Autogenous Arteriovenous Access Research Articles

Early Kidney Transplantation or Conversion to Peritoneal Dialysis after First-Time Arteriovenous Access Creation

After autogenous arteriovenous (AV) access creation for end-stage renal disease, a majority of patients will continue on hemodialysis (HD), a minority will receive definitive treatment with kidney transplantation, and a subset of patients will convert to peritoneal dialysis (PD). Our goal was to identify patient factors associated with early transition from HD to either kidney transplantation or PD. This is a case-control study of all patients with first-time AV access creation in the Vascular Quality Initiative (2011-2022) who had long-term follow-up. Patients who remained on HD after AV access creation were the control group while patients who received early kidney transplant or who converted to PD were the 2 case groups. Relationship among demographics, comorbidities, neighborhood social disadvantage, and functional status as they relate to renal replacement therapy modality was assessed. There were 19,782 patients included; the average age was 62±15years and 57% were male. During the follow-up period of a median 306 (71-403) days, 1.3% underwent a kidney transplantation and 2.3% underwent conversion to PD. On univariable analysis, rates of kidney transplantation or conversion to PD varied with race (P<0.001), insurance status (P<0.001), area deprivation index (ADI) quintile (P<0.001), and several medical comorbidities. On multivariable analysis, impaired ambulation, current smoking, Medicaid or Medicare insurance, Black race, heart failure, body mass index, and older age were associated with decreased transplantation rates. Conversion to PD was associated with ADI Q5, Q4, and Q3. Decreased conversion to PD was associated with impaired ambulation, Hispanic ethnicity, Black race, former smoking, medication-controlled diabetes, and older age. Decreased kidney transplantation was associated with Black race and noncommercial health insurance but not ADI quintile, suggesting disparities exist beyond community-level access to care. Early kidney transplantation conveyed a 3-year survival benefit compared with HD and PD, which had similar survival. Furthermore work is required to increase access to kidney transplantation and PD.

Practical and ethical challenges of maintaining vascular access in chronic kidney disease: A qualitative interview study

ObjectiveChronic kidney disease affects 16.8% of adults in the United States, for which hemodialysis is most commonly used for renal replacement therapy. Although emphasis with the Fistula First Initiative has historically focused on the prioritization of autogenous arteriovenous access, higher rates of maturation failure and access dysfunction have prompted a reappraisal of this approach in the literature and clinical practice. Oftentimes, frail or medically complex patients with dysfunctional access are subjected to a large number of surgical procedures to maintain or reestablish patency. The influence of arteriovenous fistula (AVF) dysfunction and repetitive reintervention on patient experience and quality of life remains largely unexplored in contemporary literature. MethodsUsing a provincial database of renal failure patients (Patient-Reported Outcomes Measurement Information System [PROMIS]), we selected patients who had undergone five or more interventional procedures (open or endovascular) to maintain vascular access within a 20-year period from a single institution. Semistructured interviews were conducted with these patients and analyzed qualitatively using the constant comparative approach. ResultsSeventeen patients who met the inclusion criteria were recruited from across British Columbia. The cohort included patients from both genders (10 male, 7 female) between the ages of 52 and 87 years old. Four major thematic categories were identified; treatment values, impact of disorder, disposition toward AVF and impact of repeated interventions. Survival was the primary theme in the treatment values category (11/17), with reduction in dialysis frequency being secondary. Within impact of disorder, loss of independence was the primary theme (14/17), with psychological impact being secondary. Displeasure with the high rates of failure emerged as the primary theme (15/17) in disposition toward AVF, with pain with use (8/17) and inadequate informed consent (8/17) as secondary themes. Finally, for impact of repeated interventions, the primary theme was interruption to daily life (12/17). Overall, only 8 of 17 patients expressed satisfaction with their AVF. ConclusionsThese findings highlight that repeated interventions to maintain fistula patency pose significant disruption to patient's quality of life. Rates and impacts of fistula failure need to be explained thoroughly to patients during their informed consent process, moving toward a more patient-centered, individualized and holistic approach to vascular access over a ubiquitous fistula-first approach in all cases.

Efficacy and safety of low dose, weight-based subcutaneous enoxaparin protocol in recurrent arteriovenous access thrombosis.

