Association of race and ethnicity with initial surgical hemodialysis access type in a safety net system.

OBJECTIVES: Prior studies have found lower arteriovenous fistula (AVF) creation rates in Black and Hispanic patients. Whether this is due to health care disparities or other differences is unclear. Our objective was to evaluate the racial/ethnic differences in initial surgical access type within a high-volume, safety net system with predominantly Black and Hispanic populations. METHODS: A retrospective review of initial hemodialysis (HD) access in consecutive cases between 2014 and 2019 was conducted from all five safety net hospitals in a health care system that primarily treats underserved patients. Patient data collected included race, ethnicity, sex, comorbidities, and initial arteriovenous (AV) access type (AV fistula [AVF] vs AV graft [AVG]). The rates of cephalic vein-based AVF (CAVF; radiocephalic, brachiocephalic) were compared with basilic and brachial vein AVF (BAVF), because the latter are performed as two stages. Bivariate and multivariate logistic regression models were adjusted for demographic and clinical variables to evaluate the relationship between race/ethnicity, surgical access type, and comorbid conditions. RESULTS: We included 1334 patients (74% Hispanic, 9% Black, 7% Asian, 2% White, 8% other) who underwent first-time surgical HD access creation. The majority were male (818 [63%]). Medical comorbidities were equal among groups, except for chronic obstructive pulmonary disease and stroke, which were higher in Black patients (P < .005 and P = .005, respectively). Overall, 1303 patients (98%) underwent AVF creation and 31 AVG creation (2%), with no difference between race/ethnicity in AVF vs AVG creation. Of the AVF cohort, 991 (76%) had a CAVF and 312 (24%) had a BAVF. Males were more likely than females to get a CAVF (65% vs 35%; P = .002). CONCLUSIONS: Within our safety net health system, where most patients are under-represented minorities, nearly all patients undergoing HD access had an AVF as their initial surgery with no difference in race/ethnicity. AVF type received differed by race, with Black patients twice as likely to undergo BAVF, which required two stages. Further studies are needed to identify the reasons for these differences.

Midterm outcomes of arteriovenous fistula aneurysm repair with simultaneous inflow revision or outflow tract revascularization.

OBJECTIVE: The aim of this study was to investigate the 2-year outcomes of extensive revisions aimed at simultaneously addressing arteriovenous fistula (AVF) aneurysms, outflow stenosis, and/or high flow volumes. METHODS: This was a retrospective cohort study in a tertiary referral center. The study population comprised hemodialysis patients with aneurysmal AVFs requiring revision. Subjects were eligible if they were ≥18 years of age and had aneurysm repair associated with inflow revision or treatment of outflow lesions. Patients were followed-up for a minimum of 2 years, and the primary outcome measure was cumulative patency. RESULTS: Our cohort comprised 93 patients with a mean age of 56 ± 12 years. The most frequent access type was brachiocephalic fistula (61%), and the median access age at the time of revision was 66 months (interquartile range, 46-93 months). The median access flow volume was 2300 ml/min (interquartile range, 1281-2900), and 31 subjects (33%) presented aneurysms associated with both high flow and venous obstruction. Aneurysm repair consisted of aneurysmorraphy in the overwhelming majority (95%). Inflow revision was performed in a total of 49 cases (53%), and outflow tract obstruction was treated in 71 patients (72%), with 27 patients (29%) receiving a simultaneous 3-component revision. At 2 years, the primary, primary assisted, and cumulative patencies were 60% ± 1%, 91% ± 3%, and 94% ± 3%, respectively. The most frequent indication for first-time reinterventions was outflow tract stenosis (24%). Aneurysm recurrence was observed in 13 subjects (14%) during the entire follow-up and was responsible for reinterventions in seven of them (8%), with a 2-year freedom from aneurysm-related reintervention rate of 95% ± 3%. CONCLUSIONS: Extensive AVF revision with simultaneous aneurysm repair, inflow revision, and outflow tract revascularization is feasible, safe, and associated with favorable 2-year patency rates.

SAGES peritoneal dialysis access guideline update 2023.

