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Kingsmore D, Edgar B, Stevenson K, Greenlaw N, Aitken E, Jackson A, Thomson P. A practical review of barriers and challenges to a definitive randomised trial of grafts versus fistula. J Vasc Access 2024:11297298241234610. [PMID: 38436199 DOI: 10.1177/11297298241234610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
A definitive randomised controlled trial of arteriovenous fistula (AVF) versus arteriovenous grafts (AVG) has been advocated for more than a decade, but as yet, none has been completed. The aim of this article is to summarise the theoretical barriers, review the difficulties in trial design and practicalities that have thus far prevented this from occurring.
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Affiliation(s)
- David Kingsmore
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ben Edgar
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Karen Stevenson
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nicola Greenlaw
- Glasgow Clinical Trials Unit, Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Emma Aitken
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Andrew Jackson
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter Thomson
- Department of Renal Medicine, Queen Elizabeth University Hospital, Glasgow, UK
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Carbayo J, Muñoz de Morales A, Aragoncillo I, Abad S, Arroyo D, Vega A, Goicoechea M. Impact of preoperative exercise in not initially candidates to native arteriovenous fistulas. J Vasc Access 2023; 24:689-695. [PMID: 34553628 DOI: 10.1177/11297298211045588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Native autologous arteriovenous fistula (AVFn) is the preferred vascular access for hemodialysis due to its long term patency and low complication rate. A challenging limitation is the anatomical inability to perform AVFn and failure of maturation. Preoperative isometric exercise (PIE) can increase vascular calibers and improve the rate of distal AVF. However, it is unknown whether PIE might enhance the performance of AVFn in patients who are not initially candidates. METHODS A retrospective observational study was conducted over a population of 45 patients evaluated in vascular access clinic, 23 were not initially candidates for radiocephalic (NRC-AVF) and 22 were not candidates for autologous fistula at all (NA-AVF). They were assigned to perform PIE with handgrip device and revaluated. RESULTS After 4-8 weeks of PIE, a AVFn was performed in 16 patients from NA-AVF group and a radiocephalic AVFn was performed in 21 patients from NRC-AVF group. Both groups experienced a significant and similar increase in venous caliber 0.91 ± 0.43 mm in NA-AVF versus 0.76 ± 0.47 mm in NRC-AVF (p = 0.336) and arterial caliber 0.18 ± 0.24 mm versus 0.18 ± 0.21 mm (p = 0.928), respectively. Nevertheless, primary failure rate was significantly higher in NA-AVF (n = 8, 50%) than in NRC-AVF group (n = 3, 14.3%) (p = 0.030). After 6 months, the fistula usability for dialysis was only 50% in NA-AVF, while 86.7% were dialyzed by fistula in NRC-AVF group (p = 0.038). CONCLUSIONS PIE allowed the allocation of an AVFn in patients not initially candidates, but entailed a high rate of maturation failure. Patients not candidates to radiocephalic AVF benefited from PIE and preserved a long term usability of AVF for dialysis.
