Maintenance Of Vascular Access Research Articles

Hybrid Revision of Dysfunctional Aneurysmal Arteriovenous Fistulas.

Endovascular therapy has become the first-line treatment for failing hemodialysis arteriovenous fistulas (AVFs). However, open revision remains an important modality for vascular access maintenance and the recommended approach for AVF aneurysms. This case series describes a hybrid approach for aneurysmal access revision. Three patients were referred for second opinion after failure of endovascular therapy to establish a functioning access. The medical history is briefly described to highlight the limitations of endovascular therapy and the technical advantages of the hybrid approach in these clinical scenarios.

Venous thoracic outlet syndrome and hemodialysis.

Central venous stenotic disease is reported in 7%-40% of patients needing a central venous catheter for dialysis and in 19%-41% of hemodialysis patients who have had a prior central venous catheter. Half of these patients will be asymptomatic. Venous Thoracic Outlet syndrome in hemodialysis (hdTOS) is part of this spectrum of disease. The extrinsic mechanical compression of the subclavian vein at the costoclavicular triangle between the clavicle and 1st rib results in an area of external compression with a predisposition to intrinsic mural disease in the vein. The enhanced flow induced by the presence of a distal arteriovenous access in all patients exacerbates the subclavian vein's response to ongoing extrinsic and intrinsic injury. Repeated endovascular interventions during the maintenance of vascular access accelerates chronic untreatable occlusion of the subclavian vein in the long term. Similar to patients with central venous stenosis, patients with hdTOS can present immediately after access formation with ipsilateral edema or longitudinally with episodes of access dysfunction. hdTOS can be treated in an escalating manner with arteriovenous access flow reduction to <1,500 ml/min, endovascular management, surgical decompression by first rib resection in healthy patients and medial clavicle resection in less healthy patients followed by secondary venous interventions, or finally, a venous bypass. hdTOS represents a complex and evolving therapeutic conundrum for the dialysis community, and additional clinical investigations to establish robust algorithms are required.

Arteriovenous Graft Failure in the Veterans Health Administration: Outcome Disparities Associated with Race.

Background Vascular access for ongoing hemodialysis often fails, frequently requiring repeated procedures to maintain vascular patency. While research has shown racial discrepancies in multiple aspects of renal failure treatment, there is poor understanding of how these factors might relate to vascular access maintenance procedures after arteriovenous graft (AVG) placement. Purpose To evaluate racial disparities associated with premature vascular access failure after percutaneous access maintenance procedures following AVG placement using a retrospective national cohort from the Veterans Health Administration (VHA). Materials and Methods All hemodialysis vascular maintenance procedures performed at VHA hospitals between October 2016 and March 2020 were identified. To ensure the sample represented patients who consistently used the VHA, patients without AVG placement within 5 years of their first maintenance procedure were excluded. Access failure was defined as a repeat access maintenance procedure or as hemodialysis catheter placement occurring 1-30 days after the index procedure. Multivariable logistic regression analyses were performed to calculate prevalence ratios (PRs) measuring the association between hemodialysis maintenance failure and African American race compared with all other races. Models controlled for vascular access history, patient socioeconomic status, and procedure and facility characteristics. Results In total, 1950 access maintenance procedures in 995 patients (mean age, 69 years ± 9 [SD], 1870 men) with an AVG created in one of 61 VHA facilities were identified. Most procedures involved African American patients (1169 of 1950, 60%) and patients residing in the South (1002 of 1950, 51%). Premature access failure occurred in 215 of 1950 (11%) procedures. When compared with all other races, African American race was associated with premature access site failure (PR, 1.4; 95% CI: 1.07, 1.43; P = .02). Among the 1057 procedures in 30 facilities with interventional radiology resident training programs, there was no evidence of racial disparity in the outcome (PR, 1.1; P = .63). Conclusion African American race was associated with higher risk-adjusted rates of premature arteriovenous graft failure after dialysis maintenance. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Forman and Davis in this issue.

The challenging surgical vascular access creation.

