A UK Expert Consensus Approach for Managing Symptomatic Arteriovenous Fistula (AVF) Stenosis in Haemodialysis Patients

Abstract

Purpose Stenoses in mature arteriovenous fistulas (AVFs) are common and can negatively impact on the quality of haemodialysis, the longevity of the AVF and lead to debilitating symptoms. Multiple treatment options exist; however, management can vary between different centres. We aimed to establish multidisciplinary consensus on the optimal stepwise application of interventions based on evidence and consensus. Methods A modified Delphi process was conducted with 13 participants from hospitals across the UK, all of whom have high-volume dialysis access practice. Results The usual intervention to rectify de novo stenoses of mature AVFs is fistuloplasty, although surgery for inflow segment stenoses is also clinically acceptable. Appropriate first-line interventions include plain old balloon angioplasty or high-pressure balloon angioplasty; if these fail during the fistuloplasty, consider upsizing the balloon, prolonged balloon inflation or using alternative interventions, such as cutting or scoring balloons and ultrahigh-pressure balloons. Alternative or subsequent interventions vary by anatomical site and may require additional multidisciplinary team input. For a stenoses recurring between 3 and 12 months, it is appropriate to consider interventions used de novo, but with a lower threshold for using drug-coated balloons (DCBs) in all regions and for using stent grafts in all regions but inflow segment. Recurrence after 12 months should be treated as a de novo lesion, with DCBs considered if they have been used successfully during previous interventions. Conclusions These recommendations aim to provide a practical guide to multidisciplinary teams in order to optimise the use of multiple interventions for rectifying

A Retrospective Case-Control Study on Late Failure of Arteriovenous Fistula in Hemodialysis Patients and Prediction of Risk Factors

“…K-DOQI (the National Kidney Foundation Kidney-Dialysis Outcomes Quality Initiative), CPM (Clinical Performance Measures), and other studies also emphasized that autologous AVF is the first choice for hemodialysis patients [ 13 ]. Although AVF is the most ideal vascular pathway for MHD patients, its service life is not permanent: a 2014 study showed that the 1- and 2-year patency rates of AVF were 60% and 51%, respectively [ 14 ]; data from the 2016 DOPSS (Dialysis Outcomes and Practice Pattern Study) showed that the patency rate of autologous AVF1 was only 68% in the UK and relatively high in Europe (83%) [ 15 ]. In addition, a systematic review in 2016 showed that only 62-68% of AVF remained unobstructed after 1 year of use and dropped to 38-56% after 2 years [ 16 ].…”

Utility of a ML analytics on real time risk stratification and re-intervention risk prediction on AV access outcomes and cost

“…19,20 Reacting to flow changes could be burdensome and also not all stenotic lesions need to be addressed as some at the inflow could be protective from downstream adverse cardiovascular events. 21 Hence there is a need for a more comprehensive methodology to identify patients at risk for reinterventions.…”

Ranger™ paclitaxel-coated balloon versus conventional balloon angioplasty for treatment of failing arteriovenous fistulas and grafts in haemodialysis patients: A retrospective cohort study

“…5,6,8,10 The recently published British guidelines for managing AVF stenosis in haemodialysis patients recommended a lower threshold for the use of DCB across fistuloplasty amongst stenoses recurring between 3 and 12 months, with stenoses recurring after 12-months being treated as de novo lesions and recommending the use of POBA as first-line intervention. 11 The Ranger™ PCB (Boston Scientific, Marlborough, MA, USA) has a 'low' paclitaxel dose density of 2 μg/mm 2 and a lipohilipic acetyl tri-n-butyl citrate excipient. 12 Components of the PCB are built on the platform of the commercially available Sterling (0.018-inch wire-compatible) balloon dilation catheter (Boston Scientific, Marlborough, MA, USA).…”

“…5,6,8,10 The recently published British guidelines for managing AVF stenosis in haemodialysis patients recommended a lower threshold for the use of DCB across fistuloplasty amongst stenoses recurring between 3 and 12 months, with stenoses recurring after 12-months being treated as de novo lesions and recommending the use of POBA as first-line intervention. 11…”