BACKGROUND: Minimally invasive surgery has been used for both de novo insertion and salvage of peritoneal dialysis (PD) catheters. Advanced laparoscopic, basic laparoscopic, open, and image-guided techniques have evolved as the most popular techniques. The aim of this guideline was to develop evidence-based guidelines that support surgeons, patients, and other physicians in decisions on minimally invasive peritoneal dialysis access and the salvage of malfunctioning catheters in both adults and children. METHODS: A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons reviewed the literature since the prior guideline was published in 2014 and developed seven key questions in adults and four in children. After a systematic review of the literature, by the panel, evidence-based recommendations were formulated using the Grading of Recommendations Assessment, Development and Evaluation approach. Recommendations for future research were also proposed. RESULTS: After systematic review, data extraction, and evidence to decision meetings, the panel agreed on twelve recommendations for the peri-operative performance of laparoscopic peritoneal dialysis access surgery and management of catheter dysfunction. CONCLUSIONS: In the adult population, conditional recommendations were made in favor of: staged hernia repair followed by PD catheter insertion over simultaneous and traditional start over urgent start of PD when medically possible. Furthermore, the panel suggested advanced laparoscopic insertion techniques rather than basic laparoscopic techniques or open insertion. Conditional recommendations were made for either advanced laparoscopic or image-guided percutaneous insertion and for either nonoperative or operative salvage. A recommendation could not be made regarding concomitant clean-contaminated surgery in adults. In the pediatric population, conditional recommendations were made for either traditional or urgent start of PD, concomitant clean or clean-contaminated surgery and PD catheter placement rather than staged, and advanced laparoscopic placement rather than basic or open insertion.

Effect of insertion site on tunnelled haemodialysis catheter outcomes: an observational study of 967 catheters.

BACKGROUND: The right internal jugular vein is the preferred approach to tunnelled haemodialysis catheter placement. However, the effect of the insertion site on long-term catheter outcomes remains uncertain. AIMS: We aimed to analyse a large cohort of tunnelled haemodialysis catheter placements to compare short-term and long-term results according to central venous catheter location. METHODS: A retrospective cohort study was performed on consecutive tunnelled catheter insertions at two centres over 7 years. The primary outcome was catheter survival, compared according to the central vein site. We used the Kaplan-Meier curve method and Cox proportional hazards modelling to determine the effect of the catheterisation route on primary patency, adjusted for clinical risk factors for catheter failure. RESULTS: There were 967 tunnelled dialysis catheter placements in 620 patients. The median survival for right internal jugular vein catheters was 569 days. There were no differences in rates of catheter failure between right internal jugular, left internal jugular (adjusted hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.52-1.21), external jugular (HR, 0.79; CI, 0.33-3.13), subclavian (HR, 0.67; CI, 0.58-2.44) and femoral vein (HR, 1.20; CI, 0.36-1.33) catheters following multivariable analysis. There were no major differences in functionality or complications between the groups. CONCLUSIONS: This study identified no statistically significant relationship between tunnelled haemodialysis catheter insertion site and catheter survival. The contemporary approach to dialysis vascular access should be tailored to specific patient circumstances.

Barriers to Implementing the Kidney Disease Outcomes Quality Initiative End-Stage Kidney Disease Life Plan Guideline.

