Prior to 2007, the waiting time for vascular access surgery at our center was approximately 107 days compared to a UK average of 45 days. Two new pathways were developed; the rapid and super-rapid pathways incorporating an access liaison nurse who organized vessel mapping and referred patients for surgery. This audit was to determine whether the pathways were effective in reducing the waiting times and improving vascular accesses outcomes.
Methods
All 210 patients with established renal failure undergoing 232 vascular access procedures between January 2008 and March 2011 were studied. Detailed patient information including type of procedure and cause of access failure were stored in an Excel spreadsheet and analyzed using SPSS for Windows.
Results
One hundred and twenty patients had a brachiocephalic fistula, 61 a radiocephalic fistula, 39 an access using the basilic vein ± transposition, and 11 a transposition of the long saphenous vein and one a brachio-axillary graft. Overall median waiting time from referral to access surgery was 23 days. Patients were followed up for a median of 248 days after surgery. The overall primary failure rate was 9.1% and 25 of 27 accesses failed because of thrombosis. The overall cumulative survival probability of accesses at one year was 61.4% with a mean survival of 621.2 days (SEM = 34.8).
Conclusion
The clinical pathways have improved VA service to patients with a drastic reduction in waiting times, elimination of synthetic access, and maintenance of satisfactory results.
RaynerH.C., PisoniR.L., GillespieB.W.. Creation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study.Kidney Int.2003; 63(1): 323–330.
2.
PanellaM., MarchisioS., Di StanislaoF.Reducing clinical variations with clinical pathways: do pathways work?Int J Qual Health Care2003; 15(6): 509–521.
3.
OwenJ.E., WalkerR.J., EdgellL.. Implementation of a pre-dialysis clinical pathway for patients with chronic kidney disease.Int J Qual Health Care2006; 18(2): 145–151.
4.
BeckerB.N., Breiterman-WhiteR., NylanderW.. Care pathway reduces hospitalizations and cost for hemodialysis vascular access surgery.Am J Kidney Dis.1997; 30(4): 525–531.
5.
AkohJ.A., SinhaS., DuttaS.. A 5-year audit of haemodialysis access.Int J Clin Pract.2005; 59(7): 847–851.
6.
WooK., FarberA., DorosG., KilleenK., KohanzadehS.Evaluation of the efficacy of the transposed upper arm arteriovenous fistula: a single institutional review of 190 basilic and cephalic vein transposition procedures.J Vasc Surg.2007; 46(1): 94–99.
7.
IvesC.L., AkohJ.A., GeorgeJ., Vaughan-HuxleyE., LawsonH.Pre-operative vessel mapping and early post-operative surveillance duplex scanning of arteriovenous fistulae.J Vasc Access2009; 10(1): 37–42.
8.
RooijensP.P., TordoirJ.H., StijnenT., BurgmansJ.P., Smet deA.A., YoT.I.Radiocephalic wrist arteriovenous fistula for hemodialysis: meta-analysis indicates a high primary failure rate.Euro J Vasc Endovasc Surg.2004; 28(6): 583–589.
9.
OhiraS., KonT., ImuraT.Evaluation of primary failure in native AV-fistulae (early fistula failure).Hemodial Int.2006; 10(2): 173–179.
10.
TordoirJ.H., RooyensP., DammersR., van der SandeF.M., de HaanM., YoT.I.Prospective evaluation of failure modes in autogenous radiocephalic wrist access for haemodialysis.Nephrol Dial Transplant.2003; 18(2): 378–383.
HuijbregtsH.J., BotsM.L., WittensC.H., SchramaY.C., MollF.L., BlankestijnP.J.; CIMINO study group. Hemodialysis arteriovenous fistula patency revisited: results of a prospective, multicenter initiative.Clin J Am Soc Nephrol.2008; 3(3): 714–719.
13.
SilvaM.B.Jr., HobsonRW2nd, PappasP.J.. A strategy for increasing use of autogenous haemodialysis access procedures: impact of preoperative noninvasive evaluation.J Vasc Surg.1998; 27: 302–308.