This study aims to evaluate the safety and efficacy of a short-term, low dose, weight-based subcutaneous enoxaparin protocol (SEP) in maintaining the patency of arteriovenous (AV) access with recurrent thrombosis. Prospective follow-up of 25 patients who presented to a tertiary institution with recurrent AV access thrombosis and treated with anticoagulation according to SEP following successful thrombectomy. Patency and safety outcomes of SEP were studied. The participants were 66.4 ± 10.2 years old and predominantly male (60%) and of Chinese ethnicity (72%). The AV accesses had a median age of 1.4 (0.6, 5.6) years with 60% being non-autogenous arteriovenous access while 40% were autogenous arteriovenous access. Thrombolytic agents (urokinase (72%) or alteplase (28%)) were used in all procedures while adjunct thrombectomy device was used in only four procedures. The mean dose of enoxaparin was 36.0 ± 8.2 mg or 0.64 ± 0.1 mg/kg/day for a mean duration 30.0 days (Interquartile range: 27.5, 31.0). One patient developed minor bleeding episode. Kaplan-Meier analysis demonstrated that the mean thrombosis-free survival pre- versus post-SEP adoption was 27.3 (95% CI 17.9-36.7) versus 183.5 (95% CI 100.1-266.9) days (p < 0.001). After adjusting for the type of thrombolytic agent, use of adjunct thrombectomy device, cutting balloon, drug-coated balloon, and stent graft, SEP remained a significant factor associated with longer thrombosis-free patency (HR 0.166: 95% CI 0.070-0.392, p < 0.001). SEP appears to be a feasible and safe thromboprophylaxis method to improve thrombosis-free patency for AV access with recurrent thrombosis.

The Impact of Neighborhood Social Disadvantage on Presentation and Management of Hemodialysis Access Surgery Patients

The impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) access surgery have not been well characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members within a community. Herein, we examined the effect of ADI on health outcomes for first-time HD access patients. We identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between August 2011 and May 2022. Patient zip codes were correlated with an ADI quintile (Q1-Q5, least to most disadvantaged). Patients without ADI were excluded. Perioperative and long-term outcomes considering ADI were analyzed. There were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 10% were of Hispanic ethnicity, and 85% received autogenous arteriovenous (AV) access. Patient distribution by ADI quintile (Q) was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with decreased autogenous access creations (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.77-0.94; P = .002), fewer preoperative vein imaging (OR, 0.62; 95% CI, 0.50-0.77; P < .001), lower access maturation (OR, 0.82; 95% CI, 0.71-0.94; P = .005), and lower 1-year survival (OR, 0.80; 95% CI, 0.71-0.90; P < .001) compared to Q1. Q5 was not associated with significantly higher 1-year intervention rates (Table). The most socially disadvantaged (Q5) AV access creation patients were more likely to experience disparities at the time of preoperative AV access creation, access type, as well as well as at 1-year outcomes. Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population.TableUnivariate and multivariable analysis of outcomes of interest stratified by Area Deprivation Index (ADI) quintileADIAV fistulaVein imaging obtainedAccess matured at last follow-up1-Year intervention1-Year survivalUniMultiUniMultiUniMultiUniMultiUniMultiQ16138 (87)(ref)2413 (91)(ref)2695 (86)(ref)798 (31)(ref)6483 (92)(ref)Q26771 (85)0.84 [0.75-0.93]2254 (91)1.01 [0.80-1.26]2840 (83)0.83 [0.72-0.97]961 (32)0.98 [0.86-1.11]7121 (89)0.82 [0.72-0.93]Q37717 (85)0.81 [0.73-0.89]2575 (94)1.50 [1.18-1.90]3253 (83)0.82 [0.71-0.95]1089 (31)0.93 [0.82-1.05]8122 (89)0.80 [0.71-0.90]Q48211 (84)0.76 [0.69-0.84]2619 (91)0.96 [0.78-1.19]3529 (84)0.91 [0.78-1.05]1268 (32)0.94 [0.83-1.06]8844 (90)0.88 [0.79-0.99]Q57838 (84)0.85- [0.77-0.94]2018 (88)0.62 [0.50-0.77]3694 (82)0.82 [0.71-0.94]1433 (34)0.99 [0.88-1.12]8370 (90)0.80 [0.71-0.90]P value<.001-<.001-<.001-.047-<.001-Multi, multivariable analysis; Uni, univariate analysis.Univariate results represented as number (%). Multivariable results represented as adjusted odds ratio. Brackets in multivariable analysis indicated the 95% confidence interval. Bold indicated statistically significant results. Of patients with long-term follow-up data, the average length of last long-term follow-up data was 383 ± 240 days. Open table in a new tab

