Surveillance of the vascular access leads to better outcomes for patients, payers
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Patients on hemodialysis require functioning access sites, yet all access sites are at risk of stenosis and subsequent failure.
Of the nearly 783,000 Americans with kidney failure, approximately 500,000 of these patients require life-sustaining dialysis delivered in a dialysis center three times a week for up to 4 hours a day. Patients must have a patent, well-functioning vascular access for effective hemodialysis.
Preservation of vascular access for hemodialysis is an ongoing challenge for clinicians who care for patients with end-stage kidney disease. Commonly, patients on dialysis experience access flow dysfunction related to stenosis. Without prompt intervention, vascular stenosis can lead to thrombosis and access failure. Because patients have a limited number of anatomical sites available, preserving a functional access is a major goal of ESKD care. Loss of patency, especially for a surgically created access, results in considerable morbidity, discomfort and inconvenience for the patient as well as preventable health care expenditures.
Impact on patient outcomes
As noted, there are a limited number of viable anatomical sites in which an access can be created. Therefore, every access should be treated as if it were the last. By preventing loss of patency, clinicians hope to prevent downstream complications that could result in ineffective hemodialysis, increased morbidity, hospitalizations or life-threatening complications.
Native arteriovenous fistulas (AVFs) are the preferred hemodialysis access because of their longevity and low risk of morbidity and mortality. A recently published retrospective study of patients who had AVF creation showed that patency was reported in 71.8% and 62.6% of patients at 6 months and 1 year, respectively; 12.1% of AVF failures occurred immediately and 25.6% of failures were reported at 3 months. Notably, the likelihood of AVF failure increases with each successive fistula placement.
Arteriovenous grafts (AVGs) are considered the next best option after AVFs, but the risk of infection and thrombotic complications is higher with this type of vascular access.
Central venous catheters (CVCs) are typically inserted into the internal jugular or femoral veins. Of the three access types (AVFs, AVGs and CVCs), use of CVCs should be minimized because these carry the highest risk of infection and other complications. In fact, incident patients who require conversion from a permanent vascular access to a catheter have an 80% higher risk for death.
Cost of access loss
Vascular access dysfunction poses a significant financial burden to the U.S. health care system. Approximately 20% to 30% of hospitalizations for patients with ESKD are due to vascular access-related expenses and complications (see Figure). A 2018 study found that the annual Medicare expenditures for vascular access-related procedures and hospitalizations performed to maintain a functioning access from 2010 to 2011 was estimated at $2.8 billion.
Current guidelines recommend continuous vascular access management utilizing monitoring and surveillance, either by direct clinical examination or through surveillance technologies, to detect the presence of subclinical stenoses. Interventions, such as angioplasty or access revision, can then be used to prevent thrombosis and improve the longevity of the functional access.
Clinical monitoring
Clinical monitoring is considered best practice for detecting and correcting access stenosis. With this method, clinicians rely on clinical indicators of stenosis, such as persistent arm swelling, excessive bleeding after dialysis, the inability to maintain the prescribed blood flow rate or decreased dialysis adequacy as well as physical evaluation of the vascular access (see Table). However, solely relying on clinical indicators is problematic for several reasons. Evidence of these clinical indicators is typically not apparent until a more severe stage of stenosis, which may be too late to salvage the access. Also, there is a lack of trained clinical staff to complete physical assessments, leading to a lack of standardized and objective monitoring data for indicators of access failure.
Surveillance
Including surveillance as a routine part of the vascular access management process can ensure earlier and more efficient identification of potential complications. Surveillance data via intra-access pressure trending provide clinicians and access managers more objective and consistent information to recognize complications and refer patients for further evaluation or intervention earlier. This helps prevent emergent events such as thrombosis or loss of AV access.
- References:
- Al-Balas A, et al. J Am Soc Nephrol. 2017;doi:10.1681/ASN.2016060707.
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- COVID-19 and its impact on U.S. dialysis centers. National Kidney Foundation. https://www.kidney.org/news/covid-19-and-its-impact-kidney-patients-utilizing-u-s-dialysis-centers. Published Jan. 18, 2022. Accessed April 24, 2023.
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- Santoro D, et al. Int J Nephrol Renovasc Dis. 2014;doi:10.2147/IJNRD.S46643.
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- For more information:
- Christa James, BScN, RN, is vascular lead at East Side Vascular in Detroit. She can be reached at cjames@scsp.net.
- David Lorelli, MD, RVT, FACS, is the medical director of the Vascular Laboratory at St. John Hospital and Medical Center in Detroit as well as East Side Vascular. He can be reached at dlorelli@scsp.net.
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