Upper Extremity Axillary Loop Grafts: An Opportunity in Hemodialysis Access

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Abstract

Background

Dialysis vascular access complications are considered as significant causes of morbidity in chronic hemodialysis patients.

Objectives

The aim of the present study was a comparison of axillary loop and straight grafts patency and its complications in hemodialysis access.

Patients and Methods

In this cohort study conducted at Shahid Beheshti Medical University, 77 patients who underwent placement of loop or straight access grafts were included. Demographics, primary and secondary patency rates and complications like thrombosis, infection, bleeding, steal syndrome and other complications were compared in these two groups. The collected data was analyzed by chi-square test, t-test, and logistic regression.

Results

Primary patency rate in straight and loop groups after 1 month were 88.9% and 92.3% respectively ( P = 0.721), and after 24 months were 31% and 55.5% respectively ( P = 0.058). Secondary patency rate in straight and loop groups after 3 months were 75.6% and 92.3% respectively ( P = 0.189), and after 24 months were 37.9% and 66.7% respectively ( P = 0.044). The frequency of complications were the same among two methods of graft replacement and mal incidence of thrombosis, infection, delayed infection, pseudoaneurysm formation and steal syndrome occurrence ultimate graft failure and venous hypertension were not significantly different ( P > 0.05).

Conclusions

Polytetrafluorethylene (PTFE) vascular graft seems to be an appropriate vascular access and is a promising alternative when upper extremity arteriovenous fistulas cannot be constructed. Additionally, there was no significant difference between the two groups for complications and early patency, but late patency was improved in loop group. More study is necessary for a conclusive assessment.

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Most cited references 19

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Vascular access use and outcomes: an international perspective from the dialysis outcomes and practice patterns study

Jean Ethier, David C Mendelssohn, Stacey Elder … (2008)

Background. A well-functioning vascular access (VA) is essential to efficient dialysis therapy. Guidelines have been implemented improving care, yet access use varies widely across countries and VA complications remain a problem. This study took advantage of the unique opportunity to utilize data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) to examine international trends in VA use and trends in patient characteristics and practices associated with VA use from 1996 to 2007. DOPPS is a prospective, observational study of haemodialysis (HD) practices and patient outcomes at >300 HD units from 12 countries and has collected data thus far from >35 000 randomly selected patients. Methods. VA data were collected for each patient at study entry (1996–2007). Practice pattern data from the facility medical director, nurse manager and VA surgeon were also analysed. Results. Since 2005, a native arteriovenous fistula (AVF) was used by 67–91% of prevalent patients in Japan, Italy, Germany, France, Spain, the UK, Australia and New Zealand, and 50–59% in Belgium, Sweden and Canada. From 1996 to 2007, AVF use rose from 24% to 47% in the USA but declined in Italy, Germany and Spain. Moreover, graft use fell by 50% in the USA from 58% use in 1996 to 28% by 2007. Across three phases of data collection, patients consistently were less likely to use an AVF versus other VA types if female, of older age, having greater body mass index, diabetes, peripheral vascular disease or recurrent cellulitis/gangrene. In addition, countries with a greater prevalence of diabetes in HD patients had a significantly lower percentage of patients using an AVF. Despite poorer outcomes for central vein catheters, catheter use rose 1.5- to 3-fold among prevalent patients in many countries from 1996 to 2007, even among non-diabetic patients 18–70 years old. Furthermore, 58–73% of patients new to end-stage renal disease (ESRD) used a catheter for the initiation of HD in five countries despite 60–79% of patients having been seen by a nephrologist >4 months prior to ESRD. Patients were significantly (P < 0.05) less likely to start dialysis with a permanent VA if treated in a faciity that (1) had a longer time from referral to access surgery evaluation or from evaluation to access creation and (2) had longer time from access creation until first AVF cannulation. The median time from referral until access creation varied from 5–6 days in Italy, Japan and Germany to 40–43 days in the UK and Canada. Compared to patients using an AVF, patients with a catheter displayed significantly lower mean Kt/V levels. Conclusions. Most countries meet the contemporary National Kidney Foundation's Kidney Disease Outcomes Quality Initiative goal for AVF use; however, there is still a wide variation in VA preference. Delays between the creation and cannulation must be improved to enhance the chances of a future permanent VA. Native arteriovenous fistula is the VA of choice ensuring dialysis adequacy and better patient outcomes. Graft is, however, a better alternative than catheter for patients where the creation of an attempted AVF failed or could not be created for different reasons.

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Infectious complications of the hemodialysis access.