OBJECTIVE: The updated 2019 National Kidney Foundation Kidney Disease Outcomes Quality Initiative vascular access guidelines recommend patient-centered, multi-disciplinary construction and regular update of an individualized end-stage kidney disease (ESKD) Life-Plan (LP) for each patient, a dramatic shift from previous recommendations and policy. The objective of this study was to examine barriers and facilitators to implementing the LP among key stakeholders. METHODS: Semi-structured individual interviews were analyzed using inductive and deductive coding. Codes were mapped to relevant domains in the Consolidated Framework for Implementation Research (CFIR). RESULTS: We interviewed 34 participants: 11 patients with end-stage kidney disease, 2 care partners, and 21 clinicians who care for patients with end-stage kidney disease. In both the clinician and the patient/care partner categories, saturation (where no new themes were identified) was reached at 8 participants. We identified significant barriers and facilitators to implementation of the ESKD LP across three CFIR domains: Innovation, Outer setting, and Inner setting. Regarding the Innovation domain, patients and care partners valued the concept of shared decision-making with their care team (CFIR construct: innovation design). However, both clinicians and patients had significant concerns about the complexity of decision-making around kidney substitutes and the ability of patients to digest the overwhelming amount of information needed to effectively participate in creating the LP (innovation complexity). Clinicians expressed concerns regarding the lack of existing evidence base which limits their ability to effectively counsel patients (innovation evidence base) and the implementation costs (innovation cost). Within the Outer Setting, both clinicians and patients were concerned about performance measurement pressure under the existing "Fistula First" policies and had concerns about reimbursement (financing). In the Inner Setting, clinicians and patients stressed the lack of available resources and access to knowledge and information. CONCLUSION: Given the complexity of decision-making around kidney substitutes and vascular access, our findings point to the need for implementation strategies, infrastructure development, and policy change to facilitate ESKD LP development.

Clinical impact of left ventricular systolic dysfunction in patients undergoing dialysis access surgery.

BACKGROUND: An arteriovenous fistula (AVF) is the most frequently used dialysis access for haemodialysis. However, it can cause volume loading for the heart and may induce circulatory failure when performed in patients with low cardiac function. This study aimed to characterise patients with low cardiac function when initiating dialysis and determine how cardiac function changes after the dialysis access surgery. METHODS: We conducted a retrospective observational study at two centres incorporating 356 patients with end-stage kidney disease who underwent echocardiography before the dialysis access surgery. RESULTS: An AVF and a subcutaneously fixed superficial artery were selected in 70.4% and 23.5% of 81 patients with reduced/mildly reduced (< 50%) left ventricular ejection fraction (LVEF), respectively, and in 94.2% and 1.1% of 275 patients with preserved (≥ 50%) LVEF (p < 0.001), respectively. Follow-up echocardiography was performed in 70.4% and 38.2% of patients with reduced/mildly reduced and preserved LVEF, respectively, which showed a significant increase in LVEF (41 ± 9-44 ± 12%, p = 0.038) in patients with reduced/mildly reduced LVEF. LVEF remained unchanged in 12 patients with reduced/mildly reduced LVEF who underwent subcutaneously fixed superficial artery (30 ± 10-32 ± 15%, p = 0.527). Patients with reduced/mildly reduced LVEF had lower survival rates after surgery than those with preserved LVEF (p = 0.021 for log-rank). CONCLUSION: The LVEF subcategory was associated with dialysis access selection. After the dialysis access surgery, LVEF was increased in patients with reduced/mildly reduced LVEF. These results may help select dialysis access for patients initiating dialysis.

Practice of dialysis access interventional nephrology procedures in the Asia-Pacific region: Getting lay of the land.

AIM: This cross-sectional survey aimed to determine the prevalence of Interventional Nephrology (IN) practice amongst nephrologists in the Asia-Pacific Region (APR), specifically related to dialysis access (DA). METHODS: The Association of VA and intervenTionAl Renal physicians (AVATAR) Foundation from India conducted a multinational online survey amongst nephrologists from the Asia-Pacific to determine the practice of IN in the planning, creation, and management of dialysis access. The treatment modalities, manpower and equipment availability, monthly cost of treatment, specifics of dialysis access interventions, and challenges in the training and practice of IN by nephrologists were included in the survey. RESULTS: Twenty-one countries from the APR participated in the survey. Nephrologists from 18 (85.7%) countries reported performing at least one of the basic dialysis access-related IN procedures, primarily the placement of non-tunnelled central catheters (n-TCC; 71.5%). Only 10 countries (47.6%) reported having an average of <4% of nephrologists performing any of the advanced IN access procedures, the most common being the placement of a peritoneal dialysis (PD) catheter (20%). Lack of formal training (57.14%), time (42.8%), incentive (38%), institutional support (38%), medico-legal protection (28.6%), and prohibitive cost (23.8%) were the main challenges to practice IN. The primary obstacles to implementing the IN training were a lack of funding and skilled personnel. CONCLUSION: The practice of dialysis access-related IN in APR is inadequate, mostly due to a lack of training, backup support, and economic constraints, whereas training in access-related IN is constrained by a lack of a skilled workforce and finances.

