Primary patency time of basilic vein transposition versus prosthetic brachioaxillary access grafts in hemodialysis patients

Recruitment into randomised trials of arteriovenous grafts: A systematic review

Although randomised controlled trials (RCT) are considered the optimal form of evidence, there are relatively few in surgery. Surgical RCT are particularly likely to be discontinued with poor recruitment cited as a leading reason. Surgical RCT present challenges over and above those seen in drug trials as the treatment under study may vary between procedures, between surgeons in one unit, and between units in multi-centred RCT. The most contentious and debated area of vascular access remains the role of arteriovenous grafts, and thus the quality of the data that is used to support opinions, guidelines and recommendations is critical. The aim of this review was to determine the extent of variation in the planning and recruitment in all RCT involving AVG. The findings of this are stark: there have been only 31 RCT performed in 31 years, the vast majority of which exhibited major limitations severe enough to undermine the results. This underlines the need for better quality RCT and data, and further inform the design of future studies. Perhaps most fundamental is the planning for a RCT that accounts for the intended population, the uptake of a RCT and the attrition for the significant co-morbidity in this population.

One-staged brachial-basilic vein transposition versus arm straight arteriovenous graft for hemodialysis

OBJECTIVES

After forearm and arm cephalic veins are no longer available as options, the choices of arm vascular access between one-staged brachial-basilic vein transposition (BBAVF) and arm straight arteriovenous graft (AS-AVG) for hemodialysis are controversial. This study aims to compare outcomes between groups.

METHODS

All one-staged BBAVF and AS-AVG from August 2014 to December 2019 were reviewed. In cases of suitable basilic vein of 3 mm or more present from cubital crease to axilla, one-staged BBAVF was preferred. AS-AVG was performed for patients who need timely functioning access or have no suitable basilic vein.

RESULTS

Twenty-eight one-staged BBAVF and 74 AS-AVG were included. Baseline characteristics were not significantly different, except AS-AVG had less previous ipsilateral access (9% vs 39%; p < .001). Postoperative complications were not different. With six loss follow-ups (3 in BBAVF and 3 in AS-AVG), 24 (96%) and 64 (90%) matured after one-staged BBAVF and AS-AVG, respectively (p = .676). BBAVF took about 30 days (95% CI: 10, 51) longer time to first successful cannulation. Primary patency was significantly better for one-staged BBAVF (hazard ratio (HR) of 3.0 (95%CI: 1.2, 7.7)), whereas secondary patency was not different. The total access failure (i.e. failure to mature combined with any thrombosis or intervention to maintain patency) significantly favored BBAVF (HR 2.7 (95%CI: 1.1, 6.6)).

CONCLUSIONS

Provided a suitable arm basilic vein is available, one-staged BBAVF is preferred over AS-AVG when forearm AVF, forearm AVG, and arm cephalic veins are out. However, it requires a longer time to start cannulating than AS-AVG.

Quality assurance in surgical trials of arteriovenous grafts for haemodialysis: A systematic review, a narrative exploration and expert recommendations

BACKGROUND

Introducing new procedures and challenging established paradigms requires well-designed randomised controlled trials (RCT). However, RCT in surgery present unique challenges with much of treatment tailored to the individual patient circumstances, refined by experience and limited by organisational factors. There has been considerable debate over the outcomes of arteriovenous grafts (AVG) compared to AVF, but any differences may reflect differing practice and potential variability. It is essential, therefore, when considering an RCT of a novel surgical procedure or device that quality assurance (QA) is defined for both the new approach and the comparator. The aim of this systematic review was to evaluate the QA standards performed in RCT of AVG using a multi-national, multi-disciplinary approach and propose an approach for future RCT.

METHOD

The methods of this have been previously registered (PROSPERO: CRD420234284280) and published. In summary, a four-stage review was performed: identification of RCT of AVG, initial review, multidisciplinary appraisal of QA methods and reconciliation. QA measures were sought in four areas - generic, credentialing, standardisation and monitoring, with data abstracted by a multi-national, multi-speciality review body.

RESULTS

QA in RCT involving AVG in all four domains is highly variable, often sub-optimally described and has not improved over the past three decades. Few RCT established or defined a pre-RCT level of experience, none documented a pre-trial education programme, or had minimal standards of peri-operative management, no study had a defined pre-trial monitoring programme, and none assessed technical performance.

CONCLUSION

QA in RCT is a relatively new area that is expanding to ensure evidence is reliable and reproducible. This review demonstrates that QA has not previously been detailed, but can be measured in surgical RCT of vascular access, and that a four-domain approach can easily be implemented into future RCT.

