Understanding Surgical Preference and Practice in Hemodialysis Vascular Access Creation

Abstract

Understanding healthcare providers' preferences, values, and beliefs around AVF eligibility is important to explain variability in practice. We conducted a survey of international surgeons, using hypothetical patient scenarios, to assess resources used, variables, perceived barriers, and absolute contraindications to access creation. A total of 134 surgeons completed the survey. Venous duplex ultrasound mapping (VDUM) was offered to all patients by 90% of US, 68% Canadian, and 63% European respondents. VDUM altered clinical decision less than 25% of the time for 33% American, 48% Canadian, and 85% European surgeons. Increased comorbidities and previous failed access were deterrents to AVF creation as was vessel size. Second choice access was the AV graft in the US and Europe and the catheter in Canada. Absolute contraindications to AVF creation included patient life expectancy <1 year, left ventricular ejection fraction (LVEF) <15%, and a history of dementia, while 42% surgeons reported no absolute contraindications. Perceived barriers included patient preferences, long wait times for surgery, and late referral to a Nephrologist. Significant variability exists in the surgical preoperative assessment of patients, and the eligibility criteria used for fistula creation. Understanding surgeons' preferences can aid in establishing standardization for VA access eligibility, including surgical assessment.

Vascular Access Creation before Hemodialysis Initiation and Use

“…Additionally, Canadian patients and health care providers have attitudes that are markedly different from the rest of the world, and it would seem that Canada has a culture that is more permissive of catheters (22). In surveys, we have found that this attitude is pervasive among patients, and nephrologists as well as vascular access surgeons had marked variations in their practices regarding AV access referral patterns and creation, respectively (26,28,29). (1-3).…”

Vascular Access Management for Haemodialysis: A Value-Based Approach from NephroCare Experience

“…There is no systematic evidence that preoperative US mapping will induce an increase in the proportion of fistulas ultimately used for dialysis or a reduction in catheter use. It appears that the results from vessel mapping only influenced the decision as to the type or location of the AV access in surgeons with less than 15 years of experience [101]. In patients with pre-operative vascular mapping, on multiple variable logistic regression, factors associated with failure to mature were female gender, age > 65 years and forearm location (up to 78% if the three criteria were met), and the extracted mapping hemodynamic measurements could not differentiate patients with mature or immature forearm fistulas [102].…”

Cumulative Patency of Contemporary Fistulas versus Grafts (2000–2010)

“…Surgeons in both programs share a common goal of creating fistulas as the initial access when possible (28); however, the clinical or radiologic evaluation of patient suitability for a fistula may vary by surgeon (29). Patient information is entered prospectively into a vascular access database that is managed by a multidisciplinary vascular access team that includes trained data-entry staff.…”