Indian Journal of Vascular and Endovascular Surgery

EXPERT COMMENT
Year
: 2017  |  Volume : 4  |  Issue : 2  |  Page : 36--37

Salvaging dialysis fistula and grafts


Kumud Rai 
 Associate Editor, Department of Vascular and Endovascular Surgery, Max Superpecialty Hospital, New Delhi, India

Correspondence Address:
Kumud Rai
Associate Editor, Department of Vascular and Endovascular Surgery, Max Superpecialty Hospital, New Delhi
India




How to cite this article:
Rai K. Salvaging dialysis fistula and grafts.Indian J Vasc Endovasc Surg 2017;4:36-37


How to cite this URL:
Rai K. Salvaging dialysis fistula and grafts. Indian J Vasc Endovasc Surg [serial online] 2017 [cited 2021 Sep 25 ];4:36-37
Available from: https://www.indjvascsurg.org/text.asp?2017/4/2/36/205699


Full Text

While renal transplantation (KTP) is the ideal treatment for the end-stage chronic kidney disease (CKD) patients, this is available only to a fraction of these unfortunate patients. Furthermore, the percentage of CKD patients who receive a KTP in India is abysmally low as compared to the Western world. The vast majority needs long-term dialysis; maintenance hemodialysis (MHD) is usually the lifeline for them. Peritoneal dialysis is generally not preferred as it is cumbersome, less efficient, and more expensive than MHD. A well-functioning dialysis access procedure is the essential prerequisite for MHD. The tragedy is that almost all fistulas and grafts fail over time. Since the number of access sites/procedures is finite, it is imperative that all efforts are directed to “keep the fistula going” for as long as possible. Salvaging a dialysis fistula (or graft) assumes special importance in the light of the above-mentioned facts.

It is imperative that a failing fistula (or graft) be identified before it actually closes down. A failing fistula is far easier to treat than one which has actually thrombosed. A formal fistula surveillance program in the dialysis unit is ideal. While this requires some investment in terms of time, money, and effort, a simple sensitization of the dialysis technician toward the “red flags” can often lead to an early detection. Criteria to detect a failing fistula are varied but reasonably well defined. Clinical parameters include the presence of a good thrill; if only a pulse is present (without accompanying thrill), it indicates distal venous stenosis. Gross edema of the limb with telltale collateral veins over anterior chest wall is pathognomonic of central venous occlusion. Excessive access site bleeding after removal of dialysis cannula is another sign of proximal stenosis. Failure of fistula to mature over a reasonable time (normally 6–8 weeks) indicates a technical problem.

The most objective criteria – urea clearance with dialysis (Kt/V) – are difficult to utilize in clinical practice. Elevated venous pressure during dialysis is an early sign of a problematic fistula. Pressures in fistula >50% of mean arterial pressure (after the dialysis pump has been switched off) are considered significant. Rising trend of fistula pressures over a period of time is even more important than absolute values and mandates further evaluation. Flow measurements are more cumbersome and generally not available in most dialysis units as these require special hemodialysis monitors. The National Kidney Foundation Kidney Disease Outcome Quality Initiative guidelines recommend further evaluation if the flow rate is et al. An office-based procedure, it overcomes almost all the disadvantages of the Cath Lab-based procedures. However, it may not be all that simple as it sounds. Banerjee et al. report their experiences with office-based fistuloplasty under ultrasonography (USG) guidance in this issue of the Journal. Their initial success rate of 84% is impressive, but issues with patient selection and ultrasound- and catheter-based skills remain unanswered. In general, USG-guided fistula angioplasty has not been found superior to the conventional procedure under Cath Lab imaging. They have largely been used to treat stenosis in native veins; they are not useful in treating anastomotic stenosis – whether at the arterial or the venous end. Finally, a failed procedure adds to the effort of fistula salvage and treatment costs.

Dialysis access procedures – fistulas and grafts – need active surveillance and prompt interventions to detect and treat the failing access procedure. Failure to do so comes at a high cost to the individual and the society. Treatment is surgical or by catheter-based interventions. The latter has the advantage of being less invasive and relatively simple. Office-based procedures including USG-guided fistuloplasty are increasingly being utilized to treat these patients. Randomized controlled trials are required to test these procedures “head to head” and to clearly define the role of each procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.