Novel Approaches to Arteriovenous Access Creation, Maturation, Suitability, and Durability for Dialysis

Devita, Maria; Khine, San Kyaw; Shivarov, Hristo

doi:10.1016/j.ekir.2020.02.1024

Cited by 11 publications

(15 citation statements)

References 49 publications

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“…The desired outcome for successful AVF maturation is a timely and properly arterialized vein via outward remodeling ( Hu et al, 2016 ), but AVF maturation failure ranges from 20 to 60% in observational studies ( Cheung et al, 2017 ). Improving AVF maturation remains an important clinical target for the management of ESKD patients ( DeVita et al, 2020 ).…”

Section: Discussionmentioning

confidence: 99%

Natural Vascular Scaffolding Treatment Promotes Outward Remodeling During Arteriovenous Fistula Development in Rats

Shiu

Tey

et al. 2021

Front. Bioeng. Biotechnol.

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Following creation, an arteriovenous fistula (AVF) must mature (i.e., enlarge lumen to allow high blood flow) before being used for hemodialysis. AVF maturation failure rates are high, and currently, there are no effective therapy to treat this problem. The maturation process is likely affected by the integrity of the vascular extracellular matrix (ECM). Natural Vascular Scaffolding (NVS) Therapy is a new technology that interlinks collagen and elastin via photoactivation of a locally delivered small molecule (4-amino-1,8-naphtalamide). We hypothesized that NVS Therapy may improve AVF remodeling by preserving ECM integrity. AVFs were created in Wistar male rats by connecting the femoral vein (end) to femoral artery (side) in the same limb. Immediately after blood flow was restored to dilate the femoral vein by arterial pressure, a 10 μl-drop of the NVS compound (2 mg/ml) was placed on the anastomosis perivascularly. Following 5-min incubation, the NVS treated area was exposed to 1-min illumination by 450-nm light. The control group received 10 μl-drop of phosphate buffered saline (PBS) and the same light activation. The skin was closed, and rats were euthanized 4 weeks (n = 6–9 per group) post-AVF creation for histology, morphometry, immunohistochemistry (IHC), and multiphoton microscopy for second-harmonic-generation evaluation of collagen fibers. The vascular thickness was similar in both groups. The AVF vein’s open lumen area and % open lumen area in NVS-treated rats were significantly larger than in PBS-treated rats (4.2-fold p = 0.014 and 2-fold p = 0.009, respectively). The inflammatory markers IL-6 and MMP-9 in the AVF walls were significantly decreased in the NVS group than the PBS group. Collagen fibers in the vascular wall trended toward perpendicular alignment to the lumen circumference in the NVS-treated AVFs, with more defined shape but less area than in the PBS-treated AVFs. These results indicate that the NVS Therapy exerted changes in collagen, which may influence AVF maturation. Rats tolerated the NVS treatment well, and the lack of cell death by the treatment was confirmed in cell culture experiments. These results suggest that NVS treatment is safe and may have therapeutic potential by facilitating lumen expansion to enhanced AVF maturation in patients.

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Section: Discussionmentioning

confidence: 99%

Natural Vascular Scaffolding Treatment Promotes Outward Remodeling During Arteriovenous Fistula Development in Rats

Shiu

Tey

et al. 2021

Front. Bioeng. Biotechnol.

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“…External shunt and internal arteriovenous fistula (AVF) are the two most common vascular access methods. [ 1 ] Creating an AVF to provide vascular access in hemodialysis patients has been shown to reduce morbidity and improve survival compared to catheters. [ 2 ] However, initial AVF maturation is unsatisfactory in up to 60% of cases.…”

Section: Introductionmentioning

confidence: 99%

Mid-term results of tunneled brachial venous hemodialysis catheter placement: Our single-center experience with 21 patients

Khalil¹

2021

Turk Gogus Kalp Dama

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Background This study aims to analyze the safety and efficacy of permanent hemodialysis catheter insertion via the brachial vein in unsuitable patients for catheter insertion from other vascular access sites. Methods A total of 21 patients (6 males, 18 females; mean age: 54.4±11.3 years; range, 48 to 77 years) who underwent permanent hemodialysis catheter insertion via the brachial vein between February 2019 and February 2020 were retrospectively analyzed. All patients underwent brachial venous tunneled catheter insertion under the ultrasound guidance and under local anesthesia. Transthoracic echocardiography was performed before and six months after catheter insertion. The primary patency rate of the catheter at six months of follow-up, potential associated complications of a permanent hemodialysis catheter including catheter thrombosis and catheter infections, and all-cause mortality rates were recorded. Results Catheter removal was required in eight patients (catheter thrombosis, n=5; catheter infection, n=2; and extensive hematoma, n=1). The catheters were patent in the remaining 13 (62%) patients at six months. Mortality occurred in one patient due to bacterial pneumonia. No life-threatening complications including hemothorax or pneumothorax and neurological injury was observed in any of the patients. Conclusion Our study results show that brachial venous tunneled catheter placement for hemodialysis can be a safe and valid alternative to catheter insertion from the jugular or subclavian veins for vascular access in patients with end-stage renal disease.

