysis may be required owing to the limited availability and length of time patients may wait for allografts or for patients ineligible for transplant owing to advanced age or comorbidities. The ideal hemodialysis access should provide complication-free dialysis by creating a direct connection between an artery and vein with adequate blood flow that can be reliably and easily accessed percutaneously several times a week. Surgical arteriovenous fistulas and grafts are commonly created for hemodialysis access, with newer techniques that involve the use of minimally invasive endovascular approaches. The emphasis on proactive planning for the placement, protection, and preservation of the next vascular access before the current one fails has increased the use of US for preoperative mapping and monitoring of complications for potential interventions. Preoperative US of the extremity vasculature helps assess anatomic suitability before vascular access creation, increasing the rates of successful maturation. A US mapping protocol ensures reliable measurements and clear communication of anatomic variants that may alter surgical planning. Postoperative imaging helps assess fistula maturation before cannulation for dialysis and evaluates for early and late complications associated with arteriovenous access. Clinical and US findings can suggest developing stenosis that may progress to thrombosis and loss of access function, which can be treated with percutaneous vascular interventions to preserve access patency. Vascular access steal, aneurysms and pseudoaneurysms, and fluid collections are other complications amenable to US evaluation. ©RSNA, 2023 Supplemental material is available for this article. Test Your Knowledge questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Kedar G. Sharbidre
- From the Departments of Radiology (K.G.S., R.K.V., A.A.A.B., M.Z.,
M.U.A., M.L.R.) and Nephrology (A.A.A.B.), University of Alabama at Birmingham,
619 19th St S, Birmingham, AL 35233; and Department of Radiology, Mayo
Clinic, Jacksonville, Fla (L.F.A., D.M.S., M.P.C., M.J.C.)
| | - Lauren F. Alexander
- From the Departments of Radiology (K.G.S., R.K.V., A.A.A.B., M.Z.,
M.U.A., M.L.R.) and Nephrology (A.A.A.B.), University of Alabama at Birmingham,
619 19th St S, Birmingham, AL 35233; and Department of Radiology, Mayo
Clinic, Jacksonville, Fla (L.F.A., D.M.S., M.P.C., M.J.C.)
| | - Rakesh K. Varma
- From the Departments of Radiology (K.G.S., R.K.V., A.A.A.B., M.Z.,
M.U.A., M.L.R.) and Nephrology (A.A.A.B.), University of Alabama at Birmingham,
619 19th St S, Birmingham, AL 35233; and Department of Radiology, Mayo
Clinic, Jacksonville, Fla (L.F.A., D.M.S., M.P.C., M.J.C.)
| | - Alian A. Al-Balas
- From the Departments of Radiology (K.G.S., R.K.V., A.A.A.B., M.Z.,
M.U.A., M.L.R.) and Nephrology (A.A.A.B.), University of Alabama at Birmingham,
619 19th St S, Birmingham, AL 35233; and Department of Radiology, Mayo
Clinic, Jacksonville, Fla (L.F.A., D.M.S., M.P.C., M.J.C.)
| | - David M. Sella
- From the Departments of Radiology (K.G.S., R.K.V., A.A.A.B., M.Z.,
M.U.A., M.L.R.) and Nephrology (A.A.A.B.), University of Alabama at Birmingham,
619 19th St S, Birmingham, AL 35233; and Department of Radiology, Mayo
Clinic, Jacksonville, Fla (L.F.A., D.M.S., M.P.C., M.J.C.)
| | - Melanie P. Caserta
- From the Departments of Radiology (K.G.S., R.K.V., A.A.A.B., M.Z.,
M.U.A., M.L.R.) and Nephrology (A.A.A.B.), University of Alabama at Birmingham,
619 19th St S, Birmingham, AL 35233; and Department of Radiology, Mayo
Clinic, Jacksonville, Fla (L.F.A., D.M.S., M.P.C., M.J.C.)
| | - M. Jennings Clingan
- From the Departments of Radiology (K.G.S., R.K.V., A.A.A.B., M.Z.,
M.U.A., M.L.R.) and Nephrology (A.A.A.B.), University of Alabama at Birmingham,
619 19th St S, Birmingham, AL 35233; and Department of Radiology, Mayo
Clinic, Jacksonville, Fla (L.F.A., D.M.S., M.P.C., M.J.C.)
| | - Mohd Zahid
- From the Departments of Radiology (K.G.S., R.K.V., A.A.A.B., M.Z.,
M.U.A., M.L.R.) and Nephrology (A.A.A.B.), University of Alabama at Birmingham,
619 19th St S, Birmingham, AL 35233; and Department of Radiology, Mayo
Clinic, Jacksonville, Fla (L.F.A., D.M.S., M.P.C., M.J.C.)
| | - Muhammad U. Aziz
- From the Departments of Radiology (K.G.S., R.K.V., A.A.A.B., M.Z.,
M.U.A., M.L.R.) and Nephrology (A.A.A.B.), University of Alabama at Birmingham,
619 19th St S, Birmingham, AL 35233; and Department of Radiology, Mayo
Clinic, Jacksonville, Fla (L.F.A., D.M.S., M.P.C., M.J.C.)
| | - Michelle L. Robbin
- From the Departments of Radiology (K.G.S., R.K.V., A.A.A.B., M.Z.,
M.U.A., M.L.R.) and Nephrology (A.A.A.B.), University of Alabama at Birmingham,
619 19th St S, Birmingham, AL 35233; and Department of Radiology, Mayo
Clinic, Jacksonville, Fla (L.F.A., D.M.S., M.P.C., M.J.C.)
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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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de Oliveira Harduin L, Guerra JB, Virgini-Magalhães CE, da Costa FS, Vieira BR, Mello RS, Filippo MG, Barroso TA, de Mattos JPS, Fiorelli RKA. Oversized balloon angioplasty for endovascular maturation of arteriovenous fistulae to accelerate cannulation and to decrease the duration of catheter use. J Vasc Access 2023; 24:238-245. [PMID: 34218690 DOI: 10.1177/11297298211029558] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The functional autologous arteriovenous fistula is considered the best vascular access for patients on hemodialysis. Some fistulae exhibit maturation problems after creation and do not reach adequate vessel diameter and flow in dialysis. The aim of this study was to describe our technique of oversized balloon angioplasty for assisted maturation of arteriovenous fistulae to accelerate the cannulation and to decrease the time of catheter use and its outcome. METHODS A retrospective analysis of balloon-assisted procedures for maturation failure was performed in a single center between October 2011 and January 2019. Patients underwent imaging procedures to identify stenosis, followed by angioplasty using oversized high-pressure balloons from the anastomosis to the deep venous outflow tract. The flow volume, time interval of use of the fistula and removal of the catheter, patency rates, and complications rates were evaluated. RESULTS Seventy-eight patients underwent 124 balloon angioplasty procedures. Technical and clinical success was achieved in 91% of the cases. In patients in whom maturation was successful, the fistula was cannulated in a mean time of 5 days after the procedure (range, 1-20 days). On average, catheter removal was performed 14 days (range, 5-33 days) after the maturation procedure. The mean flow volume in the fistula before the procedure was 276 ml/min (range, 122-488 ml/min) and 24 h after the maturation was 1014 ml/min (range, 760-1800 ml/min).The primary patency rate at 3, 6, and 12 months was 87.3%, 66.2%, and 50.7%, respectively. Assisted primary patency was 100% at 3 months, 92.9% at 6 months, and 90.0% at 12 months. Minor complications occurred in 18% of cases, and major complications in 4.8%. CONCLUSIONS The oversized balloon-assisted arteriovenous fistula maturation technique is safe and effective, allowing the cannulation of the fistulae a few hours or days after the procedure and decreasing the time of catheter use.
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Affiliation(s)
- Leonardo de Oliveira Harduin
- Liv Care Centro Clínico, Niterói, Rio de Janeiro, Brazil.,Medical Postgraduate Program, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Carlos Eduardo Virgini-Magalhães
- Vascular Surgery Service, Hospital Universitário Pedro Ernesto (HUPE), Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Brunno Ribeiro Vieira
- Vascular Surgery Service, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Marcio Gomes Filippo
- Vascular Surgery Service, Hospital Universitário Clementino Fraga Filho (HUCFF), Universidade Federal do Estado do Rio de Janeiro (UFRJ), Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Rossano Kepler Alvim Fiorelli
- Medical Postgraduate Program, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, Rio de Janeiro, Brazil
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8
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Hicks A, Grzeda A, Schucht J, Bond J, Bush C, Dwivedi A, Sigdel A. Comparing Patency Rates of Arteriovenous Dialysis Access following Percutaneous Thrombectomy Using Various Catheter Directed Therapies. Ann Vasc Surg 2023; 92:131-141. [PMID: 36623720 DOI: 10.1016/j.avsg.2022.12.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 12/03/2022] [Accepted: 12/03/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Arteriovenous fistulas often require frequent interventions to maintain patency for hemodialysis. Interventions may include open or percutaneous thrombectomy with additional targeted interventions as indicated. We evaluated the primary and cumulative functional patency rates following three unique approaches to percutaneous thrombectomy of thrombosed dialysis access. METHODS A retrospective review of 236 unique patients who presented with thrombosed hemodialysis access was analyzed over a period of 4 years from 2016 to 2020. We analyzed a total of 413 procedures that utilized 3 separate percutaneous thrombectomy devices to assist with restoring patency. The Indigo System CAT-D Aspiration Thrombectomy Catheter (Penumbra; Alameda, CA), the Arrow-Trerotola Rotational Thrombectomy System (Teleflex; Wayne, PA) and the Angiojet Rheolytic Thrombectomy Catheter (Boston Scientific, Marlborough, MA) devices were compared for primary and cumulative functional patency. Primary patency was defined as time from percutaneous thrombectomy to next intervention (Angioplasty, stenting, and repeat thrombectomy). Cumulative functional patency was defined as time from percutaneous thrombectomy to time of access abandonment. Medical record chart review was utilized to determine patency rates. RESULTS A total of 413 percutaneous thrombectomy procedures were performed. Of the procedures performed, 98 utilized Angiojet, 103 utilized Trerotola, and 212 used Penumbra. The mean primary patency rates in (days) for the devices were as follows: Angiojet (194), Trerotola (204), and Penumbra (107). The mean cumulative functional patency rates (in days) for the devices were as follows: rheolytic thrombectomy (450 days), aspiration thrombectomy (292 days), and rotational thrombectomy (475 days). Angiojet versus Penumbra and Trerotola versus Penumbra both showed diminished patency rates when using the Penumbra catheter that were statistically significant (P < 0.05). CONCLUSIONS All percutaneous thrombectomy approaches do not result in the same primary or cumulative functional patency rates. Approaches with Trerotola and Angiojet resulted in improved primary and cumulative functional patency rates compared to those using Penumbra.