With the increasing life expectancy of patients with end-stage kidney disease, the creation and maintenance of hemodialysis vascular access are becoming more challenging. A comprehensive patient evaluation including a complete history, physical examination, and ultrasonographic vessel assessment is the foundation of the clinical evaluation. A patient-centered approach acknowledges the myriad of factors that impact the selection of optimal access for the distinct clinical and social circumstance of each patient. An interdisciplinary team approach involving various healthcare providers in all stages of hemodialysis access creation is important and associated with better outcomes. While patency is considered the most important parameter in most vascular reconstructive scenarios, the ultimate determinant of success in vascular access for hemodialysis is a circuit that allows consistent and uninterrupted delivery of the prescribed hemodialysis. The best conduit is one that is superficial, easily identified, straight, and of a large caliber. Individual patient factors and skill level of the cannulating technician also play a crucial role in the initial success and maintenance of vascular access. Special attention should be considered in dealing with more challenging groups such as the elderly population where the newest vascular access guidance from The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative will be transformative. The current guidelines recommend monitoring the vascular access by regular physical and clinical assessments, however, inadequate evidence is available to support routine ultrasonographic surveillance for improving access patency.

MO785: Balancing the Covid-19 Pandemic Impact on the Maintenance of Haemodialysis Vascular Access

BACKGROUND AND AIMSThe new coronavirus disease, named by World Health Organization (WHO) as COVID-19 brought great challenges to patients with end-stage renal disease (ESRD). In general, ESRD patients have a higher number of comorbidities and are at risk for the severe presentation of this disease.As a lifeline of haemodialysis patients, vascular access (VA) care has a profound impact on the patient's quality of dialysis and life but the ideal management of VA during the pandemic is currently unknown.Many centres differed on their approach and referral criteria to minimize COVID-19 risk but the impact on VA and patient survival is unknown.In this multicentre retrospective cross-sectional study, we analysed the impact of the pandemic on VA maintenance in Vascular Access Centres of Nephrocare Portugal.METHODThe authors collected VA data from haemodialysis patients treated at three Vascular Access Centers of NeproCare Portugal from January 2019 to July 2021 and compared the year before and after the pandemic.RESULTSOf the 14 352 haemodilaysis patients included, with a mean age of 68 ± 14 years, 7.161 procedures were analysed.A total of 4086 endovascular procedures and 3075 surgeries were performed from January 2019 to July 2021 in the three national vascular access centres of Nephrocare.Blood flow decrease measured by the blood temperature sensor BTM_ (Blood Temperature Monitor), Fresenius Medical Care, Bad Homburg, Germany was the most frequent motive of referral to an endovascular procedure before and after the pandemic (P .221).During both waves, physical examination and clinical signs were the most affected motives of referral, followed by a rebound significantly increase (P .058).Thrombosis remained stable during the lockdown followed by a non-significant trend to increase.New vascular access creation was the most frequent motive to send a patient to surgery before and after the pandemic (P .480).Fistula and prosthesis thrombosis also didn't significantly increase as a motive of referral to a VAC (P .221 and 1.0 respectively).Angioplasty without stent followed by thrombolysis was the most frequent types of endovascular procedures before and during the pandemic without significant differences (P .430).Surgical thrombectomy followed by fistula creation were the most frequent types of surgical procedures before and during the pandemic without significant differences (P .683).During the first wave, there was a decrease in procedures without possibility to intervention (P .037) with posterior significant rebound increase.Although there was a trend to a decrease in intervention, the number and types of procedures didn't significantly change before and during the pandemic even after separating different centres.Additionally, the number of hospital admissions related to vascular access also didn't significantly change (P .368).CONCLUSIONWith the implementation of proactive infection control measures, it was possible to maintain proper monitoring, surveillance and VA care without significantly increasing the rate of thrombosis and minimizing related hospital admissions of haemodialysis patients.

