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Mirabella D, Dinoto E, Rodriquenz E, Bellomo M, Miccichè A, Annicchiarico P, Pecoraro F. Improved Ultrasound-Guided Balloon-Assisted Maturation Angioplasty Using Drug-Eluting Balloons in the First Autogenous Arteriovenous Fistula Procedure: Early Experience. Biomedicines 2024; 12:1005. [PMID: 38790967 PMCID: PMC11118221 DOI: 10.3390/biomedicines12051005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/21/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024] Open
Abstract
In patients with end-stage renal failure requiring hemodialysis, autogenous arteriovenous fistula (AVF) is preferred over tunneled dialysis catheters due to lower complications and costs. However, AVF maturation failure remains a common issue due to small vein size, multiple venipunctures, and other factors. Guidelines recommend using vessels of >2 mm for forearm AVFs and >3 mm for upper arm AVFs. This study investigates the use of intraoperative Doppler ultrasound (DUS)-guided Balloon-Assisted Maturation (BAM) with drug-eluting balloons (DEB) during initial AVF creation. Data from 114 AVF procedures, of which 27.2% underwent BAM, were analyzed. BAM was performed in 25 distal radio-cephalic and 6 proximal brachio-cephalic AVFs. With DUS guidance, vein stenosis was identified and treated using DEB. Technical success was achieved in all cases, with no early mortality. Early BAM-related complications were minimal, and no AVF thrombosis occurred. AVF maturation time was 15 days (SD: 3), and no further complications were reported during a mean follow-up of 10.38 months. Using BAM with DEB during AVF creation led to successful maturation and dialysis use without the need for secondary procedures. This study emphasizes the importance of identifying AVF failure risk early and utilizing DUS-guided procedures to enhance AVF outcomes. A more liberal use of intraoperative BAM could limit reinterventions in patients undergoing AVFs.
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Affiliation(s)
- Domenico Mirabella
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Ettore Dinoto
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Edoardo Rodriquenz
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Michele Bellomo
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Andrea Miccichè
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Paolo Annicchiarico
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
| | - Felice Pecoraro
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (E.R.); (M.B.); (A.M.); (P.A.); (F.P.)
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy
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Chen JW, Ting M, Chang PY, Jung CJ, Chang CH, Fang SY, Liu LW, Yang KJ, Yu SH, Chen YS, Chi NH, Hsu RB, Wang CH, Wu IH, Yu HY, Chan CY. Computer-assisted image analysis of preexisting histological patterns of the cephalic vein to predict wrist arteriovenous fistula non-maturation. J Formos Med Assoc 2024:S0929-6646(24)00149-9. [PMID: 38492985 DOI: 10.1016/j.jfma.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 01/07/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND We used computer-assisted image analysis to determine whether preexisting histological features of the cephalic vein influence the risk of non-maturation of wrist fistulas. METHODS This study focused on patients aged 20-80 years who underwent their first wrist fistula creation. A total of 206 patients participated, and vein samples for Masson's trichrome staining were collected from 134 patients. From these, 94 patients provided a complete girth of the venous specimen for automatic image analysis. Maturation was assessed using ultrasound within 90 days after surgery. RESULTS The collagen to muscle ratio in the target vein, measured by computer-assisted imaging, was a strong predictor of non-maturation in wrist fistulas. Receiver operating characteristic analysis revealed an area under the curve of 0.864 (95% confidence interval of 0.782-0.946, p < 0.001). The optimal cut-off value for the ratio was 1.138, as determined by the Youden index maximum method, with a sensitivity of 89.0% and specificity of 71.4%. For easy application, we used a cutoff value of 1.0; the non-maturation rates for patients with ratios >1 and ≤ 1 were 51.7% (15 out of 29 patients) and 9.2% (6 out of 65 patients), respectively. Chi-square testing revealed significantly different non-maturation rates between the two groups (X2 (1, N = 94) = 20.9, p < 0.01). CONCLUSION Computer-assisted image interpretation can help to quantify the preexisting histological patterns of the cephalic vein, while the collagen-to-muscle ratio can predict non-maturation of wrist fistula development at an early stage.
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Affiliation(s)
- Jeng-Wei Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Mao Ting
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Po-Ya Chang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiau-Jing Jung
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Shi-Yu Fang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Wei Liu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Kelvin Jeason Yang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sz-Han Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Nai-Hsin Chi
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ron-Bin Hsu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hsien Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Hui Wu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsi-Yu Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yang Chan
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
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Suraj HS, Anil Kumar S, Rachegowda N, Rajeswari GT, Yashas Ullas L, Revanth RB. Role of Doppler Evaluation in Assessing the Maturation of the Arteriovenous Fistula for Hemodialysis: An Observational Study. Cureus 2024; 16:e55527. [PMID: 38576632 PMCID: PMC10992732 DOI: 10.7759/cureus.55527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction Arteriovenous fistulas (AVFs) are the preferred type of vascular access for hemodialysis due to their lower risk of complications. This study aimed to determine the role of Doppler evaluation in assessing AVF. Materials and methods We conducted an 18-month prospective observational study of 33 hemodialysis patients who underwent a procedure for the creation of AVF at the Department of Radio-Diagnosis at Sri Devaraj Urs Academy of Higher Education and Research. Patients were evaluated using color Doppler ultrasound. Participants underwent a careful history and clinical examination to diagnose the disease. All relevant parameters were documented in a structured study proforma. AVF maturation was assessed postoperatively at four weeks using Doppler ultrasound color flow evaluation by looking for vascular components (flow volume, vein, and arterial diameter). Data were analyzed using CoGuide V 1.0.3 Statistical Software (CoGuide, Bangalore, India). Results A total of 33 patients, with a mean age of 54.6 ± 7.8 years, were evaluated. Of the 33 participants, 24 (72.7%) were male, and nine (27.3%) were female. The majority (47%, n=16) of participants had diabetes mellitus, eight (24%) had hypertension, and 10 (29%) had both diabetes mellitus and hypertension. A brachiocephalic fistula was created in 45.5% of participants, and 33.33% had radiocephalic anastomoses. Five participants were diagnosed with AVF complications: two had a pseudoaneurysm, and three had a cephalic vein thrombus. Clinical and demographic characteristics (age, vascular components, and complications) were not significantly related to AVF maturation. Conclusions Doppler ultrasound plays an important role in selecting vessels for AVF preoperatively and assessing AVF maturation postoperatively, thus reducing the primary fistula failure rate. The findings suggest that Doppler evaluation can be a reliable tool for assessing AVF maturation and predicting surgical success, which could help healthcare providers make informed decisions about the best course of treatment for their patients. Continued research is warranted in this area to further understand the role of Doppler ultrasound in evaluating AVF surgery.
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Affiliation(s)
- H S Suraj
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Sakalecha Anil Kumar
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - N Rachegowda
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | | | - L Yashas Ullas
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - R B Revanth
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
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Turner MA, Mathlouthi A, Patel RJ, Perreault M, Malas MB, Al-Nouri O. Small Arteriovenous Anastomosis in Fistula Creation: Establishing a Functional Vascular Access while Minimizing Steal Syndrome. Ann Vasc Surg 2024; 99:142-147. [PMID: 37926140 DOI: 10.1016/j.avsg.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The size selection of the arteriovenous (AV) anastomosis in dialysis access creation requires a careful balance: the diameter must be large enough to accommodate sufficient flow for hemodialysis but small enough to minimize the complication of steal syndrome. Steal syndrome affects up to 10% of patients after creation of dialysis access with sometimes devastating consequences. Conventional teaching recommends a 7-10 mm anastomosis. We sought to assess the efficacy of using a smaller (5-6 mm) anastomosis in new arteriovenous fistula (AVF) creation. METHODS We conducted a comparative retrospective analysis of patients who underwent fistula creation with a small versus regular size anastomosis at any upper extremity anatomic site between March 2019 and October 2020 at our institution. Anatomic sites included radiocephalic, brachiocephalic, and brachiobasilic. All AV anastomoses were measured intraoperatively to be 5-6 mm in diameter for the small size groups and 8-10 mm for the regular size group. Endpoints included steal syndrome, functional patency, primary patency, and secondary patency. RESULTS Out of 110 patients who underwent an AVF creation, 59.1% received a 5-6 mm anastomosis with a median follow-up time of 10 ± 6 months. Patients' demographics and comorbidities were relatively similar between the 2 groups except for a higher rate of hyperlipidemia (55.4% vs. 28.9%, P = 0.008) in the small size group. Patients in the small size group were more likely to undergo a radiocephalic fistula (40% vs. 4.5%, P < 0.001) and to have a smaller mean vein diameter on preoperative duplex ultrasound (3.2±1 mm vs. 3.9±1 mm, P = 0.0016) when compared to their regular size counterparts. During follow-up, none of the patients in the small group developed steal syndrome (0% vs. 9%, P = 0.015). At 1 year, patients in the regular size group achieved higher rates of primary patency (67.9% vs. 46.9%, P = 0.02); however, no difference was seen in 1-year primary-assisted patency (84.9% vs. 73.6%, P = 0.3), secondary patency (89.6% vs. 79.5%, P = 0.3), or functional patency (87.7% vs. 82.2%, P = 0.64) between the small and regular size groups, respectively. CONCLUSIONS The use of a 5-6 mm anastomosis in the creation of new AVFs of the upper extremities appears to be a technically safe option for dialysis access. Our experience suggests that smaller anastomosis still creates enough flow to maintain a functional AV access while minimizing the incidence of steal syndrome. Additionally, even with smaller vein sizes preoperative, adequate dialysis access can be created via a small sized anastomosis, including distal arm access. Larger studies with longer follow-up are needed to evaluate long-term outcomes of small anastomosis fistulas.
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Affiliation(s)
- Michael A Turner
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Rohini J Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Mark Perreault
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Omar Al-Nouri
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA.
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Gan W, Zhu F, Mao H, Xiao W, Chen W, Zeng X. Effect of preoperative arterial diameter on hospitalization and mortality in patients undergoing hemodialysis with forearm arteriovenous fistula access. J Vasc Access 2023:11297298231211361. [PMID: 37997027 DOI: 10.1177/11297298231211361] [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: 11/25/2023] Open
Abstract
BACKGROUND As pointed out by the recent Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access, the current quality of evidence supporting preoperative vascular anatomy and patient outcomes is suboptimal and insufficient to make recommendations. This study assessed arteriovenous fistulas (AVFs) created with different preoperative arterial diameters on hospitalization and mortality rates in patients undergoing hemodialysis at the authors' center. METHODS Data from 261 patients who underwent HD between 2017 and 2019 were retrospectively examined. Differences in mortality and hospitalization rates between patients with different preoperative arterial diameters were compared, and risk factors for mortality and hospitalization were analyzed. RESULTS Smaller preoperative artery diameter (<2 mm) was associated with all-cause mortality (risk ratio [RR] 1.61 [95% confidence interval (CI) 1.45-1.90]; p < 0.01), and access-related (RR 1.68 [95% CI 1.24-2.44]; p < 0.01), and congestive heart failure (CHF)-related (RR 0.67 [95% CI 0.38-1.01]; p = 0.04) hospitalization. Longer catheter-dependent duration (⩾60 days) was associated with access-related hospitalization (RR 1.48 [95% CI 1.07-2.11]; p = 0.03), and higher postoperative brachial artery blood flow (⩾1500 mL/min) was associated with CHF-related hospitalization (RR 1.58 [95% CI 1.02-2.29]; p < 0.01). Higher postoperative brachial artery blood flow (⩾1500 mL/min) was associated with all-cause mortality (hazard ratio [HR] 1.20 [95% CI 1.09-2.32]; p = 0.04), whereas preoperative artery diameter (HR 0.98 [95% CI 0.93-1.86]; p = 0.08) and catheter-dependent duration (HR 1.06 [95% CI 0.47-2.13]; p = 0.82) were not associated with all-cause mortality. CONCLUSION In this cohort, smaller preoperative artery diameter was associated with all-cause and access-related hospitalizations, while a larger preoperative artery and higher postoperative brachial blood flow were associated with CHF-related hospitalization. However, only higher postoperative brachial blood flow was associated with all-cause mortality.
