Association between heart failure and arteriovenous access patency in patients with end-stage renal disease on hemodialysis

BACKGROUND

Heart disease and chronic kidney disease are often comorbid conditions owing to shared risk factors, including diabetes and hypertension. However, the effect of congestive heart failure (CHF) on arteriovenous fistula (AVF) and AV graft (AVG) patency rates is poorly understood. We hypothesize preexisting HF may diminish blood flow to the developing AVF and worsen patency.

METHODS

We conducted a single-institution retrospective review of 412 patients with end-stage renal disease who underwent hemodialysis access creation from 2015 to 2021. Patients were stratified based on presence of preexisting CHF, defined as clinical symptoms plus evidence of reduced left ventricular ejection fraction (EF) (<50%) or diastolic dysfunction on preoperative echocardiography. Baseline demographics, preoperative measures of cardiac function, and dialysis access-related surgical history were collected. Kaplan-Meier time-to-event analyses were performed for primary patency, primary-assisted patency, and secondary patency using standard definitions for patency from the literature. We assessed differences in patency for patients with CHF vs patients without CHF, patients with a reduced vs a normal EF, and AVG vs AVF in patients with CHF.

RESULTS

We included 204 patients (50%) with preexisting CHF with confirmatory echocardiography. Patients with CHF were more likely to be male and have comorbidities including, diabetes, chronic obstructive pulmonary disease, hypertension, and a history of cerebrovascular accident. The groups were not significantly different in terms of prior fistula history (P = .99), body mass index (P = .74), or type of hemodialysis access created (P = .54). There was no statistically significant difference in primary patency, primary-assisted patency, or secondary patency over time in the CHF vs non-CHF group (log-rank P > .05 for all three patency measures). When stratified by preoperative left ventricular EF, patients with an EF of <50% had lower primary (38% vs 51% at 1 year), primary-assisted (76% vs 82% at 1 year), and secondary patency (86% vs 93% at 1 year) rates than those with a normal EF. Difference reached significance for secondary patency only (log-rank P = .029). AVG patency was compared against AVF patency within the CHF subgroup, with significantly lower primary-assisted (39% vs 87% at 1 year) and secondary (62% vs 95%) patency rates for AVG (P < .0001 for both).

CONCLUSIONS

In this 7-year experience of hemodialysis access creation, reduced EF is associated with lower secondary patency. Preoperative CHF (including HF with reduced EF and HF with preserved EF together) is not associated with significant differences in overall hemodialysis access patency rates over time, but patients with CHF who receive AVG have markedly worse patency than those who receive AVF. For patients with end-stage renal disease and CHF, the risks and benefits must be carefully weighed, particularly for those with low EF or lack of a suitable vein for fistula creation.

Haemodialysis access profile in failed kidney transplant patients: Analysis of data from the Catalan Renal Registry (1998-2016)

BACKGROUND

Data about vascular access (VA) use in failed kidney transplant (KT) patients returning to haemodialysis (HD) are limited. We analysed the VA profile of these patients, the factors associated with the likelihood of HD re-initiation through fistula (AVF) and the effect of VA in use at the time of KT on kidney graft (KTx) outcome.

METHOD

Data from the Catalan Registry on failed KT patients restarting HD and incident HD patients with native kidney failure were examined over an 18-year period.

RESULTS

The VA profile of 675 failed KT patients at HD re-initiation compared with that before KT and with 16,731 incident patients starting HD was (%): AVF 79.3 versus 88.6 and 46.2 (p = 0.001 and p < 0.001), graft AVG 4.4 versus 2.6 and 1.1 (p = 0.08 and p < 0.001), tunnelled catheter TCC 12.4 versus 5.5 and 18.0 (p = 0.001 and p < 0.001) and non-tunnelled catheter 3.9 versus 3.3 and 34.7 (p = 0.56 and p < 0.001). The likelihood of HD re-initiation by AVF was significantly lower in patients with cardiovascular disease, KT duration >5 years, dialysed through AVG or TCC before KT, and females. The analysis of Kaplan-Meier curves showed a greater KTx survival in patients dialysed through arteriovenous access than in patients using catheter just before KT (λ2 = 5.59, p = 0.0181, log-rank test). Cox regression analysis showed that patients on HD through arteriovenous access at the time of KT had lower probability of KTx loss compared to those with catheter (hazard ratio 0.71, 95% CI 0.55-0.90, p = 0.005).

CONCLUSIONS

The VA profile of failed KT patients returning to HD and incident patients starting HD was different. Compared to before KT, the proportion of failed KT patients restarting HD with AVF decreased significantly at the expense of TCC. Patients on HD through arteriovenous access at the time of KT showed greater KTx survival compared with those using catheter.

Arterial revascularization in patients with hand pain dialyzing with upper arm Arteriovenous (AV) fistulas: A single center experience

BACKGROUND

Distal hand ischemia syndrome (DHIS) is a well reported adverse outcome in patients with upper arm AV access. 25%-40% of these patients have been reported to be due to primary arterial disease complicated with significant arterial calcification. The effectiveness of revascularization of the distal arterial circulation on symptom resolution has not been reported yet.

METHODS

Retrospective single center analysis of patients evaluated for hand/forearm pain in patients with upper arm AV access who had arterial revascularization between 01/2016 and 12/2020 were included for the analysis. Fifty-one patients met inclusion criteria. Stenotic lesions greater than 70% in the subclavian, axillary, brachial, radial, or ulnar artery were treated with balloon angioplasty. Institutional approval was obtained to review charts.

