Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure

Abstract

Objective The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes. Methods The RAND/UCLA Appropriateness Method was used. Accordingly, a comprehensive literature search was performed and a synthesis of results compiled. The RAND/UCLA Appropriateness Method was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts rated the appropriateness of each scenario in two rounds. On the basis of the distribution of the panelists’ scores, each scenario was determined to be appropriate, inappropriate, or indeterminate. Results Panelists achieved agreement in 2964 (77.7%) scenarios; 860 (41%) AVF and 588 (34%) AVG scenarios were scored appropriate, 686 (33%) AVF and 480 (28%) AVG scenarios were scored inappropriate, and 542 (26%) AVF and 660 (38%) AVG scenarios were indeterminate. Younger age, larger outflow vein diameter, normal or obese body mass index (vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with AVF or AVG appropriateness. Dialysis status was not associated with AVF appropriateness. Body mass index and functional status were not associated with AVG appropriateness. To simulate the surgeon’s decision-making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. Of these 864 clinical situations, 311 (36%) were rated appropriate for AVG but inappropriate or indeterminate for AVF. Conclusions The results of this study indicate that patient-specific situations exist wherein AVG is as appropriate as or more appropriate than AVF. These results provide patient-specific recommendations for clinicians to optimize vascular access selection criteria, to standardize care, and to inform payers and policy. Indeterminate scenarios will guide future research.

Influence of artery and vein diameters on autogenous arteriovenous access patency

“…These data argue strongly for a probabilistic approach to access creation that incorporates both patient factors and the probability of access creation success rather than predetermined anatomic cut points for all patients. 40 For young patients with long life expectancy and minimally diseased vessels or stable renal function, a higher maturation failure rate may be acceptable to preserve access sites. Conversely, for those with advanced age or limited life expectancy and for those actively on dialysis, an approach that maximizes access maturation and use is more appropriate.…”

Survival and Prognostic Predictors of Primary Arteriovenous Fistula for Hemodialysis

“…These data supported the results of a recent study that assessed the suitability of an AVF or an arteriovenous graft (AVG) as the primary vascular access in many scenarios and suggested that an AVG may be more appropriate than an AVF in some clinical situations, e.g., in patients at risk for AVF nonmaturation or in those with short life expectancies. 21) Considering that trends in population aging have increased substantially in recent years in most countries across the globe, 22) vascular surgeons and nephrologists should pay attention to the elderly group and take into account the balance of access failure that leads to additional interventions against life expectancy when determining the optimal vascular access for each patient.…”

Reassessing Recommendations for Choice of Vascular Access

“…Even if RCTs comparing different vascular access types are performed, they cannot possibly address every patient scenario, incorporating multiple factors including age, vascular disease, body mass index, functional status, and preoperative arterial and venous diameters. In this regard, a recent study used the RAND/UCLA Appropriateness Method to assess the appropriateness of an AVF or an AVG in a large number of scenarios (23). Eleven vascular access experts assessed the appropriateness of each access type in 864 clinical scenarios and concluded that an AVG was appropriate in 36% of them (23).…”

“…In this regard, a recent study used the RAND/UCLA Appropriateness Method to assess the appropriateness of an AVF or an AVG in a large number of scenarios (23). Eleven vascular access experts assessed the appropriateness of each access type in 864 clinical scenarios and concluded that an AVG was appropriate in 36% of them (23).…”