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Affiliation(s)
- Wenyuan Gan
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Fan Zhu
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Huihui Mao
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Xiao
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenli Chen
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xingruo Zeng
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Anderson L, Kraiss LW, Sarfati MR, Hales JB, Brooke BS. Predictors of Arteriovenous Fistula Maturation among Patients with Severe Obesity. Ann Vasc Surg 2023; 97:82-88. [PMID: 37385338 DOI: 10.1016/j.avsg.2023.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/09/2023] [Accepted: 05/25/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND There is an increasing prevalence of obesity among patients who develop end-stage renal disease and require dialysis. While referrals for arteriovenous fistulas (AVFs) among patients with class 2-3 obesity (i.e., body mass index [BMI] ≥ 35) are increasing, it is unclear what type of autogenous access is most likely to mature in this patient population. This study was designed to evaluate factors that impact maturation of AVF among patients with class ≥2 obesity. METHODS We retrospectively reviewed AVFs created at a single center from 2016 to 2019 for patients who had undergone dialysis within the same healthcare system. Ultrasound studies were used to evaluate factors that defined functional maturation, including diameter, depth, and volume flow rates through the fistula. Logistic regression models were used to evaluate the risk-adjusted association between class ≥2 obesity and functional maturation. RESULTS A total of 202 AVFs [radiocephalic (24%), brachiocephalic (43%), and transposed brachiobasilic (33%)] were created during the study period, of which 53 (26%) patients had a BMI >35. Functional maturation was significantly lower among patients with class ≥2 obesity undergoing brachiocephalic (58% obese versus 82% normal-overweight; P = 0.017), but not radiocephalic or brachiobasilic AVFs. This was primarily a result of excessive AVF depth in severely obese patients (9.6 ± 4.0 mm obese versus 6.0 ± 2.7 mm normal-overweight; P < 0.001), whereas there was no significant difference found in average volume flow or AVF diameter between groups. In risk-adjusted models, a BMI ≥35 was associated with a significantly lower likelihood of achieving AVF functional maturation (odds ratio: 0.38; 95% confidence interval: 0.18-0.78; P = 0.009) after controlling for age, sex, socioeconomic status, and fistula type. CONCLUSIONS Patients with a BMI >35 are less likely to mature AVFs after creation. This principally affects brachiocephalic AVFs and occurs because of increased fistula depth as opposed to diameter or volume flow parameters. These data can help guide decision-making when planning AVF placement in severely obese patients.
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Affiliation(s)
- Laura Anderson
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Larry W Kraiss
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Mark R Sarfati
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Julie B Hales
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT.
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Michas V, Taghipour M, Papachristodoulou A, Sidiropoulou M, Partovi S, Cokkinos D, Rafailidis V, Gadani S, Gill A, Michell H, Prassopoulos P. Multiparametric ultrasound for upper extremity dialysis access evaluation. Ultrasonography 2023; 42:490-507. [PMID: 37723649 PMCID: PMC10555685 DOI: 10.14366/usg.23064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 09/20/2023] Open
Abstract
The evolution of ultrasound (US) techniques has greatly improved the evaluation of many parameters in dialysis vascular access, which is typically achieved through an arteriovenous fistula (AVF) or graft (AVG). These techniques include grayscale B-mode, color Doppler, power Doppler, spectral Doppler, non-Doppler US flow imaging techniques, contrast-enhanced US, and elastography. In conjunction with a patient's medical history and physical examination, US provides crucial information about the native vascular bed prior to the surgical creation of an arteriovenous anastomosis. It also tracks the maturation progress of the newly created AVF or AVG and aids in diagnosing potential complications of the vascular access. These complications include thrombosis, steal syndrome, aneurysms, pseudoaneurysms, hematomas, infection, ischemic neuropathy, exacerbation of preexisting congestive heart failure, and stenosis.
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Affiliation(s)
- Vasileios Michas
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Mehdi Taghipour
- Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | | | - Maria Sidiropoulou
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Sasan Partovi
- Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | | | - Vasileios Rafailidis
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Sameer Gadani
- Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Amanjit Gill
- Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Hans Michell
- Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Panos Prassopoulos
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
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Ng JH, Yang W, Dember LM. Performance Characteristics of Candidate Criteria for Hemodialysis Arteriovenous Fistula Maturation. Clin J Am Soc Nephrol 2023; 18:1321-1332. [PMID: 37553865 PMCID: PMC10578636 DOI: 10.2215/cjn.0000000000000248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 07/31/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Twenty to 60% of newly created hemodialysis arteriovenous fistulas do not mature adequately for use. One barrier to developing interventions to improve fistula outcomes is a lack of standardized criteria for maturation. METHODS Using data from the multicenter, prospective Hemodialysis Fistula Maturation (HFM) Study, we determined sensitivities, specificities, and positive and negative predictive values of multiple candidate maturation criteria using the HFM Study maturation criteria as the reference. We also compared, across the maturation criteria, relationships between maturation and fistula survival using Cox proportional hazards models. RESULTS We included 535 of the 602 HFM Study participants. The median (interquartile range) age was 57 (47-65) years, 70% were men, and 45% were Black participants. Depending on the criterion and time frame for ascertainment (3, 4, 5, 6, or 9 months), sensitivities ranged from 57% to 100%, specificities ranged from 85% to 100%, positive predictive values ranged from 88% to 100%, and negative predictive values ranged from 65% to 100%. For all criteria, areas under the curve for the 6-month (0.90-0.97 for unassisted maturation and 0.89-0.95 for overall maturation) and 9-month time frames were similar. Attainment of unassisted maturation was associated with lower risks of fistula abandonment, with hazard ratios ranging from 0.10 to 0.40 depending on the criterion and time frame. Eliminating dialysis adequacy indicators, or simplifying the criteria in other ways, had little effect on performance characteristics. CONCLUSIONS High performance characteristics are maintained with maturation criteria that are simpler and less burdensome to ascertain than the HFM Study outcome measure.
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Affiliation(s)
- Jia Hwei Ng
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
| | - Wei Yang
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura M. Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Buzzell M, Chen A, Hoffstaetter T, Thompson DA, George SJ, Landis G, Silpe J, Etkin Y. Early Follow-Up after Arteriovenous Fistula Creation is Associated with Improved Access-Related Outcomes. Ann Vasc Surg 2023; 95:203-209. [PMID: 37121342 DOI: 10.1016/j.avsg.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Up to 60% of arteriovenous fistulas (AVF) require intervention to assist maturation, which prolongs the time until it can be used for hemodialysis (HD). Current guidelines recommend early postoperative AVF examination to detect and address immaturity to decrease time to maturation. This study evaluates how the timing of postoperative follow-up to assess AVF maturity affects patients' outcomes. METHODS All patients who underwent AVF creation between 2017 and 2021 in an academic medical center were retrospectively reviewed, excluding patients lost to follow-up or not on HD. Outcomes were compared between patients that had delayed follow-up to assess AVF maturity, >8 weeks post surgery, versus early follow-up, <8 weeks post-surgery. AVF evaluation for maturity consisted of physical examination and duplex ultrasound. Primary endpoints were time to first cannulation (interval from AVF creation to first successful cannulation) and time to catheter-free dialysis (interval from AVF creation to central venous catheter removal). RESULTS A total of 400 patients were identified: 111 in the delayed follow-up group and 289 in the early follow-up group. The median time to follow-up was 78 days (interquartile range [IQR], 66-125) in the delayed follow-up group versus 39 days (IQR, 36-47) in the early follow-up group, (P < 0.0001). The maturation rate was 87% in the delayed follow-up group versus 81% in the early follow-up group, (P = 0.1) and both groups had similar rates of interventions to assist maturation (66% vs. 57%, P = 0.2). The early follow-up group had a significantly shorter median time to first cannulation (50 vs. 88 days; P < 0.0001) and shorter time to catheter-free HD (75 vs. 118 days; P <0.0001). At 4 months after AVF creation, the incidence of first cannulation was 74% in the early follow-up group versus 63% in the delayed follow-up group (P = 0.001). Similarly, the incidence of catheter-free dialysis was 65% in the early follow-up group versus 50% in the delayed follow-up group at 4 months postoperatively, (P = 0.036). CONCLUSIONS Early postoperative follow-up for evaluation of fistula maturation is associated with reduced time to first successful cannulation of AVF for HD and reduced time to catheter-free dialysis.
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Affiliation(s)
- Mariah Buzzell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Adrian Chen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Tabea Hoffstaetter
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Dane A Thompson
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Sam J George
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Gregg Landis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jeffrey Silpe
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Yana Etkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
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10
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Kim H, Park HS, Ban TH, Yang SB, Kwon YJ. Evaluation of outcomes with permanent vascular access in an elderly Korean population based on the National Health Insurance Service database. Hemodial Int 2023. [PMID: 36943638 DOI: 10.1111/hdi.13077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/12/2023] [Accepted: 02/26/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION As nearly half of patients with end-stage kidney disease (ESKD) who initiate hemodialysis (HD) are over 65 years old (commonly defined as elderly), the fistula first strategy is controversial even in HD patients ≥65 years. METHODS In Korea's National Health Insurance Service database from 2008 to 2019, 41,989 elderly (≥ 65 years) HD patients were retrospectively reviewed to identify their clinical characteristics and outcomes. Vascular access (VA) patencies, risk factors associated with patencies and patient survival between arteriovenous fistula (AVF) and arteriovenous graft (AVG) were compared. RESULTS Elderly AVF group (n = 28,467) had superior primary, primary assisted, and secondary patencies than elderly AVG group (n = 13,522) (all p values are <0.001). Patient survival was also better in the elderly AVF group than in the elderly AVG (p < 0.001). In multivariate Cox regression analyses for diverse outcomes, AVG (vs. AVF) was identified as a risk factor for all-cause mortality (adjusted hazard ratio [HR]: 1.307; 95% confidence interval [CI]: 1.272-1.343; p < 0.001), primary patency (adjusted HR: 1.745; 95% CI: 1.701-1.790; p < 0.001), primary-assisted patency (adjusted HR: 2.163; 95% CI: 2.095-2.233; p < 0.001), and secondary patency (adjusted HR: 3.718; 95% CI: 3.533-3.913; p < 0.001). CONCLUSION Our study demonstrated that as a permanent VA for HD, AVF should be strongly considered in elderly (≥ 65 years) ESKD Korean patients. The age limit for AVF creation in ESKD patients should be adjusted more upward.
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Affiliation(s)
- Hyangkyoung Kim
- Department of Surgery, Ewha Womans University College of Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Hoon Suk Park
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, The Catholic University of Korea School of Medicine/Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, The Catholic University of Korea School of Medicine/Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Seung Boo Yang
- Department of Radiology, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Young Joo Kwon
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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11
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Alnahhal KI, Rowse J, Kirksey L. The challenging surgical vascular access creation. Cardiovasc Diagn Ther 2023; 13:162-172. [PMID: 36864962 PMCID: PMC9971302 DOI: 10.21037/cdt-22-560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
With the increasing life expectancy of patients with end-stage kidney disease, the creation and maintenance of hemodialysis vascular access are becoming more challenging. A comprehensive patient evaluation including a complete history, physical examination, and ultrasonographic vessel assessment is the foundation of the clinical evaluation. A patient-centered approach acknowledges the myriad of factors that impact the selection of optimal access for the distinct clinical and social circumstance of each patient. An interdisciplinary team approach involving various healthcare providers in all stages of hemodialysis access creation is important and associated with better outcomes. While patency is considered the most important parameter in most vascular reconstructive scenarios, the ultimate determinant of success in vascular access for hemodialysis is a circuit that allows consistent and uninterrupted delivery of the prescribed hemodialysis. The best conduit is one that is superficial, easily identified, straight, and of a large caliber. Individual patient factors and skill level of the cannulating technician also play a crucial role in the initial success and maintenance of vascular access. Special attention should be considered in dealing with more challenging groups such as the elderly population where the newest vascular access guidance from The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative will be transformative. The current guidelines recommend monitoring the vascular access by regular physical and clinical assessments, however, inadequate evidence is available to support routine ultrasonographic surveillance for improving access patency.
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Affiliation(s)
- Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jarrad Rowse
- Department of Vascular Surgery, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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12
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Saati A, Puffenberger D, Kirksey L, Fendrikova-Mahlay N. The role of hemodialysis access duplex ultrasound for evaluation of patency and access surveillance. Cardiovasc Diagn Ther 2023; 13:190-195. [PMID: 36864960 PMCID: PMC9971298 DOI: 10.21037/cdt-22-129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/19/2022] [Indexed: 11/06/2022]
Abstract
The rise in prevalence of end stage renal disease (ESRD) and the impact on health care resulted in increasing focus on delivery of vascular access. Hemodialysis vascular access is the most common renal replacement therapy method. The vascular access types include arteriovenous fistula, arteriovenous graft, and tunneled central venous catheters. Vascular access function remains an important outcome measure with significant impact on morbidity and health care cost. The survival and quality of life of patients on hemodialysis is dependent on the adequacy of dialysis through proper vascular access. Early detection of failure to mature vascular access, stenosis, thrombosis, and aneurysm or pseudoaneurysm formation remains crucial. Ultrasound can help identify complications, even though ultrasound evaluation of the arteriovenous access is less well defined. Some published vascular access guidelines support ultrasound for detecting stenosis. The evolution of ultrasound has improved throughout the years, both multi parametric top-line systems and hand-held systems. Ultrasound evaluation is inexpensive, rapid, noninvasive, and repeatable, it is a powerful tool used for early diagnosis. The ultrasound image quality still depends on the skill of the operator. Careful attention to technical details is needed and avoidance of several diagnostic pitfalls is necessary. This review is focused on the role of ultrasound for hemodialysis access surveillance, evaluation of maturation, detection of access complications, and aid with cannulation.
