Dialysis arteriovenous access monitoring and surveillance according to the 2017 Spanish Guidelines

The Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology (S.E.N.), vascular surgery (SEACV), interventional radiology (SERAM-SERVEI), infectious diseases (SEIMC), and nephrology nursing (SEDEN)), along with the methodological support of the Iberoamerican Cochrane Centre, has developed the Spanish Clinical Guidelines on Vascular Access for Hemodialysis. This article summarizes the main issues from the guideline’s chapter entitled “Monitoring and surveillance of arteriovenous access.” We will analyze the current evidence on conflicting topics such as the value of the flow-based screening methods for the arteriovenous access surveillance or the role of Doppler ultrasound as the imaging exploration to confirm suspected stenosis. In addition, the concept of significant stenosis and the criteria to perform the elective intervention for stenosis were reviewed. The adoption of these guidelines will hopefully translate into a reduced risk of thrombosis and increased patency rates for both arteriovenous fistulas and grafts.

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Role of Doppler ultrasonography in the evaluation of hemodialysis arteriovenous access maturation and influencing factors

The Journal of Vascular Access ◽

10.1177/1129729820965064 ◽

2021 ◽

pp. 112972982096506

Author(s):

Eva Chytilova ◽

Tamara Jemcov ◽

Jan Malik ◽

Jernej Pajek ◽

Branko Fila ◽

...

Keyword(s):

Vascular Access ◽

Doppler Ultrasonography ◽

Arteriovenous Graft ◽

Central Venous ◽

Preoperative Mapping ◽

High Incidence ◽

Arteriovenous Access ◽

Ultrasound Parameters ◽

Fistula Maturation

The goal of vascular access creation is to achieve a functioning arteriovenous fistula (AVF) or arteriovenous graft (AVG). An autologous fistula has been shown to be superior to AVG or to central venous catheters (CVCs) with lowest rate of re-intervention, but vessel obstruction or immaturity accounts for 20 % to 54% of cases with primary failure of AVF. This review is focused on the factors influencing maturation; indication and timing of preoperative mapping/creation of vascular access; ultrasound parameters for creation AVF/AVG; early postoperative complications following creation of a vascular access; ultrasound determinants of fistula maturation and endovascular intervention in vascular access with maturation failure. However, vascular accesses that fail to develop, have a high incidence of correctable abnormalities, and these need to be promptly recognized by ultrasonography and managed effectively if a high success rate is to be expected. We review approaches to promoting fistula maturation and duplex ultrasonography (DUS) of evaluating vascular access maturation.

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Arteriovenous fistulas for hemodialysis: Brief review and current problems

The Journal of Vascular Access ◽

10.1177/11297298211007720 ◽

2021 ◽

pp. 112972982110077

Author(s):

John J Manov ◽

Prasoon P Mohan ◽

Roberto Vazquez-Padron

Keyword(s):

Renal Disease ◽

Arteriovenous Fistula ◽

Vascular Access ◽

End Stage Renal Disease ◽

State Of The Art ◽

Arteriovenous Fistulas ◽

Number Of Patients ◽

Stage Renal Disease ◽

End Stage

The number of people worldwide living with end-stage renal disease is increasing. Arteriovenous fistulas are the preferred method of vascular access in patients who will require hemodialysis. As the number of patients with arteriovenous fistulas grows, the role of physicians who intervene who maintain and salvage these fistulas will grow in importance. This review aims to familiarize practitioners with the rationale for arteriovenous fistula creation, the detection of fistula dysfunction, and the state of the art on fistula maintenance and preservation. Current controversies are briefly reviewed.

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The Role of Doppler Ultrassonography in Significant and Borderline Stenosis Definition

Blood Purification ◽

10.1159/000488442 ◽

2018 ◽

Vol 46 (2) ◽

pp. 94-102

Author(s):

Ana Castro ◽

Carla Moreira ◽

Paulo Almeida ◽

Norton de Matos ◽

Luís Loureiro ◽

...

