Vascular Access In Patients Research Articles

Mortality in hemodialysis patients over 65 years of age.

Introduction:Based on the statistics the population in Bosnia and Herzegovina is getting older. In 2013 the average life span for women was 73.6 years and 68.1 for men. The chronic hemodialysis program is mainly reserved for elderly patients with high mortality risk. The most common cause of hemodialysis mortality relates to cardiovascular diseases (60.2%), regardless of frequent innovations and improvement of hemodialysis procedures.The aim of the study:was to determine the mortality rate by age groups with comments on the presence of non-traditional predictors (anemia, hypoalbuminemia, CRP, vascular access and PTH) in dialysis patients in the follow-up period of 36 months.Methods:The study included all patients undergoing chronic hemodialysis treatment at the Clinic of Hemodialysis of the Clinical Center University of Sarajevo (CCUS).Results:Out of a total number of hemodialysis patients (n=232), the specific mortality rate in patients under 65 years of age was 16.8%, and 50.5% in patients over 65 years of age. According to the age groups the mortality rate in elderly patients is as follows: from 65 to 74 years (45.1%), from 75 to 84 years (55.0%), over ≥85 years (75.0%). The most frequent vascular access in patients under and above 65 is arteriovenous fistula (79.6% and 62.1 %), temporary hemodialysis catheter (11.7% and 43.8 %) and long-term hemodialysis catheter (8.8% and 4.2 %). In the age group under 65 years of age the temporary hemodialysis catheter is significantly and more frequently used in diseased patients in respect to survivors (34.8% vs. 7.0%) [χ2(2)=15.769, p=0.001]. Diseased patients from the age group over 65 had a significantly lower mean value of haemoglobin in blood (M=100.9±17.5 g/L) in respect to survivors (M=109.2±17.1)[t(93)=2.339; p=0.021], lower mean value of albumin in blood (Me=32.0; IQR=29.0 do 35.0) in respect to survivors (Me=34.0; IQR=32.0 to 38.0) [U=762.5; p=0.006], and higher mean value of CRP in blood (Me=19.3 mg/L; IQR=6.6 to 52.0) in respect to survivors (Me=7.8; IQR=4.0 to 16.7) [U=773.5; p=0.008]. Diseased patients belonging to the age group over 65 had lower mean value of PTH, but without statistical significance (p>0.05).Conclusion:older age, temporary vascular access, anaemia and hypoalbuminemia are strong predictors of mortality in hemodialysis patients. Old age does not present contraindication for hemodialysis treatment, and treatment of terminal renal illness should not be abandoned.

Patient safety culture and nurse-reported adverse events in outpatient hemodialysis units.

Patient safety culture is an important quality indicator in health care facilities and has been associated with key patient outcomes in hospitals. The purpose of this analysis was to examine relationships between patient safety culture and nurse-reported adverse patient events in outpatient hemodialysis facilities. A cross-sectional correlational, mailed survey design was used. The analytic sample consisted of 422 registered nurses who worked in outpatient dialysis facilities in the United States. The Handoff and Transitions and the Overall Patient Safety Grade scales of the Agency for Healthcare Research and Quality's (AHRQ) Hospital Patient on Safety Survey were modified and used to measure patient safety culture in outpatient dialysis facilities. Nurse-reported adverse patient events was measured as a series of questions designed to capture the frequency with which nurses report that 13 adverse events occur in the outpatient dialysis facility setting. Handoff and transitions safety during patient shift change in dialysis centers was perceived negatively by a majority of nurses. On the other hand, a majority of nurses rated the overall patient safety culture in their dialysis facility as good to excellent. All relationships between patient safety culture items and adverse patient events were in the expected direction. Negative ratings of handoffs and transitions safety were independently associated with increased odds of frequent occurrences of vascular access thrombosis and patient complaints. Negative ratings of overall patient safety culture in dialysis units were independently associated with increased odds of frequent occurrences of medication errors by nurses, patient hospitalization, vascular access infection, and patient complaints. Findings from this analysis indicate that a positive patient safety culture is an important antecedent for optimal patient outcomes in ambulatory care settings.

