Disparities in Fistula Maturation Persist Despite Preoperative Vascular Mapping

Peterson, William J.; Barker, Jill; Allon, Michael

doi:10.2215/cjn.03480807

Cited by 184 publications

(151 citation statements)

References 17 publications

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“…Studies have demonstrated several clinical factors contributing to AV fistula success or failure, with older age, diabetes, and their associated complications (e.g., cardiac and peripheral vascular disease) as strong predictors of failure (10)(11)(12). In the first described AV fistulas, the failure rate was 12.5% (3), but it is as high as 40% today (13,14), probably reflecting the effect of an older dialysis population with greater comorbidity.…”

Section: Incidence and Prevalencementioning

confidence: 99%

Vascular Access Morbidity and Mortality

Lok

Foley²

2013

Clinical Journal of the American Society of Nephrology

212

135

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SummaryDuring the past decade, clear trends in the types of incident and prevalent hemodialysis vascular access can be observed. There has been a steady increase and recent stabilizaton of patients initiating hemodialysis with a central venous catheter, representing approximately 80% of all incident accesses. There has also been a steady increase in prevalent fistula use, currently greater than 50% within 4 months of hemodialysis initiation. Patient and vascular access related morbidity and mortality are reflected in the type of vascular access used at initiation and for long-term maintenance dialysis. There is a three-to fourfold increase in risk of infectious complications in patients initiating dialysis with a catheter compared with either a fistula or graft and a sevenfold higher risk when the catheter is used as a prevalent access. Procedure rates have increased two-to threefold for all types of access. There is a significant increased risk of mortality associated with catheter use, especially within the first year of dialysis initiation.

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Section: Incidence and Prevalencementioning

confidence: 99%

Vascular Access Morbidity and Mortality

Lok

Foley²

2013

Clinical Journal of the American Society of Nephrology

212

135

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“…Answer AVF nonmaturation or early failure is associated with older age, female sex, forearm location, and cardiovascular disease (57)(58)(59)(60). In contrast, no clinical factors have been associated with early AVG failure.…”

Section: James C Harms Md (Nephrology Fellow At University Of Alabamentioning

confidence: 99%

A Patient with Recurrent Arteriovenous Graft Thrombosis

Allon¹

2015

Clinical Journal of the American Society of Nephrology

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Arteriovenous grafts (AVGs) are prone to frequent thrombosis that is superimposed on underlying hemodynamically significant stenosis, most commonly at the graft-vein anastomosis. There has been great interest in detecting AVG stenosis in a timely fashion and performing preemptive angioplasty, in the belief that this will prevent AVG thrombosis. Three surveillance methods (static dialysis venous pressure, flow monitoring, and duplex ultrasound) can detect AVG stenosis. Whereas observational studies have reported that surveillance with preemptive angioplasty substantially reduces AVG thrombosis, randomized clinical trials have failed to confirm such a benefit. There is a high frequency of early AVG restenosis after angioplasty caused by aggressive neointimal hyperplasia resulting from vascular injury. Stent grafts prevent AVG restenosis better than balloon angioplasty, but they do not prevent AVG thrombosis. Several pharmacologic interventions to prevent AVG failure have been evaluated in randomized clinical trials. Anticoagulation or aspirin plus clopidogrel do not prevent AVG thrombosis, but increase hemorrhagic events. Treatment of hyperhomocysteinemia does not prevent AVG thrombosis. Dipyridamole plus aspirin modestly decreases AVG stenosis or thrombosis. Fish oil substantially decreases the frequency of AVG stenosis and thrombosis. In patients who have exhausted all options for vascular access in the upper extremities, thigh AVGs are a superior option to tunneled internal jugular vein central vein catheters (CVCs). An immediate-use AVG is a reasonable option in patients with recurrent CVC dysfunction or infection. Tunneled femoral CVCs have much worse survival than internal jugular CVCs.Clin J Am Soc Nephrol 10: 2255-2262, 2015. doi: 10.2215/CJN.00190115 Patient PresentationThe following vignette illustrates the numerous challenges in optimizing arteriovenous graft (AVG) patency in hemodialysis patients. A 28-year-old woman initiated peritoneal dialysis when she developed ESRD because of focal glomerular sclerosis. She was hospitalized with an intracerebral bleed caused by a ruptured aneurysm 1.5 years later. A ventricular-peritoneal shunt was placed to treat hydrocephalus, and she was anticoagulated with warfarin to keep the shunt patent. Because of residual left-sided weakness and inadequate family support, she was no longer able to perform peritoneal dialysis. A tunneled central vein catheter (CVC) was placed in the right internal jugular vein, and she was switched to maintenance hemodialysis. A left forearm arteriovenous fistula (AVF) clotted 2 weeks after its creation. A subsequent looped left upper-arm AVG was successfully cannulated 5 weeks after its creation. It clotted four times during the ensuing 6 months and was treated each time by an interventional radiologist or nephrologist, who performed percutaneous thrombectomy, in conjunction with angioplasty of a venous anastomotic stenosis. The patient resumed hemodialysis with an internal jugular CVC when the AVG failed. A right radiocephalic AV...