Comparison between transposed arteriovenous fistulas and arteriovenous graft for the hemodialysis patients: A meta-analysis and systematic review

It is challenging for a surgeon to determine the appropriate vascular access for hemodialysis patients whose cephalic vein is usually inaccessible. The purpose of the study is to compare the complications and patency rates between transposed arteriovenous fistulas (tAVF) and arteriovenous graft (AVG) for the hemodialysis patients. Studies were recruited from PubMed, Cochrane library, EMBASE, the web of science databases, and reviewing reference lists of related studies from the inception dates to September 2, 2021. Statistical analyses were conducted using the statistical tool Review Manager version5.3 (Cochrane Collaboration, London, UK). I2 > 50% was defined as a high degree of heterogeneity, and then a random-effects model was used. Otherwise, the fixed-effects model was used. Odds ratio with its 95% confidence interval (95% CI) was used. Thirty-three trials (26 retrospective studies, four randomized controlled trials, two prospective trials, and one controlled-comparative study) with 6430 enrolled participants were identified in our analysis. The results showed that tAVF was accompanied with lower thrombosis rate (103/1184 (8.69%) vs 257/1367 (18.80%); I2 = 45%; 95% CI, 0.34 (0.26, 0.45)) and infection rate (43/2031 (2.12%) vs 180/2147 (8.38%); I2 = 0%; 95% CI, 0.20 (0.14, 0.30)) than arteriovenous graft. The significantly better primary patency rates, secondary patency rates, and primary assisted patency rates during follow-up were found in tAVF. However, the failure rate and the prevalence of hematoma were significantly lower in AVG group. No evidence showed the rate of overall mortality, steal syndrome, and aneurysm reduced in tAVF. Our results showed that tAVF is a promising vascular access technique for hemodialysis patients whose cephalic vein is inaccessible. Our data showed that tAVF has less thrombosis, infection risk, and better patency rates when compared with AVG. However, more attentions need to be paid to transposed arteriovenous fistulas maturation and hematoma.

Early-cannulation arteriovenous grafts: Multidisciplinary learning is essential to optimize outcomes

BACKGROUND

It is likely that there will be an increasing role for early-cannulation arteriovenous grafts (ecAVG) with a wider recognition of the need to tailor vascular access to avoid futile procedures and unnecessary TCVC. However, experience of these products is not common and limited to early surgical adopters, with little information on the systemic changes and multi-disciplinary care needed to optimize outcomes. The aim of this study was to report the impact of a multi-disciplinary approach on quantifiable outcomes.

METHODS

A retrospective analysis of a prospectively maintained database of 295 ecAVG implanted over an 8-year time-period was performed. Indicative outcomes were chosen to reflect nephrology (patient selection), nursing care (cannulation complications of infection and pseudoaneurysm) and radiology (thrombosis) on cumulative impact (functional patency) over three distinct time periods.

RESULTS

The incidence of ecAVG increased 10-fold over the three time periods. The use of ecAVG changed significantly from salvage tertiary access to TCVC avoidance and salvage of existing AVF. Nursing complications reduced markedly with significantly fewer over-cannulation episodes and pseudo-aneurysms. With an improved pro-active surveillance programme, the time to first thrombosis doubled and the risk of thrombosis halved. Ultimately this resulted in significantly improved functional patency with a risk of ecAVG loss less than one-third by the last time-period.

CONCLUSIONS

All aspects of ecAVG use require scrutiny and critical appraisal. Failure or success is not simply achieved by performing good technical surgery with an efficacious product, but by the care taken across a wide range of elements spanning case selection, implantation, use and maintenance.

Quality assurance in surgical trials of arteriovenous grafts for haemodialysis: protocol for a systematic review

INTRODUCTION

Decisions regarding the optimal vascular access for haemodialysis patients are becoming increasingly complex, and the provision of vascular access is open to variations in systems of care as well as surgical experience and practice. Two main surgical options are recognised: arteriovenous fistula and arteriovenous graft (AVG). All recommendations regarding AVG are based on a limited number of randomised controlled trials (RCTs). It is essential that when considering an RCT of a surgical procedure, an appropriate definition of quality assurance (QA) is made for both the new approach and the comparator, otherwise replication of results or implementation into clinical practice may differ from published results. The aim of this systematic review will be to assess the methodological quality of RCT involving AVG, and the QA measures implemented in delivering interventions in these trials.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines will be followed. A systematic search will be performed of the MEDLINE, Embase and Cochrane databases to identify relevant literature. Studies will be selected by title and abstract review, followed by a full-text review using inclusion and exclusion criteria. Data collected will pertain to generic measures of QA, credentialing of investigators, procedural standardisation and performance monitoring. Trial methodology will be compared against a standardised template developed by a multinational, multispecialty review body with experience in vascular access. A narrative approach will be taken to synthesise and report data.

