Recirculation: Review, Techniques for Measurement and Ability to Predict Hemoaccess Stenosis before and after Angioplasty

Nardi, Lorraine; Bosch, Juan P.

doi:10.1159/000169488

Cited by 20 publications

(3 citation statements)

References 10 publications

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“…These results did confirm the clinical suspicion that accesses with prior thromboses were at greater risk for yet another thrombosis. Unlike several other studies [8,[20][21][22], we did not find a significant correlation between graft failure and recirculation rate, venous line pressure during dialysis, or dialyzer clearances measured by URR. This is possibly related to the fact that only a baseline recirculation, venous pressure and URR were correlated with subsequent clotting.…”

Section: Discussioncontrasting

confidence: 99%

Predicting Hemodialysis Access Failure with Color Flow Doppler Ultrasound

et al. 1998

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Color flow doppler ultrasound examination of the hemodialysis access was conducted in 2,792 hemodialysis patients to evaluate its value in predicting hemodialysis access failure. After baseline assessment of vascular access function with clinical and laboratory tests including color flow doppler evaluation these patients were followed for a minimal of 6 months or until graft failure occurred (defined as surgery or angioplasty intervention, or graft loss). The patient demographics and vascular accesses were typical of a standard hemodialysis patient population. On the day of the color flow doppler examination systolic and diastolic blood pressure, hematocrit, urea reduction ratio, dialysis blood flow, venous line pressure at a dialysis blood flow of 250 ml/min, and access recirculation rate were measured. At the conclusion of the study 23.5% of the patients had access failure. Case mix predictors for access failure were determined using the Cox Model. Case mix predictors of access failure were race, non-white was higher than white (p < 0.005), younger accesses had a higher risk than older accesses (p < 0.025), accesses with prior thrombosis had a higher risk of failure (p = 0.042), polytetrafluoroethylene (PTFE) grafts had a higher risk than native vein fistulae (p < 0.05), loop PTFE grafts had a higher risk than straight PTFE grafts (p < 0.025), and upper arm accesses had a higher risk than forearm accesses (p = 0.033). Most significant, however, was decreased access blood flow as measured by color flow doppler (p < 0.0001). The relative risk of graft failure increased 40% when the blood flow in the graft decreased to less than 500 ml/min and the relative risk doubled when the blood flow was less than 300 ml/min. This study has shown that color flow doppler evaluation, quantifying blood flow in a prosthetic graft, can identify those grafts at risk for failure. In contrast, color doppler volume flow in native AV fistulae could not predict fistula survival. This technique is noninvasive, painless, portable, and reproducible. We believe that preemptory repair of an anatomical abnormality in vascular access grafts with decreased blood flow may decrease patient inconvenience, associated morbidity, and associated costs.

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Section: Discussioncontrasting

confidence: 99%

Predicting Hemodialysis Access Failure with Color Flow Doppler Ultrasound

et al. 1998

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“…Access recirculation (AR), which can significantly decrease the efficiency of hemodialysis, is a function of access blood flow (Q ac ) and has been used to measure access performance and prognosis [1]. AR is assumed as a late manifestation of the failing access.…”

Section: Introductionmentioning

confidence: 99%

Sensitivity and Specificity of the Thermodilution Technique in Detection of Access Recirculation