The Impact of Seasonality on Prosthetic Arteriovenous Vascular Access Graft Thrombosis

Highlights Abstract Introduction: Arteriovenous prosthetic grafts are susceptible to recurrent thrombotic occlusions mainly due to venous outflow disease secondary to neointimal hyperplasia. Maintenance of vascular access for dialysis is a perpetual challenge for both patients and health care systems. In regions with hotter climates, there is a clinical impression that episodes of prosthetic arteriovenous vascular access graft thrombosis are more frequent during hot dry summers secondary to dehydration and increased blood viscosity. Seasonality of thrombotic events has been observed in multiple vascular beds. However, a seasonal pattern or any association of arteriovenous graft thrombosis with temperature and relative humidity levels has never been fully demonstrated. Methods: Data were collected prospectively from January 2014 until December 2020 but analyzed retrospectively. In this 7-year timeframe, 289 episodes of arteriovenous graft thrombosis were identified from 142 grafts fashioned. Results: No monthly variation (P = 0.35) or seasonal variation (P = 0.91) was identified. No statistically significant correlation between episodes of thrombosis and mean monthly temperature and mean relative humidity was noted. Conclusion: No evidence was identified to support this theory. However, multiple issues with assessments of events must be conceded. Graft thrombosis is multifactorial in nature, and venous outflow disease contributes toward a significant number of these events. Within our local cohort, a low primary patency rate was identified, which further contributes to graft interventions. Relatively small numbers were recruited, and therefore, potential correlations could have been missed.

Endovasal laser obliteration of arteriovenous fistulas in patients on chronic hemodialy

Introduction. Vascular access complications are associated with about 30% of patient hospitalizations, and annual costs of vascular access maintenance account for 14–20% of total healthcare costs for dialysis patients. At the same time, current international clinical guidelines emphasize the need to implement a patient-centered approach with planning of possible vascular access complications and selection of optimal surgical interventions (risk/benefit balance) for correction of compromised access.Aim. To present the first experience of endovasal laser obliteration of arteriovenous fistulas for correction of venous hypertension syndrome.Materials and methods. The first experience of complicated arteriovenous fistulas liquidation using endovasal laser obliteration in 6 patients receiving hemodialysis replacement therapy for stage 5 chronic kidney disease (National kidney Foundation (NkF) classification) is presented. In 5 patients due to the presence of venous hypertension of the upper extremity, where the arteriovenous fistula functioned, open intervention was unacceptable because of the high risk of bleeding. In one patient the arteriovenous fistula was closed due to its aneurysmatic transformation. we performed endovasal laser obliteration of four Cimino-type radial artery-cephalic arteriovenous fistulas, one brachial-basilar arteriovenous fistula, and one brachial-cubital arteriovenous fistula. Endovasal laser obliteration was performed with an endovascular light guide under ultrasound navigation using tumescent anesthesia. we used a laser device with a wavelength of 1.56 µm and power of 15 w, working in continuous mode (time 2–4 min, energy density 500 to 1,000 J/cm). The average diameter (Me) of the fistula vein was 8 mm.Results. The course of the early postoperative period in all patients was uncomplicated. The follow-up period was 30 days. Symptoms of venous hypertension were eliminated in all patients, the pain syndrome disappeared completely, there were slight feelings of heaviness and fullness of the limb.Discussion. Experience has shown that standard modes used for varicose vein obliteration for elimination of arteriovenous fistulas in chronic renal failure are ineffective: under conditions of blood flow in the area of arteriovenous anastomosis the energy density is almost 10 times higher. Therefore, other modes were used in our study: energy density from 500 to 1,000 J/cm. This was due to the lack of coagulation of the fistula vein when using standard parameters due to high blood flow rate, despite the use of proximal and distal vascular compression. In all cases we obtained positive results (obliteration of arteriovenous fistulas) without complications along with the correction of venous hypertension within 1 month after the intervention.Conclusion. The advantages of this method are technical simplicity and minimal blood loss, which is especially important for this cohort of patients with initial anemia against chronic renal failure.

Sono-angiography for dialysis vascular access based on the freehand 2D ultrasound scanning.

