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Vascular access should be tailored to the patient
Author’s Accepted Manuscript Vascular access should be tailored to the patient Krzysztof Letachowicz, Przemysław Szyber, Tomasz Gołębiowski, Mariusz Kusztal, Waldemar Letachowicz, Wacław Weyde, Jerzy Garcarek, Marian Klinger www.elsevier.com/locate/enganabound
PII: DOI: Reference:
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To appear in: Seminars in Vascular Surgery Cite this article as: Krzysztof Letachowicz, Przemysław Szyber, Tomasz Gołębiowski, Mariusz Kusztal, Waldemar Letachowicz, Wacław Weyde, Jerzy Garcarek and Marian Klinger, Vascular access should be tailored to the patient, Seminars in Vascular Surgery, http://dx.doi.org/10.1053/j.semvascsurg.2016.11.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Seminars in Vascular Surgery Dialysis Access Issue
Vascular access should be tailored to the patient Krzysztof Letachowicz1, Przemysław Szyber2, Tomasz Gołębiowski1, Mariusz Kusztal1, Waldemar Letachowicz1, Wacław Weyde1, Jerzy Garcarek3, Marian Klinger1 1
Department of Nephrology and Transplantation Medicine, Wroclaw Medical University,
Borowska 213, 50-556 Wroclaw, Poland 2
Department of Vascular, General and Transplantation Surgery, Wroclaw Medical
University, Borowska 213, 50-556 Wroclaw, Poland 3
Department of Radiology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw,
Poland
Corresponding author: Krzysztof Letachowicz Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland Tel. +48 717332546 Fax. +48 717332509 E-mail: [email protected]
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Abstract A cornerstone of hemodialysis treatment is the creation of a functional and durable dialysis vascular access. Every patient with chronic kidney disease should have a plan of renal replacement therapy and access site protection. Factors having a crucial impact on vascular access selection include age, comorbidity, vessel quality, prognosis, dialysis urgency and surgeon’s preferences. Our medical group have reviewed these factors in our patients and based on recently published data developed a clinical decision tree for dialysis access in the chronic kidney disease (CKD) patient. Vascular access care should be patient-centered with the aim to maximize patient survival without loss of vascular access options; and not focused only the primary patency rates of dialysis access procedures.
Key words: arteriovenous fistula, vascular access, hemodialysis
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Introduction The rules of vascular access care are well described, but trends in vascular access use are disadvantageous. Patients with diagnosed chronic kidney disease (CKD) should be educated on all renal replacement therapy (RRT) options, including transplantation (1). The protection of vessels is crucial and must be considered when accessing veins and arteries regardless of the stage of CKD (2). Patients who prefer hemodialysis should be referred for vascular access creation when they reach stage 4 of CKD (2). Timely creation of an arteriovenous fistula (AVF) allows dialysis to be started with a functioning vascular access. Placement of an arteriovenous graft (AVG) should be postponed to reduce the number of repeated interventions before dialysis initiation (3). The decision on the type of created vascular access should be preceded by careful history taking, physical examination and imaging (1-3). The aims are: AVF in more than 65% of patients, thrombosis rate below 0.25 per patient per year, and a tunneled catheter as a permanent vascular access in less than 10% of patients (1). Recent European registry data have shown that the incidence of AVF at dialysis initiation was reduced and the proportion of catheter-dependent patients was increased (4). Changes in dialysis reimbursement in the United States resulted in an increase of AVFs and a reduction of catheter dependency among prevalent hemodialysis patients. However, still 70% of patients initiated dialysis with catheters (5). The results from the Dialysis Outcomes and Practice Patterns Study showed that it is possible to reduce the ratio of catheters on dialysis initiation if time to access creation is short or AVFs are used earlier (6). Creation of vascular access needs multistep approach and will be considered in this review. Vascular access options and complications It is important to provide an access sequence to support the patient through the entire renal failure life. About 10 options are possible on every upper extremity, excluding AVGs (7). In
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the planning of AVF creation and increasing the success of AVF procedures, it is necessary to take into consideration the possible vascular variations of the forearm and upper arm (8, 9). A few AVG options are also available, with priority of forearm grafts (10). AVGs are produced from various materials, not only synthetic, but also biological (11). Lower extremities offer some options with acceptable survival rates (12, 13). Avoidance of femoral vein puncturing should reduce the risk of future outflow stenosis (14). Recently, tissue-engineered vascular grafts built from allogeneic fibroblasts were used for vascular access creation (15). In single-arm phase 2 trials primary patency of bioengineered human acellular vessels for dialysis was 28 % at 12 months. Interventions to maintain or restore patency were done at a rate of 1.89 per patient-year despite blood flows exceeding 1 L/min and use of acetylsalicylic acid. Secondary patency at 12 months was 89 %. What is notice worthy there was no evidence of systemic immune or inflammatory response (16). The Hemodialysis Reliable Outflow graft (HeRO®; CryoLife, Kennesaw,GA) is a novel vascular access option that is ideally suited for catheter-dependent patients and those in whom previously functional fistulas and grafts have failed as a result of venous outflow stenosis and/or occlusions (17). In the case of exhaustion of standard access sites, translumbar catheters (18) could be used. Another option for patients with vascular access problems is peritoneal dialysis (19). Nevertheless, in such a situation priority kidney transplantation provides the best outcome (20). If the necessity of catheter usage cannot be avoided, less popular solutions, e.g. a citrate-filled temporary catheter (21) or single lumen tunneled catheters (22), should be kept in mind. In selected cases arterial access could be a valuable possibility (23-26). The major benefit of broad use of AVF is reduction of the risk of bacteremia (27). Although in recent years catheter design and care have improved (28, 29), catheter-related bacteremia occurred with incidence of 0.45/1000 catheter days for gentamicin and citrate lock and 1.68/1000 catheter days for heparin lock (30). The second
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important complication is central vein stenosis (31). In patients with AVF the risk of infection is much lower compared to AVG and especially to catheters (27). However, the price is risk of primary failure (32), hyper-flow access (33), and access-induced distal ischemia (34). A recent meta-analysis showed a primary failure rate of 23%. The primary patency rate was 60% at 1 year and 51% at 2 years. The secondary patency rate was 71% at 1 year and 64% at 2 years (35). A more proximal location of AVF may decrease the nonmaturation rate (36-41), but potentially deleterious effects on cardiac functions particularly in the setting of preexisting heart disease (42) are not always considered by physicians creating a vascular access. In a prospective study conducted by Basile et al., 96 patients bearing an AVF were evaluated and had the vascular access flow and cardiac output measured. The flow of the lower arm AVFs was significantly smaller, and upper arm AVFs were associated with an increased risk of high-output cardiac failure (43). It was even found that patients with cubital AVFs have poorer survival compared to the group with distal AVF (44). Another complication of vascular access manifested as a cold hand was found in 50% of patients with brachiocephalic AVF, in 25% of patients with prosthetic forearm loops and in 12% of radiocephalic AVFs. The risk of ischemia was higher in diabetics (45). It is advised to monitor high-risk patients and individuals with upper arm AVF for adverse hemodynamic consequences (46). Factors affecting vascular access formation Vascular access choice should take into consideration characteristics of the patient. The interaction between factors, patient and practice affecting AVF patency is very complex and needs to be carefully considered on AVF planning and follow-up (47). The major disadvantage of AVF is the necessity of maturation. There is no agreement whether earlier puncture has a negative impact on access survival (48, 49). However, if possible AVF use should be postponed for about 6 weeks (2). In some circumstances, avoidance of catheter use