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Affiliation(s)
- Javier Carbayo
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Inés Aragoncillo
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - David Arroyo
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Almudena Vega
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Halbert RJ, Nicholson G, Nordyke RJ, Pilgrim A, Niklason L. Patency of ePTFE Arteriovenous Graft Placements in Hemodialysis Patients: Systematic Literature Review and Meta-Analysis. KIDNEY360 2020; 1:1437-1446. [PMID: 35372887 PMCID: PMC8815525 DOI: 10.34067/kid.0003502020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/08/2020] [Indexed: 04/29/2023]
Abstract
Arteriovenous grafts (AVGs) are an appropriate option for vascular access in certain hemodialysis patients. Expanded polytetrafluoroethylene (ePTFE) has become the dominant material for such grafts, due in part to innovations in graft design and surgical interventions to reduce complications and improve patency rates. Comprehensive evidence syntheses have not been conducted to update AVG performance in an era in which both access choice and ePTFE graft functioning may have changed. We conducted a systematic review and meta-analysis summarizing outcomes from recent studies of ePTFE AVGs in hemodialysis, following PRISMA standards. Literature searches were conducted in multiple databases to identify observational and interventional studies of AVG patency and infection risk. Primary, primary-assisted, and secondary patency rates were analyzed at 6, 12, 18, and 24 months postplacement. Kaplan-Meier graft survival plots were digitized to recreate individual patient-level data. Patency rates were pooled using a random effects model. We identified 32 studies meeting our selection criteria that were published from 2004 through 2019. A total of 38 study arms of ePTFE grafts were included, representing 3381 AVG accesses placed. The mean primary, primary-assisted, and secondary patency rates at 1 year were 41% (95% CI, 35% to 47%), 46% (95% CI, 41% to 51%), and 70% (95% CI, 64% to 75%), respectively. Mean 24-month patency rates were 28% (95% CI, 22% to 33%), 34% (95% CI, 27% to 41%), and 54% (95% CI, 47% to 61%), respectively. A high degree of heterogeneity across studies was observed. Overall risk of infection was not consistently reported, but among available studies the pooled estimate was 9% per patient-year (95% CI, 6% to 12%). This meta-analysis provides an up-to-date estimate of the performance of ePTFE AVGs, within the context of improved graft designs and improved interventional techniques.
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Affiliation(s)
| | | | | | | | - Laura Niklason
- Humacyte, Incorporated, Morrisville, North Carolina
- Yale University, New Haven, Connecticut
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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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Case report of an arteriovenous graft for renal dialysis, with multiple complications treated successfully over 5 years. Int J Surg Case Rep 2020; 66:158-161. [PMID: 31846869 PMCID: PMC6920319 DOI: 10.1016/j.ijscr.2019.11.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/23/2019] [Accepted: 11/28/2019] [Indexed: 11/24/2022] Open
Abstract
Case report of 35 year old patient with arteriovenous graft formation (AVG). Multiple interventions performed with successful salvage over a course of 5 years. Outline of role of arteriovenous grafts and current literature and recommendations. The learning point from our case is that close monitoring and surveillance can lead to a prolongation of an active AVG.
Introduction Arteriovenous grafts (AVG) is a good alternative when native arteriovenous fistula (AVF) is not possible. However, complications are higher and close surveillance is required for successful salvage intervention. Presentation of case We present the case of a 35 year old man with a history of a successful Brachio-Axillary AVG performed in his right arm in 2012. He had a background of multiple previous failed attempts of a native AVF formation. He presented in 2014 with symptoms consistent with AVF stenosis. He underwent a successful fistuloplasty and 2 stent insertion. In June 2015 he presented again with re-stenosis and successful fistuloplasty was performed with balloon dilatation. In October 2015 he presented with AVF thrombosis. This was treated with fistuloplasty and thrombolysis. He presented again in August 2016 with a recurrent thrombosis in his AVG and this was again treated with a successful fistuloplasty and thrombolysis on two separate occasions. He then presented in September 2016 with re-stenosis. This was treated with fistuloplasty and 2 stent insertion. He underwent a successful renal transplant during this time and presented again with a sinus discharge in February 2019 when the plan was made for subtotal graft excision. Conclusion Incidence of complications is higher when a graft is used over a native AVF. However, close surveillance and prompt intervention can lead to multiple successful salvage procedures thus prolonging the lifespan of the graft. As in our case we were able to prolong the lifespan of the AVG with multiple successful interventions.
