Influence of surgeons' specialty on the selection of vascular access for hemodialysis treatment

What is the best training for vascular access surgery?

Questions have been raised whether there is a lack of appropriate training in access creation and maintenance, and if training juniors in arteriovenous (AV) fistulas may affect the outcome. A survey was undertaken to study "experts" opinion in access training using a closed questionnaire. The majority of "experts" consented that there is a lack of appropriate training in access creation and maintenance in a great extent, although they located the main deficit regarding access training in the preoperative planning and decision making. Regarding the second question, a literature search revealed only four studies, comparing the outcomes of AV fistulas created either by consultant surgeons or trainees. A meta-analysis performed revealed that 1-year patency rate was not statistically significant different among access procedures created either by consultants or trainees. Access surgery shares the same basic principles with vascular surgery and provides a valuable workload for the trainees and is a necessity to become a building component in all "core" vascular curricula; the required skills can be acquired with the trainees operating independently simple cases, as the latter is not leading to suboptimal outcomes.

Thrombolysis with alteplase: a non-invasive treatment for occluded arteriovenous fistulas and grafts

Thrombolysis with recombinant tissue type plasminogen activator (t-PA) has been successfully used in occluded arteriovenous (AV) hemodialysis grafts and tunneled catheters, especially as an adjunctive regimen to invasive or semi-invasive procedures. We performed a retrospective study to evaluate the effectiveness and outcomes of thrombolysis with t-PA in occluded AV hemodialysis accesses. We used low doses of t-PA in 40 cases of thrombosed AV fistulas and grafts. Primary success was noted in 55% of the cases ensuring patency rates of 30 and 90 days at 90.9 and 69.8%, respectively. Inflammation (increased C-reactive protein concentration) and shorter functioning time of AV access were independently associated with primary outcome, whereas there was no difference in outcome between AV fistulas or grafts. No major complications were noted. We conclude that the use of t-PA is a safe and easy treatment for clotted AV accesses that can be applied in an outpatient setting.

Enhanced training in vascular access creation predicts arteriovenous fistula placement and patency in hemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study

OBJECTIVE

To investigate whether intensity of surgical training influences type of vascular access placed and fistula survival.

SUMMARY BACKGROUND DATA

Wide variations in fistula placement and survival occur internationally. Underlying explanations are not well understood.

METHODS

Prospective data from 12 countries in the Dialysis Outcomes and Practice Patterns Study were analyzed; outcomes of interest were type of vascular access in use (fistula vs. graft) in hemodialysis patients at study entry and time from placement until primary and secondary access failures, as predicted by surgical training. Logistic and Cox regression models were adjusted for patient characteristics and time on hemodialysis.

RESULTS

During training, US surgeons created fewer fistulae (US mean = 16 vs. 39-426 in other countries) and noted less emphasis on vascular access placement compared with surgeons elsewhere. Significant predictors of fistula versus graft placement in hemodialysis patients included number of fistulae placed during training (adjusted odds ratio [AOR] = 2.2 for fistula placement, per 2 times greater number of fistulae placed during training, P < 0.0001) and degree of emphasis on vascular access creation during training (AOR = 2.4 for fistula placement, for much-to-extreme emphasis vs. no emphasis, P = 0.0008). Risk of primary fistula failure was 34% lower (relative risk = 0.66, P = 0.002) when placed by surgeons who created > or = 25 (vs. < 25) fistulae during training.

CONCLUSIONS

Surgical training is key to both fistula placement and survival, yet US surgical programs seem to place less emphasis on fistula creation than those in other countries. Enhancing surgical training in fistula creation would help meet targets of the Fistula First Initiative.

Approach to patients with "complex" hemodialysis access problems

The approach to patients with "complex" permanent hemodialysis (HD) access problems remains poorly defined. The purpose of this review is to outline our current algorithm for patients presenting for dialysis access and to address the management of specific problems that complicate this objective of establishing permanent access. The key components of the algorithm include noninvasive imaging in the diagnostic vascular laboratory to determine all the possible access configurations and invasive imaging with both venography and arteriography to confirm the optimal choice. The specific access-related problems addressed include inadequate ipsilateral vein, inadequate arterial inflow, central vein stenosis/occlusion, multiple previous access failures, and obesity. Despite the label of "complex" access problems, it is possible to construct native arteriovenous fistulas (AVFs) in almost all patients presenting for access using the standard principles of vascular surgery that are based on establishing adequate arterial inflow, adequate venous outflow, and selecting an appropriate conduit.