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Affiliation(s)
- Adam Hicks
- University of Louisville, Department of General Surgery, Division of Vascular Surgery, Louisville, KY.
| | - Anthony Grzeda
- University of Louisville, Department of General Surgery, Division of Vascular Surgery, Louisville, KY
| | - Jessica Schucht
- University of Louisville, Department of General Surgery, Division of Vascular Surgery, Louisville, KY
| | - Jordan Bond
- University of Louisville, Department of General Surgery, Division of Vascular Surgery, Louisville, KY
| | - Charles Bush
- University of Louisville, Department of General Surgery, Division of Vascular Surgery, Louisville, KY
| | - Amit Dwivedi
- University of Louisville, Department of General Surgery, Division of Vascular Surgery, Louisville, KY
| | - Abindra Sigdel
- University of Louisville, Department of General Surgery, Division of Vascular Surgery, Louisville, KY
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9
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Sattari SA, Sattari AR, Hicks CW, Howard JF, Shoucair S, Almanzar A, Bannazadeh M, Arnold MW. Primary Balloon Angioplasty Versus Hydrostatic Dilation for Arteriovenous Fistula Creation in Patients with Small-Caliber Cephalic Veins: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2022; 87:351-361. [PMID: 36029949 PMCID: PMC9833288 DOI: 10.1016/j.avsg.2022.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND For arteriovenous fistula (AVF) presence of a venous segment with adequate diameter is essential which is lacking in many patients. To find the optimal augmentation technique in patients with small-caliber cephalic vein (i.e., cephalic vein diameter <3 mm), studies compared primary balloon angioplasty (PBA) versus hydrostatic dilation (HD); however, it remained debatable. This systematic review seeks to determine which technique is preferable. METHODS We searched MEDLINE, PubMed, Embase, and Google Scholar. Primary outcomes were 6-month primary patency, reintervention, and working AVF. Secondary outcomes were immediate success, the AVF's maturation time (day), and surgical site infection. RESULTS Three randomized controlled trials yielding 180 patients were included, of which 89 patients were in the PBA group. The odds ratio (OR) of primary patency was significantly higher in the PBA group (OR 6.09, 95% confidence interval [CI], 2.36-15.76, P = 0.0002), the OR of reintervention was significantly lower in the PBA group (OR 0.16, 95% CI, 0.06-0.42, P = 0.0002), and the OR of working AVF was greater in PBA group (OR 4.22, 95% CI, 1.31-13.59, P = 0.02). The OR of immediate success was significantly greater in the PBA group (OR 11.42, 95% CI, 2.54-51.42, P = 0.002), and the AVF maturation time was significantly shorter in patients who underwent PBA (mean difference -20.32 days, 95% CI, -30.12 to -10.52, P = 0.0001). The certainty of the evidence was high. CONCLUSIONS PBA of small cephalic veins with diameter ≤2.5 cm is a safe, feasible, and efficacious augmentation method for AVF creation. This technique achieves favorable maturation outcomes, and PBA is superior to the standard hydrostatic dilatation technique.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | | | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jason F Howard
- Department of Surgery, MedStar Health Baltimore, Baltimore, MD
| | - Sami Shoucair
- Department of Surgery, MedStar Health Baltimore, Baltimore, MD
| | | | - Mohsen Bannazadeh
- Department of Surgery, North Shore University Hospital, Manhasset, NY
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10
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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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11
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Rajan DK, Ahmed O. Percutaneous Hemodialysis Fistula Creation. J Vasc Interv Radiol 2022; 33:1135-1142.e2. [PMID: 35753616 DOI: 10.1016/j.jvir.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/03/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022] Open
Abstract
Two devices have been recently introduced to European Union and North American clinical practice that allow for percutaneous creation of autogenous hemodialysis fistulas (pAVF). Although there are similarities between the devices, there are many differences. Adoption of either or both technologies by an interventionalist may be determined by the individual's comfort with the device. Importantly, current and future outcomes will shape acceptance and use of these devices. This review focuses on the similarities and differences of each device, the procedures, published outcomes to date and their interpretation and other clinical considerations towards initiation of a successful pAVF program.
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Affiliation(s)
- Dheeraj K Rajan
- Division of Vascular and Interventional Radiology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, ON, Canada.
| | - Osman Ahmed
- Section of Vascular and Interventional Radiology, 21727University of Chicago Medical Center, Chicago, IL, USA
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12
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Hull JE, Jennings WC, Cooper RI, Narayan R, Mawla N, Decker MD. Long Term Results from The Pivotal Multicenter Trial of Ultrasound Guided Percutaneous Arteriovenous Fistula Creation for Hemodialysis Access. J Vasc Interv Radiol 2022; 33:1143-1150. [PMID: 35659573 DOI: 10.1016/j.jvir.2022.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/20/2022] [Accepted: 05/25/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To report the five-year results from the Pivotal Multicenter Trial of Ultrasound Guided Percutaneous Arteriovenous Fistula (pAVF) Creation for Hemodialysis Access. MATERIALS AND METHODS Retrospective review of 107 intent-to-treat (ITT) patients from the pivotal trial provided a long-term follow-up population (LTP) of 85 patients followed a median 50 months (range 12-60). Data evaluated in the LTP group were fistula maturation and use, secondary procedures, and complications. Kaplan-Meier analysis of primary, primary assisted, cumulative patency, and functional patency (time from two-needle to abandonment) were performed for the ITT population. RESULTS In the LTP 99% (84/85) of fistulas were mature with 99% (78/79) of patients requiring hemodialysis using their pAVF. Sustained fistula use (two-needle cannulation at prescribed rate, 2/3 sessions) was achieved in 92% (78/85) of patients, with seven patients never using their pAVF because not on dialysis (n=4), peritoneal dialysis (n=2), and refusing to use fistula (n=1). Fistula maintenance was required in 31.8% (27/85) of patients and included fistula dysfunction (21.2%), thrombosis (5.9%), cannulation injury (12.9%), and arm swelling (4.7%). The number of procedures performed per patient per year (PPPY) to maintain function and patency was 0.32 (91/288) for years 2-5. The cumulative patency was 89.5%, 88.4%, 88.4%, 85.6%, and 82.0% years 1-5, respectively. The functional patency was 91.8% at the end of the study. There were no major complications related to pAVF during long-term follow-up CONCLUSION: Percutaneous fistulae have provided clinically effective and durable access for hemodialysis with low complications. Continued use and evaluation of pAVF is warranted.
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Affiliation(s)
- Jeffrey E Hull
- Richmond Vascular Center, 173 Wadsworth Drive, North Chesterfield, VA 23236
| | - William C Jennings
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma.
| | - Randy I Cooper
- Southwest Vascular Center, 1100 East University Drive Suite 103, Tempe, AZ 85281
| | - Rajeev Narayan
- San Antonio Kidney Disease Center, 26927 Hardy Run, San Antonio, TX 78015
| | - Neghae Mawla
- Dallas Nephrology, 3604 Live Oak, Suite 300, Dallas, TX 75204-6169
| | - Meredith D Decker
- Willes Consulting Group, Inc., 1327 Walnutview Dr., Encinitas, CA 92024
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13
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Walsh JP, Hentschel DM, Sharma G, Lotto CE, Ozaki CK. Contemporary Strategies to Promote Dialysis Access Fistula Maturation. Vasc Endovascular Surg 2022; 56:590-594. [PMID: 35574704 DOI: 10.1177/15385744211037834] [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: 11/17/2022]
Abstract
Background: The inability of a newly created arteriovenous fistula to support hemodialysis due to non-maturation results in increased complications secondary to catheter dependence. Methods: In view of the highly variable approaches by providers with heterogenous backgrounds (general surgery, vascular surgery, interventional radiology and interventional nephrology, urology, transplant surgery, etc.) we sought to describe a collection of algorithms that have functioned well in our hands to manage this challenging clinical problem and guide trainees and practicing clinicians alike.Results: Physical examination along with selective duplex ultrasound and fistulogram can identify most pathologies underlying non-maturation.Conclusion: Both endovascular and open techniques can be employed to optimize maturation rates in this complex population.
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Affiliation(s)
- Jillian P Walsh
- 1861Division of Vascular and Endovascular Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Dirk M Hentschel
- Brigham Health, Renal Division, 1861Brigham & Women's Faulkner Hospital, Boston, MA, USA
| | - Gaurav Sharma
- 1861Division of Vascular and Endovascular Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Christine E Lotto
- Division of Vascular and Endovascular Surgery, Capital Health Medical Center, Pennington, NJ, USA
| | - Charles Keith Ozaki
- 1861Division of Vascular and Endovascular Surgery, Brigham & Women's Hospital, Boston, MA, USA
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14
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Abdel Aal AK, Jefferson X, Klusman C, Garcia L, Hassanein H, Abdel Aal T, Shahin MM. Devices and Techniques for Percutaneous Creation of Dialysis Arteriovenous Fistulas. Semin Intervent Radiol 2022; 39:66-74. [PMID: 35210735 PMCID: PMC8856769 DOI: 10.1055/s-0042-1742381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Dialysis treatment for chronic kidney disease was first developed by Dr. Willem Kolff in 1943, and its availability began to grow in 1962 after which it has become a mainstay treatment for patients with chronic kidney disease. It is estimated that, in 2021, 15% of adults in the United States (∼37 million people) have chronic kidney disease, of which 661,000 individuals have renal failure, and 468,000 individuals require dialysis. There have been several advancements in dialysis treatment since its advent, most notably the creation of arteriovenous fistulas (AVFs) for venous access in 1966. In recent years, the U.S. Food and Drug Administration approved two new devices for AVF creation using a percutaneous approach. These are the WavelinQ (Becton Dickinson, New Jersey) and the Ellipsys (Avenu Medical, California) endovascular AVF (endoAVF) devices that use radiofrequency and thermal technologies, respectively, to create the AVF. Since the introduction of these technologies, several studies have shown that they are safe and effective, with favorable durability and low rate of serious adverse events. In this article, we will discuss these two devices and the techniques used for percutaneous creation of dialysis AVF as an alternative to traditional open surgical techniques.
