Vascular Access Care Research Articles

Ultrasound- Versus Landmark-Guided Femoral Catheterization in the Pediatric Catheterization Laboratory: A Randomized-Controlled Trial

Ultrasound (US) is the standard of care for vascular access in many clinical scenarios. Limited data exist regarding the benefits of US- versus landmark (LM)-guided femoral vascular access in the pediatric catheterization laboratory. This study aimed to compare US- and LM-guided vascular access in the pediatric catheterization laboratory. A single operator randomized 95 patients (201 vessels) to undergo either LM- or US-guided vascular access. The primary end point was the access success rate. Number of attempts, inadvertent access, time to sheath placement, and complications also were compared between the two groups. No difference was seen in the overall access success rate: 98 % with US versus 93 % with LM (p = 0.17). The success rate for the targeted vessel was higher with US (89 %) than with LM (67 %) (p = 0.012). US facilitated fewer attempts (1.1 ± 0.4 vs 1.4 ± 0.9; p = 0.048) and improved the first-attempt success rate (87 vs 77 %; p = 0.049). The time to access did not differ significantly between the two groups (US 2:55 ± 4:03 vs LM 3:37 ± 2:54; p = 0.28). No differences in complication rates were noted. The benefits of US were accentuated in the subgroup weighing less than 10 kg. In this study, US access in the pediatric catheterization laboratory did not improve overall success. However, US improved accuracy and reduced the number attempts necessary for access without prolonging the access time of the procedure. Small children realized the greatest benefit of US-guided access.

Vascular access management and education for hemodialysis patients

Appropriate management and care of vascular access are very important to hemodialysis patient care. Access is the cornerstone of hemodialysis therapy. Vascular access with good function and few complications not only promotes hemodialysis therapy success but also facilitates the ability of patients to restore normalcy to life. Proper vascular access maintenance requires good cooperation between medical care personnel and patients. Nurses are responsible to apply their professional knowledge and technology in clinical practice and educate and encourage patients to take care of themselves. Patients are responsible to apply learned self-care knowledge to their daily life. Such cooperation is essential to enhancing the effectiveness of comprehensive care. This article provides an overview of vascular access issues in hemodialysis therapy, including related nursing assessment, management, and proper cannulation procedures. Enhancing patient self-care abilities and working together with patients on proper vascular access care can prolong vascular access site viability.

Barriers to adopting a fistula-first policy in Europe: an international survey among national experts.

The purpose of this study is to explore how vascular access care was reimbursed, promoted, and organised at the national level in European and neighbouring countries. An electronic survey among national experts to collect country-level data. Forty-seven experts (response rate, 76%) from 37 countries participated. Experts from 23 countries reported that 50% or less of patients received routine preoperative imaging of vessels. Nephrologists placed catheters and created fistulas in 26 and 8 countries, respectively. Twenty-one countries had a fee per created access; the reported fee for catheter placement was never higher than for fistula creation. As the number of haemodialysis patients in a centre increased, more countries had a dedicated coordinator or multidisciplinary team responsible for vascular access maintenance at the centre-level; in 11 countries, responsibility was always with individual nephrologists, independent of a centre's size. In 23 countries, dialysis centres shared vascular access care resources, with facilitation from a service provider in 4. In most countries, national campaigns (n = 35) or educational programmes (n = 29) had addressed vascular access-related topics; 19 countries had some form of training for creating fistulas. Forty experts considered the current evidence base robust enough to justify a fistula-first policy, but only 13 believed that more than 80% of nephrologists in their country would attempt a fistula in a 75-year-old woman with comorbidities. Suboptimal access to surgical resources, lack of dedicated training of clinicians, limited routine use of preoperative diagnostic imaging and patient characteristics primarily emerged as potential barriers to adopting a fistula-first policy in Europe.

