Vascular Access Surveillance: Time to End the Controversy

Abstract

The establishment and maintenance of permanent vascular access for hemodialysis patients are important clinical problems. Vascular access surveillance, currently mandated by the CMS, refers to the task of identifying and correcting an underlying vascular access stenosis to prolong vascular access patency and survival. While this premise makes intuitive sense, this article discusses the underlying evidence to support it, outlining disparate conclusions of clinical practice guidelines and a recent commentary by experts in vascular access.

The Impact of Access Blood Flow Surveillance on Reduction of Thrombosis in Native Arteriovenous Fistula: A Randomized Clinical Trial

“…This can be considered a large multicenter RCT that consolidates the utility of Q A surveillance in AVF, the final step to establish a paradigm. Our results, in addition to the other RCTs in AVF, published in both meta-analyses, could be enough evidence to avoid the false paradigm of QA usefulness in AVF that has been suggested in literature (5, 39).…”

“…The conclusions of meta-analyses have been widely analyzed and criticized (3537394143). There was a mixture of RCT analyzing grafts, AVF, or both, as well as large heterogeneity in the designs, the variability in Q A cut-off and the device used.…”

“You know your own fistula, it becomes a part of you”—Patient perspectives on vascular access: A semistructured interview study

“…The success of hemodialysis for patients with end-stage kidney disease depends on the integrity of the vascular access. 1 However, the creation and maintenance of a working access are still major challenges because of poor acceptability among patients and high rates of complications. 2,3 Vascular access function is an important determinant of patient mortality, morbidity, and quality of life.…”

Arteriovenous access practices in Australian and New Zealand dialysis units

“…Routine surveillance of fistulas and grafts with additional technologies beyond clinical examination and intradialytic venous pressure recordings was common, although the methods used varied between units. Debate as to the benefits or harms of such surveillance continues, 15 with current Australian guidelines making no recommendation regarding monitoring of fistulas due to a lack of definitive evidence. 1 The combination of routine ultrasound and measurement of access blood flow (via ultrasound dilution flowmetry) has been shown to reduce the rate of fistula thrombosis and improve secondary patency in randomised trials and meta-analyses.…”