Reduction in arteriovenous graft impairment: Results of a vascular access surveillance protocol

Cayco, Antonio V.; Abu‐Alfa, Ali K.; Mahnensmith, Rex L.; Perazella, Mark A.

doi:10.1053/ajkd.1998.v32.pm9708617

Cited by 61 publications

(50 citation statements)

References 23 publications

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“…Each reported a substantial decrease (by 41 to 77%) in the rate of graft thrombosis during the monitoring/surveillance period, as compared with the historical control period. This reduction in graft thrombosis was observed for clinical monitoring (23,58,71), dialysis venous pressure measurements (67,76), and flow monitoring (11).…”

Section: Mechanical Interventions To Reduce Graft Thrombosismentioning

confidence: 61%

Current Management of Vascular Access

Allon¹

2007

Clinical Journal of the American Society of Nephrology

244

231

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Optimizing vascular access outcomes remains an ongoing challenge for clinical nephrologists. All other things being equal, fistulas are preferred over grafts, and grafts are preferred over catheters. Mature fistulas have better longevity and require fewer interventions, as compared with mature grafts. The major hurdle to increasing fistula use is the high rate of failure to mature of newly created fistulas. There is a desperate need for enhanced understanding of the mechanisms of failure to mature and the optimal type and timing of interventions to promote maturity. Grafts are prone to frequent stenosis and thrombosis. Surveillance for graft stenosis with preemptive angioplasty may reduce graft thrombosis, but recent randomized clinical trials have questioned the efficacy of this approach. Graft stenosis results from aggressive neointimal hyperplasia, and pharmacologic approaches to slowing this process are being investigated in clinical trials. Catheters are prone to frequent thrombosis and infection. The optimal management of catheter-related bacteremia is a subject of ongoing debate. Prophylaxis of catheter-related bacteremia continues to generate important clinical research. Close collaboration among nephrologists, surgeons, radiologists, and the dialysis staff is required to optimize vascular access outcomes and can be expedited by having a dedicated access coordinator to streamline the process. The goal of this review is to provide an update on the current status of vascular access management.

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Section: Mechanical Interventions To Reduce Graft Thrombosismentioning

confidence: 61%

Current Management of Vascular Access

Allon¹

2007

Clinical Journal of the American Society of Nephrology

244

231

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“…Cayco et al (6) reported a graft thrombosis rate of 0.30 events per graft-year using DVP. Allowing for an expected 1-yr event-free rate of 70%, 63 subjects per group were required to detect a hazard ratio of 0.4 with 80% power and a two-sided ␣ of 0.05.…”

Section: Methodsmentioning

confidence: 99%

Regular Monitoring of Access Flow Compared with Monitoring of Venous Pressure Fails to Improve Graft Survival

Moist¹,

Churchill²,

House³

et al. 2003

Journal of the American Society of Nephrology

190

168

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ABSTRACT. Regular vascular access blood flow (Qa) surveillance is recommended to detect graft stenosis; however, there is little evidence that monitoring and correcting with angioplasty improves graft survival. This blinded, randomized, controlled trial of 112 patients studied time to graft thrombosis and graft loss, comparing monthly Qa plus standard surveillance (dynamic venous pressure and physical examination) (treatment group) to standard surveillance alone (control group). Only the treatment group was referred for angiogram if Qa <650 ml/min or a 20% decrease in Qa from baseline. Percutaneous angioplasty was performed for stenosis >50%. The rate of graft thrombosis per patient-year at risk was 0.41 and 0.51 in the control and treatment groups, respectively. Fifty-one interventions (0.93/patient-years at risk) were performed in the treatment group versus 31 interventions (0.61/patient-years at risk) in the control group. There was no difference in time to graft loss (P = 0.890). In a multivariate analysis, aspirin (ASA) therapy at baseline was associated with an 84% reduction in risk of graft thrombosis (odds ratio [OR], 0.14; P = 0.002). Higher baseline Qa (OR, 0.84; P = 0.05) and longer interval since graft insertion (OR, 0.97; P = 0.07) were associated with a decrease in graft thrombosis. Results reveal that graft surveillance that uses Qa increases the detection of stenosis, compared with standard surveillance; however, intervention with angioplasty does not improve the time to graft thrombosis or time to graft loss. E-mail: louise.moist@lhsc.on.ca

