Increasing arteriovenous fistulas in hemodialysis patients: Problems and solutions

Abstract

Increasing arteriovenous fistulas in hemodialysis patients: Problems and solutions. National guidelines promote increasing the prevalence of fistula use among hemodialysis patients. The prevalence of fistulas among hemodialysis patients reflects both national, regional, and local practice differences as well as patient-specific demographic and clinical factors. Increasing fistula prevalence requires increasing fistula placement, improving maturation of new fistulas, and enhancing long-term patency of mature fistulas for dialysis. Whether a patient receives a fistula depends on several factors: timing of referral for dialysis and vascular access, type of fistula placed, patient demographics, preference of the nephrologist, surgeon, and dialysis nurses, and vascular anatomy of the patient. Whether the placed fistula is useable for dialysis depends on additional factors, including adequacy of vessels, surgeon's experience, patient demographics, nursing skills, minimal acceptable dialysis blood flow, and attempts to revise immature fistulas. Whether a mature fistula achieves long-term patency depends on the ability to prevent and correct thrombosis. An optimal outcome is likely when there is (1) a multidisciplinary team approach to vascular access; (2) consensus about the goals among all interested parties (nephrologists, surgeons, radiologists, dialysis nurses, and patients); (3) early referral for placement of vascular access; (4) restriction of vascular access procedures to surgeons with demonstrable interest and experience; (5) routine, preoperative mapping of the patient's arteries and veins; (6) close, ongoing communication among the involved parties; and (7) prospective tracking of outcomes with continuous quality assessment. Implementing these measures is likely to increase the prevalence of fistulas in any given dialysis unit. However, differences among dialysis units are likely to persist because of differences in gender, race, and co-morbidity mix of the patient population. Increasing arteriovenous fistulas in hemodialysis patients: Problems and solutions. National guidelines promote increasing the prevalence of fistula use among hemodialysis patients. The prevalence of fistulas among hemodialysis patients reflects both national, regional, and local practice differences as well as patient-specific demographic and clinical factors. Increasing fistula prevalence requires increasing fistula placement, improving maturation of new fistulas, and enhancing long-term patency of mature fistulas for dialysis. Whether a patient receives a fistula depends on several factors: timing of referral for dialysis and vascular access, type of fistula placed, patient demographics, preference of the nephrologist, surgeon, and dialysis nurses, and vascular anatomy of the patient. Whether the placed fistula is useable for dialysis depends on additional factors, including adequacy of vessels, surgeon's experience, patient demographics, nursing skills, minimal acceptable dialysis blood flow, and attempts to revise immature fistulas. Whether a mature fistula achieves long-term patency depends on the ability to prevent and correct thrombosis. An optimal outcome is likely when there is (1) a multidisciplinary team approach to vascular access; (2) consensus about the goals among all interested parties (nephrologists, surgeons, radiologists, dialysis nurses, and patients); (3) early referral for placement of vascular access; (4) restriction of vascular access procedures to surgeons with demonstrable interest and experience; (5) routine, preoperative mapping of the patient's arteries and veins; (6) close, ongoing communication among the involved parties; and (7) prospective tracking of outcomes with continuous quality assessment. Implementing these measures is likely to increase the prevalence of fistulas in any given dialysis unit. However, differences among dialysis units are likely to persist because of differences in gender, race, and co-morbidity mix of the patient population. Vascular access procedures and complications account for over 20% of hospitalizations of dialysis patients in the United States and cost about $1 billion annually1.Feldman H.I. Kobrin S. Wasserstein A. Hemodialysis vascular access morbidity.J Am Soc Nephrol. 