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is a priority and AVF could be punctured earlier. Use of plastic needles allows for safe puncturing and dialysis performance in individuals with a low comorbidity burden and high quality vessels (50). An AVG does not need maturation, so it allows for cannulation after swelling resolution. New materials have been implemented for AVG construction, which allows for earlier usage. New, early-cannulation AVGs have similar patency and complication rates as standard grafts (51). If dialysis could be postponed up to a few days, catheter use should be avoided and early arteriovenous access use should be considered. But if RRT has to be started immediately, in majority of cases there is no alternative to catheters. It concerns especially the patients with highest comorbidity burden. It was found that in a specific group, patients over 75 years old with high comorbidity, the survival advantage from dialysis compared to conservative management is likely to be small (52). In these patients more efforts should be made to improve quality of life and postpone dialysis initiation. If a decision to initiate dialysis has been made, a vascular access which allows for an uneventful course should be placed. The optimal access choice is modified by the likelihood of successful fistula placement, procedure-related and subsequent costs, and patient survival. Vessel quality and patient prognosis should equally contribute to the decision. In patients who initiated RRT with a catheter, individual patient characteristics need consideration. Placement of the AVF, creation of an AVG or continuation with the catheter had similar outcomes in women with diabetes and elderly men with diabetes (53). In patients with uncertain prognosis, who need to start dialysis soon, a tunneled catheter could be the optimal vascular access. But after a few weeks of dialysis the decision on AVF or AVG creation should be reconsidered. Age, comorbidity, gender, vessel quality, patient and surgeon’s preferences are factors having an impact on access selection and outcome. Aging of the general and dialysis population is progressive. It is related to comorbidity and frailty. On the other hand, more
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healthy octogenarians are also found. It is suggested that vessel quality, not age, should be the determinant of access choice (54). Our experience showed that autogenous AVF could be successfully performed in the majority of elderly patients with acceptable access outcome. What is important, most AVFs were placed on the forearm (55, 56). In patients over 75 years primary patency was 70 +/- 4.7% at 6 months and 58 +/- 4.9% at 5 years (55). Age was also included in both recent scores for AVF outcome prediction (57, 58). Creation of AVF was recommended in all patients from 18 to 48 years whenever possible (59). On the other hand, in pediatric patients, who are transplanted after a few months of hemodialysis, placement of a tunneled catheter started to be preferred over AVF creation (60). Whether a similar approach in adult patients who are candidates for urgent transplantation (e.g. preemptive transplantation or living donation) would be beneficial is a matter of debate. Nevertheless, in younger patients the principle “saving proximal vessels” should be superior to “primary patency and high flow”. There are data suggesting that vascular access patency is inferior in women compared to men. Women were less likely to use AVF within the first year of dialysis compared to men. Also catheters were used more commonly in women on chronic hemodialysis. Female sex was mentioned as a risk factor for access complication, non-maturation and steal syndrome (61). Prediction score for snuffbox AVF included female sex as a risk factor of thrombosis (57). Although the radial artery diameter was smaller in women than in men, it was not the only factor determining fistula maturation (62). Recently, a decision analysis evaluating vascular access strategies for patients initiating hemodialysis with a central venous catheter was performed. Access patency modified by age, sex, and diabetes, access-specific mortality and costs were included in the decision model. An AVF placement strategy was superior to AVG creation and maintaining the catheter in regard to mortality and cost for the majority of patient characteristics. However, among women with diabetes (also elderly men with
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diabetes) the AVF attempt strategy was not beneficial. It was associated with lower AVF patency and lower life expectancy (53). These findings should be considered in access planning. The impact of concomitant diseases is complex. The arterial wall is affected by atherosclerosis, which is more pronounced in diabetics. Diabetes mellitus is a well-described factor of poorer AVF survival and is related to vascular access complications. Because arterial dilatation after AVF creation is affected, many authors recommend more proximal anastomosis (63). Obesity is not an obstacle for AVF formation; it may even protect forearm venous vessels from cannulation before the onset of hemodialysis therapy (64). However, in the majority of patients superficialization of the venous part of the fistula under the skin is needed for easy and uncomplicated access puncture (65). The alternative is the Venous Window Needle Guide (VWING; Vital Access Corp, Salt Lake City, Utah), surgically implanted titanium device. It was designed to facilitate cannulation of excessive depth located AVFs (66). Presence of peripheral arterial occlusive disease has a negative impact on AVF patency. Diabetes, ischemic heart disease (57) and atherosclerosis in arteries of legs (59) were included in the scoring system predicting AVF outcome. Moreover, the radial artery is commonly used as a route for coronary intervention. Its use could have an impact on the possibility of AVF creation (67). Puncture of the radial artery should be avoided in CKD, or, if necessary, one side should be exploited. It is quite common that the left subclavian vein is used as a route for a pacemaker, and the right radial artery is an entry for coronary intervention. We suppose that in CKD patients cardiac devices should be placed, if possible, after evaluation for future vascular access. Moreover, the vasculature, arteries and veins of the extremity opposite to the site of wire placement should not be punctured. Broad introduction of a subcutaneous implantable cardioverter defibrillator (ICD) could be the best option for CKD patients. This approach might offer the advantage of reduced risk of central
