1
|
Northrup H, He Y, Berceli S, Cheung AK, Shiu YT. Arteriovenous Fistula Histology, Hemodynamics, and Wall Mechanics: A Case Report of Successful and Failed Access in a Single Patient. Kidney Med 2024; 6:100801. [PMID: 38562969 PMCID: PMC10982562 DOI: 10.1016/j.xkme.2024.100801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
The low 1-year patency rate of mature arteriovenous fistulas (AVFs) remains a significant clinical problem. Although vessel properties and biomechanics have been suggested to affect AVF function, understanding their roles in AVF patency failure is challenging owing to the heterogeneity within the patient population, including demographics and comorbid conditions. In this study, we present a case of a patient with 2 upper-arm AVFs with different 1-year patency outcomes and investigate whether they had different histologic features before the AVF creation surgery and biomechanics at 1 day and 6 weeks after the AVF creation surgery using magnetic resonance imaging-based fluid structure interaction simulations. Despite both AVFs being in the upper arm, created <1 year apart by the same surgeon, and having similar preoperative vessel diameters, the 1-year patent AVF had less preoperative intimal collagen and higher wall shear stress 1 day after AVF creation, when compared with the AVF that failed by 1 year. Thus, a low intimal collagen content before the AVF surgery and higher wall shear stress immediately after the AVF creation surgery may be important for long-term AVF patency and should be investigated with larger cohorts.
Collapse
Affiliation(s)
- Hannah Northrup
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Yong He
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Scott Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Alfred K. Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT
| |
Collapse
|
2
|
Chen JW, Ting M, Chang PY, Jung CJ, Chang CH, Fang SY, Liu LW, Yang KJ, Yu SH, Chen YS, Chi NH, Hsu RB, Wang CH, Wu IH, Yu HY, Chan CY. Computer-assisted image analysis of preexisting histological patterns of the cephalic vein to predict wrist arteriovenous fistula non-maturation. J Formos Med Assoc 2024:S0929-6646(24)00149-9. [PMID: 38492985 DOI: 10.1016/j.jfma.2024.03.004] [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: 07/17/2023] [Revised: 01/07/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND We used computer-assisted image analysis to determine whether preexisting histological features of the cephalic vein influence the risk of non-maturation of wrist fistulas. METHODS This study focused on patients aged 20-80 years who underwent their first wrist fistula creation. A total of 206 patients participated, and vein samples for Masson's trichrome staining were collected from 134 patients. From these, 94 patients provided a complete girth of the venous specimen for automatic image analysis. Maturation was assessed using ultrasound within 90 days after surgery. RESULTS The collagen to muscle ratio in the target vein, measured by computer-assisted imaging, was a strong predictor of non-maturation in wrist fistulas. Receiver operating characteristic analysis revealed an area under the curve of 0.864 (95% confidence interval of 0.782-0.946, p < 0.001). The optimal cut-off value for the ratio was 1.138, as determined by the Youden index maximum method, with a sensitivity of 89.0% and specificity of 71.4%. For easy application, we used a cutoff value of 1.0; the non-maturation rates for patients with ratios >1 and ≤ 1 were 51.7% (15 out of 29 patients) and 9.2% (6 out of 65 patients), respectively. Chi-square testing revealed significantly different non-maturation rates between the two groups (X2 (1, N = 94) = 20.9, p < 0.01). CONCLUSION Computer-assisted image interpretation can help to quantify the preexisting histological patterns of the cephalic vein, while the collagen-to-muscle ratio can predict non-maturation of wrist fistula development at an early stage.
