Surgical Creation Of Arteriovenous Fistula Research Articles

Cost-effectiveness analysis of endovascular vs surgical arteriovenous fistula creation in the United States

ObjectiveIn the United States, an estimated $2.8 billion annually is spent on vascular access and its complications. Endovascular arteriovenous fistula (endoAVF) creation is a novel, minimally invasive alternative to traditional surgical AV fistula (sAVF) creation in ≤60% of patients. Although cost effective in single-payer systems, the clinical and financial impact of endoAVF in the United States remains uncertain. MethodsWe constructed a decision tree followed by a probabilistic cohort state-transition model to study the cost effectiveness of endoAVF vs sAVF creation. We conducted a systematic review to obtain input parameters including technical success, maturation, patency, and utility values. We derived costs from the Medicare 2022 fee schedule and from the literature. We used a 5-year time horizon, an annual discount rate of 3% for costs and utilities (measured in quality-adjusted life-years [QALYs]), and the common willingness-to-pay threshold of $50,000. One-way and Monte Carlo probabilistic sensitivity analyses were performed varying technical success, patency, reintervention, cost, and utility parameters. ResultsIn the base-case scenario, endoAVF ($30,129 average per-person costs, 2.19 QALYs gained, 65% patent at 5 years) was not cost effective compared with sAVF ($12.987 average per-person costs, 2.11 QALYs gained, 66% patent at 5 years), generating an incremental cost-effectiveness ratio of $227,504 per QALY gained. In one-way sensitivity analyses, endoAVF becomes cost effective when the initial cost of sAVF creation exceeds endoAVF by ≥$600 (eg, if endoAVF creation costs ≤$3000 relative to the base-case sAVF cost of $3600), the additional QALYs gained from endoAVF exceeds 0.12 QALYs/year (eg, 0.81 QALYs gained/year from endoAVF compared with base-case sAVF 0.69 QALYs/year), the endoAVF maturation rate is >90% (base case 78%), or the sAVF maturation rate is <65% (base case 78%). Probabilistic sensitivity analysis demonstrated that sAVF remained the optimal strategy in 71% of iterations. ConclusionsEndoAVF is not cost effective compared with sAVF when modeling 5-year outcomes. The main driver of sAVF remaining cost effective is the four times higher up-front cost for endoAVF creation, as well as a relatively low additional increase in quality of life for endoAVF. It will be important to establish how the endoAVF learning curve contributes to upfront costs and, given the annual cost attributed to vascular access nationally, a randomized controlled trial is warranted.

P289 HEART FAILURE DUE TO HIGH OUTPUT ARTERIOVENOUS FISTULA IN A DIALYSIS PATIENT AFFECTED BY AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

Abstract Autosomal dominant polycystic kidney disease (ADPKD) can determine end stage renal disease (ESRD) which require haemodialysis. Surgical creation of arteriovenous fistula (AVF) has been associated with development of left ventricular (LV) dilatation and high output heart failure (HF) and right ventricle (RV) dysfunction at long term follow–up. Databases show an association between ADPKD and idiopathic dilated cardiomyopathy, suggesting that PKD mutations contribute to development of heart failure. 36 ys old female patient affected by ADPKD who required in 2018 bilateral nephrectomy, due to a relapse of severe urinary tract bleeding, and then put in thrice–weekly hemodialysis. Before the procedure in 2016 an echocardiogram showed normal biventricular function, with valvular defects. An AVF, between left humeral artery and the perforator vein of the elbow, was employed as vascular access. 6 months later she was referred to our center for atypical chest pain and palpitations. A transthoracic echocardiogram showed a diffuse hypokinesia with severe left ventricular dysfunction and dilation (EF 25%, VTDi 90ml/mq), a cardiac output of 6,5 l/min, moderate mitral insufficiency, hypokinetic RV, pulmonary artery systolic pressure (PASP) of 56mmHg, severe biatrial dilatation. No signs of congestion. She was admitted to our service. The coronary angiogram was normal, ruling out an underlying ischemic cardiomyopathy. Therapy with b–blocker and ACE–I was started. Doppler ultrasonography of the AVF was performed and showed an high output fistula. Two weeks later at Hospital discharge with medical therapy only, EF improved to 43%. Five months later, the AVF was ligated, after the creation of another more distal one. Echocardiographic re–evaluation one month after the intervention showed a normalization of left ventricular function and volumes ( EF 55%, VDTi 54ml/mq)and of PASP. In 2020 she underwent renaltransplant without complications. The patient is nowadays stable only on beta–blocker for some PVCs, with ongoing annual follow–up. Even if dilated cardiomyopathy and HF in patients affected by APDKD can be caused by genetic predisposition, in our case the main factor was a high output AVF, as showed by complete reversion of left ventricular dysfunction after its ligation.