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Caro Acevedo P, Marchante R, Thuissard IJ, Sanz-Rosa D, Amann R, Hernandez B, Delgado R. A systematic follow-up protocol achieving a low hemodialysis graft thrombosis rate. J Vasc Access 2019; 20:683-690. [PMID: 31002279 DOI: 10.1177/1129729819838795] [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 Graft is an alternative to native arteriovenous fistula to ensure permanent vascular access in hemodialysis patients. The most common complication is significant stenosis, which frequently causes thrombosis and graft loss. Periodic monitoring and surveillance with elective correction of stenotic lesions can prolong graft survival. OBJECTIVE To describe the effect of early diagnosis of significant stenosis on the rate of thrombosis and graft patency. METHODS Retrospective, observational study of a cohort of 86 prevalent patients undergoing hemodialysis with a graft as their vascular access. We applied a systematic follow-up protocol of 115 grafts based on various screening methods of monitoring (clinical monitoring, pre-pump arterial pressure, dynamic venous pressure, percentage of recirculation, and dose of dialysis) in conjunction with surveillance (normalized intra-access venous pressure and access flow). The annual rates of thrombosis, and primary, primary-assisted, and secondary patency were assessed. RESULTS The incidence of significant stenosis and thrombosis was 57.4% (65/115) and 39.0% (45/115), respectively. Of all screening procedures, normalized intra-access venous pressure was the best predictor of significant stenosis (hazards ratio, 7.71; 95% confidence interval, 3.06-19.46). The annual rate of thrombosis fluctuated from 0 to 0.26 thromboses/patient/year, with an average rate of 0.14 thromboses/patient/year. Primary, primary-assisted, and secondary patency were 74%/79%/82%, 50%/60%/66%, and 23%/35%/37% at 1, 2, and 5 years, respectively. CONCLUSION The implementation of a systematic graft follow-up protocol combined with monitoring and surveillance enabled early diagnosis and elective correction of significant stenosis, prolonged graft patency, and a low thrombosis rate.
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Affiliation(s)
| | - Rosa Marchante
- Department of Nephrology, Hospital Ruber Juan Bravo, Madrid, Spain
| | - Israel J Thuissard
- School of Doctoral Studies and Research, Universidad Europea, Madrid, Spain
| | - David Sanz-Rosa
- School of Doctoral Studies and Research, Universidad Europea, Madrid, Spain
| | - Raquel Amann
- Department of Nephrology, Hospital Ruber Juan Bravo, Madrid, Spain
| | | | - Ramón Delgado
- Department of Nephrology, Hospital Ruber Juan Bravo, Madrid, Spain
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Drouven JW, de Bruin C, van Roon AM, Oldenziel J, Zeebregts CJ. Outcomes of basilic vein transposition versus polytetrafluoroethylene forearm loop graft as tertiary vascular access. J Vasc Surg 2019; 69:1180-1186. [DOI: 10.1016/j.jvs.2018.06.220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 06/07/2018] [Indexed: 10/28/2022]
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Tam K, Wu M, Siddiqui FJ, Chan ESY, Zhu Y, Jafar TH. Omega-3 fatty acids for dialysis vascular access outcomes in patients with chronic kidney disease. Cochrane Database Syst Rev 2018; 11:CD011353. [PMID: 30480758 PMCID: PMC6517057 DOI: 10.1002/14651858.cd011353.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Maintaining long-term vascular access patency is necessary for high quality haemodialysis (HD) treatment of patients with the terminal and most serious stage of chronic kidney disease (CKD) - end-stage kidney disease (ESKD). Oral supplementation with omega-3 fatty acids (ω-3FA) may help to prevent blockage of the vascular access by reducing the risk of thrombosis and stenosis. OBJECTIVES To evaluate the efficacy and safety of ω-3FA supplementation versus placebo or no treatment for maintaining vascular access patency in ESKD patients undergoing HD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 23 July 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) of omega-3 fatty acids versus placebo that assessed the patency of arteriovenous fistula (AVF) or arteriovenous graft (AVG) types of vascular access in ESKD patients. DATA COLLECTION AND ANALYSIS We assessed the risk of bias of each eligible study using the Cochrane Risk of