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“…A number of studies have evaluated the positive predictive value of an abnormality of clinical AVG monitoring or surveillance for the presence of hemodynamically significant stenosis. The values were 69%-93% for clinical monitoring (80% for physical examination, 69% for unexplained decrease in Kt/V, and 66% for difficulties encountered during the dialysis session) (3,5,(8)(9)(10), 92% for static dialysis venous pressure (6), 87%-100% for flow monitoring (11,12), and 80% for duplex ultrasound (5).…”

Section: Can One Identify Avgs With Significant Stenosis By Noninvasimentioning

confidence: 99%

“…Such an approach makes sense intuitively. In fact, numerous observational studies have reported that implementation of routine AVG stenosis surveillance, in conjunction with preemptive angioplasty, markedly lowers the frequency of AVG thrombosis in comparison with a historical period without AVG surveillance (6,9,10,(15)(16)(17). More recently, six randomized clinical trials (RCTs) have evaluated this research question (4,5,12,(18)(19)(20) (Figure 2).…”

Section: Does Stenosis Surveillance With Preemptive Angioplasty Prevementioning

confidence: 99%

A Patient with Recurrent Arteriovenous Graft Thrombosis

Allon¹

2015

Clinical Journal of the American Society of Nephrology

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Arteriovenous grafts (AVGs) are prone to frequent thrombosis that is superimposed on underlying hemodynamically significant stenosis, most commonly at the graft-vein anastomosis. There has been great interest in detecting AVG stenosis in a timely fashion and performing preemptive angioplasty, in the belief that this will prevent AVG thrombosis. Three surveillance methods (static dialysis venous pressure, flow monitoring, and duplex ultrasound) can detect AVG stenosis. Whereas observational studies have reported that surveillance with preemptive angioplasty substantially reduces AVG thrombosis, randomized clinical trials have failed to confirm such a benefit. There is a high frequency of early AVG restenosis after angioplasty caused by aggressive neointimal hyperplasia resulting from vascular injury. Stent grafts prevent AVG restenosis better than balloon angioplasty, but they do not prevent AVG thrombosis. Several pharmacologic interventions to prevent AVG failure have been evaluated in randomized clinical trials. Anticoagulation or aspirin plus clopidogrel do not prevent AVG thrombosis, but increase hemorrhagic events. Treatment of hyperhomocysteinemia does not prevent AVG thrombosis. Dipyridamole plus aspirin modestly decreases AVG stenosis or thrombosis. Fish oil substantially decreases the frequency of AVG stenosis and thrombosis. In patients who have exhausted all options for vascular access in the upper extremities, thigh AVGs are a superior option to tunneled internal jugular vein central vein catheters (CVCs). An immediate-use AVG is a reasonable option in patients with recurrent CVC dysfunction or infection. Tunneled femoral CVCs have much worse survival than internal jugular CVCs.Clin J Am Soc Nephrol 10: 2255-2262, 2015. doi: 10.2215/CJN.00190115 Patient PresentationThe following vignette illustrates the numerous challenges in optimizing arteriovenous graft (AVG) patency in hemodialysis patients. A 28-year-old woman initiated peritoneal dialysis when she developed ESRD because of focal glomerular sclerosis. She was hospitalized with an intracerebral bleed caused by a ruptured aneurysm 1.5 years later. A ventricular-peritoneal shunt was placed to treat hydrocephalus, and she was anticoagulated with warfarin to keep the shunt patent. Because of residual left-sided weakness and inadequate family support, she was no longer able to perform peritoneal dialysis. A tunneled central vein catheter (CVC) was placed in the right internal jugular vein, and she was switched to maintenance hemodialysis. A left forearm arteriovenous fistula (AVF) clotted 2 weeks after its creation. A subsequent looped left upper-arm AVG was successfully cannulated 5 weeks after its creation. It clotted four times during the ensuing 6 months and was treated each time by an interventional radiologist or nephrologist, who performed percutaneous thrombectomy, in conjunction with angioplasty of a venous anastomotic stenosis. The patient resumed hemodialysis with an internal jugular CVC when the AVG failed. A right radiocephalic AV...

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Reduction in arteriovenous graft impairment: Results of a vascular access surveillance protocol

Cited by 61 publications

References 23 publications

Current Management of Vascular Access

Current Management of Vascular Access

Regular Monitoring of Access Flow Compared with Monitoring of Venous Pressure Fails to Improve Graft Survival

A Patient with Recurrent Arteriovenous Graft Thrombosis

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