Dear Editor
The COVID-19 crisis has opened the Pandora’s box of interconnected challenges where,
vascular access and renal physicians must confront with and adapt in order to deliver
the maximum desired health care service for their dialysis patients. Raising the bar
for quality means that high surgical and endovascular standards are becoming the cornerstone
of treatment option and dedicated experienced medical staff is the sine qua non for
achieving this goal. An operative team checklist should be developed to accomplish
maximum safety with optimal results coupled with larger patient volume and a rapid
turnover, at the same time focusing on reducing the potential risk of COVID-19 transmission.
The recommendations recently proposed by the European and American Vascular Societies
in this new “COVID-19” era, regarding the deferral of vascular access (VA) creation
in incident pre-dialysis patients, or revision for VA malfunction/steal in prevalent
dialysis patients aims to protect them, the medical staff and the community from uncontrolled
spread of the virus and consequently from possible avoidable mortality.
1
,
2
Fortunately, the coronavirus pandemic will not last forever, and even though there
will be a second intense wave of the epidemic in some countries, many things will,
and must change, after the quarantine is permanently lifted, especially the safely
care of high risk patients, like those on maintenance hemodialysis. However, this
global pandemic crisis really unmasked the general rule that if these potentially
non-infected hemodialysis patients are handled appropriately, by dialysis clinicians
and VA surgeon teams, this can be turned into a high opportunity to avoid COVID-19
infection. We will describe in this letter, our strategies and proposals for optimum
VA surgery results in the pandemic period establishing the lowest risk of COVID-19
transmission.
1
The need of dedicated vascular access care
Clinicians know that the infectivity of this virus is high in this cohort, not only
due to immunosuppression and increased comorbidity,
3
but also due to disproportional great burden of infectious risk factors at regular
life-saving dialysis sessions.
4
Furthermore, patients receiving maintenance hemodialysis are more susceptible to COVID-19
and hemodialysis centers are high-risk settings, as confirmed in a recently published
article from Wuhan, China.
5
As such, a shift of patients to less frequent hemodialysis schedules (twice-weekly)
has been proposed, an option that would likely provide adequate control of uremia,
at least over a matter of weeks and also proved beneficial for the patients and staff,
providing less exposure to potential coronavirus disease 2019 infection.
6
On the other hand, dialysis dependent patients, acknowledging their high vulnerability
because of their chronic illness, are worried that patient clustering during dialysis
in large medical centers or private facilities, could expose them to viral transmission
from asymptomatic people having the disease, thus becoming future outbreaks. Notably,
we were witnessing negative responses to this pandemic, from hemodialysis patients,
that we have never seen before. Patients are refusing to receive declotting of thrombosed
arteriovenous grafts, correction of large access-related pseudoaneurysms (FIG) or
even transplantation that was expected for several months! Additionally, we experienced
patients even refusing treatment for foot gangrene attributed to severe peripheral
arterial disease due to anxiety of a prolonged hospital stay! This reluctance for
salvaging VA for example, comes from the fear of acquiring COVID-19 infection, since
residents in every country receiving maintenance dialysis treatment, belong to one
of the most vulnerable sub-populations in medical practice. Surprisingly, in many
occasions, this hesitation overcomes the benefit of establishing a well-functioning
fistula or graft!
In this regards, all VA surgeons must give priority in altering modifiable factors
of different aspects of VA care of these patients, leading to the lower hospitalization
rates with optimum results. Both nephrologists and VA surgeons have to persuade them
that the delivery of healthcare will be safe and of the best quality even in this
global human threat period. Although several COVID-19 related organizational models
for the protection of renal patients and staff have been described in many dialysis
units,
7
clinical choices and operational strategies guided to VA creation and maintenance
are lacking. Recent universal recommendations state that operations on patients with
confirmed or suspected COVID-19 infection must be carried out in a designated room
with necessary protection for medical staff.
8
This of course contributes to the big challenge of epidemic control, but VA issues
still remain unresolved, while re-establishing confidence between patients and healthcare
workers is urgently required. The following are some of the critical points, non-dialysis
facilities related, but VA-related, in mitigating the risk of COVID-19 spread and
keeping VA complications to a minimum.
