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Adding access blood flow surveillance reduces thrombosis and improves arteriovenous fistula patency: a randomized
Inés Aragoncillo1,2, Soraya Abad1, Silvia Caldés3
1Nephrology Unit, Hospital Gregorio Marañón, Madrid - Spain.
Insights
Vascular access blood flow (QA) surveillance significantly reduces arteriovenous fistula thrombosis and improves patency. This cost-effective method enhances AVF longevity compared to standard monitoring.
Area of Science:
- Nephrology
- Vascular Surgery
- Radiology
Background:
- Arteriovenous fistula (AVF) stenosis is a primary cause of AVF failure.
- The efficacy of vascular access blood flow (QA) surveillance in improving AVF function and longevity remains uncertain.
Purpose of the Study:
- To compare QA-based surveillance with pre-emptive stenosis repair against standard monitoring for prevalent mature AVFs.
- To evaluate the impact of QA surveillance on AVF thrombosis, patency rates, and associated costs.
Main Methods:
- A three-year, randomized, controlled, multicenter, open-label trial was conducted.
- AVFs were assigned to either standard surveillance or QA surveillance (quarterly Doppler ultrasound and ultrasound dilution).
- Intervention criteria in the QA group included a 25% QA reduction, QA < 500 mL/min, or significant stenosis with hemodynamic repercussions.
Main Results:
- The QA group showed a significantly lower thrombosis rate (0.025 vs. 0.086 thrombosis/patient/year).
- Improved thrombosis-free patency (HR, 0.30) and secondary patency (HR, 0.49) were observed in the QA group.
- The control group required more central venous catheters, experienced more hospitalizations, and incurred higher vascular access-related costs.
Conclusions:
- QA-based surveillance, integrating Doppler ultrasound and ultrasound dilution, effectively reduces AVF thrombosis frequency.
- This method proves cost-effective and enhances both thrombosis-free and secondary patency rates in autologous AVFs.
Purpose:
Stenosis is the main cause of arteriovenous fistula (AVF) failure. It is still unclear whether surveillance based on vascular access blood flow (QA) enhances AVF function and longevity.
Methods:
We conducted a three-year follow-up randomized, controlled, multicenter, open-label trial to compare QA-based surveillance and pre-emptive repair of subclinical stenosis with standard monitoring/surveillance techniques in prevalent mature AVFs. AVFs were randomized to either the control group (surveillance based on classic alarm criteria; n = 104) or to the QA group (QA measured quarterly using Doppler ultrasound [M-Turbo®] and ultrasound dilution [Transonic®] added to classic surveillance; n = 103).The criteria for intervention in the QA group were: 25% reduction in QA, QA<500 mL/min or significant stenosis with hemodynamic repercussion (peak systolic velocity [PSV] more than 400 cm/sc or PSV pre-stenosis/stenosis higher than 3).
Results:
At the end of follow-up we observed a significant reduction in the thrombosis rate in the QA group (0.025 thrombosis/patient/year in the QA group vs. 0.086 thrombosis/patient/year in the control group [p = 0.007]). There was a significant improvement in the thrombosis-free patency rate (HR, 0.30; 95% CI, 0.11-0.82; p = 0.011) and in the secondary patency rate in the QA group (HR, 0.49; 95% CI, 0.26-0.93; p = 0.030), with no differences in the primary patency rate between the groups (HR, 0.98; 95% CI, 0.57-1.61; p = 0.935).There was greater need for a central venous catheter and more hospitalizations associated with vascular access in the control group (p = 0.034/p = 0.029).Total vascular access-related costs were higher in the control group (€227.194 vs. €133.807; p = 0.029).
Conclusions:
QA-based surveillance combining Doppler ultrasound and ultrasound dilution reduces the frequency of thrombosis, is cost effective, and improves thrombosis free and secondary patency in autologous AVF.
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