Access Survival amongst Hemodialysis Patients Referred for Preventive Angiography and Percutaneous Transluminal Angioplasty

Abstract

SummaryBackground and objectives Referring hemodialysis patients for elective access angiography and percutaneous transluminal angioplasty (PTA) is commonly done to prevent access failure, yet the effectiveness of this procedure remains unclear.Design, setting, participants, & measures An observational matched cohort analysis among 40,132 Medicare beneficiaries receiving hemodialysis with a fistula or graft was performed. Cox regression was used to determine whether access intervention was associated with improved 1-year access survival.Results Nonsurgical access intervention was found to be frequent at a rate of 20.9 procedures per 100 access years. In the 1-year period after intervention using angiography and PTA, the overall access failure rate was 53.7 per 100 access years in the intervention group and 49.6 in the nonintervention group (HR ϭ 1.02; 95% CI, 0.96 to 1.08). Similar findings were also seen when the analysis was repeated in only fistulas (HR ϭ 1.06; 95% CI, 0.98 to 1.15) and grafts (HR ϭ 0.95; 95% CI, 0.86 to 1.05). In patients with a low intraaccess flow rate (HR ϭ 0.86; 95% CI, 0.75 to 0.99) or a new access (HR ϭ 0.79; 95% CI, 0.71 to 0.89), angiography and PTA significantly increased access survival when compared with nonintervention (P for interaction was Ͻ0.0001). Angiography-PTA-related upper-extremity hematoma, vessel injury, or embolismthrombosis occurred in 1.1% of all patients.Conclusions Access characteristics significantly modify the survival benefits of angiography and PTA intervention where the benefits of these interventions are most seen in newer accesses or accesses with insufficient flow.

Sonographic detection of a radiolucent object in dialysis vascular access

“…Percutaneous endovascular angioplasty is the primary choice for treating vascular access failure . By improving dialysis efficiency, the angioplasty has reduced the necessity for vascular access surgical reconstructions .…”

“…Sufficient blood flow in vascular access is mandatory for adequate dialysis, but can be compromised by stenosis and thrombosis (vascular access failure) . Percutaneous endovascular angioplasty is the primary tool to salvage vascular access failures . The increasing number of patients on dialysis has increased the number of vascular access failures and has increased the possibility of angioplasties being performed by unskilled operators, who may accidentally deteriorate the vascular access.…”

AIUM Practice Guideline for the Performance of a Vascular Ultrasound Examination for Postoperative Assessment of Dialysis Access

“…There is uncertainty, and even doubt, in the literature of whether aggressive routine monitoring and angioplasty of a hemodialysis access, especially in a graft, can predict or affect subsequent thrombosis or cumulative patency 4 , 33 – 41 …”

“…The failure rate of hemodialysis access in the first year is high 4 . Clinical monitoring of access function is recommended to detect deterioration in function of the access before thrombosis occurs 5 – 7 .…”

“…In patients who have abnormal flow volumes, salvage procedures or surgical revision may lengthen the life of the access, but there is conflicting data in the literature 10 – 13 . In a data analysis of 40,132 Medicare beneficiaries, the benefits of percutaneous intervention were greatest in patients with new access or low access flow rates 4 . Differences in flow within an arteriovenous fistula (AVF) versus graft must be considered, as there are different diagnostic criteria associated with these two access types.…”