Vascular Access Center Research Articles

Maintaining Vascular Access Response in a Severely COVID-19 Hit Country.

The COVID-19 pandemic has caused an unprecedented disruption in healthcare systems worldwide, and Portugal was no exception. We analyze the impact of the COVID-19 pandemic in activity of our Vascular Access Center (Grupo Estudos Vasculares - GEV). This is a retrospective study, during March 2019 and February 2021. An analysis of surgical and appointments records in 2,495 patients from 25 hemodialysis centers followed by GEV was performed. Patients were divided into two periods: non-pandemic (NPP) (March 2019 to February 2020) and pandemic periods (PP) (March 2020 to February 2021). The number of surgeries and appointments were analyzed per month and per week. The number of thrombosis were analyzed in both periods. Normality was tested by the Shapiro-Wilk test and by the Lilliefors (Kolmogorov-Smirnov) test. Comparisons were made by the t-test (paired samples) when normality was not rejected and by the Wilcoxon test otherwise. All the variables (normal or otherwise) were described by the usual descriptive measures such as the mean, median and quartiles. No categorical data were collected. To avoid COVID-19 infection a set of measures were created: Sars-cov-2 PCR test for every patient, individual protection equipment for staff, rotating teams and schedules, and only one patient allowed in the circuit to the intervention room. A descriptive statistical analysis was performed with SPSS version28. The statistical significance was confirmed for p-value < 0.05. A total of 1756 surgeries and 800 appointments were made in both PP and NPP. Comparing the periods, we performed 914 (52%) interventions in the NPP and 842 (48%) in PP, 423 (53%) consultations in NPP and 377 (47%) at PP. Comparing the NPP and PP by months we observed more appointments in the NPP (p=0.004). However, the difference in the number of surgeries did not reach statistical significance (p=0.533). There were more thrombosis during the summer and fall in the NPP and PP. A total of 138 in NPP and 131 in PP thrombosis were observed in the 2 years period. There was no record of COVID-19 infections between all GEV staff (n=25). Due to timed and tight set of measures taken in the pandemic lockdown by GEV, a similar clinical and surgical activity regarding hemodialysis patients was obtained in both periods (PP and NPP). The hypothesis that the PP could diminish vascular access assessment/intervention or more thrombosis could occur was not verified at our institution. The set of measures established to deal with the COVID-19 pandemic was also effective to prevent infection in staff members.

Outflow Rescue of Elbow-Blockade Forearm Arteriovenous Fistulas: Outcomes of Open Surgical Techniques

Venous scarring at the elbow is a common problem that can cause early and late forearm arteriovenous fistula (AVF) dysfunction in hemodialysis patients. However, any effort to prolong the long-term patency of distal vascular accesses could benefit the patient's survival, maximizing the use of restricted venous patrimony. This study aims to report a single-center experience in the recovery of distal autologous AVF with venous outflow obstruction at the elbow using different surgical techniques. Retrospective observational study of all patients treated at a single vascular access center from January 2011 to March 2022, with dysfunctional forearm AVFs presenting with outflow stenosis or occlusions at the elbow treated by open surgery, using 3 different surgical techniques. Demographics and clinically relevant data were collected. Evaluated endpoints included primary, assisted primary, and secondary patency rates at 1 and 2years. Twenty-three patients with elbow-blocked outflow forearm AVFs have been treated with a mean age of 64±15years. The majority (96%) had a radiocephalic fistula. The median time from vascular access creation to intervention was 34.5months (12-216months). A total of 24 procedures have been performed using 3 different surgical techniques for bypassing the obstructed venous outflow at the elbow. Technical success was achieved in 96% of the surgically treated patients. Primary and secondary patency rates at 1year were 67.4% and 89.4%, respectively, and 52.9% and 82.0% at 2years, with a median follow-up of 19months (6-92months). AVFs outflow stenosis or occlusions at the elbow not amenable to endovascular therapy could lead to vascular access abandonment. Our study demonstrates multiple surgical solutions to avoid this adverse outcome. Elbow venous outflow surgical reconstruction seems effective for distal vascular access preservation. Close surveillance is essential for timely endovascular treatment of newly developed stenosis at the venous drainage.

