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De Vriese AS, D'Haeninck A, Mendes A, Ministro A, Krievins D, Kingsmore D, Mestres G, Villanueva G, Rodrigues H, Turek J, Zieliński M, De Letter J, Coelho A, Loureiro LA, Tozzi M, Menegolo M, Alija PF, Theodoridis PG, Gibbs P, Ebrahimi R, Nauwelaers S, Kakkos SK, Matoussevitch V, Moll F, Gargiulo M. Study protocol of a prospective single-arm multicenter clinical study to assess the safety and performance of the aXess hemodialysis graft: The pivotal study. J Vasc Access 2024; 25:1301-1307. [PMID: 37165650 DOI: 10.1177/11297298231174932] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Arteriovenous grafts (AVGs) are used for patients deemed unsuitable for the creation of an autogenous arteriovenous fistula (AVF) or unable to await maturation of the AVF before starting hemodialysis. However, AVGs are prone to infection and thrombosis resulting in low long-term patency rates. The novel aXess Hemodialysis Graft consists of porous polymeric biomaterial allowing the infiltration by cells and the growth of neotissue, while the graft itself is gradually absorbed, ultimately resulting in a fully functional natural blood vessel. The Pivotal Study will examine the long-term effectiveness and safety of the aXess Hemodialysis Graft. METHODS The Pivotal Study is a prospective, single-arm, multicenter study that will be conducted in 110 subjects with end-stage renal disease who are not deemed suitable for the creation of an autogenous vascular access. The primary efficacy endpoint will be the primary patency rate at 6 months. The primary safety endpoint will be the freedom from device-related serious adverse events at 6 months. The secondary endpoints will include the procedural success rate, time to first cannulation, patency rates, the rate of access-related interventions to maintain patency, the freedom from device-related serious adverse events and the rate of access site infections. Patients will be followed for 60 months. An exploratory Health Economic and Outcomes Research sub-study will determine potential additional benefits of the aXess graft to patients, health care institutions, and reimbursement programs. DISCUSSION The Pivotal study will examine the long-term performance and safety of the aXess Hemodialysis Graft and compare the outcome measures with historical data obtained with other graft types and autogenous AVFs. Potential advantages may include superior long-term patency rates and lower infection rates versus currently available AVGs and a shorter time to first cannulation compared to an autologous AVF. As such, the aXess Hemodialysis Graft may fulfill an unmet clinical need in the field of hemodialysis access.
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Affiliation(s)
- An S De Vriese
- Department of Nephrology and Infectious Diseases, AZ-Sint Jan Brugge, Bruges, Belgium
| | | | | | - Augusto Ministro
- Vascular Surgery Department, Hospital Santa Maria, Lisbon, Portugal
| | | | - David Kingsmore
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Gaspar Mestres
- Division of Vascular Surgery, Cardiovascular Institute, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Gonzalo Villanueva
- Department of Angiology and Vascular Surgery, Bellvitge University Hospital, Barcelona, Spain
| | - Hugo Rodrigues
- Centro Hospitalar de Lisboa Central EPE, Lisbon, Portugal
| | - Jakub Turek
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Maciej Zieliński
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Jan De Letter
- Department of Vascular Surgery, AZ-Sint Jan Brugge, Bruges, Belgium
| | - Andreia Coelho
- Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | | | - Matteo Tozzi
- Vascular Unit, Department of Medicine and Surgery, Insubria University and Research Center, Varese, Italy
| | - Mirko Menegolo
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua, Padua, Italy
| | - Palma Fariñas Alija
- Division of Angiology and Vascular Surgery, University Hospital of Ribera, Valencia, Spain
| | | | - Paul Gibbs
- Department of Renal and Transplant Surgery, Wessex Kidney Centre at Queen Alexandra Hospital, Portsmouth, UK
| | - Reze Ebrahimi
- Department of Vascular Surgery, Riuniti Hospitals, Ancona, Italy
| | - Sigi Nauwelaers
- Department of Thoracic and Vascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras, Patras, Greece
| | - Vladimir Matoussevitch
- Vascular Access Unit, Department of Vascular and Endovascular Surgery, University Clinic of Cologne, Cologne, Germany
| | - Frans Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mauro Gargiulo
- Department of Experimental, Diagnostic, and Specialty Medicine, Polyclinic SantÓrsola, University of Bologna, Bologna, Italy
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Kingsmore D, Edgar B, Stevenson K, Greenlaw N, Aitken E, Jackson A, Thomson P. A practical review of barriers and challenges to a definitive randomised trial of grafts versus fistula. J Vasc Access 2024:11297298241234610. [PMID: 38436199 DOI: 10.1177/11297298241234610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
A definitive randomised controlled trial of arteriovenous fistula (AVF) versus arteriovenous grafts (AVG) has been advocated for more than a decade, but as yet, none has been completed. The aim of this article is to summarise the theoretical barriers, review the difficulties in trial design and practicalities that have thus far prevented this from occurring.
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Affiliation(s)
- David Kingsmore
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ben Edgar
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Karen Stevenson
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nicola Greenlaw
- Glasgow Clinical Trials Unit, Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Emma Aitken
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Andrew Jackson
- Renal Transplant and Vascular Access Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter Thomson
- Department of Renal Medicine, Queen Elizabeth University Hospital, Glasgow, UK
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Quantifying The Costs of Creating and Maintaining Hemodialysis Access in An All-Payer Rate-Controlled Health System. Ann Vasc Surg 2021; 76:142-151. [PMID: 34153489 DOI: 10.1016/j.avsg.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/28/2021] [Accepted: 05/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The creation and maintenance of durable hemodialysis access is critically important for reducing patient morbidity and controlling overall costs within health systems. Our objective was to quantify the costs associated with hemodialysis access creation and its maintenance over time within a rate-controlled health system where charges equate to payments. METHODS The Maryland Health Services Cost Review Commission administrative claims database was used to identify patients who underwent first-time access creation from 2012-2020. Patients were identified using CPT codes for access creation, and costs were accrued for the initial encounter and all subsequent outpatient access-related encounters. T-tests and Wilcoxon tests were used to compare reinterventions and access-related costs ($USD) between arteriovenous fistulae (AVF) and arteriovenous grafts (AVG). Multivariable modeling was used to quantify the association of access type with charge variation. RESULTS Overall, 12,716 patients underwent first-time access creation (69.3% AVF vs. 30.7% AVG). There was no difference in freedom from reintervention between the two access types at any point following creation (HR: 1.03, 95%CI: 0.97-1.10); however, AVF were associated with a lower number of cumulative reinterventions (1.50 vs. 2.24) compared to AVG (P<0.0001). AVF was associated with lower overall costs in the year of creation ($9,388 vs. $13,539, P<0.0001), a difference that remained significant over the subsequent 3 years. The lower costs associated with AVF were present both in the costs associated with creation and subsequent maintenance. On multivariable analysis, AVF was associated with a $3,557 reduction in total access-related costs versus AVG (95%CI -$3828, -3287). CONCLUSION AVF require fewer interventions and are associated with lower costs at placement and over the first three years of maintenance compared to AVG. The use of AVF for first-time hemodialysis access represents an opportunity for healthcare savings in appropriately selected patients with a high preoperative likelihood of AVF maturation.
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