Surgical creation of upper extremity arteriovenous fistula and grafts: a narrative review.

Surgical creation of arteriovenous fistulas (AVF) and grafts (AVG) continues to be the mainstay access for hemodialysis (HD). Avoidance of dependence on dialysis catheters continues to be a worldwide mission in dialysis access. Importantly, there is no one-size-fits-all approach to hemodialysis access and each patient should undergo access creation that is patient-centered. The aim of this paper is to review the literature, current guidelines, and discuss the common types of upper extremity hemodialysis access and their reported outcomes. We will also share our institutional experience regarding the surgical creation of upper extremity hemodialysis access. The literature review incorporates twenty-seven relevant articles from 1997 to present and one case report series from 1966. Sources were gathered from electronic databases including PubMed, EMBASE, Medline, and Google Scholar. Only articles written in the English language were considered and study designs varied from current clinical guidelines, systematic and meta-analyses, randomized controlled trials, observational studies, and two main vascular surgery textbooks. This review exclusively focuses on the surgical creation of upper extremity hemodialysis accesses. Creating a graft versus fistula ultimately is decided by the existing anatomy, and is centered around the need of the patient. Preoperatively, the patient should undergo a thorough history and physical exam, with special attention to any previous central venous access, as well as, delineating the vascular anatomy with ultrasound imaging. The major tenets of access creation are choosing the most distal site of the non-dominant upper extremity whenever possible; and ideally creation of an autogenous access is preferred over a prosthetic graft. Described in this review are multiple surgical approaches for upper extremity hemodialysis access creation and associated institutional practices performed by the surgeon author. In the postoperative period, follow up care and surveillance are imperative to preserve a functioning access. The most recent guidelines regarding hemodialysis access still favor arteriovenous fistula as the primary goal for patients with suitable anatomy. Preoperative evaluation including patient education, intraoperative ultrasound assessment, meticulous technique, and careful postoperative management are all paramount for successful access surgery. Dialysis access remains quite challenging, but with diligence the great majority of patients can be dialyzed without catheter dependence.

A Comparison Between the Efficacy and Safety of Endovascular Arteriovenous Fistula Creation and Surgical Fistula Creation: A Systematic Review and Meta-Analysis.

An endovascular arteriovenous fistula is a recent technological advancement in hemodialysis vascular access. This systematic review and meta-analysis aimed to investigate the efficacy and safety of endovascular arteriovenous fistula (eAVF) creation compared with surgical arteriovenous fistula (sAVF) creation among patients with chronic kidney disease.We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Clinical Trials.gov, and the WHO International Clinical Trials Registry Platform until May 2021 to perform meta-analyses using random-effects models. Pre-specified primary outcomes were fistula maturation, procedure-related complications, and patient satisfaction. Secondary outcomes were procedural technical success, procedure time, all adverse events, and medical expenditure. The risk of bias in non-randomized studies of the interventions assessment tool, and the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach were used to assess the quality of individual studies and the body of evidence, respectively.In seven studies including 860 patients, endovascular arteriovenous fistula creation had little to no effect on fistula maturation (odds ratio, 0.58; 95% confidence intervals, 0.05 to 6.91). Meta-analysis could not be performed for procedure-related complications and patient satisfaction due to insufficient data. For secondary outcomes, endovascular arteriovenous fistula resulted in a slight to no difference in procedural technical success (odds ratio, 0.69: 95% confidence intervals, 0.04 to 11.98) and all adverse events (odds ratio, 6.31; 95% confidence intervals, 0.64 to 62.22). Endovascular fistula creation incurred less medical expenditure than sAVF (mean difference, USD 12760; 95% confidence intervals, -19710 to -5820). Meta-analysis for procedure time was not performed because one of the studies had a critical risk of bias. All of these outcomes were of low certainty of evidence or very low certainty of evidence.There was limited evidence for supporting endovascular arteriovenous fistula creation over conventional surgical arteriovenous fistula creation for patients with chronic kidney disease. Multicenter randomized controlled trials are needed to confirm the efficacy and safety of eAVFs in selected populations.

