This study examined the relationship between preoperative vein diameter and arteriovenous fistula outcomes in 158 patients. The results showed that fistulas with a minimum vein diameter above 3.3 mm on preoperative ultrasound had significantly greater likelihood of maturation and long-term patency compared to fistulas with a diameter below 2.7 mm. Over a third of fistulas with a diameter under 2.7 mm failed to mature within 6 months. Having coronary artery disease was associated with decreased risk of fistula failure, possibly due to antiplatelet medication use in these patients. Being on dialysis before fistula placement improved long-term patency. This study supports using preoperative ultrasound to determine minimum vein diameter for planning fistula operations.
This study examined the relationship between preoperative vein diameter and arteriovenous fistula outcomes in 158 patients. The results showed that fistulas with a minimum vein diameter above 3.3 mm on preoperative ultrasound had significantly greater likelihood of maturation and long-term patency compared to fistulas with a diameter below 2.7 mm. Over a third of fistulas with a diameter under 2.7 mm failed to mature within 6 months. Having coronary artery disease was associated with decreased risk of fistula failure, possibly due to antiplatelet medication use in these patients. Being on dialysis before fistula placement improved long-term patency. This study supports using preoperative ultrasound to determine minimum vein diameter for planning fistula operations.
This study examined the relationship between preoperative vein diameter and arteriovenous fistula outcomes in 158 patients. The results showed that fistulas with a minimum vein diameter above 3.3 mm on preoperative ultrasound had significantly greater likelihood of maturation and long-term patency compared to fistulas with a diameter below 2.7 mm. Over a third of fistulas with a diameter under 2.7 mm failed to mature within 6 months. Having coronary artery disease was associated with decreased risk of fistula failure, possibly due to antiplatelet medication use in these patients. Being on dialysis before fistula placement improved long-term patency. This study supports using preoperative ultrasound to determine minimum vein diameter for planning fistula operations.
Irene D. Feurer, PhD and David Shaffer, MD, FACS INTRODUCTION Autogenous arteriovenous hemodialysis accesses/ arteriovenous fistulas (AVFs) preferred vascular access for chronic hemodialysis Higher patency rates Reduced complications Reduced costs NKF-KDOQI (Fistula First Breakthrough Initiative) → preoperative duplex ultrasound as the standard of care before placement AVF Recent single-center studies report a primary AVF failure rate of 26% to 50% → primary 1-year patency rate of 36% to 46% Multicenter Dialysis Access Consortium study → 60% of AVFs failed to mature. Some experts suggest a vein diameter of 2.5 mm as adequate for AVF creation One study that did include preoperative vein diameter as a predictor of fistula maturation used a threshold vein diameter of >4 mm The aim of this study was to Test after adjustment for clinical factors Long term patency in patients. METHODS Retrospective review of new AVF access creation from February 2009 to June 2011 by one of three surgeons The selection criteria for type of arteriovenous access followed KDOQI and Society for Vascular Surgery guidelines Radiocephalic Brachiobasilic Brachiocephalic Prosthetic graft This study exclude : Patients younger than 18 years without preoperative vein mapping Fistula for intermittent plasmapheresis Patients who underwent placement of a radiocephalic fistula This study do not include : Presence or absence of central venous stenosis Patients with a prior failed fistula or graft AVF revisions Minimum vein diameter (MVD) was determined from the results of preoperative duplex ultrasound → Intersocietal Accreditation Commission-accredited vascular ultrasound laboratory Measurements of maximum axis of vein lumen diameter were made by the vascular ultrasound technicians: antecubital fossa, distal, midpoint, and proximal The duplex ultrasound examination was performed without a tourniquet by a Philips iU22 ultrasound machine (Philips, Bothell, Wash) with a high-frequency (5- 9 MHz) linear probe Definition Fistula maturation was defined as at least one successful use of the fistula with two needles for dialysis after a clinical determination by the operating surgeon and dialysis technician Long-term or secondary patency was defined as the time to fistula abandonment and could include open or percutaneous interventions to maintain patency. Analysis Statistical analyses were