Systematic CKD Care Approaches: A Potential Solution for the Costly ESRD Program

Care of patients with advanced kidney disease includes dialysis, kidney transplant, vascular access, primary care, and other specialist care, which are often siloed among multiple physicians, dialysis clinics, vascular access centers, and health system or hospital-based transplant programs. Other than the patient themselves, no one provider has holistic patient visibility or responsibility. Given that hospitals often lose money on Medicare patients who require dialysis services, momentum from innovation in advanced kidney care management, new technology with the potential for reduced costs, expansion of Medicare Advantage, and Medicare incentives for home dialysis could be leveraged by health systems to ultimately reduce the nearly $50 billion annual Federal spending on patients with kidney failure in the United States. Health systems, which offer many primary and specialty care services, may be uniquely positioned to leverage the more favorable economics associated with these changes to move kidney care from siloed, provider-centric care to integrated, patient-centric care. With 60% of patients initiating dialysis through an unplanned hospitalization, a holistic health system approach that includes offerings of kidney care management and kidney replacement therapy could move financial incentives away from the interests of any single provider and toward better addressing the total needs and the goals of the patient.

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.

Multicenter European real-world utilization of VasQ anastomotic external support device for arteriovenous fistulae.

To evaluate the outcomes of arteriovenous fistulae (AVF), created with VasQ external support device under standard clinical practice across three vascular access clinics. This multinational, retrospective study evaluated prospectively collected clinical outcomes of both forearm and upper arm brachiocephalic AVF (BCAVF) created using the VasQ device. Fifty-one AVF patients were pooled from three different vascular access centers in Germany, Italy, and Spain. Postprocedure outcomes were assessed by flow measurement with ultrasound examination in all centers. Primary failure, usability, patency, and intervention rates during the study period were evaluated. Fifty-one VasQ devices were implanted during 37 forearm (36 radiocephalic and 1 ulnar-basilic AVF) and 14 BCAVF procedures. The study population comprised mostly males (73%) and Caucasians (82%), with a mean age of 62.5years (range, 38-84years) and mean body mass index of 29.2. One patient died owing to access-unrelated reasons, and one patient was lost to follow-up without AVF assessment after its creation. From the remaining 49, 3 patients had a follow-up of less than 4weeks and were excluded from maturation, primary failure, and dialysis initiation analysis (because those factors could not be evaluated yet), leaving 46 patients in this evaluation. Maturation was achieved in 91% of patients. The primary failure rate was 9%. A primary patency rate of 77% was observed at 6, 12, and 18months. The secondary patency rate was 91% at 6months, and 85% at 12months and 18months. Both primary patency and secondary patency did not differ statistically when comparing forearm AVF with BCAVF (P > .25). Successful cannulation was achieved in 86% of patients (32/37) requiring dialysis with a median time from creation to cannulation of 46days. Of those patients, the functional patency rate was 94%. Five patients underwent seven interventions to maintain or restore patency or functionality, with an overall rate of 0.248 interventions per patient-year. AVFs created with VasQ external support device demonstrated promising patency and functionality outcomesin multicentric real-world setting across the two most commonly used anatomic locations.

A cost-effective analysis of drug-eluting balloon in highly recurrent stenosis on dialysis vascular access

Background: The efficacy and cost-effectiveness of drug-eluting balloon (DEB) in vascular access for dialysis remain unclear. Methods: Data obtained from using DEB in highly recurrent stenosis were retrospectively analyzed. These data were obtained from procedures performed in the Vascular Access Center, responsible for attending over 3600 patients from 30 dialysis centers. Highly recurrent stenosis is defined as stenosis having three or more previous interventions and/or associated with early recurrence defined as the last procedure in less than 90 days. Patency and cost-effectiveness were evaluated. Patency was defined as the number of days free of interventions after applying DEB. Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio (ICER) and an estimation of costs per day/patient/year. Results: Data from 37 consecutive procedures on 32 patients were assessed. The average patency time between interventions was 107.22 ± 104.428 days before DEB intervention. After the procedure, the average patency time intervention was 160.27 ± 96.472 days (ρ=0.001). The cost analysis revealed an ICER of 10.37€/ patency day gained. The costs estimation revealed improved patency of 14.5 days/patient/year, and an increased cost of 1028.4€/patient/year when compared to conventional balloon. Conclusions: This retrospective analysis may suggest a benefit of DEB on this highly recurrent stenosis. Although it appears to be more expensive, the increased patency at long term may be considered encouraging.