OUTCOMES

Successful revascularization, improvement in pain in 48 h, 1 month, and 3 months.

RESULTS

Seventy six percent of patients had an upper arm Arteriovenous Fistula (AVF) and 24% patients had an upper arm Arteriovenous Graft (AVG). Mean access flow was 1210 (556) ml/min. 55% of patients had radial or ulnar arterial stenosis, 45% had brachial/axillary or subclavian artery stenosis. 45% patients had lesions in both radial and ulnar arteries, 88% of patients were successfully revascularized. 76% (18) of patients had improvement in symptoms within 48 h and 68% remained symptom free in 3 months. Mean DHIS stage was 3.1 before intervention and improved to 1.1 post intervention (p < 0.001). Patient satisfaction with their AV access improved from 34% to 72% (p < 0.01). Multiple regression analysis did not reveal statistically significant correlations between time on dialysis vintage and other chronic medical conditions on post procedure symptom improvement.

CONCLUSIONS

DHIS with occlusive arterial disease can be successfully revascularized to improve symptoms. Complete evaluation of the inflow arterial segment and optimal endovascular revascularization could decrease the need for access revision procedures or access abandonment.

Standardized Methodology for Duplex Ultrasound Examination of Arteriovenous Access for Hemodialysis: A Proposal of the French Society of Vascular Medicine and the French-Speaking Society of Vascular Access

Duplex ultrasound (DUS) is an essential tool for characterizing and monitoring arteriovenous (AV) access for hemodialysis. The aim of the work described here, requested by the French Society of Vascular Medicine in collaboration with the French-Speaking Vascular Access Society, is to propose a standardized methodology for performing and documenting DUS, taking into account the variety of AV access techniques and the problems routinely encountered. A steering committee reviewed the literature and selected the relevant references. A draft was prepared, and all items with missing or conflicting data were submitted to a Delphi consensus. The final document was discussed and approved by all participants. The principles of DUS evaluation of AV access consist of examination of the afferent artery, the anastomosis and the entire venous drainage system. DUS uses B-mode ultrasound, color flow, pulsed wave and power Doppler analysis. DUS can be used in a variety of clinical situations, which can directly influence the methodology of the examination and the interpretation of the results. Blood flow should be assessed as it correlates with the risk of thrombosis. The measurement should be adapted to the different anatomical and hemodynamic conditions encountered. Characterization of stenosis should take into account the residual diameter of the drainage vein and its hemodynamic consequences. Other complications can be assessed with a standardized DUS examination. When performed according to a rigorous methodology, DUS of the AV access allows a comprehensive assessment of its functionality and eliminates the need for further invasive diagnostic procedures.

Sedoanalgesia with intravenous midazolam and fentanyl for angioplasty of dysfunctional arteriovenous access: A retrospective single-center analysis

BACKGROUND

Endovascular therapy, such as percutaneous transluminal angioplasty (PTA), stenting, or embolization, is a well-established form of treatment to prolong the lifespan of arteriovenous access. These procedures, especially PTA, can be accompanied with severe pain. We reviewed and analyzed the efficacy, safety, and outcome of sedoanalgesia using intravenous midazolam and fentanyl, for pain relief during these procedures.

METHODS

Two hundred and two consecutive patients with dysfunctional dialysis access that had undergone endovascular procedure in our institute between July and November 2017 were included in this study. The dialysis access profile, procedure complication, and 10-point Visual Analog Scale (VAS) were collected. One-year clinical follow-up record was also collected to evaluate arteriovenous access patency and long-term complications.

RESULTS

Among the 202 patients, the mean age was (mean ± SD) 67.0 ± 12.08 years. Dialysis access profile of these patients were 119 (58.9%) native arteriovenous fistula and 162 (74.2%) forearm access. The number of lesions treated were 1.63 ± 0.802.Immediate complications included 11 (5.44%) nausea/vomiting, 24 (11.88%) desaturation (SpO2 < 90%, resolved after pillow removal or jaw trust), 16 (7.9%) hypotension (SBP < 90 mmHg, resolved without inotropic agents). There was a low average pain score (1.16 ± 1.594) during the procedure with 136 (67.3%) no pain (VAS 0-1) and 56 (27.7%) mild pain (VAS 2-4). Higher VAS score correlated with overweight patients, longer PTA time and pain after procedure. Six-month primary patency rate was 49.17% and primary assisted patency rate was 93.04%.

CONCLUSIONS

Sedoanalgesia with intravenous midazolam and fentanyl is an easy, safe, and effective method for surgeons.

Study protocol of a randomized controlled trial of fistula vs. graft arteriovenous vascular access in older adults with end-stage kidney disease on hemodialysis: the AV access trial

BACKGROUND

Treatment of end-stage kidney disease (ESKD) with hemodialysis requires surgical creation of an arteriovenous (AV) vascular access-fistula (AVF) or graft (AVG)-to avoid (or limit) the use of a central venous catheter (CVC). AVFs have long been considered the first-line vascular access option, with AVGs as second best. Recent studies have suggested that, in older adults, AVGs may be a better strategy than AVFs. Lacking evidence from well-powered randomized clinical trials, integration of these results into clinical decision making is challenging. The main objective of the AV Access Study is to compare, between the two types of AV access, clinical outcomes that are important to patients, physicians, and policy makers.