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Affiliation(s)
- Ahmed Kamel Abdel Aal
- University of Texas Health Science Center at Houston, Department of Radiology, Houston, Texas,Address for correspondence Ahmed Kamel Abdel Aal, MD, PhD, FSIR Department of Radiology, University of Texas Health Science Center at HoustonHouston, TX 77030
| | | | | | | | | | | | - Mohamed M. Shahin
- University of Texas Health Science Center at Houston, Department of Radiology, Houston, Texas
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15
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Huang X, Guan J, Sheng Z, Wang M, Xu T, Guo G, Wan P, Tian B, Zhou J, Huang A, Hao J, Yao L. Effect of local anti-vascular endothelial growth factor therapy to prevent the formation of stenosis in outflow vein in arteriovenous fistula. J Transl Int Med 2021; 9:307-317. [PMID: 35136729 PMCID: PMC8802407 DOI: 10.2478/jtim-2021-0045] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Vascular stenosis and angiogenesis are the major causes of short expectancy of arteriovenous fistula (AVF). Increased expression of vascular endothelial growth factor-A (VEGF-A) has been suggested to play an important role in the pathophysiologic process. Anti-VEGF has been proved to be effective on anti-angiogenesis and applied in clinical practice, but its effect on anti-stenosis remains to be verified before it could be applied to prevent stenosis of AVF. This study was aimed to evaluate the effect of local anti-VEGF therapy to prevent the formation of stenosis in the outflow vein in AVF and its mechanism. METHODS Bioinformatics of VEGF-A and its downstream-regulated molecules from the STRING PPI database were analyzed in this study. The biopsy samples from outflow veins of AVF in patients and C57BL/6 mouse models were analyzed to examine the mechanisms of pathologic vascular stenosis associated with VEGF pathways and their potential therapeutic targets. RESULTS We found that the reduction of VEGF-A could downregulate downstream molecules and subsequently reduce the intimal hyperplasia and abnormal vascular remodeling by analyzing the STRING PPI database. Venous wall thickening, intimal neointima formation, and apoptosis of vascular endothelial cells in the proliferative outflow vein of the AVF were significantly more obvious, and upregulation of expression of VEGF was observed in dysfunctional AVF in patients. In mouse models, the expression of VEGF, Ephrin receptor B4 (EphB4), matrix metalloproteinase (MMP)2, MMP9, tissue inhibitor of metalloproteinase (TIMP)1, TIMP2, and caspase 3 in the control-shRNA surgical group was significantly higher than in the sham group (P < 0.05), and all of these indicators were significantly lower in lentiviral transfection group and Avastin group than in control-shRNA surgical group (P < 0.05) on the 14th day after AVF operation. CONCLUSION VEGF expression is significantly increased in vascular endothelial cells in stenosed or occluded outflow veins of dysfunctional AVF. Local injection of Avastin into the adventitia of the proximal outflow vein in autologous AVF procedure has an excellent potential to prevent the subsequent local stenosis of the proximal outflow vein.
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Affiliation(s)
- Xin Huang
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Jibin Guan
- College of Pharmacy, University of Minnesota, Minneapolis55455, MN, USA
| | - Zitong Sheng
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Menghua Wang
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Tianhua Xu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Guangying Guo
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Pengzhi Wan
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Binyao Tian
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Junlei Zhou
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Aoran Huang
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Junfeng Hao
- Department of Nephrology, Jinqiu Hospital Liaoning Province, Shenyang110016, Liaoning Province, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
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16
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Sahasrabudhe P, Bindu A. Nuances of Arteriovenous Fistula Creation for Vascular Access in Hemodialysis. Indian J Plast Surg 2021; 54:257-263. [PMID: 34667508 PMCID: PMC8515349 DOI: 10.1055/s-0041-1734576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background
With rising incidence and increased life expectancy of patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD), the number of patients requiring hemodialysis has increased substantially. Vascular access is the lifeline for a patient on hemodialysis (HD), and an arteriovenous fistula (AVF) is the undisputed gold standard for HD access. An effective and long-lasting fistula serves to increase the life expectancy of ESRD patients and improves their quality of life.
Learning Objectives
This paper aims to give a comprehensive overview of AVF creation, including the various techniques, patient selection, troubleshooting with decision-making, and common complications. Authors share their experience from previous publications and over 2000 AVF surgeries. They have not only described a new modification of the technique of proximal fistula but have also established a direct correlation between bruit and thrill on operation table and success of fistula surgery.
Conclusion
A standardized, protocol-driven multidisciplinary approach with careful patient and site selection, guided by outcome predictors, is vital in AVF surgery. Knowledge about the potential complications of AVFs contributes to their timely detection and allows measures to be taken that might prevent deleterious consequences that range from loss of vascular access to serious morbidity and mortality.
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Affiliation(s)
- Parag Sahasrabudhe
- Department of Plastic Surgery, B.J. Govt. Medical College & Sassoon Hospitals, Pune, Maharashtra, India.,Depatment of Plastic Surgery, Deenanath Hospital, Pune, Maharashtra, India
| | - Ameya Bindu
- Depatment of Plastic Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India
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17
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Shahverdyan R, Beathard G, Mushtaq N, Litchfield TF, Vartanian S, Konner K, Jennings WC. Comparison of Ellipsys Percutaneous and Proximal Forearm Gracz-Type Surgical Arteriovenous Fistulas. Am J Kidney Dis 2021; 78:520-529.e1. [PMID: 33662481 DOI: 10.1053/j.ajkd.2021.01.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/11/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Percutaneous arteriovenous fistulas (AVF) are created by establishing a proximal forearm anastomosis and offer a safe and reliable vascular access. This study compares the Ellipsys percutaneous AVF with a proximal forearm Gracz-type surgical AVF, chosen for comparison as it is constructed at the same anatomical site. STUDY DESIGN Retrospective study of prospectively collected clinical data. SETTING & PARTICIPANTS All vascular access procedures conducted during a 34-month period were reviewed. The study groups comprised 89 percutaneous AVFs and 69 surgical AVFs. EXPOSURE Percutaneous or surgical AVF placement. OUTCOME AVF patency, function, and complications. ANALYTICAL APPROACH Patency rates for each AVF group were evaluated by competing risk survival analysis using a cumulative incidence function. Association of primary, primary assisted, and secondary patency with the AVF groups was examined by Cox proportional hazard models. RESULTS Technical success was 100% for both groups. Average procedure times were 14 minutes for percutaneous AVFs and 74 minutes for surgical AVFs (P < 0.001). Proximal radial artery (PRA) was used in all percutaneous AVF cases. Inflow for surgical AVFs included radial (30%), ulnar (12%), and brachial (58%) arteries. Outflow veins for both groups were the cephalic and/or basilic veins. Access flow volumes, times to maturation, and overall numbers of interventions per patient-year were not significantly different. Cumulative incidence of primary patency failure at 12 months was lower for surgical AVF (47% vs 64%, P = 0.1), but secondary patency failure was not different between groups (20% vs 12%, P = 0.3). PRA surgical AVFs had similar primary patency (65% vs 64%, P = 0.8) but higher secondary patency failure rates than percutaneous AVFs at 12 months (34% vs 12%, P = 0.04). LIMITATIONS Retrospective study with a relatively short follow-up period, and not all patients required hemodialysis at the end of study. CONCLUSIONS Both percutaneous and surgical AVFs demonstrated high rates of technical success and secondary patency. Percutaneous AVFs required shorter procedure times. The rate of intervention was similar. When a distal radial artery AVF is not feasible, percutaneous AVF might offer an appropriate procedure for creating a safe and functional access, maintaining further proximal forearm surgical AVF creation options.
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Affiliation(s)
| | - Gerald Beathard
- Division of Nephrology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Nasir Mushtaq
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Tulsa, OK
| | | | - Shant Vartanian
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California-San Francisco, San Francisco, CA
| | - Klaus Konner
- Vascular Access Unit, University Hospital of Cologne, Cologne, Germany
| | - William C Jennings
- Department of Vascular Surgery, School of Community Medicine, University of Oklahoma, Tulsa, OK
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18
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Lawson JH, Niklason LE, Roy-Chaudhury P. Challenges and novel therapies for vascular access in haemodialysis. Nat Rev Nephrol 2020; 16:586-602. [PMID: 32839580 PMCID: PMC8108319 DOI: 10.1038/s41581-020-0333-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
Advances in standards of care have extended the life expectancy of patients with kidney failure. However, options for chronic vascular access for haemodialysis - an essential part of kidney replacement therapy - have remained unchanged for decades. The high morbidity and mortality associated with current vascular access complications highlights an unmet clinical need for novel techniques in vascular access and is driving innovation in vascular access care. The development of devices, biological approaches and novel access techniques has led to new approaches to controlling fistula geometry and manipulating the underlying cellular and molecular pathways of the vascular endothelium, and influencing fistula maturation and formation through the use of external mechanical methods. Innovations in arteriovenous graft materials range from small modifications to the graft lumen to the creation of completely novel bioengineered grafts. Steps have even been taken to create new devices for the treatment of patients with central vein stenosis. However, these emerging therapies face difficult hurdles, and truly creative approaches to vascular access need resources that include well-designed clinical trials, frequent interaction with regulators, interventionalist education and sufficient funding. In addition, the heterogeneity of patients with kidney failure suggests it is unlikely that a 'one-size-fits-all' approach for effective vascular access will be feasible in the current environment.
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Affiliation(s)
- Jeffrey H Lawson
- Department of Surgery, Duke University, Durham, NC, USA.
- Humacyte, Inc., Durham, NC, USA.
| | - Laura E Niklason
- Humacyte, Inc., Durham, NC, USA
- School of Engineering & Applied Science, Yale University, New Haven, CT, USA
| | - Prabir Roy-Chaudhury
- University of North Carolina Kidney Center, Chapel Hill, NC, USA
- WG (Bill) Hefner VA Medical Center, Salisbury, NC, USA
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19
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Lee SM, Na JB, Choi HC, Won JH, Kim JE, Shin JH, Park HO, Park SE. Percutaneous intervention for salvage of non-maturing arteriovenous fistulas: Which is the better approach, arterial or venous? PLoS One 2020; 15:e0238788. [PMID: 32991608 PMCID: PMC7523969 DOI: 10.1371/journal.pone.0238788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/24/2020] [Indexed: 11/18/2022] Open
Abstract
Objectives To evaluate the efficacy and long-term patency of endovascular treatment for non-maturing native arteriovenous fistulas according to the approach route (arterial vs. venous). Methods Eighty-five patients underwent percutaneous transluminal angioplasty for non-maturing fistulas (63 radiocephalic and 22 brachiocephalic) between 2010 and 2019. Outcome variables such as procedural success, complications, and primary and secondary patency rates were analyzed from the patients’ demographic, angiographic, clinical, and hemodialysis records according to the approach route (venous access group, n = 53 and arterial access group, n = 32). The Kaplan-Meier method was used to analyze the patency rates. Results The mean duration from fistula creation to fistulography was 78.4±51.4 days (range, 1–180 days). The anatomical and clinical success rates were 98.8% and 83.5%, respectively. Lesions were most commonly located at the juxta-anastomosis (55.3%). Accessory cephalic veins were observed in 16 patients. The primary patency rates were 83.9%, 71.9%, and 66.3% and the secondary patency rates were 98.6%, 95.9%, and 94.2% at 3 months, 6 months, and 1 year, respectively. The degree of hypertension (P = 0.023), minimal preoperative vein size (P = 0.041), and increment in postoperative vein diameter were higher in the venous access group than in the arterial access group (P<0.01). The frequency of using cutting balloons (P = 0.026) and complication rate were higher in the arterial access group than in the venous access group (arterial access: 1 major, 8 minor; venous access: 4 minor; P = 0.015). Conclusions Aggressive evaluation and endovascular therapy can salvage most non-maturing fistulas. Transradial and distal radial approaches can be effective even for challenging lesions.
