O7
EFFICACY OF SURVEILLANCE AND TIMELY INTERVENTION ON ARTERIOVENOUS
FISTULA FOR HAEMODIALYSIS
Nair, A, Bayswater, M, Brogan, R, Nair, H
Glan Clwyd Hospital, North Wales
BACKGROUND: Renal association guideline for haemodilaysis recommends ‘80% of patients to be
dialysed through an AVF and there should be robust criteria for vascular access surveillance and timely
intervention for failing fistula’ (guideline 4.3&4.4). Polkinghorne et al demonstrated that the addition of
AVF Qa(fistula blood flow) monitoring to clinical screening for AVF stenosis resulted in a nonsignificant doubling in the detection of angiographically significant AVF stenosis but failed to confirm
whether this approach will lead to increased AVF survival. Besarab et al suggested that when AVF
stenosis is likely, intervention is indicated for functional assessment.
PURPOSE: To assess the need and efficacy of our surveillance programme and also to assess the
efficacy of intervention to maintain patency of haemodialysis access and planning for further access
surgery in a timely way in our dialysis and predialysis cohort.
DESIGN: A retrospective analysis of all radiological interventions on AVF in our hospital for 3
years(October 2007 to September 2008). Data was extracted from our computer database including timing
of intervention, Qa flow rates(before and serially post intervention showing the effectiveness of
intervention), type of intervention and complications. Surveillance was based around the pyramid of
observation, dialysis adequacy and advanced monitoring techniques based on fistula blood flow.
RESULTS: There were 70 AVF radiological interventions on 52 patients(18 repeat procedures) of them
42 were on males. 21 had previous interventions and the mean age was 64(22– 85). Indications varied
from poor flow (48%), needling problems (31%), suspected thrombosis (9%), Swelling of arm(8%) and
Others (4%). Diagnosis was made through observation & Qa measurement (42%) and Qa & Duplex
(58%). Fistula were 2 to 63 months old(Mean 19 months) with 60 % of them being on the nondominant
left arm. Venoplasty was done in 67 %, with angioplasty 9 % and Fistulogram & embolisation – 15 % and
7 % needing thrombolysis. Only 3 patients (0.4 %) needed emergency dialysis lines and no significant
complications were encountered. 82% of our patients had a patent AVF, further to our surveillance
programme/vascular access meetings.
Timing
of Same
intervention
day
from diagnosis
Numbers (%)
12.5
<1
week
1-2
weeks
2-3
weeks
3-4
weeks
4-12
weeks
43
22
11
0.5
11
Flow rates
Immedia
post
procedure
>300 ml/mt
29
at diagnosis
<200 ml/mt
Number
36
of patients
Comments
3/12
post 6/12
post 12/12 post
procedure
procedure
procedure
>300 ml/m
>300 ml/mt >300 ml/mt
24
22
18
2 died
1 transplant 2 PD
1 Transplant 1 died
2 died
2 thrombosis
CONCLUSION: Our study demonstrates optimal access surveillance through Qa measurement could
trigger early identification and intervention in at risk fistula. This multidisciplinary approach could help in
achieving long term AVF patency and thus renal association standards for good patient care.
Reference: 1. Does monthly native arteriovenous fistula blood-flow surveillance detect significant
stenosis—a RCT), Polkinghorne, K R etal; NDT 2006.
2.The
native
arteriovenous
fistula
in
2007.
Surveillance
and
monitoring.
Besarab et al. J Nephrol 2007; 20(6): 656 – 667.