Anticorps antiphospholipides et hémodialyse : une association fréquente corrélée à la thrombose de l’abord vasculaire

Antiphospholipid antibodies (APL) are a heterogeneous family of auto-antibodies that recognize phospholipoproteins bound antigenic epitopes. APL prevalence in patients on chronic hemodialysis ranges from 11 to 37% in the literature. The association of APL with hemodialysis vascular access (VA) thrombosis has already been reported in small studies. In this single center and retrospective study, we defined the APL prevalence and APL risk factors in a large cohort of 192 hemodialysis patients. The association between history of VA thrombosis and APL presence was also analyzed. At least one type of APL was found in 38 patients (19.8%) of which 74% (n=28) had only lupus anticoagulant. Median age of APL positive patients was 68.1years vs 71.3years in APL negative patients (P=0.02). Smoking history was associated with APL presence: 35.5% of APL positive patients had a smoking history vs only 18.3% of APL negative patients (P=0.04). The multivariate analysis showed an association between the history of VA thrombosis and patient age (HR [IC 95%]=1.04 [1.02–1.06]; P=0.001) or APL presence (HR [IC 95%]=3.03 [1.69–4.42]; P<10–3). In conclusion, the prevalence of APL in hemodialysis patients remains high despite hemodialysis techniques improvement: hemodiafiltration, biocompatibility improvements, ultrapure dialysis water. We report that a younger age and past history of smoking are associated with an increased risk of APL presence. The presence of APL, especially lupus anticoagulant, is associated to VA thrombosis in hemodialysis patients.

Advanced teamworking in emergency surgical situations: Improving patient safety through the design of a multi-professional, multi-disciplinary course focusing on non-technical skills

Advanced teamworking in emergency surgical situations: Improving patient safety through the design of a multi-professional, multi-disciplinary course focusing on non-technical skills

Transposition of the cephalic vein in therapeutic rescue of cephalic arch stenosis.

Autogenous arteriovenous fistulas (AVFs) are considered the most reliable long-term vascular access in patients undergoing haemodialysis. Although AVFs generally require fewer interventions than arteriovenous grafts (AVGs) to maintain patency, some sites of venous stenosis account for a large portion of repeated interventions. A particularly troublesome site within brachiocephalic AVFs is the cephalic arch. Cephalic arch stenosis (CAS) has been implicated in 19–77% of brachiocephalic fistula failures [1]. The cephalic arch has a unique architecture. In addition to containing a high concentration of valves and having a steep angulation, it crosses multiple tissue planes, bridging the superficial and deep venous systems while being tethered to rigid extravascular structures. These factors combine to make the cephalic arch particularly vulnerable to the development of stenotic lesions, as changes in vessel compliance produce turbulent flow. When an anastomosis is created between the brachial artery and the cephalic vein, the flow within the cephalic vein increases and the vessel starts dilating. However, the tissues surrounding the cephalic arch preclude its expansion, so that the cephalic vein narrows as it approaches its junction with the central veins. This sudden reduction in the circumference of a high-flow pathway results in an inflow–outflow mismatch, potentiating turbulence and the increased shear stress associated with it [1, 2]. When a CAS occurs, the management is not easy. Angioplasty of stenotic lesions involving the cephalic arch has limited effectiveness, which led investigators to seek surgical alternatives to treat these lesions and to preserve current fistula [1]. The option for cephalic vein transposition (CVT), described by Chen et al., involves surgical revision to redirect the blood flow to the adjacent patient veins. The surgical procedure entailed transecting the healthy portion of the cephalic vein distal to the stenotic segment in the arch, transposing and anastomosing it to the upper basilic [2] (Figure ​(Figure11). Fig. 1. Illustration of the cephalic vein transposition technique. We present the experience of our centre with upper arm CVT procedures in three haemodialysis patients who underwent haemodialysis treatment in the haemodialysis unit of Centro Hospitalar de Setubal E.P.E. Two of the 3 cases did not have the possibility of endovascular treatment. In these cases CVT to basilic vein made possible the preservation of vascular access. Both accesses are patents to date, 6 and 9 months, respectively. In the other case, the CVT allowed the reduction of percutaneous transluminal angioplasties (PTAs)/access-year in a patient with frequent recurrent CAS (requiring angioplasty in <3-month intervals) and is also patent to date (52 months).