Dialysis vascular access, preferably an autogenous arteriovenous fistula, remains an end stage renal disease (ESRD) patient's lifeline providing a means of connecting the patient to the dialysis machine. Once an access is created, the current gold standard of care for maintenance of vascular access is angiography and angioplasty to treat stenosis. While point of care 2D ultrasound has been used to detect access problems, we sought to reproduce angiographic results comparable to the gold standard angiogram (fistulogram) using ultrasound data acquired from a conventional 2D ultrasound scanner. A 2D ultrasound probe was used to acquire a series of cross sectional images of the vascular access including arteriovenous anastomosis of a subject with a radio-cephalic fistula. These 2D B-mode images were used for 3D vessel reconstruction by binary thresholding to categorize vascular versus non-vascular structures followed by standard image segmentation to select the structure representative of dialysis vascular access and morphologic filtering. Image processing was done using open source Python Software. The open source software was able to: (1) view the gold standard fistulogram images, (2) reconstruct 2D planar images of the fistula from ultrasound data as viewed from the top, analogous to computerized tomography images, and (3) construct a 2D representation of vascular access similar to the angiogram. We present a simple approach to obtain an angiogram-like representation of the vascular access from readily available, non-proprietary 2D ultrasound data in the point of care setting. While the sono-angiogram is not intended to replace angiography, it may be useful in providing 3D imaging at the point of care in the dialysis unit, outpatient clinic, or for pre-operative planning for interventional procedures. Future work will focus on improving the robustness and quality of the imaging data while preserving the straightforward freehand approach used for ultrasound data acquisition.

Effect of Infrared Irradiation Combined with External Application Nursing on Maintenance of Vascular Access in Hemodialysis Patients

Objective: This paper mainly analyzes the effect of infrared radiation combined with external application nursing on maintenance of vascular access in hemodialysis patients. Methods: A total of 150 hemodialysis patients in our hospital from December 2019 to September 2020 were divided into the conventional group and the study group, 75 cases in each group. The conventional group was given external application nursing alone, and the study group was given infrared radiation combined with external application nursing, and the effect on the maintenance of vascular access was counted. Results: After the intervention, the indexes of URR, kt / V and human albumin in the study group were higher than those in the routine group, and the indexes of ?2-mg and MIS in the study group were lower than those in the routine group, P &lt; 0.05;The improvement of vascular elasticity and quality of life in the study group was higher than that in the conventional group, and the incidence of complications was lower than that in the conventional group, P &lt; 0.05. Conclusion: Infrared radiation combined with external application of nursing care in hemodialysis patients with vascular access maintenance effect is significant, can effectively improve vascular elasticity.

Interventional nephrology: A review of literature

Interventional nephrology (IN) is one of the prominent nephrology fields that mainly copes with the diagnosis and treatment of patients with renal failure by using special techniques, such as ultrasonography of kidneys, performance of kidney biopsy, insertion of peritoneal dialysis catheters, tunneled dialysis catheters, and maintenance of vascular access for patients receiving hemodialysis. The IN also deals with performing percutaneous endovascular procedures to maintain arteriovenous fistulas or grafts that are functional in patients with renal failure. When performed by a variety of experts, all these procedures resulted in delays in diagnosis and treatment. This led to the formation of a team of nephrologists who started performing these procedures themselves. They opened training centers and provided training to other nephrologists. Excellent results were obtained when these procedures were performed by nephrologists. The IN has ensured to provide renal care with effectiveness, safety, and reduced costs. There is a need to develop awareness among the people, so that these procedures can be performed in an outpatient setting with lower costs. Nephrologists should get adequate training to develop necessary skills to provide standard renal care.

Hemodialysis Vascular access maintenance in the Covid-19 pandemic: Positioning paper from the Interventional Nephrology Committee of the Brazilian Society of Nephrology.

ABSTRACTVascular accesses for hemodialysis are considered the patient’s lifeline and their maintenance is essential for treatment continuity. Following the example of institutions in other countries affected by the Covid-19 pandemic, the Brazilian Society of Nephrology developed these guidelines for healthcare services, elaborating on the importance of carrying out procedures for the preparation and preservation of vascular accesses. Creating definitive accesses for hemodialysis, grafts and arteriovenous fistulas are non-elective procedures, as well as the transition from the use of non-tunneled catheters to tunneled catheters, which cause less morbidity. In the case of patients with suspected or confirmed coronavirus infection, one may postpone the procedures for the quarantine period, to avoid spreading the disease.