Determinants of urgent start dialysis in a chronic kidney disease cohort followed by nephrologists.

BACKGROUND: The French Renal Epidemiology and Information Network (REIN) registry collect dialysis initiation context for each patient starting dialysis with a flawed definition of urgent start dialysis (USD). The main objective of this study was to identify factors associated with USD in patients regularly followed-up by a nephrologist using a classification of USD considering the preparation to renal replacement therapy. METHODS: This retrospective cohort study included adult patients who started dialysis between 2012 and 2018 in the Franche-Comté region of France after a minimum of two nephrology consultations. We classified dialysis initiation context as follows: USD for patients with no dialysis access (DA) created or planned, unplanned non urgent start dialysis (UNUSD) for patients starting with a recent or non-functional DA and planned start dialysis (PSD) for those starting with a functional and mature DA. RESULTS: Four hundred and sixty-five patients met inclusion criteria. According to REIN registry, 94 (20.3%) patients were urgent starters (US) whereas with our classification 80 (17.2%) and 73 (15.7%) where respectively US and unplanned non urgent starters (UNUS). The factors independently associated with USD in our classification were: stroke (odds ratio(OR) = 2.76, 95% confidence interval (95%CI)=[1.41-5.43]), cardiac failure (OR = 1.78, 95%CI=[1.07-2.96]) and the number of nephrology consultations prior dialysis onset (OR = 0.73, 95%CI=[0.64-0.83]). Thirty-one patients died during the first year after dialysis start. According to our classification, we observed significantly different survival probabilities: 95.7%, 89.5% and 83.4% respectively for planned starters, UNUS and US (p = 0.001). CONCLUSION: The two factors independently associated with USD were cardiac failure and stroke.

Surgical removal of a foreshortened right innominate vein Wallstent causing venous outflow obstruction.

OBJECTIVES: Stenting of central venous stenosis to preserve upper extremity hemodialysis access is well-described, though upper extremity complications secondary to these stents are less frequently discussed. METHODS: We present the case of a 43-year-old male with a right brachiocephalic fistula who developed symptoms of venous hypertension following placement of a Wallstent for central venous stenosis. Workup demonstrated venous outflow obstruction secondary to stent foreshortening into the right subclavian vein. RESULTS: The Wallstent was removed in a piecemeal fashion using an open surgical technique and a HeRO graft was placed for dedicated fistula outflow with complete relief of the patient's symptoms. CONCLUSION: In situations where a stent has migrated and endovascular removal is not possible, individual Wallstent fibers can be removed through a limited venotomy.

Role of stem cells in arteriovenous access: perspective from Lower Middle Income Countries.

Adequately created well functional haemodialysis access is an important part for the physical and mental wellbeing of renal failure patients. Every effort should be made to enhance the patency of these accesses. Recently, stem cell treatment modalities have opened new avenues in the better patency of arteriovenous fistula. Use of mesenchymal stromal cells (MSC) to prevent venous neointimal hyperplasia have been studied with good success rates. Adopting such costly treatment modalities in low middle income class country like Pakistan is associated with significant challenges. This short report discusses the current role of stem cells in arteriovenous access and how this exciting modality can be utilized in our country.

Pseudomonas aeruginosa Infections Are Associated with Infection Recurrence in Arteriovenous Grafts Treated with Revision.