Maintaining Vascular Access in Chronic Kidney Disease: Patient Perspectives

Chronic kidney disease affects 16.8% of adults in the United States for which hemodialysis is most commonly used for renal replacement therapy. Although emphasis with the Fistula First Initiative has historically focused on the creation of autogenous arteriovenous access, higher rates of maturation failure and access dysfunction have prompted a reappraisal of this approach in the literature and clinical practice. Often, frail or medically complex patients with dysfunctional access will be subjected to a large number of surgical procedures to maintain or reestablish patency. The influence of arteriovenous fistula (AVF) dysfunction and repetitive reintervention on patient experience and quality of life remains largely unexplored in the contemporary literature. Using a provincial database of renal failure patients, we selected patients who had undergone five or more interventional procedures (open or endovascular) to maintain vascular access within a 20-year period from a single institution. Semistructured interviews were conducted with these patients, and the responses were analyzed qualitatively using the constant comparative approach. Sixteen patients who had met the inclusion criteria were recruited from across British Columbia. The cohort included patients from both genders (10 men; 6 women) aged 52 to 87 years. Four major thematic categories emerged from the interviews: impact of dialysis, treatment values, impact of repeated surgical intervention, and AVF satisfaction. For the impact of dialysis category, loss of independence (13 of 16) was a dominant theme, with the psychological impact secondary. Regarding treatment values, 11 of 16 patients stated survival was of primary importance, with a reduction in dialysis frequency secondary. The dominant theme in the impact of repeated surgical interventions was interruption to daily life (12 of 16), with travel interruptions and fatigue being minor. For AVF satisfaction, failure of the AVF was dominant (14 of 16), with pain associated with using the AVF considered the most common negative factor. Only 7 of 16 expressed satisfaction with their management pathway. Reduced independence and interruption to daily routine were the most cited difficulties regarding dialysis and surgical intervention. As expected, survival was a key treatment value. Recurrent access failure and reintervention were significant causes of impaired quality of life for patients requiring hemodialysis.

Ultrasound-Guided Cradle-Like Infiltrative Anesthesia for Percutaneous Transluminal Angioplasty of Stenotic Autogenous Arteriovenous Hemodialysis Access

Percutaneous transluminal angioplasty (PTA) is an effective treatment for autogenous arteriovenous hemodialysis access (AAVA) stenosis; however, it causes pain in most cases. Therefore, safe and effective anesthesia for PTA is required. We introduced a method of ultrasound-guided cradle-like infiltration anesthesia (UCIA) to administer analgesia during PTA. Using ultrasound guidance, 1% lidocaine was injected into the bilateral and inferior perivascular spaces of the stenosis to form a cradle-like region. In this study, 100 consecutive patients were divided into two groups, and the analgesic effect of UCIA was evaluated using a numerical rating scale with non-ultrasound-guided infiltration anesthesia as a control. Meanwhile, we compared the effect of PTA between the two groups with the postoperative internal diameter of the stenosis. The numerical rating scale score was 4.6 ± 1.9 and 2.0 ± 1.6 (P < 0.001) in UCIA group and non-ultrasound-guided infiltration anesthesia group, respectively. The postoperative internal diameter of stenosis was 3.9 ± 0.6 mm and 4.1 ± 0.7 mm (P=0.113); the postoperative AAVA flow volume was 627 ± 176 mL/min and 644 ± 145 mL/min (P=0.600). This study preliminarily showed that UCIA is effective and safe for the analgesia of AAVA PTA.