Bias tool and made separate overall risk of bias judgments for the efficacy and safety outcomes. The certainty of evidence was assessed using the GRADE approach. The primary efficacy outcome was loss of vascular patency and the primary safety outcomes were occurrences of serious adverse events (e.g. death, hospitalisation, cardiovascular events, major bleeding). Secondary outcomes were the occurrence of non-serious adverse events (e.g. minor bleeding, gastrointestinal events and other adverse events). Efficacy effects were reported as risk ratios (RR) and safety effects as risk differences (RD) with 95% confidence intervals (CI). Studies were pooled separately by type of vascular access using a random-effects model. MAIN RESULTS Five studies (833 participants) were included; one was a very small pilot study of 7 participants. All studies compared oral ω-3FA supplements against placebo. Four studies enrolled participants with arteriovenous grafts (AVGs), and the other had participants with arteriovenous fistulas (AVFs). The risk of bias for both efficacy and safety outcomes was unclear for all studies, due mainly to incomplete reporting for allocation concealment and incompleteness of study follow-up.In AVF patients, ω-3FA supplementation probably makes little or no difference to the 12-month risk of patency loss (1 study, 536 participants: RR 1.01, 95% CI 0.84 to 1.21; moderate certainty evidence), risk of death (1 study, 567 participants: RD 0.00, 95% CI -0.03 to 0.02; moderate certainty evidence) and risk of hospitalisation (1 study, 567 participants: RD 0.00, 95% CI -0.08 to 0.08; low certainty evidence). There was no information on cardiovascular events and major bleeding.In AVG patients, it is very uncertain whether ω-3FA supplementation reduces the risk of patency loss within 6 months (2 studies, 41 participants: RR 0.91, 95% CI 0.36 to 2.28; very low certainty evidence) or 12 months (2 studies, 220 participants: RR 0.59, 95% CI 0.27 to 1.31; very low certainty evidence). ω-3FA supplementation may make little or no difference to the risk of death within 6 to 12 months in AVG patients (4 studies, 261 participants: RD 0.01, 95% CI -0.05 to 0.07; low certainty evidence). It is very uncertain if ω-3FA supplementation increases the risk of hospitalisation (3 studies, 65 participants: RD 0.08, 95% CI -0.11 to 0.28; very low certainty evidence), changes the risk of cardiovascular events (4 studies, 261 participants: RD -0.02, 95% CI -0.11 to 0.07; very low certainty evidence), or increases the risk of major bleeding (3 studies, 65 participants: RD 0.08, 95% CI -0.11 to 0.28; very low certainty evidence) within 6 to 12 months in AVG patients. There may be an increase in the risk of mild gastrointestinal adverse reactions (3 studies, 65 participants: RD 0.25, 95% CI 0.07 to 0.43; low certainty evidence) such as a sensation of bloatedness, gas or a fishy aftertaste. AUTHORS' CONCLUSIONS In CKD patients with an AVF, there is moderate certainty that ω-3FA supplementation makes little or no difference to preventing patency loss; and in patients with an AVG, it is very uncertain that ω-3FA supplementation prevents patency loss within 12 months.
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Affiliation(s)
- Ka‐Wai Tam
- Taipei Medical University‐Shuang Ho HospitalDivision of General Surgery, Department of Surgery291, Zhongzheng Road, Zhonghe DistrictNew Taipei CityTaiwan23561
- School of Medicine, College of Medicine, Taipei Medical UniversityDivision of General Surgery, Department of SurgeryTaipeiTaiwan
| | - Mei‐Yi Wu
- Taipei Medical University‐Shuang Ho HospitalDivision of Nephrology, Department of Internal Medicine291 Jhongjheng RdJhonghe DistrictNew Taipei CityTaiwan23561
- School of Medicine, College of Medicine, Taipei Medical UniversityDivision of Nephrology, Department of Internal MedicineTaipeiTaiwan
| | - Fahad Javaid Siddiqui
- The Hospital for Sick Children (SickKids)Centre for Global Child Health686 Bay StTorontoOntarioCanadaM5G 1X8
- Duke NUS Graduate Medical SchoolHealth Services & Systems Research ProgramSingaporeSingapore
| | - Edwin SY Chan
- Singapore Clinical Research InstituteCochrane SingaporeNanos Building #02‐0131 Biopolis WaySingaporeSingapore138669
| | - Yanan Zhu
- A*STARSingapore Institute of Clinical Sciences61 Compassvale Bow, #08‐21SingaporeSingapore544989
| | - Tazeen H Jafar