2
The “surgeon and center effect” phenomenon
Starting from the impact of surgeon’s experience, substantial variations in outcomes
of VA surgery exist between countries,
9
suggesting that in countries with high COVID-19 contamination burden, like Italy Spain,
UK and USA for example, a focus on the “surgeon effect”
10
in the pandemic period, could result in better fistula outcomes from the best qualified
VA surgeons. Furthermore, a study from the Netherlands showed that the probability
of primary failure is strongly related to the center of access creation, suggesting
an important role for the vascular surgeon’s skills and decisions, apart from the
similarly important role of the caring nephrologists. More specific, the primary fistula
failure rate, varied from 8% to 50% among 11 centers, and when adjusted for potential
risk factors and for surgery-related factors, some centers had 5.5 to 9.4 fold lower
performances compared to reference ones,
11
suggesting that the “center effect” phenomenon is also countable even within the same
country or region. Translating this to a “global effect” phenomenon, in which great
differences in the distribution of VA use by country (Dialysis Outcomes and Practice
Patterns Study data) exist, nations with high prevalence of fistulas, like China,
Germany and UK, (87%, 80% and 80% respectively)
12
must regulate their strategies tailoring every complicated case to the most qualified
VA surgeons with the best judgment and techniques. This modified strategy will keep
known and unjust disparities in health care of end-stage-renal-disease patients, which
generally represent institutional or provider biases, to a minimum. In real-world
conditions, identification of centers of VA excellence and/or experienced VA physicians
is a composite and multifactorial process. However, physician-centered quality indicators,
self-reported VA preference surveys and patient questionnaires could indicate the
continuing efforts by dialysis units to optimize vascular access use for their patients.
The adjustment of each National health-care system to the local aspects involved in
increasing AVF functionality through monitoring and optimizing vascular access surgery
should be able to improve VA outcomes, leading to the “surgeon and center effect”
phenomenon. As a surgical tactic, this is more important in countries with the highest
threat by the coronavirus pandemic, which should assess their available VA surgeon
capacity and match this to the dialysis dependent patient’s needs, keeping their complications
to a minimum. Developed operative teams should be able to accomplish maximum safety
with optimal results coupled with rapid turnover.
Taking the responsibility of this proposal, in our view, only vascular surgeons and
a few expert nephrologists should be involved in the care of dialysis patients,
13
in the pandemic period, especially those performing increased rate of complex procedures.
It is reasonable for everyone to assume that surgical trainees should not be involved,
considering the reduced likelihood of fistula use reported in a previous DOPPS study,
when performed by uncertified and not qualified residents,
14
leading to readmissions for a new VA, for fistula thrombosis episodes or prolongation
of central venous catheter (CVC) use. In another DOOPS study, the risk of primary
fistula failure was 34% lower when created by surgeons who exceeded the threshold
of 25 fistulas during training (relative risk, 0.66; P=0.002).
15
Furthermore, increased surgeon training in fistula placement was associated with a
greater likelihood of fistula versus graft placement, with an adjusted odds ratio
of 2.2 for fistula placement for each 2-fold-higher number of fistulas created during
training (P=0.0001).
15
Apart from first time fistulas in incident or prevalent CVC patients, expeditious
but effective VA surgery requires that time and type of access, complicated redo operations
salvaging failing or managing failed fistulas are beyond the technical surgical performance
of trainees and less experienced VA surgeons, potentially leading to suboptimal results.
16
Taking in aggregate, a low “failure to save” index (defined as the number of abandoned
fistulas divided by the number of failing/failed and non-matured ones within 6 weeks
from creation) obtained in the pandemic period, is the mirror of high performance
quality in VA surgery, since this index is less sensitive to patient related factors
than hospital/surgeon performances.
17
Besides VA saving issues, the meticulous planning and process of “proper VA selection”
are fundamental in order to avoid type of accesses that will eventually not fulfill
the needs of the patient’s dialysis prescription leading to more future interventions
18
undesirable in this pandemic period. Until studies able to predict which patients
will likely have fistulas, that will mature but also, those that will require procedures
to assist maturation and patency, a more thoughtful approach to VA selection is required
during the ongoing COVID-19 outbreak. Considering all above, and ensuring the best
VA team and procedure, VA creation and revision, will come a priority even in the
pandemic era. Delivering on that promise to patients and nephrologists resides to
the more smoothly transition from a “VA lockdown” to VA establishing practices.