Role of far infra-red therapy in dialysis arterio-venous fistula maturation and survival: systematic review and meta-analysis.

IntroductionA well-functioning arteriovenous fistula (AVF) is the best modality for vascular access in patients with end-stage renal disease (ESRD) requiring haemodialysis (HD). However, AVFs’ main disadvantage is the high rate of maturation failure, with approximately one third (20%–50%) not maturing into useful access. This review examine the use of Far-Infra Red therapy in an attempt to enhance both primary (unassisted) and secondary (assisted) patency rates for AVF in dialysis and pre-dialysis patients.MethodWe performed an online search for observational studies and randomised controlled trials (RCTs) that evaluated FIR in patients with AVF. Eligible studies compared FIR with control treatment and reported at least one outcome measure relating to access survival. Primary patency and secondary patency rates were the main outcomes of interest.ResultsFour RCTs (666 patients) were included. Unassisted patency assessed in 610 patients, and was significantly better among those who received FIR (228/311) compared to (185/299) controls (pooled risk ratio of 1.23 [1.12–1.35], p = 0.00001). In addition, the two studies which reported secondary patency rates showed significant difference in favour of FIR therapy- 160/168 patients - compared to 140/163 controls (pooled risk ratio of 1.11 [1.04–1.19], p = 0.003).ConclusionFIR therapy may positively influence the complex process of AVF maturation improving both primary and secondary patency rates. However blinded RCTs performed by investigators with no commercial ties to FIR therapy technologies are needed.

Patients’ Perspectives on Hemodialysis Vascular Access: A Systematic Review of Qualitative Studies

Delayed creation of vascular access may be due in part to patient refusal and is associated with adverse outcomes. Concerns about vascular access are prevailing treatment-related stressors for patients on hemodialysis therapy. This study aims to describe patients' perspectives on vascular access initiation and maintenance in hemodialysis. Systematic review and thematic synthesis of qualitative studies. Patients with chronic kidney disease who express opinions about vascular access for hemodialysis. MEDLINE, EMBASE, PsycINFO, CINAHL, reference lists, and PhD dissertations were searched to October2013. Thematic synthesis was used to analyze the findings. From 46 studies involving 1,034 patients, we identified 6 themes: heightened vulnerability (bodily intrusion, fear of cannulation, threat of complications and failure, unpreparedness, dependence on a lifeline, and wary of unfamiliar providers), disfigurement (preserving normal appearance, visual reminder of disease, and avoiding stigma), mechanization of the body (bonded to a machine, internal abnormality, and constant maintenance), impinging on way of life (physical incapacitation, instigating family tension, wasting time, and added expense), self-preservation and ownership (task-focused control, advocating for protection, and acceptance), and confronting decisions and consequences (imminence of dialysis therapy and existential thoughts). Non-English articles were excluded. Vascular access is more than a surgical intervention. Initiation of vascular access signifies kidney failure and imminent dialysis, which is emotionally confronting. Patients strive to preserve their vascular access for survival, but at the same time describe it as an agonizing reminder of their body's failings and "abnormality" of being amalgamated with a machine disrupting their identity and lifestyle. Timely education and counseling about vascular access and building patients' trust in health care providers may improve the quality of dialysis and lead to better outcomes for patients with chronic kidney disease requiring hemodialysis.

Fistula first, graft on arterialized vein second.