Quality indicators of vascular access procedures for hemodialysis

Improved quality of surgical procedures can minimize complications, the morbidity and mortality of patients, and in addition decrease costs. Quality indicators in angioaccess surgery are, however, not clearly defined. The aim of this review article is therefore to find the most important factors affecting quality in vascular access procedures. Even though autogenous arteriovenous fistula has been recognized as the best vascular access for hemodialysis, the high percentage of unsuccessful attempts associated with it raises the question about quality assessment in angioaccess procedures. Unfortunately, quality indicators in vascular access surgery are difficult to define and measure. Among those that can be obtained are: the time between the presentation of patients to a vascular access surgeon and the construction of a fistula, the percentage of autogenous fistulas, the percentage of functional fistulas in prevalent and incident hemodialysis patients, the percentage of creation of a functional fistula in the first attempt, and durability of an access. Organizational improvement and educational programs are also necessary at institutions with inferior quality indicators of vascular access care, as even small increase in quality may mean the survival of an individual patient. Quality indicators in angioaccess surgery can also serve as a helpful tool in choosing the best vascular access surgeon or vascular access center. The choice can consequently reflect on increased survival and quality of life in patients needing hemodialysis.

Misalignment between reimbursement and clinical guidelines for dialysis access intervention is unlikely to improve quality or efficiency of patient care

In their article, Madden et al1 have appropriately focused our attention on recent changes in reimbursement for specific procedures used to prolong the lifespan of dialysis arteriovenous fistulae and grafts. In a constantly shifting effort to drive care for these patients to more cost-efficient venues, the Centers for Medicare and Medicaid Services (CMS) reimbursement has resulted in the proliferation of outpatient vascular access centers across the country. The positive aspects of this shift include avoidance of high hospital-based facility fees, preservation of high-capability hospital-based facilities for patients who need to be treated in these facilities, and potentially increasing patient satisfaction in a specialized facility that can expeditiously manage access complications with a team specifically designed for this purpose.

A Novel Inside-out Access Approach for Hemodialysis Catheter Placement in Patients With Thoracic Central Venous Occlusion

Left-sided internal jugular and all subclavian central venous catheters (CVCs) cause thoracic central vein occlusions (TCVOs) more often than right-sided internal jugular catheters. To enable right-sided CVC placement in patients with TCVO, an inside-out access (IOA) approach was established at 3 vascular access centers in Europe involving use of a novel IOA device advanced from the right femoral vein. In the current analysis, we assessed the eligibility and success rate of this IOA approach in a cohort of patients with TCVO requiring a tunneled dialysis catheter. Retrospective multicenter observational study. 36 patients with TCVO treated in Vienna, Austria; Oxford, England; or Cologne, Germany, who required hemodialysis access between July 2016 and June2018. Application of the IOA approach to gain vascular access. The primary end point was the success rate of passing the TCVO to gain dialysis access using the IOA approach. Secondary end points were catheter patency at 3 months and procedure-related complications (early infections, bleeding, hematoma, and pericardial effusions). Descriptive statistics to characterize eligibility, success rate, and complications of the IOA approach. 36 patients with TCVO and history of multiple CVCs and arteriovenous fistulas were referred to the participating centers for vascular access. 32 (89%) patients were eligible for the IOA approach. 39 treatments were performed, with 7 patients undergoing the IOA procedure a second time more than 3 months after initial CVC placement. Dialysis access was established successfully in 38 of 39 (97%) implementations of the IOA procedure. Median intervention time was 43 minutes. No complications occurred. No comparison to other methods to place CVCs and the observational study design. The IOA approach is a promising method to enable rapid access to the right jugular vein in the setting of pre-existing TCVO. Additional experience is needed to understand the generalizability of these observations.

An Implanted Blood Vessel Support Device for Arteriovenous Fistulas: A Randomized Controlled Trial