Research Priorities for Percutaneous Arteriovenous Fistula Creation in Patients with End-Stage Renal Disease: Proceedings and Recommendations from a Multidisciplinary Research Consensus Panel

Recently developed endovascular techniques to create percutaneous arteriovenous fistulas are an alternative to surgical arteriovenous fistula creation, although there is currently a lack of high-level evidence regarding their creation, maturation, utilization, and long-term function. Recognizing this, the Society of Interventional Radiology Foundation sponsored a Research Consensus Panel and Summit for the prioritization of a research agenda to identify and address the gaps in current knowledge.

Hypoxia and hypoxia-inducible factors promote the development of neointimal hyperplasia in arteriovenous fistula.

Patients with end-stage renal failure need arteriovenous fistulas (AVF) to undergo dialysis. However, AVFs present a high rate of failure as a result of excessive venous thickness. Excessive venous thickness may be a consequence of surgical dissection and change in oxygen concentration within the venous wall. We show that venous cells adapt their metabolism and growth depending on oxygen concentration, and drugs targeting the hypoxic response pathway modulate this response in vitro. We used the same drugs on a mouse model of AVF and show that direct or indirect inhibition of the hypoxia-inducible factors (HIFs) help decrease excessive venous thickness. Hypoxia and HIFs can be targets of therapeutic drugs to prevent excessive venous thickness in patients undergoing AVF surgical creation. Because the oxygen concentration changes in the venous wall, surrounding tissue and the blood during surgical creation of arteriovenous fistula (AVF), we hypothesized that hypoxia could contribute to AVF failure as a result of neointimal hyperplasia. We postulated that modulation of the hypoxia-inducible factors (HIF) with pharmacological compounds could promote AVF maturation. Fibroblasts [normal human fibroblasts (NHF)], smooth muscle cells [human umbilical vein smooth muscle cells (HUVSMC)] and endothelial cells [human umbilical vein endothelial cells (HUVEC)], representing the three layers of the venous wall, were tested in vitro for proliferation, cell death, metabolism, reactive oxygen species production and migration after silencing of HIF1/2-α or after treatment with deferioxamine (DFO), everolimus (Eve), metformin (Met), N-acetyl-l-cysteine (NAC) and topoisomerase I (TOPO), which modulate HIF-α stability or activity. Compounds that were considered to most probably modify intimal hyperplasia were applied locally to the vessels in a mouse model of aortocaval fistula. We showed, in vitro, that NHF and HUVSMC can adapt their metabolism and thus their growth depending on oxygen concentration, whereas HUVEC appears to be less flexible. siHIF1/2α, DFO, Eve, Met, NAC and TOPO can modulate metabolism and proliferation depending on the cell type and the oxygen concentration. In vivo, siHIF1/2α, Eve and TOPO decreased neointimal hyperplasia by 32%-50%, 7 days after treatment. Within the vascular wall, hypoxia and HIF-1/2 mediate early failure of AVF. Local delivery of drugs targeting HIF-1/2 could inhibit neointimal hyperplasia in a mouse model of AVF. Such compounds may be delivered during the surgical procedure for AVF creation to prevent early AVF failure.