The creation and maintenance of vascular access for chronic hemodialysis in the Moscow region: a five-year experience of a regional center

Aim:to analyze the results of the regional center for the creation and maintenance of vascular access for hemodialysis.Materials and methods.We performed a retrospective analysis. In five years (2012–2016) we performed 3,837 different operations on vascular access (VA) in 1,862 patients.Results.There is a strong dependence of type VA and the cause of CKD 5D. At the time of the HD start, the proportion of arteriovenous fistula (AVF), synthetic vascular graft (SVG) and central venous catheter (CVC) was 73.7, 0.3 and 26% for glomerulonephritis; 58.4, 0.4 and 41% for pyelonephritis; 53, 1 and 26% for diabetes mellitus; 32, 8 and 60% for polycystic disease and 33, 2 and 65% for systemic processes, respectively. After one year on HD the shares of AVF, SVG and CVC were 89, 2 and 9% for glomerulonephritis; 76, 6 and 18% of pyelonephritis; 70, 5 and 25% for diabetes mellitus; 68, 10 and 22% for polycystic disease and 53, 5 and 42% for systemic processes, respectively. In a case of start of HD via AVF, five years survival was 61% [95% CI 51.8; 71.9]; in a case of start HD via CVC with followed by conversion to AVF – 53.9% [95% CI 42.5; 67]; in a case of CVC remained the only access – 31.6% [21.4; 41.4]. Non-maturation of AVF was observed in 5.9% of new AVF (the risk increased in a case of diabetes mellitus), early thrombosis (before the first use of AVF) was observed in 12.7% of new AVF (the risk increased with diabetes, polycystic and systemic diseases). Creation of AVF a week before the start of HD or 1–2 weeks later significantly increased the risk of thrombosis. Primary patency in a year, three and five years was 77.2% (95% CI 71.7; 81.7); 48% (95% CI 41.6, 54.1); 34.1% (95% CI 27.8, 40.5) respectively; secondary patency – 87% [95% CI 83.7; 89.7]; 74.4% [95% CI 70.3; 78,12]; 60.9% [95% CI 56.4; 65.1] respectively. The use of temporary CVC is associated with a three-fold increase of the risk of infection compared with permanent CVC: IRR 3,31 (2,46; 4,43), p &lt; 0,0001.Conclusion.A more detailed analysis is required to identify risk factors for complications of vascular access and to optimize approaches to its creation and maintenance.

Vascular access for hemodialysis: Current practice in Vietnam.

A well-functioning vascular access is a mainstay to perform an efficient hemodialysis procedure, which directly affects the quality of life in hemodialysis patients. We use three main types of access: native arteriovenous fistula, arteriovenous graft, and central venous catheter. Arteriovenous fistula remains the first and best choice for chronic hemodialysis. It is the best access for longevity, the lowest related complications, and for this reason, arteriovenous fistula use is strongly recommended by guidelines from different countries, including Vietnam. In practice, well-functioning arteriovenous fistula creation is not always simple. In this case, arteriovenous fistula creation with vein transposition or translocation is certainly useful. When native vein options have been exhausted, prosthetic can be used as the second option of maintenance hemodialysis access alternatives. Central venous catheters are very common and have become an important adjunct in maintaining patients on hemodialysis. In Bach Mai hospital, we certainly create about 1000 new arteriovenous fistulas every year (among these, about 84.98% new hemodialysis patients start hemodialysis without permanent accesses and depend on temporary central venous catheters) and successfully matured arteriovenous fistula rate is 92.6%. Among hemodialysis population in Bach Mai, 2.29% have arteriovenous grafts and 2.81% of patients still depend on cuffed tunneled catheters. The preferable locations for catheter insertions are the internal jugular and femoral veins. Proper vascular access maintenance requires integration of different professionals to create a vascular access team. Percutaneous transluminal angioplasty is not available. In our circumstance, we have achieved some advantages for hemodialysis patients but still a big gap to an advanced country.