Single-Institution Learning Curve for Management of Mega-Fistulae Revision

Mega-fistulae are generalized aneurysmal dilations of a high flow (1500-4000 mL/min) autogenous arteriovenous (AV) access which may result in hemorrhage and/or high-output cardiac failure. Current treatments include ligation, ligation with prosthetic jump graft, and imbrication; however, these may not be suitable for advanced disease, or may result in loss of functioning access, poor cosmesis, or recurrence. We describe our early experience with a technique of complete mega-fistula resection and replacement with an early use prosthetic graft that both maintains existing AV access and eliminates the need for long-term catheter (LTC) placement; including lessons learned. A single-center, retrospective review of medical records was conducted fromMarch 2018-February 2021. Outcomes were technical success, LTC use, time to cannulation, and complications. Mega-fistulae were completely resected from the proximal to distal aneurysmal segment, including all pseudoaneurysms, followed by tunneling a prosthetic graft (Propaten later converted to Acuseal; W.L. Gore Assoc.) with an end-to-end anastomosis to the remaining arterial and venous ends of the previous AV access. We had 100% immediate technical success (n=12). Pre-operative long-term catheters were placed in all eight Propaten patients; one was already placed in an Acuseal patient. Average time to cannulation was six weeks with Propaten and 4.5 days with Acuseal. At 30 days, three Propaten patients developed complications including one instance of skin necrosis, one seroma, and one hematoma. Two Acuseal patients developed complications including one central venous occlusion (CVO) and one graft infection. Of the six patients with long-term follow-up, five continue to use their access, however, two required thrombectomies and central venous angioplasties. One patient required a new contralateral access due to CVO. Complete mega-fistula resection and replacement with Acuseal graft maintains existing AV access and may eliminate the need for long-term catheter placement. Our early experience with this technique is encouraging, but further follow-up is required to determine the durability of this approach.

Preoperative Vein Mapping is Not Associated With Arteriovenous Access Type Created But is Associated With Improved Patency

Autogenous arteriovenous (AV) fistulas are preferred for hemodialysis access, with AV grafts (AVGs) reserved for when a suitable vein is unavailable. Preoperative vein mapping can be used to identify usable veins for autogenous access. We evaluated whether vein mapping is associated with access type and outcomes. We queried the Vascular Quality Initiative database for patients who had undergone initial AV access creation from 2011 to 2019. We evaluated the associations of preoperative vein ultrasound/venogram mapping with patient characteristics, access type, and 30-day and 1-year patency. Of 20,461 patients receiving an initial AV access, 92% had undergone preoperative vein mapping. The patients who had undergone vein mapping were more likely to be women (43.1% vs 39.8%; P = .01), outpatients (84.1% vs 81.2%; P = .002), obese (43.3% vs 39.2%; P = .002), and diabetic (62.6% vs 59.8%; P = .03). They were also more likely to have concomitant coronary artery disease (21.8% vs 18.9%; P = .008), congestive heart failure (31.3% vs 25.9%; P < .001), and concurrent tunneled dialysis catheters (43.7% vs 35%; P < .001) and to already require dialysis (55.8% vs 52%; P = .004). We found no significant difference in AVG creation between the patients who had and had not undergone vein mapping (14.2% vs 13.6%; P = .5). Furthermore, no significant correlation was found between the proportions of preoperative vein mapping and AVG creation at the center and regional levels (P = .14 and P = .1; and P = .4 and P = .11, respectively). Preoperative vein mapping was associated with higher 30-day patency (94.7% vs 90%; P = .001) and 1-year patency (90% vs 82%; P < .001) for autogenous access. On multivariable analysis, concurrent tunneled dialysis catheter use, congestive heart failure, coronary artery disease, obesity, female sex, and outpatient status were independently associated with increased preoperative vein mapping use (P < .05 for all). Preoperative vein mapping was not independently associated with AVG creation likelihood (odds ratio, 0.98; 95% confidence interval [CI], 0.81-1.17; P = .8) but was independently associated with increased 30-day patency (odds ratio, 2.23; 95% CI, 1.44-3.45; P < .001) and 1-year patency (hazard ratio, 1.56; 95% CI, 1.19-2.04; P = .001). Preoperative vein mapping was more likely to be performed in patients presenting with cardiovascular comorbidities and potential technical concerns. Vein mapping did not appear to minimize AVG creation; however, it was associated with improved autogenous access patency. Although most patients received preoperative vein mapping, increasing its use might further improve access outcomes.