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Affiliation(s)
- Ammar Saati
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Debra Puffenberger
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Levester Kirksey
- Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Natalia Fendrikova-Mahlay
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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13
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Heindel P, Dey T, Feliz JD, Hentschel DM, Bhatt DL, Al-Omran M, Belkin M, Ozaki CK, Hussain MA. Predicting radiocephalic arteriovenous fistula success with machine learning. NPJ Digit Med 2022; 5:160. [PMID: 36280681 PMCID: PMC9592575 DOI: 10.1038/s41746-022-00710-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
After creation of a new arteriovenous fistula (AVF), assessment of readiness for use is an important clinical task. Accurate prediction of successful use is challenging, and augmentation of the physical exam with ultrasound has become routine. Herein, we propose a point-of-care tool based on machine learning to enhance prediction of successful unassisted radiocephalic arteriovenous fistula (AVF) use. Our analysis includes pooled patient-level data from 704 patients undergoing new radiocephalic AVF creation, eligible for hemodialysis, and enrolled in the 2014-2019 international multicenter PATENCY-1 or PATENCY-2 randomized controlled trials. The primary outcome being predicted is successful unassisted AVF use within 1-year, defined as 2-needle cannulation for hemodialysis for ≥90 days without preceding intervention. Logistic, penalized logistic (lasso and elastic net), decision tree, random forest, and boosted tree classification models were built with a training, tuning, and testing paradigm using a combination of baseline clinical characteristics and 4-6 week ultrasound parameters. Performance assessment includes receiver operating characteristic curves, precision-recall curves, calibration plots, and decision curves. All modeling approaches except the decision tree have similar discrimination performance and comparable net-benefit (area under the ROC curve 0.78-0.81, accuracy 69.1-73.6%). Model performance is superior to Kidney Disease Outcome Quality Initiative and University of Alabama at Birmingham ultrasound threshold criteria. The lasso model is presented as the final model due to its parsimony, retaining only 3 covariates: larger outflow vein diameter, higher flow volume, and absence of >50% luminal stenosis. A point-of-care online calculator is deployed to facilitate AVF assessment in the clinic.
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Affiliation(s)
- Patrick Heindel
- grid.38142.3c000000041936754XDivision of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,grid.62560.370000 0004 0378 8294Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Tanujit Dey
- grid.62560.370000 0004 0378 8294Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Jessica D. Feliz
- grid.38142.3c000000041936754XDivision of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,grid.62560.370000 0004 0378 8294Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Dirk M. Hentschel
- grid.38142.3c000000041936754XDivision of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Deepak L. Bhatt
- grid.38142.3c000000041936754XDivision of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Mohammed Al-Omran
- grid.17063.330000 0001 2157 2938Division of Vascular Surgery and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, ON Canada ,grid.415310.20000 0001 2191 4301Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Michael Belkin
- grid.38142.3c000000041936754XDivision of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - C. Keith Ozaki
- grid.38142.3c000000041936754XDivision of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Mohamad A. Hussain
- grid.38142.3c000000041936754XDivision of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,grid.62560.370000 0004 0378 8294Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
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14
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Kuo CH, Chang TI, Chen CH, Chen CY, Hsieh HL, Hsu SC, Cheng HS, Sue YM, Chen TH, Hsu YH, Lin FY, Shih CM, Huang PH, Liu CT. Luminal pressure gradient and risk of arteriovenous fistula nonmaturation. Medicine (Baltimore) 2022; 101:e30835. [PMID: 36181113 PMCID: PMC9524947 DOI: 10.1097/md.0000000000030835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
While arteriovenous fistula (AVF) nonmaturation is a major issue of hemodialysis care, an effective treatment to improve AVF maturation remains lacking. AVF introduces pulsatile arterial blood flow into its venous limb and produces high luminal pressure gradient, which may have adverse effect on vascular remodeling. As such, the aim of the present study is to investigate effect of luminal pressure gradient on AVF nonmaturation. This single-center, prospective observational study includes patients receiving autologous AVF creation. Participants received early postoperative ultrasound 5-7 days after surgery to collect parameters including diameters, flow rates, and volume at inflow and outflow sites. Luminal pressure gradient was estimated by using modified Bernoulli equation. The outcome was spontaneous AVF maturation within 8 weeks after surgery without intervention. Thirty patients were included, of which the mean age was 66.9 years and 70% were male. At the end of study, 13 (43.3%) patients had spontaneous AVF maturation. All demographic and laboratory characteristics were similar between patients with mature and nonmature AVF. Regarding ultrasonographic parameters, nonmature AVF showed significantly higher inflow/outflow diameter ratio, inflow velocity, and luminal pressure gradient. While these 3 parameters were significantly correlated, multivariate logistic regression showed their significant association with AVF nonmaturation. Receiver operating characteristic curve exhibited their high predictive value for AVF nonmaturation. Our findings showed that higher inflow/outflow ratio, inflow velocity, and AVF luminal pressure gradient in early postoperative ultrasound predicted risk of AVF nonmaturation. Reducing inflow/outflow diameter ratio or inflow rate may be an approach to improve AVF maturation. The predictive value of this early assessment might have impact on the clinical practice of AVF care.
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Affiliation(s)
- Chi-Heng Kuo
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
- Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Te-I Chang
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Cheng-Hsien Chen
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taiwan
| | - Chun-You Chen
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hui-Ling Hsieh
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shih-Chang Hsu
- Emergency Department, Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ho-Shun Cheng
- Division of Cardiology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yuh-Mou Sue
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Tso-Hsiao Chen
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yung-Ho Hsu
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taiwan
| | - Feng-Yen Lin
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Ming Shih
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Po-Hsun Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Te Liu
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU Research Center of Urology and Kidney, Taipei, Taiwan
- *Correspondence: Chung-Te Liu, Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan (e-mail: )
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15
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Ramadan OI, Dember LM, Wang GJ, Ng JH, Mantell MP, Neuman MD. Association between anaesthesia type and arteriovenous fistula maturation. BJA OPEN 2022; 3:100031. [PMID: 36267664 PMCID: PMC9581339 DOI: 10.1016/j.bjao.2022.100031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Whereas general anaesthesia is commonly used for haemodialysis fistula creation, regional or local anaesthesia has been posited to lead to better fistula maturation outcomes. We sought to measure the association between anaesthesia type and arteriovenous fistula maturation. METHODS We performed a secondary analysis of data from the Hemodialysis Fistula Maturation study, a multicentre prospective cohort study of advanced chronic kidney disease patients who underwent single-stage upper extremity fistula creation between 2010 and 2013. We evaluated the relationship between anaesthesia type and unassisted (without maturation-facilitating interventions) or overall (unassisted or assisted) fistula maturation using multivariable logistic regression. RESULTS Among 602 participants, 336 (55.8%) received regional/local anaesthesia and 266 (44.2%) received general anaesthesia. Unassisted maturation occurred in 164/309 patients (53.1%) after regional/local vs 91/226 patients (40.3%) after general anaesthesia (P=0.003). After adjustment for patient factors and fistula type, regional/local anaesthesia was associated with greater odds of unassisted maturation than general anaesthesia (odds ratio 1.72, 95% confidence interval 1.24-2.39; P=0.001). However, after further adjustment for clinical centre fixed effects, odds of unassisted maturation did not differ by anaesthesia type (odds ratio 1.03, 95% confidence interval 0.78-1.36; P=0.830). Similar findings were observed for overall maturation and composite endpoints accounting for potential survivorship bias. CONCLUSIONS Regional/local anaesthesia was associated with increased odds of fistula maturation when adjusting for patient factors and fistula type. However, this association did not persist after adjusting for centre fixed effects. Future research is needed to better understand the relationship between anaesthesia type and centre factors to optimise outcomes after fistula surgery.
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Affiliation(s)
- Omar I. Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura M. Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Grace J. Wang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jia Hwei Ng
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Mark P. Mantell
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark D. Neuman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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16
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Radiocephalic Arteriovenous Fistula Patency and Use. ANNALS OF SURGERY OPEN 2022; 3:e199. [PMID: 36199486 PMCID: PMC9508986 DOI: 10.1097/as9.0000000000000199] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/21/2022] [Indexed: 01/05/2023] Open
Abstract
We sought to confirm and extend the understanding of clinical outcomes following creation of a common distal autogenous access, the radiocephalic arteriovenous fistula (RCAVF). Mini-abstract: In this post hoc analysis of randomized clinical trial data including 914 adults with chronic kidney disease, the most robust predictors of radiocephalic arteriovenous fistula patency were larger cephalic vein diameter and access creation prior to a chronic hemodialysis requirement. Successful use occurred at increased rates in men, patients with larger diameter cephalic veins, smaller diameter arteries (albeit ≥2 mm), and when accesses were created using regional anesthesia and at higher volume centers.
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17
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Snuff-Box Versus Wrist Radiocephalic Arteriovenous Fistulas for Hemodialysis: Maturation Tend and its Affecting Factors. Ann Vasc Surg 2022; 87:495-501. [PMID: 35780948 DOI: 10.1016/j.avsg.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Thanks to its well proved long-term patency rates, native radiocephalic arteriovenous fistula remains the most commonly used vascular access type. Many articles had approached the criteria leading to a mature fistula. The aims of this work are to evaluate variables that may affect the maturation of distal fistulas and to determine if wrist fistulas have less risk of maturation failure than the snuff-box fistulas. METHODS We recorded all distal radiocephalic fistulas that had been created from January 2018 to February 2021. Epidemiological and clinical profile of patients, characteristics of performed fistulas and per and post-operative data were recorded and analyzed. RESULTS From January 2018 to February 2021, 165 upper limb vascular accesses for hemodialysis had been created including 47 (28.5%) distal radiocephalic fistulas. Among the latter, 39 (83%) fistulas were performed at the wrist and 8 (17%) at snuff-box area. There were 34 men (72.3%). Mean age was 67 years (37-87). Both types of fistulas had approximately an identic frequency of primary maturation failure (50% for radiocephalic versus 47.2% for snuff-box fistulas). Secondary maturation had been achieved in 9 fistulas. Patients with medical history of dyslipidemia, peripheral arterial disease (PAD), central catheter placement, and bad quality of vessels tend to develop an immature fistula. CONCLUSIONS No significant differences in maturation tend between snuff-box and wrist fistulas had been demonstrated. Thus, it seems reasonable to privilege the creation of the most distal fistulas allowing preservation of wrist fistulas as a second option in case of snuff-box fistulas maturation failure. However, selection of the most suitable cases for snuff-box fistulas creation, based on clinical and duplex ultrasound data, remains primordial.
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18
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Li YC, Yu SY, Kao TC, Ko PJ, Wei WC, Su TW, Wu YJ, Li YS. The clinical outcome of balloon-assisted maturation procedure between autogenous radiocephalic fistula and brachiocephalic fistula in a single center experience. J Vasc Surg 2022; 76:1060-1065. [PMID: 35697313 DOI: 10.1016/j.jvs.2022.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 04/04/2022] [Accepted: 04/10/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Balloon-assisted maturation by an endovascular method plays an important role in treating an immature arteriovenous fistula. However, the results between radiocephalic fistula and brachiocephalic fistula were rarely reported. This retrospective study aimed to investigate the effectiveness and outcome of balloon-assisted maturation in different sites of autogenous arteriovenous fistulas. METHODS This single-center retrospective study included patients who underwent balloon-assisted maturation procedures from January 2015 to December 2016. Of 148 patients, 117 and 31 patients had a radiocephalic fistula and a brachiocephalic fistula, respectively. The primary outcome was balloon-assisted maturation success. Data regarding fistula lesions, balloon types and size, frequency of procedures, and maturation time were collected for balloon-assisted maturations. The secondary outcome was the patency of a fistula in the follow-up period. RESULTS No difference was observed in procedure of balloon-assisted maturation frequency between the radiocephalic and brachiocephalic fistula groups. The total success rate was 77.7%, without significant difference between radiocephalic and brachiocephalic fistula groups (81.20% vs. 64.50%; P=0.055). Within the procedures, the culprit lesion of juxta-anastomosis segment (73.5% vs. 25.5%, P<0.001) and arterial inlet (21.2% vs. 7.8%, P=0.04) were more common in the radiocephalic fistula group, whereas the venous outlet was more common in the brachiocephalic fistula group (88.2% vs. 57.7%, P<0.001). Both groups had an equivalent patency rate after the balloon-assisted maturation within the follow-up period (P=0.272). CONCLUSIONS Balloon-assisted maturation was an effective procedure for immature fistulas, without significant difference between the radiocephalic and brachiocephalic fistulas. Through the procedure, the culprit lesions causing non-maturation were found to be different between the two groups. The patency rate between the two groups after surgery seems to be equivalent within the follow-up period.
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Affiliation(s)
- Ying-Ching Li
- Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Sheng-Yueh Yu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Tsung-Chi Kao
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Po-Jen Ko
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Cheng Wei
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Ta-Wei Su
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Jen Wu
- Division of Thoracic and Cardiovascular Surgery, Department of Nursing, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Ying-Sheng Li
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan.