Keyword(s):

Clinical Monitoring ◽

Feeding Artery ◽

Cumulative Survival ◽

Significant Stenosis ◽

Arteriovenous Fistulas ◽

Luminal Stenosis ◽

Definition Of ◽

Thrombosis Rate

Background: The definition of significant stenosis (SS) remains controversial. Methods: We retrospectively reviewed 1,040 consultations. SS was defined in the presence of clinical and echo-Doppler (DDU) criteria: Qa <500 mL/min or Qa decrease >25%; RI >0.7 in the feeding artery or absolute minimal luminal stenosis diameter <2.0 mm. Stenosis without any additional criteria were considered borderline stenosis (BS). Results: Two hundred twenty-one arteriovenous fistulas (AVFs) were included: 58.8% had SS, 18.6% had BS, and 22.6% had no dysfunctional access (ND). SS had a significantly higher thrombotic events than BS and ND (13.1 vs. 4.4%, p = 0.018). The annual thrombosis rate was 0.007, 0.037, and 0.004 in the ND, SS, and BS, respectively. AVF cumulative survival at 5 years was significantly lower in SS (89.5%) compared to BS (100%) and ND (97.4%; p = 0.03). BS had an HR for AVF failure of 1.1, p = 0.955, while the SS presented an HR of 5.9, p = 0.09. Conclusion: AVF clinical monitoring with additional DDU criteria appear to be appropriate for therapeutic referral.

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Drug-Coated Balloon for Arteriovenous Access Stenosis in Hemodialysis Patients

Kidney and Dialysis ◽

10.3390/kidneydial1010004 ◽

2021 ◽

Vol 1 (1) ◽

pp. 20-28

Author(s):

Hyangkyoung Kim

Keyword(s):

Neointimal Hyperplasia ◽

Transluminal Angioplasty ◽

Current Evidence ◽

Dialysis Access ◽

Muscle Injuries ◽

Arteriovenous Access ◽

Effective Use ◽

Flow Circuit ◽

Drug Coated Balloon

Hemodialysis access stenosis is a pervasive problem that occurs due to the physiology of the high-flow circuit. Stenosis occurs due to endothelial and smooth muscle injuries that result in neointimal hyperplasia. Percutaneous transluminal angioplasty is the standard treatment for dialysis access-induced stenosis. Unfortunately, it is also associated with vessel wall trauma, which causes further intimal hyperplasia and restenosis. Data from randomized controlled trials (RCTs) and systematic reviews of the use of drug-coated balloons (DCBs) for dialysis access stenosis have been controversial. While several single-center trials or RCTs have reported safe and effective use of DCBs, conflicting results still exist. Furthermore, paclitaxel is known to be associated with an increased mortality risk. Herein, we review the current evidence on the role of DCBs in the treatment of dialysis access stenosis.

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A systematic follow-up protocol achieving a low hemodialysis graft thrombosis rate

The Journal of Vascular Access ◽

10.1177/1129729819838795 ◽

2019 ◽

Vol 20 (6) ◽

pp. 683-690

Author(s):

Pilar Caro Acevedo ◽

Rosa Marchante ◽

Israel J Thuissard ◽

David Sanz-Rosa ◽

Raquel Amann ◽

...

Keyword(s):

Early Diagnosis ◽

Vascular Access ◽

Venous Pressure ◽

Graft Patency ◽

Secondary Patency ◽

Graft Thrombosis ◽

Significant Stenosis ◽

Monitoring And Surveillance ◽

Thrombosis Rate

Introduction: Graft is an alternative to native arteriovenous fistula to ensure permanent vascular access in hemodialysis patients. The most common complication is significant stenosis, which frequently causes thrombosis and graft loss. Periodic monitoring and surveillance with elective correction of stenotic lesions can prolong graft survival. Objective: To describe the effect of early diagnosis of significant stenosis on the rate of thrombosis and graft patency. Methods: Retrospective, observational study of a cohort of 86 prevalent patients undergoing hemodialysis with a graft as their vascular access. We applied a systematic follow-up protocol of 115 grafts based on various screening methods of monitoring (clinical monitoring, pre-pump arterial pressure, dynamic venous pressure, percentage of recirculation, and dose of dialysis) in conjunction with surveillance (normalized intra-access venous pressure and access flow). The annual rates of thrombosis, and primary, primary-assisted, and secondary patency were assessed. Results: The incidence of significant stenosis and thrombosis was 57.4% (65/115) and 39.0% (45/115), respectively. Of all screening procedures, normalized intra-access venous pressure was the best predictor of significant stenosis (hazards ratio, 7.71; 95% confidence interval, 3.06–19.46). The annual rate of thrombosis fluctuated from 0 to 0.26 thromboses/patient/year, with an average rate of 0.14 thromboses/patient/year. Primary, primary-assisted, and secondary patency were 74%/79%/82%, 50%/60%/66%, and 23%/35%/37% at 1, 2, and 5 years, respectively. Conclusion: The implementation of a systematic graft follow-up protocol combined with monitoring and surveillance enabled early diagnosis and elective correction of significant stenosis, prolonged graft patency, and a low thrombosis rate.