ETHICS AND DISSEMINATION

Ethical approval is not required as it is a protocol for a systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations, with the ultimate aim of providing recommendations for future RCT of AVG design.

Smoking is associated with a higher complication and failure rate in arteriovenous grafts for haemodialysis: A multi-centre experience

INTRODUCTION

Arteriovenous grafts (AVG) for haemodialysis (HD) access are recommended as a second line modality due to higher morbidity and mortality rates than arteriovenous fistulae (AVF). Smoking is already established as a risk factor in lower extremity bypass graft failure used for peripheral vascular disease, but its effect on AVGs remains unclear. We aimed to investigate the relationship of smoking on AVG outcomes.

METHODS

A 3 year (01/08/2015-01/08/2018) multi-centre retrospective study was carried out on patients receiving an AVG for HD. Data included patient demographics, medical history, operation, type of graft, postoperative course and primary and secondary patency rates. Statistical analyses performed were Kaplan-Meier curves and Cox's proportional hazard regression.

RESULTS

Fifty-five AVGs were performed (1052 AVF performed) in this period. The most common complication was thrombosis (38.9%). Primary patency at 6, 12 and 24 months were 55%, 45% and 44% respectively. Secondary patency at 6, 12 and 24 months were 63%, 56% and 54% respectively. Smoking was found to be a poor prognostic factor for primary (HR 3.734 (1.818-7.668 95% CI) p < 0.001) and secondary patency (HR 6.238 (2.729-14.257) p < 0.001). Smoking was also significantly associated with graft thrombosis (HR 5.741 (2.380-13.848 95% CI) p < 0.001).

DISCUSSION

Primary patency rates are lower than previous reports whilst secondary patency is equivalent. Smoking results in a greater risk of thrombosis and poorer primary and secondary patency. This is recognised in vascular surgical grafts, but has not been previously described in AVGs for HD access. Smoking is a modifiable risk factor and as AVGs are typically used for end-stage vascular access patients. Pre-operative strategies to promote smoking cessation, including patient education and prehabilitation should be employed to improve outcomes.

Comparing Outcomes of Upper Extremity Brachiobasilic Arteriovenous Fistulas and Arteriovenous Grafts: A Systematic Review and Meta-Analysis

OBJECTIVE

It is unclear what the optimal upper extremity hemodialysis access is for patients without a suitable cephalic vein for arteriovenous fistulas (AVFs). The objective of this systematic review and meta-analysis was to compare the outcomes for upper extremity transposed brachiobasilic AVFs (BBAVFs) and prosthetic arteriovenous grafts (AVGs).

METHODS

A systematic review was performed to identify all English publications and abstracts comparing the patency outcomes of upper extremity BBAVFs and AVGs (January 1st, 1994 to April 1st, 2020). The outcomes assessed were 1-year and 2-year primary and secondary patency rates. Pooled odds ratios (OR) were calculated using the random-effects model, and I² statistic was used to assess between-study variability.

RESULTS

Twenty-three studies examining 2799 patients were identified and included in the study. The 1-year primary patency rates (OR = 1.68, 95% CI 1.24-2.28, p = 0.001, I² = 69.40%) and 2-year primary patency rates (OR = 2.33, 95% CI 1.59-3.43, p < 0.001, I² = 68.26%) were significantly better for BBAVFs than AVGs. Compared to AVGs, the 1-year secondary patency rates (OR = 1.45, 95% CI 1.05-1.98, p = 0.022, I² = 56.64%) and 2-year secondary patency rates (OR = 1.93, 95% CI 1.39-2.68, p < 0.001, I² = 57.61%) were also significantly higher for BBAVFs.

CONCLUSION

The outcomes for upper extremity BBAVFs appear to be consistently superior to prosthetic hemodialysis access. This analysis supports the preferential placement of BBAVFs over AVGs in patients with a suitable upper extremity basilic vein.

Brachio-basilic upper arm transposition fistulas vs. prosthetic brachio-axillary vascular access grafts-Which one is preferred for hemodialysis?

INTRODUCTION

There is still controversy on the use of brachio-basilic upper arm transposition fistula (BBAVF) and prosthetic brachio-axillary vascular access grafts (BAPTFE) in patients with no suitable cephalic veins for creating an autogenous brachio-cephalic fistula.