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Affiliation(s)
- Sang Min Lee
- Department of Radiology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jae Boem Na
- Department of Radiology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
- * E-mail:
| | - Ho Cheol Choi
- Department of Radiology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jung Ho Won
- Department of Radiology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Ji Eun Kim
- Department of Radiology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyun Oh Park
- Thoracic and Cardiovascular Surgery, Gyeongsang National University School of Medicine and Gyeonsang National University Hospital, Jinju, Republic of Korea
| | - Sung Eun Park
- Department of Radiology, Gyeongsang National University College of Medicine and Gyeonsang National University Changwon Hospital, Changwon, Republic of Korea
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Wang B, Rao A, Pappas K, Silpe J, Garlapati A, Talathi S, Mussa F, Landis GS, Etkin Y. Maturation Rates of Arteriovenous Fistulas Using Small Veins in the Era of Endovascular Interventions. Ann Vasc Surg 2020; 71:208-214. [PMID: 32890643 DOI: 10.1016/j.avsg.2020.08.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Traditional practice suggests the abandonment of veins smaller than 3 mm in diameter for arteriovenous fistula (AVF) creation because of a low rate of maturation. This study aims to show that with balloon-assisted maturation (BAM), undersized veins can be used to create functional AVFs with a high rate of success. METHODS All patients who underwent AVF creation between 2014 and 2018 at a tertiary academic medical center were retrospectively reviewed. The patients without preoperative vein mapping, those who failed to follow-up, and the patients who were not on dialysis were excluded. A fistula was considered to be mature if it was successfully cannulated for dialysis. A total of 596 patients were identified for analysis. The cohort was divided into the small-vein group (SVG, <2.5 mm) and large-vein group (LVG, ≥2.5 mm) based on preoperative vein size. Categorical variables were analyzed with the chi-squared test for their association with maturation status. Continuous variables were analyzed with the Wilcoxon rank sum test. A P-value less than 0.05 was considered significant. RESULTS In the study cohort, 61.9% of the patients were male, with an average age of 62.8 ± 13.7 years, and an average preoperative vein size of 2.9 ± 1.1 mm. With similar demographic distribution, the participants in the SVG (n = 216) had significantly smaller preoperative vein size of 1.9 ± 0.4 mm than the patients in the LVG (n = 380), 3.5 ± 0.8 mm (P = 0.001). There were significantly more radio-cephalic AVFs created in the SVG (77.8% versus 48.7%, P < 0.0001). The overall maturation rate was 83.1% (n = 495), 219 fistulas (36.7%) matured primarily and 276 (46.3%) required interventions. Ninety-one percent of the patients required only 1 or 2 BAMs to achieve maturation. The SVG achieved a maturation rate of 75.9% as compared with 87.1% in the LVG (P = 0.002). A significantly higher number of patients in the SVG required BAM for maturation as compared with the LVG (67.7% versus 49.9%, P = 0.0002); however, there was no difference in the average number of BAMs required for fistula maturation between the groups (1.5 ± 0.8 for the SVG vs. 1.4 ± 0.7 for the LVG). In multivariable logistic regression analysis, vein size ≥2.5 mm (odds ratio (OR) = 2.11, confidence interval (CI): 1.36-3.27, P = 0.0009) and male sex (OR = 2.30, CI: 1.49-3.57, P = 0.0002) were independent predictors of maturation. CONCLUSIONS Small veins can be used for AVF creation with lower but still favorable maturation rates using BAM interventions, especially in male patients. This practice can increase the creation of autogenous dialysis access and potentially reduce complications related to prosthetic dialysis access.
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Affiliation(s)
- Bo Wang
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Amit Rao
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Karalyn Pappas
- The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY
| | - Jeffrey Silpe
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Avinash Garlapati
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Sonia Talathi
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Firas Mussa
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Gregg S Landis
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Yana Etkin
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
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Rognoni C, Tozzi M, Tarricone R. Endovascular versus surgical creation of arteriovenous fistula in hemodialysis patients: Cost-effectiveness and budget impact analyses. J Vasc Access 2020; 22:48-57. [PMID: 32425096 PMCID: PMC7897778 DOI: 10.1177/1129729820921021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives: The aim of the present study was to perform cost-effectiveness and budget impact analyses comparing endovascular arteriovenous fistula creation to surgical arteriovenous fistula creation in hemodialysis patients from the National Healthcare Service (NHS) perspective in Italy. Methods: A systematic literature review has been conducted to retrieve complications’ rates after arteriovenous fistula creation procedures. One study comparing endovascular arteriovenous fistula creation, performed with WavelinQ device, to the surgical approach through propensity score matching was preferred to single-arm investigations to execute the economic evaluations. This study was chosen to populate a Markov model to project, on a time horizon of 1 year, quality adjusted life years and costs associated with endovascular arteriovenous fistula (WavelinQ) and surgical arteriovenous fistula options for both cohorts of incident and prevalent hemodialysis patients. Results: For both incident and prevalent hemodialysis patients, endovascular arteriovenous fistula creation, performed with WavelinQ, was the dominant strategy over surgical arteriovenous fistula approach, showing less cost and better patients’ quality of life. Compared to the current scenario, progressively increasing utilization rates of WavelinQ over surgical arteriovenous fistula creation in the next 5 years in incident hemodialysis patients are expected to save globally 30–36 million euros to the NHS. Conclusion: Endovascular arteriovenous fistula creation performed with WavelinQ could be a cost-saving strategy in comparison with the surgical approach for patients in hemodialysis. Future studies comparing different devices for endovascular arteriovenous fistula creation versus the surgical option would be needed to confirm or reject the validity of this preliminary evaluation. In the meantime, decision-makers can use these results to take decisions on the diffusion of endovascular procedures in Italy.
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Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milan, Italy
| | - Matteo Tozzi
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milan, Italy.,Department of Policy Analysis and Public Management, Bocconi University, Milan, Italy
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Farrington CA, Robbin ML, Lee T, Barker-Finkel J, Allon M. Early Predictors of Arteriovenous Fistula Maturation: A Novel Perspective on an Enduring Problem. J Am Soc Nephrol 2020; 31:1617-1627. [PMID: 32424000 DOI: 10.1681/asn.2019080848] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 03/26/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Preoperative ultrasound mapping is routinely used to select vessels meeting minimal threshold diameters for surgical arteriovenous fistula (AVF) creation but fails to improve AVF maturation rates. This suggests a need to reassess the preoperative ultrasound criteria used to optimize AVF maturation. METHODS We retrospectively identified 300 catheter-dependent patients on hemodialysis with a new AVF created between 2010 and 2016. We then evaluated the associations of preoperative vascular measurements and hemodynamic factors with unassisted AVF maturation (successful use for dialysis without prior intervention) and overall maturation (successful use with or without prior intervention). Multivariable logistic regression was used to identify preoperative factors associated with unassisted and overall AVF maturation. RESULTS Unassisted AVF maturation associated with preoperative arterial diameter (adjusted odds ratio [aOR], 1.50 per 1-mm increase; 95% confidence interval [95% CI], 1.23 to 1.83), preoperative systolic BP (aOR, 1.16 per 10-mm Hg increase; 95% CI, 1.05 to 1.28), and left ventricular ejection fraction (aOR, 1.07 per 5% increase; 95% CI, 1.01 to 1.13). Overall AVF maturation associated with preoperative arterial diameter (aOR, 1.36 per 1-mm increase; 95% CI, 1.10 to 1.66) and preoperative systolic BP (aOR, 1.17; 95% CI, 1.06 to 1.30). Using receiver operating curves, the combination of preoperative arterial diameter, systolic BP, and left ventricular ejection fraction was fairly predictive of unassisted maturation (area under the curve, 0.69). Patient age, sex, race, diabetes, vascular disease, obesity, and AVF location were not associated with maturation. CONCLUSIONS Preoperative arterial diameter may be an under-recognized predictor of AVF maturation. Further study evaluating the effect of preoperative arterial diameter and other hemodynamic factors on AVF maturation is needed.
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Affiliation(s)
- Crystal A Farrington
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle L Robbin
- Department of Radiology, University of Alabama at Birmingham, Birmingham Alabama
| | - Timmy Lee
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Nephrology, Veterans Affairs Medical Center, Birmingham, Alabama
| | - Jill Barker-Finkel
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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23
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Beathard GA, Litchfield T, Jennings WC. Two-year cumulative patency of endovascular arteriovenous fistula. J Vasc Access 2020; 21:350-356. [PMID: 31566061 PMCID: PMC7222285 DOI: 10.1177/1129729819877780] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/30/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The recent advent of a device to create a proximal radial artery arteriovenous fistula using an endovascular approach to create the anastomosis represents a significant advance in dialysis access creation. This endovascular arteriovenous fistula offers the beneficial attributes of the proximal radial artery arteriovenous fistula while adding the advantages of avoiding a surgical procedure. The endovascular arteriovenous fistula can be created safely, functions well, has excellent patency, and has a high degree of patient satisfaction. The purpose of this study is to report the 2-year cumulative patency rate for a large multicenter cohort of endovascular arteriovenous fistula cases. DESIGN An endovascular arteriovenous fistula was created in 105 patients using either local or regional anesthesia and conscious sedation. Patient data were obtained from each program's electronic health record system. Data collection was truncated at 2 years postprocedure and used to calculate cumulative patency. Post-access creation patient satisfaction was assessed. RESULTS A physiologically mature arteriovenous fistula (blood flow ⩾500 mL/min and a target vein internal diameter ⩾4 mm) was obtained in 98%. A clinically functional arteriovenous fistula (supporting two-needle dialysis according to the patient's dialysis prescription) was demonstrated in 95%. Access failure resulting in the loss of access occurred in eight cases during the study period. The cumulative patency rate at 6, 12, 18, and 24 months was 97.1%, 93.9%, 93.9%, and 92.7%, respectively. The post-procedure patient evaluation emphasized a high level of patient satisfaction. CONCLUSION The proximal radial artery arteriovenous fistula created using an endovascular approach for the anastomosis is associated with excellent 2-year cumulative patency and is associated with a high level of patient satisfaction.
