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Finding Consensus on Dialysis Access Stent-Graft Utilisation Strategies in Symptomatic Dysfunctional Arteriovenous
Gianmarco de Donato1,2, Jose Maria Abadal3, Paul Gibbs4
1Vascular Surgery, University of Siena, Siena, Italy.
Insights
European experts reached consensus on using stent-grafts for dysfunctional haemodialysis vascular access (VA). This guidance aims to standardize treatment strategies for improved patient outcomes.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Nephrology
Background:
- Treatment algorithms for dysfunctional haemodialysis vascular access (VA) lack standardization.
- The role of stent-grafts in managing symptomatic dysfunctional VA is not universally defined.
Purpose of the Study:
- To establish consensus among European experts on stent-graft strategies for symptomatic dysfunctional VA.
- To develop standardized recommendations for the use of stent-grafts in vascular access management.
Main Methods:
- A modified 3-round Delphi study involving 12 European experts from diverse specialties.
- Experts evaluated 57 statements on stent-graft utilization, patient factors, and specific anatomical challenges.
- Consensus was defined as ≥75% agreement, with a grading system applied to indicate agreement levels.
Main Results:
- Strong consensus (81% of statements) was achieved across multiple domains regarding stent-graft use.
- Expert panel consensus supported stent-graft application for graft-venous anastomosis, recurrent central venous stenosis, in-stent stenosis, and cannulation zone restenosis.
- High response stability and expert retention (100%) were observed throughout the Delphi process.
Conclusions:
- The Delphi consensus provides robust guidance for current stent-graft strategies in dysfunctional VA.
- Recommendations cover best practices for stent-graft utilization in various vascular access scenarios.
- This multidisciplinary expert-based consensus aims to improve the management of haemodialysis vascular access.
Purpose:
The algorithm of treatment for dysfunctional haemodialysis vascular access (VA) varies significantly between centres, and the role of stent-grafts is not yet standardised. A multidisciplinary panel of European experts on VA was convened, with the aim of finding consensus on stent-graft strategies in symptomatic dysfunctional VA using a modified Delphi approach.
Methods:
A modified 3-round Delphi study was conducted with a panel of 12 European experts from high-volume dialysis access practices across multiple specialties (5 vascular surgeons, 5 interventional radiologists, 1 transplant surgeon and 1 nephrologist). Round 1 involved semi-structured interviews to identify key parameters. Round 2 assessed extent of expert agreement to the statements or if neutral. Round 3 allowed experts to revise responses after viewing anonymised panel results. To highlight gradations of consensus, a grading system (A-D) was applied based on agreement or disagreement, with consensus defined as ≥75% agreement.
Results:
Each expert voted on the 57 statements on treatment considerations relating to optimal stent-graft utilisation; patient background; vascular occlusive pathology; considerations specific to the graft-venous anastomosis, cephalic arch and thoracic central vein stenoses; general treatment considerations with stent-grafts; and a summary treatment algorithm by anatomical location. The analysis revealed strong consensus across multiple domains, with 81% of statements (46/57) achieving ≥75% agreement. An expert panel consensus (≥75% agreement) on the use of stent-graft was found for the treatment of graft-venous anastomosis, recurrent restenosis in the central venous system, in-stent stenosis in previously-placed bare metal stents, and restenosis of the cannulation zone if to be abandoned. All 12 experts completed 3 rounds (100% retention). Response stability was high with only 3 experts adjusting 11 responses (1.6%) between rounds regarding 9 statements that changed the overall consensus level of the panel.
Conclusions:
Based on the elevated strength and high consistency of this international multidisciplinary expert-based Delphi consensus, most of the statements might guide the current stent-graft strategies of dysfunctional VA, including practical recommendations on best practice using stent-grafts.
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