Collapse
Affiliation(s)
- Jeng-Wei Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Mao Ting
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Po-Ya Chang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiau-Jing Jung
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Shi-Yu Fang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Wei Liu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Kelvin Jeason Yang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sz-Han Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Nai-Hsin Chi
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ron-Bin Hsu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hsien Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Hui Wu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsi-Yu Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yang Chan
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
| |
Collapse
|
3
|
Laboyrie SL, de Vries MR, Bijkerk R, Rotmans JI. Building a Scaffold for Arteriovenous Fistula Maturation: Unravelling the Role of the Extracellular Matrix. Int J Mol Sci 2023; 24:10825. [PMID: 37446003 DOI: 10.3390/ijms241310825] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Vascular access is the lifeline for patients receiving haemodialysis as kidney replacement therapy. As a surgically created arteriovenous fistula (AVF) provides a high-flow conduit suitable for cannulation, it remains the vascular access of choice. In order to use an AVF successfully, the luminal diameter and the vessel wall of the venous outflow tract have to increase. This process is referred to as AVF maturation. AVF non-maturation is an important limitation of AVFs that contributes to their poor primary patency rates. To date, there is no clear overview of the overall role of the extracellular matrix (ECM) in AVF maturation. The ECM is essential for vascular functioning, as it provides structural and mechanical strength and communicates with vascular cells to regulate their differentiation and proliferation. Thus, the ECM is involved in multiple processes that regulate AVF maturation, and it is essential to study its anatomy and vascular response to AVF surgery to define therapeutic targets to improve AVF maturation. In this review, we discuss the composition of both the arterial and venous ECM and its incorporation in the three vessel layers: the tunica intima, media, and adventitia. Furthermore, we examine the effect of chronic kidney failure on the vasculature, the timing of ECM remodelling post-AVF surgery, and current ECM interventions to improve AVF maturation. Lastly, the suitability of ECM interventions as a therapeutic target for AVF maturation will be discussed.
Collapse
Affiliation(s)
- Suzanne L Laboyrie
- Department of Internal Medicine, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
| | - Margreet R de Vries
- Department of Surgery and the Heart and Vascular Center, Brigham & Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
- Department of Vascular Surgery, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
| | - Roel Bijkerk
- Department of Internal Medicine, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
| |
Collapse
|
4
|
Gan W, Shao D, Xu L, Tuo Y, Mao H, Wang W, Xiao W, Xu F, Huang X, Chen W, Zeng X. Maturation and survival of arteriovenous fistula: The challenge starts from the preoperative assessment stage. Semin Dial 2021; 35:228-235. [PMID: 34734660 DOI: 10.1111/sdi.13036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/27/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND It is necessary to assess the association between the preoperative indicators and the maturation and survival of arteriovenous fistula (AVF). METHODS We retrospectively identified 236 patients with a new AVF created between 2016 and 2018 in our Dialysis Center. RESULTS Multivariate Logistic regression showed that preoperative arterial diameter (odds ratio [OR] = 1.452, 95% confidence interval [CI] [1.233, 1.710], p < 0.001), preoperative venous diameter (OR = 1.296, 95% CI [1.166, 1.477], p < 0.001), left ventricular ejection fraction (LVEF) (OR = 1.187, 95% CI [1.103, 1.277], p < 0.001), and diabetes mellitus (OR = 0.245, 95% CI [0.107, 0.560], p = 0.01) were independent influential factors for AVF maturation. Two years after the AVF surgery follow-up, multivariate Cox proportional-hazards model showed that the preoperative arterial diameter (OR = 0.510, 95% CI [0.320, 0.813], p = 0.005), preoperative venous diameter (OR = 0.940, 95% CI [0.897, 0.985], p = 0.010) and diabetes mellitus (OR = 1.785, 95% CI [1.117, 2.855], p = 0.016) was prognostic factors of AVF survival. The Kaplan-Meier method showed that the primary survival of AVF in patients with different preoperative arterial diameter was statistically significant (log-rank χ2 = 15.415, p < 0.001), while the secondary survival was not statistically significant (log-rank χ2 = 0.131, p = 0.717). CONCLUSION In our cohort, the preoperative arterial and venous diameter and diabetes mellitus were independent influential factors for AVF maturation and prognostic factors of AVF survival. However, the preoperative LVEF only associated with the maturation of AVF. Meanwhile, smaller arterial diameter (≤2.15 mm) was associated with AVF maturation failure, but did not impact secondary survival of AVF.
