Ram Kasthuri

A randomized controlled trial and cost-effectiveness analysis of early cannulation arteriovenous grafts versus tunneled central venous catheters in patients requiring urgent vascular access for hemodialysis

Objective: Early cannulation arteriovenous grafts (ecAVGs) are proposed as an alternative to tunneled central venous catheters (TCVCs) in patients requiring immediate vascular access for hemodialysis (HD). We compared bacteremia rates in patients treated with ecAVG and TCVC. Methods: The study randomized 121 adult patients requiring urgent vascular access for HD in a 1:1 fashion to receive an ecAVG with or without (+/−) an arteriovenous fistula (AVF; n = 60) or TCVC+/−AVF (n = 61). Patients were excluded if they had active systemic sepsis, no anatomically suitable vessels, or an anticipated life expectancy <3 months. The primary end point was the culture‐proven bacteremia rate at 6 months, with the trial powered to detect a reduction in bacteremia from 24% to 5% (&agr; = .05, &bgr; = .8). Secondary end points included thrombosis, reintervention, and mortality. A cost‐effectiveness analysis was also performed. Results: Culture‐proven bacteremia developed in 10 patients (16.4%) in the TCVC arm ≤6 months compared with two (3.3%) in the ecAVG+/−AVF arm (risk ratio, 0.2; 95% confidence interval, 0.12–0.56; P = .02). Mortality was also higher in the TCVC+/−AVF cohort (16% [n = 10] vs 5% [n = 3]; risk ratio, 0.3; 95% CI, 0.08–0.45; P = .04). The difference in treatment cost between the two arms was not significant (£11,393 vs £9692; P = .24). Conclusions: Compared with TCVC+/−AVF, a strategy of ecAVG+/−AVF reduced the rate of culture‐proven bacteremia and mortality in patients requiring urgent vascular access for HD. The strategy also proved to be cost‐neutral.

Bilateral Central Vein Stenosis: Options for Dialysis Access and Renal Replacement Therapy when all upper Extremity Access Possibilities have been Lost:

Purpose Patients with bilateral central vein stenosis present a unique challenge: treatment options are limited, largely unproven and associated with reputedly poor outcomes. Our aim was to compare patency rates of different access and renal replacement treatment (RRT) modalities in patients with bilateral central vein stenosis/occlusion. Material and methods Data on all patients presenting to a tertiary referral vascular access centre with end-stage vascular access (defined by bilateral central vein stenosis/occlusion with loss of upper limb access) over a 5-year period were included. 3, 6 and 12-month patencies of translumbar catheters (TLs), tunnelled femoral catheters (Fem), native long saphenous vein loops (SV), prosthetic mid-thigh loop grafts (ThGr), peritoneal dialysis (PD), and expedited donation after cardiac death (DCD) cadaveric renal transplants (Tx) via local allocation policies were compared using log-rank test. Kaplan–Meier survival analysis was used to estimate long-term access survival. Results One hundred forty-six vascular access modalities were attempted in 62 patients (62 Fem, 25 TL, 15 SV, 25 ThGr, 8 PD, 11 Tx). Median follow-up was 876±57 days. Three, 6 and 12-month primary-assisted patencies for each modality were as follows: Fem: 75.4%, 60% and 28%; TL: 88%, 65% and 50%; SV: 87.5%, 60% and 44.6%; ThGr: 64%, 38% and 23.5%; PD: 62.5%, 62.5% and 50%; Tx: 72.7%, 72.7% and 72.7%. SV had better secondary patency at 900 days (76.9%) than ThGr (49.2%) or Fem (35.8%) (p<0.01). No patients died as a result of loss of access. Conclusion Patients with bilateral central vein stenosis often require more than one vascular access modality to achieve a “personal access solution.” Native long saphenous vein loops provided the best long-term patency. Expedited renal transplantation with priority local allocation of DCD organs to patients with precarious vascular access provides a potential solution to this difficult problem.

Are early cannulation arteriovenous grafts (ecAVG) a viable alternative to tunnelled central venous catheters (TCVCs)? An observational “virtual study” and budget impact analysis

Background Early cannulation arteriovenous grafts (ecAVGs) are advocated as an alternative to tunnelled central venous catheters (TCVCs). A real-time observational “virtual study” and budget impact model was performed to evaluate a strategy of ecAVG as a replacement to TCVC as a bridge to definitive access creation. Methodology Data on complications and access-related bed days was collected prospectively for all TCVCs inserted over a six-month period (n = 101). The feasibility and acceptability of an alternative strategy (ecAVGs) was also evaluated. A budget impact model comparing the two strategies was performed. Autologous access in the form of native fistula was the goal wherever possible. Results We found 34.7% (n = 35) of TCVCs developed significant complications (including 17 culture-proven bacteraemia and one death from line sepsis). Patients spent an average of 11.9 days/patient/year in hospital as a result of access-related complications. The wait for TCVC insertion delayed discharge in 35 patients (median: 6 days). The ecAVGs were a practical and acceptable alternative to TCVCs in over 80% of patients. Over a 6-month period, total treatment costs per patient wereGBP5882 in the TCVC strategy and GBP4954 in the ecAVG strategy, delivering potential savings of GBP927 per patient. The ecAVGs had higher procedure and re-intervention costs (GBP3014 vs. GBP1836); however, these were offset by significant reductions in septicaemia treatment costs (GBP1322 vs. GBP2176) and in-patient waiting time bed costs (GBP619 vs. GBP1870). Conclusions Adopting ecAVGs as an alternative to TCVCs in patients requiring immediate access for haemodialysis may provide better individual patient care and deliver cost savings to the hospital.

