Does monthly native arteriovenous fistula blood-flow surveillance detect significant stenosis—a randomized controlled trial

Polkinghorne, Kevan R.; Lau, Kenneth; Saunder, Alan; Atkins, Robert C.; Kerr, Peter G.

doi:10.1093/ndt/gfl242

Cited by 77 publications

(70 citation statements)

References 19 publications

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“…Changes in those parameters have potential interobserver variability and may erroneously be attributed to transitory or occasional alterations during HD. 20 There is evidence that stenosis surveillance by DUS combined with preemptive correction, regardless of other criteria, may be superior to an invasive strategy based only on clinical or flow criteria. 21 Two recent clinical trials reported different results using DUS screening followed by PTA in prosthetic grafts for HD access.…”

Section: A B Cmentioning

confidence: 99%

Maintenance of Hemodialysis Arteriovenous Fistulas by an Interventional Strategy

Scaffaro

Bettio

Cavazzola

et al. 2009

Journal of Ultrasound in Medicine

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Objective. A native arteriovenous fistula (NAF) is a widely used access location for hemodialysis (HD). Monitoring of the NAF followed by percutaneous transluminal angioplasty (PTA) as needed may reduce the incidence of NAF failure according to nonrandomized studies. The aim of this randomized study was to determine whether an interventional strategy consisting of clinical and duplex ultrasonographic (DUS) surveillance of NAFs followed by PTA reduces the rate of the need of central venous dialysis catheters (CVCs) and NAF thrombosis in patients undergoing HD. Methods. A total of 108 patients with 111 functioning NAFs in an HD program were randomized to control and interventional strategy groups. The control group received standard care: clinical and hemodynamic NAF assessment followed by vascular surgeon consultation in cases of dysfunction. In the interventional group, the patients underwent clinical monitoring and systematic DUS surveillance every 3 months. Cases with access dysfunction underwent angiography followed by PTA for stenosis of 50% or greater. Primary outcomes were the need of temporary CVCs and fistula thrombosis. Results. Fifty-eight NAFs were randomized to the control group, and 53 were randomized to the interventional group. Groups had similar baseline characteristics. The interventional strategy showed a significant reduction in the CVC need (25.9% versus 7.5% for control and interventional groups, respectively; P = .021). No significant difference was observed for thrombosis rates (24.1% versus 17.0%; P = .487). The composite end point of NAF thrombosis or CVC need was reduced by the interventional strategy (44.8% versus 20.8%; P = .033). Conclusions. This randomized study indicates the benefit of a surveillance program for maintenance of NAFs based on clinical and DUS surveillance followed by PTA of major stenosis.

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Section: A B Cmentioning

confidence: 99%

Maintenance of Hemodialysis Arteriovenous Fistulas by an Interventional Strategy

Scaffaro

Bettio

Cavazzola

et al. 2009

Journal of Ultrasound in Medicine

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“…It is a single-center study on a small group of patients mainly with forearm AVFs. Another limitation may be that it considered the intermediate outcome (stenosis) rather than the clinically more relevant AVF failure, although an early and accurate identification of stenosis may be of value because it is the foremost risk factor for AVF dysfunction and thrombosis (1,4,6). This approach may also reduce the burden of access monitoring by selecting the AVFs requiring more frequent surveillance (if any stenosis is not corrected as soon as it has been identified).…”

Section: Discussionmentioning

confidence: 99%

In Search of an Optimal Bedside Screening Program for Arteriovenous Fistula Stenosis

Tessitore

Bedogna

Melilli

et al. 2011

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives: Guidelines recommend systematically screening for stenosis using various methods, but no studies so far have compared all of the options. A prospective blinded study was performed to compare the performance of several bedside tests performed during dialysis in diagnosing angiographically proven Ͼ50% fistula stenosis. Design, setting, participants, & measurementsIn an unselected population of 119 hemodialysis patients with mature fistulas, physical examination (PE) was conducted; dynamic and derived static venous pressure (VAPR), blood pump flow/arterial pressure (Qb/AP) ratio, recirculation (R), and access blood flow (Qa) were measured; and angiography was performed.Results Angiography identified 59 stenotic fistulas: 43 stenoses were located upstream from the venous needle (inflow stenosis), 12 were located downstream (outflow stenosis), and 4 were located at both sites. The optimal tests for identifying an inflow stenosis were Qa Ͻ 650 ml/min and the combination of a positive PE "or" Qa Ͻ 650 ml/min (accuracy 80% and 81%, respectively), the latter being preferable because it was more sensitive (85% versus 65%, respectively) for a comparable specificity (79% versus 89%, respectively). The best tests for identifying outflow stenosis were PE and VAPR, with no difference between the two (accuracy 91% and 85%, sensitivity 75% and 81%, specificity 93% and 86%, respectively), the former being preferable because it was more reproducible, easier to perform, and applicable to all fistulas. ConclusionsThis study showed that fistula stenosis can be detected and located during dialysis with a moderate-to-excellent accuracy using PE and Qa measurement as screening procedures.

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“…The UDT was used as reference standard as it has been validated previously for clinical outcomes [3,4]. A Transonic HD03 (Transonic Systems, Ithaca, N.Y., USA) was used to obtain measurements, calibrated as per the manufacturer’s recommendation.…”

Section: Methodsmentioning

confidence: 99%

“…The most extensively validated and accepted method of assessing the adequacy of flow in AVF or AVG is the ultrasound dilution technique (UDT) [3,4,5]. It has been shown that reductions in blood flow measured by UDT can predict graft and fistula failure [6,7,8] and that intervention based on the changes in these flows can reduce graft thrombosis [9].…”

Section: Introductionmentioning

confidence: 99%

Validation of the Measurement of Haemodialysis Access Flow Using a Haemoglobin Dilution Test

Jiang

Clayton²,

Maguire³

et al. 2011

Blood Purif

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Monitoring of blood flows in arteriovenous fistulae and arteriovenous grafts is recommended to predict access thrombosis. The ultrasound dilution technique (UDT) is the gold standard. We compare a recently described haemoglobin dilution technique (HDT) with the UDT in measurement of vascular access flow. Access blood flow was measured in 67 stable dialysis patients using HDT by bedside Hemocue (Hemocue AB, Ängelholm, Sweden) and laboratory measurement. Access blood flow was then measured by UDT in the same dialysis session. Median flow rate by UDT was 950 ml/min (IQR 490–1,440 ml/min), by Hemocue HDT 935 ml/min (IQR 475–1,395 ml/min, p = 0.534), and by laboratory haemoglobin HDT 920 ml/min (IQR 463–1,378 ml/min). Bland-Altman plots demonstrated poor agreement between UDT and HDT (limits of agreement for Hemocue HDT –22.7 to 20.1%, for laboratory HDT –21.2 to 20.4%). HDT can be used to measure vascular access flow but requires validation against clinical outcomes before being recommended as an alternative to UDT.

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Does monthly native arteriovenous fistula blood-flow surveillance detect significant stenosis—a randomized controlled trial

Cited by 77 publications

References 19 publications

Maintenance of Hemodialysis Arteriovenous Fistulas by an Interventional Strategy

Maintenance of Hemodialysis Arteriovenous Fistulas by an Interventional Strategy

In Search of an Optimal Bedside Screening Program for Arteriovenous Fistula Stenosis

Validation of the Measurement of Haemodialysis Access Flow Using a Haemoglobin Dilution Test

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