Competence is central to vascular access care

Competence is central to vascular access care

Ultrasound as a Tool for Preoperative Planning, Monitoring, and Interventions in Dialysis Arteriovenous Access

The rising prevalence of end-stage renal disease has resulted in increasing focus on delivery of vascular access care for hemodialysis. Duplex Doppler ultrasound, with its unique ability to reliably evaluate both structural and functional aspects of the peripheral vessels, is the preferred imaging modality for access planning and follow-up. This article will review how ultrasound is currently used to evaluate patients pre-, intra-, and postoperatively for vascular access.

Vascular Access Care and Treatment Practices Associated with Outcomes of Arteriovenous Fistula: International Comparisons from the Dialysis Outcomes and Practice Patterns Study

Background: Vascular access (VA) guidelines recommend the native arteriovenous fistula (AVF) as VA of first choice for chronic hemodialysis patients. AVF management is important in hemodialysis patient care. AVF survival is associated with various physical factors, but the effects of dialysis treatment factors upon AVF survival are still not clear. Methods: Study patients were treated at 498 dialysis facilities participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS) 2 or 3 (2002-2007). Analyses included 1,183 incident hemodialysis patients (on dialysis ≤7 days and using an AVF at study entry) and 949 prevalent patients (on dialysis >7 days at DOPPS entry and using a new AVF created during study observation). AVF survival was modeled from the study entry date for incident patients and date of first AVF use for prevalent patients. Predictors of primary and final AVF survival were compared across Japan, North America and Europe/Australia/New Zealand (EUR/ANZ) with adjustments for patient characteristics. Results: No meaningful relationship was seen between AVF survival and various physician and staff practices. However, patients with prior catheter use displayed higher rates of primary and final AVF failure. Final AVF failure rates were higher in facilities with higher median blood flow rates (BFR). They were also greater in North America and EUR/ANZ than in Japan, but this difference was substantially attenuated after accounting for regional differences in facility median BFR. Conclusion: AVF longevity differed according to the DOPPS region, and was related to prior patient catheter use and facility BFR practice. Further longitudinal studies may help demonstrate meaningful associations between VA-handling skill and patency.

Clinical and Economic Value of Performing Dialysis Vascular Access Procedures in a Freestanding Office‐Based Center as Compared with the Hospital Outpatient Department among Medicare ESRD Beneficiaries

Dialysis vascular access (DVA) care is being increasingly provided in freestanding office-based centers (FOC). Small-scale studies have suggested that DVA care in a FOC results in favorable patient outcomes and lower costs. To further evaluate this issue, data were drawn from incident and prevalent ESRD patients within a 4-year sample (2006-2009) of Medicare claims (USRDS) on cases who receive at least 80% of their DVA care in a FOC or a hospital outpatient department (HOPD). Using propensity score matching techniques, cases with a similar clinical and demographic profile from these two sites of service were matched. Medicare utilization, payments, and patient outcomes were compared across the matched cohorts (n=27,613). Patients treated in the FOC had significantly better outcomes (p<0.001), including fewer related or unrelated hospitalizations (3.8 vs. 4.4), vascular access-related infections (0.18 vs. 0.29), and septicemia-related hospitalizations (0.15 vs. 0.18). Mortality rate was lower (47.9% vs. 53.5%) as were PMPM payments ($4,982 vs. $5,566). This study shows that DVA management provided in a FOC has multiple advantages over that provided in a HOPD.

Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Patients on Chronic Dialysis in the United States, 2005-2011

