Access-related hand ischemia and the Hemodialysis Fistula Maturation Study

Abstract

Objectives Access-related hand ischemia (ARHI) is a major complication after hemodialysis access construction. This study was designed to prospectively describe its incidence, predictors, interventions and associated access maturation. Methods The Hemodialysis Fistula Maturation Study is a multicenter prospective cohort study designed to identify predictors of autogenous arteriovenous access (AVF) maturation. Symptoms and interventions for ARHI were documented and participants who received interventions for ARHI were compared to other participants using a nested case-control design. Associations of ARHI with clinical, ultrasound, vascular function, and vein histological variables were each individually evaluated using conditional logistic regression and the association with maturation assessed by relative risk, Pearson's chi-square test, and multiple logistic regression. Results The study cohort included 602 participants with median follow-up 2.1 years (10th - 90th percentiles: 0.7 - 3.5 yrs). Mean age was 55.1 ± 13.4 (SD) years and the majority were male (70%), Caucasian (47%), diabetic (59%), smokers (55%), on dialysis (64%), and underwent an upper arm AVF (76%). Symptoms of ARHI occurred in 45 (7%) participants and intervention was required in 26 (4%). Interventions included distal revascularization with interval ligation (13), ligation (7), banding (4), revision using distal inflow (1), and proximalization of arterial inflow (1). Interventions were performed ≤ 7 days after AVF creation in 4 participants (15%), between 8 - 30 days in 6 (23%) and > 30 days in 16 (63%). Female gender (OR 3.17: 95% CI 1.27 - 7.91, p = 0.013), diabetes (13.62: 1.81 - 102.4, p = 0.011), coronary artery disease (2.60: 1.03 - 6.58, p = 0.044), higher pre-operative venous capacitance (per % /10mmHg: 2.76: 1.07 - 6.52, p = 0.021) and maximum venous outflow slope (per (mL/100 mL/min) /10 mmHg: 1.13: 1.03 - 1.25, p = 0.011) were significantly associated with interventions, while a lower carotid-femoral pulse-wave velocity and the outflow vein diameter in the early postoperative period (days 0 - 3) approached significance (p < .10). Intervention for ARHI was not associated with AVF maturation failure (unadjusted risk ratio 1.18: 0.69 - 2.04, p = 0.56, adjusted odds ratio 0.97: 0.41 - 2.31, p = 0.95). Conclusions Remedial intervention for ARHI after AVF construction is uncommon. Diabetes, female gender, capacitant outflow veins and coronary artery disease are all associated with an increased risk of intervention. These higher risk patients should be counseled preoperatively, their operative plans designed to reduce the risk of hand ischemia, and followed closely.

Prediction of Arteriovenous Fistula Clinical Maturation from Postoperative Ultrasound Measurements: Findings from the Hemodialysis Fistula Maturation Study

“…Baseline clinical and demographic characteristics of the 602participant HFM study cohort, enrolled from March 2010 to September 2013 and followed prospectively, have been previously described in detail. 29,30 A concise summary is provided in Table 1; at baseline, the mean age of participants was 55.1613.4 (SD) years, 70% were men, 44% were black, 59% had diabetes, and 64% had already initiated maintenance hemodialysis.…”

Particularity of Hemodynamics in Hemodialysis Patients With Hand Ischemia

“…Основной причиной терминальной хронической почечной недостаточности был хронический гломерулонефрит, что совпадает с данными литературы [1][2][3][4]. Клиническая симптоматика у пациентов с синдромом обкрадывания кисти была типичной (боль, похолодание конечности, онемение и парестезии) и подробно описана в ряде работ [5,7,8]. Так, стилсиндром у пациентов, находящихся на хроническом гемодиализе, встречался чаще (7,25%) [2,3], чем в нашем исследовании (2,7%), вероятно, потому, что нами учитывались пациенты с выраженной клинической симптоматикой, при которой дальнейшее проведение гемодиализа становилось невозможным.…”

“…Так, стилсиндром у пациентов, находящихся на хроническом гемодиализе, встречался чаще (7,25%) [2,3], чем в нашем исследовании (2,7%), вероятно, потому, что нами учитывались пациенты с выраженной клинической симптоматикой, при которой дальнейшее проведение гемодиализа становилось невозможным. Ишемия кисти встречалась чаще при проксимальных артериовенозных фистулах, чем при сосудистых доступах на предплечье, что соответствует литературным данным [1,5,8]. Синдром обкрадывания появлялся в более ранние сроки у пациентов с артериовенозным графтом по сравнению с дистальными радиоцефалическими фистулами (р = 0,03).…”

“…2020;11(3):5-12. doi: 10.17816/clinpract34257) ляется синдром обкрадывания (steal-синдром; от англ. steal -красть, похищать) кисти [1,4,5].…”

AIUM Practice Parameter for the Performance of Vascular Ultrasound Examinations for Postoperative Assessment of Hemodialysis Access

“…In a large prospective series of AVF‐related hand ischemia, 7% of patients with hemodialysis access AVFs had symptoms, and 4% required interventions. Interventions are associated with female sex, diabetes, capacious outflow veins, and coronary artery disease . Hand ischemia may occur for several reasons: inflow artery stenosis or occlusion, either in the feeding or a more proximal artery (such as the subclavian artery), outflow artery stenosis or occlusion, poor arterial collaterals, or an excessive fistula flow volume.…”