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Role of Hypoxia and Metabolism in the Development of Neointimal Hyperplasia in Arteriovenous Fistulas

International Journal of Molecular Sciences ◽

10.3390/ijms20215387 ◽

2019 ◽

Vol 20 (21) ◽

pp. 5387 ◽

Cited By ~ 1

Author(s):

Nirvana Sadaghianloo ◽

Julie Contenti ◽

Alan Dardik ◽

Nathalie M. Mazure

Keyword(s):

Vascular Access ◽

Neointimal Hyperplasia ◽

Vasa Vasorum ◽

Wall Thickening ◽

Arteriovenous Fistulas ◽

Flow Parameters ◽

Stage Renal Disease ◽

End Stage ◽

Venous Wall

For patients with end-stage renal disease requiring hemodialysis, their vascular access is both their lifeline and their Achilles heel. Despite being recommended as primary vascular access, the arteriovenous fistula (AVF) shows sub-optimal results, with about 50% of patients needing a revision during the year following creation. After the AVF is created, the venous wall must adapt to new environment. While hemodynamic changes are responsible for the adaptation of the extracellular matrix and activation of the endothelium, surgical dissection and mobilization of the vein disrupt the vasa vasorum, causing wall ischemia and oxidative stress. As a consequence, migration and proliferation of vascular cells participate in venous wall thickening by a mechanism of neointimal hyperplasia (NH). When aggressive, NH causes stenosis and AVF dysfunction. In this review we show how hypoxia, metabolism, and flow parameters are intricate mechanisms responsible for the development of NH and stenosis during AVF maturation.

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Buttonhole Cannulation of Arteriovenous Fistulas in the United States

Kidney360 ◽

10.34067/kid.0000052020 ◽

2020 ◽

Vol 1 (4) ◽

pp. 306-313 ◽

Cited By ~ 1

Author(s):

Tushar J. Vachharajani ◽

Leslie Wong ◽

Vandana D. Niyyar ◽

Kenneth D. Abreo ◽

Michele H. Mokrzycki

Keyword(s):

United States ◽

Vascular Access ◽

The United States ◽

Current Evidence ◽

Maintenance Hemodialysis ◽

Arteriovenous Fistulas ◽

Randomized Controlled Studies ◽

Hemodialysis Vascular Access ◽

Increased Risk ◽

Cannulation Technique

The cannulation technique of a hemodialysis vascular access has remained controversial with differing viewpoints. The quality of dialysis, overall patient safety, and individual dialysis experience often dictate the type of cannulation technique used in clinical practice. The three commonly used techniques to access a hemodialysis vascular access are the rope ladder, area, and buttonhole. Although the buttonhole technique has been around since the mid-1970s, the dialysis community remains divided on its suitability for routine use to provide maintenance hemodialysis therapy. The proponents of this technique value the ease of cannulation with less pain and discomfort whereas the opponents highlight the increased risk of infection. The actual clinical evidence from the United States is limited and remains inconclusive. The current review provides an overview of the available experience from the United States, highlighting the correct technique of creating a buttonhole, summarizing the current evidence, and recommending a need for larger randomized controlled studies in both in-center and home hemodialysis populations.

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The Emerging Role of Coronary CT in Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS)

Indonesian Journal of Cardiology ◽

10.30701/ijc.1132 ◽

2021 ◽

Vol 42 (2) ◽

Author(s):

Jimmy Oi Santoso ◽

Nurnajmia Curie Proklamartina ◽

Roy Christian

Keyword(s):

Acute Coronary Syndrome ◽

Clinical Practice ◽

Current Evidence ◽

Significant Stenosis ◽

Coronary Syndrome ◽

Non Invasive ◽

Coronary Ct ◽

St Elevation ◽

Rule Out

NSTEACS is subset of ACS that may present with a wide degree of stenosis from normal vessels to severe obstruction. Identification of which population of NSTEACS that has normal vessels has attracted a great attention. Several trials on non-invasive imaging such as coronary CT have been largely investigated. Current available trials have showed that coronary CT is accurately identify significant stenosis in patients with NSTEACS thus can be used to rule out the disease and reduce the need and duration of unneeded antithrombotic. However, several limitations of the studies has to be taken into account when translating into clinical practice. Nevertheless, current evidence are showing promising results on the role of coronary CT in management of NSTEACS.

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