Approximately 15 700 invasive methicillin-resistant Staphylococcus aureus (MRSA) infections occurred in US dialysis patients in 2010. Frequent hospital visits and prolonged bloodstream access, especially via central venous catheters (CVCs), are risk factors among hemodialysis patients. We describe the epidemiology of and recent trends in invasive MRSA infections among dialysis patients. We analyzed population-based data from 9 US metropolitan areas from 2005 to 2011. Cases were defined as MRSA isolated from a normally sterile body site in a surveillance area resident who received dialysis, and were classified as hospital-onset (HO; culture collected >3 days after hospital admission) or healthcare-associated community-onset (HACO; all others). Incidence was calculated using denominators from the US Renal Data System. Temporal trends in incidence and national estimates were calculated controlling for age, sex, and race. From 2005 to 2011, 7489 cases were identified; 85.7% were HACO infections, and 93.2% were bloodstream infections. Incidence of invasive MRSA infections decreased from 6.5 to 4.2 per 100 dialysis patients (annual decrease, 7.3%) with annual decreases of 6.7% for HACO and 10.5% for HO cases. Among cases identified during 2009-2011, 70% of patients were hospitalized in the year prior to infection. Among hemodialysis cases, 60.4% of patients were dialyzed through a CVC. The 2011 national estimated number of MRSA infections was 15 169. There has been a substantial decrease in invasive MRSA infection incidence among dialysis patients. Most cases had previous hospitalizations, suggesting that efforts to control MRSA in hospitals might have contributed to the declines. Infection prevention measures should include improved vascular access and CVC care.

Interventional Nephrology

The nascent field of interventional nephrology has its origins from the mid-1980s when a nephrologist named Gerald Beathard was frustrated by the challenges facing timely and effective care of vascular access in his ESRD patients. He took it upon himself to train and then perform angiograms and

Bloodstream Infection Rates in Outpatient Hemodialysis Facilities Participating in a Collaborative Prevention Effort: A Quality Improvement Report

Bloodstream infections (BSIs) cause substantial morbidity in hemodialysis patients. In 2009, the US Centers for Disease Control and Prevention (CDC) sponsored a collaborative project to prevent BSIs in outpatient hemodialysis facilities. We sought to assess the impact of a set of interventions on BSI and access-related BSI rates in participating facilities using data reported to the CDC's National Healthcare Safety Network (NHSN). Quality improvement project. Patients in 17 outpatient hemodialysis facilities that volunteered to participate. Facilities reported monthly event and denominator data to NHSN, received guidance from the CDC, and implemented an evidence-based intervention package that included chlorhexidine use for catheter exit-site care, staff training and competency assessments focused on catheter care and aseptic technique, hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff. Crude and modeled BSI and access-related BSI rates. Up to 12 months of preintervention (January 2009 through December 2009) and 15 months of intervention period (January 2010 through March 2011) data from participating centers were analyzed. Segmented regression analysis was used to assess changes in BSI and access-related BSI rates during the preintervention and intervention periods. Most (65%) participating facilities were hospital based. Pooled mean BSI and access-related BSI rates were 1.09 and 0.73 events per 100 patient-months during the preintervention period and 0.89 and 0.42 events per 100 patient-months during the intervention period, respectively. Modeled rates decreased 32% (P = 0.01) for BSIs and 54% (P < 0.001) for access-related BSIs at the start of the intervention period. Participating facilities were not representative of all outpatient hemodialysis centers nationally. There was no control arm to this quality improvement project. Facilities participating in a collaborative successfully decreased their BSI and access-related BSI rates. The decreased rates appeared to be maintained in the intervention period. These findings suggest that improved implementation of recommended practices can reduce BSIs in hemodialysis centers.

Pre Dialysis care and types of Vascular Access Employed in Incident Hemodialysis Patients: A study from Pakistan.

To determine frequency of different vascular access use in Incident hemodialysis (HD) patients and determine whether predialysis care in terms of timely advice for vascular access placement was better in the hands of nephrologist. A cross sectional study was conducted. Data was collected on the type of access used for first HD, including temporary Central venous catheters (CVC), permanent CVC (Permacath), arteriovenous fistula (AVF), or arteriovenous graft (AVG). In addition, information was also gathered if patients were aware of their renal disease and was followed by other physicians or nephrologist. A total of 120 patients were enrolled in the study, 80% required CVC as their first access for HD (96/120 patients) out of which 74.2% were dialyzed through temporary catheter and 5.8% through Permacath. About 20% of patients were dialyzed through mature Arteriovenous (AV) access. Majority (95.8%) of patients were being followed by any health care provider. 68% of them were aware of their renal disease. About 55.8% were referred to nephrologist and 40% were followed by other physicians. About 83.5% of patients followed by nephrologist were advised AV access prior to commencing HD, compared to only 10.4% followed by other physicians (p<0.05). 24/61 (39.3%) patients that were advised AV access by both groups had timely made AV access and underwent HD by it. Very high incidence of temporary HD catheter was used in Incident HD patients. Moreover, pre dialysis care in terms of placement of AV access prior to initiating HD is better in the hands of nephrologist and patients should be timely referred to nephrologist especially when they have Stage 4 chronic kidney disease (CKD).