METHODS

In a randomized controlled clinical trial, 60 hemodialysis patients who were not a suitable candidate for BCAVF were randomly assigned into two groups: BBAVF and BAPTFE. The patients were clinically followed up to 1 year and the patency rate and access-related complications were compared between the two groups.

FINDINGS

Access failure rate in the BBAVF and BAPTFE groups was 30.0% and 36.6%, respectively. The primary patency time was 232.73 ± 113.36 and 261.53 ± 147.37 days, respectively (P = 0.40). Thrombosis formation and infection were the two main causes for access failure, yet indicating no significant difference between the two groups (P > 0.05).

DISCUSSION

BBAVF and BAPTFE have comparable clinical outcomes in short-term follow-up. Therefore, BAPTFE can be used as an alternative vascular access for hemodialysis in patients who are not a suitable candidate for BBAVF.

Arteriovenous graft patency outcomes and prognostic factors

OBJECTIVES

Arteriovenous graft for hemodialysis shows poorer outcomes than arteriovenous fistula, due to frequent stenosis and thrombosis. We investigated arteriovenous graft patency outcomes and prognostic factors for these outcomes.

METHODS

We included a single-center cohort of patients receiving arteriovenous graft for hemodialysis access from 2010 to 2014. Demographics, laboratory data, comorbidities, and medications were collected from medical records. Surgical factors related to graft operation including the type and diameter of connected vessels, graft location, and type of operation (elective or emergency) were also recorded. Outcomes included primary and secondary patency. Survival analysis was conducted using the Kaplan-Meier method; univariate and multivariate analyses were used to evaluate the prognostic factors.

RESULTS

Data from 225 grafts were analyzed. During the follow-up period (mean: 583 days, range: 1-1717 days), 138 (61%) grafts required intervention and 46 (20%) permanently failed. Primary patency at one, two, and three years was 42%, 20%, and 16%, respectively. Secondary patency at one, two, and three years was 85%, 72%, and 64%, respectively. Multivariate analysis showed that primary patency was negatively associated with increasing age and location of vessel anastomosis (reference-brachiobrachial anastomosis; brachiobasilic - HR, 0.569; 95% CI, 0.376-0.860; p = 0.007; brachioaxillary anastomosis - HR 0.407; 95% CI, 0.263-0.631; p < 0.0001); secondary patency was positively associated with diastolic blood pressure, serum albumin level, and hemoglobin over 10 g/dL. Adverse events other than stenosis or thrombosis, such as infection/inflammation or pseudoaneurysm were observed in approximately 20% of grafts.

CONCLUSIONS

Factors associated with diminished primary arteriovenous graft patency included increased patient age and location of vessel anastomosis (brachiobrachial type compared to brachiobasilic or brachioaxillary type); diminished secondary patency was associated with low diastolic blood pressure, low serum albumin, and hemoglobin level under 10 g/dL. Among these factors, diastolic blood pressure, serum albumin, and hemoglobin level may be modifiable and could improve arteriovenous graft patency outcomes.

Transposed Basilic Vein Fistula: A Credible Option

Objective: Native fistula creation for hemodialysis in patients who have exhausted all their superficial veins presents a challenge to vascular practice. We review our experience in transposed basilic vein fistula (BVT) creation and its usage for hemodialysis.

Materials and Methods: We analyzed the hospital operative registry from January 2009 till June 2012 to identify the total number of BVT created in our center. Medical records of all patients were traced, and patients were interviewed using a standard proforma. In our center, BVT is performed as a two-stage procedure. All patients were routinely assessed with duplex scan preoperatively and postoperatively.

Results: Two hundred thirty-nine patients were recruited in the study. Of these patients, 50.6% were male and 49.4% were female. Mean age was 53.4 years. Of these patients, 81.2% had history of other previous fistula creation. Risk factors profile includes diabetes mellitus in 59.8%, hypertension in 86.2%, and smoking in 13.0%. Of these patients, 84.5% had no operative complication. Commonest complication was wound infection, 6.3%, followed by hemorrhage or hemotoma required surgical intervention, 5.9%, and pseudoaneurysm, 1.3%. Primary and secondary patencies were at 84.2% and 86.1% at 1 year and 67.7% and 70.5% at 3 years, respectively.

Conclusion: BVT is a credible option for challenging patients with absence of superficial veins for native fistula creation with good patency and low operative complication rate. Preoperative ultrasound assessment improves patient selection and outcome of BVT.