Reducing turbulent blood flow through dialysis arteriovenous fistulas (AVFs) and radial stretching of their venous wall may attenuate hyperplasia and stenosis and improve AVF outcomes in hemodialysis patients. The goal of this study was to evaluate the safety and efficacy of the VasQ implant, which intervenes on these mechanisms by physically supporting the surgical arteriovenous anastomosis. Prospective, randomized, controlled, multicenter study. 40 consecutive patients with kidney failure referred for creation of a brachiocephalic fistula in 4 vascular access centers in the United Kingdom and Israel. AVF surgical creation with placement of the VasQ implant (treatment) versus AVF placement without the implant (control). Safety assessed as percentage of severe device-related adverse events was the primary outcome. Secondary outcomes were efficacy assessments including: (1) AVF maturation at 3 months, defined as cephalic vein diameter≥5mm and flow≥500mL/min; (2) functional cumulative patency, defined as successful 2-needle cannulation for two-thirds or more of all dialysis runs for 1 month in study participants receiving dialysis; (3) cephalic vein diameter and blood flow; and (4) primary and cumulative patency at 6 months. No severe device-related adverse events were observed. There was no significant difference in maturation at 3 months or primary patency at 6 months between treatment and control (85% vs 80% and 80% vs 66%). Significantly larger vein luminal diameters were observed in the treatment group versus controls at 3 and 6 months (8.27±2.2 vs 6.69±1.8mm [P=0.03] and 9.6±2.5 vs 7.56±2.7mm [P=0.03]). Functional patency at 6 months was significantly greater in the treatment group (100% vs 56% [P= 0.01]). Small sample size, limited power for secondary end points. No safety signals were detected for the VasQ external support of brachiocephalic AVFs. Higher functional patency and vein luminal diameters were achieved with the device at 3 and 6 months. VasQ may safely intervene on mechanisms associated with the disturbed hemodynamic profile in the juxta-anastomotic region. Funded by Laminate Medical Technologies Ltd. Registered at ClinicalTrials.gov with study number NCT02112669.

Quality assessment of vascular access procedures for hemodialysis: A position paper of the Vascular Access Society based on the analysis of existing guidelines.

Quality assessment in vascular access procedures for hemodialysis is not clearly defined. The aim of this article is to compare various guidelines regarding recommendation on quality control in angioaccess surgery. The overall population of end-stage renal disease patients and patients in need for hemodialysis treatment is growing every year. Chronic intermittent hemodialysis is still the main therapy. The formation of a functional angioaccess is the cornerstone in the management of those patients. Native (autologous) arteriovenous fistula is the best vascular access available. A relatively high percentage of primary failure and fistula abandonment increases the need for quality control in this field of surgery. There are very few recommendations of quality assessment on creation of a vascular access for hemodialysis in the searched guidelines. Some guidelines recommend the proportion of native arteriovenous fistula in incident and prevalent patients as well as the maximum tolerable percentage of central venous catheters and complications. According to some guidelines, surgeon's experience and expertise have a considerable influence on outcomes. There are no specific recommendations regarding surgeon's specialty, grade, level of skills, and experience. In conclusion, there is a weak recommendation in the guidelines on quality control in vascular access surgery. Quality assessment criteria should be defined in this field of surgery. According to these criteria, patients and nephrologists could choose the best vascular access center or surgeon. Centers with best results should be referral centers, and centers with poorer results should implement quality improvement programs.

Tract dilation to salvage failing buttonholes in arteriovenous dialysis fistulae.

Hemodialysis patients with an arteriovenous fistula can use buttonhole techniques for cannulation. Although buttonholes generally work well, patients may report difficult and painful cannulation, and buttonholes may fail over time. We aimed to assess the effectiveness of tract dilation in treatment of failing buttonholes. We retrospectively analyzed data from patients treated with buttonhole tract dilation at an outpatient vascular access center between January 2013 and August 2015. Data from 23 patients were analyzed. There were 51 tract dilation procedures during 36 encounters for failing arteriovenous fistula buttonhole tract(s). The technical success rate for established tract dilation with "blunt-recanalization" was 90% (n = 46). The five remaining buttonholes had "sharp-recanalization" to create and dilate new tract through the buttonhole. For 46 buttonholes treated with "blunt-recanalization," there was an 85% clinical success rate at one week (39 buttonholes), and one was lost to follow-up; there was a 70% clinical success rate after one month (32 buttonholes). In the five buttonholes with "sharp-recanalization," there was only one clinical success with p < 0.05 for difference in success rate compared to "blunt-recanalization" at both one week and one month. There was one complication from "sharp-recanalization" requiring abandonment of the buttonhole tract. Buttonhole tract dilation is a useful method to treat difficult cannulation and painful cannulation and has the potential to extend the life of failing buttonholes.