Lifting the Veil

In this issue of CJASN , Ong et al. ([1][1]) and Lok et al. ([2][2]) address two important issues on either end of the vascular access care spectrum. Lok et al. ([2][2]) evaluate data pertinent to choosing the optimal access for those patients initiating hemodialysis, including the autologous native

Stenosis Complicating Vascular access for Hemodialysis: Indications for Treatment

The aim of the multidisciplinary team committed to the care of vascular access (VA) for hemodialysis is to prolong as much as possible the functional patency of the access. Stenosis is definitely the most frequent complication of arteriovenous VA. Whereas the best surveillance strategy is still a matter of debate, some evidence is now available about treatment indication and options. The available body of evidence on the best strategy facing this complication of VA is reviewed.

Comprehensive and personalized care of the hemodialysis patient in tassin, france: a model for the patient-centered medical home for subspecialty patients.

The Centre de Rein Artificiel in Tassin, France, provides comprehensive care to patients with chronic renal disease similar to the model proposed for Patient Center Medical Homes; patients with end-stage renal disease in the Tassin Hemodialysis Center appear to have better outcomes than patients in the United States. These differences likely reflect this center's approach to patient-centered care, the use of longer dialysis times, and focused vascular access care. Longer dialysis times provide better clearance of small and middle toxic molecules, salt, and water; 85% of patients at the Tassin center have a normal blood pressure without the use of antihypertensive medications. The observed mortality rate in patients at the Tassin Center is approximately 50% of that predicted based on the United States Renal Data system standard mortality tables. Patient outcomes at the Tassin center suggest that longer dialysis times and the use of multidiscipline teams led by nephrologists directing all health care needs probably explain the outcomes in these patients. These approaches can be imported into the U.S healthcare system and form the framework for patient-centered medical practice for ESRD patients.

Back to the Future: How Biology and Technology Could Change the Role of PTFE Grafts in Vascular Access Management

Although the arteriovenous fistula (AVF) is the preferred mode of dialysis vascular access, AVF maturation failure remains a huge clinical problem, often resulting in a prolonged duration of use of tunneled dialysis catheters. In contrast, polytetrafluoroethylene (PTFE) grafts do not suffer from early failure, but have significant problems with later stenosis and thrombosis. This review will initially summarize the pathology and pathogenesis of PTFE graft dysfunction and will then use this as a basis for describing some novel therapies, which may have the potential to reduce PTFE graft dysfunction. Finally, we will emphasize that the introduction of such therapies could be an important first step toward individualizing overall vascular access care.

Academic Interventional Nephrology

Dialysis vascular access dysfunction is currently a huge clinical problem. We believe that comprehensive academic-based dialysis vascular access programs that go all the way from basic and translational science investigation to clinical research to a dedicated curriculum and opportunities in vascular access for nephrologists in training are essential for improving dialysis vascular access care. This paper reviews the fundamental concepts and requirements for us to move toward this vision.

Quality of care of vascular access in hemodialysis patients in a hemodialysis center in Iran

Because of the lack of study in the field of vascular access care for hemodialysis patients, an observational study was conducted on 110 patients undergoing chronic hemodialysis in the Isfahan's AliAsghar Hospital. Data were collected using a demographic questionnaire and a checklist related to vascular access care techniques. A total of 63 male and 47 female with an average of 40.02 months of hemodialysis were studied. In addition, 72 patients were under hemodialysis through arteriovenous fistula and 38 patients through subclavian catheters. The overall quality of care for vascular access site was moderate. Selecting an inappropriately high speed for the apparatus at the beginning of dialysis, needling of an aneurysm or needling near the fistula, and incomplete priming of the filter and the tubes were the most frequent inappropriate actions. Reinforcement of the nurses' continuing education programs and development of standard vascular access care protocols are recommended.