Preoperative assessment for percutaneous and open surgical arteriovenous fistula creation in patients for haemodialysis

Preoperative assessment prior to surgical arteriovenous fistulas (AVFs) including ultrasound-guided mapping has been shown to have beneficial effects on their immediate success as well as early outcomes. This has led to their wide acceptance and adoption however clinical practice criteria is variable and is reflected in variabilities in practice. When transposing this to percutaneously created endovascular AVFs (endoAVFs), variable preoperative assessment criteria could equally result in variable practice and potentially subsequent and expectant outcomes. We aimed to review literature on reported validated methodologies and workflows of preoperative assessment for surgical AVF creation as reported in highest levels of available evidence, specifically randomized controlled trials. Published practice recommendations and guidelines on best clinical practice as well as systematic reviews and meta-analyses of published studies were also reviewed. Data on practice methodology from identified trial publications and protocols was collated and a summative narrative synthesis was carried out which compared these methodologies to additional assessments that may be required when targeting assessment for percutaneous endoAVF formation, based on our units experience as part of an international multicentre trial. In this review we present a brief overview of published literature and guidelines and propose a unified and uniform workflow for preoperative assessment for surgical AVFs and endoAVFs to aide clinical and imaging practice.

Patient selection, education, and cannulation of percutaneous arteriovenous fistulae: An ASDIN White Paper.

End-stage kidney disease patients who are candidates for surgical arteriovenous fistula creation commonly experience obstacles to a functional surgical arteriovenous fistula, including protracted wait time for creation, poor maturation, and surgical arteriovenous fistula dysfunction that can result in significant patient morbidity. The recent approval of two endovascular devices designed to create a percutaneous arteriovenous fistula enables arteriovenous fistula creation to be placed in the hands of interventionalists, thereby increasing the number of arteriovenous fistula providers, reducing wait times, and allowing the patient to avoid surgery. Moreover, current studies demonstrate that patients with percutaneous arteriovenous fistula experience improved time to arteriovenous fistula maturation. Yet, in order to realize the potential advantages of percutaneous arteriovenous fistula creation within our hemodialysis patient population, it is critical to select appropriate patients, ensure adequate patient and dialysis unit education, and provide sufficient instruction in percutaneous arteriovenous fistula cannulation and monitoring. In this White Paper by the American Society of Diagnostic and Interventional Nephrology, experts in interventional nephrology, surgery, and interventional radiology convened and provide recommendations on the aforementioned elements that are fundamental to a functional percutaneous arteriovenous fistula.

Preoperative assessment for percutaneous and open surgical arteriovenous fistula creation in patients for haemodialysis.

Preoperative assessment prior to surgical arteriovenous fistulas (AVFs) including ultrasound-guided mapping has been shown to have beneficial effects on their immediate success as well as early outcomes. This has led to their wide acceptance and adoption however clinical practice criteria is variable and is reflected in variabilities in practice. When transposing this to percutaneously created endovascular AVFs (endoAVFs), variable preoperative assessment criteria could equally result in variable practice and potentially subsequent and expectant outcomes. We aimed to review literature on reported validated methodologies and workflows of preoperative assessment for surgical AVF creation as reported in highest levels of available evidence, specifically randomized controlled trials. Published practice recommendations and guidelines on best clinical practice as well as systematic reviews and meta-analyses of published studies were also reviewed. Data on practice methodology from identified trial publications and protocols was collated and a summative narrative synthesis was carried out which compared these methodologies to additional assessments that may be required when targeting assessment for percutaneous endoAVF formation, based on our units experience as part of an international multicentre trial. In this review we present a brief overview of published literature and guidelines and propose a unified and uniform workflow for preoperative assessment for surgical AVFs and endoAVFs to aide clinical and imaging practice.