Predictive factors of recurrent endovascular intervention for cephalic arch stenosis after percutaneous transluminal angioplasty

ObjectiveCephalic arch stenosis (CAS) is an important and recurring problem arising in hemodialysis patients because of the requirement for repeated interventions to maintain patency. The aim of this study was to determine predictive factors for recurrence of CAS after successful angioplasty. MethodsA retrospective, case-control study was conducted at two ambulatory vascular access (VA) centers. All patients with a dysfunctional VA referred for an angiographic procedure and with a documented CAS as evidenced during the endovascular intervention (EI) between January 1, 2013, and December 31, 2015, were enrolled; 15 patients in whom an efficacious intervention was not possible were excluded. The study thus concerned 375 EIs using percutaneous transluminal angioplasty without stent placement on 241 VAs for CAS (9% of all procedures performed) during a 3-year period. Patients were compared regarding the absence (group 1; n = 181) or presence (group 2; n = 60) of recurrent CAS. We defined recurrence as that which occurred within 180 days of the previous successful EI for CAS. Any CAS diagnosed and treated >180 days after a previous one was considered a novel CAS and not a recurrence. Multivariate analysis was performed to determine variables independently associated with recurrence of CAS. Kaplan-Meier analysis was performed for determination of primary and assisted primary patency in this population. ResultsThe recurrence rate of CAS was high (25%). Patients in both groups had similar demographic characteristics, time on hemodialysis, and mean dialysis dose and access flow rate at referral (P > .05). Multivariate analysis provided a significant discriminatory influence pertaining to diabetes (hazard ratio [HR], 2.054; 95% confidence interval [CI], 1.22-3.46; P = .007), residual stenosis even though it was <30% (HR, 1.86; 95% CI, 1.005-3.439; P = .048), and the finding of an isolated CAS lesion (HR, 0.445; 95% CI, 0.219-0.905; P = .025) in comparing group 1 and group 2. All other variables lost statistical significance on multivariate analysis. Primary patency at 6 months was 72%, increasing to an assisted primary patency of 89% at 6 months. The median durations of primary patency and assisted primary patency were 9.5 months and 15.6 months, respectively. ConclusionsMultivariate analysis showed that diabetes and residual stenosis (albeit <30%) were predictive of recurrence, whereas the finding of an isolated CAS lesion as opposed to stenoses in multiple locations was shown to be negatively associated with recurrent CAS, appearing to be “protective”.

Effects of Access to Vascular Access Center Surgeons on Catheter Rates in Hemodialysis Patients

Effects of Access to Vascular Access Center Surgeons on Catheter Rates in Hemodialysis Patients

Surgical site infection rates in dialysis patients undergoing endovascular procedures.

A surgical site infection (SSI) is an infection related to surgery that develops within 30 days after an operation or within 1 year of implant placement. Postoperative SSIs are the most common health-care-associated infections, occurring in up to 5% of surgical patients. Endovascular surgical procedures related to vascular access are common in the dialysis population and may cause SSIs. A large outpatient vascular access system developed and implemented a surveillance program to measure and monitor SSIs in their population. The health-care surveillance system extended to 76 ambulatory care centers across the United States and Puerto Rico. Based on a recorded 92,880 patient encounters, the surveillance system tabulated 12,541 valid patient survey responses documenting self-reported symptoms of infection within a 30-day postoperative period. The SSI rate was tabulated based on the presence of two or more specified indicators of infection: antibiotics, pus, dehiscence, pain, warmth, and swelling. Patients undergoing interventional procedures received surveys at discharge. Data were collected and analyzed using SPSS software. Survey analysis indicated a less than 3% superficial incisional SSI rate in hemodialysis patients undergoing endovascular procedures. The SSI rate for clean wound procedures is generally 2% or less. These data indicate that dialysis patients undergoing interventional procedures in vascular access centers may have a slightly greater risk of developing SSIs due to the presence of additional risk factors including obesity, diabetes, and age. This study was limited by a set of loose diagnostic criteria self-reported by patients, which may have overestimated the prevalence of infection. SSIs are a serious medical problem associated with increased morbidity and mortality and increased medical care costs. All providers should consider an active surveillance program following endovascular procedures given the comorbidities associated with the dialysis population.

Increased Length of Stay and Costs Associated with Inpatient Management of Vascular Access Failures

The creation and maintenance of vascular access for hemodialysis patients is responsible for a significant amount of morbidity and hospital expenses which continue to escalate with increasing population of ESRD patients. A retrospective review of patient charts were performed from 2008 to May 2011 at an academic tertiary care center who had a diagnosis of vascular access failure based on ICD 9 coding. Data regarding demographic information, length of stay (LOS), source of insurance, hospital expenses, and discharge status were obtained. Based on strict inclusion criteria we identified 172 total patients. The mean age among all patients was 60.53 ± 15.35 years and the majority of patients were Hispanic (n = 81). The Mean LOS was 5.30 ± 4.64 days. Mean hospital costs were 41,896 ± 20,318 US$. Patients admitted for tunneled dialysis placement had greater length of stay (p-value = 0.011) as did patients with hypertension (p-value = 0.030). Hospital expenses were significantly higher for patients admitted for arterio-venous fistula complications (55,456 ± 23,779 US$) compared with admissions for catheter or dialysis graft related complications (p-value = 0.004). Patients on Medicare had significantly lower length of stay (3.98 ± 3.32 days) compared with patients with Medicare/Medical (6.59 ± 5.69 days), p-value = 0.047. Inpatient management of vascular access failure is associated with increased length of stay, and significant hospital expenses. Timely referral to vascular access centers can prevent unnecessary hospitalizations and provide cost-saving benefits.