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Affiliation(s)
| | | | - William C Jennings
- Department of Surgery, School of Community Medicine, University of Oklahoma, Tulsa, OK, USA
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24
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Wang D, Calabro-Kailukaitis N, Mowafy M, Kerns ES, Suvarnasuddhi K, Licht J, Ahn SH, Hu SL. Urgent-start peritoneal dialysis results in fewer procedures than hemodialysis. Clin Kidney J 2020; 13:166-171. [PMID: 32296520 PMCID: PMC7147319 DOI: 10.1093/ckj/sfz053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/08/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Peritoneal dialysis (PD) is an underutilized modality for hospitalized patients with an urgent need to start renal replacement therapy in the USA. Most patients begin hemodialysis (HD) with a tunneled central venous catheter (CVC). METHODS We examined the long-term burden of dialysis modality-related access procedures with urgent-start PD and urgent-start HD in a retrospective cohort of 73 adults. The number of access-related (mechanical and infection-related) procedures for each modality was compared in the first 30 days and cumulatively through the duration of follow-up. RESULTS Fifty patients underwent CVC placement for HD and 23 patients underwent PD catheter placement for urgent-start dialysis. Patients were followed on average >1 year. The PD group was significantly younger, with less diabetes, with a higher pre-dialysis serum creatinine and more likely to have a planned dialysis access. The mean number of access-related procedures per patient in the two groups was not different at 30 days; however, when compared over the duration of follow-up, the number of access-related procedures was significantly higher in the HD group compared with the PD group (4.6 ± 3.9 versus 0.61 ± 0.84, P < 0.0001). This difference persisted when standardized to procedures per patient-month (0.37 ± 0.57 versus 0.081 ± 0.18, P = 0.019). Infection-related procedures were similar between groups. Findings were the same even after case-matching was performed for age and diabetes mellitus with 18 patients in each group. CONCLUSIONS Urgent-start PD results in fewer invasive access procedures compared with urgent-start HD long term, and should be considered for urgent-start dialysis.
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Affiliation(s)
- Delin Wang
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Medicine, Aspirus Nephrology Clinic, Wausau, WI, USA
| | - Nathan Calabro-Kailukaitis
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Mahmoud Mowafy
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Eric S Kerns
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Khetisuda Suvarnasuddhi
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jonah Licht
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Providence Access Care, Providence, RI, USA
| | - Sun H Ahn
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Radiology, Rhode Island Hospital, Providence, RI, USA
| | - Susie L Hu
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
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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: 964] [Impact Index Per Article: 241.0] [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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26
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Nauta L, Voorzaat BM, Rotmans JI, Ghariq E, Urlings T, van der Bogt KEA, van der Linden E. Endovascular salvage of non-maturing autogenous arteriovenous fistulas by using angioplasty and competitive vein embolization. J Vasc Access 2019; 21:615-622. [PMID: 31865843 DOI: 10.1177/1129729819895185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The aim of this study is to evaluate the maturation and patency rates after endovascular treatment of non-maturing arteriovenous fistulas with percutaneous transluminal angioplasty, embolization of competitive veins, or a combination of both in a series of consecutive patients. MATERIAL AND METHODS Retrospective evaluation of patients with non-matured arteriovenous fistulas treated in our hospital was performed. Fistulography and ultrasonography was performed in all patients to evaluate the presence of stenosis and competitive veins. Significant stenoses (> 50%) were treated with balloon angioplasty and competitive veins (accessory and collateral veins) with coil embolization. RESULTS A total of 78 fistulas were treated. Angioplasty and coil embolization were performed in 73 and 51 patients, respectively. No major complications occurred. In 65 out of 78 arteriovenous fistulas (83%), successful cannulation with two needles was possible after endovascular treatment. Sixty-three arteriovenous fistulas (81%) were used successfully for at least 3 months. Accessory veins were the only lesion present in 14% of the arteriovenous fistulas; coil embolization of these accessory veins resulted in 100% successful maturation. The estimated 3, 6, and 12 months postintervention assisted primary patency rates were, respectively, 73%, 55%, and 45%. The estimated 3, 6, and 12 months postintervention secondary patency rates were, respectively, 81%, 78%, and 73%. CONCLUSION AND DISCUSSION Angioplasty and coil embolization are successful and safe procedures that can convert a non-mature fistula into a mature one in more than 80% of patients. Accessory vein embolization may be more important than collateral vein embolization in the presence of stenosis.
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Affiliation(s)
- Lisette Nauta
- Department of Radiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Bram M Voorzaat
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Elyas Ghariq
- Department of Radiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Thijs Urlings
- Department of Radiology, Haaglanden Medical Center, The Hague, The Netherlands
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Endovascular Creation of Arteriovenous Fistulae for Hemodialysis Access with a 4 Fr Device: Clinical Experience from the EASE Study. Ann Vasc Surg 2019; 60:182-192. [DOI: 10.1016/j.avsg.2019.02.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 02/11/2019] [Accepted: 02/19/2019] [Indexed: 11/24/2022]
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Yan Wee IJ, Yap HY, Tang TY, Chong TT. A systematic review, meta-analysis, and meta-regression of the efficacy and safety of endovascular arteriovenous fistula creation. J Vasc Surg 2019; 71:309-317.e5. [PMID: 31564584 DOI: 10.1016/j.jvs.2019.07.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 07/15/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The percutaneous endovascular approach to arteriovenous fistula (AVF) creation is a minimally invasive alternative to surgical AVF creation. This systematic review and meta-analysis aimed to investigate the efficacy and safety of endovascular AVF creation in patients with end-stage renal disease. METHODS This study conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search was performed on major databases to identify relevant articles. Meta-analysis of proportions and meta-regression were conducted. RESULTS Seven studies totaling 300 patients were included, of which four evaluated the everlinQ (TVA Medical, Austin, Tex) and three employed the Ellipsys (Avenu Medical, San Juan Capistrano, Calif) systems. The overall technical success rate was 97.50% (95% confidence interval [CI], 94.98-99.31%; I2 = 0.00%; P = .487). The 90-day maturation rate was 89.27% (95% CI, 84.00-93.66%; I2 = 21.29%; P = .283), and the 6-month patency and 12-month patency were 91.99% (95% CI, 87.98-95.35%; I2 = 0.00%; P = .780) and 85.71% (95% CI, 79.90-90.71%; I2 = 0.00%; P = NS), respectively. The overall procedure-related complication rate was 5.46% (95% CI, 0.310-14.42%; I2 = 81.21%; P = .000). Meta-regression was conducted on the pooled rates of technical success and complication, showing that age, diabetes, white race, hypertension, on dialysis, and body mass index were not significant sources of heterogeneity. CONCLUSIONS Current endovascular AVF systems appear to be effective and safe. However, given the lack of head-to-head comparative analyses with surgical AVF creation, superiority cannot be established.
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Affiliation(s)
- Ian Jun Yan Wee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hao Yun Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore.
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Balamuthusamy S, Miller LE, Clynes D, Kahle E, Knight RA, Conway PT. American Association of Kidney Patients survey of patient preferences for hemodialysis vascular access. J Vasc Access 2019; 21:230-236. [PMID: 31464539 DOI: 10.1177/1129729819870962] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To determine the vascular access modalities used for hemodialysis, the reasons for choosing them, and determinants of satisfaction with vascular access among patients with end-stage renal disease. METHODS The American Association of Kidney Patients Center for Patient Research and Education used the American Association of Kidney Patients patient engagement database to identify eligible adult hemodialysis patients. Participants completed an online survey consisting of 34 demographic, medical history, and hemodialysis history questions to determine which vascular access modalities were preferred and the reasons for these preferences. RESULTS Among 150 respondents (mean age 54 years, 53% females), hemodialysis was most frequently initiated with central venous catheter (64%) while the most common currently used vascular access was arteriovenous fistula (66%). Most (86%) patients previously received an arteriovenous fistula, among whom 77% currently used the arteriovenous fistula for vascular access. Older patients and males were more likely to initiate hemodialysis with an arteriovenous fistula. The factors most frequently reported as important in influencing the selection of vascular access modality included infection risk (87%), physician recommendation (84%), vascular access durability (78%), risk of complications involving surgery (76%), and impact on daily activities (73%); these factors were influenced by patient age, sex, and race. Satisfaction with current vascular access was 90% with arteriovenous fistula, 79% with arteriovenous graft, and 67% with central venous catheter. CONCLUSION Most end-stage renal disease patients continue to initiate hemodialysis with central venous catheter despite being associated with the lowest satisfaction rates. While arteriovenous fistula was associated with the highest satisfaction rate, there are significant barriers to adoption that vary based on patient demographics and perception of procedure invasiveness.