METHODS

This is a prospective, multicenter, randomized controlled trial in adults ≥ 60 years old receiving chronic hemodialysis via a CVC. Eligible participants must have co-existing cardiovascular disease, peripheral arterial disease, and/or diabetes mellitus; and vascular anatomy suitable for placement of either type of AV access. Participants are randomized, in a 1:1 ratio, to a strategy of AVG or AVF creation. An estimated 262 participants will be recruited across 7 healthcare systems, with average follow-up of 2 years. Questionnaires will be administered at baseline and semi-annually. The primary outcome is the rate of CVC-free days per 100 patient-days. The primary safety outcome is the cumulative incidence of vascular access (CVC or AV access)-related severe infections-defined as access infections that lead to hospitalization or death. Secondary outcomes include access-related healthcare costs and patients' experiences with vascular access care between the two treatment groups.

DISCUSSION

In the absence of studies using robust and unbiased research methodology to address vascular access care for hemodialysis patients, clinical decisions are limited to inferences from observational studies. The goal of the AV Access Study is to generate evidence to optimize vascular access care, based on objective, age-specific criteria, while incorporating goals of care and patient preference for vascular access type in clinical decision-making.

TRIAL REGISTRATION

This study is being conducted in accordance with the tenets of the Helsinki Declaration, and has been approved by the central institutional review board (IRB) of Wake Forest University Health Sciences (approval number: 00069593) and local IRB of each participating clinical center; and was registered on Nov 27, 2020, at ClinicalTrials.gov (NCT04646226).

Hemodialysis Arteriovenous Access Cosmesis Scale (AVACS): A new measure for vascular access

RATIONALE AND OBJECTIVE

This study aimed to develop a cosmesis scale to evaluate the cosmetic appearance of hemodialysis (HD) arteriovenous (AV) accesses from the perspective of the patient and clinician, which could be incorporated into clinical trials.

STUDY DESIGN

Using a modified Delphi process, two AV access cosmesis scale (AVACS) components were developed in a four-round Delphi panel consisting of two surveys and two consensus meetings with two rounds of patient consultation.

SETTING AND PARTICIPANTS

The Delphi panel consisted of 15 voting members including five interventional or general nephrologists, five vascular surgeons, three interventional radiologists, and two vascular access nurse coordinators. Four patients experienced with vascular access were involved in patient question development.

ANALYTICAL APPROACH

For a component to be included in the AVACS, it had to meet the prespecified panel consensus agreement of ⩾70%.

RESULTS

The clinician component of the AVACS includes nine questions on the following AV access features: scarring, skin discoloration, aneurysm/pseudoaneurysms and megafistula appearance. The patient component includes six questions about future vascular access decisions, interference with work or leisure activities, clothing choices, self-consciousness or attractiveness, emotional impact, and overall appearance.

LIMITATIONS

Delphi panel methods are subjective by design, but with expert clinical opinion are used to develop classification systems and outcome measures. The developed scale requires further validation testing but is available for clinical trial use.

CONCLUSIONS

While safety and efficacy are the primary concerns when evaluating AV access for HD, cosmesis is an important component of the ESKD patient experience. The AVACS has been designed to assess this important domain; it can be used to facilitate patient care and education about vascular access choice and maintenance. AVACS can also be used to inform future research on developing new techniques for AV access creation and maintenance, particularly as relates to AV access cosmesis.

Long-term outcomes of arteriovenous snuffbox fistulas for hemodialysis

OBJECTIVE

Autologous arteriovenous fistulas in the arm have been shown to be superior to all other types of arteriovenous access and should be placed as far distally as possible. The aim of the present study was to delineate the advantages of snuffbox fistulas (SBFs).

METHODS

From January 2007 through April 2017, first time or new arteriovenous fistula surgery was performed in 375 patients. If feasible, an SBF was chosen. The observation period ended in December 2019. The focus of the present study was on the patency rates, redo surgery, complications, and mortality rates.

RESULTS

SBFs were created in 236 patients (92 women and 144 men; mean age, 67 years; 46% with diabetes). Within the first 6 weeks, 11% of the fistulas had failed. The primary patency rates were 75%, 69%, 64%, 61%, 60%, and 58% after 1, 2, 3, 5, 7, and 9 years, respectively. The secondary patency rates were 86%, 83%, 80%, and 77% after 1, 2, 3, and 5 years, respectively. Age, sex, and the presence of diabetes mellitus had no effect on the primary patency rates. Patients with a right-sided SBF had significantly worse primary patency. Of the 236 patients, 154 (65%) had died during the observation period. The incidence of surgical site infection within the first 30 days and access-related ischemia during the observation period was <1%.

CONCLUSIONS

The results from the present study have shown that with suitable anatomic conditions, a SBF is a good choice for the creation of dialysis access. The patency rates were encouraging, and it offers the longest puncturable segment of the cephalic vein. Also, the rate of perioperative complications was low.

First Clinical Results of the Merit WRAPSODY™ Cell-Impermeable Endoprosthesis for Treatment of Access Circuit Stenosis in Haemodialysis Patients

PURPOSE

This prospective, observational first in human study evaluated the safety and effectiveness of WRAPSODY^TM Cell-impermeable Endoprosthesis (Merit Medical Systems, Inc.) in the treatment of arteriovenous fistula and arteriovenous graft access circuit stenosis.