Guía Clínica Española del Acceso Vascular para Hemodiálisis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Drug eluting balloons for resistant arteriovenous dialysis access stenosis.

Vascular access maintenance is vital for hemodialysis patients. Conventional balloon angioplasty is the gold standard of treatment in endovascular therapy according to published guidelines, accompanied by bare metal stents as a bail-out method. Several devices have been used so far with a view to improve patency outcomes, but only covered stents have been proposed as a valid alternative and only for venous juxta-anastomotic stenosis of arteriovenous grafts. Paclitaxel-coated balloons (PCBs) have been extensively investigated in the last few years in pilot studies with small numbers of patients in dialysis access. Results from these studies have been promising so far; however, a larger number of subjects is needed to prove outcomes. Aim of this analysis is to discuss current available studies and explore some critical aspects of PCB use in dialysis access treatment.

A national appraisal of haemodialysis vascular access provision in Scotland.

Published registry data demonstrate longstanding variation in the utilisation of different vascular access (VA) modalities between Scottish renal units; this may reflect different clinical processes between centres. A comprehensive appraisal was undertaken to understand the processes underpinning VA creation and maintenance across Scotland. A mixed methods approach was utilised. Fifty-two semi-structured interviews were conducted with patients and clinicians in all ten, adult and paediatric, Scottish renal units. Interview transcripts were subjected to thematic analysis. Clinical activity data were prospectively collected for six weeks, and correlated with registry data. VA accounts for a large clinical workload. There was significant inter-centre variation in the utilisation of different VA modalities, and patients described frustrating, dissatisfying experiences. VA creation and maintenance pathways functioned best when nephrologists, surgeons and radiologists were co-located on the same campus with close multi-disciplinary working, protected clinical time, and proactive VA maintenance. No unit routinely measured or discussed procedure outcomes or strategic aspects of their service. Varied clinical outcomes reflected varied clinical processes. Optimised clinical pathways, staff education and measurement of clinical outcomes may improve VA service quality and facilitate safer, more effective, patient-centred care.

VASCULAR ACCESS IN PATIENTS ON CHRONIC HEMODIALYSIS IN THE MOSCOW REGION: CURRENT STATE AND OUTLOOK

Background: The prevalence of chronic kidney disease (CKD) is annually growing worldwide. Stable functioning arteriovenous fistula (AVF) is one of the main prerequisites of survival for patients on chronic hemodialysis (HD). As a rule, available clinical guidelines for creation and maintenance of HD vascular access do not give a clear answer to some important questions. We have summarized and analyzed our experience of the creation and maintenance of the vascular access. Aim: To analyze the results of the creation and maintenance of vascular access in a large population of patients on chronic HD (in the Moscow Region). Materials and methods: We analyzed the results of 3837 surgeries for creation and reconstruction of the vascular access in 1862 patients, performed from 2012 to 2016. Results: The CKD stage 5D incidence has increased from 239 to 391 over the last three years. Currently, 2204 patients are followed up and receiving treatment in 38 outpatient centers. Almost one half of all interventions, 43.5% (1668/3837), has been performed to create AVF. Only one third, i.e. 33% (1266/3837) of them was de novo operations, whereas 10.5% (403/3837) were done to create a new AVF in HD patients after thrombosis of the existing AVF. 15.4% (590/3837) of the interventions were performed for AVF reconstruction, 4% (154/3837) for AVF closure after successful kidney transplantation, 3.2% (121/3837) for creation of AVF with vascular graft, 3% (115/3837) for thrombectomy from the graft, 14.6% (559/3837) to implant a permanent central venous catheter (CVC), and 13.6% (520/3837) for placement of a temporary CVC. 54.4% (1012/1862) of the patients had their functional AVF, 2.2% (41/1862) had a vascular graft at the beginning of HD, and one year later, there were 73.8% (1152/1561) and 5.3% (83/1561) of such patients, respectively. The type of vascular access at the start of HD strongly depended on the cause of CKD. 60.4% (192/318) of patients with polycystic kidney disease and 65.1% (181/278) with systemic disease or cancer started HD with the CVC. Oneyear survival of patients who started HD with AVF, who started HD with CVC and switched to AVF, and those who initiated and continued HD with CVC only, was 87.5% (95% confidence interval [CI] 83.5– 90.6), 79.6% [95% CI 72.3–82.5], and 66.4% (95% CI 57–74.2), respectively. The 5-year survival in these groups was 61% (95% CI 51.8–71.9), 53.9% (95% CI 42.5–67), and 31.6% (95% CI 21.4–41.4), respectively. At one year, primary and secondary AVF patency amounted to 77.2% (95% CI 71.7–81.8) and 87% (95% CI 83.7–89.7), respectively, at 5 years 34.1% (95% CI 27.8–40.5) and 60.9% (95% CI 56.4– 65.1), respectively. Conclusion: A more detailed analysis is necessary to identify risk factors for complications of the vascular access and to optimize approaches to its creation and reconstruction. An effective way to achieve this goal is to establish a local registry of CKD patients.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Strategies for Hemodialysis Access: A Vascular Surgeon’s Perspective