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Affiliation(s)
- Saravanan Balamuthusamy
- Vascular and Interventional Nephrology, Tarrant Vascular Access Center, Fort Worth, TX, USA.,Texas Research Institute, PPG Healthcare PA, Fort Worth, TX, USA.,Nephrology Division, Department of Medicine, University of North Texas, Fort Worth, TX, USA
| | | | - Diana Clynes
- American Association of Kidney Patients, Tampa, FL, USA
| | - Erin Kahle
- American Association of Kidney Patients, Tampa, FL, USA
| | | | - Paul T Conway
- American Association of Kidney Patients, Tampa, FL, USA
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30
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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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Arnold RJ, Han Y, Balakrishnan R, Layton A, Lok CE, Glickman M, Rajan DK. Comparison between Surgical and Endovascular Hemodialysis Arteriovenous Fistula Interventions and Associated Costs. J Vasc Interv Radiol 2018; 29:1558-1566.e2. [DOI: 10.1016/j.jvir.2018.05.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 05/15/2018] [Accepted: 05/15/2018] [Indexed: 10/28/2022] Open
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Jones RG, Morgan RA. A Review of the Current Status of Percutaneous Endovascular Arteriovenous Fistula Creation for Haemodialysis Access. Cardiovasc Intervent Radiol 2018; 42:1-9. [DOI: 10.1007/s00270-018-2037-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022]
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Allon M, Imrey PB, Cheung AK, Radeva M, Alpers CE, Beck GJ, Dember LM, Farber A, Greene T, Himmelfarb J, Huber TS, Kaufman JS, Kusek JW, Roy-Chaudhury P, Robbin ML, Vazquez MA, Feldman HI. Relationships Between Clinical Processes and Arteriovenous Fistula Cannulation and Maturation: A Multicenter Prospective Cohort Study. Am J Kidney Dis 2018; 71:677-689. [PMID: 29398178 PMCID: PMC5916528 DOI: 10.1053/j.ajkd.2017.10.027] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 10/31/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Half of surgically created arteriovenous fistulas (AVFs) require additional intervention to effectively support hemodialysis. Postoperative care and complications may affect clinical maturation. STUDY DESIGN Hemodialysis Fistula Maturation (HFM) Study, a 7-center prospective cohort study. SETTING & PARTICIPANTS 491 patients with single-stage AVFs who had neither thrombosis nor AVF intervention before a 6-week postoperative ultrasonographic examination and who required maintenance hemodialysis. PREDICTORS Postoperative care processes and complications. OUTCOMES Attempted cannulation, successful cannulation, and unassisted and overall clinical maturation as defined by the HFM Study criteria. RESULTS AVF cannulation was attempted in 443 of 491 (90.2%) participants and was eventually successful in 430 of these 443 (97.1%) participants. 263 of these 430 (61.2%) reached unassisted and 118 (27.4%) reached assisted AVF maturation (overall maturation, 381/430 [88.6%]). Attempted cannulation was less likely in patients of surgeons with policies for routine 2-week versus later-than-2-week first postoperative visits (OR, 0.21; 95% CI, 0.06-0.70), routine second postoperative follow-up visits (OR, 0.39; 95% CI, 0.15-0.97), and a routine clinical postoperative ultrasound (OR, 0.28; 95% CI, 0.14-0.55). Attempted cannulation was also less likely among patients undergoing procedures to assist maturation (OR, 0.51; 95% CI, 0.27-0.98). Unassisted maturation was more likely for patients treated in facilities with access coordinators (OR, 1.91; 95% CI, 1.17-3.12), but less likely after precannulation nonstudy ultrasounds (OR per ultrasound, 0.42 [95% CI, 0.26-0.68]) and initial unsuccessful cannulation attempts (OR per each additional attempt, 0.90 [95% CI, 0.83-0.98]). Overall maturation was less likely with infiltration before successful cannulation (OR, 0.44; 95% CI, 0.22-0.89). Among participants receiving maintenance hemodialysis before AVF surgery, unassisted and overall maturation were less likely with longer intervals from surgery to initial cannulation (ORs for each additional month of 0.81 [95% CI, 0.76-0.88] and 0.93 [95% CI, 0.89-0.98], respectively) and from initial to successful cannulation (ORs for each additional week of 0.87 [95% CI, 0.81-0.94] and 0.88 [95% CI, 0.83-0.94], respectively). LIMITATIONS Surgeons' management policies were assessed only by questionnaire at study onset. Most participants received upper-arm AVFs, planned 2-stage AVFs were excluded, and maturation time windows were imposed. Some care processes may have been missed and the observational design limits causal attribution. CONCLUSIONS Multiple processes of care and complications are associated with AVF maturation outcomes.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL.
| | - Peter B Imrey
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT; Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Milena Radeva
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Charles E Alpers
- Department of Pathology, University of Washington Medical Center, Seattle, WA
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
| | - Tom Greene
- Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Jonathan Himmelfarb
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Thomas S Huber
- Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, FL
| | - James S Kaufman
- VA New York Harbor Healthcare System and New York University School of Medicine, New York, NY
| | - John W Kusek
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Michelle L Robbin
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern, Dallas, TX
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Ahmad I. Salvage of Arteriovenous Fistula by Angioplasty of Collateral Veins Establishing a new Channel. J Vasc Access 2018. [DOI: 10.1177/112972980700800211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Patents with end-stage renal disease depend on the patency of their dialysis access. As these patients have only finite access options, and no access lasts indefinitely, it is imperative that each access should be maintained for as long as possible. This report describes a case of salvage of an upper arm fistula by repeated angioplasty of the collateral veins after the main out flow vein was occluded and could not be recanalyzed.
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Affiliation(s)
- I. Ahmad
- American Access Care, Pittsburgh, PA - USA
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Beathard GA, Lok CE, Glickman MH, Al-Jaishi AA, Bednarski D, Cull DL, Lawson JH, Lee TC, Niyyar VD, Syracuse D, Trerotola SO, Roy-Chaudhury P, Shenoy S, Underwood M, Wasse H, Woo K, Yuo TH, Huber TS. Definitions and End Points for Interventional Studies for Arteriovenous Dialysis Access. Clin J Am Soc Nephrol 2018; 13:501-512. [PMID: 28729383 PMCID: PMC5967683 DOI: 10.2215/cjn.11531116] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This paper is part of the Clinical Trial Endpoints for Dialysis Vascular Access Project of the American Society of Nephrology Kidney Health Initiative. The purpose of this project is to promote research in vascular access by clarifying trial end points which would be best suited to inform decisions in those situations in which supportive clinical data are required. The focus of a portion of the project is directed toward arteriovenous access. There is a potential for interventional studies to be directed toward any of the events that may be associated with an arteriovenous access' evolution throughout its life cycle, which has been divided into five distinct phases. Each one of these has the potential for relatively unique problems. The first three of these correspond to three distinct stages of arteriovenous access development, each one of which has been characterized by objective direct and/or indirect criteria. These are characterized as: stage 1-patent arteriovenous access, stage 2-physiologically mature arteriovenous access, and stage 3-clinically functional arteriovenous access. Once the requirements of a stage 3-clinically functional arteriovenous access have been met, the fourth phase of its life cycle begins. This is the phase of sustained clinical use from which the arteriovenous access may move back and forth between it and the fifth phase, dysfunction. From this phase of its life cycle, the arteriovenous access requires a maintenance procedure to preserve or restore sustained clinical use. Using these definitions, clinical trial end points appropriate to the various phases that characterize the evolution of the arteriovenous access life cycle have been identified. It is anticipated that by using these definitions and potential end points, clinical trials can be designed that more closely correlate with the goals of the intervention and provide appropriate supportive data for clinical, regulatory, and coverage decisions.
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Affiliation(s)
- Gerald A Beathard
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Tordoir JH, Zonnebeld N, van Loon MM, Gallieni M, Hollenbeck M. Surgical and Endovascular Intervention for Dialysis Access Maturation Failure During and After Arteriovenous Fistula Surgery: Review of the Evidence. Eur J Vasc Endovasc Surg 2018; 55:240-248. [DOI: 10.1016/j.ejvs.2017.12.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 12/03/2017] [Indexed: 01/01/2023]
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Miller GA, Goel N, Khariton A, Friedman A, Savransky Y, Trusov I, Jotwani K, Savransky E, Preddie D, Arnold WP. Aggressive Approach to Salvage Non-Maturing Arteriovenous Fistulae: A Retrospective Study with follow-up. J Vasc Access 2018; 10:183-91. [DOI: 10.1177/112972980901000309] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose To establish a standardized approach for the maturation of non-maturing arteriovenous fistulae. Methods consecutive patients (n=122) with non-maturing fistulae presented to our outpatient vascular access center for percutaneous interventions to assist in maturation. The techniques used included flow rerouting, competing branch vein elimination, staged balloon angioplasty, and limited controlled extravasation. Results Successful fistula maturations were achieved in 118/122 patients. Fistulae were divided into two classes according to initial vessel size: class 1 (6.0–8.0 mm diameter, >6 mm deep) and class 2 (2.0–5.0 mm diameter) fistulae were evaluated for differences in technical procedures and clinically successful fistula maturation. Class 1 and class 2 fistulae were evaluated for mean number of procedures to maturation (1.6 and 2.6, respectively), and time to maturation (5 and 7 weeks, respectively). Follow-up for 109 of the initial 118 patients was achieved (mean=24 months, range=0.25–60 months). Class 1 and class 2 fistulae had primary patencies of 17 and 39% at 6 months; and secondary patencies of 72 and 77% at 12 months, 53 and 61% at 24 months, and 42 and 32% at 36 months, respectively. Primary and secondary patencies (Mann-Whitney test, p=0.44 and p=0.38, respectively) of class 1 and class 2 fistulae did not differ significantly, and secondary patencies were comparable to other fistula salvage studies. Conclusion Fistula salvage attempts should not be limited by factors such as a diffusely small diameter or an inaccessibly deep position.
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Affiliation(s)
| | - Naveen Goel
- American Access Care of Florida, Plantation, Florida - USA
| | | | | | | | - Ilya Trusov
- American Access Care of Brooklyn, Brooklyn, New York - USA
| | - Kiran Jotwani
- American Access Care of Queens, Queens, New York - USA
| | - Eric Savransky
- American Access Care of Brooklyn, Brooklyn, New York - USA
| | - Dean Preddie
- American Access Care of Brooklyn, Brooklyn, New York - USA
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Dumaine CS, Brown RS, MacRae JM, Oliver MJ, Ravani P, Quinn RR. Central venous catheters for chronic hemodialysis: Is "last choice" never the "right choice"? Semin Dial 2017; 31:3-10. [PMID: 29098715 DOI: 10.1111/sdi.12655] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Since the publication of the first vascular access clinical practice guidelines in 1997, the global nephrology community has dedicated significant time and resources toward increasing the prevalence of arteriovenous fistulas and decreasing the prevalence of central venous catheters for hemodialysis. These efforts have been bolstered by observational studies showing an association between catheter use and increased patient morbidity and mortality. To date, however, no randomized comparisons of the outcomes of different forms of vascular access have been conducted. There is mounting evidence that much of the difference in patient outcomes may be explained by patient factors, rather than choice of vascular access. Some have called into question the appropriateness of fistula creation for certain patient populations, such as those with limited life expectancy and those at high risk of fistula-related complications. In this review, we explore the extent to which catheters and fistulas exhibit the characteristics of the "ideal" vascular access and highlight the significant knowledge gaps that exist in the current literature. Further studies, ideally randomized comparisons of different forms of vascular access, are required to better inform shared decision making.