Arterovenous grafts (AVGs) present a feasible solution for creating a vascular access in patients who are unsuitable for autogenous fistula (AVF). The aim of this study is to assess the prevention rate of vein stenosis, placing a graft on an arterialized vein (GAV) instead of an anastomized AVG in a native vein (GNV). This was a cohort study conducted from January 2009 to November 2012. All consecutive patients who underwent AVG in our institution were included. All patients requiring a secondary intervention were also referred to our centre. Patients underwent ultrasound follow up at first and the every month. A Kaplan-Meier method was used; a Log-rank test was used to identify whether significant difference existed between GAV and GNV (p < 0.05). Forty-six grafts were placed. Twenty patients had arterialized receiving veins (group A), while 26 patients received an AVG immediately because they lacked autogenous veins suitable for fistula (group B).The average follow-up period was 16.1 months (range 0-41). The group A 41 months-patency rate was 84.3%, while group B was 43.7% (p = 0.06). Secondary patency was similar in the two groups. Vein arterialization seems to prevent venous stenosis improving AVG-patency rate. More data are needed; however, the borderline p value encourages new studies.

VS5 Human Tissue-Engineered Grafts for Hemodialysis: Development, Preclinical Data, and Early Investigational Human Implant Experience

Current synthetic grafts have high rates of failure, due primarily to thrombosis and intimal hyperplasia. We have developed a tissue-engineered vascular graft that consists of human extracellular matrix and is similar in strength to native human vein and artery. This investigational graft is currently in clinical studies for evaluation of safety and efficacy in hemodialysis vascular access in patients with end-stage renal disease. In this presentation, we describe the development, preclinical experience, and early human implant experience for these tissue-engineered vascular grafts. A video is presented on the first case in the United States in which a human tissue-engineered vascular graft was implanted into a patient for hemodialysis access. Perspective is presented on the key developmental milestones that led to the first clinical implantation. These milestones include graft growth, animal studies, and clinical implantation of the graft. Banked human aortic smooth muscle cells were cultured in bioreactors in vitro to produce vascular tissue grafts, and a decellularization process was subsequently used to remove immunogenic cellular antigens. Arteriovenous grafts were implanted into nonhuman primates for up to 6 months and were evaluated for patency, durability, cannulation, rejection, and cellular repopulation. In addition, these grafts were evaluated for long-term arterial reconstruction in a canine model, using canine-derived grafts. In animal studies, histologic analysis demonstrated evidence of host vascular cell migration into grafts and endothelialization. Little intimal hyperplasia was observed in animal studies. These preclinical studies supported initiation of clinical trials.

Transradial versus Transfemoral Approach in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome. A Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials

BackgroundTransfemoral approach (TFA) remains the most common vascular access for percutaneous coronary intervention (PCI) in many countries. However, in the last years several randomized trials compared transradial approach (TRA) with TFA in patients with acute coronary syndrome (ACS), but only few studies were powered to estimate rare events. The aim of the current study was to clarify whether TRA is superior to TFA approach in patients with ACS undergoing percutaneous coronary intervention. A meta-analysis, meta-regression and trial sequential analysis of safety and efficacy of TRA in ACS setting was performed.Methods and ResultsMedline, the Cochrane Library, Scopus, scientific session abstracts and relevant websites were searched. Data concerning the study design, patient characteristics, risk of bias, and outcomes were extracted. The primary endpoint was death. Secondary endpoints were: major bleeding and vascular complications. Outcomes were assessed within 30 days. Eleven randomized trials involving 9,202 patients were included. Compared with TFA, TRA significantly reduced the risk of death (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.53–0.94; p = 0.016), but this finding was not confirmed in trial sequential analysis, indicating that sufficient evidence had not been yet reached. Furthermore, TRA compared with TFA reduced the risk of major bleeding (OR 0.60; 95% CI, 0.41–0.88; p = 0.008) and vascular complications (OR 0.35; 95% CI, 0.28–0.46; p<0.001); these findings were supported by trial sequential analyses.ConclusionsIn patients with ACS undergoing PCI, a lower risk of death was observed with TRA. Nevertheless, the association between mortality and TRA in ACS setting should be interpreted with caution because it is based on insufficient evidence. However, because of the clinical relevance associated with major bleeding and vascular complications reduction, TRA should be recommended as first-choice vascular access in patients with ACS undergoing cardiac catheterization.