Wang¹,

Schneditz

Kaufman³

et al. 2000

Nephron

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Background/Aim: Recirculation measured by thermodilution includes effects caused by access and cardiopulmonary recirculation. The aims of this study were to illustrate the accuracy of thermodilution in measurement of hemodialysis recirculation and also to identify a sensitive and specific threshold to detect access recirculation. Methods: 110 studies were performed in 19 patients. Recirculation obtained directly by the blood temperature monitor (BTM) was compared to that calculated from access blood flow, pump blood flow, and cardiac output determined by ultrasound dilution using the hemodialysis monitor (HDM). Results: A highly significant linear correlation was obtained between repeated BTM recirculation measurements (R_{BTM, 2} = 0.99·R_{BTM, 1} – 0.22%, r² = 0.99). There were no significant differences between repeated BTM recirculation measurements with correct placement (11.4 ± 7.1 vs. 10.9 ± 7.4%, p = NS) or reversed placement (30.0 ± 15.6 vs. 30.2 ± 15.9%, p = NS) of blood lines. A strong linear relationship was obtained between the recirculation determined by thermodilution and the recirculation calculated from HDM measurements (R_calc = 0.98·R_BTM – 1.49%, r² = 0.95). The mean recirculation obtained by BTM was not significantly different from the recirculation calculated by HDM with correct placement (9.5 ± 2.2 vs. 8.6 ± 2.5%, p = NS) or with reversed placement (25.4 ± 7.8 vs. 23.8 ± 7.7%, p = NS) of blood lines. When a recirculation greater than 15% measured by the BTM was considered as the threshold at which true access recirculation occurred, sensitivity and specificity of the thermodilution method to detect access recirculation were 93 and 98%, respectively. Conclusions: Recirculation measurements made by the BTM are accurate and precise. Even though BTM thermodilution includes effects of cardiopulmonary recirculation, so that low levels of access recirculation might not be detected, a BTM recirculation >15% represents a highly significant access recirculation.

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“…Several methods have been used to predict hemodialysis access failure with the hope that elective intervention would prevent or lessen the incidence of thrombosis and prolong access survival. These methods include Doppler ultrasonography (15,16), venous pressure monitoring during dialysis (17), measurement of the ratio of venous to systemic pressure (18), and measurement of elevated recirculation (19,20). All of these methods have been capable of predicting venous stenosis and subsequent clotting to varying degrees.…”

mentioning

confidence: 99%

State-of-the-Art Review : Treatment of Hemodialysis Access Failure: A Role for Thrombolysis

Sands

Miranda

1996

Clin Appl Thromb Hemost

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Thrombosis of hemodialysis accesses remains a major source of morbidity, hospitalization, and expense for patients with end-stage renal disease. Treatment of hemodialysis accesses includes strategies to prevent ac cess failure and methods for treating acute thromboses. Such techniques as Doppler ultrasonography, venous pressure monitoring during dialysis, measurement of ra tios of venous to systemic pressures, and measurement of recirculation have been used to predict accesses at risk of thrombosis. Elective interventions, including surgical re visions and angioplasties, have been shown to lessen the thrombosis rate in both polytetrafluoroethylene (PTFE) grafts and arterio-venous fistulas. Elective revision has also improved long-term patency of both grafts and fistu las when compared with repairing the accesses only after thrombosis. Despite these attempts, acute thrombosis of hemodialysis accesses remains a common complication for patients with end-stage renal disease. Historically, surgical thrombectomy has been the gold standard for treatment of acute hemodialysis access failure. Over the past 10 years, thrombolytic therapy has gained an in creasing role in the treatment of acutely thrombosed PTFE grafts. Thrombolysis has had at least comparable results to surgical thrombectomy in the best centers, with similar complication rates. Thrombolytic therapy is also significantly less expensive than surgical thrombectomy. In summary, we believe that hemodialysis access treat ment should encompass a comprehensive program, in cluding access surveillance to select accesses at risk of failure. Elective intervention should be performed in an attempt to prevent thrombosis and increase long-term ac cess patency. When thrombosis does occur, pharmaco mechanical thrombolysis is the preferable first interven tion for acutely occluded PTFE hemodialysis accesses.

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Recirculation: Review, Techniques for Measurement and Ability to Predict Hemoaccess Stenosis before and after Angioplasty

Cited by 20 publications

References 10 publications

Predicting Hemodialysis Access Failure with Color Flow Doppler Ultrasound

Predicting Hemodialysis Access Failure with Color Flow Doppler Ultrasound

Sensitivity and Specificity of the Thermodilution Technique in Detection of Access Recirculation

State-of-the-Art Review : Treatment of Hemodialysis Access Failure: A Role for Thrombolysis

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