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19
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Hakim AJ, Brooke BS, Beckstrom JL, Sarfati MR, Kraiss LW. Rules of 6 Criteria Predict Dialysis Fistula Maturation but Not All Rules are Equal. J Vasc Surg 2022; 76:232-238.e2. [DOI: 10.1016/j.jvs.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/03/2022] [Indexed: 11/30/2022]
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20
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Huang X, Guan J, Sheng Z, Wang M, Xu T, Guo G, Wan P, Tian B, Zhou J, Huang A, Hao J, Yao L. Effect of local anti-vascular endothelial growth factor therapy to prevent the formation of stenosis in outflow vein in arteriovenous fistula. J Transl Int Med 2021; 9:307-317. [PMID: 35136729 PMCID: PMC8802407 DOI: 10.2478/jtim-2021-0045] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Vascular stenosis and angiogenesis are the major causes of short expectancy of arteriovenous fistula (AVF). Increased expression of vascular endothelial growth factor-A (VEGF-A) has been suggested to play an important role in the pathophysiologic process. Anti-VEGF has been proved to be effective on anti-angiogenesis and applied in clinical practice, but its effect on anti-stenosis remains to be verified before it could be applied to prevent stenosis of AVF. This study was aimed to evaluate the effect of local anti-VEGF therapy to prevent the formation of stenosis in the outflow vein in AVF and its mechanism. METHODS Bioinformatics of VEGF-A and its downstream-regulated molecules from the STRING PPI database were analyzed in this study. The biopsy samples from outflow veins of AVF in patients and C57BL/6 mouse models were analyzed to examine the mechanisms of pathologic vascular stenosis associated with VEGF pathways and their potential therapeutic targets. RESULTS We found that the reduction of VEGF-A could downregulate downstream molecules and subsequently reduce the intimal hyperplasia and abnormal vascular remodeling by analyzing the STRING PPI database. Venous wall thickening, intimal neointima formation, and apoptosis of vascular endothelial cells in the proliferative outflow vein of the AVF were significantly more obvious, and upregulation of expression of VEGF was observed in dysfunctional AVF in patients. In mouse models, the expression of VEGF, Ephrin receptor B4 (EphB4), matrix metalloproteinase (MMP)2, MMP9, tissue inhibitor of metalloproteinase (TIMP)1, TIMP2, and caspase 3 in the control-shRNA surgical group was significantly higher than in the sham group (P < 0.05), and all of these indicators were significantly lower in lentiviral transfection group and Avastin group than in control-shRNA surgical group (P < 0.05) on the 14th day after AVF operation. CONCLUSION VEGF expression is significantly increased in vascular endothelial cells in stenosed or occluded outflow veins of dysfunctional AVF. Local injection of Avastin into the adventitia of the proximal outflow vein in autologous AVF procedure has an excellent potential to prevent the subsequent local stenosis of the proximal outflow vein.
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Affiliation(s)
- Xin Huang
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Jibin Guan
- College of Pharmacy, University of Minnesota, Minneapolis55455, MN, USA
| | - Zitong Sheng
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Menghua Wang
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Tianhua Xu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Guangying Guo
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Pengzhi Wan
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Binyao Tian
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Junlei Zhou
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Aoran Huang
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
| | - Junfeng Hao
- Department of Nephrology, Jinqiu Hospital Liaoning Province, Shenyang110016, Liaoning Province, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang110001, Liaoning Province, China
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21
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Goodney PP. Building Systems to Measure Success and Improve Outcomes in Dialysis Access-Not a "Steal" but Probably a Bargain. JAMA Surg 2021; 156:1119. [PMID: 34550321 DOI: 10.1001/jamasurg.2021.4528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Philip P Goodney
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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22
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Gan W, Shao D, Xu L, Tuo Y, Mao H, Wang W, Xiao W, Xu F, Huang X, Chen W, Zeng X. Maturation and survival of arteriovenous fistula: The challenge starts from the preoperative assessment stage. Semin Dial 2021; 35:228-235. [PMID: 34734660 DOI: 10.1111/sdi.13036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/27/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND It is necessary to assess the association between the preoperative indicators and the maturation and survival of arteriovenous fistula (AVF). METHODS We retrospectively identified 236 patients with a new AVF created between 2016 and 2018 in our Dialysis Center. RESULTS Multivariate Logistic regression showed that preoperative arterial diameter (odds ratio [OR] = 1.452, 95% confidence interval [CI] [1.233, 1.710], p < 0.001), preoperative venous diameter (OR = 1.296, 95% CI [1.166, 1.477], p < 0.001), left ventricular ejection fraction (LVEF) (OR = 1.187, 95% CI [1.103, 1.277], p < 0.001), and diabetes mellitus (OR = 0.245, 95% CI [0.107, 0.560], p = 0.01) were independent influential factors for AVF maturation. Two years after the AVF surgery follow-up, multivariate Cox proportional-hazards model showed that the preoperative arterial diameter (OR = 0.510, 95% CI [0.320, 0.813], p = 0.005), preoperative venous diameter (OR = 0.940, 95% CI [0.897, 0.985], p = 0.010) and diabetes mellitus (OR = 1.785, 95% CI [1.117, 2.855], p = 0.016) was prognostic factors of AVF survival. The Kaplan-Meier method showed that the primary survival of AVF in patients with different preoperative arterial diameter was statistically significant (log-rank χ2 = 15.415, p < 0.001), while the secondary survival was not statistically significant (log-rank χ2 = 0.131, p = 0.717). CONCLUSION In our cohort, the preoperative arterial and venous diameter and diabetes mellitus were independent influential factors for AVF maturation and prognostic factors of AVF survival. However, the preoperative LVEF only associated with the maturation of AVF. Meanwhile, smaller arterial diameter (≤2.15 mm) was associated with AVF maturation failure, but did not impact secondary survival of AVF.
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Affiliation(s)
- Wenyuan Gan
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Danni Shao
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Xu
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanhong Tuo
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huihui Mao
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenzhe Wang
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Xiao
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fang Xu
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaomei Huang
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenli Chen
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xingruo Zeng
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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23
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Huber TS, Berceli SA, Scali ST, Neal D, Anderson EM, Allon M, Cheung AK, Dember LM, Himmelfarb J, Roy-Chaudhury P, Vazquez MA, Alpers CE, Robbin ML, Imrey PB, Beck GJ, Farber AM, Kaufman JS, Kraiss LW, Vongpatanasin W, Kusek JW, Feldman HI. Arteriovenous Fistula Maturation, Functional Patency, and Intervention Rates. JAMA Surg 2021; 156:1111-1118. [PMID: 34550312 DOI: 10.1001/jamasurg.2021.4527] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance National initiatives have emphasized the use of autogenous arteriovenous fistulas (AVFs) for hemodialysis, but their purported benefits have been questioned. Objective To examine AVF usability, longer-term functional patency, and remedial procedures to facilitate maturation, manage complications, or maintain patency in the Hemodialysis Fistula Maturation (HFM) Study. Design, Setting, and Participants The HFM Study was a multicenter (n = 7) prospective National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases cohort study performed to identify factors associated with AVF maturation. A total of 602 participants were enrolled (dialysis, kidney failure: 380; predialysis, chronic kidney disease [CKD]: 222) with AVF maturation ascertained for 535 (kidney failure, 353; CKD, 182) participants. Interventions All clinical decisions regarding AVF management were deferred to the individual centers, but remedial interventions were discouraged within 6 weeks of creation. Main Outcomes and Measures In this case series analysis, the primary outcome was unassisted maturation. Functional patency, freedom from intervention, and participant survival were summarized using Kaplan-Meier analysis. Results Most participants evaluated (n = 535) were men (372 [69.5%]) and had diabetes (311 [58.1%]); mean (SD) age was 54.6 (13.6) years. Almost two-thirds of the AVFs created (342 of 535 [64%]) were in the upper arm. The AVF maturation rates for the kidney failure vs CKD participants were 29% vs 10% at 3 months, 67% vs 38% at 6 months, and 76% vs 58% at 12 months. Several participants with kidney failure (133 [37.7%]) and CKD (63 [34.6%]) underwent interventions to facilitate maturation or manage complications before maturation. The median time from access creation to maturation was 115 days (interquartile range [IQR], 86-171 days) but differed by initial indication (CKD, 170 days; IQR, 113-269 days; kidney failure, 105 days; IQR, 81-137 days). The functional patency for the AVFs that matured at 1 year was 87% (95% CI, 83.2%-90.2%) and at 2 years, 75% (95% CI, 69.7%-79.7%), and there was no significant difference for those receiving interventions before maturation. Almost half (188 [47.5%]) of the AVFs that matured had further intervention to maintain patency or treat complications. Conclusions and Relevance The findings of this study suggest that AVF remains an accepted hemodialysis access option, although both its maturation and continued use require a moderate number of interventions to maintain patency and treat the associated complications.
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Affiliation(s)
- Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Erik M Anderson
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham
| | - Alfred K Cheung
- Nephrology and Hypertension Division, University of Utah School of Medicine, Salt Lake City
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle
| | | | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern, Dallas
| | | | | | - Peter B Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Alik M Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, Massachusetts
| | - James S Kaufman
- Renal Section, Veterans Affairs New York Harbor Healthcare System, New York
| | - Larry W Kraiss
- Division of Vascular Surgery, University of Utah, Salt Lake City
| | | | - John W Kusek
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Harold I Feldman
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia
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24
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Mordhorst A, Clement J, Kiaii M, Faulds J, Hsiang Y, Misskey J. A Comparison of Outcomes Between Open and Endovascular Arteriovenous Access Creation for Hemodialysis. J Vasc Surg 2021; 75:238-247.e1. [PMID: 34303803 DOI: 10.1016/j.jvs.2021.07.104] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Preliminary outcomes for percutaneous endovascular autogenous access (endoAVF) have shown promising results; however, comparisons with surgical cohorts in dialysis populations are lacking. This study compares autogenous arteriovenous access created with the EverlinQ endoAVF system with accesses created by conventional surgical technique with respect to functional and patency related outcomes. METHODS This is a multicenter, retrospective review of autogenous arteriovenous accesses entered into a prospective database. Patients receiving radiocephalic, brachiocephalic, or endoAVF arteriovenous accesses between 2014 -2019 were included. Autogenous access maturation, primary patency, secondary patency, steal syndrome, and re-interventions were collected and analyzed using standard statistical and survival analyses. RESULTS A total of 369 accesses were created during the study period, including 61 endovascular accesses, 171 radiocephalic accesses, and 137 brachiocephalic accesses (median follow-up 17 months; range 1 - 71 months). Maturation failure at the end of follow-up was 27±6%, 27±5%, and 18±4% for endovascular, radiocephalic, and brachiocephalic accesses, respectively (p =.049 for brachiocephalic vs. endovascular accesses). Primary patencies at 12 and 24 months were 42±5% and 32±7% for endovascular accesses, 43±4% and 24±4% for radiocephalic accesses, and 42±4% and 29±4% for brachiocephalic accesses (p=.906). Secondary patencies at 12 and 24 months were 68±6% and 60±7% for endovascular accesses, 75±3% and 67±4% for radiocephalic accesses, and 91±3% and 81±4% for brachiocephalic accesses (p=.006 for brachiocephalic vs. endovascular accesses). There were no statistically significant differences in ischemic steal syndrome (3.3%, 4.1% and 8.0%; p=.229) or total reinterventions/year (1.0±3.1, 0.9±1.8, and 1.2±1.8; p=.289) for endovascular, radiocephalic, or brachiocephalic arteriovenous accesses, respectively. CONCLUSIONS EndoAVF compare favorably with respect to maturation and patency compared with surgically created accesses in a real-world cohort. Outcomes and reintervention rates are similar to conventional radiocephalic arteriovenous accesses, but are inferior with respect to patency and maturation to brachiocephalic accesses.
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Affiliation(s)
- Alexa Mordhorst
- Division of Vascular Surgery, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada.
| | - Jason Clement
- Department of Radiology, St. Paul's Hospital, Vancouver, BC, Canada
| | - Mercedeh Kiaii
- Department of Nephrology, St. Paul's Hospital, Vancouver, BC, Canada
| | - Jason Faulds
- Division of Vascular Surgery, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - York Hsiang
- Division of Vascular Surgery, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Jonathan Misskey
- Division of Vascular Surgery, Department of Surgery, Vancouver General Hospital, Vancouver, BC, Canada
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25
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Manov JJ, Mohan PP, Vazquez-Padron R. Arteriovenous fistulas for hemodialysis: Brief review and current problems. J Vasc Access 2021; 23:839-846. [PMID: 33818180 DOI: 10.1177/11297298211007720] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The number of people worldwide living with end-stage renal disease is increasing. Arteriovenous fistulas are the preferred method of vascular access in patients who will require hemodialysis. As the number of patients with arteriovenous fistulas grows, the role of physicians who intervene who maintain and salvage these fistulas will grow in importance. This review aims to familiarize practitioners with the rationale for arteriovenous fistula creation, the detection of fistula dysfunction, and the state of the art on fistula maintenance and preservation. Current controversies are briefly reviewed.