Transposed Brachial-Basilic Arteriovenous Fistula for Vascular Access in Japan

As more than 320,000 patients are currently receiving hemodialysis treatment in Japan, the creation and maintenance of hemodialysis access is a major concern. The national guidelines recommend autogenous arteriovenous hemodialysis, and the brachial-basilic arteriovenous fistula has been the focus of attention, because the need for secondary, tertiary, or even more vascular access is growing. Although favorable results have been reported in terms of patency and access-related complication, this fistula involves various unsolved or controversial issues, with limitations including complex procedures, which might contribute to the lower prevalence at this point in Japan. This review addresses those issues and discusses the role of fistula in Japan.

Angioplasty and stenting for the proximal anastomotic stenosis of a brachio-axillary bypass graft using a helical interwoven nitinol stent: A case report

RATIONALE

Thrombosis due to anastomotic site stenosis is the most common complication in patients with brachio-axillary arteriovenous graft (AVG). Intravascular stent placement may play a special role in the salvage of dialysis grafts that have been previously performed percutaneous angioplasty or surgical procedure on the graft. Herein, we applied a novel stent named Supera which has a high degree of flexibility and resistance to external compression for treating a patient with recurrent venous anastomotic stenosis of brachio-axillary AVG.

PATIENTS CONCERNS AND DIAGNOSES

We report a case of the patient with end-stage renal disease who presented with brachio-axillary AVG malfunction.

INTERVENTIONS

The patient underwent repeated percutaneous angioplasty with thrombectomy for total graft occlusion, and we placed the Supera stent to salvage the graft.

OUTCOMES

Postprocedural Doppler ultrasonography did not show any restenosis on the 1- and 3-month follow-up periods, and average flow volume in the stent was >1000 mL/min. And he has been on dialysis for 6 months without any problems after stent placement.

LESSONS

The Supera stent is a useful treatment option of interventional procedure for recurrent venous anastomotic stenosis of brachio-axillary AVG in the clinical practice.

Basilic Vein Transposition Used as a Tertiary Vascular Access for Hemodialysis: 15 Years of Experience

INTRODUCTION

The quality of the life in patients requiring long term hemodialysis is directly proportional to the long-term patency of their vascular access. Basilic vein transposition for vascular access (BAVA) represents a suitable option for creating a tertiary native vascular access for hemodialysis on the upper extremities for patients requiring long term hemodialysis. The purpose of the study is to compare BAVAs with arteriovenous grafts (AVG).

METHOD

Data collection was based on selecting all of the patients with BAVA created in the time period in between January 1996 and August 2011. A questionnaire was created and sent to the selected hemodialysis centers. The resulting set of data was statistically analyzed and evaluated.

RESULTS

In the time period between 1 January 1996 and August 2011, arteriovenous access for hemodialysis was created in 6754 patients (7203 procedures in total). Out of these patients, 175 BAVAs were created. Our patient database of those undergoing the BAVA procedure consisted of 98 females (56%) and 77 males (44%) with an average age of 64.5 years. The prevalence of diabetes mellitus was 60% (105 patients). Primary patency after 12 months was 68.8%, 24 months 59.7%, 36 months 53.8, 48 months 53.8%, and 60 months 50%. Primary assisted patency after 12 months was 89.9%, 24 months 84.6%, 36 months 77.8%, 48 months 77.9%, 60 months 70.8%. Secondary patency after 12 months was 89.4%, 24 months 86.9%, 36 months 81%, 48 months 78.9%, 60 months 75.7%. Twenty-nine BAVAs (16.5%) were obliterated.

CONCLUSION

Patients benefit from this type of procedure due to the longer patency of a native arteriovenous access, as well as a lower incidence of infectious complications.

Review of Transposed Basilic Vein Access for Hemodialysis

Background

There is ongoing debate about the use of transposed basilic vein (TBV) fistula and the choice between it and prosthetic arteriovenous graft (AVG). This paper reviews the available literature relating to TBV fistula in terms of surgical technique, patency rates, complications, access survival and compares it with prosthetic AVG for hemodialysis (HD).

Methods

Review of English language publications on TBV during the last two decades.

Findings

The rate of fistula maturation was higher in the two-stage group, although the mean diameter of the basilic vein was smaller. Dialysis via central venous catheters at time of surgery was most prevalent in patients undergoing staged procedures—14% in one-stage TBV and 43% in two-stage TBV. Several authors report 1-year cumulative patency rate of 47% to 96% and 59% to 90% for TBV and AVG, respectively. TBV provides a more cost-effective option and should be considered the next choice when primary autogenous fistulae are not possible, whereas AVGs are easier to create, can be punctured earlier and have a greater reintervention rate if the access fails.

Conclusions

This analysis shows that TBV has several advantages over AVG and provides a valuable access for HD but raises the need for a comparative trial between TBV and the newer generation AVGs. There is no clear superiority of the one-stage over the two-stage procedure.