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venous stenosis and infection over an endocardial ICD with transvenous leads (68). Finally, patients with a high comorbidity burden are at risk of hospitalization and venipuncture and unnecessary intravenous catheters, which could result in thrombophlebitis (69). The effect of AVF creation on the cardiovascular system has been reviewed (42, 46). It was found that creation of an AVF induced left ventricle diastolic dysfunction toward a restrictive filling pattern (70). In patients with coronary artery grafting with internal thoracic artery ipsilateral location of the AVF, more cardiac events were found (71). Moreover, creation of an AVF reduced the subendocardial viability ratio, which predicted a worse clinical outcome (72). Although high flow rates (>1500 mL/min) were not associated with increased risk of death (73), creation of AVFs with blood flows predicting occurrence of high-output cardiac failure (43) should be avoided. As mentioned above, comorbidities have a huge impact on the vasculature, especially on the arterial wall. Presence of macro- or microcalcification reduces the patency of a surgically created AVF (74). Many studies have focused on arterial diameter as a predictor of access maturation (2). Other studies have shown acceptable outcome of AVFs feeding from small caliber radial arteries (75). So, if the radial artery diameter is the only unfavorable factor, we suggest distal AVF instead of upper arm AVF as a first choice. Moreover, ligation, if practiced, of distally located AVFs after kidney transplantation is less deleterious for the vasculature. The vein diameter and distension ability are the second most important factors of AVF maturation. If larger veins are used, the risk of thrombosis is reduced (76). Avoidance of puncturing veins of the elbow and forearm in CKD patients is a cornerstone for vascular access perspectives. Veins of the elbow have a relatively large diameter and are immobile. So, they could be punctured cautiously even a few days after AVF creation (50). Ultrasound assessment, called mapping, is recommended before vascular access surgery (2). However, there is no accordance whether ultrasound mapping gives any benefit compared to clinical
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judgment (77-79). In lean patients superficial veins are well seen and palpable, and ultrasound gives no benefit for access selection. Vascular access is created not only by surgeons but also by dedicated nephrologists (80). It is remarkable that huge differences in access location exist. The group from Swansea creates around 280 fistulas yearly, 70–75% of which are radial fistulas. About 25% of all fistulas are located at the snuffbox (57). In a study by Ravani et al., 420 of 513 AVFs (81.9%) were located distally (48). On the other hand, in a study by Lok et al., radiocephalic fistulas were created in 52.2% of incident first-time AVF patients (81). Increasing brachiocephalic AVF creation (from 38 to 56%) and reducing reliance on radiocephalic AVFs (36 to 27%) resulted in a significant increase in primary functional patency (36). However, the benefits of proximal location of vascular access could be transient and result in exhaustion of access options. In such circumstances thigh AVGs were placed. In a report by Ponikvar it was done in patients in whom the dialysis vintage was 11.9 ± 7.3 years and the mean number of previous vascular accesses was 4.4 ± 1.9 (12). In the study of Miller et al. thigh AVGs were created in patients who were on dialysis for 4.5 ± 4.9 years and underwent 2.3 ± 1.4 previous vascular access procedures (13). Although the two groups cannot be easily compared, the differences in time and number of procedures to exhaust the upper extremity are clearly apparent. It could reflect a different attitude to vascular access placement. Time for access creation varies worldwide. Shorter waiting times are reported in countries with the highest prevalence of AVF (6). Referral delays are minimized if nephrologists are involved in vascular access creation and care, as practiced in our center. The proportion of AVF use refusal is also not homogeneous (82). The awareness of kidney disease is not a guarantee of AVF placement. In patients with kidney transplant failure, despite their being younger and healthier compared to the overall hemodialysis population, the arteriovenous access creation rate was low. The access was created only in 16% of patients within the 12
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months before dialysis and in 47% of patients during the 24 months after dialysis (83). Previously, we reported that AVF was successfully reconstructed in 73% of patients with a failing transplanted kidney (84). Our strategy of vascular access creation Creation of a durable and safe vascular access requires a multifocal approach. Often the cooperation of many specialists is needed. Our center, Department of Nephrology and Transplantation Medicine of Wroclaw Medical University, is engaged in creation and maintaining of vascular access for decades (85, 86). Every year we perform more than 200 AVFs and insert about 200 catheters. We consult a cohort of more than 500 patients in case of vascular access problems. Four nephrologists are able to perform broad spectrum of autogenous vascular access procedures on upper extremity. Most of decisions are based on physical examination, but Doppler ultrasound is used to confirm and document the findings. The snuffbox AVF is the first choice, especially in young patients without comorbidities (87). If the vessels are not appropriate, a more proximal option on the forearm is chosen. In cases of destruction of forearm and elbow vessels, use of the forearm basilic vein could be a good alternative for AVF construction (88). Most AVFs are created on a non-dominant extremity, but with priority of vessel condition. Even in the case of atherosclerosis we prefer AVFs originating from the radial artery, because it reduces the risk of negative cardiovascular consequences, distal ischemia and high-flow access. Out of 200 AVFs created every year, no more than 5% originate from the brachial artery. For autogenous brachiobasilic fistula creation we used the modified technique with primary patency of 74% at one year (89). Our observation showed that upper-arm vascular access, including modified Gracz AVF originating from the radial artery, was limited to 11.7% of dialysis patients (90). We do not use minimal vessel diameters for access selection. In patients with narrow vessels we try to perform AVF as distal as possible. If access is not feasible for dialysis then more proximal
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anastomosis, using dilated artery and vein, is done within 4-6 weeks. If arterial and vein conditions are not sufficient for AVF creation, other RRT modalities are considered. In younger patients renal transplantation priority is given. In patients who are not candidates for transplantation, optimal conservative management is offered and tunneled catheters are placed if needed. We are also looking after 80 hemodialysis patients. The majority of our patients have AVF located on forearm. We do not use any surveillance protocol, but monitor AVF function by detailed physical examination that cannot be substituted by any of available diagnostic tools. Doppler ultrasound is used to confirm the findings. For perianastomotic stenosis, the most common in forearm AVF, we prefer more proximal anastomosis as the most efficient solution. The outflow stenoses are treated by devoted radiologist. Complicated cases are solved in cooperation with vascular surgeon. On evaluation of patients referred for vascular access creation or initiating hemodialysis in unplanned manner we try to follow an algorithm (Figure 1). The necessity of RRT is verified and risk of vascular access dysfunction is stratified. Answering few basic questions after detailed assessment makes vascular access choices much easier. Recent Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis updated by the Japanese Society for Dialysis Therapy recommend very careful patient education by a nephrologist and vascular access expert, early referral and planning. Distal location, wrist or snuffbox AVF, is advised. Moreover, the impact on peripheral circulation and cardiac function is included in the decision model. Physical examination is fundamental for vasculature assessment, and ultrasound is recommended for doubtful cases. It is stated that the arterial diameter should be at least 1.5 mm, and a lower success rate is achieved with smaller arteries. However, arterial diameter is only one indicator for a successful AVF, and other factors should be included in
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the consideration. Following the guidelines resulted in arteriovenous access in 96.8% of hemodialysis patients (26).