Maintaining Continuous Arteriovenous Access in Mega-Fistula Repair: Surgical Technique and Outcomes

Mega-fistulae of autogenous arteriovenous (AV) access could result in arterial steal, high-output cardiac failure, or rupture with resulting hemorrhage. Current treatment options, which include ligation with or without jump prosthetic graft or imbrication, are suboptimal, leaving possible need for new accesses to be placed, cosmetically unappealing results, or future recurrent dilations. We describe a technique that allows for a complete resection of the mega-fistula while allowing continuous use of the AV access.

Cost-effectiveness analysis of radiobasilic and brachiobasilic arteriovenous fistulas in hemodialysis patients.

We evaluated the cost and efficacy of radiobasilic and brachiobasilic arteriovenous fistula (AVF) methods in terms of forearm autogenous arteriovenous access in hemodialysis patients. We used a decision tree to compare the cost-effectiveness of proximal radiobasilic AVF (pRBAVF) and brachiobasilic AVF (BBAVF), considering the mean direct medical costs and patency rates. The overall mean cost of pRBAVF per patient (1767.59 Turkish lira [TL]) was lower than that of BBAVF (1877.99 TL). Also, the mean patency duration per patient was higher for pRBAVF (25.72 months) than BBAVF (20.21 months). The incremental cost-effectiveness ratio (ICER) showed that pRBAVF was 20.04-fold more effective than BBAVF. The monthly ICERs also favored pRBAVF, which was less costly and more effective. The pRBAVF provided clinical and economic benefits for hemodialysis patients requiring forearm autogenous arteriovenous access. pRBAVF was more effective in terms of patency than BBAVF, and was also less expensive.

A Comparison of Outcomes Between Open and Endovascular Arteriovenous Access Creation for Hemodialysis

The preliminary outcomes of percutaneous endovascular autogenous access (endoAVF) have shown promising results. However, comparisons with surgical cohorts are lacking. The present study compared autogenous arteriovenous access created using the EverlinQ endoAVF system (Vascupedia, Sunnyvale, Calif) with the conventional surgical technique. We performed a multicenter, retrospective review of the data from autogenous arteriovenous access cases entered into a prospective database. Patients who had undergone radiocephalic, brachiocephalic, or endoAVF arteriovenous access from 2014 to 2019 were included. Autogenous access maturation, primary patency, secondary patency, steal syndrome, and repeat interventions were analyzed using standard statistical and survival analyses. A total of 369 accesses were created during the study period: 61 endoAVF, 171 radiocephalic, and 137 brachiocephalic (median follow-up, 17 months; range, 0-71 months). Maturation failure at the end of the follow-up period was 26.5% ± 6%, 27.0% ± 5%, and 18.4% ± 4% for endovascular, radiocephalic, and brachiocephalic access, respectively (P = .049 for brachiocephalic vs endovascular access). The primary patency rates at 12 and 24 months were 42% ± 5% and 32% ± 7% for endoAVF, 43% ± 4% and 24% ± 4% for radiocephalic access, and 42% ± 4% and 29% ± 4% for brachiocephalic access, respectively (P = NS). The secondary patency rates at 12 and 24 months were 68% ± 6% and 61% ± 7% for endoAVF, 75% ± 3% and 67% ± 4% for radiocephalic access, and 87% ± 3% and 81% ± 4% for brachiocephalic access, respectively (P = .019 for brachiocephalic vs endovascular access). No statistically significant differences were found in the incidence of ischemic steal syndrome (3.3%, 4.1%, and 8.0%; P = .229) or total reinterventions annually (0.8 ± 2.0, 0.9 ± 1.6, and 1.2 ± 1.7; P = .120) for endovascular, radiocephalic, or brachiocephalic arteriovenous access, respectively. EndoAVF compared favorably with respect to maturation and patency compared with surgically created access in a real-world cohort. The outcomes and reintervention rates were similar to those with conventional radiocephalic arteriovenous access but inferior with respect to patency and maturation using brachiocephalic access.