Collapse
Affiliation(s)
- Wenyuan Gan
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Danni Shao
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Xu
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanhong Tuo
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huihui Mao
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenzhe Wang
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Xiao
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fang Xu
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaomei Huang
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenli Chen
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xingruo Zeng
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
5
|
Shiu YT, He Y, Tey JCS, Knysheva M, Anderson B, Kauser K. Natural Vascular Scaffolding Treatment Promotes Outward Remodeling During Arteriovenous Fistula Development in Rats. Front Bioeng Biotechnol 2021; 9:622617. [PMID: 33681159 PMCID: PMC7928390 DOI: 10.3389/fbioe.2021.622617] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
Following creation, an arteriovenous fistula (AVF) must mature (i.e., enlarge lumen to allow high blood flow) before being used for hemodialysis. AVF maturation failure rates are high, and currently, there are no effective therapy to treat this problem. The maturation process is likely affected by the integrity of the vascular extracellular matrix (ECM). Natural Vascular Scaffolding (NVS) Therapy is a new technology that interlinks collagen and elastin via photoactivation of a locally delivered small molecule (4-amino-1,8-naphtalamide). We hypothesized that NVS Therapy may improve AVF remodeling by preserving ECM integrity. AVFs were created in Wistar male rats by connecting the femoral vein (end) to femoral artery (side) in the same limb. Immediately after blood flow was restored to dilate the femoral vein by arterial pressure, a 10 μl-drop of the NVS compound (2 mg/ml) was placed on the anastomosis perivascularly. Following 5-min incubation, the NVS treated area was exposed to 1-min illumination by 450-nm light. The control group received 10 μl-drop of phosphate buffered saline (PBS) and the same light activation. The skin was closed, and rats were euthanized 4 weeks (n = 6-9 per group) post-AVF creation for histology, morphometry, immunohistochemistry (IHC), and multiphoton microscopy for second-harmonic-generation evaluation of collagen fibers. The vascular thickness was similar in both groups. The AVF vein's open lumen area and % open lumen area in NVS-treated rats were significantly larger than in PBS-treated rats (4.2-fold p = 0.014 and 2-fold p = 0.009, respectively). The inflammatory markers IL-6 and MMP-9 in the AVF walls were significantly decreased in the NVS group than the PBS group. Collagen fibers in the vascular wall trended toward perpendicular alignment to the lumen circumference in the NVS-treated AVFs, with more defined shape but less area than in the PBS-treated AVFs. These results indicate that the NVS Therapy exerted changes in collagen, which may influence AVF maturation. Rats tolerated the NVS treatment well, and the lack of cell death by the treatment was confirmed in cell culture experiments. These results suggest that NVS treatment is safe and may have therapeutic potential by facilitating lumen expansion to enhanced AVF maturation in patients.
Collapse
Affiliation(s)
- Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, UT, United States.,Veterans Affairs Medical Center, Salt Lake City, UT, United States
| | - Yuxia He
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Jason C S Tey
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Marina Knysheva
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Blake Anderson
- Alucent Biomedical Inc., Salt Lake City, UT, United States
| | - Katalin Kauser
- Alucent Biomedical Inc., Salt Lake City, UT, United States
| |
Collapse
|
6
|
Pisoni RL, Zepel L, Zhao J, Burke S, Lok CE, Woodside KJ, Wasse H, Kawanishi H, Schaubel DE, Zee J, Robinson BM. International Comparisons of Native Arteriovenous Fistula Patency and Time to Becoming Catheter-Free: Findings From the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2021; 77:245-254. [DOI: 10.1053/j.ajkd.2020.06.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 06/30/2020] [Indexed: 11/11/2022]
|
7
|
Koirala N, McLennan G. Blood flow quantification in dialysis access using digital subtraction angiography: A retrospective study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 190:105379. [PMID: 32050137 DOI: 10.1016/j.cmpb.2020.105379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 01/29/2020] [Accepted: 01/31/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Vascular access is the "lifeline" of end-stage renal disease patients, which is surgically constructed to remove blood-waste and return artificially filtered blood into circulation. The arteriovenous shunting causes an abrupt change in blood flow and results in increased fluidic stress, which predisposes to access stenosis and thrombosis. While access flow is crucial to evaluate interventional endpoint, application to measure flow using digital angiogram is not yet available. The goal of this study was to determine the feasibility of flow quantification in dialysis access using a software tool and to guide the design of an imaging protocol. METHODS 173 digital subtraction angiographic (DSA) images were retrospectively analyzed to evaluate access flow in a custom-programming environment. Four bolus transit time algorithms and a distance calculation method were assessed for flow computation. Gamma variate function was applied to remove secondary flow and intensity outliers in the bolus time-intensity curves and evaluated for enhancement in computational accuracy. The percent deviations of flow rates computed from dilution of iodinated radio-contrast material were compared with in situ catheter-based flow measurement. RESULTS Among the implemented bolus transit time algorithms, quantification error (mean ± standard error) of cross-correlation algorithm without and with gamma variate curve fitting was 35 ± 1% and 22 ± 1%, respectively. All other algorithms had quantification error >27%. The bias and limits of agreement of the cross-correlation algorithm with gamma variate curve fit was -94 ml/min and [-353, 165] mL/min, respectively. CONCLUSIONS The cross-correlation algorithm with gamma variate curve fit had the best accuracy and reproducibility for image-based blood flow computation. To further enhance accuracy, images may need to be acquired with a dedicated injection protocol with predetermined parameters such as the duration, rate and mode of bolus injection, and the acquisition frame rate.
