Arteriovenous fistula thrombosis in hemodialysis patients with COVID-19: epiphenomenon or marker of severe clinical disease?

Background: Pandemic condition due to Coronavirus disease (COVID-19) caused a fastest augmentation of hospitalization, impairing the healthcare organization. As a consequence, diagnostic and therapeutic delays have been showed. COVID-19-associated coagulopathy is an endothelial disease related to SARSCoV-2 infection. Our study evaluated the thrombosis of arteriovenous fistula (AVF) as risk marker of mortality. Methods: the analysis included 24 dialysis-dependent patients admitted in a period between March 2020 and June 2021. Patients were divided based on AVF thrombosis: the A group without AVF thrombosis (13 patients), and the B group with AVF thrombosis events (11 patients). Pearson or Spearman' correlation tests were performed to detect possible confounding variable to include in multivariate models. Kaplan Meier and Cox regression analysis were performed to compute mortality analysis. Results: Delta D-dimer (Rho: 0.613, p=0.007), over-infections (Rho 0.456; p= 0,026), C-reactive Protein (CRP) (Rho=0.417, p=0.043), death (Rho=0.492, p=0.027), positive pulmonary imaging (Rho 0.388, p=0.074), and high OLT (0.408, p=0.047) were related to AVF thrombosis, using Pearson or Spearman correlation tests. Kaplan Meier test showed a death average of 19 days in group B compared to a global average of 38 days (p=0.029), and Cox analysis showed an HR of 5.01, 95% CI 1.01-24.99, p=0.049. Furthermore, AVF thrombosis explained about the 68% of the mortality, evaluated through the Harrel's C test. Conclusion: We can speculate that AVF thrombosis in hemodialysis patients with COVID-19 could be an early marker of both pro-coagulative process and severe clinical disease and it could be used to stratify patients and identify the ones that can be considered "frail".

Recurrent thrombosis of an arteriovenous fistula as a complication of COVID-19 in a chronic hemodialysis patient: A case report.

Patients with end-stage kidney disease are at increased risk of death from coronavirus disease 2019 (COVID-19). In addition, severe COVID-19 has been associated with an increased risk of arterial and venous thromboses. In this report, we describe the case of a hemodialysis patient who developed an otherwise-unexplained thrombosis of an arteriovenous fistula during a symptomatic COVID-19 infection. Despite prompt treatment with three technically successful thrombectomies along with systemic intravenous heparin and two rounds of catheter-directed thrombolysis with tissue plasminogen activator, the fistula rapidly re-thrombosed each time and he required tunneled dialysis catheter placement. He subsequently required admission for hypoxemia from COVID-19 pneumonia and ultimately developed a catheter-related blood stream infection that likely contributed to his death. As the fistula had been previously well functioning and no angiographic explanation for the thrombosis was found, we speculate in this case the recurrent thromboses were related to the hypercoagulable state characteristic of severe COVID-19. Interventionalists performing hemodialysis access procedures should be aware of the prothrombotic state associated with COVID-19 and should consider it when deliberating how to best plan and approach access interventions in patients with symptomatic COVID-19.

Arteriovenous fistulas thrombosis in hemodialysis patients with COVID-19.

BACKGROUND: The current Coronavirus disease 2019 (COVID-19) outbreak is associated with significant mortality, especially in patients suffering from end stage renal disease (ESRD) and hemodialysis patients. Several previous studies reported an over-risk of arterial and venous thrombosis, in particular pulmonary embolism and venous thrombosis of catheter in COVID19 patients in intensive care unit. However, arteriovenous fistula (AVF) thrombosis has rarely been reported yet in these patients. AVF thrombosis is a serious complication that impacts significantly patients outcome. Here, we aim to describe characteristics and prognosis of a cohort of COVID-19 hemodialysis (HD) patients presenting with AVF thrombosis. METHODS: In the Ile de France region (Paris area) during the March 11th-April 30th 2020 period, fistula thrombosis cases were collected among COVID-19 hemodialysis patients in seven dialysis units and in interventional vascular departments. These patients' characteristics were analyzed through a review of the patient's medical records. RESULTS: Seventeen patients were included in our study (median age 69 years). Ten patients (59%) were men. Ten patients (59%) were diabetic and 88% had a high blood pressure. The mortality rate in these patients was 47%. All thrombosis treated with a declotting procedures (64%) were successfully cleared, but with early relapse in 36%. CONCLUSION: Our study highlights AVF thrombosis as a severe complication in COVID-19 hemodialysis patients that contributed to the severity and accelerated death.

The management of vascular access in hemodialysis patients during the coronavirus disease 2019 epidemic: A multicenter cross-sectional study.

BACKGROUND: Coronavirus disease 2019 is an epidemic disease throughout the world. The management of vascular access during the epidemic is currently unknown. METHODS: In this multicenter cross-sectional study, we collected vascular access data from hemodialysis patients treated at 44 hospitals in Hubei from 22 January to 10 March 2020. We estimated the management of vascular access during the coronavirus disease 2019 outbreak. RESULTS: Of the 9231 hemodialysis patients included, 5387 patients (58.4%) were men and 2959 patients (32.1%) were older than 65 years. Arteriovenous fistula was the predominant type of vascular access, accounting for 76.5%; 496 patients (5.4%) developed vascular access complications; catheter flow reduction was the most common vascular access complication, and stenosis was the predominant complication among those with arteriovenous access. Overall, 280 vascular access sites were placed in patients newly diagnosed with uremia, of whom 260 (92.8%) underwent catheter insertion; 149 rescue procedures were carried out to treat the vascular access complications, which consisted of 132 catheters, 7 percutaneous transluminal angioplasties, 6 arteriovenous fistula repairs, and 4 arteriovenous fistulas. Occlusion of the arteriovenous access had the highest rescue rate (92.7%), while many other vascular access complications remained untreated; 69 and 142 patients were diagnosed with confirmed and suspected coronavirus disease 2019, respectively. A total of 146 patients died, of whom 29 patients (19.9%) died due to vascular access complications. CONCLUSION: Catheter flow reduction and stenosis of arteriovenous access were the major vascular access complications. Most of the vascular access sites established were catheters, and many of the vascular access complications remained untreated.

Balancing the Covid-19-motivated vascular access guidelines and patient-centred care of pre-dialysis candidates.

The recommendations recently proposed by the European and American Vascular Societies in this new 'Covid-19' era regarding the triage of various vascular operations into urgent, emergent and programmed based on the nature of their pathology aim at reserving health care expenses and hospital staff towards managing the current unexpected worldwide pandemic to the highest possible degree. The suggestion for implementation of these changes into real-world practice, however, does not come without a cost. In particular, the recommendation for deferral of access creation in pre-dialysis patients, ethical, socio-economic and medico-legal issues arise which should be seriously taken into consideration. At the end of the day, vascular access creation is the lifeline of haemodialysis patients and the indication for surgery warrants patient-specific clinical judgement rather than 'group labelling'.