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Affiliation(s)
- John J Manov
- Department of Radiology, University of Miami, Miami, FL, USA
| | - Prasoon P Mohan
- Department of Interventional Radiology, University of Miami, Miami, FL, USA
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26
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Heindel P, Dieffenbach BV, Sharma G, Belkin M, Ozaki CK, Hentschel DM. Contemporary outcomes of a "snuffbox first" hemodialysis access approach in the United States. J Vasc Surg 2021; 74:947-956. [PMID: 33667611 DOI: 10.1016/j.jvs.2021.01.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 01/28/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The Society for Vascular Surgery guidelines for permanent hemodialysis (HD) access creation recommend prioritizing the most distal possible autogenous access to minimize complications and preserve more proximal options. The "snuffbox" arteriovenous fistula (AVF) is the most distal radial artery-cephalic vein AVF. Despite the theoretical benefits of the snuffbox approach, recent trends have been toward upper arm access. Our study sought to investigate the feasibility of a snuffbox-first strategy for HD access in all anatomically appropriate candidates. METHODS From January 2016 to August 2019, all patients with end-stage renal disease (ESRD) or pre-ESRD under consideration for HD access were evaluated for a snuffbox-first approach by a team of vascular surgeons and nephrologists at a single, urban academic medical center in the United States. Data were collected prospectively and supplemented by medical record review. A survival analysis was performed to evaluate primary unassisted and secondary patency and clinical and functional maturation. Patients were censored if they had received a kidney transplant or had died. Cox proportional hazards regression was used to determine the risk factors for prolonged clinical maturation and functional maturation. RESULTS A total of 55 snuffbox AVFs were created. The median patient age was 60 years (interquartile range [IQR], 52-70 years), and 52.7% of the patients were men. The median follow-up was 369 days (IQR, 166-509 days). The median survival for primary unassisted patency was 90 days (95% confidence interval [CI], 79-111). Secondary patency at 1 year was 92.3% (95% CI, 85.3%-99.9%). The clinical maturation rate at 1 year was 83.7% (n = 55; 95% CI, 66.8%-91.9%), and the functional maturation rate at 1 year was 85.6% (n = 40; 95% CI, 63.3%-94.4%). Of the patients who were pre-ESRD at AVF creation and had initiated HD during the study period, 87.5% had successfully received incident HD with their snuffbox AVF. Twenty-four patients were receiving HD via a catheter at snuffbox creation. Of those patients, the functional maturation rate at 1 year was 82.5% (95% CI, 44.8%-94.4%). The patients had undergone a median of two interventions (IQR, zero to seven interventions) in the first year. Of these, 46.9% were percutaneous angioplasty and 31.2% were side-branch ligation. Diabetes was associated with slower AVF clinical maturation (multivariate hazard ratio, 0.35; 95% CI, 0.15-0.82; P = .016). A larger artery diameter was associated with earlier AVF clinical maturation (multivariate hazard ratio, 6.64; 95% CI, 2.11-20.9). CONCLUSIONS A snuffbox-first approach to HD access is a viable option for distal access creation in a cohort of patients requiring HD in the United States. Subsequent ancillary interventions to facilitate access maturation were required for most patients.
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Affiliation(s)
- Patrick Heindel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Bryan V Dieffenbach
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Gaurav Sharma
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Dirk M Hentschel
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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27
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Pisoni RL, Zepel L, Zhao J, Burke S, Lok CE, Woodside KJ, Wasse H, Kawanishi H, Schaubel DE, Zee J, Robinson BM. International Comparisons of Native Arteriovenous Fistula Patency and Time to Becoming Catheter-Free: Findings From the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2021; 77:245-254. [DOI: 10.1053/j.ajkd.2020.06.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 06/30/2020] [Indexed: 11/11/2022]
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28
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Jie K, Feng W, Boxiang Z, Maofeng G, Jianbin Z, Zhaoxuan L, Yangyi Z, Liang C, Haobo S, Wensheng L, Guoping C, Jianping G, Xu H, Jianyan W. Identification of Pathways and Key Genes in Venous Remodeling After Arteriovenous Fistula by Bioinformatics Analysis. Front Physiol 2020; 11:565240. [PMID: 33363475 PMCID: PMC7755109 DOI: 10.3389/fphys.2020.565240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 10/30/2020] [Indexed: 01/24/2023] Open
Abstract
The arteriovenous fistula (AVF) is the first choice for vascular access for hemodialysis of renal failure patients. Venous remodeling after exposure to high fistula flow is important for AVF to mature but the mechanism underlying remodeling is still unknown. The objective of this study is to identify the molecular mechanisms that contribute to venous remodeling after AVF. To screen and identify the differentially expressed genes (DEGs) that may involve venous remodeling after AVF, we used bioinformatics to download the public microarray data (GSE39488) from the Gene Expression Omnibus (GEO) and screen for DEGs. We then performed gene ontology (GO) function analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis, and gene set enrichment analysis (GSEA) for the functional annotation of DEGs. The protein-protein interaction (PPI) network was constructed and the hub genes were carried out. Finally, we harvested 12 normal vein samples and 12 AVF vein samples which were used to confirm the expressions of the hub genes by immunohistochemistry. A total of 45 DEGs were detected, including 32 upregulated and 13 downregulated DEGs. The biological process (BP) of the GO analysis were enriched in the extrinsic apoptotic signaling pathway, cGMP-mediated pathway signaling, and molting cycle. The KEGG pathway analysis showed that the upregulated DEGs were enriched in glycosaminoglycan biosynthesis and purine metabolism, while the downregulated DEGs were mainly enriched in pathways of glycosaminoglycan biosynthesis, antifolate resistance, and ABC transporters. The GSEA analysis result showed that the top three involved pathways were oxidative phosphorylation, TNFA signaling via NF-K B, and the inflammatory response. The PPI was constructed and the hub genes found through the method of DMNC showed that INHBA and NR4A2 might play an important role in venous remodeling after AVF. The integrated optical density (DOI) examined by immunohistochemistry staining showed that the expression of both INHBA and NR4A2 increased in AVF compared to the control group. Our research contributes to the understanding of the molecular mechanism of venous remodeling after exposure to high fistula flow, which may be useful in treating AVF failure.
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Affiliation(s)
- Kong Jie
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wang Feng
- Graduate School of Peking Union Medical College, Beijing, China
| | - Zhao Boxiang
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Gong Maofeng
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhang Jianbin
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Lu Zhaoxuan
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhou Yangyi
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chen Liang
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Su Haobo
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lou Wensheng
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chen Guoping
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Gu Jianping
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - He Xu
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wen Jianyan
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
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29
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Arteriovenous Fistula in Dialysis Patients Remains Patent with Strict Control of Blood Pressure. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02196-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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30
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Jeong S, Kwon H, Chang JW, Han Y, Kwon TW, Cho YP. Outcomes of arteriovenous access among cancer patients requiring chronic haemodialysis. BMC Nephrol 2020; 21:297. [PMID: 32703168 PMCID: PMC7379794 DOI: 10.1186/s12882-020-01969-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/20/2020] [Indexed: 11/24/2022] Open
Abstract
Background There are limited data focusing specifically on the types of arteriovenous (AV) access used and outcomes of AV access among cancer patients as a consequence of cancer. We aimed to describe outcomes of AV access among cancer patients requiring chronic haemodialysis, and also to compare outcomes between patients with and without cancer. Methods In this single-centre, retrospective, observational cohort study, 84 patients diagnosed with cancer before AV access placement were included; we analysed outcomes of AV access among these patients and compared these outcomes with our previous results. The study endpoints were AV access patency and early failure, defined as AV access abandonment within 12 months after AV access placement. Results Various cancer types, stages, and treatments were identified in our analysis. Autologous arteriovenous fistulas (AVFs) were used for 92.9% of this study population. Using our previous results for comparison, we found no significant difference in death-censored primary (P = 0.546) and secondary (P = 0.266) patency of AV access between patients with and without cancer; however, the rate of early AVF failure was statistically significantly higher among cancer patients (25.6% vs 13.9%; P = 0.008), and the most common cause of AVF failure was patient death. The rate of early failure was significantly higher among patients with advanced-stage cancer (59.1%) than among those with early-stage cancer (12.9%) (P < 0.001). Conclusions Although AV access patency rates were similar among patients with and without cancer in the death-censored analysis, cancer patients were more prone to early AVF failure, mainly due to cancer-associated deaths, and this consideration needs to be carefully balanced against individual patients’ life expectancies, according to cancer type and stage.
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Affiliation(s)
- Seonjeong Jeong
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hyunwook Kwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jai Won Chang
- Division of Nephrology, Department of Internal Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Tae-Won Kwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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31
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Farrington CA, Robbin ML, Lee T, Barker-Finkel J, Allon M. Early Predictors of Arteriovenous Fistula Maturation: A Novel Perspective on an Enduring Problem. J Am Soc Nephrol 2020; 31:1617-1627. [PMID: 32424000 DOI: 10.1681/asn.2019080848] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 03/26/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Preoperative ultrasound mapping is routinely used to select vessels meeting minimal threshold diameters for surgical arteriovenous fistula (AVF) creation but fails to improve AVF maturation rates. This suggests a need to reassess the preoperative ultrasound criteria used to optimize AVF maturation. METHODS We retrospectively identified 300 catheter-dependent patients on hemodialysis with a new AVF created between 2010 and 2016. We then evaluated the associations of preoperative vascular measurements and hemodynamic factors with unassisted AVF maturation (successful use for dialysis without prior intervention) and overall maturation (successful use with or without prior intervention). Multivariable logistic regression was used to identify preoperative factors associated with unassisted and overall AVF maturation. RESULTS Unassisted AVF maturation associated with preoperative arterial diameter (adjusted odds ratio [aOR], 1.50 per 1-mm increase; 95% confidence interval [95% CI], 1.23 to 1.83), preoperative systolic BP (aOR, 1.16 per 10-mm Hg increase; 95% CI, 1.05 to 1.28), and left ventricular ejection fraction (aOR, 1.07 per 5% increase; 95% CI, 1.01 to 1.13). Overall AVF maturation associated with preoperative arterial diameter (aOR, 1.36 per 1-mm increase; 95% CI, 1.10 to 1.66) and preoperative systolic BP (aOR, 1.17; 95% CI, 1.06 to 1.30). Using receiver operating curves, the combination of preoperative arterial diameter, systolic BP, and left ventricular ejection fraction was fairly predictive of unassisted maturation (area under the curve, 0.69). Patient age, sex, race, diabetes, vascular disease, obesity, and AVF location were not associated with maturation. CONCLUSIONS Preoperative arterial diameter may be an under-recognized predictor of AVF maturation. Further study evaluating the effect of preoperative arterial diameter and other hemodynamic factors on AVF maturation is needed.
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Affiliation(s)
- Crystal A Farrington
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle L Robbin
- Department of Radiology, University of Alabama at Birmingham, Birmingham Alabama
| | - Timmy Lee
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Nephrology, Veterans Affairs Medical Center, Birmingham, Alabama
| | - Jill Barker-Finkel
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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Choi J, Ban TH, Choi BS, Baik JH, Kim BS, Kim YO, Park CW, Yang CW, Jin DC, Park HS. Comparison of vascular access patency and patient survival between native arteriovenous fistula and synthetic arteriovenous graft according to age group. Hemodial Int 2020; 24:309-316. [PMID: 32372545 DOI: 10.1111/hdi.12836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/06/2020] [Accepted: 04/16/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Arteriovenous fistula (AVF) is historically known to be the ideal option for vascular access (VA) for hemodialysis compared with arteriovenous graft (AVG). However, this approach has been recently questioned in the aging population because of their poor vessel quality and multiple comorbidities. METHODS Data from a total of 2200 patients from the VA category of The Catholic Medical Center nephrology registry from March 2009 to February 2017 were analyzed. We compared VA patency and patient survival between two groups, AVF and AVG, according to age. FINDINGS Compared with the AVG group, survival benefit in the AVF group continued even in patients ≥80 years. In the whole population, all the primary patency (PP), primary-assisted patency (PAP), and secondary patency (SP) measures were superior in the AVF group. With regard to subgroups, PP was comparable between the two groups in patients ≥65 years, whereas PAP and SP were superior in the AVF group even in septuagenarian patients who are from 70 to 79 years old. In patients ≥80 years, all the patency measures were comparable between the two groups. When the separate comparison of lower-arm AVF (or upper-arm AVF) and AVG, lower-arm AVF failed to demonstrate its superiority in any kind of patency in septuagenarian patients compared with AVG, whereas upper-arm AVF demonstrated its superiority in PAP and SP in septuagenarian patients. However, even upper-arm AVF failed to demonstrate its superiority in any kind of patency in patients ≥80 years. DISCUSSION Arteriovenous fistula if using upper-arm vessel showed the superior VA patency up to septuagenarian patients, whereas, in HD patients ≥80 years, AVF and AVG were comparable in VA patency.
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Affiliation(s)
- Joonsung Choi
- Department of Radiology, The Catholic University of Korea School of Medicine/ St. Vincent's Hospital, Suwon, Republic of Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea.,Departmentof Internal Medicine, The Catholic University of Korea School of Medicine/ Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea.,Departmentof Internal Medicine, The Catholic University of Korea School of Medicine/ Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Jun Hyun Baik
- Department of Radiology, The Catholic University of Korea School of Medicine/ St. Vincent's Hospital, Suwon, Republic of Korea
| | - Byung Soo Kim
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea.,Departmentof Internal Medicine, The Catholic University of Korea School of Medicine/ Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Young Ok Kim
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
| | - Cheol Whee Park
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
| | - Dong Chan Jin
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
| | - Hoon Suk Park
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea.,Departmentof Internal Medicine, The Catholic University of Korea School of Medicine/ Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
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Shah S, Chan MR, Lee T. Perspectives in Individualizing Solutions for Dialysis Access. Adv Chronic Kidney Dis 2020; 27:183-190. [PMID: 32891301 DOI: 10.1053/j.ackd.2020.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/15/2020] [Accepted: 03/05/2020] [Indexed: 11/11/2022]
Abstract
The vascular access is the lifeline for the hemodialysis patient. Previous national vascular access guidelines have emphasized placement of arteriovenous fistulas in most hemodialysis patients. However, the new Kidney Disease Outcomes Quality Initiative guidelines for vascular access, soon to be published, will focus on a patient's end-stage kidney disease "life plan" and take a patient "first" approach. One of the major themes of the new Kidney Disease Outcomes Quality Initiative guidelines is selecting the "right access, for the right patient, at the right time, for the right reason". Given the availability of new advances in biomedical technologies, techniques, and devices in the vascular access field, this shift to a more patient-centered vascular access approach presents unique opportunities to individualize the solutions and care for patients requiring a dialysis vascular access. This review article will address 3 potential areas where there is an unmet need to individualize solutions for dialysis vascular access care: (1) biological approaches to improve vascular access selection and selection of therapies, (2) vascular access care for the post-transplant patient, and (3) vascular access disparities in race, gender, and the elderly patient.