MATERIALS AND METHODS

Investigators conducted a prospective analysis of 46 patients with access circuit stenosis from three centres. Treatment sites included the peripheral outflow veins (e.g. cephalic arch, basilic vein swing point; 16 fistula and 10 graft patients); the graft-vein anastomosis (9 patients); and the central veins (up to, but not including the SVC; 11 patients). Primary outcome measures included 30-day freedom from access circuit-related safety events and 30-day target lesion primary patency. Secondary outcome measures included procedural success; device- and procedure-related adverse events; target lesion primary patency; access circuit primary patency; and secondary patency. In-person follow-up was scheduled at 1, 3, 6, and 12 months. An independent data monitoring/clinical event committee adjudicated all reinterventions and device/procedure-relatedness for adverse events.

RESULTS

All initial procedures were successful. All but one patient was free from safety events through the first 30 days (97.8% (45/46)). This event was not device-related. Over the remainder of the study, one adverse event was adjudicated as possibly device-related. Six- and 12-month target lesion primary patency rates were 97.7% (42/43) and 84.6.% (33/39), respectively. Six- and 12-month access circuit primary patency rates were 84.4% (38/45) and 65.9% (29/44), respectively.

CONCLUSION

Results suggest that the study device is safe and effective for treatment of stenoses in the peripheral and central veins of arteriovenous access circuits.

LEVEL OF EVIDENCE

Level 2b, cohort study.

A Comparison of Outcomes Between Open and Endovascular Arteriovenous Access Creation for Hemodialysis

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.

Arteriovenous Access Type and Risk of Mortality, Hospitalization, and Sepsis Among Elderly Hemodialysis Patients: A Target Trial Emulation Approach

RATIONALE & OBJECTIVE

Evidence is mixed regarding the optimal choice of the first permanent vascular access for elderly patients receiving hemodialysis (HD). Lacking data from randomized controlled trials, we used a target trial emulation approach to compare arteriovenous fistula (AVF) versus arteriovenous graft (AVG) creation among elderly patients receiving HD.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Elderly patients included in the US Renal Data System who initiated HD with a catheter and had an AVF or AVG created within 6 months of starting HD.

EXPOSURE

Creation of an AVF versus an AVG as the incident arteriovenous access.

OUTCOMES

All-cause mortality, all-cause and cause-specific hospitalization, and sepsis.

ANALYTICAL APPROACH

Target trial emulation approach, high-dimensional propensity score and inverse probability of treatment weighting, and instrumental variable analysis using the proclivity of the operating physician to create a fistula as the instrumental variable.

RESULTS

A total of 19,867 patients were included, with 80.1% receiving an AVF and 19.9% an AVG. In unweighted analysis, AVF creation was associated with significantly lower risks of mortality and hospitalization, especially within 6 months after vascular access creation. In inverse probability of treatment weighting analysis, AVF creation was associated with lower incidences of mortality and hospitalization within 6 months after creation (hazard ratios of 0.82 [95% CI, 0.75-0.91] and 0.82 [95% CI, 0.78-0.87] for mortality and all-cause hospitalization, respectively), but not between 6 months and 3 years after access creation. No association between AVF creation and mortality, sepsis, or all-cause, cardiovascular disease-related, or infection-related hospitalization was found in instrumental variable analyses. However, AVF creation was associated with a lower risk of access-related hospitalization not due to infection.

LIMITATIONS

Potential for unmeasured confounding, analyses limited to elderly patients, and absence of data on actual access use during follow-up.

CONCLUSIONS

Using observational data to emulate a target randomized controlled trial, the type of initial arteriovenous access created was not associated with the risks of mortality, sepsis, or all-cause, cardiovascular disease-related, or infection-related hospitalization among elderly patients who initiated HD with a catheter.

Comparison of the Clinical Outcomes between Angiojet Pharmacomechanical Thrombectomy and Hybrid Surgical Thrombectomy for Thrombotic Occlusion of Hemodialysis Access

Purpose

This retrospective study aimed to compare the clinical outcomes between hybrid surgical thrombectomy (ST) and AngioJet pharmacomechanical thrombectomy (PMT) for thrombotic occlusion of arteriovenous graft.

Materials and Methods

This study enrolled patients who underwent either hybrid ST or AngioJet PMT in Presbyterian Medical Center from July 2018 to December 2018. We primarily compared the technical and clinical success rates between the two groups immediately after the procedures. Subsequently, the postprocedure clinical outcomes, including the primary and secondary patency rates and complications, were also compared.

Results

The hybrid ST group had a significantly higher bleeding amount than the AngioJet PMT group (P=0.02). The technical and clinical success rates were 96.7% and 93.3% in the AngioJet PMT group and 100% and 100% in the hybrid ST group, respectively. There was no significant difference in complications between the groups. The primary and secondary patencies at 12 months were not statistically different between the groups.

Conclusion

Comparable clinical outcomes were observed between the AngioJet PMT and hybrid ST groups, highlighting an equivalent efficacy of these two methods. Although the cost is more expensive, AngioJet PMT lowered the bleeding amount. Therefore, it can be considered in selected patients who are at risk of bleeding or reluctant to surgery.

The survival analysis of tunnel-cuffed central venous catheter versus arteriovenous hemodialysis access among elderly patients: A retrospective single center study

BACKGROUND

There is currently a controversy for the optimal vascular access option in the elderly, regarding their multiple comorbidities and life expectancies. Our study aimed to compare the survival of tunneled cuff venous catheter (CVC) and arteriovenous access (AV access) in elderly patients.