Collapse
Affiliation(s)
- Nischal Koirala
- Department of Chemical and Biomedical Engineering, Cleveland State University, Cleveland, OH, USA; Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gordon McLennan
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Division of Vascular and Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
8
|
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: 34] [Impact Index Per Article: 8.5] [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.
Collapse
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
| |
Collapse
|
9
|
Martinez L, Tabbara M, Duque JC, Selman G, Falcon NS, Paez A, Griswold AJ, Ramos-Echazabal G, Hernandez DR, Velazquez OC, Salman LH, Vazquez-Padron RI. Transcriptomics of Human Arteriovenous Fistula Failure: Genes Associated With Nonmaturation. Am J Kidney Dis 2019; 74:73-81. [PMID: 30826088 PMCID: PMC10980359 DOI: 10.1053/j.ajkd.2018.12.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 12/17/2018] [Indexed: 12/16/2022]
Abstract
RATIONALE & OBJECTIVE Improving arteriovenous fistula (AVF) outcomes requires better understanding of the biology underlying maturation or failure. Our current knowledge of maturation relies on extrapolation from other vascular pathologies, which does not incorporate unique aspects of AVF remodeling. This study compares the RNA expression of pre-access (native) veins and AVFs with distinct maturation outcomes. STUDY DESIGN Case-control study. SETTING & PARTICIPANTS 64 patients undergoing 2-stage AVF surgeries at a single center. 19 native veins and 19 AVF samples were analyzed using RNA sequencing (RNA-seq). 58 native veins were studied using real-time polymerase chain reaction; 45, using immunohistochemistry; and 19, using Western blot analysis. PREDICTOR RNA expression in native veins and AVFs. OUTCOME Anatomic nonmaturation, defined as an AVF that never achieved an internal diameter ≥ 6mm. ANALYTICAL APPROACH Pre-access native veins and AVF samples were obtained from patients undergoing 2-stage AVF creation. Veins that subsequently matured or failed after access creation were analyzed using RNA-seq to search for genes associated with maturation failure. Genes associated with nonmaturation were confirmed using real-time polymerase chain reaction, immunohistochemistry, and Western blot analysis. In addition, the association between pre-access gene expression and postoperative morphology was evaluated. RNA-seq was also performed on AVFs to search for transcriptional differences between AVFs that matured and those that failed at the time of transposition. RESULTS Pro-inflammatory genes (CSF3R, FPR1, S100A8, S100A9, and VNN2) were upregulated in pre-access veins that failed (false discovery rate < 0.05), and their expression colocalized to smooth muscle cells. Expression of S100A8 and S100A9 correlated with postoperative intimal hyperplasia and the product of medial fibrosis and intimal hyperplasia (r=0.32-0.38; P < 0.05). AVFs that matured or failed were transcriptionally similar at the time of transposition. LIMITATIONS Small sample size, analysis of only upper-arm veins and transposed fistulas. CONCLUSIONS Increased expression of proinflammatory genes in pre-access veins appears to be associated with greater risk for AVF nonmaturation.
Collapse
Affiliation(s)
- Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Juan C Duque
- Division of Nephrology and Hypertension, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Guillermo Selman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY
| | - Nieves Santos Falcon
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Angela Paez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Anthony J Griswold
- John P. Hussman Institute for Human Genomics, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Gioser Ramos-Echazabal
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Diana R Hernandez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Omaida C Velazquez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Loay H Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL.
| |
Collapse
|
10
|
Gameiro J, Ibeas J. Factors affecting arteriovenous fistula dysfunction: A narrative review. J Vasc Access 2019; 21:134-147. [PMID: 31113281 DOI: 10.1177/1129729819845562] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Vascular access dysfunction is one of the most important causes of morbidity and mortality in haemodialysis patients, contributing to up to one third of hospitalisations and accounting for a significant amount of the health care costs of these patients. In the past decades, significant scientific advances in understanding mechanisms of arteriovenous fistula maturation and failure have contributed to an increase in the amount of research into techniques for creation and strategies for arteriovenous fistula dysfunction prevention and treatment, in order to improve patient care and outcomes. The aim of this review is to describe the pathogenesis of vascular access failure and provide a comprehensive analysis of the associated risk factors and causes of vascular access failure, in order to interpret possible future therapeutic approaches. Arteriovenous fistula failure is a multifactorial process resulting from the combination of upstream and downstream events with consequent venous neo-intimal hyperplasia and/or inadequate outward remodelling. Inflammation appears to be central in the biology of arteriovenous fistula dysfunction but important triggers still need to be revealed. Given the significant association of arteriovenous fistula failure and patient's prognosis, it is therefore imperative to further research in this area in order to improve prevention, surveillance and treatment, and ultimately patient care and outcomes.
