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PC98. Plication of Arteriovenous Access for Ischemic Steal Syndrome and Pathologic High Flow, Durable and Effective
JOURNAL OF VASCULAR SURGERY June Supplement 2015
144S Abstracts
Author Disclosures: T. M. Loh: Nothing to disclose; M. E. Bennett: Nothing to disclose; E. K. Peden: Up to date royalty, W. L. Gore; Bard, speakers bureau; W. L. Gore, Humacyte, consulting fee. PC100. Insurance Status and Vascular Access for Hemodialysis Jeffrey B. Edwards, Zachary B. Fang, Susan M. Shafii, Shipra Arya, Yazan Duwayri, Luke P. Brewster, Ravi K. Veeraswamy, Thomas F. Dodson, Ravi Rajani. Emory University, Atlanta, Ga
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Author Disclosures: M. M. Archie: Nothing to disclose; N. Nassiri: Nothing to disclose; H. Henning Eckstein: Nothing to disclose; P. F. Lawrence: Nothing to disclose. PC98. Plication of Arteriovenous Access for Ischemic Steal Syndrome and Pathologic High Flow, Durable and Effective Thomas M. Loh, Matthew E. Bennett, Eric K. Peden. Houston Methodist Hospital, Houston, Tex Objectives: Ischemic steal syndrome (ISS) and pathologic high flow (HF) are dreaded complications following hemodialysis access creation. Plication of inflow is a welldescribed technique for the treatment of ISS and HF. However, there are concerns about the procedure’s effectiveness and durability. We present the largest series to date of our experience with plication for ISS and HF. Methods: We retrospectively reviewed consecutive patients who underwent plication for ISS and HF from February 2008 to June 2014. Data collection included demographics, past medical histories, subsequent procedures, volume flows, access usage, and patient survival. Results: We performed 223 plications in 171 patients (83 women, 88 men). Indications for surgery were ISS in 83 and HF in 140. Twenty-eight percent had a prior surgical intervention for ISS or HF. Accesses were predominantly brachial based (83%). Assisted primary patency was 87% at 1 year and 69% at 3 years. Secondary patency was 90% at 1 year and 73% at 3 years. ISS resolution was reported as complete in 79% and partial in 16%. Use of a dilator/balloon for sizing resulted in a decrease in the rate of postoperative symptoms from 34% to 6% (P ¼ .002). Subsequent flow reduction was required for HF in 38 patients (27%) and ISS in eight patients (10%). Ultimately four accesses were ligated for continued steal. Postoperative flow reduction was considerably higher in the complete responders, 771 mL/min vs 481 mL/min (partial), e315 mL/min (no response). Conclusions: Plication is an effective procedure for management of ISS and shows good durability. Postoperative flow rates correlate with symptom resolution. Reoperation for ISS is significantly lower than previous reports. Use of a balloon or dilator is necessary for appropriate sizing of inflow limitation.
Objectives: Permanent arteriovenous (AV) access is the preferred modality of vascular access for hemodialysis (HD) due to its improved outcomes compared with other options. Current guidelines recommend that HD should be initiated via permanent access, but access to timely creation of permanent AV access is a challenge in some patient populations. Insurance status has been implicated as one potential barrier to achieving optimal access. Methods: Retrospective record review was performed for all patients who underwent first-time permanent AV access creation at an urban county hospital between July 2011 and June 2014. Data collected included standard demographics, insurance status and type, access creation, and follow-up data. Patients were grouped according to insurance status: any insurance (private, pre-existing Medicare or Medicaid) and no insurance. The primary outcomes were severity of kidney disease at presentation and total time from HD initiation to vascular access creation. Secondary outcome measures included successful initial access maturation and subsequent patency rates. Results: We identified 97 patients. Fifty (52%) were insured. There were no significant differences in comorbidities between the two groups, except insured patients were more likely to have HIV (4% vs 20%, P < .05) and to be smokers (17% vs 36%, P < .05). Fifty-four patients (56%) presented with end-stage renal disease (ESRD) as opposed to predialysis chronic kidney disease, and 24 (44%) of these were insured. Uninsured patients with ESRD spent significantly more time on HD prior to permanent access creation compared with their insured counterparts (351 days vs 54 days, P < .005). Successful maturation was achieved at similar rates in uninsured and insured patients (67% vs 63%, P ¼ .82), and Kaplan-Meier curves for subsequent patency showed no difference in primary patency at 3 and 6 months. Conclusions: Insurance status remains a barrier to achieving optimal vascular access for HD. Technical maturation and patency rates are similar regardless of insurance status, but uninsured patients are referred for access creation at significantly delayed intervals. Further efforts in health system improvement must focus on improving timely referral for permanent AV access in socioeconomically disadvantaged populations. Author Disclosures: J. B. Edwards: Nothing to disclose; Z. B. Fang: Nothing to disclose; S. M. Shafii: Nothing to disclose; S. Arya: Nothing to disclose; Y. Duwayri: Cook Medical, consulting fee; L. P. Brewster: Nothing to disclose; R. K. Veeraswamy: Cook Inc, Lombard Medical Inc, consulting fee; Medtronic Inc, contracted research; T. F. Dodson: Nothing to disclose; R. Rajani: Nothing to disclose.
