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Prolongation of hemodialysis access survival with elective revision
1Renal Consultants of Wyoming Valley, P.C., Wikes-Barre, Pennsylvania, USA.
Insights
Elective intervention for hemodialysis accesses, including PTFE grafts and AV fistulas, significantly prolongs access survival. Proactive revision before clotting reduces future complications and interventions, improving overall access longevity.
Area of Science:
- Vascular Surgery
- Nephrology
- Dialysis Access Management
Background:
- Hemodialysis requires reliable vascular access, typically arteriovenous (AV) fistulas or PTFE grafts.
- Access failure, often due to clotting or stenosis, necessitates interventions and can lead to significant morbidity.
- The optimal timing for access intervention remains a critical clinical question.
Purpose of the Study:
- To evaluate whether elective intervention prolongs the survival of hemodialysis accesses compared to intervention after clotting.
- To compare the rates of clotting episodes and subsequent interventions between electively revised and post-clotting repaired accesses.
Main Methods:
- A retrospective study followed 153 hemodialysis accesses (56 fistulas, 97 PTFE grafts).
- Accesses were categorized based on whether the first intervention was elective revision or post-clotting repair.
- Survival, clotting episodes, and intervention rates were compared between these groups.
Main Results:
- Elective intervention in PTFE grafts improved survival (1023 vs. 689 days, p=0.01) and reduced clotting episodes (1.1 vs. 3.6/patient-year, p=0.02).
- In AV fistulas, elective revision significantly increased access longevity (999 vs. 358 days, p=0.005) and decreased clotting (0.5 vs. 4.8/patient-year, p=0.014).
- Electively revised accesses generally required fewer total interventions per patient year in both grafts and fistulas.
Conclusions:
- Proactive, elective correction of abnormalities in both PTFE grafts and AV fistulas extends access lifespan.
- Early intervention before clotting events leads to fewer subsequent clotting episodes and overall interventions.
- This strategy enhances the durability and functional longevity of hemodialysis vascular accesses.
Abstract:
153 hemodialysis accesses (56 fistulas and 97 PTFE grafts) were followed from placement to see if elective intervention prolonged access survival. The mean follow-up was 772 days (minimum 14 days, maximum 2755 days). Patients who expired, were transplanted or transferred were excluded. The groups of fistulas and grafts were subdivided into those whose first intervention was an episode of clotting versus those whose first intervention was an elective revision (either surgical repair or angioplasty of an area of stenosis within the access or run-off). These groups were compared to see whether electively revising an access prior to clotting would change the ultimate longevity of the access when compared to repairing the access after clotting. PTFE grafts with an initial elective intervention had an improved survival compared to grafts that clotted first (1023 days vs 689 days, p = 0.01). The electively revised grafts had fewer subsequent clotting episodes (1.1 clots per patient year vs 3.6, p = 0.02) and fewer interventions (1.8 interventions per patient year vs 3.7, p = 0.06). In fistulas, an initial elective revision increased access longevity when compared to repair after the fistula clotted (999 days vs 358 days, p = 0.005). Clotting episodes were decreased in those electively revised (0.5 clots per patient year vs 4.8, p = 0.014). Total interventions per patient year were also lower in those electively revised (1.2 vs 5.3, p = 0.028). In conclusion, elective correction of abnormalities in PTFE grafts and in AV fistulas prolongs access life when compared to repair after an initial episode of clotting. Elective revision also decreased the subsequent number of clotting episodes per patient year and the total number of interventions (revisions and declottings) per patient year in both grafts and fistulas.