1996; 7: 523-535PubMed Google Scholar,2.Hakim R. Himmelfarb J. Hemodialysis access failure: A call to action.Kidney Int. 1998; 54: 1029-1040https://doi.org/10.1046/j.1523-1755.1998.00122.xAbstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar. In an effort to improve vascular access outcomes the National Kidney Foundation published the Dialysis Outcome Quality Initiative (DOQI) guidelines in 1997, a set of evidence-based and opinion-based guidelines regarding the optimal management of vascular access3.NKF-DOQI clinical practice guidelines for vascular access.Am J Kidney Dis. 1997; 37: S150-S191Google Scholar. The DOQI guidelines have stimulated a large body of epidemiologic and clinical studies on vascular access, thereby expanding our understanding of this important topic. One important DOQI guideline has urged nephrologists to increase the number of patients dialyzing with arteriovenous (A-V) fistulas, rather than grafts. The present review summarizes recent clinical research that helps us understand how to achieve this important goal. The relative merits of A-V fistulas and grafts have been a subject of ongoing investigation and debate for many years. Thirty years ago, patient selection for dialysis was relatively stringent, and most patients were young, non-diabetic men with minimal co-morbidity Table 1. Within this select population, the arteries and veins were generally well preserved and permitted construction of native A-V fistulas in the wrist. The expectation was that the vast majority of fistulas placed would mature adequately to be used for dialysis, and subsequently remain patent and useable for dialysis for many years with minimal intervention. In addition, up until the mid-1980s the median dialysis blood flow in the United States was about 250 mL/min4.Port F.K. Morbidity and mortality in dialysis patients.Kidney Int. 1994; 46: 1728-1737Abstract Full Text PDF PubMed Scopus (118) Google Scholar, such that even relatively small diameter fistulas could deliver the desired flows.Table 1Hemodialysis patient characteristics in the United States (1967 and 1999) and in Europe (1999)U.S. data for 1967 are adapted from60.Levinsky N.G. The organization of medical care: Lessons from the Medicare End-Stage Renal Disease Program.N Engl J Med. 1993; 329: 1395-1399https://doi.org/10.1056/NEJM199311043291907Crossref PubMed Scopus (44) Google Scholar and 61.Rostand S.G. Gretes J.C. Kirk K.A. et al.Ischemic heart disease in patients with uremia undergoing maintenance hemodialysis.Kidney Int. 1979; 16: 600-611Abstract Full Text PDF PubMed Scopus (166) Google Scholar. U.S. and European data for 1999 are adapted from18.Pisoni R.L. Young E.W. Dykstra D.M. et al.Vascular access use in Europe and in the United states: Results from the DOPPS.Kidney Int. 2002; 61: 305-316https://doi.org/10.1046/j.1523-1755.2002.00117.xAbstract Full Text Full Text PDF PubMed Scopus (721) Google Scholar and Goodkin et al (abstract, J Am Soc Nephrol 10: 242A, 1999). NS is not significant.1967 (US)1999 (US)1999 (Europe)P valueaComparison between United States and Europe in 1999Female gender %2547430.03Black race %9381<0.001Age, mean±SD60.5±15.560.7±15.2NSage>65 years %750Diabetes %<54622<0.001Coronary artery disease %265131<0.001Cerebrovascular disease %1913.5<0.001Peripheral vascular disease %23190.005Congestive heart failure4823<0.001a Comparison between United States and Europe in 1999 Open table in a new tab In recent years, as a result of more liberal selection criteria, the chronic dialysis population has become substantially older, more likely to be female and diabetic, and has higher co-morbidity, including extensive atherosclerotic vascular disease Table 1. Many of these patients appear to have poor vessels for construction of native fistulas. Concurrently, increased emphasis on dialysis adequacy (Kt/V) has led to the recognition that higher blood flows can improve urea clearance, and thereby permit delivery of adequate dialysis to larger patients without entailing substantial increases in dialysis times. These considerations have led to increased utilization of A-V grafts and decreased use of A-V fistulas. By the mid-1990s only 20% of patients in the United States were dialyzing with fistulas5.Tokars J.I. Miller E.R. Alter M.J. Arduino M.J. National surveillance of dialysis-associated diseases in the United States, 1997.Semin Dial. 2000; 13: 75-85https://doi.org/10.1046/j.1525-139x.2000.00026.xCrossref PubMed Scopus (95) Google Scholar. With the growing use of A-V grafts, it became evident that the prosthetic vascular access is prone to an alarming frequency of thrombosis6.Schwab S.J. Vascular access for hemodialysis.Kidney Int. 1999; 55: 2078-2090https://doi.org/10.1046/j.1523-1755.1999.00409.xAbstract Full Text Full Text PDF PubMed Scopus (332) Google Scholar. Further investigation led to the observation that graft thrombosis usually arises from progressive stenosis at the venous anastomosis or the draining vein, and that prophylactic angioplasty of stenotic lesions decreases the frequency of graft thrombosis substantially7.Schwab S.J. Raymond J.R. Saeed M. et al.Prevention of hemodialysis fistula thrombosis. Early detection of venous stenosis.Kidney Int. 1989; 36: 707-711Abstract Full Text PDF PubMed Scopus (396) Google Scholar, 8.Besarab A. Sullivan K.L. Ross R.P. Moritz M.J. Utility of intra-access pressure monitoring in detecting and correcting venous outlet stenoses prior to thrombosis.Kidney Int. 1995; 47: 1364-1373Abstract Full Text PDF PubMed Scopus (255) Google Scholar, 9.Safa A.A. Valji K. Roberts A.C. et al.Detection and treatment of dysfunctional hemodialysis access grafts: Effect of a surveillance program on graft patency and the incidence of thrombosis.Radiology. 