A comparison of Outcomes Between Open and Endovascular Arteriovenous Access Creation for Hemodialysis

Preliminary outcomes for percutaneous endovascular autogenous access (endoAVF) have shown promising results; however, comparisons with surgical cohorts in dialysis populations are lacking. The present study compared autogenous arteriovenous access created using the EverlinQ endoAVF system (TVA Medical, Becton Dickinson Co., Franklin Lakes, NJ) with accesses created by conventional surgical technique with respect to functional- and patency-related outcomes. We performed a multicenter, retrospective review of autogenous arteriovenous accesses entered into a prospective database. Patients undergoing radiocephalic, brachiocephalic, or endoAVF arteriovenous accesses from 2014 to 2019 were included. Autogenous access maturation, primary patency, secondary patency, steal syndrome, and reinterventions were collected and analyzed using standard statistical and survival analyses. A total of 369 accesses were created during the study period, including 61 endovascular accesses, 171 radiocephalic accesses, and 137 brachiocephalic accesses (median follow-up, 17 months; range, 0-71 months). Maturation failure at the end of follow-up was 26.5% ± 6%, 27.0% ± 5%, and 18.4% ± 4% for endovascular, radiocephalic, and brachiocephalic accesses, respectively (P = .049 for brachiocephalic vs endovascular access). The primary patency rates at 12 and 24 months were 42% ± 5% and 32% ± 7% for endovascular access, 43% ± 4% and 24% ± 4% for radiocephalic access, and 42% ± 4% and 29% ± 4% for brachiocephalic access, respectively (P = NS). The secondary patency rates at 12 and 24 months were 68% ± 6% and 61% ± 7% for endovascular access, 75% ± 3% and 67% ± 4% for radiocephalic access, and 87% ± 3% and 81% ± 4% for brachiocephalic access, respectively (P = .019 for brachiocephalic vs endovascular access). No statistically significant differences were found in ischemic steal syndrome (3.3%, 4.1%, and 8.0%; P = .229) or total reinterventions annually (0.8 ± 2.0, 0.9 ± 1.6, and 1.2 ± 1.7; P = .120) for endovascular, radiocephalic, or brachiocephalic arteriovenous access, respectively. EndoAVF compared favorably with respect to maturation and patency with surgically created access in a real-world cohort. The outcomes and reintervention rates were similar to those with conventional radiocephalic arteriovenous access but inferior with respect to patency and maturation compared with brachiocephalic access.

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Strategies of Hemodialysis Access

Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula), autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access, autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access, straight access, and body wall straight access, HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates. This review contains 20 figures, 3 tables, and 76 references. Keywords: Chronic Kidney Disease, End-stage renal disease, Short- and Long-term dialysis catheters, Autogenous AV access, Prosthetic AV access, HeRO graft, Arterial Steal, Venous hypertension, Pseudoaneurysm, Megafistula

Single-Center Experience of 150 Acuseal Early Cannulation Grafts

In patients with multiple failed autogenous arteriovenous accesses, use of early cannulation grafts allows immediate cannulation for hemodialysis. This study analyzes the outcomes of a single-center experience with Acuseal (Gore Medical, Newark, Del) grafts.

Influence of artery and vein diameters on autogenous arteriovenous access patency

