Hemodialysis arteriovenous access: Detection of stenosis and response to treatment by vascular access blood flow

Schwab, Steve J.; Oliver, Matthew J.; Suhocki, Paul V.; McCann, Richard L.

doi:10.1046/j.1523-1755.2001.00498.x

Cited by 253 publications

(185 citation statements)

References 18 publications

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“…PTA was consistently associated with an improved AVF hemodynamic status, because it abolished R, restored Qb to the prescribed value, and, as reported by others (9,(21)(22)(23), it produced a direct median 323 ml/min increase in Qa, which was constant over the whole range of baseline Qa levels. In addition, post-PTA Qa levels were always higher than 300 ml/min, a threshold below which the risk of incipient thrombosis is reported very high (24).…”

Section: Discussionsupporting

confidence: 75%

A Prospective Controlled Trial on Effect of Percutaneous Transluminal Angioplasty on Functioning Arteriovenous Fistulae Survival

Tessitore¹,

Mansueto²,

Bedogna³

et al. 2003

Journal of the American Society of Nephrology

158

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Abstract. Balloon angioplasty (PTA) is an established treatment modality for stenosis in dysfunctional arteriovenous fistulae (AVF), although most studies showing efficacy have been retrospective, uncontrolled, and nonrandomized. In addition, it is unknown whether correction of stenosis not associated with significant hemodynamic, functional, and clinical abnormality may improve survival in AVF. This study was a prospective controlled open trial to evaluate whether prophylactic PTA of stenosis not associated with access dysfunction improves survival in native, virgin, radiocephalic forearm AVF. Sixty-two stenotic, functioning AVF, i.e., able to provide adequate dialysis, were enrolled in the study: 30 were allocated to control and 32 to PTA. End points of the study were either AVF thrombosis or surgical revision due to reduction in delivered dialysis dose. Kaplan-Meier analysis showed that PTA improved AVF functional failure-free survival rates (P ϭ 0.012) with a fourfold increase in median survival and a 2.87-fold decrease in risk of failure. Cox proportional hazard model identified PTA as the only variable associated with outcome (P ϭ 0.012). PTA induced an increase in access blood flow rate (Qa) by 323 (236 to 445) ml/min (P Ͻ 0.001), suggesting that improved AVF survival is the result of increased Qa. PTA was also associated with a significant decrease in access-related morbidity by approximately halving the risk of hospitalization, central venous catheterization, and thrombectomy (P Ͻ 0.05). This study shows that prophylactic PTA of stenosis in functioning forearm AVF improves access survival and decreases access-related morbidity, supporting the usefulness of preventive correction of stenosis before the development of access dysfunction. It also strongly supports surveillance program for early detection of stenosis.

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Section: Discussionsupporting

confidence: 75%

A Prospective Controlled Trial on Effect of Percutaneous Transluminal Angioplasty on Functioning Arteriovenous Fistulae Survival

Tessitore¹,

Mansueto²,

Bedogna³

et al. 2003

Journal of the American Society of Nephrology

158

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“…In one study [8] of 21 patients with prosthetic arteriovenous accesses that had not previously clotted or required intervention, preemptive angioplasty reduced the risk of thrombosis from 44% to 10% per 100 patients-yrs (P ¼ 0.01). Another study [20] reported that prophylactic angioplasty (N ¼ 32) was superior to the standard treatment of fistulas (N ¼ 30) in reducing thrombosis rate from 25% to 16% per 100 patient-yrs [20]. Tessitore et al [6] evaluated the cost effectiveness of access blood-flow measurements and preemptive angioplasty in 159 patients and observed that a threefold increase in the number of angiographic procedures offset a 77% reduction in thrombosis events and a 65% reduction in fistula loss, thus defining an ''economically dominant therapy'' (i.e., cost-saving).…”

Section: Preemptive Angioplastymentioning

confidence: 99%

Economic analysis of angiography and preemptive angioplasty to prevent hemodialysis‐access thrombosis