METHODS

A retrospective cohort study was performed by electronic medical record review. All hemodialysis patients aged 65 years and over who firstly initiated dialysis from January 1, 2012 to December 31, 2016 at Siriraj hospital, Thailand, were included. The primary outcomes are to compare a 2-year period of survival between CVC and AV access in terms of abandonment, death, and combined outcome. Propensity score covariate and Charlson Comorbidity Score (CCI) were used for multivariable analysis adjustment.

RESULTS

A total of 359 patients were included; 216 (60.2%) patients had initiated hemodialysis via CVC while the rest used AV access. The patients' average ages were 76.7 ± 7.0 and 74.0 ± 5.8 years (p-value<0.001) in the CVC and AV access group, respectively. The 2-year mortality rates of CVC and AV access groups were 24.1% and 15.4%, respectively (p-value = 0.038). Multivariable analyses showed that the adjusted hazard ratio (aHR) of combined endpoints, i.e., vascular access abandonment and death, was statistically different only in the CCI-adjusted model (aHR = 0.68, 95% CI: 0.46-0.99). Mortality from infection cause was more common in the CVC group than the AV access group.

CONCLUSION

CVC access maybe considers an alternative option for frail elderly patients. However, the patient selection is a crucial issue, given higher infection-related mortality in patients using CVC.

Factors associated with a tunneled dialysis catheter in place at initial arteriovenous access creation

OBJECTIVE

Arteriovenous (AV) access is the preferred hemodialysis modality to avoid the complications associated with tunneled dialysis catheters (TDCs). Despite efforts to create timely AV access, many patients still initiate hemodialysis through TDCs. Our goal was to determine the patient factors associated with having a TDC present at initial AV access creation and how this affects survival.

METHODS

We performed a single-center, retrospective review of all patients who had undergone initial AV fistula creation from 2014 to 2019. Patients with previous peritoneal or AV access were excluded. Univariable and multivariable analyses were used to identify associations with a TDC present at initial AV access creation and patient survival.

RESULTS

Of 509 patients who had undergone initial AV access creation, a TDC was present in 280 (55%). The mean patient age was 59.7 ± 14.1 years. The access types were brachiocephalic (47.2%), brachiobasilic (22.4%), radiocephalic (15.5%), and prosthetic (12.6%). The patients with a TDC compared with those without a TDC were less likely to be obese (68.9% vs 54.2%), more likely to be homeless (10.4% vs 4.8%), and more likely to be an inpatient (44.6% vs 18.8%). They were less likely to have seen a primary care physician within 1 year preoperatively (54.3% vs 88.6%) and a nephrologist within 3 months preoperatively (39.3% vs 93%; P < .05 for all). On multivariable analysis, the presence of a TDC at initial AV access creation was associated with no nephrology visit within 3 months preoperatively (odds ratio [OR], 25; 95% confidence interval [CI], 12.5-50; P < .001), homeless status (OR, 2.6; 95% CI, 1.1-6.2; P = .03), and the absence of obesity (OR, 1.8; 95% CI, 1.1-2.9; P = .02). The 1-year survival was similar for patients with (95%) and without (94.8%) a TDC (P = .36) as confirmed by multivariable analysis (hazard ratio, 1.2; 95% CI, 0.65-2.1; P = .63).

CONCLUSIONS

The absence of a preoperative nephrology visit, homeless status, and the absence of obesity were associated with a TDC present at initial AV access creation. However, the presence of a TDC did not appear to confer changes in short-term survival. Targeted improvements in high-risk populations such as increasing the frequency of preoperative subspecialty evaluation might be warranted to reduce TDC placement before AV access creation at urban safety-net hospitals.

Outcomes of arteriovenous access among cancer patients requiring chronic haemodialysis

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.

Arteriovenous access in hemodialysis: A multidisciplinary perspective for future solutions

In hemodialysis, vascular access is a key issue. The preferred access is an arteriovenous fistula on the non-dominant lower arm. If the natural vessels are insufficient for such access, the insertion of a synthetic vascular graft between artery and vein is an option to construct an arteriovenous shunt for punctures. In emergency situations and especially in elderly with narrow and atherosclerotic vessels, a cuffed double-lumen catheter is placed in a larger vein for chronic use. The latter option constitutes a greater risk for infections while arteriovenous fistula and arteriovenous shunt can fail due to stenosis, thrombosis, or infections. This review will recapitulate the vast and interdisciplinary scenario that characterizes hemodialysis vascular access creation and function, since adequate access management must be based on knowledge of the state of the art and on future perspectives. We also discuss recent developments to improve arteriovenous fistula creation and patency, the blood compatibility of arteriovenous shunt, needs to avoid infections, and potential development of tissue engineering applications in hemodialysis vascular access. The ultimate goal is to spread more knowledge in a critical area of medicine that is importantly affecting medical costs of renal replacement therapies and patients’ quality of life.

Intravenous drug use history is not associated with poorer outcomes after arteriovenous access creation

OBJECTIVE

Rising intravenous drug use (IVDU) paralleled with an increasing dialysis-dependent end-stage renal disease population may pose a challenge for creating and maintaining arteriovenous (AV) access for hemodialysis. We aimed to elucidate baseline characteristics and outcomes of AV access creation in the IVDU population.