- Duke NUS Graduate Medical SchoolHealth Services & Systems Research ProgramSingaporeSingapore
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Wagner JK, Dillavou E, Nag U, Ali AA, Truong S, Chaer R, Hager E, Yuo T, Makaroun M, Avgerinos ED. Immediate-access grafts provide comparable patency to standard grafts, with fewer reinterventions and catheter-related complications. J Vasc Surg 2018; 69:883-889. [PMID: 30528400 DOI: 10.1016/j.jvs.2018.06.204] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND No independent comparisons, with midterm follow-up, of standard arteriovenous grafts (SAVGs) and immediate-access arteriovenous grafts (IAAVGs) exist. The goal of this study was to compare "real-world" performance of SAVGs and IAAVGs. METHODS Consecutive patients who underwent placement of a hemodialysis graft between November 2014 and April 2016 were retrospectively identified from the electronic medical record and Vascular Quality Initiative database at two tertiary centers. Only primary graft placements were included for analysis. Patients were divided into two groups based on the type of graft implanted. Patients' comorbidities, graft configuration, operative characteristics, and follow-up were collected and analyzed with respect to primary and secondary patency. Additional outcomes included graft-related complications, time to first cannulation, time to tunneled catheter removal, catheter-related complications, and overall survival. Patency was determined from the time of the index procedure; χ2, Kaplan-Meier, and Cox regression analyses were used, with the P value set as significant at < .05. RESULTS There were 210 grafts identified, 148 SAVGs and 62 IAAVGs. At baseline, the patients' characteristics were similar between groups, except for a greater prevalence of preoperative central venous occlusions in the IAAVG group (16.3% vs 6.8%; P < .04). Of the IAAVG group, 50 were Acuseal (W. L. Gore & Associates, Flagstaff, Ariz) and 12 were Flixene (Atrium Medical Corporation, Hudson, NH). Primary patency was similar at both 1 year (SAVG, 39.4%; IAAVG, 56.7%; P = .4) and 18 months (SAVG, 29.0%; IAAVG, 43.7%; P = .4). Secondary patency was similar at 1 year (SAVG, 50.7%; IAAVG, 52.1%; P = .73) and 18 months (SAVG, 42.3%; IAAVG, 46.3%; P = .73). Overall survival was 48% at 24 months. IAAVG patients required fewer overall additional procedures to maintain patency (mean number of procedures, 0.99 for SAVGs vs 0.61 for IAAVGs; P = .025). There was no difference in occurrence of steal syndrome (SAVG, 6.8%; IAAVG, 8.1%; P = .74) or graft infection (SAVG, 19.0%; IAAVG, 12.0%; P = .276). Seventy-five percent of all grafts were successfully cannulated, with shorter median time to first cannulation in the IAAVG group (6 days; interquartile range [IQR], 1-19 days) compared with the SAVG group (31 days; IQR, 26-47 days; P < .01). Of all pre-existing catheters, 65.75% were removed, with a shorter median time until catheter removal in the IAAVG cohort at 34 days (IQR, 22-50 days) vs 49 days (IQR, 39-67 days) in the SAVG group (P < .01). Catheter-related complications occurred less frequently in the IAAVG group (16.4% vs 2.9%; P < .045). CONCLUSIONS IAAVGs allow earlier cannulation and tunneled catheter removal, thereby significantly decreasing catheter-related complications. Patency and infection rates were similar between SAVGs and IAAVGs, but fewer secondary procedures were performed in IAAVGs.
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Affiliation(s)
- Jason K Wagner
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Ellen Dillavou
- Division of Vascular Surgery, Duke University Medical Center, Durham, NC
| | - Uttara Nag
- Division of Vascular Surgery, Duke University Medical Center, Durham, NC
| | - Adham Abou Ali
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Sandra Truong
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Eric Hager
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Theodore Yuo
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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10
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Spanish Clinical Guidelines on Vascular Access for Haemodialysis. Nefrologia 2018; 37 Suppl 1:1-191. [PMID: 29248052 DOI: 10.1016/j.nefro.2017.11.004] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/21/2017] [Indexed: 12/26/2022] Open
Abstract
Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.