ObjectivePrevious investigations have suggested that a minimum venous outflow diameter (MVOD) and perianastomotic arterial diameter are associated with successful autogenous arteriovenous maturation and patency. The goal of this study was to determine anatomic and clinical variables that may influence access patency to guide optimal autogenous access configuration selection. MethodsAccesses created from 2010 to 2016 were analyzed from data entered into a prospective database. Preprocedure duplex ultrasound mapping data of artery and tourniquet-derived vein diameters and demographic and clinical variables were collected. Survival-based cut point analysis was used to determine anatomic parameters most predictive of access failure. Kaplan-Meier and Cox proportional hazards analyses were used to assess patencies and maturation and to identify independent predictors of access failure. ResultsA total of 356 first-time autogenous accesses were created (median follow-up, 20 months; range, 0-73 months). Of these, 202 (56.7%) were radiocephalic and 154 (43.3%) were brachiocephalic. Maturation failure at end of follow-up for arteriovenous accesses was 26% ± 3% for radiocephalic accesses and 15% ± 3% for brachiocephalic accesses (P < .001). For radiocephalic accesses, MVOD <3.0 mm and radial artery diameter <2.1 mm independently predicted access maturation failure (MVOD <3.0 mm: hazard ratio [HR], 2.62 [95% confidence interval (CI), 1.27-5.39; P = .009]; radial artery diameter <2.1 mm: HR, 2.20 [95% CI, 1.20-4.05; P = .011]) and secondary patency loss (MVOD <3.0 mm: HR, 2.21 [95% CI, 1.24-3.96; P = .007]; radial artery diameter <2.1 mm: HR, 2.11 [95% CI, 1.26-3.63; P = .004]). A combination of radial artery diameter <2.1 mm and MVOD <3.0 mm most strongly predicted maturation failure (HR, 4.24; 95% CI, 1.71-10.49; P = .002) and loss of secondary patency (HR, 4.03; 95% CI, 1.88-8.64; P < .001). Only diabetes mellitus (HR, 2.24; P = .012) predicted secondary patency loss. For brachiocephalic accesses, MVOD <3.4 mm (HR, 2.12; 95% CI, 1.02-4.46; P = .043) was found to independently predict secondary patency loss in addition to previous ipsilateral (HR, 2.37; P = .038) and bilateral (HR, 4.00; P = .015) tunneled hemodialysis catheters. Brachial artery diameter was not associated with either access maturation or patency. ConclusionsArtery and tourniquet-derived vein diameters independently predict radiocephalic access patency and functional outcomes. A combination of a radial artery diameter <2.1 mm and MVOD <3.0 mm best predicts maturation failure and patency loss for radiocephalic access. MVOD <3.4 mm was associated with increased loss of brachiocephalic access secondary patency, but MVOD was not associated with maturation.

A national study of autogenous arteriovenous access use and patency in a contemporary hemodialysis population

ObjectiveThe predicted outcomes of autogenous arteriovenous (AV) hemodialysis access creation are predominantly based on historical data; however, both the hemodialysis population and clinical practices have changed significantly during the last decade. This study examined contemporary AV access clinical use and patencies. MethodsA multicenter observational cohort study was performed of all new AV accesses created in Scotland in 2015. The primary end point was efficacy assessed by successful AV access use for a minimum of 30 days and primary, primary assisted, and secondary patency at 1 year. Data obtained included all interventions to maintain or to restore patency. Predictors of patency loss including demographics, comorbid conditions, dialysis status, AV access location, duplex ultrasound surveillance, procedures, prior access, and antiplatelets were assessed. Kaplan-Meier and competing risks analyses were performed to estimate the probability of AV access failure. All patients were followed up for at least 1 year or had a censoring event. ResultsA total of 582 AV accesses were created in 537 patients (mean age, 60 [standard deviation, 14] years; 60% men; 42% with diabetes) in nine adult renal centers. Mean follow-up was 11.8 (standard deviation, 7.6) months. By the end of the follow-up, 322 (55.3%) AV accesses were successfully used for dialysis. At 1 year, 48% (95% confidence interval [CI], 44-52) of AV accesses had primary patency, (95% CI, 63-71) had primary assisted patency, and 69% (95% CI, 65-73) had secondary patency. The leading cause of primary patency loss was primary failure (30%). An average of 0.48 intervention per patient-year was required to maintain patency. On multivariable analysis, patency was better for an upper arm than for a forearm AV access (1-year secondary patency of upper arm vs forearm AV accesses, 74% vs 58%). The cumulative hazard and incident functions for AV access failure were 31% (95% CI, 27-35) and 23% (95% CI, 20-27) at 1 year, respectively. ConclusionsDespite advances in recent years with preoperative vessel assessment and surveillance, patency rates have not improved, with primary failure remaining the major obstacle. Competing events should be taken into consideration; otherwise, biases may occur with overestimation of the probability of AV access failure.

Unanticipated late maturation of an arteriovenous fistula after creation of separate graft access.

Autogenous arteriovenous vascular access with an arteriovenous fistula (AVF) is the gold standard for attaining long-term hemodialysis vascular access (1). When compared to prosthetic arteriovenous grafts (AVGs) and tunneled hemodialysis catheters, an AVF has less frequent rates of thrombosis, stenosis, and infection.