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Outcomes of Vascular Access Care and Surgery Managed by Interventional Nephrologists: A Twelve-Year Experience
Giordano Fumagalli1, Stefano De Pietro, Massimiliano Migliori
1Nephrology and Dialysis Unit, USL 12 Versilia Hospital, Lido di Camaiore, Lucca, Italy.
Insights
Nephrologist-led care improves vascular access for hemodialysis patients. This approach increases fistula use and reduces complications, leading to better patient outcomes and less reliance on catheters.
Area of Science:
- Nephrology
- Vascular Surgery
- Dialysis Access
Background:
- Vascular access is critical for hemodialysis, yet arteriovenous fistulas often fail to mature, leading to catheter dependence.
- Optimizing vascular access remains a significant clinical challenge.
Purpose of the Study:
- To evaluate the outcomes of a nephrologist-managed, patient-centered vascular access program.
- To assess the effectiveness of individualized strategies in improving fistula maturation and reducing complications.
Main Methods:
- Retrospective analysis of 305 fistulas and 61 grafts in 270 patients (2002-2013).
- Access planning, surgery, and maintenance managed by a dedicated nephrology team.
- Inclusion of specific surgical techniques like mid-forearm or perforating vein fistulas and selective graft placement.
Main Results:
- 68.6% of patients initiated hemodialysis with mature access.
- Fistula prevalence was 71.7%, graft 15.7%, and catheter 12.6% among prevalent patients.
- Fistulas showed lower primary failure (14.4% vs. 4.9%) and significantly fewer complications (0.188 vs. 1.040 per patient-year) and interventions (0.066 vs. 0.743 per patient-year) compared to grafts (p < 0.001).
Conclusions:
- A nephrologist-driven, patient-centered approach significantly improves vascular access outcomes.
- Individualized strategies, including specific fistula creations and judicious graft use, enhance access prevalence and reduce morbidity.
- This model promotes high fistula utilization and low catheter dependence, optimizing hemodialysis care.
Background:
Optimizing vascular access outcomes is still a challenge, since 30-60% of arteriovenous fistulas fail or do not mature and catheters are widely used in contemporary patients.
Methods:
This study reports on strategies and outcomes in a single center in which access planning, surgery and maintenance are managed by a team of nephrologists. We retrospectively analyzed 305 fistulas and 61 grafts created in 270 consecutive patients between 2002 and 2013.
Results:
The percentage of patients receiving a fistula or graft who initiated hemodialysis with a mature access was 68.6%. Among prevalent patients, 71.7% used a fistula, 15.7% a graft and 12.6% a catheter. Rates of primary failure and revision before cannulation were 14.4 and 1.6% for fistulas vs. 4.9 and 3.3% for grafts. After maturation, complications (1.040 vs. 0.188 per patient-year (py)) and interventions (0.743 vs. 0.066 per py) were greater for grafts than for fistulas (p < 0.001). Secondary patency did not significantly differ between grafts and fistulas (median survival 34.8 vs. 57.3 months, p = 0.36), unless primary failures were excluded from Kaplan-Meier analysis (median survival 34.9 vs. 70.9 months, p = 0.03).
Conclusions:
High fistula prevalence, low access-related morbidity and catheter dependence were achieved using individualized strategies, including mid-forearm or perforating vein fistula creation and selective graft placement in high risk patients. Direct involvement of nephrologists throughout all steps of access care can improve access outcomes, by promoting a patient-centered approach.
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