Arteriovenous fistula creation for hypoxia after single ventricle palliation: A single‐institution experience and literature review

Hypoxia is a common and sometimes severe morbidity of single ventricle congenital heart disease (CHD). Creation of an arteriovenous fistula (AVF) is occasionally performed for patients after superior or total cavopulmonary connection (SCPC or TCPC) in an attempt to improve oxygen saturations. Despite previous reports, AVF creation is a rare palliation with inadequately defined benefits and risks. We sought to determine changes in peripheral oxygen saturation (SpO2 ) and risk of adverse event after AVF creation in children with single ventricle CHD at our institution. We conducted a retrospective chart review of patients with a history of single ventricle palliation and history of surgical AVF creation who were seen at our tertiary care center from 1996 to 2017. A total of seven patients were included in our study. SpO2 for the overall cohort did not significantly increase after AVF creation (pre-AVF 79.1±6.9%, post-AVF 82.7±6.0% [P=.23]). SpO2 trended up for large shunts (>5mm) (pre-AVF 75.0±7.6%, post-AVF 84.0±5.3% [P=.25]). SpO2 did not improve for small shunts (≤5mm) (pre-AVF 82.3±6.5%, post-AVF 81.0±8.5% [P=.50]). The 12-month overall and transplant-free survival were 85.7% and 71.4%, respectively. Freedom from AVF-related complication (cephalic edema, thrombotic occlusion) was 51.4% at 12months. Palliative AVF creation for patients with single ventricle CHD and hypoxia does not universally improve SpO2 and is prone to early complications. Despite a lack of durable benefit and known risks, AVF creation remains a reasonable palliation for a subset of patients after SCPC who are not candidates for TCPC, or potentially as a bridge to heart transplantation.

Assessment of apoptosis in the native vein used for hemodialysis access.

AimTo determine whether apoptosis is more common in previously punctured native veins than in non-punctured native veins among patients who undergo surgical creation of arteriovenous fistula (AVF) for dialysis access.MethodsCephalic vein specimens were obtained from January 1, 2013 to December 31, 2014 from 60 patients, 30 with previously punctured native veins and 30 with non-punctured native veins. Before AVF placement, a 1-cm vein segment was excised from distal part of the vein for histological, histochemical, and immunohistochemical analysis. Vein specimens were divided into two portions along the longitudinal axis and stained with hematoxylin and eosin for routine histological evaluation. Immunohistochemical analysis was used to localize Bax, p53, caspase 3, and Bcl-2 expression.ResultsThe group with previously punctured veins showed significantly increased caspase 3 (P < 0.001, two-sided Fisher`s Exact Test) and Bax expression (P = 0.002, two-sided Fisher`s Exact Test) and significantly decreased Bcl-2 expression (P < 0.001, two-sided Fisher`s Exact Test) compared with the control group. There were no significant differences between the groups in p53 expression (χ2 = 0.071, df = 1, P = 0.791). Fistula failure was significantly more common in the study group (26.7% vs 6.7%, χ2 = 4.32, df = 1, P = 0.038).ConclusionOur study indicates a possible role of venipuncture in apoptosis development and a possible role of apoptosis in fistula failure, but we do not have sufficient evidence to conclude that it represents its main cause.

Unsuccessful treatment of accelerated hypertension and persistent hyperkinetic state in a haemodialysed patient with high-output arteriovenous fistula

