Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 63-65

Systematic surveillance of arteriovenous fistula patency in renal failure patients – Our early experience


1 Department of Surgery, Vascular Surgery Unit, Sultan Qaboos University Hospital, Muscat, Oman
2 Department of Radiology, Sultan Qaboos University Hospital, Muscat, Oman
3 Department of Medicine, Nephrology Unit, Sultan Qaboos University Hospital, Muscat, Oman

Date of Submission04-May-2020
Date of Decision22-May-2020
Date of Acceptance25-May-2020
Date of Web Publication20-Feb-2021

Correspondence Address:
Edwin Stephen
Department of Surgery, Vascular Surgery Unit, Sultan Qaboos University Hospital, Muscat
Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_52_20

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  Abstract 


Objective: Does systematic surveillance help improve arteriovenous fistula (AVF) patency and health economics in renal failure patients? Materials and Methods: As part of a quality initiative project, prospective data were maintained in the electronic medical records at the Sultan Qaboos University Hospital by our clinical nurse specialist, of AVFs created for patients requiring renal replacement therapy from December 2015. Beginning in January 2018, a surveillance program of patients undergoing intervention to improve patency of AVF was started. The records of these patients up to December 31, 2019, were accessed to see if the program helped improve patency, thereby reducing the number of emergency admissions and improving health economics. The minimum follow-up period was 8 weeks. Results: A total of 143 patients had AVFs created during the study period. Fifty-one patients required fistulogram with or without fistuloplasty. Thirty-six out of 51 (70%) fistulas remain patent, whereas 9 (18%) thrombosed and 6 (12%) were either lost to follow-up or deceased. The number presenting to the emergency department reduced by 50%. In addition, we observed a noticeable reduction in the number of emergency procedures required to sustain the fistula. Both duration of in-hospital stay and repetitive investigations were reduced. Conclusion: A surveillance program requires liaising with the patient, their relatives, local health center, regional dialysis unit, interventional radiology, nephrology, and vascular surgery team. We have seen a significant reduction in emergency interventions, increase in overall patency rate of AVFs, shorter in-patient hospital stays, and a decrease in number of laboratory investigations repeated.

Keywords: Arteriovenous fistula, chronic kidney disease, nurse specialist, Oman, patency, renal replacement therapy, surveillance, vascular


How to cite this article:
Al-Hinai M, Al-Maawali H, Stephen E, Abdelhady I, Al-Aufi A, Al Sukaiti R, Al Riyami D, Al-Wahaibi K. Systematic surveillance of arteriovenous fistula patency in renal failure patients – Our early experience. Indian J Vasc Endovasc Surg 2021;8:63-5

How to cite this URL:
Al-Hinai M, Al-Maawali H, Stephen E, Abdelhady I, Al-Aufi A, Al Sukaiti R, Al Riyami D, Al-Wahaibi K. Systematic surveillance of arteriovenous fistula patency in renal failure patients – Our early experience. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Mar 1];8:63-5. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/63/309717




  Introduction Top


In Oman, the incidence of end-stage renal disease (ESRD) was 120 per million population in 2013, with over 40% attributed to either diabetes mellitus or hypertension.[1] Interestingly, 31.5% of the Omani's with ESRD are below the ages of 44, as compared to 47.1% between 45 and 64 years of age. This was attributed to the high incidence of inherited nephropathies within the population,[1] which poses an additional demand to provide reliable hemodialysis access as a bridge for renal transplantation.

An arteriovenous fistula (AVF) is considered a lifeline for an individual with ESRD and is widely accepted as the best modality for hemodialysis owing to its superior long-term patency and lower incidence of stenosis, thrombosis, and infection as compared to other access methods.[2] High-risk features such as thrombosis, bleeding after the removal of cannula, aneurysmal dilatation, and venous hypertension [Figure 1]a remain a threat to ESRD patients.
Figure 1: (a) Aneursymal brachiocephalic arteriovenous fistula with dilated chest veins- suggests central stenosis. (b) Fistuloplasty of cephaloaxillary junction stenosis

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A surveillance program would reduce the morbidity and mortality associated with AVF complications by enabling the early detection and prompt intervention for high-risk fistulas. This quality initiative project we hoped would improve clinical outcomes and reduce the financial burden on health-care institutes.[3]


  Materials and Methods Top


Prospective data were maintained in the electronic medical records at Sultan Qaboos University Hospital by our clinical nurse specialist (CNS), for all AVFs created from December 2015 in patients requiring renal replacement therapy. From January 2018 up to December 31, 2019, a surveillance program of patients undergoing intervention to improve patency of AVF was started with a minimum follow-up period of 8 weeks.

