Outcomes of Vascular Access Care and Surgery Managed by Interventional Nephrologists: A Twelve-Year Experience

Abstract

Background: Optimizing vascular access outcomes is still a challenge, since 30-60% of arteriovenous fistulas fail or do not mature and catheters are widely used in contemporary patients. Methods: This study reports on strategies and outcomes in a single center in which access planning, surgery and maintenance are managed by a team of nephrologists. We retrospectively analyzed 305 fistulas and 61 grafts created in 270 consecutive patients between 2002 and 2013. Results: The percentage of patients receiving a fistula or graft who initiated hemodialysis with a mature access was 68.6%. Among prevalent patients, 71.7% used a fistula, 15.7% a graft and 12.6% a catheter. Rates of primary failure and revision before cannulation were 14.4 and 1.6% for fistulas vs. 4.9 and 3.3% for grafts. After maturation, complications (1.040 vs. 0.188 per patient-year (py)) and interventions (0.743 vs. 0.066 per py) were greater for grafts than for fistulas (p < 0.001). Secondary patency did not significantly differ between grafts and fistulas (median survival 34.8 vs. 57.3 months, p = 0.36), unless primary failures were excluded from Kaplan-Meier analysis (median survival 34.9 vs. 70.9 months, p = 0.03). Conclusions: High fistula prevalence, low access-related morbidity and catheter dependence were achieved using individualized strategies, including mid-forearm or perforating vein fistula creation and selective graft placement in high risk patients. Direct involvement of nephrologists throughout all steps of access care can improve access outcomes, by promoting a patient-centered approach.

The forearm arteriovenous graft between the brachial artery and the brachial vein as a reliable dialysis vascular access for patients with inadequate superficial veins

“…The mentioned comorbidities were defined previously. 34 VA outcomes were defined in accordance with recommended standards of the Society for Vascular Surgery 35 and the North American Vascular Access Consortium. 36 Primary patency was defined as the time interval from access placement until any intervention to maintain patency, first occurrence of thrombosis, or time of patency measurement.…”

Quality assessment of vascular access procedures for hemodialysis: A position paper of the Vascular Access Society based on the analysis of existing guidelines

“…18 Globally, it has been reported that interventional nephrologists have comparable or even better results than surgeons. 19–23 It seems reasonable to state that dedication to angioaccess surgery is more important than specialty of VA surgeon. The grade of operating surgeon may also influence outcomes.…”

Interventional nephrology: current status and clinical impact in Japan

“…To date, HD access surgery by nephrologists and its main effects have also been reported [ 12 , 15 – 17 ]. VA surgery and endovascular intervention by nephrologists can improve access outcomes [ 18 ] and timely detection of malfunctions in vascular access, increases the survival of vascular access [ 19 ] and use of AVF, and decreases HD catheter utilization [ 20 ]. In these regards, frequent practice of interventional nephrology may contribute to good survival of HD patients in Japan [ 21 ].…”