METHODS

The Vascular Quality Initiative (2011-2018) was queried for patients undergoing AV access placement. Univariable and multivariable analyses comparing outcomes of patients with and without IVDU history were performed.

RESULTS

Of 33,404 patients undergoing AV access creation, 601 (1.8%) had IVDU history (21.8% current and 78.2% past users). IVDU patients receiving AV access were more often younger, male, nonwhite, smokers, homeless, Medicaid recipients, and hospitalized at the time of surgery (P < .001 for all). They exhibited higher rates of congestive heart failure, chronic obstructive pulmonary disease, and human immunodeficiency virus/acquired immunodeficiency syndrome (P < .05 for all). They more frequently had tunneled catheters at the time of access creation (53.6% vs 42%; P < .001) and had a previous AV access (25.3% vs 21.7%; P = .002). IVDU patients more often received prosthetic AV grafts (28.6% vs 18%; P < .001) and more often had anastomoses created to basilic veins (33.1% vs 23.2%; P < .001) but less often to cephalic veins (36.8% vs 57.7%; P < .001). IVDU patients had longer postoperative length of stay (2 ± 6 days vs 0.9 ± 5 days; P < .001) but no significant difference in 30-day mortality (1.7% vs 1.2%; P = .3). Comparing IVDU vs no IVDU cohorts, 1-year access infection-free survival (85.4% vs 86.6%; P = .382), primary patency loss-free survival (39.5% vs 37.9%; P = .335), endovascular/open reintervention-free survival (58% vs 57%; P = .705), and overall survival (89.7% vs 88.9%; P = .635) were similar. On multivariable analysis, IVDU was independently associated with postoperative length of stay (odds ratio, 1.64; 95% confidence interval, 1.35-2; P < .001) but not with 30-day mortality or 1-year infection-free survival, primary patency loss-free survival, reintervention-free survival, and all-cause mortality. The null results were confirmed in a propensity score-matched cohort.

CONCLUSIONS

IVDU history was uncommon among patients undergoing AV access creation at Vascular Quality Initiative centers and was not independently associated with major morbidity or mortality postoperatively. IVDU patients more often received grafts or autogenous access with anastomoses to basilic veins. Although these patients frequently have more comorbidities, IVDU should not deter AV access creation.

Higher body mass index is associated with reinterventions and lower maturation rates after upper extremity arteriovenous access creation

OBJECTIVE

A patient's body mass index (BMI) can affect both perioperative and postoperative outcomes across all surgical specialties. Given that obesity and end-stage renal disease are growing in prevalence, we aimed to evaluate the association between BMI and outcomes of upper extremity arteriovenous (AV) access creation.

METHODS

A retrospective single-institution review was conducted for AV access creations from 2014 to 2018. Patient demographics, comorbidities, and AV access details were recorded. BMI groups were defined as normal weight (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), obese (30-39.9 kg/m²), and morbidly obese (>40 kg/m²). Perioperative complications and long-term outcomes including access maturation (defined as access being used for hemodialysis or the surgeon's judgment that access was ready for use in patients not yet on hemodialysis), occlusion, and reintervention were evaluated.

RESULTS

A total of 611 upper extremity AV access creations were performed on patients who were normal weight (29.6%), overweight (31.3%), obese (29.6%), and morbidly obese (9.5%). Access type included brachiocephalic (43.2%), brachiobasilic (25.5%), and radiocephalic (14.2%) fistulas and AV grafts (14.2%). Median age was 60.9 years, and 59.6% were male. Univariable analysis showed no difference between BMI groups for perioperative steal, hematoma, home discharge, or 30-day primary patency. Freedom from reintervention at 2 years on Kaplan-Meier analysis differed by BMI (44.5% ± 4.6% normal weight, 29% ± 3.8% overweight, 39.8% ± 4.3% obese, 34.7% ± 8% morbidly obese; P = .041). There was no difference in 2-year freedom from new access creation or survival. AV access maturity within 180 days differed between BMI groups (74.3% normal weight, 66% overweight, 65.7% obese, 46.6% morbidly obese; P < .001). On multivariable analysis, failure to mature within 180 days was associated with overweight (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.14-3.29; P = .002), obese (OR, 2.12; 95% CI, 1.19-3.47; P = .009), and morbidly obese (OR, 3.68; 95% CI, 1.85-7.3; P < .001) relative to normal weight BMI. AV access reintervention was associated with overweight (hazard ratio [HR], 1.83; 95% CI, 1.34-2.5), obese (HR, 1.56; 95% CI, 1.12-2.16), and morbidly obese (HR, 1.69; 95% CI, 1.1-2.58; P = .02) relative to normal weight BMI. BMI was not independently associated with long-term readmission or survival.

CONCLUSIONS

Obesity is associated with higher rates of AV access failure to mature and reintervention. Surgeons performing access creation on obese patients must consider this for planning and setting expectations. Weight loss assistance may need to be incorporated into treatment algorithms.

Outcomes of autogenous fistulas and prosthetic grafts for hemodialysis access in diabetic and nondiabetic patients

BACKGROUND

This study evaluated the effect of diabetes on outcomes of autogenous fistulas and prosthetic grafts for hemodialysis access in a large population-based cohort of patients.

METHODS

A retrospective cohort study was conducted of all patients who initiated hemodialysis in the United States Renal Database System (2007-2014). The χ² test, Student t-test, Kaplan-Meier analysis, log-rank test, and multivariable logistic and Cox regression analyses were employed to evaluate maturation, interventions, patency, infection, and mortality.