Association between vascular access type and patient mortality among elderly patients on hemodialysis in Canada

Optimal vascular access in elderly patients requires consideration of the benefits and risks in a population with increased comorbidity and mortality. Our objective was to examine the association between vascular access type and patient mortality by age category among incident adult hemodialysis patients registered in the Canadian Organ Replacement Register between 2001 and 2010. We also describe the secular trend in incident and prevalent vascular access use. We used a Cox proportional hazards model to evaluate the overall mortality in patients aged less than 65, 65-74, 75-85, and greater than 85 years who initiated hemodialysis using a central venous catheter (catheter) or arteriovenous (AV)-access (fistula or graft) using an intention-to-treat approach. The cohort of 39,721 patients consisted of 42%, 27%, 26%, and 5% of patients aged <65, 65-74, 75-85, and >85, respectively. Patients who initiated hemodialysis using an AV-access constituted 21%, 22%, 20%, and 15% of each age category. AV access use was associated with lower adjusted mortality compared with catheter use in each age category (Hazard Ratios [HR], 0.67; 95% Confidence Interval [0.62-0.72]; HR, 0.76 [0.63-0.91]; HR, 0.77 [0.64-0.93], HR, 0.73 [0.56-0.96], respectively). In Canada, use of an AV-access is associated with lower mortality across all age categories, even in the very elderly. Further studies are required to understand the patient preference, complications, and resource use when selecting access type in the elderly.

Effect of Race and Insurance Status on Outcomes after Vascular Access Placement for Hemodialysis

Race and insurance status are seen as potential barriers to health care access and maintenance. Our goal was to see how these, as well as other patient and procedural characteristics, affected our populations' upper extremity vascular access outcomes. We retrospectively reviewed 601 vascular access patients from 2004 through 2012 in our urban university hospital. We recorded patient demographics, insurance status, comorbidities, and complications. Primary outcomes were reintervention, long-term mortality, and transplantation. Median age was 62 ± 15.8 years, and 58% were male. Most operations were arteriovenous fistulas (66%). The majority of patients identified themselves as Hispanic (50%), followed by white (22%), and black (19%). Most patients had Medicare only (42%), 31% had private insurance, and 27% had Medicaid as their insurance. Black/African American patients were more likely to receive an arteriovenous graft (AVG) compared with white and Hispanic patients (44% vs. 28% and 33%, P < 0.05). White patients were significantly older (68) than Hispanics (61) or blacks (58). Freedom from reintervention at 5 years was 55% with previous tunneled catheter use predictive. Mortality at 5 years was 35% and predicted by age, AVG placement, white race, and not receiving a kidney transplant. Predictors of not receiving a transplant included older age, lower albumin, AVG placement, and coronary artery disease. There were no disparities with insurance status in long-term outcomes in our population. Race was not a factor for reintervention or transplantation; however, black/African American patients were more likely have an AVG placed, and white patients had a lower long-term survival after access placement.

TCT-293 Ultrasound guidance for vascular access in patients undergoing coronary angiography via the trans-radial approach: A prospective clinical study.

Trans-radial access (TRA) for invasive coronary assessment and percutaneous coronary intervention (PCI) has evolved as an alternative default strategy for vascular access to the femoral approach, and in many centers is used more frequently than femoral access. One of the barriers to more widespread

Ultrasound Guidance for Vascular Access in Patients Undergoing Coronary Angiography Via the Transradial Approach: A Prospective Clinical Study

Ultrasound Guidance for Vascular Access in Patients Undergoing Coronary Angiography Via the Transradial Approach: A Prospective Clinical Study

Pose de voie veineuse périphérique sous échographie chez les patients ayant un accès veineux difficile : intérêt et facteurs prédictifs d’échec

Ultrasound-guided peripheral intravenous (USGPIV) technology is being utilized more frequently in emergency department settings. Traditionally, physicians have performed this procedure to gain vascular access in patients for whom standard intravenous line procedures are unsuccessful. Nurses at Wexner Medical Center at The Ohio State University have shown that a nurse-driven ultrasound program can be successfully implemented in an emergency department.Standardized training for registered nurses includes a 4-hour didactic and hands-on course and 24 hours of 1-on-1 individualized instruction with a nurse champion. Emphasis is placed on avoiding the larger upper arm veins.A peripheral intravenous line database has been maintained since the beginning of the program in 2009. This database shows a significant percentage of admitted patients received USGPIV service. In 2010, USGPIVs were successfully placed 90% to 98% of the time.Utilizing UGSPIV can expedite treatment and disposition in an emergency department. Ultimately, throughput and wait time for an emergency department bed can thus be similarly affected, positively affecting customer service.