The D&amp;T Report

The D&amp;T Report

Radiation Exposure in Dialysis Access‐Related Procedures Decreases with Increase in Number of Procedures Performed by the Interventional Nephrologist

An appreciation of the inherent risks with radiation exposure to patients and to the physician performing the procedure and the staff is urgently needed. The objective of this study is to assess radiation exposure to both patients and interventional nephrologists performing procedures and see any trends in the procedure and fluoroscopy times over a 2-year period. A total of 400 procedures performed at our vascular access center by a new to practice interventional nephrologist were recorded and retrospectively analyzed. Fluoroscopic time and procedure time for various procedures over the course of 2 years were recorded. This data were subsequently separated into eight groups (four quarters per year) based on the date of the procedure. Our study demonstrates a decrease in mean and median fluoroscopy times and procedure times for newly trained interventional with gain in number of procedures. The mean fluoroscopy time for the first two quarters was 5 minutes and 4 seconds, and the median was 3 minutes and 37 seconds. The mean procedure time for the first two quarters was 38 minutes, and the median was 32 minutes. The mean fluoroscopy time for the last two quarters was 1 minute and 54 seconds, and the median was 1 minute and 26 seconds. The mean procedure time for the last two quarters was 27 minutes, and the median was 21 minutes. In conclusion, gain of experience by the practicing Interventional Nephrologist from performing an increasing number of procedures leads to decreased procedure times and fluoroscopy times, which lowers the risk of radiation.

Successful Models of Interventional Nephrology at Academic Medical Centers

The foundation of endovascular procedures by nephrologists was laid in the private practice arena. Because of political issues such as training, credentialing, space and equipment expenses, and co-management concerns surrounding the performance of dialysis-access procedures, the majority of these programs provided care in an outpatient vascular access center. On the basis of the improvement of patient care demonstrated by these centers, several nephrology programs at academic medical centers have also embraced this approach. In addition to providing interventional care on an outpatient basis, academic medical centers have taken a step further to expand collaboration with other specialties with similar expertise (such as with interventional radiologists and cardiologists) to enhance patient care and research. The enthusiastic initiative, cooperative, and mutually collaborative efforts used by academic medical centers have resulted in the successful establishment of interventional nephrology programs. This article describes various models of interventional nephrology programs at academic medical centers across the United States.

Aggressive Approach to Salvage Non-Maturing Arteriovenous Fistulae: A Retrospective Study with follow-up

To establish a standardized approach for the maturation of non-maturing arteriovenous fistulae. Consecutive patients (n=122) with non-maturing fistulae presented to our outpatient vascular access center for percutaneous interventions to assist in maturation. The techniques used included flow rerouting, competing branch vein elimination, staged balloon angioplasty, and limited controlled extravasation. Successful fistula maturations were achieved in 118/122 patients. Fistulae were divided into two classes according to initial vessel size: class 1 (6.0-8.0 mm diameter, >6 mm deep) and class 2 (2.0-5.0 mm diameter) fistulae were evaluated for differences in technical procedures and clinically successful fistula maturation. Class 1 and class 2 fistulae were evaluated for mean number of procedures to maturation (1.6 and 2.6, respectively), and time to maturation (5 and 7 weeks, respectively). Follow-up for 109 of the initial 118 patients was achieved (mean=24 months, range=0.25-60 months). Class 1 and class 2 fistulae had primary patencies of 17 and 39% at 6 months; and secondary patencies of 72 and 77% at 12 months, 53 and 61% at 24 months, and 42 and 32% at 36 months, respectively. Primary and secondary patencies (Mann-Whitney test, p=0.44 and p=0.38, respectively) of class 1 and class 2 fistulae did not differ significantly, and secondary patencies were comparable to other fistula salvage studies. Fistula salvage attempts should not be limited by factors such as a diffusely small diameter or an inaccessibly deep position.