Conclusions Vascular access care has to be patient centered. Our aim should not be primary patency of vascular access, but the longest patient survival without loss of vascular access options. The cornerstone is vessel saving through all stages of chronic kidney disease, especially in younger patients. In older individuals we should focus on effectiveness and the lowest complication rate. An individualized attitude and stepwise attempts on the forearm are factors protecting against exhaustion of vascular access options.
Conflicts of interest: none This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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39. Bhalodia R, Allon M, Hawxby AM, Maya ID. Comparison of radiocephalic fistulas placed in the proximal forearm and in the wrist. Semin Dial. 2011; 24(3):355-357. 40. Palmes D, Kebschull L, Schaefer RM, Pelster F, Konner K. Perforating vein fistula is superior to forearm fistula in elderly haemodialysis patients with diabetes and arterial hypertension. Nephrol Dial Transplant. 2011; 26(10):3309-3314. 41. Sultan S, Hynes N, Hamada N, Tawfick W. Patients on hemodialysis are better served by a proximal arteriovenous fistula for long-term venous access. Vasc Endovasc Surg. 2012; 46(8):624-634. 42. Alkhouli M, Sandhu P, Boobes K, Hatahet K, Raza F, Boobes Y. Cardiac complications of arteriovenous fistulas in patients with end-stage renal disease. Nefrologia. 2015;35(3):234-245. 43. Basile C, Lomonte C, Vernaglione L, Casucci F, Antonelli M, Losurdo N. The relationship between the flow of arteriovenous fistula and cardiac output in haemodialysis patients. Nephrol Dial Transplant. 2008;23(1):282-287. 44. Stolic RV, Trajkovic GZ, Krstic NJ, Stolic DZ, Subaric-Gorgieva G. Correlation of mortality and location of arteriovenous fistula in hemodialysis patients. Int J Artif Organs. 2011;34(1):26-33. 45. van Hoek F, Scheltinga MR, Kouwenberg I, Moret KE, Beerenhout CH, Tordoir JH. Steal in hemodialysis patients depends on type of vascular access. Eur J Vasc Endovasc Surg. 2006;32(6):710-717. 46. Agarwal AK. Systemic effects of hemodialysis access. Adv Chronic Kidney Dis. 2015;22(6):459-465. 47. Smith GE, Gohil R, Chetter IC. Factors affecting the patency of arteriovenous fistulas for dialysis access. J Vasc Surg. 2012;55(3):849-855.
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48. Ravani P, Brunori G, Mandolfo S, et al. Cardiovascular comorbidity and late referral impact arteriovenous fistula survival: a prospective multicenter study. J Am Soc Nephrol. 2004;15(1):204-209. 49. Saran R, Dykstra DM, Pisoni RL et al. Timing of first cannulation and vascular access failure in haemodialysis: an analysis of practice patterns at dialysis facilities in the DOPPS. Nephrol Dial Transplant. 2004;19(9):2334-2340. 50. Letachowicz K, Kusztal M, Gołębiowski T, Letachowicz W, Weyde W, Klinger M. Use of plastic needles for early arteriovenous fistula cannulation. Blood Purif. 2015;40(2):155-159. 51. Glickman MH, Burgess J, Cull D, Roy-Chaudhury P, Schanzer H. Prospective multicenter study with a 1-year analysis of a new vascular graft used for early cannulation in patients undergoing hemodialysis. J Vasc Surg. 2015;62(2):434-441. 52. Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011;26(5):1608-1614. 53. Drew DA, Lok CE, Cohen JT, Wagner M, Tangri N, Weiner DE. Vascular access choice in incident hemodialysis patients: a decision analysis. J Am Soc Nephrol. 2015; 26(1):183-191. 54. Olsha O, Hijazi J, Goldin I, Shemesh D. Vascular access in hemodialysis patients older than 80 years. J Vasc Surg. 2015;61(1):177-183. 55. Weyde W, Letachowicz W, Kusztal M, Porazko T, Krajewska M, Klinger M. Outcome of autogenous fistula construction in hemodialyzed patients over 75 years of age. Blood Purif. 2006;24(2):190-195.
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56. Watorek E, Golebiowski T, Kusztal M, et al. Creation of arteriovenous fistulae for hemodialysis in octogenarians. Hemodial Int. 2014;18(1):113-117. 57. Twine CP, Haidermota M, Woolgar JD, Gibbons CP, Davies CG. A scoring system (DISTAL) for predicting failure of snuffbox arteriovenous fistulas. Eur J Vasc Endovasc Surg. 2012;44(1):88-91. 58. Bosanquet DC, Rubasingham J, Imam M, Woolgar JD, Davies CG. Predicting outcomes in native AV forearm radio-cephalic fistulae; the CAVeA2T2 scoring system. J Vasc Access. 2015;16(1):19-25. 59. Hicks CW, Canner JK, Arhuidese I, et al. Mortality benefits of different hemodialysis access types are age dependent. J Vasc Surg. 2015;61(2):449-456. 60. Merouani A, Lallier M, Paquet J, Gagnon J, Lapeyraque AL. Vascular access for chronic hemodialysis in children: arteriovenous fistula or central venous catheter? Pediatr Nephrol. 2014;29(12):2395-2401. 61. Pounds LL, Teodorescu VJ. Chronic kidney disease and dialysis access in women. J Vasc Surg. 2013;57(4 Suppl):49S-53S.e1 62. Peterson WJ, Barker J, Allon M. Disparities in fistula maturation persist despite preoperative vascular mapping. Clin J Am Soc Nephrol. 2008;3(2):437-441. 63. Georgiadis GS, Georgakarakos EI, Antoniou GA, et al. Correlation of pre-existing radial artery macrocalcifications with late patency of primary radiocephalic fistulas in diabetic hemodialysis patients. J Vasc Surg. 2014;60(2):462-470. 64. Weyde W, Krajewska M, Letachowicz W, et al. Obesity is not an obstacle for successful autogenous arteriovenous fistula creation in haemodialysis. Nephrol Dial Transplant. 2008;23(4):1318-1322.