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Current Experience and Midterm Follow-up of Immediate-Access Arteriovenous Grafts. Ann Vasc Surg 2018; 53:123-127. [PMID: 30012446 DOI: 10.1016/j.avsg.2018.04.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 04/08/2018] [Accepted: 04/19/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND No independent reviews, with midterm follow-up, of current experience with immediate-access arteriovenous grafts (IAAVGs) exist. The goal of this project was to assess the real-world performance of 2 different IAAVGs over a 2-year period at a large tertiary referral center. METHODS Between January 2014 and April 2016, all consecutive patients who underwent placement of Acuseal (Gore) or Flixine (Maquet) IAAVGs were identified for retrospective analysis from the electronic medical record and Vascular Quality Initiative database. Primary, primary-assisted and secondary patency rates, time to first cannulation, time to tunneled catheter removal, and overall survival were recorded. RESULTS Forty-three patients were identified to have undergone placement of IAAVG, 31 Acuseal (72%), and 12 Flixine (28%). Of the Acuseal cohort, 7 were implanted with outflow through a HeRO catheter system (Merit Medical). Mean follow-up time was 8.4 months. Overall survival was 57.4% at 18 months. Overall primary, primary assisted, and secondary patency at 18 months were 33.36%, 34.31%, and 51.03%, respectively. Eighty three percent of grafts were successfully cannulated, and 78% of preexisting catheters were removed. Mean time to successful graft cannulation and catheter removal were 14.85 and 32.26 days, respectively. CONCLUSIONS Real-world experience with novel arteriovenous access grafts is consistent with results from industry-sponsored studies. Early cannulation of immediate-access grafts can be successfully performed in a wide variety of patients. However, prolonged catheter dwell times persist despite increased rates of successful early-graft cannulation. Further study of methods for promoting catheter removal in this patient population is warranted.
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Woo K, Ulloa J, Allon M, Carsten CG, Chemla ES, Henry ML, Huber TS, Lawson JH, Lok CE, Peden EK, Scher L, Sidawy A, Maggard-Gibbons M, Cull D. Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure. J Vasc Surg 2017; 65:1089-1103.e1. [PMID: 28222990 DOI: 10.1016/j.jvs.2016.10.099] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes. METHODS The RAND/UCLA Appropriateness Method was used. Accordingly, a comprehensive literature search was performed and a synthesis of results compiled. The RAND/UCLA Appropriateness Method was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts rated the appropriateness of each scenario in two rounds. On the basis of the distribution of the panelists' scores, each scenario was determined to be appropriate, inappropriate, or indeterminate. RESULTS Panelists achieved agreement in 2964 (77.7%) scenarios; 860 (41%) AVF and 588 (34%) AVG scenarios were scored appropriate, 686 (33%) AVF and 480 (28%) AVG scenarios were scored inappropriate, and 542 (26%) AVF and 660 (38%) AVG scenarios were indeterminate. Younger age, larger outflow vein diameter, normal or obese body mass index (vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with AVF or AVG appropriateness. Dialysis status was not associated with AVF appropriateness. Body mass index and functional status were not associated with AVG appropriateness. To simulate the surgeon's decision-making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. Of these 864 clinical situations, 311 (36%) were rated appropriate for AVG but inappropriate or indeterminate for AVF. CONCLUSIONS The results of this study indicate that patient-specific situations exist wherein AVG is as appropriate as or more appropriate than AVF. These results provide patient-specific recommendations for clinicians to optimize vascular access selection criteria, to standardize care, and to inform payers and policy. Indeterminate scenarios will guide future research.
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Affiliation(s)
- Karen Woo
- Division of Vascular Surgery, David Geffen School of Medicine, University of California, Los Angeles, Calif.