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34
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Jeong S, Kwon H, Chang JW, Kim MJ, Ganbold K, Han Y, Kwon TW, Cho YP. Effects of patient age on patency of chronic hemodialysis vascular access. BMC Nephrol 2019; 20:422. [PMID: 31752721 PMCID: PMC6873763 DOI: 10.1186/s12882-019-1604-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 10/29/2019] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND In this single-center, retrospective observational study, we assessed the long-term patency of vascular access (VA) after first VA placement to uncover independent risk factors associated with VA patency in Asian hemodialysis (HD) patients stratified by age. We also investigated factors associated with VA patency among older HD patients according to the type of VA in the overall study population. METHODS The study period was from January 2011 to December 2013. A total of 651 chronic HD patients with confirmed first upper-extremity VA placement were enrolled, and their records were analyzed retrospectively. A total of 445 patients (68.4%) made up the nonelderly group (< 65 years), and 206 patients (31.6%) were in the elderly group (≥ 65 years). Study outcomes were defined as primary or secondary VA patency. RESULTS Autologous arteriovenous fistula (AVF) was more common in the nonelderly group (P < 0.01). Kaplan-Meier curve survival analysis indicated that primary patency was longer in the nonelderly group (P < 0.01); secondary patency, however, was similar between groups (P = 0.37). The multivariate analysis of factors associated with primary VA patency revealed that increased age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P < 0.01) was associated with shorter primary patency, and AVF (HR, 0.38; 95% CI, 0.28-0.51; P < 0.01) was associated with longer primary patency. AVF (HR, 0.57; 95% CI, 0.37-0.87; P = 0.010) and diabetes mellitus (HR, 1.56; 95% CI, 1.07-2.29; P = 0.02) were independently associated with longer and shorter secondary patency periods, respectively; however, increased age was not a risk factor for decreased secondary patency. CONCLUSIONS Increased age was associated with shorter primary patency but not secondary patency, whereas AVF placement was associated with longer primary and secondary patency. Considering the similar rates of secondary patency between groups and the superior patency of AVF compared to arteriovenous graft, a fistula-first strategy should be applied to appropriate older patients.
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Affiliation(s)
- Seonjeong Jeong
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hyunwook Kwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jai Won Chang
- Division of Nephrology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Khaliun Ganbold
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Tae-Won Kwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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35
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Khawaja AZ, Tullett KAJ, Jones RG, Inston NG. Preoperative assessment for percutaneous and open surgical arteriovenous fistula creation in patients for haemodialysis. Clin Kidney J 2019; 14:408-417. [PMID: 33564445 PMCID: PMC7857810 DOI: 10.1093/ckj/sfz121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 08/07/2019] [Indexed: 11/14/2022] Open
Abstract
Preoperative assessment prior to surgical arteriovenous fistulas (AVFs) including ultrasound-guided mapping has been shown to have beneficial effects on their immediate success as well as early outcomes. This has led to their wide acceptance and adoption however clinical practice criteria is variable and is reflected in variabilities in practice. When transposing this to percutaneously created endovascular AVFs (endoAVFs), variable preoperative assessment criteria could equally result in variable practice and potentially subsequent and expectant outcomes. We aimed to review literature on reported validated methodologies and workflows of preoperative assessment for surgical AVF creation as reported in highest levels of available evidence, specifically randomized controlled trials. Published practice recommendations and guidelines on best clinical practice as well as systematic reviews and meta-analyses of published studies were also reviewed. Data on practice methodology from identified trial publications and protocols was collated and a summative narrative synthesis was carried out which compared these methodologies to additional assessments that may be required when targeting assessment for percutaneous endoAVF formation, based on our units experience as part of an international multicentre trial. In this review we present a brief overview of published literature and guidelines and propose a unified and uniform workflow for preoperative assessment for surgical AVFs and endoAVFs to aide clinical and imaging practice.
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Affiliation(s)
- Aurang Z Khawaja
- University Hospitals Birmingham NHS Foundation Trust, Renal Transplantation and Dialysis Access, Birmingham, UK
| | - Karen A J Tullett
- University Hospitals Birmingham NHS Foundation Trust, Renal Transplantation and Dialysis Access, Birmingham, UK
| | - Robert G Jones
- University Hospitals Birmingham NHS Foundation Trust, Diagnostic and Interventional Radiology, Birmingham, UK
| | - Nicholas G Inston
- University Hospitals Birmingham NHS Foundation Trust, Renal Transplantation and Dialysis Access, Birmingham, UK
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36
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Jeong S, Kwon H, Chang JW, Kim MJ, Ganbold K, Han Y, Kwon TW, Cho YP. Comparison of outcomes between type 2 diabetic and non-diabetic incident hemodialysis patients with functioning arteriovenous fistulas. Medicine (Baltimore) 2019; 98:e18216. [PMID: 31770282 PMCID: PMC6890339 DOI: 10.1097/md.0000000000018216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This study compared clinical outcomes of patient survival and arteriovenous fistula (AVF) patency between incident hemodialysis patients with and without type 2 diabetes mellitus (T2DM).Between January 2011 and December 2013, 384 consecutive incident hemodialysis patients with confirmed first upper-extremity AVF placement were divided into a T2DM group (n = 180, 46.9%) and a non-DM group (n = 204, 53.1%) and analyzed retrospectively. The primary outcome was all-cause mortality, and secondary outcome was AVF patency.Patients in the T2DM group had a higher prevalence of hypertension (P = .02), smoking (P < .01), cardiovascular disease (P < .01), history of cerebrovascular accident (CVA) (P < .01), and peripheral arterial occlusive disease (P < .01) than those in the non-DM group. On Kaplan-Meier survival analysis, the overall survival and AVF patency rates were significantly higher in the non-DM group relative to the T2DM group (both P < .01). In the adjusted model, older age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.02-1.06; P < .01), T2DM (HR, 1.76; 95% CI, 1.12-2.77; P = .014), and history of CVA (HR, 1.76; 95% CI, 1.04-2.98; P = .04) were significantly associated with an increased risk of mortality. Older age and T2DM were independently associated with decreased primary (HR, 1.03; 95% CI, 1.02-1.04; P < .01, HR, 1.69; 95% CI, 1.22-2.33; P < .01, respectively) and secondary (HR, 1.03; 95% CI, 1.01-1.04; P < .01, HR, 2.07; 95% CI, 1.42-3.00; P < .01, respectively) AVF patency during follow-up.Compared with patients in the non-DM group, patients in the T2DM group had a higher mortality rate and worse AVF patency rates.
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Affiliation(s)
| | | | | | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Khaliun Ganbold
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
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Meyer A, Flicker E, König ST, Vetter AS. Determinants of successful arteriovenous fistulae creation including intraoperative transit time flow measurement. J Vasc Access 2019; 21:387-394. [PMID: 31621478 DOI: 10.1177/1129729819874312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The prevalence of hemodialysis patients is increasing, and it is important to create the arteriovenous fistula as early as possible to avoid hemodialysis by central venous catheter. International guidelines recommend arteriovenous fistula as the vascular access of first choice. Arteriovenous fistulae are associated with a failure rate of 23%. The success of an arteriovenous fistula can be evaluated intraoperatively by physical examination and by measuring the blood flow. OBJECTIVES The aim of the study is to describe the predictive value of various factors for fistula maturation in the context to the current literature. METHODS We report on a prospective cohort study of 41 patients, undergoing a primary arteriovenous fistula at the upper extremity. The primary endpoint of the study was the successful fistula maturation after 6 weeks. RESULTS The intraoperative measurement of the blood flow in the outflow vein has been identified as the unique significant parameter for the fistula maturation. CONCLUSION The predictive value of intraoperative flow measurement is superior to intraoperative physical examination and could help reduce the fistula dysmaturation rate. Intraoperative transit time flow measurement is an easy method and can be used to predict successful fistula maturation in a high percentage rate.
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Affiliation(s)
- Alexander Meyer
- Department of General and Vascular Surgery, Johanniter Krankenhaus Rheinhausen, Duisburg, Germany.,Interdisciplinary Vascular Access Center Duisburg, Duisburg, Germany
| | - Eberhard Flicker
- Interdisciplinary Vascular Access Center Duisburg, Duisburg, Germany.,Nephrological Center Moers, Moers, Germany
| | - Sascha T König
- Department of General and Vascular Surgery, Johanniter Krankenhaus Rheinhausen, Duisburg, Germany.,Interdisciplinary Vascular Access Center Duisburg, Duisburg, Germany
| | - Anne Sabine Vetter
- Department of General and Vascular Surgery, Johanniter Krankenhaus Rheinhausen, Duisburg, Germany.,Interdisciplinary Vascular Access Center Duisburg, Duisburg, Germany
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38
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Shahinian VB, Zhang X, Tilea AM, He K, Schaubel DE, Wu W, Pisoni R, Robinson B, Saran R, Woodside KJ. Surgeon Characteristics and Dialysis Vascular Access Outcomes in the United States: A Retrospective Cohort Study. Am J Kidney Dis 2019; 75:158-166. [PMID: 31585684 DOI: 10.1053/j.ajkd.2019.08.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022]
Abstract
RATIONALE & OBJECTIVE An arteriovenous fistula (AVF) is the preferred access for most patients receiving maintenance hemodialysis, but maturation failure remains a challenge. Surgeon characteristics have been proposed as contributors to AVF success. We examined variation in AVF placement and AVF outcomes by surgeon and surgeon characteristics. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS National Medicare claims and web-based data submitted by dialysis facilities on maintenance hemodialysis patients from 2009 through 2015. EXPOSURES Patient characteristics, including demographics and comorbid conditions; surgeon characteristics, including specialty, prior volume of AVF placements, and years since medical school graduation. OUTCOMES Percent of access placements that were an AVF from 2009 to 2015 (designated AVF placement), and percent of AVFs with successful use within 6 months of placement (maturation) from 2013 to 2014. ANALYTICAL APPROACH Multilevel logistic regression models examining the association of surgeon characteristics with the outcomes, adjusted for patient characteristics and dialysis facilities as random effects. RESULTS Among 4,959 surgeons placing 467,827 accesses, median AVF placement was 71% (IQR, 59%-84%). More recent year of medical school graduation and general surgery specialty (vs vascular, cardiothoracic, or transplantation surgery) were associated with higher odds of AVF placement. Among 2,770 surgeons placing 49,826 AVFs, the median AVF maturation rate was 59% (IQR, 44%-71%). More recent year of medical school graduation, but not surgical specialty, was associated with higher odds of AVF maturation. Greater prior volume of AVF placement was associated with higher odds of AVF maturation: OR of 1.46 (95% CI, 1.37-1.57) for highest (>84 AVF placements in 2years) versus lowest (<14) volume quintile. LIMITATIONS The study relied on administrative data, limiting capture of some factors affecting access outcomes. CONCLUSIONS There is substantial surgeon-level variation in AVF placements and AVF maturation. Surgeons' prior volume of AVF placements is strongly associated with AVF maturation.
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Affiliation(s)
- Vahakn B Shahinian
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Xiaosong Zhang
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Anca M Tilea
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Kevin He
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
| | - Douglas E Schaubel
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
| | - Wenbo Wu
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI.
| | - Kenneth J Woodside
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
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39
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Allon M. Lessons From International Differences in Vascular Access Practices and Outcomes. Am J Kidney Dis 2019; 71:452-454. [PMID: 29579416 DOI: 10.1053/j.ajkd.2017.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/08/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL.