Background and Objectives: This study was conducted to investigate whether Pseudomonas aeruginosa (PA) infections of arteriovenous grafts (AVGs) recur more frequently than other bacterial infections following treatment with revision. Materials and Methods: Operative procedures, including total excision, subtotal excision, and revision, were performed on 60 patients to treat 65 AVG infections. Final outcomes were classified as no infection recurrence, infection recurrence, and death without prior recurrence. In the competing risk setting, the cumulative incidence was estimated using the cumulative incidence function and Gray's test, and the associations between outcomes and different variables were estimated using a subdistribution hazard (SDH) model. Results: Comparing AVG infections with and without recurrence, PA infection was not associated with a higher risk of infection recurrence (p = 0.13); however, the first operative procedure type was associated with infection recurrence (p = 0.04). AVGs with PA infection were associated with a higher total number of surgical interventions (p < 0.05) than AVGs without PA infection. Regarding the cumulative incidences of outcomes, for AVGs treated with subtotal excision or revision, the cumulative incidence of recurrent infection was 3.3-fold higher for those with PA infection than without one year after the first surgery. However, when AVGs were treated with revision alone, the cumulative incidence was 4.1-fold. After excluding AVGs treated with total excision, the SDH model was applied, obtaining a hazard ratio for infection recurrence of 16.05 (p = 0.02) for AVGs with PA infection compared with AVGs without PA infection. No other variables were significantly associated with infection recurrence. Conclusions: For subtotal resection and revision, AVGs infected with PA had a higher recurrence rate than those infected with other species. However, revision surgery may aggravate the recurrence rate.

Early Intervention for Steal Syndrome in Patients on Hemodialysis.

Dialysis access-associated steal syndrome (DASS) is a serious, challenging complication related to diminished arterial blood flow to the hand. Patients may not be routinely assessed for this diagnosis, resulting in a delayed presentation with severe hand pain, nerve damage, and tissue loss. This pilot project examined the feasibility of implementing an assessment tool to routinely screen patients for steal syndrome. The tool was used for all patients in three participating dialysis centers. Positive patients had a streamlined referral to vascular surgery for assessment and possible treatment. This pilot project demonstrates that education and subsequent routine screening for DASS within the dialysis facility is feasible, and can be incorporated into the workflow for both the dialysis facility and the servicing vascular surgery office. Early recognition of DASS will prevent severe injuries and tissue loss.

Comparison of Outcomes between Percutaneous and Surgical Placement of Peritoneal Dialysis Catheters in Uremic Patients: A Meta-Analysis.

BACKGROUND: The optimal technique for inserting peritoneal dialysis catheters in uremic patients remains debated. This meta-analysis aimed to summarize the current evidence evaluating the efficacy and safety of percutaneous insertion methods compared to surgical methods. METHOD: A literature search was performed in the PubMed, EMBASE, Cochrane, and Web of Science databases. The primary outcome was defined as catheter survival. The secondary outcomes were mechanical and infectious complications related to catheter insertion. RESULTS: Twenty studies were finally identified, including 2 randomized controlled trials. The pooled results of catheter survival, overall mechanical complications, and infectious complications were not significant (odds ratio [OR] = 1.10, 95% confidence interval (CI) = 0.76-1.57, p = 0.62; OR = 0.73, 95% CI = 0.48-1.11, p = 0.14; and OR = 0.64, 95% CI = 0.37-1.09, p = 0.14, respectively). Comparison stratified by the blind percutaneous method versus open surgery indicated a lower overall number of mechanical complications (OR = 0.54, 95% CI = 0.31-0.93, I2 = 72%) and malposition rate (OR = 0.56, 95% CI = 0.34-0.90, I2 = 0%). The leakage rate was higher in the blind percutaneous group than in the open surgery group (OR = 2.55, 95% CI = 1.72-3.79, I2 = 0%); the guided percutaneous method achieved a similar leakage risk to the surgical methods. CONCLUSIONS: The blind percutaneous method performed better with fewer overall mechanical complications and less malposition than open surgery. The leakage risk was higher in the blind percutaneous group, while the guided percutaneous placement group showed similar outcomes to the surgical method groups. Percutaneous methods also had a lower infection risk, which needs further evidence to be confirmed.

Effectiveness and safety of repeated percutaneous intervention in an office-based endovascular center in maintaining hemodialysis access.