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65. Weyde W, Krajewska M, Letachowicz W, Klinger M. Superficialization of the wrist native arteriovenous fistula for effective hemodialysis vascular access construction. Kidney Int. 2002;61(3):1170-1173. 66. Galt S, Crawford M, Blebea J, Ladenheim E, Browne B. The efficacy and durability of the Venous Window Needle Guide implanted on uncannulatable arteriovenous fistulas. J Vasc Surg. 2016 May 27. pii: S0741-5214(16)30007-6. doi: 10.1016/j.jvs.2016.03.425. [Epub ahead of print] 67. Wang S, Asif A. Transradial approach for cardiovascular interventions and its implications for hemodialysis vascular access. Semin Dial. 2013;26(3):E20-E29. 68. Dhamija RK, Tan H, Philbin E, et al. Subcutaneous implantable cardioverter defibrillator for dialysis patients: a strategy to reduce central vein stenoses and infections. Am J Kidney Dis. 2015;66(1):154-158. 69. Gӧransson K, Johansson E. Prehospital peripheral venous catheters: a prospective study of patient complications. J Vasc Access. 2012;13(1):16-21. 70. Takami Y, Horio T, Iwashima Y, et al. Diagnostic and prognostic value of plasma brain natriuretic peptide in non-dialysis-dependent CRF. Am J Kidney Dis. 2004;44(3):420-428. 71. Feldman L, Tkacheva I, Efrati S, et al. Effect of arteriovenous hemodialysis shunt location on cardiac events in patients having coronary artery bypass graft using an internal thoracic artery. Ther Apher Dial. 2014;18(5):450-454. 72. Vizinho RS, Santos C, Lucas C, Adragão T, Barata JD. Effect of the arteriovenous access for hemodialysis on subendocardial viability ratio, pulse pressure and hospitalizations. J Nephrol. 2014;27(5):563-570.
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73. Al-Ghonaim M, Manns BJ, Hirsch DJ, Gao Z, Tonelli M; Alberta Kidney Disease Network. Relation between access blood flow and mortality in chronic hemodialysis patients. Clin J Am Soc Nephrol. 2008; 3(2):387-391. 74. Choi SJ, Yoon HE, Kim YS, et al. Pre-existing arterial micro-calcification predicts primary unassisted arteriovenous fistula failure in incident hemodialysis patients. Semin Dial. 2015;28(6):665-669. 75. Pirozzi N, Apponi F, Napoletano AM, Luciani R, Pirozzi V, Pugliese F. Microsurgery and preventive haemostasis for autogenous radial-cephalic direct wrist access in adult patients with radial artery internal diameter below 1.6 mm. Nephrol Dial Transplant. 2010; 25(2):520-525. 76. Dageforde LA, Harms KA, Feurer ID, Shaffer D. Increased minimum vein diameter on preoperative mapping with duplex ultrasound is associated with arteriovenous fistula maturation and secondary patency. J Vasc Surg. 2015;61(1):170-176. 77. Smith GE, Barnes R, Chetter IC. Randomized clinical trial of selective versus routine preoperative duplex ultrasound imaging before arterio-venous fistula surgery. Br J Surg. 2014;101(5):469–474. 78. Georgiadis GS, Charalampidis DG, Argyriou C, Georgakarakos EI, Lazarides MK. The necessity for routine pre-operative ultrasound mapping before arteriovenous fistula creation: a meta-analysis. Eur J Vasc Endovasc Surg. 2015;49(5):600-605. 79. Kosa SD, Al-Jaishi AA, Moist L, Lok CE. Preoperative vascular access evaluation for haemodialysis patients. Cochrane Database Syst Rev. 2015;9:CD007013.
80. Mishler R, Yang Z, Mishler E. Arteriovenous fistula creation by nephrologist access surgeons worldwide. Adv Chronic Kidney Dis. 2015;22(6):425-430.
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81. Lok CE, Oliver MJ, Su J, Bhola C, Hannigan N, Jassal SV. Arteriovenous fistula outcomes in the era of the elderly dialysis population. Kidney Int. 2005;67(6):24622469. 82. Xi W, Harwood L, Diamant MJ, et al. Patient attitudes towards the arteriovenous fistula: a qualitative study on vascular access decision making. Nephrol Dial Transplant. 2011;26(10):3302-3308. 83. Zhang JC, Al-Jaishi A, Perl J, Garg AX, Moist LM. Hemodialysis arteriovenous vascular access creation after kidney transplant failure. Am J Kidney Dis. 2015;66(4):646-654. 84. Weyde W, Letachowicz W, Krajewska M, et al. Arteriovenous fistula reconstruction in patients with kidney allograft failure. Clin Transplant. 2008 Mar-Apr; 22(2):18590.
85. Szepietowski T, Kurbiel A. [One-year experience in the use of subcutaneous arteriovenous fistula for extracorporeal dialysis]. Pol Tyg Lek. 1969;24(35):13431346. Polish. 86. Weyde W, Letachowicz W, Klinger M. Feasibility of a native arteriovenous fistula as the initial type of permanent vascular access in the majority of chronic haemodialysis patients. Nephrol Dial Transplant. 1998;13(2):527-528. 87. Letachowicz K, Gołębiowski T, Kusztal M, Letachowicz W, Weyde W, Klinger M. The snuffbox fistula should be preferred over the wrist arteriovenous fistula. J Vasc Surg 2016;63:436-40. 88. Weyde W, Letachowicz W, Krajewska M, et al. Native forearm fistulas utilizing the basilic vein: an underused type of vascular access. J Nephrol. 2008;21(3):363-367.
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89. Weyde W, Krajewska M, Letachowicz W, Kusztal M, Penar J, Klinger M. A new technique for autogenous brachiobasilic upper arm transposition for vascular access for hemodialysis. J Vasc Access. 2006;7(2):74-76. 90. Letachowicz K, Weyde W, Letachowicz W, Klinger M. The effect of type and vascular access quality on the outcome of chronic hemodialysis treatment. J Ren Nutr. 2010;20(5 Suppl):S118-S121.
