Endovascular Arteriovenous Dialysis Fistula Intervention: Outcomes and Factors Contributing to Fistula Failure

RATIONALE & OBJECTIVE

Primary patency is variable with arteriovenous fistulas, and many patients require angiographic procedures to obtain patency. Accordingly, we determined postintervention patency rates and contributing factors for fistula failure following intervention to establish secondary patency in non-dialysis-dependent patients with advanced chronic kidney disease following creation of an arteriovenous fistula.

STUDY DESIGN

Observational study from a single referral center.

SETTING & PARTICIPANTS

210 non-dialysis-dependent patients with advanced chronic kidney disease who underwent upper-extremity fistula creation for anticipated dialysis between October 1995 and January 2015 and who required subsequent endovascular therapy to establish or maintain patency were reviewed.

EXPOSURE

Endovascular therapy for dialysis arteriovenous fistula primary patency failure.

OUTCOMES

Postintervention patency duration following endovascular therapy.

ANALYTICAL APPROACH

Descriptive study with outcomes determined using Cox proportional hazards models.

RESULTS

Multiple fistula configurations were reviewed: 138 (65.7%) brachiocephalic, 39 (18.6%) radiocephalic, 30 (14.3%) brachiobasilic, 2 (1.0%) ulnocephalic, and 1 (0.5%) radiobasilic. There were 261 initial stenoses treated. Postintervention primary patency is defined as the time from the index intervention to repeat intervention for stenosis. Postintervention primary-assisted patency is the time from the index intervention to thrombectomy for fistula thrombosis or change in modality. Postintervention secondary patency is the time from the index intervention to fistula abandonment. Median postintervention primary patency, postintervention primary-assisted patency, and secondary patency were 2.7, 3.2, and 3.6 years, respectively. The overall 1-year primary, primary-assisted, and secondary patency rates in this cohort were 53.0%, 87.7%, and 83.5%, respectively. Compared with radiocephalic fistulas, brachiocephalic fistulas had higher risk for postintervention primary patency loss (HR, 1.90; 95% CI, 1.13-3.20; P = 0.02).

LIMITATIONS

Dialysis fistula revascularization techniques varied.

CONCLUSIONS

The radiocephalic fistula configuration had the best postintervention primary patency in this cohort. Postintervention primary-assisted patency and secondary patency were not significantly different among different fistula configurations.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

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.

Exercise effectiveness of arteriovenous fistula maturation in chronic renal patients: A systematic review with meta-analysis

Aims:

The purpose of this research is to evaluate the effectiveness of upper limb exercises to improve arteriovenous fistula maturation in patients with chronic kidney disease.

Methods:

A bibliographic search was carried out from February to August 2015 in the following databases: PUBMED, CINAHL, Web of Science, SCOPUS, LILACS, SCIELO and CENTRAL.

Results:

Three studies were included, involving 134 participants (total). According to the total effect estimation, a mean difference of 0.36 (-0.95–1.67) was found for vein diameter, meanwhile a mean difference of 107.87 (-3.90–219.64) was found for blood flow.

Conclusion:

It was not possible to determine the effect size of the treatment due to a high bias risk of all included studies. Given this, the available evidence is still insufficient to support the prescription of upper limb exercises in order to improve arteriovenous fistula maturation. Therefore, randomised and controlled clinical trials monitored by methodological rigour should be developed in order to verify if the AVF maturation process can be evidenced through exercise.

Venous Hemodialysis Catheters and Cardiac Implantable Electronic Devices: Avoiding a High-Risk Combination

End-stage renal disease is frequently accompanied by cardiac comorbidity that warrants treatment with a cardiovascular implantable electronic device (permanent pacemaker or implantable cardioverter-defibrillator). In the United States, chronic hemodialysis (HD) population, cardiac implantable devices are present in up to 10.5% of patients; a venous HD catheter is utilized for blood access in 18% of prevalent patients. The concomitant presence of a venous HD catheter and cardiovascular implantable device creates a high-risk circumstance, with potential for causing symptomatic central venous stenosis, and for developing complicated endovascular infection. This dangerous combination may be avoided for many patients by utilizing nondialysis methods for management of advanced chronic kidney disease, initiating dialysis without venous catheter access, or managing cardiac rhythm disorders without use of transvenous cardiac implantable electronic devices. In those situations where the combination of a venous HD catheter and cardiac implantable device is unavoidable, there are strategies to minimize duration of venous catheter access, and to reduce risks for infectious complications. It is essential for nephrologists and cardiologists to understand the indications, alternatives, and risks involved with venous HD access and cardiac implantable devices. Coordinated management of renal disease and cardiac rhythm disorders has potential to minimize risks, improve outcomes, and substantially reduce the cost of care.