OBJECTIVES: Percutaneous dialysis access interventions are routinely used to maintain the patency of dialysis access despite the lack of data regarding their long-term effectiveness. This retrospective study was undertaken to study the effectiveness and safety of percutaneous dialysis access interventions in arm fistulas and bridge grafts in an office-based endovascular center. METHODS: Patients who had a percutaneous dialysis access intervention in their upper extremity access site, performed at a single office-based endovascular center over a nine-year period (2007-2016) were included in this study. The patients' demographic factors, patency, and complications were analyzed. Patients were entered in the study after first percutaneous dialysis access intervention. RESULTS: A total of 298 limbs in 259 patients had 913 procedures carried out over a nine-year period. There were 190 access arteriovenous fistulas and 108 arteriovenous grafts. The two most common arteriovenous fistulas were the brachiocephalic fistula (n = 74, 39%) and radio cephalic fistula (n = 69, 36%). Arteriovenous grafts were most commonly placed in the upper arm (n = 66, 61%) followed by the forearm (n = 42, 39%). The mean overall patency for all limbs was 50.86 months. Arteriovenous fistulas had a significantly longer patency than arteriovenous grafts (51.65 vs. 42.09 months; P = 0.01). In addition, patients with two or more percutaneous dialysis access intervention in their arteriovenous fistula had significantly greater patency than those with only one percutaneous dialysis access intervention (58.5 vs. 7.6 months; hazard ratio 0.41; P = 0.0008). This was not true for the arteriovenous graft group. Women represented 49% of the patient group. Their accesses had shorter patency than men (39.8 vs. 60 months; P = 0.0007). CONCLUSIONS: This data support the use of repeated percutaneous dialysis access intervention to maintain long-term patency of dialysis access sites in an office-based endovascular center. Overall, fistulas have longer patency than grafts and women have poorer outcomes as compared to men.

Comparison of Ellipsys Percutaneous and Proximal Forearm Gracz-Type Surgical Arteriovenous Fistulas.

RATIONALE & OBJECTIVE: Percutaneous arteriovenous fistulas (AVF) are created by establishing a proximal forearm anastomosis and offer a safe and reliable vascular access. This study compares the Ellipsys percutaneous AVF with a proximal forearm Gracz-type surgical AVF, chosen for comparison as it is constructed at the same anatomical site. STUDY DESIGN: Retrospective study of prospectively collected clinical data. SETTING & PARTICIPANTS: All vascular access procedures conducted during a 34-month period were reviewed. The study groups comprised 89 percutaneous AVFs and 69 surgical AVFs. EXPOSURE: Percutaneous or surgical AVF placement. OUTCOME: AVF patency, function, and complications. ANALYTICAL APPROACH: Patency rates for each AVF group were evaluated by competing risk survival analysis using a cumulative incidence function. Association of primary, primary assisted, and secondary patency with the AVF groups was examined by Cox proportional hazard models. RESULTS: Technical success was 100% for both groups. Average procedure times were 14 minutes for percutaneous AVFs and 74 minutes for surgical AVFs (P < 0.001). Proximal radial artery (PRA) was used in all percutaneous AVF cases. Inflow for surgical AVFs included radial (30%), ulnar (12%), and brachial (58%) arteries. Outflow veins for both groups were the cephalic and/or basilic veins. Access flow volumes, times to maturation, and overall numbers of interventions per patient-year were not significantly different. Cumulative incidence of primary patency failure at 12 months was lower for surgical AVF (47% vs 64%, P = 0.1), but secondary patency failure was not different between groups (20% vs 12%, P = 0.3). PRA surgical AVFs had similar primary patency (65% vs 64%, P = 0.8) but higher secondary patency failure rates than percutaneous AVFs at 12 months (34% vs 12%, P = 0.04). LIMITATIONS: Retrospective study with a relatively short follow-up period, and not all patients required hemodialysis at the end of study. CONCLUSIONS: Both percutaneous and surgical AVFs demonstrated high rates of technical success and secondary patency. Percutaneous AVFs required shorter procedure times. The rate of intervention was similar. When a distal radial artery AVF is not feasible, percutaneous AVF might offer an appropriate procedure for creating a safe and functional access, maintaining further proximal forearm surgical AVF creation options.