1996; 199: 653-657Crossref PubMed Scopus (183) Google Scholar, 10.Allon M. Bailey R. Ballard R. et al.A multidisciplinary approach to hemodialysis access: Prospective evaluation.Kidney Int. 1998; 53: 473-479https://doi.org/10.1046/j.1523-1755.1998.00761.xAbstract Full Text PDF PubMed Scopus (172) Google Scholar, 11.McCarley P. Wingard R.L. Shyr Y. et al.Vascular access blood flow monitoring reduces access morbidity and costs.Kidney Int. 2001; 60: 1164-1172https://doi.org/10.1046/j.1523-1755.2001.0600031164.xAbstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar. Recognition of the value of elective angioplasty led to considerable research on monitoring methods for detection of hemodynamically significant graft stenosis2.Hakim R. Himmelfarb J. Hemodialysis access failure: A call to action.Kidney Int. 1998; 54: 1029-1040https://doi.org/10.1046/j.1523-1755.1998.00122.xAbstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar. Nonetheless, it became clear that graft stenosis is a frequent and recurrent process, and that monitoring and intervention to prevent graft thrombosis is costly and labor intensive2.Hakim R. Himmelfarb J. Hemodialysis access failure: A call to action.Kidney Int. 1998; 54: 1029-1040https://doi.org/10.1046/j.1523-1755.1998.00122.xAbstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar. Arteriovenous fistulas once again came into favor due to their lower frequency of stenosis, thrombosis, and infection, as compared to A-V grafts. In this context, the DOQI vascular access guidelines advocated intensive efforts to increase the prevalence of fistula use among dialysis patients3.NKF-DOQI clinical practice guidelines for vascular access.Am J Kidney Dis. 1997; 37: S150-S191Google Scholar. These guidelines recommend attempting fistula placement in at least 50% of patients, with A-V grafts being reserved for patients whose vascular anatomy does not permit construction of a native A-V fistula. DOQI guidelines predict that such a strategy will result in 40% of prevalent patients dialyzing with a fistula. A major hurdle in achieving this goal is the high frequency of new A-V fistulas that are never useable for dialysis (primary failures) either due to early thrombosis or due to lack of maturation. A deliberate policy of placing A-V fistulas in the majority of dialysis patients, many of whom have marginal vessels, necessarily increases the frequency of primary failure. Whereas studies from 20 to 25 years ago observed a primary fistula failure rate of about 10%, more recent investigations have typically reported a 20 to 50% primary failure rate Table 2. The primary (intervention-free) survival of fistulas at one year was better than that of grafts in some studies, but not in others Table 2. These comparisons are often misleading, because some investigators have specifically excluded fistulas that never matured, whereas others have included primary failures, when calculating primary patency. Given the higher rates of non-maturation of fistulas as compared with grafts, the two types of calculations lead to different conclusions. Thus, for example, Oliver et al reported that the primary patency of fistulas was superior to that of grafts, when primary failures were excluded12.Oliver M.J. McCann R.L. Indridason O.S. et al.Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas.Kidney Int. 2001; 60: 1532-1539https://doi.org/10.1046/j.1523-1755.2001.00956.xAbstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar. 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Caps M.T. Kohler T.R. et al.Assessment of a policy to reduce placement of prosthetic hemodialysis access.Kidney Int. 2001; 59: 2335-2345Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar13092235636Allon, 200113.Allon M. Lockhart M.E. Lilly R.Z. et al.Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients.Kidney Int. 2001; 60: 2013-2020https://doi.org/10.1046/j.1523-1755.2001.00031.xAbstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar1397846214243Oliver, 200112.Oliver M.J. McCann R.L. Indridason O.S. et al.Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas.Kidney Int. 2001; 60: 1532-1539https://doi.org/10.1046/j.1523-1755.2001.00956.xAbstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar1158026156547Sedlacek, 200143.Sedlacek M. Teodorescu V. Falk A. et al.Hemodialysis access placement with preoperative noninvasive vascular mapping: Comparison between patients with and without diabetes.Am J Kidney Dis. 2001; 38: 560-564Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar14025Dixon, 200226.Dixon B.S. Novak l Fangman J. Hemodialysis vascular access survival: the upper arm native arteriovenous fistula.Am J Kidney Dis. 2002; 39: 92-101Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar20511730235327Pisoni, 200218.Pisoni R.L. Young E.W. Dykstra D.M. et al.Vascular access use in Europe and in the United states: Results from the DOPPS.Kidney Int. 2002; 61: 305-316https://doi.org/10.1046/j.1523-1755.2002.00117.xAbstract Full Text Full Text PDF PubMed Scopus (721) Google Scholar1772516849Primary failure is defined as thrombosis or failure to mature adequately for dialysis, while primary survival is time from access placement to initial intervention. Open table in a new tab Primary failure is defined as thrombosis or failure to mature adequately for dialysis, while primary survival is time from access placement to initial intervention. Similarly, studies comparing the cumulative survival (time from access placement to permanent failure) at one year of fistulas and grafts have yielded contradictory results Table 3. Again, these discrepancies can be attributed to discrepancies in the primary failure rates of fistulas as compared with grafts, as well as whether primary access failures were included in the calculations of access survival. Oliver et al reported that, when primary failures were excluded, the cumulative patency of fistulas was superior to that of grafts12.Oliver M.J. McCann R.L. Indridason O.S. et al.Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas.Kidney Int. 2001; 60: 1532-1539https://doi.org/10.1046/j.1523-1755.2001.00956.xAbstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar. However, when primary failures were included, the cumulative patency of fistulas and grafts was comparable at one year Figure 1. The equivalent outcome occurred because the higher primary failure rate of fistulas was offset by the lower rate of subsequent failures. Similar observations on the relative short- and long-term outcomes of fistulas and grafts have been reported by our institution13.Allon M. Lockhart M.E. Lilly R.Z. et al.Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients.Kidney Int. 2001; 60: 2013-2020https://doi.org/10.1046/j.1523-1755.2001.00031.xAbstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar.Table 3Long-term outcomes of arteriovenous (A-V) fistulas versus graftsCumulative survival at 1 year %Revision rate per access-yearInfection rate %CitationFGRatio (G/F)FGRatio (G/F)FGRatio (G/F)Winsett, 198566.Winsett O.E. Wolma F.J. Complications of vascular access for hemodialysis.South Med J. 1985; 78: 513-517Crossref PubMed Scopus (110) Google Scholar0.060.447.3<112>12Palder, 198565.Palder S.B. Kirkman R.L. Whittemore A.D. et al.Vascular access for hemodialysis: Patency rates and results of revisions.Ann Surg. 1985; 202: 235-239Crossref PubMed Scopus (509) Google Scholar63821.3022Kherlakian, 198621.Kherlakian G.M. Roedersheimer L.R. Arbaugh J.J. et al.Comparison of autogenous fistula versus expanded polytetrafluoroethylene graft fistula for angioaccess in hemodialysis.Am J Surg. 1986; 152: 238-243https://doi.org/10.1016/0002-9610(86)90249-7Abstract Full Text PDF PubMed Scopus (282) Google Scholar2126.0Churchill, 199267.Churchill D.N. Taylor D.W. Cook R.J. et al.Canadian hemodialysis morbidity study.Am J Kidney Dis. 1992; 19: 214-234Abstract Full Text PDF PubMed Scopus (509) Google Scholar4.519.74.4Coburn, 199420.Coburn M.C. Carney W.I. Comparison of basilic vein and polytetrafluoroethylene for brachial arteriovenous fistula.J Vasc Surg. 1994; 20: 896-904Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar87640.743.416.14.7Rocco, 199623.Rocco M.V. Bleyer A.J. Burkart J.M. Utilization of inpatient and outpatient resources for the management of hemodialysis access complications.Am J Kidney Dis. 1996; 28: 250-256Abstract Full Text PDF PubMed Scopus (82) Google Scholar78881.130.340.802.406.2Miller, 199734.Miller A. Holzenbein T.J. Gottlieb M.N. et al.Strategies to increase the use of autogenous arteriovenous fistula in end-stage renal disease.Ann Vasc Surg. 1997; 11: 397-405https://doi.org/10.1007/s100169900068Abstract Full Text PDF PubMed Scopus (47) Google Scholar83730.880.171.176.9Hodges, 199768.Hodges T.C. Fillinger M.F. Zwolak R.M. et al.Longitudinal comparison of dialysis access methods: Risk factors for failure.J Vasc Surg. 1997; 26: 1009-1019Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar46591.280.070.507.109Gibson, 200135.Gibson K.D. Caps M.T. Kohler T.R. et al.Assessment of a policy to reduce placement of prosthetic hemodialysis access.Kidney Int. 2001; 59: 2335-2345Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar72580.802.9Oliver, 200112.Oliver M.J. McCann R.L. Indridason O.S. et al.Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas.Kidney Int. 2001; 60: 1532-1539https://doi.org/10.1046/j.1523-1755.2001.00956.xAbstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar65681.050.552.44.42126.0Allon, 200113.Allon M. Lockhart M.E. Lilly R.Z. et al.Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients.Kidney Int. 2001; 60: 2013-2020https://doi.org/10.1046/j.1523-1755.2001.00031.xAbstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar44481.090.571.672.9McCarley, 200111.McCarley P. Wingard R.L. Shyr Y. et al.Vascular access blood flow monitoring reduces access morbidity and costs.Kidney Int. 2001; 60: 1164-1172https://doi.org/10.1046/j.1523-1755.2001.0600031164.xAbstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar0.180.804.4Dixon, 200226.Dixon B.S. Novak l Fangman J. Hemodialysis vascular access survival: the upper arm native arteriovenous fistula.Am J Kidney Dis. 2002; 39: 92-101Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar61540.880.451.804.0Only studies reporting outcomes of both fistulas and grafts have been included. Abbreviations are: F, fistula; G, graft. Cumulative survival is defined as time from access placement to permanent failure of access despite revisions; revision rate is angioplasty, thrombectomy, and surgical revisions. Open table in a new tab Only studies reporting outcomes of both fistulas and grafts have been included. Abbreviations are: F, fistula; G, graft. Cumulative survival is defined as time from access placement to permanent failure of access despite revisions; revision rate is angioplasty, thrombectomy, and surgical revisions. Despite the comparable cumulative survival of fistulas and grafts, the major advantage of fistulas over grafts is the lower frequency of interventions and complications, once they mature. Maintaining long-term graft patency requires a 2.4- to 7.1-fold higher frequency of salvage procedures (angioplasty, thrombectomy, and surgical revision; Table 3). Moreover, access infections occur substantially more frequently in grafts as compared to fistulas Table 3. In the short-term, placing a fistula requires a greater investment, due to the higher primary failure rate and much longer time to maturation. The long-term payoff, however, is prolonged patency with far fewer interventions, complications, and expenditures. A major clinical challenge is to optimize the approach to constructing A-V fistulas, so as to maximize the proportion of patients receiving a fistula while minimizing the proportion of fistulas that never mature. The goal of the present review is to examine critically the reasons underlying the discrepancy between the goals and reality. Specifically, we will examine the clinical and logistic obstacles to increasing the prevalence of fistulas among hemodialysis patients. We will also address specific measures that have been documented to improve vascular access outcomes at selected institutions. Practice patterns can have a major impact on the prevalence of patients dialyzing with fistulas. In a landmark study Hirth et al reported substantial geographic variations in the prevalence of fistulas among new dialysis patients within the United States, ranging from a high of 77% in New England to a low of 15% in the Southeast14.Hirth R.A. Turenne M.N. Woods J.D. et al.Predictors of type of vascular access in hemodialysis patients.JAMA. 1996; 276: 1303-1307https://doi.org/10.1001/jama.276.16.1303Crossref PubMed Scopus (209) Google Scholar. Similarly, analysis of a cohort of 1824 patients enrolled in the HEMO Study at 45 American dialysis units found substantial geographic variations15.Allon M. Ornt D. Schwab S. et al.Factors associated with the prevalence of A-V fistulas in hemodialysis patients in the HEMO Study.Kidney Int. 2000; 58: 2178-2185Abstract Full Text Full Text PDF PubMed Google Scholar. The prevalence of fistulas was 45.3% in the Northeast, but only 30.6% in the Southeast. In both reports, these geographic differences persisted even after adjustment for multiple demographic factors and co-morbid conditions. Variations in the type of vascular access are also reflected in the 2000 Annual Report of ESRD Clinical Performance Measures16.HCFA: HEALTH CARE FINANCING ADMINISTRATION 2000 Annual Report, End Stage Renal Disease Clinical Performances Measures Project. Department of Health and Human Services, Health Care Financing Administration, Office of Clinical Standards and Quality, Baltimore2000Google Scholar. During the fourth quarter of 1999, 27% of U.S