| | - Jesus Ulloa
- Department of Surgery, UCSF School of Medicine, University of California, San Francisco, Calif
| | - Michael Allon
- Division of Nephrology, University of Alabama School of Medicine, University of Alabama, Birmingham, Ala
| | - Christopher G Carsten
- Division of Vascular Surgery, University of South Carolina School of Medicine, University of South Carolina, Greenville, SC
| | - Eric S Chemla
- St. George's University Hospitals NHS Foundation Trust Vascular Institute, St. George's University, London, United Kingdom
| | - Mitchell L Henry
- Division of Transplantation Surgery, The Ohio State University College of Medicine, The Ohio State University, Columbus, Ohio
| | - Thomas S Huber
- Division of Vascular Surgery, University of Florida College of Medicine, University of Florida, Gainesville, Fla
| | - Jeffrey H Lawson
- Division of Vascular Surgery, Duke University School of Medicine, Duke University, Durham, NC
| | - Charmaine E Lok
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eric K Peden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Tex
| | - Larry Scher
- Department of Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Anton Sidawy
- Division of Vascular Surgery, George Washington School of Medicine and Health Sciences, George Washington University, Washington, D.C
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Calif
| | - David Cull
- Division of Vascular Surgery, University of South Carolina School of Medicine, University of South Carolina, Greenville, SC
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Vascular access for incident hemodialysis patients in Catalonia: analysis of data from the Catalan Renal Registry (2000-2011). J Vasc Access 2015; 16:472-9. [DOI: 10.5301/jva.5000410] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2015] [Indexed: 11/20/2022] Open
Abstract
Purpose Arteriovenous fístula is the best vascular access (VA) for hemodialysis. We analyzed the VA used at first session and the factors associated with the likelihood to start hemodialysis by fistula in 2000-2011. Methods Data of VA type were obtained in 9,956 incident hemodialysis patients from the Catalan Registry. Results Overall, 47.9% of patients initiated hemodialysis with a fistula, 1.2% with a graft, 15.9% with a tunneled catheter and 35% with an untunneled catheter. The percentage of incident patients with fistula and catheter has remained stable at around 50% over the years. The likelihood to start hemodialysis with fistula was significantly lower in females [adjusted odds ratio: 0.69, 95% confidence interval (CI): 0.61-0.75], patients aged 18-44 years (0.78, 95% CI: 0.64-0.94), patients with comorbidity (0.67, 95% CI: 0.60-0.75) and tended to be lower in patients aged over 74 years (0.89, 95% CI: 0.78-1.01). The probability to use fistula was significantly higher in patients with polycystic kidney disease (2.08, 95% CI: 1.63-2.67), predialysis nephrology care longer than 2 years (4.14, 95% CI: 3.63-4.73) and steady chronic kidney disease (CKD) progression (10.97, 95% CI: 8.41-14.32). During 1 year of follow-up, 67.2% and 59.6% of patients using untunneled and tunneled catheter changed to fistula, respectively. Conclusions Starting hemodialysis by fistula was related with nonmodifiable patient characteristics and modifiable CKD practice processes, such as predialysis care duration. Half of the incident patients were exposed annually in Catalonia to potential catheter complications. This scenario can be improved by optimizing the processes of CKD care.
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14
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Preferred haemodialysis vascular access for diabetic chronic kidney disease patients: a systematic literature review. J Vasc Access 2015; 16:259-64. [PMID: 25656252 DOI: 10.5301/jva.5000323] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Vascular access problems are one of the main concerns in the diabetic end-stage kidney disease (ESKD) population. However, the optimal strategy for the establishment of vascular access in this population remains to be solved. We performed a systematic review in order to clarify the most advisable approach of vascular access planning in diabetic patients with ESKD. METHODS MEDLINE, EMBASE and CENTRAL databases were searched for English-language articles without time restriction through focused, high-sensitive search strategies. We included all studies providing outcome data on diabetics starting chronic haemodialysis treatment on the basis of the type of primary placed vascular access. RESULTS A total of 13 studies comprising over 2,800 participants with diabetes were reviewed in detail and included in the review. We found that diabetic patients using a dialysis catheter apparently experience a higher risk of death and infection compared with patients who successfully achieved and maintained an arteriovenous fistula as dialysis access. The comparison between the use of a graft or an autogenous fistula as dialysis access generated conflicting results. Primary patency rates appeared to be lower in diabetics versus non-diabetics. CONCLUSIONS Our study suggests that diabetic ESKD patients with dialysis catheters incur a higher risk of death in comparison to those who achieve an arteriovenous access. It is however unclear whether this is caused by residual selection bias or by a true advantage of native vascular access.
