Postoperative Ultrasound, Unassisted Maturation, and Subsequent Primary Patency of Arteriovenous Fistulas

Farrington, Crystal A.; Robbin, Michelle L.; Lee, Timmy; Barker-Finkel, Jill; Allon, Michael

doi:10.2215/cjn.02230218

Cited by 30 publications

(25 citation statements)

References 27 publications

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“…Furthermore, this imaging technique is independent of diameter and is less affected by flow profile than conventional duplex ultrasonography [14,15]. Conversely, Farrington et al [17] used color and spectral Doppler ultrasonography conducted by experienced sonographers for a postoperative evaluation within 6 weeks after AVF creation. They predicted AVF patency after maturation based only on postoperative AVF diameter.…”

Section: Discussionmentioning

confidence: 99%

Clinical Value of Intraoperative Flow Measurements of Brachiocephalic Arteriovenous Fistulas for Hemodialysis

Lee

Chang

et al. 2020

Korean J Thorac Cardiovasc Surg

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Background: The aim of this study was to analyze the clinical outcomes of autogenous brachiocephalic arteriovenous fistulas and to investigate the factors associated with 1-year patency after initiation of hemodialysis. Methods: We retrospectively reviewed the medical records of 41 patients who underwent surgery to create an autogenous brachiocephalic arteriovenous fistula between January 2015 and December 2017, received hemodialysis at the same hospital for longer than 1 year, and were monitored for their vascular access status. Intraoperative flow was measured using transit-time ultrasonography. Results: The 1-year primary and secondary patency rates were 61% (n=25) and 87.8% (n=36), respectively. The functional group (subjects who required no intervention to maintain patency within the first year after hemodialysis initiation) displayed a significantly higher median intraoperative flow rate (450 mL/min) than the non-functional group (subjects who required intervention at least once regardless of 1-year patency) (275 mL/min) (p=0.038). Based on a receiver operating characteristic curve analysis, all patients were additionally subdivided into a high-flow group (>240 mL/min) and a low-flow group (≤240 mL/min). The high-flow group included a significantly greater number of functional brachiocephalic arteriovenous fistulas than the low-flow group (74.2% vs. 20%, respectively; p=0.007). Conclusion: Transit-time flow, as measured with intraoperative transit-time ultrasonography, was associated with patency without the need for intervention at 1 year after initiation of hemodialysis.

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Section: Discussionmentioning

confidence: 99%

Clinical Value of Intraoperative Flow Measurements of Brachiocephalic Arteriovenous Fistulas for Hemodialysis

Lee

Chang

et al. 2020

Korean J Thorac Cardiovasc Surg

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“…The findings of Farrington et al (11) accurately capture what happens when practitioners choose to create upper arm accesses: there are indeed more unassisted maturations. However, this choice also invites a higher number of high flow-associated later complications, such an steal, high-output heart failure, and aneurysmic degeneration of the access and (much) later, the artery.…”

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confidence: 85%

Determinants of Arteriovenous Fistula Maturation

Hentschel

2018

CJASN

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Vascular access is the Achilles' heel of hemodialysis. This was true for the first patient with CKD treated repeatedly by Willem Kolff in 1943, who ran out of access sites. It remains a challenge today; creation of autogenous accesses (arteriovenous fistulas [AVFs]) is characterized by high primary failure rates. Successful maturation is most usefully defined as the state when an AVF is used successfully and reliably with needles, and any tunneled catheter placed for initiation of dialysis has been removed. In more detail, this means that dialysis unit staff members have to be able to place needles without trying several times and that needle removal has to occur without excessive bleeding. During dialysis, the AVF has to provide sufficient flow with minimal recirculation, such that the clearance goal can be achieved. There are (at least) six contributors to the game of maturation, and it is useful to review what we perceive to be known about their contributions. The access surgeon is in the unique position to form something entirely unnatural out of a named vein and artery with the hope that it will last for years to decades. The available data indicate that performing more than several hundred fistula surgeries per year increases maturation rates (1). Analysis of 2016 Center for Medicare Services data suggest that approximately 0.5% of United States access surgeons create .75 AVFs per year, whereas 86% create 10 or less (2). Surgical techniques have not been studied in any randomized fashion. The inflow artery diameter in conjunction with heart rate and BP determine the potential AVF flow volume. After AVF surgery, blood flow rates may increase tento 80-fold from a baseline of approximately 50 ml/min in a brachial artery due to a decrease in resistance. The change in shear stress facilitates outward remodeling such that, over time, flow volume in the dialysis access circuit increases. This continues unless there is a narrow segment that limits flow. In the vast majority of humans, the brachial artery at the elbow before any remodeling is large enough to allow for blood flow rates in excess of 1200-1500 ml/min, with mean arterial pressures .70 mm Hg. Arteries with diameters ,2 mm may limit blood flow to ,400 ml/min depending on BP (3). A vein as part of an AVF experiences changes in diameter as well as wall thickness. There is the general perception that veins after AVF creation remodel depending on shear stress: too little will not change vein diameter, and too much may lead to inward remodeling, whereas the right amount leads to outward remodeling.