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“…A number of novel therapies to promote maturation and maintain patency of arteriovenous accesses have shown promise. 9 Two techniques of percutaneous endovascular AVF (pAVF) creation have shown high success rates (87%-88%) in select patients. 10,11 A retrospective comparison of pAVFs to surgically created AVFs showed superior maturation for pAVFs but similar patency and percutaneous procedural rates.…”

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confidence: 99%

“…These devices have been tested in a small number of patients and the results are inconclusive at this time. 9 Recurrent stenosis, the most common cause for dysfunction in mature AVFs, requires repeated angioplasty. A recent randomized controlled trial, in patients with mature dysfunctional AVFs, showed decreased recurrence of stenosis at 6 months with paclitaxel-coated drug-eluting balloons compared to standard balloon angioplasty, thereby decreasing procedural burden.…”

mentioning

confidence: 99%

“…13 Bioengineered vessels and grafts, such as the human acellular vessel (Humacyte Inc) and STARgraft (Healionics), are undergoing trials with the hope of fewer required maintenance procedures in patients with AVGs. 9,14 Woodside et al have illustrated the high procedural burden for patients receiving hemodialysis, a problem well known to practicing interventional nephrologists/radiologists and vascular surgeons. The solution will require attention to each step from the development of advanced chronic kidney disease to the start of hemodialysis.…”

mentioning

confidence: 99%

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Recurrent Arteriovenous Hemodialysis Access Procedures: The Hidden Details

Abreo

Amin

Abreo

2021

American Journal of Kidney Diseases

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M uch attention has been devoted to the avoidance of tunneled hemodialysis catheters, in favor of arteriovenous fistulas (AVFs) or arteriovenous grafts (AVGs), in patients receiving maintenance hemodialysis, given the risk of serious infection. Less is known about the burden of interventional procedures following surgical placement of AVFs and AVGs. The challenge of initiating patients with AVFs is complicated by a primary failure rate of 30%-70% and 1-year primary patency rate of 40%-70%. 1,2 In this issue of AJKD, Woodside et al 3 use the US Renal Data System to characterize the procedural burden faced by incident hemodialysis patients during the maturation and maintenance phases of their AVFs/AVGs. Maturation phase was defined as the time period between the date of AVF/ AVG placement and date of first use and maintenance phase as the time period between first AVF/AVG use and the end of follow-up. Using administrative data, they found that 24.4% of patients in the AVF group required a procedural intervention in the maturation phase and 39.6% required intervention in the maintenance phase. In the AVG group, the corresponding values were 18.4% and 57.7%, respectively. Taken together, the total procedural burden for AVFs and AVGs are similar but the distribution in time differs, in that AVFs require more maturation procedures and AVGs more maintenance procedures.Maturation of an AVF involves a response of endothelial cells to changes in blood flow, requiring adequate cardiac output, adequate arterial pressure, a suitable arterial vessel, and an unrestricted venous vessel. 4,5 A decade and a half ago, Lok et al 5 identified coronary artery disease (a comorbidity impacting adequate inflow) and peripheral vascular disease (a comorbidity impacting adequate outflow) as predictors of inadequate fistula maturation. Additional epidemiologic risk factors for failed maturation included age ≥ 65 years, non-White race, and female sex. Obesity and diabetes are additional factors that may influence maturation and patency of AVFs. 6 Surgeon experience is an important contributor to successful maturation of AVFs and cannot be assumed to be homogeneous in a national population. 7 Efforts to achieve successful maturation and function of an arteriovenous access begin long before the need for hemodialysis. Decisions about timing of access placement and type of hemodialysis access are influenced by patient demographics, comorbidities, anatomical considerations, and process factors. 6 When done in patients at risk for primary or secondary access failure, preoperative

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Novel Approaches to Arteriovenous Access Creation, Maturation, Suitability, and Durability for Dialysis

Cited by 11 publications

References 49 publications

Natural Vascular Scaffolding Treatment Promotes Outward Remodeling During Arteriovenous Fistula Development in Rats

Natural Vascular Scaffolding Treatment Promotes Outward Remodeling During Arteriovenous Fistula Development in Rats

Mid-term results of tunneled brachial venous hemodialysis catheter placement: Our single-center experience with 21 patients

Recurrent Arteriovenous Hemodialysis Access Procedures: The Hidden Details

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