Collapse
Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
| | - Jose Ibeas
- Nephrology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| |
Collapse
|
11
|
Shiu YT, Rotmans JI, Geelhoed WJ, Pike DB, Lee T. Arteriovenous conduits for hemodialysis: how to better modulate the pathophysiological vascular response to optimize vascular access durability. Am J Physiol Renal Physiol 2019; 316:F794-F806. [PMID: 30785348 PMCID: PMC6580244 DOI: 10.1152/ajprenal.00440.2018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 02/04/2019] [Accepted: 02/17/2019] [Indexed: 12/11/2022] Open
Abstract
Vascular access is the lifeline for patients on hemodialysis. Arteriovenous fistulas (AVFs) are the preferred vascular access, but AVF maturation failure remains a significant clinical problem. Currently, there are no effective therapies available to prevent or treat AVF maturation failure. AVF maturation failure frequently results from venous stenosis at the AVF anastomosis, which is secondary to poor outward vascular remodeling and excessive venous intimal hyperplasia that narrows the AVF lumen. Arteriovenous grafts (AVGs) are the next preferred vascular access when an AVF creation is not possible. AVG failure is primarily the result of venous stenosis at the vein-graft anastomosis, which originates from intimal hyperplasia development. Although there has been advancement in our knowledge of the pathophysiology of AVF maturation and AVG failure, this has not translated into effective therapies for these two important clinical problems. Further work will be required to dissect out the mechanisms of AVF maturation failure and AVG failure to develop more specific therapies. This review highlights the major recent advancements in AVF and AVG biology, reviews major clinical trials, and discusses new areas for future research.
Collapse
Affiliation(s)
- Yan-Ting Shiu
- Division of Nephrology, University of Utah , Salt Lake City, Utah
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center , Leiden , The Netherlands
| | - Wouter Jan Geelhoed
- Department of Internal Medicine, Leiden University Medical Center , Leiden , The Netherlands
| | - Daniel B Pike
- Division of Nephrology, University of Utah , Salt Lake City, Utah
| | - Timmy Lee
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham , Birmingham, Alabama
- Veterans Affairs Medical Center , Birmingham, Alabama
| |
Collapse
|
12
|
Pike D, Shiu YT, Cho YF, Le H, Somarathna M, Isayeva T, Guo L, Symons JD, Kevil CG, Totenhagen J, Lee T. The effect of endothelial nitric oxide synthase on the hemodynamics and wall mechanics in murine arteriovenous fistulas. Sci Rep 2019; 9:4299. [PMID: 30862797 PMCID: PMC6414641 DOI: 10.1038/s41598-019-40683-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 02/19/2019] [Indexed: 11/12/2022] Open
Abstract
Creation of a hemodialysis arteriovenous fistula (AVF) causes aberrant vascular mechanics at and near the AVF anastomosis. When inadequately regulated, these aberrant mechanical factors may impede AVF lumen expansion to cause AVF maturation failure, a significant clinical problem with no effective treatments. The endothelial nitric oxide synthase (NOS3) system is crucial for vascular health and function, but its effect on AVF maturation has not been fully characterized. We hypothesize that NOS3 promotes AVF maturation by regulating local vascular mechanics following AVF creation. Here we report the first MRI-based fluid-structure interaction (FSI) study in a murine AVF model using three mouse strains: NOS3 overexpression (NOS3 OE) and knockout (NOS3−/−) on C57BL/6 background, with C57BL/6 as the wild-type control (NOS3+/+). When compared to NOS3+/+ and NOS3−/−, AVFs in the OE mice had larger lumen area. AVFs in the OE mice also had smoother blood flow streamlines, as well as lower blood shear stress at the wall, blood vorticity, inner wall circumferential stretch, and radial wall thinning at the anastomosis. Our results demonstrate that overexpression of NOS3 resulted in distinct hemodynamic and wall mechanical profiles associated with favorable AVF remodeling. Enhancing NOS3 expression may be a potential therapeutic approach for promoting AVF maturation.