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“…Walaupun begitu, setelah dihubungkan dengan maturitas, untuk jarak kulit-vena intraoperasi tidak didapatkan adanya hubungan bermakna dengan maturitas (P=0,281 >0,05). Hal ini selaras dengan yang dilaporkan Farrington et al 16 yaitu terdapat penurunan jarak kulit-vena terutama pada kelompok yang matur, namun nilainya tidak bermakna.…”

Section: Gambar 3 Sebaran Data Bfr Intraoperasi Dan 6 Mingguunclassified

Korelasi Blood Flow Rate Intraoperasi dan Enam Minggu Pascaoperasi Arteriovenous Fistula Brakiosefalika Dihubungkan dengan Maturitas di RSUP Prof. Dr. R. D. Kandou Manado

Palin¹,

Tjandra²,

Sumangkut³

2019

JBM

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American National Kidney Foundation (2002) states that end-stage kidney disease is an indication for renal replacement therapy, one of which is hemodialysis. Vascular access comprises a fundamental component of hemodialysis therapy (HD), facilitating the patient’s blood flow to the dialyzer. However, there are some factors affecting the maturity of an arteriovenous fistula (AVF), inter alia the patient, comorbidities, and anatomical and functional conditions of the blood vessels involving the blood flow rate (BFR). This study was aimed to establish the differences between intra-operative BFR and BFR six weeks after surgery as well as any correlations between intraoperative BFR, venous diameter, and skin to vein distance with maturity of brachiocephalic AVF. This was prospective cohort study conducted at the Department of Surgery, Prof. Dr. R. D. Kandou General Hospital Manado. Subjects were 41 CKD patients who underwent brachiocephalic AVF surgery. The vein diameter, skin to vein distance, and BFR were measured immediately as intra-operative data using a Doppler USG and all were re-measured at six-week-follow-up examination as six-week-postoperative data. The results showed that there was a significant increase in BFR at six weeks postoperation compared to intraoperation (t=-19.215; P <0.0001). Bi-serial point correlation analysis revealed that there was a significant correlation between intraoperative venous diameter and maturity (rpb=0.276; P=0.04) as well as a significant correlation between intraoperative BFR and maturity (rpb=0.615; P=0.002). No significant correlation was observed between intra-operative skin to vein distance and maturity (rpb=0.093; P=0.281). Conclusion: There was a significant difference in BFR between intraoperation and 6 weeks postoperation in the mature AV fistula. There was a significant relationship between intraoperative BFR and maturity as well as between intraoperative venous diameter and maturity, while no significant relationship between skin-vein distance and maturity was found.Keywords: brachiocephalic AVF, BFR, maturityAbstrak: American National Kidney Foundation (2002) menyatakan bahwa penderita dengan penyakit ginjal tahap akhir diindikasikan untuk dilakukan terapi pengganti ginjal, salah satunya hemodialisis (HD). Akses vaskular merupakan komponen penting pada terapi HD karena melalui akses vaskular darah dari tubuh pasien dapat dialirkan menuju dialyzer. Terdapat banyak faktor yang memengaruhi maturitas suatu arteriovenous fistula (AVF), yaitu pasien itu sendiri, komorbid, serta keadaan anatomi dan fungsional pembuluh darah termasuk nilai blood flow rate (BFR). Penelitian ini bertujuan untuk mengetahui perbedaan BFR intraoperasi dan BFR enam minggu pascaoperasi serta adanya korelasi antara BFR intraoperasi, diameter vena, dan jarak kulit-vena dengan maturitas AVF brakiosefalika. Penelitian ini dilaksanakan di Bagian Bedah RSUP Prof. Dr. R. D. Kandou Manado dengan desain kohort prospektif. Subyek penelitian ialah 41 pasien PGK yang menjalani operasi pembuatan AVF brakiosefalika. Setelah selesai operasi dihitung diameter vena, jarak kulit-vena, dan BFR sebagai data intraoperasi menggunakan USG Doppler. Penghitungan dilakukan kembali 6 miggu pascaoperasi. Hasil penelitian mendapatkan peningkatan BFR yang sangat bermakna pada enam minggu pascaoperasi dibandingkan intraoperasi (t =-19,215, P<0,0001). Dengan analisis korelasi point biserial didapatkan hubungan bermakna antara diameter vena intraoperasi dengan maturitas (rpb=0,276; P=0,04), tidak terdapat hubungan bermakna antara jarak kulit-vena intraoperasi dengan maturitas (rpb=0,093; P=0,281), dan terdapat hubungan bermakna antara BFR intraoperasi dengan maturitas (rpb=0,615; P=0,002). Simpulan: Terdapat perbedaan bermakna antara BFR intraoperasi dan BFR 6 minggu pascaoperasi pada AVF matur. Terdapat hubungan bermakna antara BFR intraoperasi dan diameter vena intraoperasi dengan maturitas namun tidak terdapat hubungan bermakna antara jarak kulit-vena dengan maturitas.Kata kunci: AVF brakiosefalika, BFR, maturitas

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Postoperative Ultrasound, Unassisted Maturation, and Subsequent Primary Patency of Arteriovenous Fistulas

Abstract: Unassisted AVF maturation is predicted by AVF blood flow, location, depth, and stenosis. AVF patency after unassisted maturation is predicted only by the postoperative AVF diameter.

Cited by 30 publications

References 27 publications

Clinical Value of Intraoperative Flow Measurements of Brachiocephalic Arteriovenous Fistulas for Hemodialysis

Clinical Value of Intraoperative Flow Measurements of Brachiocephalic Arteriovenous Fistulas for Hemodialysis

Determinants of Arteriovenous Fistula Maturation

Korelasi Blood Flow Rate Intraoperasi dan Enam Minggu Pascaoperasi Arteriovenous Fistula Brakiosefalika Dihubungkan dengan Maturitas di RSUP Prof. Dr. R. D. Kandou Manado

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