J C Ayus, Lawrence G Nassar (2001)

Infectious complications of the vascular access are a major source of morbidity and mortality among hemodialysis (HD) patients. Numerous reports implicate the vascular access in up to 48 to 73% of all bacteremias in HD patients. The incidence of vascular access-related infection is highest when central venous dialysis catheters are employed. Native arteriovenous fistulas carry the lowest risk of infection. Unfortunately, prosthetic arteriovenous grafts, which represent the most common type of HD access in the United States, have been repeatedly shown to be a risk factor for bacteremic and nonbacteremic infections. Silent infection in old nonfunctional clotted prosthetic arteriovenous grafts has recently been recognized as a frequent cause of bacteremia and morbidity among HD patients. High proportions of infections related to the vascular access are caused by staphylococcal organisms, which carry high rates of mortality, recurrence, and metastatic complications. Management of vascular access-related infection has two aspects: The first relates to the choice, duration, and mode of administration of antibiotic therapy. Empiric antibiotic therapy, guided by demographic data and severity of illness, should be employed when the causative organisms are unknown. Prolonged administration of specific parenteral antibiotics is crucial in decreasing complications of infection, especially in cases of staphylococcal bacteremia. The second aspect relates to management of the vascular access. Efforts directed toward bacteriological cure should be concurrent with efforts to preserve native venous access sites whenever possible. Efforts to prevent vascular access-related infection should focus on increasing placement of arteriovenous fistulas and minimizing insertion of central venous dialysis catheters. Careful inspection and monitoring of the vascular access is of paramount importance in early detection of vascular access site-related infections. Several new approaches aimed at preventing catheter and prosthetic graft-related infection are being explored.

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Hemodialysis vascular access morbidity in the United States.

Harold I. Feldman, Philip J. Held, John Hutchinson … (1993)

Extensive morbidity related to hemodialysis vascular access exists among end-stage renal disease (ESRD) patients, but the risk factors for this morbidity have not been extensively studied. Medicare ESRD patient data were obtained from 1984, 1985, and 1986. Hospitalization for vascular access morbidity (ICD-996.1, 996.6, or 996.7) was analyzed among prevalent patients and, using survival analysis, among incident patients to assess sex, age, race, and underlying cause of renal failure as risk factors. We found that 15 to 16% of hospital stays among prevalent ESRD patients were associated with vascular access-related morbidity. Black race, older age, female sex, and diabetes mellitus as a cause of kidney failure were all independent risk factors for access-related morbidity. The rate ratio comparing Blacks to Whites was 1.12 (95% C.I., 1.09, 1.16); > 64 years to 20 to 44 years, 1.53 (1.46, 1.59); men to women, 0.81 (0.79, 0.84); and diabetes to glomerulonephritis, 1.29 (1.24, 1.35). We conclude that hemodialysis vascular access malfunction causes much hospitalization among ESRD patients. Women, Blacks, the elderly, and diabetics appear to be at particularly high risk, and additional studies are needed to understand these patterns.

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Author and article information

Journal

Journal ID (nlm-ta): Nephrourol Mon

Journal ID (iso-abbrev): Nephrourol Mon

Journal ID (doi): 10.5812/numonthly

Journal ID (publisher-id): Kowsar

Title: Nephro-urology monthly

Publisher: Kowsar

ISSN (Print): 2251-7006

ISSN (Electronic): 2251-7014

Publication date (Electronic): 15 December 2012

Publication date (Print): Winter 2013

Volume: 5

Issue: 1

Pages: 697-701

Affiliations

[1 ]Department of Vascular Surgery, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran

[2 ]Department of Surgery, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran

Author notes

[* ]Corresponding author: Mohammad Reza Sobhiyeh, Department of Surgery, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran. Tel.: +98-2122721144, Fax: +98-2122721144, E-mail: mreza_sobhiyeh@ 123456yahoo.com .

Article

DOI: 10.5812/numonthly.5056

PMC ID: 3614332

PubMed ID: 23577334

SO-VID: c425b615-c2c4-4b2a-9db8-4fc3a61f4885

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 06 April 2012

Date revision received : 22 April 2012

Date accepted : 29 April 2012

Upper Extremity Axillary Loop Grafts: An Opportunity in Hemodialysis Access

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Abstract

Background

Objectives

Patients and Methods

Results

Conclusions

Related collections

Regulatory T cell (Treg) therapy

Most cited references 19

Vascular access use and outcomes: an international perspective from the dialysis outcomes and practice patterns study

Infectious complications of the hemodialysis access.

Hemodialysis vascular access morbidity in the United States.

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