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40
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Kubiak RW, Zelnick LR, Hoofnagle AN, Alpers CE, Terry CM, Shiu YT, Cheung AK, de Boer IH, Robinson-Cohen C, Allon M, Dember LM, Feldman HI, Himmelfarb J, Huber TS, Roy-Chaudhury P, Vazquez MA, Kusek JW, Beck GJ, Imrey PB, Kestenbaum B. Mineral Metabolism Disturbances and Arteriovenous Fistula Maturation. Eur J Vasc Endovasc Surg 2019; 57:719-728. [PMID: 31000459 PMCID: PMC7259372 DOI: 10.1016/j.ejvs.2019.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The arteriovenous fistula (AVF) is central to haemodialysis treatment, but up to half of surgically created AVF fail to mature. Chronic kidney disease often leads to mineral metabolism disturbances that may interfere with AVF maturation through adverse vascular effects. This study tested associations between mineral metabolism markers and vein histology at AVF creation and unassisted and overall clinical AVF maturation. METHODS Concentrations of fibroblast growth factor 23, parathyroid hormone, calcium, phosphate, and vitamin D metabolites: 1,25(OH)2D, 24,25(OH)2D, 25(OH)D, and bioavailable 25(OH)D were measured in pre-operative serum samples from 562 of 602 participants in the Haemodialysis Fistula Maturation Study, a multicentre, prospective cohort study of patients undergoing surgical creation of an autologous upper extremity AVF. Unassisted and overall AVF maturation were ascertained for 540 and 527 participants, respectively, within nine months of surgery or four weeks of dialysis initiation. Study personnel obtained vein segments adjacent to the portion of the vein used for anastomosis, which were processed, embedded, and stained for measurement of neointimal hyperplasia, calcification, and collagen deposition in the medial wall. RESULTS Participants in this substudy were 71% male, 43% black, and had a mean age of 55 years. Failure to achieve AVF maturation without assistance occurred in 288 (53%) participants for whom this outcome was determined. In demographic and further adjusted models, mineral metabolism markers were not significantly associated with vein histology characteristics, unassisted AVF maturation failure, or overall maturation failure, other than a biologically unexplained association of higher 24,25(OH)2D with overall failure. This exception aside, associations were non-significant for continuous and categorical analyses and relevant subgroups. CONCLUSIONS Serum concentrations of measured mineral metabolites were not substantially associated with major histological characteristics of veins in patients undergoing AVF creation surgery, or with AVF maturation failure, suggesting that efforts to improve AVF maturation rates should increase attention to other processes such as vein mechanics, anatomy, and cellular metabolism among end stage renal disease patients.
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Affiliation(s)
- Rachel W Kubiak
- Kidney Research Institute, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Leila R Zelnick
- Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Andy N Hoofnagle
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Charles E Alpers
- Department of Pathology, University of Washington, Seattle, WA, USA
| | - Christi M Terry
- Division of Nephrology & Hypertension, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Yan-Ting Shiu
- Division of Nephrology & Hypertension, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Ian H de Boer
- Kidney Research Institute, University of Washington, Seattle, WA, USA
| | | | - Michael Allon
- Department of Vascular Surgery, University of Alabama, Birmingham, AL, USA
| | - Laura M Dember
- Renal, Electrolyte & Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Prabir Roy-Chaudhury
- Division of Nephrology and the University of Arizona Kidney Disease Program, University of Arizona, Tucson, AZ, USA
| | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern, Dallas, TX, USA
| | - John W Kusek
- National Institutes of Diabetes and Digestive and Kidney Diseases, Division of Kidney, Urologic & Hematologic Diseases, Bethesda, MD, USA
| | - Gerald J Beck
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Peter B Imrey
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Bryan Kestenbaum
- Kidney Research Institute, University of Washington, Seattle, WA, USA
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Shiu YT, Rotmans JI, Geelhoed WJ, Pike DB, Lee T. Arteriovenous conduits for hemodialysis: how to better modulate the pathophysiological vascular response to optimize vascular access durability. Am J Physiol Renal Physiol 2019; 316:F794-F806. [PMID: 30785348 PMCID: PMC6580244 DOI: 10.1152/ajprenal.00440.2018] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 02/04/2019] [Accepted: 02/17/2019] [Indexed: 12/11/2022] Open
Abstract
Vascular access is the lifeline for patients on hemodialysis. Arteriovenous fistulas (AVFs) are the preferred vascular access, but AVF maturation failure remains a significant clinical problem. Currently, there are no effective therapies available to prevent or treat AVF maturation failure. AVF maturation failure frequently results from venous stenosis at the AVF anastomosis, which is secondary to poor outward vascular remodeling and excessive venous intimal hyperplasia that narrows the AVF lumen. Arteriovenous grafts (AVGs) are the next preferred vascular access when an AVF creation is not possible. AVG failure is primarily the result of venous stenosis at the vein-graft anastomosis, which originates from intimal hyperplasia development. Although there has been advancement in our knowledge of the pathophysiology of AVF maturation and AVG failure, this has not translated into effective therapies for these two important clinical problems. Further work will be required to dissect out the mechanisms of AVF maturation failure and AVG failure to develop more specific therapies. This review highlights the major recent advancements in AVF and AVG biology, reviews major clinical trials, and discusses new areas for future research.
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Affiliation(s)
- Yan-Ting Shiu
- Division of Nephrology, University of Utah , Salt Lake City, Utah
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center , Leiden , The Netherlands
| | - Wouter Jan Geelhoed
- Department of Internal Medicine, Leiden University Medical Center , Leiden , The Netherlands
| | - Daniel B Pike
- Division of Nephrology, University of Utah , Salt Lake City, Utah
| | - Timmy Lee
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham , Birmingham, Alabama
- Veterans Affairs Medical Center , Birmingham, Alabama
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Kim SM, Jung IM, Kim D, Lee JP, So YH. Effect of Inflow Arterial Calcification on Arteriovenous Fistula Maturation. Ann Vasc Surg 2019; 58:331-337. [PMID: 30769062 DOI: 10.1016/j.avsg.2018.10.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 10/23/2018] [Accepted: 10/31/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study is to investigate the effect of preexisting calcification in the inflow artery on maturation and flow volume of an arteriovenous fistula (AVF). METHODS Patients who underwent AVF creation for hemodialysis were prospectively recruited between March and November 2017. On preoperative duplex ultrasound, calcification in the arterial media within 5 cm of the planned anastomosis area was assessed. Clinical maturation was defined as the successful use of the fistula for ≥75% of the dialysis sessions during a month within 6 months after surgery. Radiological maturation was defined as a venous diameter of ≥0.4 cm and a flow volume of ≥500 mL/min. Flow volumes of the inflow artery and the cephalic vein were measured at 6 and 12 weeks after AVF creation. RESULTS Eighteen patients with calcification and 29 patients without calcification were enrolled in this study. There was no significant difference in the clinical and radiological maturation between the groups. The flow volume of the inflow artery, measured at 6 weeks postoperatively, was significantly higher in the noncalcification group than in the calcification group (P = 0.042). The flow volume of the inflow artery in the noncalcification group was increased at 12 weeks postoperatively (P = 0.091). Flow volume of the vein was higher in the noncalcification group than in the calcification group, although it did not reach statistical significance. CONCLUSIONS In conclusions, preexisting arterial calcification did not adversely affect the AVF maturation. However, arterial calcification correlated with the flow volume of the inflow artery of AVF.
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Affiliation(s)
- Suh Min Kim
- Department of Surgery, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - In Mok Jung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea.
| | - Daehwan Kim
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jung Pyo Lee
- Department of Internal medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Young Ho So
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
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Jeong S, Kwon H, Chang JW, Kim MJ, Ganbold K, Han Y, Kwon TW, Cho YP. Patency rates of arteriovenous fistulas created before versus after hemodialysis initiation. PLoS One 2019; 14:e0211296. [PMID: 30689672 PMCID: PMC6349337 DOI: 10.1371/journal.pone.0211296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/10/2019] [Indexed: 11/19/2022] Open
Abstract
In an incident hemodialysis (HD) population, we aimed to investigate whether arteriovenous fistula (AVF) creation before HD initiation was associated with improved AVF patency compared with AVF creation from a central venous catheter (CVC), and also to compare patient survival between these patients. Between January 2011 and December 2013, 524 incident HD patients with identified first predialysis vascular access with an AVF (pre-HD group, n = 191) or an AVF from a CVC (on-HD group, n = 333) were included and analyzed retrospectively. The study outcome was defined as AVF patency and all-cause mortality (time to death). On Kaplan-Meier survival analysis, primary and secondary AVF patency rates did not differ significantly between the two groups (P = 0.812 and P = 0.586, respectively), although the overall survival rate was significantly higher in the pre-HD group compared with the on-HD group (P = 0.013). On multivariate analysis, well-known patient factors were associated with decreased primary (older age and diabetes mellitus [DM]) and secondary (DM and peripheral arterial occlusive disease) AVF patency, whereas use of a CVC as the initial predialysis access (hazard ratios, 1.84; 95% confidence intervals, 1.20-2.75; P = 0.005) was significantly associated with worse survival in addition to well-known patient factors (older age, diabetes mellitus, and peripheral arterial occlusive disease). Worse survival in the on-HD group was likely confounded by selection bias because of the retrospective nature of our study. Therefore, the observed lower mortality associated with AVF creation before HD initiation is not fully attributable to CVC use, but rather, affected by other patient-level prognostic factors. There were no CVC-related complications in the pre-HD group, whereas 10.2% of CVC-related complications were noted in the on-HD group. In conclusion, among incident HD patients, compared with patients who underwent creation of an AVF from a CVC, initial AVF creation showed similar primary and secondary AVF patency rates, but lower mortality risk. We also observed that an initial CVC use was an independent risk factor associated with worse survival. A fistula-first strategy might be the best option for incident HD patients who are good candidates for AVF creation.
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Affiliation(s)
- Seonjeong Jeong
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hyunwook Kwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jai Won Chang
- Division of Nephrology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Khaliun Ganbold
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Tae-Won Kwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
- * E-mail:
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Robbin ML, Greene T, Allon M, Dember LM, Imrey PB, Cheung AK, Himmelfarb J, Huber TS, Kaufman JS, Radeva MK, Roy-Chaudhury P, Shiu YT, Vazquez MA, Umphrey HR, Alexander L, Abts C, Beck GJ, Kusek JW, Feldman HI. Prediction of Arteriovenous Fistula Clinical Maturation from Postoperative Ultrasound Measurements: Findings from the Hemodialysis Fistula Maturation Study. J Am Soc Nephrol 2018; 29:2735-2744. [PMID: 30309898 DOI: 10.1681/asn.2017111225] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 09/06/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The utility of early postoperative ultrasound measurements in predicting arteriovenous fistula (AVF) clinical maturation is uncertain. METHODS We investigated the relationships of ultrasound parameters with AVF clinical maturation in newly created AVF, measured at 1 day and 2 and 6 weeks, in 602 participants of a multicenter, observational cohort study. A backward elimination algorithm identified ultrasound measurements that independently predicted unassisted and overall AVF maturation. Candidate variables included AVF blood flow, diameter, and depth, upper arm arterial diameter, presence of stenosis, presence of accessory veins, seven case-mix factors (age, sex, black race, AVF location, diabetes, dialysis status, and body mass index), and clinical center. We evaluated the accuracy of the resulting models for clinical prediction. RESULTS At each ultrasound measurement time, AVF blood flow, diameter, and depth each predicted in a statistically significant manner both unassisted and overall clinical maturation. Moreover, neither the remaining ultrasound parameters nor case-mix factors were associated with clinical AVF maturation after accounting for blood flow, diameter, and depth, although maturation probabilities differed among clinical centers before and after accounting for these parameters. The crossvalidated area under the receiver operating characteristic curve for models constructed using these three ultrasound parameters was 0.69, 0.74, and 0.79 at 1 day and 2 and 6 weeks, respectively, for unassisted AVF clinical maturation and 0.69, 0.71, and 0.76, respectively, for overall AVF maturation. CONCLUSIONS AVF blood flow, diameter, and depth moderately predicted unassisted and overall AVF clinical maturation. The other factors considered did not further improve AVF maturation prediction.
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Affiliation(s)
| | - Tom Greene
- Departments of Population Health Sciences and.,Internal Medicine and
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, and Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter B Imrey
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Alfred K Cheung
- Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah.,Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah.,Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Jonathan Himmelfarb
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, Washington
| | - Thomas S Huber
- Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - James S Kaufman
- Renal Section, Veterans Affairs New York Harbor Healthcare System, New York, New York.,Division of Nephrology, New York University School and Medicine, New York, New York
| | - Milena K Radeva
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Prabir Roy-Chaudhury
- Division of Nephrology, University of Arizona College of Medicine, Tucson, Arizona
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Miguel A Vazquez
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | - Gerald J Beck
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - John W Kusek
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology, Department of Medicine, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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45
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Affiliation(s)
- Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario
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46
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Wang K, Zelnick LR, Hoofnagle AN, Vaisar T, Henderson CM, Imrey PB, Robinson-Cohen C, de Boer IH, Shiu YT, Himmelfarb J, Beck GJ. Alteration of HDL Protein Composition with Hemodialysis Initiation. Clin J Am Soc Nephrol 2018; 13:1225-1233. [PMID: 30045914 PMCID: PMC6086713 DOI: 10.2215/cjn.11321017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 04/13/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES HDL particles obtained from patients on chronic hemodialysis exhibit lower cholesterol efflux capacity and are enriched in inflammatory proteins compared with those in healthy individuals. Observed alterations in HDL proteins could be due to effects of CKD, but also may be influenced by the hemodialysis procedure, which stimulates proinflammatory and prothrombotic pathways. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We compared HDL-associated proteins in 143 participants who initiated hemodialysis within the previous year with those of 110 participants with advanced CKD from the Hemodialysis Fistula Maturation Study. We quantified concentrations of 38 HDL-associated proteins relative to total HDL protein using targeted mass spectrometry assays that included a stable isotope-labeled internal standard. We used linear regression to compare the relative abundances of HDL-associated proteins after adjustment and required a false discovery rate q value ≤10% to control for multiple testing. We further assessed the association between hemodialysis initiation and cholesterol efflux capacity in a subset of 80 participants. RESULTS After adjustment for demographics, comorbidities, and other clinical characteristics, eight HDL-associated proteins met the prespecified false discovery threshold for association. Recent hemodialysis initiation was associated with higher HDL-associated concentrations of serum amyloid A1, A2, and A4; hemoglobin-β; haptoglobin-related protein; cholesterylester transfer protein; phospholipid transfer protein; and apo E. The trend for participants recently initiating hemodialysis for lower cholesterol efflux capacity compared with individuals with advanced CKD did not reach statistical significance. CONCLUSIONS Compared with advanced CKD, hemodialysis initiation within the previous year is associated with higher concentrations of eight HDL proteins related to inflammation and lipid metabolism. Identified associations differ from those recently observed for nondialysis-requiring CKD. Hemodialysis initiation may further impair cholesterol efflux capacity. Further work is needed to clarify the clinical significance of the identified proteins with respect to cardiovascular risk. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_07_25_CJASNPodcast_18_8_W.mp3.