Effects of Tongmai oral liquid in femoral ateriovenous fistula

BACKGROUND

This study was conducted to investigate the protective effect of Tongmai oral liquid on arteriovenous fistula function and to provide an effective method to promote fistula maturation.

METHODS

Fifteen female and fifteen male SPF New Zealand rabbits were randomly allocated into 3 groups including control, Aspirin and Tongmai oral liquid groups. A side-to-side femoral arteriovenous fistula was established in each rabbit and then animals were treated with Aspirin or Tongmai oral liquid for 2 weeks. The concentrations of circulating ET-1 and NO were determined before and after operation (on preoperative day, operative day, post-D1, post-D3, post-D7 and post-D15), respectively. Blood flow of the fistula stoma and contralateral artery and vein was determined on the 15th postoperative day. Last, the fistula stoma was dissected to observe patency, thrombosis and adhesion with surrounding tissues.

RESULTS

28 rabbits survived during the surgical process and the following 15-day observational period. Tissue adhesion of arteriovenous fistula with surrounding tissues was improved and fistula thrombosis was reduced by treatment with Tongmai oral liquid. NO concentration decreased to a different extent after vascular surgery. Tongmai oral liquid failed to regulate the equilibrium between NO and ET-1, but it improved blood flow of fistula stoma, as compared to control and Aspirin groups. Blood flow of fistula stoma in the three groups was lower than that of the contralateral femoral artery.

CONCLUSIONS

Tongmai oral liquid improved the function of femoral ateriovenous fistula in the rabbit model by increasing blood flow and reducing thrombosis, probably not by regulating the dynamic equilibrium between NO and ET-1.

Proactive Surveillance Approach to Guarantee a Functional Arteriovenous Fistula at First Dialysis is Worth

Purpose

To evaluate the impact of a proactive surveillance program on functional access rate at the time of first dialysis.

Methods

In January 2010, a proactive surveillance program to intercept failures to mature was set up at the University Hospitals Leuven. Patients receiving an arteriovenous fistula (AVF) for pre-dialysis end-stage renal disease between January 2010 and May 2013 were retrospectively analyzed. The primary end-point was a functional AVF at first dialysis. Also, AVF- associated complications and reinterventions were analyzed. Furthermore, primary, assisted primary and secondary patency rates were estimated using Kaplan-Meier survival curves.

Results

One hundred sixty-four patients were included in the study. Patients were followed until first dialysis. Median follow-up time was 287 days (interquartile range, 108-551 days). During follow-up, 40 patients (24.4%) needed one or more additional interventions, resulting in 60 reinterventions. Ten patients needed dialysis within the minimal accepted maturation period of the AVF (4 weeks). Of the 154 patients who could await the maturation period of the AVF, 145 (94.2%) appeared ready for use at the time of dialysis or at the end of the study period. In 34 of them (22%), this was thanks to one or more interventions during follow-up.

Conclusions

A dedicated surveillance program of patients with AVFs in the pre-dialysis stadium detects failure to mature. Close coaching and proactive intervention can aid the patient in his own “fistula first” project.

Coil Embolization as a Treatment Alternative for Dialysis-Associated Steal Syndrome

Steal syndrome is a rare but serious complication of arteriovenous fistulas (AVF) created as well as the angioplasty technique used for its maturation and can have severe consequences if left untreated. Standard treatment options generally lead to loss of fistula access, although newer practices such as coil embolization are being utilized to conserve the AVF. Here we illustrate a case of a 65-year-old man with end-stage renal disease on dialysis, who had a Brescia-Cimino (radiocephalic) AV fistula created and subsequently underwent balloon-assisted maturation for an underdeveloped fistula. One month later, the patient presented with a cold thumb and index finger along with parasthesias in those digits and was treated with coil embolization of the distal radial artery while leaving the AVF functional. Steal syndrome and the novel treatment option of coil embolization are reviewed here.