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Figure 1. Clinical decision-tree for chronic kidney disease (CKD) patient referred for dialysis access creation. AVF-arteriovenous fistula, AVG- arteriovenous graft, HD- hemodialysis, Ktx- kidney transplantation, PC- permanent catheter
PII: DOI: Reference:
S0895-7967(16)30045-X http://dx.doi.org/10.1053/j.semvascsurg.2016.11.003 YSVAS50517
To appear in: Seminars in Vascular Surgery Cite this article as: Krzysztof Letachowicz, Przemysław Szyber, Tomasz Gołębiowski, Mariusz Kusztal, Waldemar Letachowicz, Wacław Weyde, Jerzy Garcarek and Marian Klinger, Vascular access should be tailored to the patient, Seminars in Vascular Surgery, http://dx.doi.org/10.1053/j.semvascsurg.2016.11.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Seminars in Vascular Surgery Dialysis Access Issue
Vascular access should be tailored to the patient Krzysztof Letachowicz1, Przemysław Szyber2, Tomasz Gołębiowski1, Mariusz Kusztal1, Waldemar Letachowicz1, Wacław Weyde1, Jerzy Garcarek3, Marian Klinger1 1
Department of Nephrology and Transplantation Medicine, Wroclaw Medical University,
Borowska 213, 50-556 Wroclaw, Poland 2
Department of Vascular, General and Transplantation Surgery, Wroclaw Medical
University, Borowska 213, 50-556 Wroclaw, Poland 3
Department of Radiology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw,
Poland
Corresponding author: Krzysztof Letachowicz Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland Tel. +48 717332546 Fax. +48 717332509 E-mail: [email protected]
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Abstract A cornerstone of hemodialysis treatment is the creation of a functional and durable dialysis vascular access. Every patient with chronic kidney disease should have a plan of renal replacement therapy and access site protection. Factors having a crucial impact on vascular access selection include age, comorbidity, vessel quality, prognosis, dialysis urgency and surgeon’s preferences. Our medical group have reviewed these factors in our patients and based on recently published data developed a clinical decision tree for dialysis access in the chronic kidney disease (CKD) patient. Vascular access care should be patient-centered with the aim to maximize patient survival without loss of vascular access options; and not focused only the primary patency rates of dialysis access procedures.
Key words: arteriovenous fistula, vascular access, hemodialysis
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Introduction The rules of vascular access care are well described, but trends in vascular access use are disadvantageous. Patients with diagnosed chronic kidney disease (CKD) should be educated on all renal replacement therapy (RRT) options, including transplantation (1). The protection of vessels is crucial and must be considered when accessing veins and arteries regardless of the stage of CKD (2). Patients who prefer hemodialysis should be referred for vascular access creation when they reach stage 4 of CKD (2). Timely creation of an arteriovenous fistula (AVF) allows dialysis to be started with a functioning vascular access. Placement of an arteriovenous graft (AVG) should be postponed to reduce the number of repeated interventions before dialysis initiation (3). The decision on the type of created vascular access should be preceded by careful history taking, physical examination and imaging (1-3). The aims are: AVF in more than 65% of patients, thrombosis rate below 0.25 per patient per year, and a tunneled catheter as a permanent vascular access in less than 10% of patients (1). Recent European registry data have shown that the incidence of AVF at dialysis initiation was reduced and the proportion of catheter-dependent patients was increased (4). Changes in dialysis reimbursement in the United States resulted in an increase of AVFs and a reduction of catheter dependency among prevalent hemodialysis patients. However, still 70% of patients initiated dialysis with catheters (5). The results from the Dialysis Outcomes and Practice Patterns Study showed that it is possible to reduce the ratio of catheters on dialysis initiation if time to access creation is short or AVFs are used earlier (6). Creation of vascular access needs multistep approach and will be considered in this review. Vascular access options and complications It is important to provide an access sequence to support the patient through the entire renal failure life. About 10 options are possible on every upper extremity, excluding AVGs (7). In
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the planning of AVF creation and increasing the success of AVF procedures, it is necessary to take into consideration the possible vascular variations of the forearm and upper arm (8, 9). A few AVG options are also available, with priority of forearm grafts (10). AVGs are produced from various materials, not only synthetic, but also biological (11). Lower extremities offer some options with acceptable survival rates (12, 13). Avoidance of femoral vein puncturing should reduce the risk of future outflow stenosis (14). Recently, tissue-engineered vascular grafts built from allogeneic fibroblasts were used for vascular access creation (15). In single-arm phase 2 trials primary patency of bioengineered human acellular vessels for dialysis was 28 % at 12 months. Interventions to maintain or restore patency were done at a rate of 1.89 per patient-year despite blood flows exceeding 1 L/min and use of acetylsalicylic acid. Secondary patency at 12 months was 89 %. What is notice worthy there was no evidence of systemic immune or inflammatory response (16). The Hemodialysis Reliable Outflow graft (HeRO®; CryoLife, Kennesaw,GA) is a novel vascular access option that is ideally suited for catheter-dependent patients and those in whom previously functional fistulas and grafts have failed as a result of venous outflow stenosis and/or occlusions (17). In the case of exhaustion of standard access sites, translumbar catheters (18) could be used. Another option for patients with vascular access problems is peritoneal dialysis (19). Nevertheless, in such a situation priority kidney transplantation provides the best outcome (20). If the necessity of catheter usage cannot be avoided, less popular solutions, e.g. a citrate-filled temporary catheter (21) or single lumen tunneled catheters (22), should be kept in mind. In selected cases arterial access could be a valuable possibility (23-26). The major benefit of broad use of AVF is reduction of the risk of bacteremia (27). Although in recent years catheter design and care have improved (28, 29), catheter-related bacteremia occurred with incidence of 0.45/1000 catheter days for gentamicin and citrate lock and 1.68/1000 catheter days for heparin lock (30). The second
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important complication is central vein stenosis (31). In patients with AVF the risk of infection is much lower compared to AVG and especially to catheters (27). However, the price is risk of primary failure (32), hyper-flow access (33), and access-induced distal ischemia (34). A recent meta-analysis showed a primary failure rate of 23%. The primary patency rate was 60% at 1 year and 51% at 2 years. The secondary patency rate was 71% at 1 year and 64% at 2 years (35). A more proximal location of AVF may decrease the nonmaturation rate (36-41), but potentially deleterious effects on cardiac functions particularly in the setting of preexisting heart disease (42) are not always considered by physicians creating a vascular access. In a prospective study conducted by Basile et al., 96 patients bearing an AVF were evaluated and had the vascular access flow and cardiac output measured. The flow of the lower arm AVFs was significantly smaller, and upper arm AVFs were associated with an increased risk of high-output cardiac failure (43). It was even found that patients with cubital AVFs have poorer survival compared to the group with distal AVF (44). Another complication of vascular access manifested as a cold hand was found in 50% of patients with brachiocephalic AVF, in 25% of patients with prosthetic forearm loops and in 12% of radiocephalic AVFs. The risk of ischemia was higher in diabetics (45). It is advised to monitor high-risk patients and individuals with upper arm AVF for adverse hemodynamic consequences (46). Factors affecting vascular access formation Vascular access choice should take into consideration characteristics of the patient. The interaction between factors, patient and practice affecting AVF patency is very complex and needs to be carefully considered on AVF planning and follow-up (47). The major disadvantage of AVF is the necessity of maturation. There is no agreement whether earlier puncture has a negative impact on access survival (48, 49). However, if possible AVF use should be postponed for about 6 weeks (2). In some circumstances, avoidance of catheter use