RESULTS

The study of 381,622 patients comprised 303,307 (79.5%) autogenous fistulas and 78,315 (20.5%) prosthetic grafts placed in 231,134 (60.6%) diabetic patients and 150,488 (39.4%) nondiabetic patients. There was decrease in maturation for diabetics compared to nondiabetics who received autogenous fistulas (adjusted hazard ratio [aHR], 0.86; 95% confidence interval [CI], 0.83-0.88; P < .001) and prosthetic grafts (aHR, 0.88; 95% CI, 0.83-0.93; P < .001). Comparing diabetics vs nondiabetics, primary patency at 5 years was 19.4% vs 23.5% (P < .001) for autogenous fistulas and 9.1% vs 11.2% (P < .001) for prosthetic grafts. Primary assisted patency at 5 years was 35.2% vs 38.7% (P < .001) for autogenous fistulas and 17.2% vs 19.2% (P = .015) for prosthetic grafts. Secondary patency at 5 years was 44.8% vs 48.6% (P < .001) for autogenous fistulas and 34.1% vs 36.8% (P = .002) for prosthetic grafts. There was 5% decrease in primary patency (aHR, 0.95; 95% CI, 0.94-0.96; P < .001) for diabetics compared to nondiabetics who received autogenous fistulas. There was no difference in primary assisted and secondary patency for autogenous fistulas as well as primary, primary assisted, and secondary patency for prosthetic grafts in comparing diabetic to nondiabetic patients. There was also no significant difference in severe prosthetic graft infection between the groups (aHR, 0.99; 95% CI, 0.92-1.08; P = .90). There was a 19% increase in patient mortality for diabetic relative to nondiabetic autogenous fistula recipients (aHR, 1.19; 95% CI, 1.17-1.20; P < .001) and 12% increase for prosthetic graft recipients (aHR, 1.12; 95% CI, 1.10-1.15; P < .001).

CONCLUSIONS

In this population-based cohort of hemodialysis patients, diabetes mellitus was associated with a decrease in patient survival, access maturation, and primary fistula patency. In contrast, there was no association between diabetes and prosthetic graft patency and severe prosthetic graft infection warranting excision.

Acute Kidney Injury before Dialysis Initiation Predicts Adverse Outcomes in Hemodialysis Patients

BACKGROUND

Acute kidney injury (AKI) is associated with increased morbidity and mortality. Mortality in end-stage renal disease (ESRD) patients is highest during the first year of dialysis. The impact of pre-ESRD AKI events on long-term outcomes in incident ESRD patients remains unknown.

METHODS

We evaluated a retrospective cohort of 47,341 incident hemodialysis patients from the United States Renal Data System with linked Medicare data for at least 2 years prior to hemodialysis initiation. We examined the impact of pre-ESRD AKI events in the 2-year pre-ESRD period on the type of vascular access used at hemodialysis initiation (central venous catheter (CVC) versus arteriovenous access), and 1-year all-cause mortality after initiating hemodialysis.

RESULTS

The mean age was 72 ± 11 years. Of the study cohort, 18% initiated hemodialysis with arteriovenous access, and 54% of patients had at least one pre-ESRD AKI event. One-year, all-cause mortality was 32%. Compared to 75% for patients without a pre-ESRD AKI event, 89% of patients with a pre-ESRD AKI event initiated hemodialysis with CVC than arteriovenous access (p < 0.001). A pre-ESRD AKI event was associated with lower adjusted odds of starting hemodialysis with an arteriovenous access (OR 0.47; 95% CI 0.44-0.50, p < 0.001), and higher adjusted odds of 1-year mortality (OR 1.36; 95% CI 1.30-1.42, p < 0.001).

CONCLUSION

An AKI event prior to initiating hemodialysis independently increases the risk of CVC use and predicts 1-year mortality. Improving processes of care after AKI events may improve dialysis outcomes in patients who progress to ESRD.

Utilization of stent grafts in the management of arteriovenous access pseudoaneurysms

Objective Endovascular stent graft repair for exclusion of pseudoaneurysm is currently being explored to replace open surgical repair as current management. The objective of the study was to evaluate the clinical safety and efficacy of endovascular stent graft intervention in pseudoaneurysms complicating arteriovenous reconstructions in patients on chronic hemodialysis. Methods A retrospective analysis of all pseudoaneurysms treated with stent grafts at our institution over a period of five years was performed. The indications for endovascular intervention included bleeding from the pseudoaneurysm, infection, and significant skin compromise overlying the pseudoaneurysm or combination of the above. The rates of technical success, complication, and primary patency were measured at one-week, one-month, and six-month follow-up. Results A total of 33 endovascular stent graft interventions in 29 patients were performed for the treatment of pseudoaneurysms. The average age of patients was 68 years (range 31-90 years), with 13 female. Diabetes and hypertension were present in 15 and 22 patients, respectively. In eight patients, there was evidence of active infection at the fistula site. The choice of stent grafts include Viabahn ( n = 31), Wallgraft ( n = 1), and i-Cast ( n = 1). The initial technical success rate was 94%. The two failed interventions included occlusion of inflow artery with immediate conversion to open procedure ( n = 1) and incomplete pseudoaneurysm exclusion ( n = 1). Primary patency at one month and six months was 83 and 60%, respectively. An additional balloon angioplasty of outflow tract or central stenosis was performed in 18 cases (54%). The explanation of stent grafts due to persistent or recurrent bacteremia/site infection was required in four out of eight patients. The average time to explanation was 93 days (range 6-204 days). Conclusion The stent graft implantation is a safe, minimally invasive and efficient way to control and manage arteriovenous accesses with pseudoaneurysms. In the presence of infection, this approach may be less durable.

