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Graft surveillance and angioplasty prolongs dialysis graft patency
A B Roberts1, M B Kahn, S Bradford
1Allegheny University Hospital, East Falls, Department of Surgery, Philadelphia, PA 19129, USA.
Insights
Implementing graft surveillance and percutaneous treatment significantly improved hemodialysis graft survival and reduced thrombosis. This policy enhances long-term outcomes for end-stage renal disease patients requiring vascular access.
Area of Science:
- Nephrology
- Vascular Surgery
- Interventional Radiology
Background:
- Vascular access complications, particularly thrombosis, are a leading cause of mortality in end-stage renal disease (ESRD) patients on hemodialysis.
- Prosthetic grafts are common vascular access in the US, but prone to complications like thrombosis, necessitating frequent interventions.
- A university dialysis unit implemented a graft surveillance policy involving venous resistance measurement, fistulagrams, and percutaneous dilatation to improve graft longevity.
Purpose of the Study:
- To evaluate the impact of a graft surveillance and percutaneous treatment policy on prosthetic graft patency and survival in hemodialysis patients.
- To compare outcomes before and after the policy implementation using a retrospective study design.
Main Methods:
- A retrospective review compared outcomes of 210 patients (control group) for two years pre-policy with 260 patients (study group) for three years post-policy.
- Complicated patients were defined as those requiring more than one intervention within 12 months.
- Data collected included number of thrombotic episodes, operations, fistulagrams, angioplasties, new graft placements, primary patency, and mean graft survival time.
Main Results:
- The study group experienced a significant reduction in thrombotic episodes per patient year (0.52 vs. 1.04, p < .001) compared to the control group.
- Primary graft patency improved from 3.9 months in the control group to 11.5 months in the study group (p < .001).
- Mean graft survival time increased substantially from 6.3 months to 15.8 months (p < .001) after policy implementation.
Conclusions:
- The implemented policy of graft surveillance and percutaneous treatment of stenosis is effective in prolonging prosthetic graft patency and survival.
- This proactive approach significantly reduces thrombotic complications and the need for repeated interventions in hemodialysis patients.
- The findings support the adoption of such surveillance and treatment strategies to improve long-term outcomes for ESRD patients with prosthetic grafts.
Background:
In the United States of America, vascular access complications are the most frequent cause of death among patients with end-stage renal disease on hemodialysis. The majority of American patients with end-stage renal disease have prosthetic grafts for access. The most common complication of prosthetic graft fistulas is thrombosis. To prolong graft life and decrease the frequency of operations, a university-based dialysis unit adopted a policy of graft surveillance by measuring venous resistance, followed by fistulagram and percutaneous dilatation of identified stenoses. The purpose of this retrospective study is to determine if this policy affected graft patency and graft life.
Study Design:
This retrospective review compares outcomes for two years before adoption of this policy (control group, 210 patients) with the outcomes for three years after adoption (study group, 260 patients). Fifty (24 percent) of the control group and 71 (27 percent) of the study group were defined as "complicated" patients because they underwent more than one intervention over any 12-month period.
Results:
The 50 complicated patients in the control group underwent 104 operations for thrombosis over two years, 1.04 thrombotic episodes and operations per patient year. Seventy new grafts were placed with a mean primary patency of 3.9 months. Mean graft survival time was 6.3 months. The 71 complicated patients in the study group underwent 111 fistulagrams, 80 angioplasties, and 110 operations over three years, for 0.52 thrombotic episodes per patient year (p < .001). Forty-five new grafts were placed with a primary patency of 11.5 months (p < .001). Mean graft survival time was 15.8 months (p < .001).
Conclusions:
This retrospective study demonstrates the effectiveness of a policy of graft surveillance and percutaneous treatment of graft stenosis in prolonging primary surgical patency and graft survival.