Our protocol is for all patients who had AVFs created to come for a routine follow-up 4 weeks after AVF creation. The AVF is examined for thrill, limb for any sign of ischemia, and healing of the surgical site. Duplex ultrasonography is performed to assess the depth of the vein from the skin, vein diameter and flow rate in the AVF. If features of maturation are seen and no potential difficulties to cannulation, the patient is referred back to their regional dialysis unit (RDU) with documentation regarding the type of fistula, date after which it may be used, how to care for it and contact details of our CNS-to be contacted directly if high-risk features are noted. The CNS liaisons with the vascular surgery team, nephrologist/s, interventional radiology team [Figure 1]b, to arrange prompt evaluation and management. The patient would receive a direct day-care admission bypassing the need to be seen in the emergency department (ED).

The records were accessed to see if the surveillance helped improve patency, reduced number of emergency admissions, and its effect on health economics.


  Results Top


There were a total of 143 patients during the study period; 51 required fistulogram with or without fistuloplasty. At follow-up, 36 (70%) remain patent, 9 (18%) thrombosed and 6 (12%) were either lost to follow-up or deceased [Figure 2]a. Number presenting to the ED reduced 50% with an observed reduction in in-hospital stay as all the patients were treated as day-care admissions. Coagulation and electrolyte studies were from the RDU, and therefore, investigations were not repeated.

The above lead to a noticeable reduction in the number of emergency procedures required [Figure 2]b.
Figure 2: (a) Patency rates. (b) Trend of emergency procedures required

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  Discussion Top


Thrombosis is the leading cause for primary fistula failure and permanent access loss,[4] it complicates 1 of 4 fistulas created. If detected and corrected early, adequate dialysis is maintained, maturation facilitated, and access loss avoided.

Stenosis along the AVF is the second-most prevalent AVF complication with an incidence of 14%–42%; it initially presents as difficult cannulation, painful arm edema or prolonged bleeding after cannulation and may eventually lead to access thrombosis.[5] At our center, evaluation and treatment of these patients was frequently delayed due to – poor communication from the RDU, nonavailability of intervention slots in radiology suite thus prolonging the patient's in-hospital stay and mandating insertion of a temporary dialysis access line (if AVF is thrombosed) thereby increasing the risk of line-associated complications and overall economic burden.

In a world with ever-increasing economic turbulence, it becomes particularly important to optimize expenditure cost-effectively. Thamer et al. observed that vascular access costs were 2–3 times higher for patients whose AVFs experienced primary or secondary patency loss and 4 times higher for patients who never used their AVFs.[6] Thereby justifying a need for a surveillance system to be in place.

The quality initiative project, despite its limitations of small numbers has encouraged us to change our practice since we observed positive outcomes in individuals with early fistula complications. Admissions through ED were reduced; patients had shorter waiting times, quicker intervention, resulting in high assisted patency rates.

This was also seen as an effective method to reduce health-care costs as patients were managed as day-care admissions with investigations not being repeated in RDU and our hospital. We found no such study in English or Arabic medical literature.


  Conclusion Top


The clinical and financial impact seen at this point may appear small due to the limited number of patients. We anticipate more tangible benefits as we continue to implement this surveillance program over the coming years.

Centers managing patients requiring renal replacement therapy should have an open channel of communication between the vascular, interventional radiology, nephrology, and RDU to identify high-risk patients enabling improved patency rates of AVF created and a CNS plays a key role in orchestrating the smooth timely transfer of care for such patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Al Alawi I, Al Salmi I, Al Mawali A, Al Maimani Y, Sayer JA. Endstage kidney failure in Oman: An analysis of registry data with an emphasis on congenital and inherited renal diseases. Int J Nephrol 2017;2017. Available from: https://doi.org/10.1155/2017/6403985. [Last accessed on 2020 Jan 10].  Back to cited text no. 1
    
2.
Bylsma LC, Gage SM, Reichert H, Dahl SLM, Lawson JH. Arteriovenous fistulae for haemodialysis: A systematic review and meta-analysis of efficacy and safety outcomes. Eur J Vasc Endovasc Surg 2017;54:513-22.  Back to cited text no. 2
    
3.
Kumbar L, Karim J, Besarab A. Surveillance and monitoring of dialysis access. Int J Nephrol 2012;2012:649735. Availabler from: https://doi.org/10.1155/2012/649735. [Last accessed on 2020 Jan 15].  Back to cited text no. 3
    
4.
Gjorgjievski N, Dzekova-Vidimliski P, Gerasimovska V, Pavleska-Kuzmanovska S, Gjorgievska J, Dejanov P, et al. Primary failure of the arteriovenous fistula in patients with chronic kidney disease stage 4/5. Open Access Maced J Med Sci 2019;7:1782-7.  Back to cited text no. 4
    
5.
Stolic R. Most important chronic complications of arteriovenous fistulas for hemodialysis. Med Princ Pract 2013;22:220-8.  Back to cited text no. 5
    
6.
Thamer M, Lee TC, Wasse H, Glickman MH, Qian J, Gottlieb D, et al. Medicare costs associated with arteriovenous fistulas among US hemodialysis patients. Am J Kidney Dis 2018;72:10-8.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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