The Challenge of Methicillin‐Resistant Staphylococcus aureus Prevention in Hemodialysis Therapy

Methicillin-resistant Staphylococcus aureus (MRSA) infections have challenged care process and resource utilization in the acute hospital care setting for nearly 30 years. These infections have become important causes of morbidity, mortality, and a source of concern in the primary and emergency care context over the past decade. As individuals receiving recurrent therapy with features of both ambulatory care and acute care, hemodialysis patients are exposed to numerous opportunities for MRSA acquisition. Surprisingly, high prevalence rates for MRSA colonization have been demonstrated for both hemodialysis patients and their care providers. The necessity of vascular access and the persistent high prevalence of endovascular catheter use among patients repeatedly exposed to healthcare settings provide the perfect milieu for the troubling rates of MRSA infection, particularly bloodstream infections, in outpatient dialysis care. Dialysis industry shifts, including increased requirements for compliance and reporting in other areas of dialysis care, tax resources for infection prevention processes. Multifaceted strategies that include reassessment of vascular access care, attention to the interruption of MRSA transmission dynamics, and emphasis on organizational learning processes are needed to accomplish a meaningful reduction in the morbidity, mortality, and cost associated with MRSA infections in dialysis care.

A Vascular Access Coordinator Improves the Prevalent Fistula Rate

The Centers for Medicare and Medicaid Services set the prevalent arteriovenous fistula (AVF) rate of 66% as a national standard. To test the hypothesis that the use of a clinical vascular access coordinator could increase the rate of AVF in a large Nephrology group practice, we implemented an aggressive, multidisciplinary vascular access improvement program led by a trained vascular access coordinator (VAC). In early 2009, we established protocols, approved by all physicians, for the care of vascular access and implemented by a nurse VAC. We retrospectively reviewed Network vascular access data reports from January 2008 through December 2010. The data show that after the implementation of a comprehensive access program led by a VAC, the prevalent AVF rate increased from 50% to 65%. The number of grafts decreased while the percentage of dialysis catheters used for more than 90 days was cut in half. These data suggest that despite an unchanged catheter rate at dialysis initiation, the use of a VAC implementing an aggressive, multidisciplinary access program can significantly increase the AVF rate while decreasing grafts and prevalent catheter use.

PICC Zone Insertion MethodTM (ZIMTM): A Systematic Approach to Determine the Ideal Insertion Site for PICCs in the Upper Arm

The consequences of random PICC practice can be serious and manifest as deep vein thrombosis, pulmonary embolism, catheter related bloodstream infection, and post thrombotic syndrome. Risk factors related to site selection have been well established for other central venous access devices, but not for ultrasound guided PICC insertion in the upper arm. The author presents observations of upper arm PICC insertion designated by color zones to highlight the variability of PICC practice. The author also details site risk factors associated with each color zone and proposes an ideal insertion location for upper arm ultrasound guided PICC procedures.The PICC Zone Insertion Method (ZIM) is a proposed system design for patient safety related to PICC insertions; performed by optimizing and organizing the clinical approach. It aids in identifying the Ideal Zone for upper arm needle insertion with ultrasound guidance. The significance of a systematic approach is that it is reproducible, measurable, and as a result will reduce variation in PICC insertion practice. The ZIM combines known mechanisms for vascular access insertion site complications with a systematic measuring and ultrasound scanning process, to reduce the impact of site risk factors. The impact of thrombosis cannot be underestimated, as it will likely limit the future use of veins for life saving vascular access. This issue should not be ignored by hospitals or clinicians, in fact, systematic solutions like PICC Zone Insertion Method, should be explored and supported as part of a comprehensive approach to vascular access care.