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Affiliation(s)
- Chance S Dumaine
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Robert S Brown
- Division of Nephrology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Jennifer M MacRae
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Pietro Ravani
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Robert R Quinn
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
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Ting CY, Wu WS, Tang KT, Wang HE, Lin CC. Evaluation of radiation dose during the percutaneous angioplasty for arteriovenous shunt assembling. Radiat Phys Chem Oxf Engl 1993 2017. [DOI: 10.1016/j.radphyschem.2017.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Radosa CG, Radosa JC, Weiss N, Schmidt C, Werth S, Hofmockel T, Plodeck V, Gatzweiler C, Laniado M, Hoffmann RT. Endovascular Creation of an Arteriovenous Fistula (endoAVF) for Hemodialysis Access: First Results. Cardiovasc Intervent Radiol 2017; 40:1545-1551. [PMID: 28785804 DOI: 10.1007/s00270-017-1750-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Surgical creation of a radiocephalic fistula is the gold standard of vascular access for hemodialysis. Recently, an endovascular approach for upper arm fistula creation (endoAVF) has been developed, which may be an alternative to open surgery. We describe a case series of eight cases showing feasibility, early complications and outcome of this novel treatment option. MATERIALS AND METHODS Between July 2015 and February 2016, we created an endoAVF in eight patients. Indications for endoAVF were confirmed by a multidisciplinary vascular board upon the exclusion for Cimino fistula candidates. Patients were suitable for the procedure after a pre-therapeutic ultrasound showed adequate brachial and ulnar vessels and no ipsilateral central venous stenosis. Patient characteristics, technical success, total patient radiation dose, complication rates, time to maturation of endoAVF and clinical effectiveness at six months were assessed retrospectively. RESULTS Creation of endoAVF using the everlinQ endoAVF system (TVA Medical Inc., Austin, TX, USA) was successful in all eight cases. There were one minor intraprocedural complication and no postoperative complications. Median time to endoAVF maturation was 63 days (range 26-137 days). One patient was lost to follow-up after the first monitoring visit. In the remaining seven patients, hemodialysis was started without problems. Patency after 6 months was 100%. DISCUSSION The endoAVF demonstrated to be feasible and safe for the creation of arteriovenous fistula suitable for hemodialysis access. Further studies with more patients and longer follow-up periods are needed to assess long-term outcomes and comparability to surgical dialysis access creation.
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Affiliation(s)
- Christoph Georg Radosa
- Department of Radiology, Dresden University Hospital, Fetscherstraße 74, 01307, Dresden, Germany
| | - Julia Caroline Radosa
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany
| | - Norbert Weiss
- Department of Internal Medicine III - Section Angiology, Dresden University Hospital, Fetscherstraße 74, 01307, Dresden, Germany
| | - Christine Schmidt
- Department of Internal Medicine III - Section Angiology, Dresden University Hospital, Fetscherstraße 74, 01307, Dresden, Germany
| | - Sebastian Werth
- Department of Internal Medicine III - Section Angiology, Dresden University Hospital, Fetscherstraße 74, 01307, Dresden, Germany
| | - Thomas Hofmockel
- Department of Radiology, Dresden University Hospital, Fetscherstraße 74, 01307, Dresden, Germany
| | - Verena Plodeck
- Department of Radiology, Dresden University Hospital, Fetscherstraße 74, 01307, Dresden, Germany
| | - Christian Gatzweiler
- Department of Visceral, Thoracic and Vascular Surgery, Dresden University Hospital, Fetscherstraße 74, 01307, Dresden, Germany
| | - Michael Laniado
- Department of Radiology, Dresden University Hospital, Fetscherstraße 74, 01307, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Department of Radiology, Dresden University Hospital, Fetscherstraße 74, 01307, Dresden, Germany.
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Al-Balas A, Lee T, Young CJ, Kepes JA, Barker-Finkel J, Allon M. The Clinical and Economic Effect of Vascular Access Selection in Patients Initiating Hemodialysis with a Catheter. J Am Soc Nephrol 2017; 28:3679-3687. [PMID: 28710090 DOI: 10.1681/asn.2016060707] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 06/08/2017] [Indexed: 11/03/2022] Open
Abstract
Patients in the United States frequently initiate hemodialysis with a central venous catheter (CVC) and subsequently undergo placement of a new arteriovenous fistula (AVF) or arteriovenous graft (AVG). Little is known about the clinical and economic effects of initial vascular access choice. We identified 479 patients starting hemodialysis with a CVC at a large medical center (during 2004-2012) who subsequently had an AVF (n=295) or AVG (n=105) placed or no arteriovenous access (CVC group, n=71). Compared with patients receiving an AVG, those receiving an AVF had more frequent surgical access procedures per year (1.01 [95% confidence interval, 0.95 to 1.08] versus 0.62 [95% confidence interval, 0.55 to 0.70]; P<0.001) but a similar frequency of percutaneous access procedures per year. Patients receiving an AVF had a higher median annual cost (interquartile range) of surgical access procedures than those receiving an AVG ($4857 [$2523-$8835] versus $2819 [$1411-$4274]; P<0.001), whereas the annual cost of percutaneous access procedures was similar in both groups. The AVF group had a higher median overall annual access-related cost than the AVG group ($10,642 [$5406-$19,878] versus $6810 [$3718-$13,651]; P=0.001) after controlling for patient age, sex, race, and diabetes. The CVC group had the highest median annual overall access-related cost ($28,709 [$11,793-$66,917]; P<0.001), largely attributable to the high frequency of hospitalizations due to catheter-related bacteremia. In conclusion, among patients initiating hemodialysis with a CVC, the annual cost of access-related procedures and complications is higher in patients who initially receive an AVF versus an AVG.
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Affiliation(s)
| | - Timmy Lee
- Divisions of Nephrology and.,Division of Nephrology, Veterans Affairs Medical Center, Birmingham, Alabama
| | - Carlton J Young
- Transplant Surgery, University of Alabama at Birmingham, Birmingham, Alabama; and
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Lok CE, Rajan DK, Clement J, Kiaii M, Sidhu R, Thomson K, Buldo G, Dipchand C, Moist L, Sasal J. Endovascular Proximal Forearm Arteriovenous Fistula for Hemodialysis Access: Results of the Prospective, Multicenter Novel Endovascular Access Trial (NEAT). Am J Kidney Dis 2017. [PMID: 28624422 DOI: 10.1053/j.ajkd.2017.03.026] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hemodialysis arteriovenous fistulas (AVFs) are suboptimally used primarily due to problems with maturation, early thrombosis, and patient nonacceptance. An endovascular approach to fistula creation without open surgery offers another hemodialysis vascular access option. STUDY DESIGN Prospective, single-arm, multicenter study (Novel Endovascular Access Trial [NEAT]). SETTINGS & PARTICIPANTS Consecutive adult non-dialysis-dependent and dialysis-dependent patients referred for vascular access creation at 9 centers in Canada, Australia, and New Zealand. INTERVENTION Using catheter-based endovascular technology and radiofrequency energy, an anastomosis was created between target vessels, resulting in an endovascular AVF (endoAVF). OUTCOMES Safety, efficacy, functional usability, and patency end points. MEASUREMENTS Safety as percentage of device-related serious adverse events; efficacy as percentage of endoAVFs physiologically suitable (brachial artery flow ≥ 500mL/min, vein diameter ≥ 4mm) for dialysis within 3 months; functional usability of endoAVFs to provide prescribed dialysis via 2-needle cannulation; primary and cumulative endoAVF patencies per standardized definitions. RESULTS 80 patients were enrolled (20 roll-in and 60 participants in the full analysis set; the latter are reported). EndoAVFs were created in 98% of participants; 8% had a serious procedure-related adverse event (2% device related). 87% were physiologically suitable for dialysis (eg, mean brachial artery flow, 918mL/min; endoAVF vein diameter, 5.2mm [cephalic vein]). EndoAVF functional usability was 64% in participants who received dialysis. 12-month primary and cumulative patencies were 69% and 84%, respectively. LIMITATIONS Due to the unique anatomy and vessels used to create endoAVFs, this was a single-arm study without a surgical comparator. CONCLUSIONS An endoAVF can be reliably created using a radiofrequency magnetic catheter-based system, without open surgery and with minimal complications. The endoAVF can be successfully used for hemodialysis and demonstrated high 12-month cumulative patencies. It may be a viable alternative option for achieving AVFs for hemodialysis patients in need of vascular access.
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Affiliation(s)
- Charmaine E Lok
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario; University of Toronto, Toronto, Ontario.
| | - Dheeraj K Rajan
- University of Toronto, Toronto, Ontario; Division of Vascular & Interventional Radiology, Department of Medical Imaging, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario
| | - Jason Clement
- Department of Radiology, St. Paul's Hospital, Vancouver, BC, Canada
| | - Mercedeh Kiaii
- Division of Nephrology, Department of Medicine, St. Paul's Hospital, Vancouver, BC, Canada
| | - Ravi Sidhu
- Division of Vascular Surgery, St. Paul's Hospital, Vancouver, BC, Canada
| | - Ken Thomson
- Department of Radiology, Alfred Hospital, Melbourne, Australia
| | - George Buldo
- Division of Nephrology, Department of Medicine, Lakeridge Health, Oshawa, ON
| | - Christine Dipchand
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS
| | - Louise Moist
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London
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Beathard GA, Urbanes A, Litchfield T. Changes in the Profile of Endovascular Procedures Performed in Freestanding Dialysis Access Centers over 15 Years. Clin J Am Soc Nephrol 2017; 12:779-786. [PMID: 28420654 PMCID: PMC5477215 DOI: 10.2215/cjn.09730916] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 02/10/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVES Marked changes occurred in the vascular access profile of patients receiving hemodialysis in the United States over the 15-year period of 2001-2015. This study was undertaken to evaluate how these changes have affected dialysis access maintenance and salvage procedures performed in freestanding dialysis access centers and to examine the effectiveness, efficiency, and safety of these procedures in this setting. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were collected from freestanding, dedicated dialysis access centers operating under a common system of management. Data were available on 689,676 dialysis access procedures. Data relating to case mix, procedure outcome, procedural time, and intraprocedural and immediate postprocedural complications were analyzed. RESULTS The arteriovenous procedure profile changed from one characterized by approximately equal numbers of angioplasties and thrombectomies performed on arteriovenous grafts (AVGs) to one characterized primarily by angioplasties performed on arteriovenous fistulas. The percentage of angioplasties performed throughout the study was significantly greater than thrombectomies, with a mean of 67.9% versus 32.1% (P<0.001). Interventional procedures did not decrease with increasing arteriovenous fistula utilization in prevalent patients receiving dialysis. The incidence roughly paralleled the increasing prevalence of this type of access. A decreasing percentage of AVG utilization resulted in a progressive, roughly parallel, but disproportionately higher, decrease in the percentage of AVG procedures (P<0.001). A progressive improvement in procedure outcomes and a decrease in complication rates and procedure times were observed (P<0.001 for each). A progressive decrease in tunneled dialysis catheter placement was also observed. CONCLUSIONS The procedure profile treated in freestanding, dedicated dialysis access centers changed significantly over 15 years, reflecting the changes that have occurred in the vascular access profile of the dialysis population.
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Affiliation(s)
- Gerald A. Beathard
- Lifeline Vascular Access a division of DaVita Healthcare, Denver, Colorado; and
- Department of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Aris Urbanes
- Lifeline Vascular Access a division of DaVita Healthcare, Denver, Colorado; and
| | - Terry Litchfield
- Lifeline Vascular Access a division of DaVita Healthcare, Denver, Colorado; and
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Abstract
Angiography of the dialysis access is an important procedure in dealing with dialysis arteriovenous access (AVA) dysfunction. It is an integral part and the initiating procedure for all the interventional procedures performed for the management and salvage of dialysis AVA. The performance of this procedure and normal dialysis access-related anatomy including anatomical variants are discussed. In addition, pathology commonly encountered in association with the anatomy is reviewed.