ShemeshD., ZigelmanC., OlshaO., AlbertonJ., ShapiraJ., AbramowitzH.Primary forearm arteriovenous fistula for hemodialysis access–an integrated approach to improve outcomes.Cardiovasc Surg.2003; 11: 35–41.
16.
HylandK., CohenR.M., KwakA.. Preoperative mapping venography in patients who require hemodialysis access: imaging findings and contribution to management.J Vasc Interv Radiol.2008; 19: 1027–1033.
17.
KarakayaliF., EkiciY., GörürS.K.. The value of preoperative vascular imaging in the selection and success of haemodialysis access.Ann Vasc Surg.2007; 21: 481–489.
18.
NgY.Y., WuS.C., HungY.N., KoP.J.Effect of demographic characteristics and timing of vascular access maturation on patency in Chinese incident haemodialysis patients.Nephrol Dial Transplant.2009; 24(11): 3447–3453.
19.
ChoiK.L., SalmanL., KrishnamurthyG.. Impact of surgeon selection on access placement and survival following preoperative mapping in the “Fistula First” era.Semin Dial.2008; 21(4): 341–345.
20.
Roy-ChaudhuryP., SukhatmeV.P., CheungA.K.Haemodialysis vascular access dysfunction: a cellular and molecular viewpoint.J Am Soc Nephrol.2006; 17: 1112–1127.
21.
DemberL.M., BeckG.J., AllonM.. Effect of clopidogrel on early failure of arteriovenous fistulas for haemodialysis: a randomized controlled trial.JAMA2008; 299: 2164–2171.
22.
OsbornG., EscofetX., Da SilvaA.Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts.Cochrane Database Syst Rev.2008 Oct 8;(4): CD002786.
23.
ColemanC.I., TuttleL.A., TeevanC., BakerW.L., WhiteC.M., ReinhartK.M.Antiplatelet agents for the prevention of arteriovenous fistula and graft thrombosis: a meta analysis.Int J Clin Pract.2010; 64(9): 1239–1244.
24.
HakimR., HimmelfarbJ.Haemodialysis access failure: a call to action.Kidney Int.1998; 54: 1029–1040.
25.
ChanK.E., LazarusJ.M., ThadhaniR., HakimR.M.Anticoagulant and antiplatelet usage associates with mortality among haemodialysis patients.J Am Soc Nephrol.2009; 20: 872–881.
26.
WolfordH.Y., HsuJ., RhodesJ.M.. Outcome after autogenous brachial-basilic upper arm transpositions in the post-National Kidney Foundation Dialysis Outcomes Quality Initiative era.J Vasc Surg.2005; 42(5): 951–956.
27.
MendesR.R., FarberM.A., MarstonW.A., DinwiddieL.C., KeagyB.A., BurnhamS.J.Prediction of wrist arteriovenous fistula maturation with preoperative vein mapping with ultrasonography.J Vasc Surg.2002; 36(3): 460–463.
28.
GheithO.A., KamalM.M.Risk factors of vascular access failure in patients on hemodialysis.Iranian J Kidney Dis.2008; 2(4): 201–207.
29.
GlassC., PorterJ., SinghM., GillespieD., YoungK., IlligK.A large-scale study of the upper arm basilic transposition for hemodialysis.Ann Vasc Surg.2010; 24(1): 85–91.
30.
RuddyJ.M., BrothersT.E., RobisonJ.G., ElliottB.M.Increasing the proportion of autologous arteriovenous fistulas does not diminish fistula patency.Vasc Endovasc Surg.2011; 45(1): 51–54.
31.
KeuterX.H., van der SandeF.M., KesselsA.G., de HaanM.W., HoeksA.P., TordoirJ.H.Excellent performance of one-stage brachial-basilic arteriovenous fistula.Nephrol Dial Transplant.2005; 20(10): 2168–2171.
32.
DukkipatiR., de VirgilioC., ReynoldsT., DhamijaR.Outcomes of Brachial Artery-Basilic Vein Fistula.Semin Dial.2011; 24(2): 220–230.