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15
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Wu MY, Tam KW, Siddiqui FJ, Chan ESY, Jafar T. Omega-3 fatty acids for vascular access outcomes in patients with chronic kidney disease. Hippokratia 2014. [DOI: 10.1002/14651858.cd011353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mei-Yi Wu
- Taipei Medical University-Shuang Ho Hospital; Department of Nephrology; 291 Jhongjheng Rd Jhonghe District New Taipei City Taiwan 23561
| | - Ka-Wai Tam
- Taipei Medical University-Shuang Ho Hospital; Department of Surgery; 291, Zhongzheng Road, Zhonghe District New Taipei City Taiwan 23561
| | - Fahad Javaid Siddiqui
- Duke-NUS Graduate Medical School; Centre for Quantitative Medicine, Office of Clinical Sciences; Academia, #06-69, 20, College Road Singapore Singapore 169856
| | - Edwin SY Chan
- Singapore Clinical Research Institute; Epidemiology; Nanos Building #02-01 31 Biopolis Way Singapore Singapore 138669
| | - Tazeen Jafar
- Duke NUS Graduate Medical School; Health Services & Systems Research Program; Singapore Singapore
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16
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Ankle fistula as the last resort for vascular access: case report and literature review. J Vasc Access 2014; 16:68-71. [PMID: 25198823 DOI: 10.5301/jva.5000296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2014] [Indexed: 11/20/2022] Open
Abstract
PURPOSE For the majority of patients with end-stage renal failure, renal replacement therapy in the form of dialysis offers the only means of life prolongation. Survival times on haemodialysis have improved, and consequently, patent vascular access is required for an increasing period of time. Upper extremity options for arteriovenous placement are increasingly being exhausted, leading to creation of fistulae in the lower extremities. METHODS We describe the management of a patient with superior vena cava obstruction requiring haemodialysis in whom venous access options were becoming very limited. An ankle fistula was formed by anastomosing great saphenous vein (GSV) to dorsalis pedis. CONCLUSION The long-term patency of lower limb fistulae remains unclear. An ankle fistula preserves precious venous capital in patients who have no remaining options in the upper extremities for haemodialysis access. Furthermore, it allows for proximal revision if necessary. This serves to prolong the time spent dialysing through native fistulae, with their reduced complications and greater cost-effectiveness.
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Prologo JD, Minwell G, Kent J, Pirasteh A, Corn D. Effect of the time to intervention on the outcome of thrombosed dialysis access grafts managed percutaneously. Diagn Interv Radiol 2013; 20:143-6. [PMID: 24356296 DOI: 10.5152/dir.2013.13296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to investigate the effect of the time interval from the clinical presentation of a thrombosed dialysis access graft to intervention on procedure success. MATERIALS AND METHODS Records from two academic institutions for patients who underwent percutaneous thrombectomy of occluded surgical hemodialysis graft access sites in interventional radiology from 2006 to 2011 were reviewed retrospectively. The following data were recorded: gender, age, time and date of the initial request for a thrombectomy and the procedure, age of the surgical access, angiographic outcome, and clinical outcome (successful or unsuccessful postinterventional dialysis). Univariate and multivariate logistic regression were used to evaluate whether the time to intervention significantly affected the study endpoint. RESULTS In total, 268 percutaneous thrombectomies were performed in 139 patients. Of these 224 (83.5%) were categorized as successful and 44 (16.4%) as unsuccessful. The time to intervention was 19.9±30.1 vs. 22±35 hours for successful and unsuccessful procedures, respectively. The difference between the two was not significant, and there were also no significant differences in covariate distributions between successful and unsuccessful outcomes. CONCLUSION During the first 72 hours following clinical presentation of a thrombosed dialysis access graft, time to intervention may be considered independent of procedure outcome.
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Affiliation(s)
- John David Prologo
- From the Department of Radiology (J.D.P. e-mail: ), University Hospitals of Cleveland, Cleveland, Ohio, USA; The Division of Vascular and Interventional Radiology (J.D.P.), Urological Institute, Anesthesia Pain Management, and the National Center for Regenerative Medicine, and the Departments of Radiology (J.K., A.P.), and Biomedical Engineering (D.C.), University Hospitals Case Medical Center, Cleveland, Ohio, USA; the Department of Radiology (G.M.), Johns Hopkins Medical Center, Baltimore, Maryland, USA
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