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Affiliation(s)
- Gerald A Beathard
- University of Texas Medical Branch, Lifeline Vascular Access, Houston, Texas
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Comparison of Post-Creation Procedures and Costs between Surgical and an Endovascular Approach to Arteriovenous Fistula Creation. J Vasc Access 2017; 18:8-14. [DOI: 10.5301/jva.5000723] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2017] [Indexed: 11/20/2022] Open
Abstract
Introduction Due to early and late failures that may occur with surgically created hemodialysis arteriovenous fistulas (SAVF), post-creation procedures are commonly required to facilitate AVF maturation and maintain patency. This study compared AVF post-creation procedures and their associated costs in patients with SAVF to patients with a new endovascularly created AVF (endoAVF). Methods A 5% random sample from Medicare Standard Analytical Files was abstracted to determine post- creation procedures and associated costs for SAVF created from 2011 to 2013. Medicare enrollment during the 6 months prior to and after the AVF creation was required. Patients’ follow-up inpatient, outpatient, and physician claims were used to identify post-creation procedures and to estimate average procedure costs. Comparative procedural information on endoAVF was obtained from the Novel Endovascular Access Trial (NEAT). Results Of 3764 Medicare SAVF patients, 60 successfully matched to endoAVF patients using 1:1 propensity score matching of baseline demographic and clinical characteristics. The total post-creation procedural event rate within 1 year was lower for endoAVF patients (0.59 per patient-year) compared to the matched SAVF cohort (3.43 per patient-year; p<0.05). In the endoAVF cohort, event rates of angioplasty, thrombectomy, revision, catheter placement, subsequent arteriovenous graft (AVG), new SAVF, and vascular access-related infection were all significantly lower than in the SAVF cohort. The average first year cost per patient-year associated with post-creation procedures was estimated at US$11,240 USD lower for endoAVF than for SAVF. Conclusions Compared to patients with SAVF, patients with endoAVF required fewer post-creation procedures and had lower associated mean costs within the first year.
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Bavare CS, Street TK, Peden EK, Davies MG, Naoum JJ. Stent Grafts Can Convert Unusable Upper Arm Arteriovenous Fistulas into a Functioning Hemodialysis Access: A Retrospective Case Series. Front Surg 2017; 4:13. [PMID: 28289682 PMCID: PMC5326796 DOI: 10.3389/fsurg.2017.00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/13/2017] [Indexed: 11/23/2022] Open
Abstract
Introduction Not all newly created arteriovenous fistulas (AVFs) successfully mature and develop into a functioning access for hemodialysis. Percutaneous transluminal angioplasty (PTA) and balloon-assisted maturation (BAM) have been utilized to either treat flow-limiting stenoses or to promote and accelerate maturation. We hypothesized that unusable upper arm AVFs can be rescued by conversion to a functional access using the percutaneous placement of a stent graft (SG). Methods Clinical data on 12 patients with an early non-usable upper arm AVF underwent percutaneous revision using SGs. There were six brachial–cephalic, three brachial–basilic, and three brachial–brachial vein transposition AVFs. Results All patients had either at least two or more stenoses (>2 cm) within the fistula conduit, or a long segment stenosis (>4 cm) in combination with shorter segment stenoses. Nine patients had failed PTA. Three patients had failed BAM at outside access centers. All patients were referred for failure to achieve access cannulation and concomitant hemodialysis through the AVF. SGs were placed retrograde toward the arterial anastomoses and ranged in diameter (6, 7, and 8 mm in four, seven, and one patients, respectively). The average length of the SG was 10 cm (range 5–15 cm). All SGs were post-balloon dilated at the time of placement. All AVFs were salvaged, and patients were able to maintain functional use of their access with cannulation occurring through the SG. The primary patency rate at 6 and 12 months was 91% [95% confidence interval (CI), 56–98%] and 65% (95% CI, 32–87%), respectively (n = 11 and 5 at risk, respectively). The secondary patency rate at 6 and 12 months was 100 and 72% (95% CI, 46–93%), respectively (n = 11 and 7 at risk, respectively). Conclusion This report outlines a successful initial experience using SGs to rescue, preserve, and convert an unusable upper arm AVF into a functioning hemodialysis access.
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Affiliation(s)
- Charudatta S Bavare
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital , Houston, TX , USA
| | - Tiffany K Street
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital , Houston, TX , USA
| | - Eric K Peden
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital , Houston, TX , USA
| | - Mark G Davies
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital , Houston, TX , USA
| | - Joseph J Naoum
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA; Department of Surgery, Division of Vascular and Endovascular Surgery, Lebanese American University, Beirut, Lebanon
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Optiflow anastomotic device for hemodialysis vascular access creation. J Vasc Access 2017; 18:84-87. [PMID: 28297067 DOI: 10.5301/jva.5000664] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2016] [Indexed: 11/20/2022] Open
Abstract
The need to have consistent methods and consistent technique to optimize hemodialysis outcomes is behind the concept of the Optiflow™ device. This device was created to allow for consistency in size of the arterial anastomosis and consistency in angle of the vein to the artery at the anastomosis. Early data suggest that allowing these two technical entities can improve outcomes in regards to flow and maturity in arteriovenous fistula creation. This article is a summary of early data that demonstrate the impact the Optiflow device on brachial cephalic fistulas.
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Abstract
There are substantial variations in arteriovenous fistula (AVF) use among hemodialysis patients in different countries, in different regions of the U.S., and even in different hemodialysis units within a single metropolitan area. These variations persist after adjustment for patient demographics and comorbidities, suggesting that practice patterns play a major role in determining the frequency of AVF use. These observations led to vascular access guidelines urging nephrologists and surgeons to increase AVF creation in patients with chronic kidney disease. Over the past 20 years, as clinicians have adopted these guidelines, the prevalence of AVF use in hemodialysis patients has increased substantially. At the same time, clinicians have recognized important limitations of an unwavering "Fistula First" approach. First, a substantial proportion of AVFs fail to mature even when routine preoperative vascular mapping is used, leading to prolonged catheter dependence. Second, certain patient subgroups are at high risk for AVF nonmaturation. Third, nonmaturing AVFs frequently require interventions to promote their maturation. Fourth, AVFs that require such interventions have shortened cumulative patency. Fifth, arteriovenous grafts (AVG) have several advantages over AVFs, including lower primary failure rates, fewer interventions prior to successful cannulation, and shorter duration of catheter dependence with its associated risk of bacteremia. All these observations have led nephrologists to propose an individualized approach to vascular access, with AVG being preferred in patients who initiate hemodialysis with a catheter, particularly if they are at high risk for AVF nonmaturation and have a relatively short life expectancy.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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Tham WP, Burgmans MC, Tan BS, Tay KH, Irani FG, Gogna A, Patel A, Lo RHG, Chng SP, Choong HL, Chan SXJM. Percutaneous Endovascular Treatment to Salvage Non-Maturing Arteriovenous Fistulas in a Multiethnic Asian Population. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2017. [DOI: 10.47102/annals-acadmedsg.v46n2p64] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: An arteriovenous fistula (AVF) is the preferred method for haemodialysis in patients with end-stage renal failure. Previous studies have shown value in attempting percutaneous transluminal angioplasty (PTA) to salvage AVFs that fail to mature, but they are relatively small in size and mainly reported in Western populations. We reviewed our data of PTA in non-maturing AVFs to establish whether this technique is translatable to our local multiethnic population. Materials and Methods: We retrospectively reviewed the medical records and procedural images of 105 patients who had PTA for non-maturing AVFs performed at our department from January 2008 to January 2011. Technical success was defined as ≤30% residual stenosis after angioplasty. Clinical success was defined as at least 1 successful haemodialysis session within 4 weeks after PTA. Results: All 105 patients underwent angioplasty for at least 1 haemodynamically significant stenosis. Six (5.7%) had additional embolisation of accessory veins. Technical success was achieved in 95.2% of cases. The clinical success rate was 76.2%. Primary patency rates at 3, 6 and 12 months were 83%, 45% and 28%, respectively. Secondary patency rates at 3, 6 and 12 months were 90%, 79% and 70%, respectively. The minor complication rate was 18.1%. No major complications were encountered. An average of 1.7 interventions per access-year was required to maintain AVF patency. Patients with a preoperative vein size >2.0 mm and age <55 years were more likely to achieve clinical success, although not statistically significant. Conclusion: PTA is a viable option to help salvage non-maturing AVFs in a multiethnic Asian population.
Key words: Angioplasty, Chronic renal disease, Haemodialysis, Interventional radiology
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Aktas A, Bozkurt A, Aktas B, Kirbas I. Percutaneous transluminal balloon angioplasty in stenosis of native hemodialysis arteriovenous fistulas: technical success and analysis of factors affecting postprocedural fistula patency. Diagn Interv Radiol 2016; 21:160-6. [PMID: 25698092 DOI: 10.5152/dir.2014.14348] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to determine the predictors of technical success and patency after percutaneous transluminal angioplasty (PTA) of de novo dysfunctional hemodialysis arteriovenous fistulas (AVF). METHODS We performed a retrospective analysis of first time PTA in 228 patients (129 men, 99 women; mean age, 56.8±14.6 years). Anatomical (location, length, grade, and number of stenoses) and clinical variables (sex, age, prior AVF, diabetes mellitus, AVF age, side, and location) were reviewed. RESULTS A total of 330 stenoses were found in 228 patients. PTA was technically successful in 96.3% of the stenoses (n=319). Clinical success was achieved in 97.2% (n=321). Early dysfunction (within six months) was positively correlated with patient age (P < 0.001) and diabetes (P < 0.005). Older age (P < 0.001) and diabetes (P = 0.002) were associated with a lower primary patency rate. Patient age (P %lt; 0.001), presence of diabetes (P = 0.023), length of stenosis (P = 0.003), early recurrence (P = 0.003) and presence of residual stenosis (P = 0.014) were associated with a lower secondary patency rate. CONCLUSION Patency of dysfunctional hemodialysis fistulas can be maintained safely with continuous follow-up and repeated interventions without shortening the venous segment by surgical revision. Percutaneous approach to hemodialysis access stenosis is an alternative to the conventional surgical approach and PTA is an effective treatment method for dysfunctional AVF.
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Affiliation(s)
- Ayse Aktas
- Department of Radiology, Turgut Özal University School of Medicine, Ankara, Turkey.
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