Arteriovenous Vascular Access-Related Procedural Burden Among Incident Hemodialysis Patients in the United States.

RATIONALE & OBJECTIVE: As the proportion of arteriovenous fistulas (AVFs) compared with arteriovenous grafts (AVGs) in the United States has increased, there has been a concurrent increase in interventions. We explored AVF and AVG maturation and maintenance procedural burden in the first year of hemodialysis. STUDY DESIGN: Observational cohort study. SETTING & PARTICIPANTS: Patients initiating hemodialysis from July 1, 2012, to December 31, 2014, and having a first-time AVF or AVG placement between dialysis initiation and 1 year (N = 73,027), identified using the US Renal Data System (USRDS). PREDICTORS: Patient characteristics. OUTCOME: Successful AVF/AVG use and intervention procedure burden. ANALYTICAL APPROACH: For each group, we analyzed interventional procedure rates during maturation maintenance phases using Poisson regression. We used proportional rate modeling for covariate-adjusted analysis of interventional procedure rates during the maintenance phase. RESULTS: During the maturation phase, 13,989 of 57,275 patients (24.4%) in the AVF group required intervention, with therapeutic interventional requirements of 0.36 per person. In the AVG group 2,904 of 15,572 patients (18.4%) required intervention during maturation, with therapeutic interventional requirements of 0.28 per person. During the maintenance phase, in the AVF group 12,732 of 32,115 patients (39.6%) required intervention, with a therapeutic intervention rate of 0.93 per person-year. During maintenance phase, in the AVG group 5,928 of 10,271 patients (57.7%) required intervention, with a therapeutic intervention rate of 1.87 per person-year. For both phases, the intervention rates for AVF tended to be higher on the East Coast while those for AVG were more uniform geographically. LIMITATIONS: This study relies on administrative data, with monthly recording of access use. CONCLUSIONS: During maturation, interventions for both AVFs and AVGs were relatively common. Once successfully matured, AVFs had lower maintenance interventional requirements. During the maturation and maintenance phases, there were geographic variations in AVF intervention rates that warrant additional study.

Psychosocial Factors, Intentions to Pursue Arteriovenous Dialysis Access, and Access Outcomes: A Cohort Study.

RATIONALE & OBJECTIVE: Suboptimal dialysis preparation of patients with chronic kidney disease (CKD) is common, but little is known about its relationship to psychosocial factors. This study aimed to assess patients' attitudes about access creation and to identify factors associated with patients' intentions regarding dialysis access creation and outcomes. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 190 patients with stage 4/5 CKD not receiving dialysis treated at 2 hospitals in Singapore and 128 of their family members. PREDICTORS: Self-reported measures of illness perception, health-related quality of life, and attitudes toward access creation. Sociodemographic and clinical measures were also obtained. OUTCOME: Intention to create an arteriovenous fistula (AVF; ie, proceed with access vs wait and see) and time to creation of a functional AVF. ANALYTICAL APPROACH: Exploratory factor analysis (EFA) was undertaken to construct internally consistent subscales for a newly developed questionnaire about attitudes toward access creation. Logistic regression and cause-specific hazards models were conducted to identify psychosocial factors associated with patients' access creation intentions and access outcomes, respectively. RESULTS: EFA (explained 50.1% variance) revealed 4 domains: access and dialysis concerns, need for dialysis, worry about cost, and value of access. A high risk of intention to delay access creation (51.1%) was found among patients despite early referral and education. Multivariable analysis (R2=0.45) showed that the intention to proceed with access creation was associated with greater perceived value from access (odds ratio, 2.61; 95% CI, 1.46-4.65; P<0.001). LIMITATIONS: Limited generalization, as only those already receiving nephrology care were studied. CONCLUSIONS: Approximately half of the patients studied planned to delay access creation. The questionnaire developed to evaluate attitudes about access creation may help identify individuals for whom decision-support programs would be useful. These findings highlight the need to understand and address patients' concerns about access creation.