Bloodstream infection in patients with end-stage renal disease in a teaching hospital in central-western Brazil

Vascular access in patients undergoing hemodialysis is considered a critical determinant of bloodstream infection (BSI) and is associated with high morbidity and mortality. The purpose of this study was to investigate the occurrence of BSI in patients with end-stage renal disease using central venous catheters for hemodialysis. A cohort study was conducted in a public teaching hospital in central-western Brazil from April 2010 to December 2011. For every patient, we noted the presence of hyperemia/exudation upon catheter insertion, as well as fever, shivering, and chills during hemodialysis. Fifty-nine patients were evaluated. Thirty-fi ve (59.3%) patients started dialysis due to urgency, 37 (62.7%) had BSI, and 12 (20%) died. Hyperemia at the catheter insertion site (64.9%) was a significant clinical manifestation in patients with BSI. Statistical analysis revealed 1.7 times more cases of BSI in patients with hypoalbuminemia compared with patients with normal albumin levels. The principal infective agents identified in blood cultures and catheter-tip cultures were Staphylococcus species (24 cases), non-fermentative Gram-negative bacilli (7 cases of Stenotrophomonas maltophilia and 5 cases of Chryseobacterium indologenes), and Candida species (6). Among the Staphylococci identified, 77.7% were methicillin-resistant, coagulase-negative Staphylococci. Of the bacteria isolated, the most resistant were Chryseobacterium indologenes and Acinetobacter baumannii. Blood culture was demonstrated to be an important diagnostic test and identified over 50% of positive BSI cases. The high frequency of BSI and the isolation of multiresistant bacteria were disturbing findings. Staphylococcus aureus was the most frequently isolated microorganism, although Gram-negative bacteria predominated overall. These results highlight the importance of infection prevention and control measures in dialysis units.

Radial versus femoral approach in patients undergoing percutaneous coronary intervention for acute coronary syndrome: meta-analysis and trial sequential analysis of randomized trials

Purpose: To clarify whether transradial approach (TRA) is superior to transfemoral (TFA) approach in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention. Methods: Medline, the Cochrane Library, Scopus databases were searched through October 2012. Data concerning the study design, patient characteristics, risk of bias and outcomes were extracted. The primary endpoint was death. Secondary endpoints were: major bleeding and vascular complications. Outcomes were assessed within 30 days. Results: Eleven randomized trials involving 9,202 patients were included. Compared with TFA, TRA significantly reduced the risk of death (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.53-0.94), but this finding was not confirmed by trial sequential analysis, indicating that sufficient evidence has not yet been reached. Furthermore, TRA compared with TFA reduced the risk of major bleeding (OR 0.60; 95% CI, 0.41-0.88), and vascular complications (OR 0.35; 95% CI, 0.28-0.46). Trial sequential analysis supported a 35% and 50% risk reduction in major bleeding and vascular complications with TRA compared with TFA, respectively. View this table: Main results of the study Conclusions: In patients with ACS undergoing percutaneous coronary intervention, TRA reduced major bleeding and vascular complications when compared to TFA. Although a lower risk of death was observed with TRA, the association between mortality and TRA in ACS setting should be interpreted with caution because it is based on insufficient evidence. However, because of the clinical relevance associated to major bleeding and vascular complications reduction, TRA should be recommended as first-choice vascular access in patients with ACS undergoing cardiac catheterization.