144S Abstracts
Author Disclosures: T. M. Loh: Nothing to disclose; M. E. Bennett: Nothing to disclose; E. K. Peden: Up to date royalty, W. L. Gore; Bard, speakers bureau; W. L. Gore, Humacyte, consulting fee. PC100. Insurance Status and Vascular Access for Hemodialysis Jeffrey B. Edwards, Zachary B. Fang, Susan M. Shafii, Shipra Arya, Yazan Duwayri, Luke P. Brewster, Ravi K. Veeraswamy, Thomas F. Dodson, Ravi Rajani. Emory University, Atlanta, Ga
Fig.
Author Disclosures: M. M. Archie: Nothing to disclose; N. Nassiri: Nothing to disclose; H. Henning Eckstein: Nothing to disclose; P. F. Lawrence: Nothing to disclose. PC98. Plication of Arteriovenous Access for Ischemic Steal Syndrome and Pathologic High Flow, Durable and Effective Thomas M. Loh, Matthew E. Bennett, Eric K. Peden. Houston Methodist Hospital, Houston, Tex Objectives: Ischemic steal syndrome (ISS) and pathologic high flow (HF) are dreaded complications following hemodialysis access creation. Plication of inflow is a welldescribed technique for the treatment of ISS and HF. However, there are concerns about the procedure’s effectiveness and durability. We present the largest series to date of our experience with plication for ISS and HF. Methods: We retrospectively reviewed consecutive patients who underwent plication for ISS and HF from February 2008 to June 2014. Data collection included demographics, past medical histories, subsequent procedures, volume flows, access usage, and patient survival. Results: We performed 223 plications in 171 patients (83 women, 88 men). Indications for surgery were ISS in 83 and HF in 140. Twenty-eight percent had a prior surgical intervention for ISS or HF. Accesses were predominantly brachial based (83%). Assisted primary patency was 87% at 1 year and 69% at 3 years. Secondary patency was 90% at 1 year and 73% at 3 years. ISS resolution was reported as complete in 79% and partial in 16%. Use of a dilator/balloon for sizing resulted in a decrease in the rate of postoperative symptoms from 34% to 6% (P ¼ .002). Subsequent flow reduction was required for HF in 38 patients (27%) and ISS in eight patients (10%). Ultimately four accesses were ligated for continued steal. Postoperative flow reduction was considerably higher in the complete responders, 771 mL/min vs 481 mL/min (partial), e315 mL/min (no response). Conclusions: Plication is an effective procedure for management of ISS and shows good durability. Postoperative flow rates correlate with symptom resolution. Reoperation for ISS is significantly lower than previous reports. Use of a balloon or dilator is necessary for appropriate sizing of inflow limitation.
Objectives: Permanent arteriovenous (AV) access is the preferred modality of vascular access for hemodialysis (HD) due to its improved outcomes compared with other options. Current guidelines recommend that HD should be initiated via permanent access, but access to timely creation of permanent AV access is a challenge in some patient populations. Insurance status has been implicated as one potential barrier to achieving optimal access. Methods: Retrospective record review was performed for all patients who underwent first-time permanent AV access creation at an urban county hospital between July 2011 and June 2014. Data collected included standard demographics, insurance status and type, access creation, and follow-up data. Patients were grouped according to insurance status: any insurance (private, pre-existing Medicare or Medicaid) and no insurance. The primary outcomes were severity of kidney disease at presentation and total time from HD initiation to vascular access creation. Secondary outcome measures included successful initial access maturation and subsequent patency rates. Results: We identified 97 patients. Fifty (52%) were insured. There were no significant differences in comorbidities between the two groups, except insured patients were more likely to have HIV (4% vs 20%, P < .05) and to be smokers (17% vs 36%, P < .05). Fifty-four patients (56%) presented with end-stage renal disease (ESRD) as opposed to predialysis chronic kidney disease, and 24 (44%) of these were insured. Uninsured patients with ESRD spent significantly more time on HD prior to permanent access creation compared with their insured counterparts (351 days vs 54 days, P < .005). Successful maturation was achieved at similar rates in uninsured and insured patients (67% vs 63%, P ¼ .82), and Kaplan-Meier curves for subsequent patency showed no difference in primary patency at 3 and 6 months. Conclusions: Insurance status remains a barrier to achieving optimal vascular access for HD. Technical maturation and patency rates are similar regardless of insurance status, but uninsured patients are referred for access creation at significantly delayed intervals. Further efforts in health system improvement must focus on improving timely referral for permanent AV access in socioeconomically disadvantaged populations. Author Disclosures: J. B. Edwards: Nothing to disclose; Z. B. Fang: Nothing to disclose; S. M. Shafii: Nothing to disclose; S. Arya: Nothing to disclose; Y. Duwayri: Cook Medical, consulting fee; L. P. Brewster: Nothing to disclose; R. K. Veeraswamy: Cook Inc, Lombard Medical Inc, consulting fee; Medtronic Inc, contracted research; T. F. Dodson: Nothing to disclose; R. Rajani: Nothing to disclose.