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Affiliation(s)
- Ke Wang
- Departments of Medicine and
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Leila R. Zelnick
- Departments of Medicine and
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Andrew N. Hoofnagle
- Departments of Medicine and
- Laboratory Medicine and
- Kidney Research Institute, University of Washington, Seattle, Washington
| | | | | | - Peter B. Imrey
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | | | - Ian H. de Boer
- Departments of Medicine and
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jonathan Himmelfarb
- Departments of Medicine and
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Gerald J. Beck
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - KestenbaumBryan12on behalf of the HFM Study
- Departments of Medicine and
- Laboratory Medicine and
- Kidney Research Institute, University of Washington, Seattle, Washington
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Department of Medicine, Vanderbilt University, Nashville, Tennessee; and
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, Utah
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Wang K, Zelnick LR, Imrey PB, deBoer IH, Himmelfarb J, Allon MD, Cheung AK, Dember LM, Roy-Chaudhury P, Vazquez MA, Kusek JW, Feldman HI, Beck GJ, Kestenbaum B. Effect of Anti-Hypertensive Medication History on Arteriovenous Fistula Maturation Outcomes. Am J Nephrol 2018; 48:56-64. [PMID: 30071516 DOI: 10.1159/000491828] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/29/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND The arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis. However, approximately half of AVFs fail to mature. The use of angiotensin converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) exerts favorable endothelial effects and may promote AVF maturation. We tested associations of ACE-I and ARBs, CCBs, beta-blockers, and diuretics with the maturation of newly created AVFs. METHODS We evaluated 602 participants from the Hemodialysis Fistula Maturation Study, a multi-center, prospective cohort study of AVF maturation. We ascertained the use of each medication class within 45 days of AVF creation surgery. We defined maturation outcomes by clinical use within 9 months of surgery or 4 weeks of initiating hemodialysis. RESULTS Unassisted AVF maturation failure without intervention occurred in 54.0% of participants, and overall AVF maturation failure (with or without intervention) occurred in 30.1%. After covariate adjustment, CCB use was associated with a 25% lower risk of overall AVF maturation failure (95% CI 3%-41% lower) but a non-significant 10% lower risk of unassisted maturation failure (95% CI 23% lower to 5% higher). ACE-I/ARB, beta-blocker, and diuretic use was not significantly associated with AVF maturation outcomes. None of the antihypertensive medication classes were associated with changes in AVF diameter or blood flow over 6 weeks following surgery. CONCLUSIONS CCB use may be associated with a lower risk of overall AVF maturation failure. Further studies are needed to determine whether CCBs might play a causal role in improving AVF maturation outcomes.
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Affiliation(s)
- Ke Wang
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Leila R Zelnick
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Peter B Imrey
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Ian H deBoer
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Jonathan Himmelfarb
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Michael D Allon
- Division of Nephrology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, Salt Lake City, Utah, USA
- Department of Bioengineering, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Renal Section, Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Prabir Roy-Chaudhury
- Division of Nephrology, University of Arizona Health Sciences and Banner University Medical Center, Tucson, Arizona, USA
- Medical Service, Southern Arizona Veterans Affairs Healthcare System, Tucson, Arizona, USA
| | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - John W Kusek
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Harold I Feldman
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Bryan Kestenbaum
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
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He Y, Shiu YT, Pike DB, Roy-Chaudhury P, Cheung AK, Berceli SA. Comparison of hemodialysis arteriovenous fistula blood flow rates measured by Doppler ultrasound and phase-contrast magnetic resonance imaging. J Vasc Surg 2018; 68:1848-1857.e2. [PMID: 29779960 DOI: 10.1016/j.jvs.2018.02.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/20/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The objective of this study was to compare blood flow rates measured by Doppler ultrasound (DUS) and phase-contrast magnetic resonance imaging (MRI) in patients having a hemodialysis arteriovenous fistula (AVF) and to identify scenarios in which there was significant discordance between these two approaches. METHODS Blood flow rates in the proximal artery (PA) and draining vein (DV) of newly created upper extremity AVFs were measured and compared using DUS and phase-contrast MRI at 1 day, 6 weeks, and 6 months postoperatively. RESULTS Blood flow rates in the PA measured by DUS (1155 ± 907 mL/min, mean ± standard deviation) and by MRI (1170 ± 657 mL/min) were not statistically different (P = .812) based on 78 data pairs from 49 patients. DV DUS flow (1277 ± 995 mL/min) and MRI flow (1130 ± 655 mL/min) were also not statistically different (P = .071) based on 64 data pairs. In both PA and DV, the two methods substantially agreed with each other (Cohen κ: PA, 0.66; DV, 0.67) when flow rates were put into four clinically relevant categories (<300, 300-599, 600-1499, and ≥1500 mL/min). The Bland-Altman analyses of DUS and MRI flow identified six and four outliers for PA and DV, respectively. Seven outliers had higher DUS than MRI flow, with all DUS scan sites having a large lumen or significant local curvature; the other three had lower DUS flow, partly due to an underestimation of lumen diameter by DUS. CONCLUSIONS DUS and MRI flow rates are generally comparable in both PA and DV. When DUS is used for flow measurements, careful attention to accurate lumen diameter measurements is needed and scan sites with marked curvature should be avoided. Our result may improve the accuracy of DUS-measured AVF blood flow rate.
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Affiliation(s)
- Yong He
- Department of Surgery, University of Florida, Gainesville, Fla; Malcom Randall VA Medical Center, Gainesville, Fla
| | - Yan-Ting Shiu
- Division of Nephrology & Hypertension, University of Utah, Salt Lake City, Utah
| | - Daniel B Pike
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
| | | | - Alfred K Cheung
- Division of Nephrology & Hypertension, University of Utah, Salt Lake City, Utah; Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah; Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Scott A Berceli
- Department of Surgery, University of Florida, Gainesville, Fla; Malcom Randall VA Medical Center, Gainesville, Fla.
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Allon M, Imrey PB, Cheung AK, Radeva M, Alpers CE, Beck GJ, Dember LM, Farber A, Greene T, Himmelfarb J, Huber TS, Kaufman JS, Kusek JW, Roy-Chaudhury P, Robbin ML, Vazquez MA, Feldman HI. Relationships Between Clinical Processes and Arteriovenous Fistula Cannulation and Maturation: A Multicenter Prospective Cohort Study. Am J Kidney Dis 2018; 71:677-689. [PMID: 29398178 PMCID: PMC5916528 DOI: 10.1053/j.ajkd.2017.10.027] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 10/31/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Half of surgically created arteriovenous fistulas (AVFs) require additional intervention to effectively support hemodialysis. Postoperative care and complications may affect clinical maturation. STUDY DESIGN Hemodialysis Fistula Maturation (HFM) Study, a 7-center prospective cohort study. SETTING & PARTICIPANTS 491 patients with single-stage AVFs who had neither thrombosis nor AVF intervention before a 6-week postoperative ultrasonographic examination and who required maintenance hemodialysis. PREDICTORS Postoperative care processes and complications. OUTCOMES Attempted cannulation, successful cannulation, and unassisted and overall clinical maturation as defined by the HFM Study criteria. RESULTS AVF cannulation was attempted in 443 of 491 (90.2%) participants and was eventually successful in 430 of these 443 (97.1%) participants. 263 of these 430 (61.2%) reached unassisted and 118 (27.4%) reached assisted AVF maturation (overall maturation, 381/430 [88.6%]). Attempted cannulation was less likely in patients of surgeons with policies for routine 2-week versus later-than-2-week first postoperative visits (OR, 0.21; 95% CI, 0.06-0.70), routine second postoperative follow-up visits (OR, 0.39; 95% CI, 0.15-0.97), and a routine clinical postoperative ultrasound (OR, 0.28; 95% CI, 0.14-0.55). Attempted cannulation was also less likely among patients undergoing procedures to assist maturation (OR, 0.51; 95% CI, 0.27-0.98). Unassisted maturation was more likely for patients treated in facilities with access coordinators (OR, 1.91; 95% CI, 1.17-3.12), but less likely after precannulation nonstudy ultrasounds (OR per ultrasound, 0.42 [95% CI, 0.26-0.68]) and initial unsuccessful cannulation attempts (OR per each additional attempt, 0.90 [95% CI, 0.83-0.98]). Overall maturation was less likely with infiltration before successful cannulation (OR, 0.44; 95% CI, 0.22-0.89). Among participants receiving maintenance hemodialysis before AVF surgery, unassisted and overall maturation were less likely with longer intervals from surgery to initial cannulation (ORs for each additional month of 0.81 [95% CI, 0.76-0.88] and 0.93 [95% CI, 0.89-0.98], respectively) and from initial to successful cannulation (ORs for each additional week of 0.87 [95% CI, 0.81-0.94] and 0.88 [95% CI, 0.83-0.94], respectively). LIMITATIONS Surgeons' management policies were assessed only by questionnaire at study onset. Most participants received upper-arm AVFs, planned 2-stage AVFs were excluded, and maturation time windows were imposed. Some care processes may have been missed and the observational design limits causal attribution. CONCLUSIONS Multiple processes of care and complications are associated with AVF maturation outcomes.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL.
| | - Peter B Imrey
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT; Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Milena Radeva
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Charles E Alpers
- Department of Pathology, University of Washington Medical Center, Seattle, WA
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
| | - Tom Greene
- Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Jonathan Himmelfarb
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Thomas S Huber
- Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, FL
| | - James S Kaufman
- VA New York Harbor Healthcare System and New York University School of Medicine, New York, NY
| | - John W Kusek
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Michelle L Robbin
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern, Dallas, TX
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Kordzadeh A, Askari A, Panayiotopoulos Y. Independent association of arteriovenous ratio index on the primary functional maturation of autologous radiocephalic arteriovenous fistula. J Vasc Surg 2018. [PMID: 29526374 DOI: 10.1016/j.jvs.2017.10.082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE It has been hypothesized that a novel measurement technique of arteriovenous ratio (AVR) index obtained from inflow (radial artery diameter) to that of outflow (cephalic vein diameter) and its application through the Bernoulli effect has no impact on the primary functional maturation (FM) of autogenous radiocephalic arteriovenous fistula (RCAVF). METHODS A prospective consecutive single-center cohort study with intention to treat of 324 patients undergoing RCAVF during a period of 4 years was conducted. Variables of demographics, anatomic factors, laterality, comorbidities, anesthesia type, presence of intraoperative thrill, angle of anastomosis, and AVR index were assessed through univariate and multivariate logistic regression analysis on the end point of FM. The AVR was subjected to three decimal points to ensure maximal accuracy for best sensitivity and 1 - specificity by receiver operating characteristic curve. The χ2 (subgroup) analyses were undertaken to investigate the differences in FM incidence within different ranges of AVR. Test of probability (P value) was considered to be significant with P < .05. Effect sizes were reported as odds ratio with their measure of uncertainty at 95% confidence intervals. RESULTS Among all variables, the AVR index remained the only independent factor associated with FM (66%; n = 214/324) of RCAVFs (P = .001; 95% confidence interval, 0.08-0.26). AVR of 1 to 1.06 was associated with 100% FM in RCAVFs. Decrease or increase of this index was associated with stepwise reduction in FM of RCAVFs (P < .05). CONCLUSIONS The suggested novel measurement technique (AVR index) is an independent predictor of FM in RCAVFs. This study implies that minimal diameter (ie, inflow artery dimeter to outflow cephalic vein diameter) mismatch (AVR, 1-1.06) irrespective of other variables remains crucial for optimal hemodynamics (pressure and velocity) of RACVFs and their primary FM.
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Affiliation(s)
- Ali Kordzadeh
- Faculty of Medical Sciences, Anglia Ruskin University, Cambridge, United Kingdom; Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital, Mid Essex Hospitals Services NHS Trust, Chelmsford, United Kingdom.
| | - Alan Askari
- Department of Surgery, Ipswich Hospital, Ipswich, United Kingdom
| | - Yiannis Panayiotopoulos
- Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital, Mid Essex Hospitals Services NHS Trust, Chelmsford, United Kingdom
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