Collapse
Affiliation(s)
- Daniel Pike
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA.,Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA.,Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Yun-Fang Cho
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Ha Le
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Maheshika Somarathna
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tatyana Isayeva
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lingling Guo
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J David Symons
- Department of Nutrition and Integrative Physiology and Molecular Medicine Program, University of Utah, Salt Lake City, UT, USA.,Division of Endocrinology, Metabolism, and Diabetes, University of Utah, Salt Lake City, UT, USA
| | - Christopher G Kevil
- Departments of Pathology, Molecular and Cellular Physiology, and Cellular Biology and Anatomy, LSU Health Shreveport, Shreveport, LA, USA
| | - John Totenhagen
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Timmy Lee
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA. .,Veterans Affairs Medical Center, Birmingham, AL, USA.
| |
Collapse
|
13
|
Kim SM, Jung IM, Kim D, Lee JP, So YH. Effect of Inflow Arterial Calcification on Arteriovenous Fistula Maturation. Ann Vasc Surg 2019; 58:331-337. [PMID: 30769062 DOI: 10.1016/j.avsg.2018.10.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 10/23/2018] [Accepted: 10/31/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study is to investigate the effect of preexisting calcification in the inflow artery on maturation and flow volume of an arteriovenous fistula (AVF). METHODS Patients who underwent AVF creation for hemodialysis were prospectively recruited between March and November 2017. On preoperative duplex ultrasound, calcification in the arterial media within 5 cm of the planned anastomosis area was assessed. Clinical maturation was defined as the successful use of the fistula for ≥75% of the dialysis sessions during a month within 6 months after surgery. Radiological maturation was defined as a venous diameter of ≥0.4 cm and a flow volume of ≥500 mL/min. Flow volumes of the inflow artery and the cephalic vein were measured at 6 and 12 weeks after AVF creation. RESULTS Eighteen patients with calcification and 29 patients without calcification were enrolled in this study. There was no significant difference in the clinical and radiological maturation between the groups. The flow volume of the inflow artery, measured at 6 weeks postoperatively, was significantly higher in the noncalcification group than in the calcification group (P = 0.042). The flow volume of the inflow artery in the noncalcification group was increased at 12 weeks postoperatively (P = 0.091). Flow volume of the vein was higher in the noncalcification group than in the calcification group, although it did not reach statistical significance. CONCLUSIONS In conclusions, preexisting arterial calcification did not adversely affect the AVF maturation. However, arterial calcification correlated with the flow volume of the inflow artery of AVF.
Collapse
Affiliation(s)
- Suh Min Kim
- Department of Surgery, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - In Mok Jung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea.
| | - Daehwan Kim
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jung Pyo Lee
- Department of Internal medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Young Ho So
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| |
Collapse
|
14
|
Allon M, Litovsky SH, Tey JCS, Sundberg CA, Zhang Y, Chen Z, Fang Y, Cheung AK, Shiu YT. Abnormalities of vascular histology and collagen fiber configuration in patients with advanced chronic kidney disease. J Vasc Access 2019; 20:31-40. [PMID: 29742957 PMCID: PMC6212345 DOI: 10.1177/1129729818773305] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION: Several histologic features have been identified in the upper-extremity arteries and veins of patients with advanced chronic kidney disease, which may affect arteriovenous fistula maturation. However, it is unclear whether these chronic kidney disease vascular features are abnormal. METHODS: We obtained upper-extremity arterial and venous specimens from 125 advanced chronic kidney disease patients undergoing arteriovenous fistula creation and from 15 control subjects. We quantified medial fibrosis, micro-calcification, and intimal hyperplasia with appropriate histology stains. We characterized medial collagen fiber configuration in second-harmonic-generation microscopy images for the fiber anisotropy index and the dominant fiber direction. RESULTS: The advanced chronic kidney disease patients were significantly younger than control subjects (53 ± 14 years vs 76 ± 11 years, p < 0.001). After controlling for age, the chronic kidney disease patients had greater arterial medial fibrosis (69% ± 14% vs 51% ± 10%, p < 0.001) and greater arterial micro-calcification (3.03% ± 5.17% vs 0.01% ± 0.03%, p = 0.02), but less arterial intimal thickness (30 ± 25 µm vs 63 ± 25 µm, p < 0.001), as compared to control subjects. The anisotropy index of medial collagen fibers was lower in both arteries (0.24 ± 0.10 vs 0.44 ± 0.04, p < 0.001) and veins (0.28 ± 0.09 vs 0.53 ± 0.10, p < 0.001) in chronic kidney disease patients, indicating that orientation of the fibers was more disordered. The dominant direction of medial collagen fibers in chronic kidney disease patients was greater in the arteries (49.3° ± 23.6° vs 4.0° ± 2.0°, p < 0.001) and the veins (30.0° ± 19.6° vs 3.9° ± 2.1°, p < 0.001), indicating that the fibers in general were aligned more perpendicular to the lumen. CONCLUSION: Advanced chronic kidney disease is associated with several abnormalities in vascular histology and collagen fiber configuration. Future research is needed to investigate whether these abnormalities affect the maturation outcomes of arteriovenous fistulas.