Bittl

Cohen²,

Seek

et al. 2009

Cathet Cardio Intervent

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Objectives: We sought to determine the economic value of early angiography and prophylactic angioplasty to prevent hemodialysis‐access thrombosis. Background: End stage renal disease consumes more than 6% of the Medicare budget. There is a need to understand the financial impact of each component of care. Methods: We conducted an observational economic analysis of a closed cohort of 818 hemodialysis patients, of whom 560 were referred for 1437 consecutive radiographic procedures during an 8‐year period. Patient‐level, bottom‐up microcosting methods provided supply and personnel costs before and after expansion of an angiographic referral program. Results: The rate of referral for malfunctioning but nonthrombosed hemodialysis accesses increased from 18.8 ± 8.8 to 48.3 ± 11.9 angiographic procedures per 100 patient‐years (P < 0.001), which was associated with a decline in access thrombosis from 27.6 to 22.0 events per 100 patient‐years (P = 0.029) and a net cost of $34,586 per 100 patient‐years. The incremental cost‐effectiveness ratio for invasive surveillance was $6,177 per thrombosis event avoided. The angiographic program expanded at the same time that the proportion of autogenous fistulas increased from 28.3% ± 11.3% to 59.7% ± 10.7% of total referrals (P = 0.0001). On multivariable logistic regression analysis, the expanded angiography program (P = 0.001) and the proportion of autogenous fistulas (P = 0.0001) were both independently associated with the reduction in access thrombosis. Conclusions: Given the incremental costs and the relatively modest benefits in preventing access thrombosis, preemptive angiographic management may represent a less efficient use of healthcare resources than increasing the number of patients with autogenous fistulas. © 2009 Wiley‐Liss, Inc.

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“…Thrombosis is the leading cause of arteriovenous fistula and graft failure (3), yet there are few well-established risk factors for access thrombosis (4). It is currently thought that most episodes of thrombosis are due to underlying anatomic abnormalities such as access stenosis from fibromuscular and intimal hyperplasia (5,6). However, access thrombosis can occur without anatomic abnormalities (3,6,7), and it is unknown why some patients with anatomic abnormalities experience access thrombosis whereas others do not (8).…”

mentioning

confidence: 99%

Thrombophilia and the Risk for Hemodialysis Vascular Access Thrombosis

Knoll¹,

Wells²,

Young³

et al. 2005

Journal of the American Society of Nephrology

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Vascular access thrombosis is the most common and costly complication in hemodialysis patients. The role of thrombophilia in access thrombosis is not established. A case-control study was conducted of 419 hemodialysis patients to determine whether thrombophilia was associated with arteriovenous fistula or graft thrombosis. Participants were enrolled from three in-center and five satellite dialysis units associated with a Canadian academic health science center that provides dialysis services in a catchment area of one million. Patients were tested for factor V Leiden, prothrombin gene mutation, factor XIII genotype, methylenetetrahydrofolate reductase genotype, lupus anticoagulant, anticardiolipin antibody, factor VIII, homocysteine, and lipoprotein (a) concentrations. Overall, 59 (55%) patients with access thrombosis had at least one thrombophilia compared with 122 (39%) patients without access thrombosis (unadjusted odds ratio [OR], 1.91; 95% confidence interval [CI], 1.23 to 2.98). After controlling for important risk factors, the association between any thrombophilia and access thrombosis remained (adjusted OR, 2.42; 95% CI, 1.47 to 3.99). For each additional thrombophilic disorder, the odds of access thrombosis increased significantly (adjusted OR, 1.87; 95% CI, 1.34 to 2.61). This study suggests that thrombophilia is associated with access thrombosis in dialysis patients. Large, multicenter, prospective cohort studies are needed to confirm the observations from this case-control study.

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Hemodialysis arteriovenous access: Detection of stenosis and response to treatment by vascular access blood flow

Abstract: Sequential measurement of AV access flow is an acceptable means of both monitoring for the development of access stenoses and assessing response to therapy. PTAs of AVF are more durable than PTAs of AV grafts.

Cited by 253 publications

References 18 publications

A Prospective Controlled Trial on Effect of Percutaneous Transluminal Angioplasty on Functioning Arteriovenous Fistulae Survival

A Prospective Controlled Trial on Effect of Percutaneous Transluminal Angioplasty on Functioning Arteriovenous Fistulae Survival

Economic analysis of angiography and preemptive angioplasty to prevent hemodialysis‐access thrombosis

Thrombophilia and the Risk for Hemodialysis Vascular Access Thrombosis

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