3
High surgical and endovascular vascular access standards
Managing surgical and endovascular workload during a protracted COVID-19 outbreak
also involves searching for innovative solutions.
19
Therefore, a great proportion of fistula creation or reconstruction should be switch
towards minimally invasive strategies, preferably percutaneous, in both the elective
and emergency setting. Maintenance PTA reduces the thrombosis rate and associated
hospitalization, CVC placement, and missed dialysis sessions, suggesting that despite
financial implications, dedicated endovascular fistula salvage solutions from experienced
interventionalists,
20
should be highly incorporated in this pandemic period practice. End events like fistula
thrombosis, could be catastrophic, especially if the CVC has a lengthy course, mainly
from patient reluctance to receive any hospitalization and interventional therapy
serving as potential vectors for coronavirus infection. As such, countries with already
high rates of CVCs in incident patients, like USA, will probably have a major problem
in this critical period, since CVCs are the dominant driver of morbidity and mortality.
21
However, if a CVC placement is unavoidable, placement should be performed in an isolation
suite with the use of a portable ultrasound and C-arm. Even though current practice
patterns may not align with patient interests, mismatches in patient eligibility for
fistula rather than graft should be kept to a minimum in order to avoid many pre-maturation
and post-maturation interventions contributing to shorter time periods of “complication
free fistula use.”
Special vaccine for COVID-19 disease is not yet available but until then, we will
face many necessary readmissions for VA complications considering that a typical VA
intervention rate is approximately 1.9 per patient per year. Thus, the perfect current
hospital environment, we need now, is one that requires short hospitalization period,
the least possible morbidity rates and the one-shot solution to the problem.
9
However, the lack of in-hospital beds and alterations in nursery staff might change
the whole availability organization at some hospitals, serving as the key factor in
surgical decision-making in some cases in favor of urgent or semi-urgent surgical
care alone.
22
Following these, our goals should be tailored to attain a reliable dialysis access
for each patient
18
in one operating theater visit session. Failure to obtain these needs, will eventually
lead to patients but also nephrologists to dissatisfaction. Last but not least, efficient
cannulation techniques, preferably under ultrasound guidance,
23
are highly dependent on the level of expertise of the dialysis unit medical and nursing
staff, representing a barrier to dialysis unit complications avoiding further patient
dissatisfaction when successful.
Definitely, the COVID-19 crisis has opened the Pandora’s box of interconnected challenges
where VA surgeons must confront with and adapt in order to deliver the maximum desired
health care service for dialysis patients. Raising the bar for quality means that
high surgical and minimally invasive endovascular standards are becoming the cornerstone
of treatment option and dedicated experienced medical staff is the sine qua non for
achieving this goal.
As a conclusion, uremic patients on dialysis needing VA care should not influenced
by the pandemic issue and should be motivated by our growing abilities to develop
personalized treatments for every acute and chronic VA complications. Although nephrologists
cannot modify VA disease presentation, continuity of follow-up and their updated clinical
information to dialysis patients is the key to success. Furthermore, the suitability
of therapeutic approaches when urgently needed should be addressed by an experienced
and qualified VA surgeon and center, with the lowest COVID-19 contamination risk.
Like all vascular patients, dialysis patients must not become collateral damage of
COVID-19.
24
Managing our abilities to this susceptible population, dialysis patients could overcome
their reluctance to any surgical or interventional procedure, a fact that poses risks
to their general health. Moving forward, by achieving these alliances, nephrologists
and VA surgeons could reach out, even more actively, to the broad array of VA problems
promoting the health of dialysis patients.(see Fig 1
)
Figure 1
A 14-years old girl from Somalia, living in a refugees camp in Greece, was admitted
in an emergency basis in our hospital, suffering from a large pseudoaneurysm in a
brachial-cephalic fistula (primary patency ∼4 years), with impending rupture. For
the fear of COVID-19 infection, her mother initially refused hospitalization for vascular
access revision.