Problems related to hemodialysis access are a significant cause of morbidity and mortality in patients with end-stage renal disease. Physicians of all specialties who are involved in the placement and maintenance of vascular access for hemodialysis must have a long-term strategy for sequential placement of autogenous fistulas, transpositions, and prosthetic grafts to preserve access sites and to avoid long-term use of tunneled dialysis catheters. The Fistula First and KDOQI initiatives have provided strategies and algorithms for access placement in patients with chronic kidney disease. Preservation of veins should begin before dialysis access is necessary to achieve the goal of creating a primary arteriovenous (AV) fistula or transposition suitable for cannulation when dialysis is initiated. Prosthetic and biologic grafts offer reasonable alternatives when autogenous access is not feasible. Newer graft materials and conduits are under evaluation to improve long-term outcomes. Use of tunneled dialysis catheters should be discouraged and they should be considered a last resort for long-term access. We present a strategy from the perspective of a vascular surgeon for the sequential placement of AV fistulas, venous transpositions, and AV grafts in these challenging patients. We also discuss specific concerns regarding hemodialysis access in difficult patient populations such as the elderly patient and the morbidly obese patient.

Hemodialysis Vascular Access: Rising Costs as a Surrogate Marker for Patency and Function of Arteriovenous Fistulas

Establishment and maintenance of vascular access for hemodialysis is life-sustaining for patients needing renal-replacement therapy. Arteriovenous fistulas (AVFs) are the preferred type of access, but the costs associated with creation and maintenance are poorly characterized, especially with respect to patient characteristics. A prospectively maintained registry has been established at The Mount Sinai Hospital for patients undergoing access procedures since 2007. We studied 163 patients undergoing successfully placed and cannulated AVFs as their first permanent ipsilateral access and for whom 3-year follow-up was available, including 18 patients with failed contralateral AVFs. Records were analyzed for institutional inpatient and outpatient procedures related to access maturation, imaging, catheter-related procedures, and revisions. We determined hospital costs for 3 AVF locations, assessing the contribution of various factors to variation in costs and patency. The median first-year cost of patent AVFs was $8,662, with $4,754 attributable to initial creation. For fistulas remaining patent for at least 3years, median cumulative 36-month costs were $11,639, with $1,343 attributable to imaging and $10,478 to creation and interventions. Fistulas with patent lifetimes of 19-30months (3.7%) had median cumulative costs of $26,035. Those with patent lifetimes of 6months or shorter (6.7%) had median cumulative costs of$17,526. Right-sided fistulas were associated with 41% higher 1-year costs and 38% higher 3-year costs when compared with left-sided fistulas. Human Immunodeficiency Virus (HIV) status and prior history of complex contralateral access were also associated with higher 1-year and 3-year costs. Hemodialysis access maintenance contributes significantly to the healthcare burden of renal disease. Our data suggest that particular patient characteristics factor into patency and costs. Short-term mounting costs associated with AVF maintenance may portend poor long-term patency. Rising healthcare costs cannot be easily controlled without understanding the clinical factors driving them.