Abstracts From the Emerging Science Series, April 24, 2013

Shannon L Dahl , Humacyte, Inc., Durham, NC; Jeffrey H Lawson, Duke Univ, Durham, NC; Heather L Prichard, Humacyte, Inc., Durham, NC; Roberto J Manson, Duke Univ, Durham, NC; William E Tente, Alan P Kypson, Juliana L Blum, Humacyte, Inc., Durham, NC; Laura E Niklason, Yale Univ, New Haven, CT Introduction : End stage renal disease patients who require hemodialysis access would benefit from an alternative to synthetic grafts, which have high rates of thrombosis and intimal hyperplasia. A graft with success rates that are similar to those of fistulas would be clinically advantageous. Our tissue-engineered vascular graft is comprised of human extracellular matrix and is similar in strength to native human vein and artery. This acellular graft may be stored in a regular refrigerator, making it readily available for off-the-shelf surgical use. This graft is currently in clinical studies for evaluation of safety and efficacy in hemodialysis vascular access in patients with end stage renal disease. Methods: Banked human aortic smooth muscle cells were cultured in bioreactors in vitro to produce vascular tissue grafts, and …

Race and Insurance Status Have Limited Effect on Long-Term Vascular Access Outcomes in Patients at an Inner City University Hospital

Insurance status and race are potential barriers to health care maintenance. We assessed their contribution to upper extremity vascular access outcomes in our population. We retrospectively reviewed outcomes of 601 vascular access patients from 2004-2012 at our institution. We recorded patient demographics, comorbidities, and complications. Primary outcomes were reintervention, long-term mortality, and kidney transplantation. Arteriovenous fistulas (AVF) accounted for majority (66%) of operations. Median age was 62, 58% were male. Race, a self-reported variable, was 50% Hispanic, 22% white, and 19% black. Most had Medicare only (42%), while 31% had private insurance and 27% had Medicaid. Black patients were less likely to get an AVF compared to whites and Hispanics (P < .05). White patients were significantly older than either Hispanics or blacks (68 vs 61 vs 58; P < .05). Overall freedom from reintervention at 5 years was 55%, with infection (HR, 2.0; 95% CI, 1.3-3.0), stenosis (HR, 3.2; 95% CI, 2.3-4.3), thrombosis (HR, 1.7; 95% CI, 1.2-2.4), and nerve injury (HR, 4.1; 95% CI, 1.5-11.5) being independent predictors of reintervention. Mortality at 5 years was 35%, predicted by AV graft placement (HR, 1.9; 95% CI, 1.4-2.7), low albumin (HR, 0.7; 95% CI, 0.6-0.9), white race (HR, 1.9; 95% CI, 1.3-2.8), and not receiving a kidney transplant (HR, 0.3; 95% CI, 0.2-0.6). Transplantation rate was 31% at 5 years and predicted by high albumin (HR, 1.9; 95% CI, 1.4-2.6), AVF (HR, 1.6; 95%, 1.1-2.6), and no CAD (HR, 0.6; 95% CI, 0.4-0.9). Race and insurance status did not affect reintervention or transplantation rate. Controlling for patient and clinical factors, insurance status did not have a significant effect on long term vascular access outcomes in our population. Race was not significantly associated with reintervention or transplantation, however more black patients had less suitable vasculature for AVF, and white patients had a lower long term survival, possibly due to more advanced age.

Interventional Nephrology

The patient's vascular access is critical in ensuring that hemodialysis is successful, effective, relatively uncomplicated, and consistently reproducible from one treatment to another. The choice of vascular access is dictated by a multitude of factors, some of which are generalizable to a larger system, and others of which are flavored by local experience and expertise; an important fraction is specific to the patient presenting to the clinician at a particular point in time. Some of these factors, such as patient age and sex, are not modifiable; others, like comorbidity, vessel size and urgency of presentation to the renal provider, are manageable and sometimes modifiable. The role of the autologous arteriovenous fistula as the ideal conduit for hemodialysis treatments is well established. The role of the prosthetic graft warrants discussion and investigation to most optimally apply to patients this important alternative within the armamentarium of vascular access.