Collapse
Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Silvio H. Litovsky
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jason Chieh Sheng Tey
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Chad A. Sundberg
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Yingying Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Zhen Chen
- Department of Diabetes Complications and Metabolism, Beckman Research Institute, City of Hope, Duarte, CA, USA
| | - Yun Fang
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Alfred K. Cheung
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
- Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yan-Ting Shiu
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
15
|
Allon M, Litovsky SH, Zhang Y, Le H, Cheung AK, Shiu YT. Association of Preexisting Arterial Intimal Hyperplasia with Arteriovenous Fistula Outcomes. Clin J Am Soc Nephrol 2018; 13:1358-1363. [PMID: 30139803 PMCID: PMC6140554 DOI: 10.2215/cjn.13431217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 06/18/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Preoperative arterial function is associated with arteriovenous fistula (AVF) development. Because arterial pathology may correlate with its function, preexisting arterial intimal hyperplasia may be associated with AVF development. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Vascular specimens obtained from 125 patients (with minimal 2 mm arterial diameter and 2.5 mm venous diameter) undergoing AVF creation were quantified for arterial intimal hyperplasia, arterial medial fibrosis, arterial microcalcification, and venous intimal hyperplasia. A 6-week postoperative ultrasound quantified AVF diameter, blood flow, and stenosis. Clinical AVF maturation was assessed using a predefined protocol. In a prospective cohort study design, we investigated the association of preexisting arterial intimal hyperplasia with the postoperative AVF diameter, blood flow, stenosis, and clinical maturation failure, after controlling for baseline demographics, comorbidities, and preoperative vein diameter. Additional analyses evaluated whether other vascular pathologies interacted with arterial intimal hyperplasia in affecting AVF outcomes. RESULTS The median intimal thickness of the native artery was 22.0 μm (interquartile range, 14.8-37.1 μm). The median postoperative AVF diameter was 4.8 (interquartile range, 3.7-6.8) mm, blood flow was 796 (interquartile range, 413-1036) ml/min, and stenosis was present in 37 out of 98 patients with ultrasound data (38%). AVF nonmaturation occurred in 37 out of 125 patients (30%). Preexisting arterial intimal thickness was not significantly associated with AVF blood flow (-12 ml/min; 95% confidence interval [95% CI], -55 to 30 ml/min), diameter (-0.04 mm; 95% CI, -0.21 to 0.14 mm), stenosis (odds ratio, 0.93; 95% CI, 0.75 to 1.14), or clinical maturation failure (odds ratio, 1.07; 95% CI, 0.90 to 1.28), all per 10 μm increase. There was no significant interaction of preexisting arterial intimal thickness and postoperative AVF outcomes with arterial medial fibrosis, arterial microcalcification, or venous intimal hyperplasia. CONCLUSIONS Preexisting arterial intimal hyperplasia is not associated with the 6-week AVF blood flow, diameter or stenosis, or clinical maturation when the preoperative arterial diameter is ≥2 mm.