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“…In contrast, more recent studies have reported a much higher likelihood of fistula nonmaturation, ranging between 20% and 60% (11)(12)(13). Simple clinical factors (older age, female sex, black race, vascular morbidity, and forearm location) have been repeatedly associated with fistula nonmaturation (11,14,15).…”

mentioning

confidence: 98%

“…This was highlighted in a large National Institutes of Health multicenter randomized study in which 60% of fistulas created were not suitable for dialysis despite Ͼ75% with preoperative mapping (12). Nonmaturation continues to be higher in older patients, women, and forearm fistulas (12,15,17). Although some studies have demonstrated no association between vessel size and fistula maturation (18), most centers require a minimum arterial diameter of 2 mm and a minimum venous diameter of 2.5 to 3 mm (19).…”

mentioning

confidence: 99%

Dialysis Fistula or Graft

Allon

Lok

2010

Clinical Journal of the American Society of Nephrology

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131

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The Fistula First Initiative has strongly encouraged nephrologists, vascular access surgeons, and dialysis units in the United States to make valiant efforts to increase fistula use in the hemodialysis population. Unfortunately, the rigid "fistula first" recommendations are not based on solid, current, evidence-based data and may be harmful to some hemodialysis patients by subjecting them to prolonged catheter dependence with its attendant risks of bacteremia and central vein stenosis. Once they are successfully cannulated for dialysis, fistulas last longer than grafts and require fewer interventions to maintain long-term patency for dialysis. However, fistulas have a much higher primary failure rate than grafts, require more interventions to achieve maturation, and entail longer catheter dependence, thereby leading to more catheter-related complications. Given the tradeoffs between fistulas and grafts, there is equipoise about their relative merits in patients with moderate to high risk of fistula nonmaturation. The time is right for definitive, large, multicenter randomized clinical trials to compare fistulas and grafts in various subsets of chronic kidney disease patients. Until the results of such clinical trials are known, the optimal vascular access for a given patients should be determined by the nephrologist and access surgeon by taking into account (1) whether dialysis has been initiated, (2) the patient's life expectancy, (3) whether the patient has had a previous failed vascular access, and (4) the likelihood of fistula nonmaturation. Careful clinical judgment should optimize vascular access outcomes and minimize prolonged catheter dependence among hemodialysis patients.

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Disparities in Fistula Maturation Persist Despite Preoperative Vascular Mapping

Cited by 184 publications

References 17 publications

Vascular Access Morbidity and Mortality

Vascular Access Morbidity and Mortality

A Patient with Recurrent Arteriovenous Graft Thrombosis

Dialysis Fistula or Graft

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