New therapeutic options provided by off-label deployment of stent graft for tailored arteriovenous access salvage: Two cases

A tailored therapy to patient requirements by combining endovascular and surgical steps can be necessary to prolong the life of a vascular access. Stent grafts play a growing role for the therapy of dialytic access complications. Randomized multi-center trials, however, support the on-label use of stent grafts in the treatment of graft venous outflow and in-stent restenosis. The main contraindication to their use is an ongoing infection. We report two cases of new off-label application of Viabahn (Gore, flagstaff, USA) stent graft. In the first case, the failure of a radiocephalic early cannulation graft was treated by stent graft placement on the arterial inflow anastomosis, when emergent angiographic examination revealed the previously unknown high takeoff of the radial artery from the axillary artery. At 13-month follow-up, the target lesion remained untreated. In the second case, elbow stent graft occlusion with extended thrombosis occurred in a right radiocephalic fistula after 3 years of unassisted patency. Being the last option for vascular access, successful endovascular recanalization was carried out. After 3 months, however, the clinical setting relapsed. A two-stage hybrid strategy with vascular surgeon was arranged due to ongoing signs of local infection. Flow was restored by emergent thromboaspiration associated with a new stent graft placement as a endovascular bridge to subsequent surgical treatment. After 2 days, the overlapped stent grafts were excised as planned. Surgical rerouting was completed by polytetrafluoroethylene prosthetic bridge implantation across the elbow. At 4 months, the follow-up remained uneventful. In selected instances, the off-label use of stent grafts may expand the therapeutic options of the vascular access team.

New Insights into Dialysis Vascular Access: Molecular Targets in Arteriovenous Fistula and Arteriovenous Graft Failure and Their Potential to Improve Vascular Access Outcomes

Vascular access dysfunction remains a major cause of morbidity and mortality in hemodialysis patients. At present there are few effective therapies for this clinical problem. The poor understanding of the pathobiology that leads to arteriovenous fistula (AVF) and graft (AVG) dysfunction remains a critical barrier to development of novel and effective therapies. However, in recent years we have made substantial progress in our understanding of the mechanisms of vascular access dysfunction. This article presents recent advances and new insights into the pathobiology of AVF and AVG dysfunction and highlights potential therapeutic targets to improve vascular access outcomes.

Midterm Results Following Percutaneous Rotational Thrombectomy for Acute Thrombotic Occlusions of Prosthetic Arteriovenous Access Grafts

Patent vascular access is critical for patients on regular hemodialysis. Prosthetic grafts are good alternatives when the superficial venous system is of poor quality. However, thrombosis is one of the main drawbacks of synthetic grafts, with reports of 59% to 90% patency rates for 1 year. In cases of thrombotic occlusion of prosthetic arteriovenous fistula grafts, percutaneous mechanical thrombectomy has recently gained clinical popularity as a potential alternative to surgical thrombectomy or pharmacologic thrombolysis. We reviewed our preliminary results from 30 percutaneous rotational thrombectomies performed in a total of 22 patients in the setting of acute dialysis-access prosthetic graft occlusion of the upper extremity. Among the 30 cases of acute occlusion of the arteriovenous graft, immediate success with angiographic flow restoration was observed in all patients except for 2 patients (both females; 6%), with de novo occlusion where reocclusion occurred within 12 hours despite apparent immediate angiographic patency. The mean duration between the initial presentation with acute arteriovenous graft occlusion and the thrombectomy procedure was 27.4 ± 12.4 hours. The mean duration of graft patency was 10.45 ± 0.6 months. A total of 75% of the arteriovenous grafts were patent at the end of 12 months of follow-up. Female gender, diabetes mellitus, and diagnosis to intervention interval were reviewed for midterm graft failure, and the presence of diabetes mellitus yielded significance (P < 0.05). Percutaneous techniques play important roles in the treatment of failed or failing arteriovenous fistulae and grafts. Ongoing analysis of outcomes of both percutaneous and surgical intervention is necessary to continue to identify optimum treatment algorithms.

Symptomatic central venous stenosis in a hemodialysis patient leading to loss of arteriovenous access: a case report and literature review

Central venous stenosis is a well-described sequel to the placement of hemodialysis catheters in the central venous system. The presence of an ipsilateral arteriovenous fistula or graft often leads to severe venous dilatation, arm edema and recurrent infections. Vascular access thrombosis, compromised blood flow and inadequate dialysis delivery are dreaded complications that eventually render the access unusable. We report the case of a 58-year-old male hemodialysis patient who developed symptomatic central venous stenosis to illustrate the problem and review the pertinent literature. This patient developed severe enlargement of upper extremity veins due to central venous stenosis. The symptoms were refractory to multiple endovascular interventions and eventually necessitated ligation of his arteriovenous fistula. Central venous stenosis remains a pervasive problem despite advances in our understanding of its etiology and recognition of the enormity of its consequences. Due to the lack of effective therapeutic options, prevention is better than cure.