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is a priority and AVF could be punctured earlier. Use of plastic needles allows for safe puncturing and dialysis performance in individuals with a low comorbidity burden and high quality vessels (50). An AVG does not need maturation, so it allows for cannulation after swelling resolution. New materials have been implemented for AVG construction, which allows for earlier usage. New, early-cannulation AVGs have similar patency and complication rates as standard grafts (51). If dialysis could be postponed up to a few days, catheter use should be avoided and early arteriovenous access use should be considered. But if RRT has to be started immediately, in majority of cases there is no alternative to catheters. It concerns especially the patients with highest comorbidity burden. It was found that in a specific group, patients over 75 years old with high comorbidity, the survival advantage from dialysis compared to conservative management is likely to be small (52). In these patients more efforts should be made to improve quality of life and postpone dialysis initiation. If a decision to initiate dialysis has been made, a vascular access which allows for an uneventful course should be placed. The optimal access choice is modified by the likelihood of successful fistula placement, procedure-related and subsequent costs, and patient survival. Vessel quality and patient prognosis should equally contribute to the decision. In patients who initiated RRT with a catheter, individual patient characteristics need consideration. Placement of the AVF, creation of an AVG or continuation with the catheter had similar outcomes in women with diabetes and elderly men with diabetes (53). In patients with uncertain prognosis, who need to start dialysis soon, a tunneled catheter could be the optimal vascular access. But after a few weeks of dialysis the decision on AVF or AVG creation should be reconsidered. Age, comorbidity, gender, vessel quality, patient and surgeon’s preferences are factors having an impact on access selection and outcome. Aging of the general and dialysis population is progressive. It is related to comorbidity and frailty. On the other hand, more
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healthy octogenarians are also found. It is suggested that vessel quality, not age, should be the determinant of access choice (54). Our experience showed that autogenous AVF could be successfully performed in the majority of elderly patients with acceptable access outcome. What is important, most AVFs were placed on the forearm (55, 56). In patients over 75 years primary patency was 70 +/- 4.7% at 6 months and 58 +/- 4.9% at 5 years (55). Age was also included in both recent scores for AVF outcome prediction (57, 58). Creation of AVF was recommended in all patients from 18 to 48 years whenever possible (59). On the other hand, in pediatric patients, who are transplanted after a few months of hemodialysis, placement of a tunneled catheter started to be preferred over AVF creation (60). Whether a similar approach in adult patients who are candidates for urgent transplantation (e.g. preemptive transplantation or living donation) would be beneficial is a matter of debate. Nevertheless, in younger patients the principle “saving proximal vessels” should be superior to “primary patency and high flow”. There are data suggesting that vascular access patency is inferior in women compared to men. Women were less likely to use AVF within the first year of dialysis compared to men. Also catheters were used more commonly in women on chronic hemodialysis. Female sex was mentioned as a risk factor for access complication, non-maturation and steal syndrome (61). Prediction score for snuffbox AVF included female sex as a risk factor of thrombosis (57). Although the radial artery diameter was smaller in women than in men, it was not the only factor determining fistula maturation (62). Recently, a decision analysis evaluating vascular access strategies for patients initiating hemodialysis with a central venous catheter was performed. Access patency modified by age, sex, and diabetes, access-specific mortality and costs were included in the decision model. An AVF placement strategy was superior to AVG creation and maintaining the catheter in regard to mortality and cost for the majority of patient characteristics. However, among women with diabetes (also elderly men with
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diabetes) the AVF attempt strategy was not beneficial. It was associated with lower AVF patency and lower life expectancy (53). These findings should be considered in access planning. The impact of concomitant diseases is complex. The arterial wall is affected by atherosclerosis, which is more pronounced in diabetics. Diabetes mellitus is a well-described factor of poorer AVF survival and is related to vascular access complications. Because arterial dilatation after AVF creation is affected, many authors recommend more proximal anastomosis (63). Obesity is not an obstacle for AVF formation; it may even protect forearm venous vessels from cannulation before the onset of hemodialysis therapy (64). However, in the majority of patients superficialization of the venous part of the fistula under the skin is needed for easy and uncomplicated access puncture (65). The alternative is the Venous Window Needle Guide (VWING; Vital Access Corp, Salt Lake City, Utah), surgically implanted titanium device. It was designed to facilitate cannulation of excessive depth located AVFs (66). Presence of peripheral arterial occlusive disease has a negative impact on AVF patency. Diabetes, ischemic heart disease (57) and atherosclerosis in arteries of legs (59) were included in the scoring system predicting AVF outcome. Moreover, the radial artery is commonly used as a route for coronary intervention. Its use could have an impact on the possibility of AVF creation (67). Puncture of the radial artery should be avoided in CKD, or, if necessary, one side should be exploited. It is quite common that the left subclavian vein is used as a route for a pacemaker, and the right radial artery is an entry for coronary intervention. We suppose that in CKD patients cardiac devices should be placed, if possible, after evaluation for future vascular access. Moreover, the vasculature, arteries and veins of the extremity opposite to the site of wire placement should not be punctured. Broad introduction of a subcutaneous implantable cardioverter defibrillator (ICD) could be the best option for CKD patients. This approach might offer the advantage of reduced risk of central
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venous stenosis and infection over an endocardial ICD with transvenous leads (68). Finally, patients with a high comorbidity burden are at risk of hospitalization and venipuncture and unnecessary intravenous catheters, which could result in thrombophlebitis (69). The effect of AVF creation on the cardiovascular system has been reviewed (42, 46). It was found that creation of an AVF induced left ventricle diastolic dysfunction toward a restrictive filling pattern (70). In patients with coronary artery grafting with internal thoracic artery ipsilateral location of the AVF, more cardiac events were found (71). Moreover, creation of an AVF reduced the subendocardial viability ratio, which predicted a worse clinical outcome (72). Although high flow rates (>1500 mL/min) were not associated with increased risk of death (73), creation of AVFs with blood flows predicting occurrence of high-output cardiac failure (43) should be avoided. As mentioned above, comorbidities have a huge impact on the vasculature, especially on the arterial wall. Presence of macro- or microcalcification reduces the patency of a surgically created AVF (74). Many studies have focused on arterial diameter as a predictor of access maturation (2). Other studies have shown acceptable outcome of AVFs feeding from small caliber radial arteries (75). So, if the radial artery diameter is the only unfavorable factor, we suggest distal AVF instead of upper arm AVF as a first choice. Moreover, ligation, if practiced, of distally located AVFs after kidney transplantation is less deleterious for the vasculature. The vein diameter and distension ability are the second most important factors of AVF maturation. If larger veins are used, the risk of thrombosis is reduced (76). Avoidance of puncturing veins of the elbow and forearm in CKD patients is a cornerstone for vascular access perspectives. Veins of the elbow have a relatively large diameter and are immobile. So, they could be punctured cautiously even a few days after AVF creation (50). Ultrasound assessment, called mapping, is recommended before vascular access surgery (2). However, there is no accordance whether ultrasound mapping gives any benefit compared to clinical