performed with SPSS Statistics V21 Univariate Kaplan-Meier survival analysis with log-rank tests RESULTS Between February 2009 and June 2011, 278 new arteriovenous accesses (194 AVFs (70%), 84 prosthetic grafts (30%)) were placed by one of three surgeons 194 patients who had an AVF placed, 36 were excluded from further analysis for not having vein mapping on chart review (n ¼ 17) having a radiocephalic fistula (n ¼ 14) being younger than 18 years (n ¼ 1) having a fistula placed for plasmapheresis (n ¼ 4) 32 patients (20%) had the fistula fail before use because of either failure to mature (n ¼ 13) or thrombosis (n ¼ 19). Other causes of nonuse for dialysis included ligation for steal (n ¼ 8) death before use (n ¼ 10) transplantation before use (n ¼ 4) 20 patients (13%), the patient was not yet on dialysis at the time of loss to follow-up. Consequently, 84 (53%) of patients’ fistulas were ultimately used for dialysis during the study period Vein diameter data were normally distributed with a mean of 3.4 + 1.1 mm MVD quartiles were defined for quartile 1, <2.7 mm quartile 2, 2.7 to 3.2 mm quartile 3, 3.3 to 4.1 mm quartile 4, >4.1 mm Kaplan-Meier analysis indicated that increased MVD was associated with decreased risk of failure to mature, which is synonymous with an increased likelihood of fistula maturation Fistulas with a vein diameter in the upper two quartiles (MVD > 3.3 mm) had significantly greater likelihood of fistula maturation than did fistulas in the lowest quartile (MVD <2.7 mm). More than one third of AVFs with MVD <2.7 mm failed to mature by 6 months. Model of long-term patency, the fistulas in the upper two quartiles (MVD > 3.3 mm) had a significantly higher likelihood of long-term survival compared with the fistulas in the lowest quartile (MVD <2.7 mm) AVFs with MVD <2.7 mm were associated with a higher risk of failure of maturation and a lower long-term patency than were AVFs with MVD > 3.3 mm Multivariate Analysis Multivariate Cox regression models were used to analyze associations of demographic and clinical covariates Age, sex, race, preoperative dialysis status, and BMI were not statistically significant in any of the multivariate models Having CAD was significantly associated with a decreased overall risk of fistula failure (P ¼ .039) Preoperative dialysis was associated with increased risk of fistula failure (P ¼ .022) DISCUSSION Duplex ultrasound examination has been found to be accurate compared with intraoperative findings of vein diameter This study is also unique because the cohort included patients with prior tunneled dialysis catheters and prior arteriovenous access procedures as well as patients undergoing initial placement of an AVF This study tested whether preoperative clinical covariates were associated with fistula maturation or long-term patency. CAD was significantly associated with a decreased risk of long-term fistula failure but not with failure of fistula maturation. Association between CAD and a decreased risk of failure in the long-term patency model may be secondary to the use of antiplatelet medications CAD as defined in this study are more likely to be receiving antiplatelet therapy to promote patency of cardiac stents or vessels Patients in our study with CAD may have had better long-term patency because of the use of antiplatelet medications Patient medication regimens were not reviewed for this study Being on dialysis before fistula placement was associated with improved long-term patency but not with fistula maturation. Limitation • First, this is a retrospective review, so the determination of the placement of the fistula in a particular location was made by clinical judgment of the operating surgeon. • Second, this was a retrospective study, so information such as flow rate, Kt/V,and needle size requirements to determine the adequacy of the access for dialysis are not available Third, there may be considerable day-to- day variability in vein diameters, depending on the patient’s hydration, type of anesthesia used, and technique (eg, use of tourniquet or not) or different vascular technologists. RESULTS Results from the univariate Kaplan- Meier and multivariate Cox regression models consistently indicate that a reduced vein diameter is associated with increased risk of an adverse outcome CONCLUSIONS Patients with a larger vein diameter on preoperative vein mapping are at lower risk for failure of fistula maturation and have increased long-term AVF patency Duplexultrasound should be used to determine the MVD of the vein for potential future fistula operations MVD was the only clinical or demographic factor associated with both AVF maturation and long-term patency THANK YOU...