The case we describe concerns a rapid progression of heart failure (HF) in a patient with hypertension crises (HC), haemodialysed (HD) with the use of a high-output arteriovenous fistula (AVF). The 48-year-old male with a body mass index of 19.27 kg/m2, renal insufficiency due to glomerulonephritis, treated with HD for two years (3 × 4.0 h/week), and with uncontrolled hypertension was admitted to the Military Institute of Medicine. On examination, reduced exercise tolerance, paroxysmal nocturnal dyspnoea and blood pressure (BP) 190/90 mm Hg were found. Laboratory tests revealed NT-pro B-type natriuretic peptide 302,009.0 pg/mL (n < 300.0). Echocardiography (ECHO) showed left ventricular (LV) hypertrophy (LV mass index [LVMI] 345.81 g/m2), enlarged LV diastolic diameter [LVDD] 7.15 cm), with slightly decreased ejection fraction (EF 49%), Doppler signs of elevated cardiac output (CO 15.05 L/min; cardiac index (CI) 8.91 L/min/m2), and pseudonormalised pattern of mitral inflow with elevated LV diastolic pressure (E/E’ 31). In ultrasonographic examination of left shoulder AVF, an aneurysmal expansion of the lumen from 5.5 mm to 35 mm (Fig. 1), and significantly increased flow up to 2,532 mL/min (Fig. 2) were detected. Cardiopulmonary recirculation rate (CPR) was 0.17. Computed tomography excluded renal artery stenosis. In polysomnography, heavy central apnoea with an apnoea/hypopnoea index of 35.4/h was found. In 48-h ambulatory BP monitoring (ABPM), BP was 162/95 mm Hg. Treatment of sleep apnoea was implemented by a continuous positive airway pressure device, but this did not improve BP control. Upon discharge from hospital, the patient was overtreated with eight hypotensive drugs. After a month, HC occurred (BP 220/120 mm Hg) associated with acute coronary syndrome without ST-segment elevation. Coronarography found non-obstructive atherosclerotic plaques. Because of the suspicion of hyperkinetic state related to a lack of BP control, AVF was narrowed by implanting a polytetrafluorethylene graft of 4 mm diameter (Fig. 3). Despite AVF flow being reduced to 1,400 mL/min, after two months another HC (BP 220/125 mm Hg) with pulmonary oedema was presented. The next HC took place three months later. Although ECHO showed features of LV hypertrophy regression (LVMI 335.62 g/m2), and significant decreases of CO (8.16 L/min) and CI (4.86 L/min/m2), a decrease of EF (40%) and an LV dilatation enlargement (LVDD 7.7 cm) were also observed. AVF flow increased up to 1,750 mL/min and significant CPR 0.21 was indicated. In 24-h ABPM, BP was 173/105 mm Hg. The hypotensive treatment used has been confirmed by experts and seems to be optimal and safe for the cardiovascular system. Probably, AVF banding was performed too late, and progression of HF and lack of BP control improvement were observed. In hyperkinetic AVF, blood flow exceeds 2,000 mL/min and CPR is over 0.2–0.3. Currently, in cases of difficulties in surgical AVF creation and the necessity of haemodialysotherapy termination as a result of a lack of vascular access, banding or closure of the AVF is a very rare event. However, in some cases, early ligation of AVF may be the only effective procedure, especially when there is rapid progression of HF.

Ultrasound Guided Brachial Arterial Angioplasty during the Creation of a Radio-Cephalic Arteriovenous Fistula: A Case Report

To prevent arteriovenous fistula (AVF) early failure, due to radial or brachial artery stenosis, ultrasound guided angioplasty performed while surgically creating the AVF could be an effective procedure. A 76-year-old diabetic male patient, on hemodialysis (HD) for 15 months, presented extensive thrombosis of the radio-cephalic AVF at the right arm, which had lasted for about 10 days. Ultrasound examination showed a 40% brachial artery stenosis with eccentric calcified plaque. The stenosis was localized about 1.5 cm before the artery bifurcation. The brachial artery diameter was 0.45 cm before and 0.26 cm at the level of the stenosis, the latter being 0.45 cm long. At the left wrist, under local anesthesia, the radial artery and the cephalic vein were exposed; the radial artery was then longitudinally incised for 7-8 mm in the area selected to create the AVF. A 6 Fr introducer, a metallic guide wire and a catheter for angioplasty were inserted one after the other in the radial artery. When the correct position of the angioplasty catheter in the stenotic area was established by ultrasound examination, the balloon was blown up to 13 atm for 35 sec, reducing the stenosis from 40-20%. Finally, a side-to-side radio-cephalic fistula was created, legating the distal vein. The AVF was used for HD after 3 weeks. The follow-up at 6 months demonstrated fair access performance and it was used without problems. Our satisfactory experience suggests that ultrasound guided angioplasty of brachial artery stenosis, performed simultaneously with surgical AVF creation, is possibly a successful procedure. This technique reduces the risk of early AVF failure and also allows, when required, stent implantation.