Long-term outcomes of transposed femoral vein arteriovenous fistula for abandoned upper extremity dialysis access.

BACKGROUND: The number and longevity of patients with end-stage renal disease requiring dialysis access have continued to increase, leading to challenging situations, including exhausted upper extremity access and severe central venous stenosis. This has led to an increase in the use of alternative access sites, including the lower extremities. The transposed femoral vein arteriovenous fistula for dialysis access is a previously described alternative, although limited data are available on its long-term patency. METHODS: Patients treated with a transposed femoral vein fistula were retrospectively reviewed. A transposed femoral vein fistula was created by harvesting the femoral vein and transposing it to the distal superficial femoral artery at the level of the adductor canal. The demographic information, perioperative characteristics, complications, and long-term outcomes were recorded and analyzed. RESULTS: A total of 21 patients had undergone transposed femoral vein fistula for dialysis access after an average of 5.3 ± 2.8 failed dialysis access procedures and a duration of 6.1 ± 4.9 years from the initiation of dialysis. The average age at the procedure was 53.5 ± 12.8 years. Ten patients (47.6%) had a history of diabetes mellitus and nine (42.9%) had a history of coronary artery disease. Technical success was achieved in 100% of cases, and 16 patients (76.2%) were discharged with anticoagulation therapy. The primary patency at 1, 3, and 5 years was 93%, 74%, and 74%, respectively. The secondary patency at 1, 3, and 5 years was 100%, 89%, and 89%, respectively. Two patients had compartment syndrome requiring fasciotomy, and six patients experienced wound complications. CONCLUSIONS: Transposed femoral vein fistula for dialysis access is a viable alternative for patients with an exhausted upper extremity access, with good long-term patency.

Economic evaluation of suture versus clip anastomosis in arteriovenous fistula creation.

OBJECTIVE: Techniques such as the use of nonpenetrating vascular clips for arteriovenous fistula (AVF) anastomotic creation have been developed in an effort to reduce fistula-related complications. However, the outcomes data for the use of clips have remained equivocal, and the cost evaluations to support their use have been largely theoretical. Therefore, the present study aimed to determine both the clinical and the cost outcomes of AVFs created with nonpenetrating vascular clips compared with the continuous suture technique during a 10-year period at a single institution. METHODS: All patients undergoing AVF creation in the upper extremity from 2009 through 2018 were retrospectively analyzed. The patient demographics and AVF outcomes were collected and compared stratified by the surgical technique used. A cost analysis was performed of a subgroup of patients from 2013 to 2018. RESULTS: During the 10-year study period, 916 AVFs were created (79% using the continuous suture technique and 21% using nonpenetrating vascular clips). Patient demographics and comorbid conditions did not differ between the two groups, and no differences were present in maturation, primary patency, assisted primary patency, or complication rates between the two groups at 1 year. The suture group had a shorter time to maturation (4.3 months vs 5.5 months; P < .01) and improved secondary patency compared with the clip group (77.13% vs 69.59%; P = .03) The cost analysis of the procedures revealed a significant difference in direct costs (suture, $1389.26 vs clip, $1716.51; P < .01) and contribution margin (suture, $1770.19 vs clip, $1128.36; P < .01) for the two groups. CONCLUSIONS: Both suture and clip techniques in AVF creation demonstrated equivalent rates of maturation, primary patency, assisted primary patency, and complications at 1 year with higher expense associated with the use of clips. Thus, in an effort to reduce the economic burden of healthcare in the United States, the findings from the present study support the preferential use of the standard polypropylene suture technique when creating upper extremity AVFs.

Severe leg swelling following removal of a temporary femoral venous hemodialysis catheter.

Temporary central venous catheters are commonly used for patients who require emergency hemodialysis (HD). An arteriovenous fistula (AVF) is a rare complication of this procedure. In this case report, we present a patient who was diagnosed with an iatrogenic femoral AVF after cannulation of the right femoral vein with a temporary HD catheter.