Cephalic arch stenosis: angioplasty to preserve a brachiocephalic fistula or new brachiobasilic fistula?: a cost-effectiveness study

Abstract Background: Our aim was to evaluate the cost-effectiveness of repeat angioplasty versus new brachiobasilic fistula (BBF) in patients with symptomatic cephalic arch stenosis (CAS). Methods: Patients presenting with symptomatic CAS (n = 22) underwent angioplasty. They were compared to patients undergoing BBF creation (n = 51). Primary outcomes were functional primary arteriovenous fistulae patency at 3, 6 and 12 months. Data were collected on number of interventions, alternative accesses and hospital days for access-related complications. Quality of life was assessed using Kidney Disease Quality of Life-36 scores. Decision tree, Monte Carlo simulation and sensitivity analysis permitted cost-utility analysis. Healthcare costs were derived from Department of Health figures and are presented as cost (£)/patient/year, cost/access preserved and cost/quality of life-adjusted year (QALY) for each of the treatment strategies. Results: Functional primary patency rates at 3, 6, 12 months were 87.5%, 81% and 43% for repeated angioplasty and 78%, 63% and 41% for BBF. The angioplasty cohort required 1.64 ± 0.23 angioplasties/patient and 0.64 ± 0.34 lines/patient. BBF required 0.36 ± 0.12 angioplasties/patient and 1.2 ± 0.2 lines/patient. Patients in the BBF cohort spent an additional 0.9 days/year in hospital due to access-related complications. Mean cost/patient/year in the angioplasty group was £5247.72/patient/year versus £3807.55/patient/year in the BBF cohort. Mean cost per access saved was £11,544.98 (angioplasty) versus £4979.10 (BBF). Average cost per QALY was £13,809.79 (angioplasty) versus £10,878.72 per QALY (BBF). Conclusions: CAS poses a difficult management problem with poor outcomes from conventional angioplasty. Optimal management will depend on patient factors, local outcomes and expertise, but consideration should be given to creation of a new BBF as a cost-effective means to manage this difficult problem.

Venous Outflow Stenosis of the Brachiocephalic Fistula: A Single Entity, oris the Cephalic Arch Different?

Background: Cephalic Arch Stenosis (CAS) is emerging as an important cause of Brachiocephalic Fistula (BCF) failure. The optimal management strategy for dysfunctional AVF as a result of CAS is yet to be defined. Endovascular management is generally employed as first line treatment based upon success in other venous stenosis sites. We compare the outcomes of angioplasty in CAS to other venous stenoses causing BCF dysfunction. Methods: 62 patients with dysfunctional BCF due to venous segment pathology were identified and proceeded to angioplasty. Lesions were categorized anatomically: 19 CAS, 22 venous outflow, 21 swing segment(<3cm of anastomosis). Anastomotic stenoses were excluded. Endovascular intervention was carried out in a standard fashion; 8-10mm balloon angioplasty at the interventionalist’s discretion. Patients were followed prospectively by regular clinical and venous pressure monitoring of the fistula. Re-intervention was performed on clinical suspicion of recurrence. Results: Mean duration of follow-up was 402 days. Patient demographics were comparable across the three groups except a lower incidence of diabetes in the cephalic arch cohort (15.7% vs. 28.2% vs. 25.0%). Swelling and aneurysmal fistulae were more common presenting complaints in CAS (15.7% vs. 2.6% vs. 0%). Mean length of cephalic arch stenosis was shorter(1.6cm vs.3.1cm vs.2.5cm). Primary patency of cephalic arch angioplasty was 68.8%, 43.7% and 31.0% at 3, 6 and 12 months respectively. Primary assisted patency was 87.5%, 81.0% and 43.0%. There was no significant difference in primary or primary assisted patency compared to other outflow stenoses. 2.3 interventions/ patient were required to preserve the access in the CAS cohort vs. 1.1 interventions/ patient for venous outflow stenosis and 1.3 interventions/ patient for swing segment stenoses. Conclusion: CAS bears a different clinical presentation to other venous outflow stenoses. Despite being shorter, and apparently a more attractive target lesion, the hallmark is a requirement for repeated endovascular intervention when compared to other venous stenoses causing BCF dysfunction

Vascular access: pearls and pitfalls

The successful creation and maintenance of haemodialysis (HD) vascular access remains of profound importance to patients reliant on regular dialysis. When considering the potential optimal performance of each access type, a natural hierarchy has evolved in which arteriovenous fistulae (AVFs) are favoured over arteriovenous grafts (AVGs), and in which AV access on the whole is favoured over access with central venous catheters (CVCs). Nonetheless, each access method has a specific complication profile that may impart a varying burden of procedures, imaging, complications and hospitalization—all of which may impact upon patients as well as nephrology, surgery and imaging specialties (Figure 1) [1]. In this NDT Digest, we will briefly discuss the current era of HD vascular access provision by describing some of the ‘pearls’ and ‘pitfalls’ associated with each of the main vascular access types.

MO036A FRAMEWORK FOR TARGETING QUALITY IMPROVEMENT IN HAEMODIALYSIS VASCULAR ACCESS

Sokratis Stoumpos1, Eleanor C Murray2, David B Kingsmore3, Ram Kasthuri4 and Peter C Thomson1 Queen Elizabeth University Hospital, Renal & Transplant Unit, Glasgow, UNITED KINGDOM, Queen Elizabeth University Hospital, Queen Elizabeth University Hospital, Glasgow, UNITED KINGDOM, Queen Elizabeth University Hospital, Glasgow Renal & Transplant Unit, Glasgow, UNITED KINGDOM, Queen Elizabeth University Hospital, Department of Radiology, Glasgow, UNITED KINGDOM