Collapse
Affiliation(s)
| | - Silvio H. Litovsky
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Ha Le
- Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Alfred K. Cheung
- Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah; and
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yan-Ting Shiu
- Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| |
Collapse
|
16
|
Martinez L, Duque JC, Tabbara M, Paez A, Selman G, Hernandez DR, Sundberg CA, Tey JCS, Shiu YT, Cheung AK, Allon M, Velazquez OC, Salman LH, Vazquez-Padron RI. Fibrotic Venous Remodeling and Nonmaturation of Arteriovenous Fistulas. J Am Soc Nephrol 2018; 29:1030-1040. [PMID: 29295872 DOI: 10.1681/asn.2017050559] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/16/2017] [Indexed: 02/03/2023] Open
Abstract
The frequency of primary failure in arteriovenous fistulas (AVFs) remains unacceptably high. This lack of improvement is due in part to a poor understanding of the pathobiology underlying AVF nonmaturation. This observational study quantified the progression of three vascular features, medial fibrosis, intimal hyperplasia (IH), and collagen fiber organization, during early AVF remodeling and evaluated the associations thereof with AVF nonmaturation. We obtained venous samples from patients undergoing two-stage upper-arm AVF surgeries at a single center, including intraoperative veins at the first-stage access creation surgery and AVFs at the second-stage transposition procedure. Paired venous samples from both stages were used to evaluate change in these vascular features after anastomosis. Anatomic nonmaturation (AVF diameter never ≥6 mm) occurred in 39 of 161 (24%) patients. Neither preexisting fibrosis nor IH predicted AVF outcomes. Postoperative medial fibrosis associated with nonmaturation (odds ratio [OR], 1.55; 95% confidence interval [95% CI], 1.05 to 2.30; P=0.03, per 10% absolute increase in fibrosis), whereas postoperative IH only associated with failure in those individuals with medial fibrosis over the population's median value (OR, 2.63; 95% CI, 1.07 to 6.46; P=0.04, per increase of 1 in the intima/media ratio). Analysis of postoperative medial collagen organization revealed that circumferential alignment of fibers around the lumen associated with AVF nonmaturation (OR, 1.38; 95% CI, 1.03 to 1.84; P=0.03, per 10° increase in angle). This study demonstrates that excessive fibrotic remodeling of the vein after AVF creation is an important risk factor for nonmaturation and that high medial fibrosis determines the stenotic potential of IH.
Collapse
Affiliation(s)
| | - Juan C Duque
- Division of Nephrology and Hypertension, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | | | - Angela Paez
- DeWitt Daughtry Family Department of Surgery and
| | - Guillermo Selman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York
| | | | - Chad A Sundberg
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | | | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah.,Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah.,Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama; and
| | | | - Loay H Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York
| | | |
Collapse
|
17
|
Preoperative management of arteriovenous fistula (AVF) for hemodialysis. J Vasc Access 2017; 18:451-463. [PMID: 29027182 DOI: 10.5301/jva.5000771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2017] [Indexed: 11/20/2022] Open
Abstract
Native arteriovenous fistula (AVF) is the favorite access for hemodialysis (HD). The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) recommends its creation in most patients with renal failure. Unfortunately, intensive efforts to promote native AVF in patients with marginal vessels have increased the rate of primary fistula failure. A non-functioning fistula prompts the use of central venous catheter (CVC) that, unlike AVF, has been associated with an increased risk of morbidity and mortality among patients receiving HD. We believe that successful and timely AVF placement relies on the development of a multidisciplinary integrated preoperative program divided into five stages: (i) management of patients with advanced chronic kidney disease (CKD), (ii) management of preoperative risk factors for AVF failure, (iii) planning of native AVF, (iv) assessment of patient eligibility and (v) preoperative vascular mapping. Focusing specifically on native AVF, we review scientific evidence regarding preoperative management of this vascular access in order to favor construction of long-term functioning fistula minimizing development of severe complications.
Collapse
|
18
|
Roy-Chaudhury P. Pragmatic, Precision Medicine Approaches for Dialysis Vascular Access Dysfunction: Challenges and Opportunities. Clin J Am Soc Nephrol 2016; 11:1525-1526. [PMID: 27577242 PMCID: PMC5012483 DOI: 10.2215/cjn.08160816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Prabir Roy-Chaudhury
- Division of Nephrology, University of Arizona College of Medicine and Staff Nephrologist, Southern Arizona VA Healthcare System, Tucson, Arizona
| |
Collapse
|
19
|
Vazquez-Padron RI, Allon M. New Insights into Dialysis Vascular Access: Impact of Preexisting Arterial and Venous Pathology on AVF and AVG Outcomes. Clin J Am Soc Nephrol 2016; 11:1495-1503. [PMID: 27401525 PMCID: PMC4974874 DOI: 10.2215/cjn.01860216] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Despite significant improvements in preoperative patient evaluation and surgical planning, vascular access failure in patients on hemodialysis remains a frequent and often unforeseeable complication. Our inability to prevent this complication is, in part, because of an incomplete understanding of how preexisting venous and arterial conditions influence the function of newly created arteriovenous fistulas and grafts. This article reviews the relationship between three preexisting vascular pathologies associated with CKD (intimal hyperplasia, vascular calcification, and medial fibrosis) and hemodialysis access outcomes. The published literature indicates that the pathogenesis of vascular access failure is multifactorial and not determined by any of these pathologies individually. Keeping this observation in mind should help focus our research on the true causes responsible for vascular access failure and the much needed therapies to prevent it.
Collapse
Affiliation(s)
- Roberto I. Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; and
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|