Abstract
BackgroundAutogenous arteriovenous fistula (AVF) is the best vascular access (VA) for hemodialysis, but its creation is still a critical procedure. Physical examination, vascular mapping and doppler ultrasound (DUS) evaluation are recommended for AVF planning, but they can not provide direct indication on AVF outcome. We recently developed and validated in a clinical trial a patient-specific computational model to predict pre-operatively the blood flow volume (BFV) in AVF for different surgical configuration on the basis of demographic, clinical and DUS data. In the present investigation we tested power of prediction and usability of the computational model in routine clinical setting.MethodsWe developed a web-based system (AVF.SIM) that integrates the computational model in a single procedure, including data collection and transfer, simulation management and data storage. A usability test on observational data was designed to compare predicted vs. measured BFV and evaluate the acceptance of the system in the clinical setting. Six Italian nephrology units were involved in the evaluation for a 6-month period that included all incident dialysis patients with indication for AVF surgery.ResultsOut of the 74 patients, complete data from 60 patients were included in the final dataset. Predicted brachial BFV at 40 days after surgery showed a good correlation with measured values (in average 787 ± 306 vs. 751 ± 267 mL/min, R = 0.81, p < 0.001). For distal AVFs the mean difference (±SD) between predicted vs. measured BFV was −2.0 ± 20.9%, with 50% of predicted values in the range of 86–121% of measured BFV. Feedbacks provided by clinicians indicate that AVF.SIM is easy to use and well accepted in clinical routine, with limited additional workload.ConclusionsClinical use of computational modeling for AVF surgical planning can help the surgeon to select the best surgical strategy, reducing AVF early failures and complications. This approach allows individualization of VA care, with the aim to reduce the costs associated with VA dysfunction, and to improve AVF clinical outcome.
Highlights
Autogenous arteriovenous fistula (AVF) is the best vascular access (VA) for hemodialysis, but its creation is still a critical procedure
In the present observational study we evaluated the power of prediction of AVF.SIM system and its acceptance in the routine clinical setting
Pre-operative physical examination and doppler ultrasound (DUS) evaluation currently recommended by international guidelines [16] have several potential benefits, but only a system that takes into account the complex interplay of demographic and clinical factors, as well as vessel dimensions and local blood flow volume (BFV), could really help the surgeon in identifying the best site for AVF placement, as well as in preventing very low or very high BFV, likely associated with VA complications
Summary
Autogenous arteriovenous fistula (AVF) is the best vascular access (VA) for hemodialysis, but its creation is still a critical procedure. Patient physical examination, vascular mapping and Doppler ultrasound (DUS) evaluation of vessels are recommended for AVF planning [4, 5] These procedures can suggest if patient vasculature structure and function are adequate for creation of a native fistula or if potential problems may develop during or after AVF surgery. They cannot provide an indication to the surgeon on the real outcome of the planned anastomosis in terms of AVF blood flow that will be obtained after the process of vessel remodeling and the consequent maturation of the VA. It would be useful to know pre-operatively if BFV is predicted to be too low or too high, suggesting the risk of non-maturation of VA or risk for cardiac failure, respectively
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