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judgment (77-79). In lean patients superficial veins are well seen and palpable, and ultrasound gives no benefit for access selection. Vascular access is created not only by surgeons but also by dedicated nephrologists (80). It is remarkable that huge differences in access location exist. The group from Swansea creates around 280 fistulas yearly, 70–75% of which are radial fistulas. About 25% of all fistulas are located at the snuffbox (57). In a study by Ravani et al., 420 of 513 AVFs (81.9%) were located distally (48). On the other hand, in a study by Lok et al., radiocephalic fistulas were created in 52.2% of incident first-time AVF patients (81). Increasing brachiocephalic AVF creation (from 38 to 56%) and reducing reliance on radiocephalic AVFs (36 to 27%) resulted in a significant increase in primary functional patency (36). However, the benefits of proximal location of vascular access could be transient and result in exhaustion of access options. In such circumstances thigh AVGs were placed. In a report by Ponikvar it was done in patients in whom the dialysis vintage was 11.9 ± 7.3 years and the mean number of previous vascular accesses was 4.4 ± 1.9 (12). In the study of Miller et al. thigh AVGs were created in patients who were on dialysis for 4.5 ± 4.9 years and underwent 2.3 ± 1.4 previous vascular access procedures (13). Although the two groups cannot be easily compared, the differences in time and number of procedures to exhaust the upper extremity are clearly apparent. It could reflect a different attitude to vascular access placement. Time for access creation varies worldwide. Shorter waiting times are reported in countries with the highest prevalence of AVF (6). Referral delays are minimized if nephrologists are involved in vascular access creation and care, as practiced in our center. The proportion of AVF use refusal is also not homogeneous (82). The awareness of kidney disease is not a guarantee of AVF placement. In patients with kidney transplant failure, despite their being younger and healthier compared to the overall hemodialysis population, the arteriovenous access creation rate was low. The access was created only in 16% of patients within the 12
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months before dialysis and in 47% of patients during the 24 months after dialysis (83). Previously, we reported that AVF was successfully reconstructed in 73% of patients with a failing transplanted kidney (84). Our strategy of vascular access creation Creation of a durable and safe vascular access requires a multifocal approach. Often the cooperation of many specialists is needed. Our center, Department of Nephrology and Transplantation Medicine of Wroclaw Medical University, is engaged in creation and maintaining of vascular access for decades (85, 86). Every year we perform more than 200 AVFs and insert about 200 catheters. We consult a cohort of more than 500 patients in case of vascular access problems. Four nephrologists are able to perform broad spectrum of autogenous vascular access procedures on upper extremity. Most of decisions are based on physical examination, but Doppler ultrasound is used to confirm and document the findings. The snuffbox AVF is the first choice, especially in young patients without comorbidities (87). If the vessels are not appropriate, a more proximal option on the forearm is chosen. In cases of destruction of forearm and elbow vessels, use of the forearm basilic vein could be a good alternative for AVF construction (88). Most AVFs are created on a non-dominant extremity, but with priority of vessel condition. Even in the case of atherosclerosis we prefer AVFs originating from the radial artery, because it reduces the risk of negative cardiovascular consequences, distal ischemia and high-flow access. Out of 200 AVFs created every year, no more than 5% originate from the brachial artery. For autogenous brachiobasilic fistula creation we used the modified technique with primary patency of 74% at one year (89). Our observation showed that upper-arm vascular access, including modified Gracz AVF originating from the radial artery, was limited to 11.7% of dialysis patients (90). We do not use minimal vessel diameters for access selection. In patients with narrow vessels we try to perform AVF as distal as possible. If access is not feasible for dialysis then more proximal
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anastomosis, using dilated artery and vein, is done within 4-6 weeks. If arterial and vein conditions are not sufficient for AVF creation, other RRT modalities are considered. In younger patients renal transplantation priority is given. In patients who are not candidates for transplantation, optimal conservative management is offered and tunneled catheters are placed if needed. We are also looking after 80 hemodialysis patients. The majority of our patients have AVF located on forearm. We do not use any surveillance protocol, but monitor AVF function by detailed physical examination that cannot be substituted by any of available diagnostic tools. Doppler ultrasound is used to confirm the findings. For perianastomotic stenosis, the most common in forearm AVF, we prefer more proximal anastomosis as the most efficient solution. The outflow stenoses are treated by devoted radiologist. Complicated cases are solved in cooperation with vascular surgeon. On evaluation of patients referred for vascular access creation or initiating hemodialysis in unplanned manner we try to follow an algorithm (Figure 1). The necessity of RRT is verified and risk of vascular access dysfunction is stratified. Answering few basic questions after detailed assessment makes vascular access choices much easier. Recent Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis updated by the Japanese Society for Dialysis Therapy recommend very careful patient education by a nephrologist and vascular access expert, early referral and planning. Distal location, wrist or snuffbox AVF, is advised. Moreover, the impact on peripheral circulation and cardiac function is included in the decision model. Physical examination is fundamental for vasculature assessment, and ultrasound is recommended for doubtful cases. It is stated that the arterial diameter should be at least 1.5 mm, and a lower success rate is achieved with smaller arteries. However, arterial diameter is only one indicator for a successful AVF, and other factors should be included in
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the consideration. Following the guidelines resulted in arteriovenous access in 96.8% of hemodialysis patients (26).
Conclusions Vascular access care has to be patient centered. Our aim should not be primary patency of vascular access, but the longest patient survival without loss of vascular access options. The cornerstone is vessel saving through all stages of chronic kidney disease, especially in younger patients. In older individuals we should focus on effectiveness and the lowest complication rate. An individualized attitude and stepwise attempts on the forearm are factors protecting against exhaustion of vascular access options.
Conflicts of interest: none This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Figure 1. Clinical decision-tree for chronic kidney disease (CKD) patient referred for dialysis access creation. AVF-arteriovenous fistula, AVG- arteriovenous graft, HD- hemodialysis, Ktx- kidney transplantation, PC- permanent catheter