Long-term results of thigh arteriovenous dialysis grafts.

INTRODUCTION:: A proportion of hemodialysis patients exhaust all options for arteriovenous access in upper extremities. Arteriovenous thigh grafts are a potential vascular access option in such patients. METHODS:: We performed a retrospective study of all thigh arteriovenous access grafts placed between 1995 and 2015. The clinical, demographic patient information and patency of each thigh graft was determined from the time of surgical creation placement until abandonment, transfer to other modality, or center or end of study, and the reason for access failure documented. RESULTS:: In total, 44 patients received 49 thigh arteriovenous accesses. The average age was 60 years (13-79 years); Half (53%) of the patients (n = 24) were female and 61% of the patients (n = 30) of arteriovenous accesses were left-sided. The cumulative proportion surviving (primary patency rates) at 12, 24, and 28 months were 43% (standard error = 9%), 33% (standard error = 9%), and 13% (standard error = 9%), respectively. The cumulative proportion of surviving grafts at 12, 24, and 48 months were 61% (standard error = 8%), 58% (standard error = 9%), and 31% (standard error = 13%), respectively. In total, 37 revisions were performed in 22 patients to maintain patency or eradicate infection. Infection occurred in 20 patients (39%) of thigh grafts requiring 16 patients (80% of those affected) to be removed; 14 patients had grafts (33.3%) that served as the lone hemodialysis arteriovenous access during the patients' lifetime on dialysis. CONCLUSION:: Arteriovenous thigh graft access is used infrequently, but they have an acceptable patency. Some accesses require revisions and they have a high infection rate. Despite this, an acceptable proportion of leg grafts provide durable access for the dialysis lifetime of the patient.

Hemodialysis patients' satisfaction and perspectives on complications associated with vascular access related interventions: are we listening?

PURPOSE: To understand the patient's perspective on complications associated with vascular access-related interventions. METHODS: A multi-stage comprehensive questionnaire of over 150 items was administered to 140 in-center hemodialysis patients in a large, Toronto-based academic-based facility from May 1, 2011 until July 1, 2014. The questionnaire was divided into three domains: physical complications, disruption to routine, and infection. For each of the 12 prespecified vascular access interventions, there were 9 items about the associated complications. The level of bother associated with complications was measured using a 5-point Likert scale. RESULTS: The mean Likert value (5 = extremely bothered) for the physical complications domain was highest for grafts at 1.92, followed closely by fistulas at 1.87, and catheters at 1.56. The mean Likert value for the "disruption of routine" domain was highest for catheters at 1.44, followed by grafts at 1.37, and fistulas at 1.33. For infectious complications of all vascular access-related interventions the mean Likert value was highest at 1.76 for catheters as compared to fistulas at 1.23 and grafts at 1.22. CONCLUSIONS: For hemodialysis patients, the physical complications associated with needle cannulation of fistulas and grafts are a major source of dissatisfaction, while infectious complications, including catheter-related infections, are not a significant source of their concerns. Future research should focus on developing methods to effectively: (i) reduce the fear and pain associated with cannulation and (ii) educate patients about the risks associated with vascular access-related infection.

The stuck catheter: a hazardous twist to the meaning of permanent catheters.

INTRODUCTION: Permanent central venous catheter use is associated with significant complications that often require their timely removal. An uncommon complication is resistant removal of the catheter due to adherence of the catheter to the vessel wall. This occasionally mandates invasive interventions for removal. The aim of this study is to describe the occurrence of this "stuck catheter" phenomenon and its consequences. METHODS: A retrospective review of all the removed tunneled hemodialysis catheters from July 2005 to December 2014 at a single academic-based hemodialysis center to determine the incidence of stuck catheters. Data were retrieved from a prospectively maintained computerized vascular access database and verified manually against patient charts. RESULTS: In our retrospective review of tunneled hemodialysis catheters spanning close to a decade, we found that 19 (0.92%) of catheters were retained, requiring endovascular intervention or open sternotomy. Of these, three could not be removed, with one patient succumbing to catheter-related infection. Longer catheter vintage appeared to be associated with 'stuck catheter'. CONCLUSIONS: Retention of tunneled central venous catheters is a rare but important complication of prolonged tunneled catheter use that nephrologists should be aware of. Endoluminal balloon dilatation procedures are the initial approach, but surgical intervention may be necessary.

Measuring patient satisfaction with vascular access: vascular access questionnaire development and reliability testing.

PURPOSE: The primary objective of this study is to measure hemodialysis patients' satisfaction with their vascular access. The secondary objective is to evaluate the measurement tool's psychometric properties to assess patient satisfaction with their vascular access. METHODS: We generated a comprehensive list of survey items related to patients' views and satisfaction with their vascular access and administered it to participating in-center hemodialysis patients over 4 months. Following a factor analysis, the items were reduced and rescaled to generate the final short-form vascular access questionnaire (SF-VAQ). The SF-VAQ was then administered to a new cohort of hemodialysis patients on two occasions 1 week apart from February 1, 2012, to April 1, 2014. A repeated measures analysis of variance and psychometric evaluation was conducted. RESULTS: The final SF-VAQ with 13 items and four domains was administered to 132 patients (35 fistulas, 14 grafts and 83 catheters). The mean Likert value for overall satisfaction on a scale of 1 (low) to 7 (high) was 5.98, with catheters, fistulas and grafts with values of 5.92, 6.46 and 5.21, respectively. The test-retest reliability for two occasions is 0.92 and the internal consistency for the first administration is high at 0.84. CONCLUSIONS: The SF-VAQ is a short, simple to administer vascular access-specific questionnaire with robust psychometric properties that can be used to obtain the patient's views on their vascular access. Based on the newly developed SF-VAQ, patients were the most satisfied with fistulas, scores.

Using tunneled femoral vein catheters for "urgent start" dialysis patients: a preliminary report.

BACKGROUND: Multiple benefits of arteriovenous fistulas (AVF) and arteriovenous grafts (AVGs) exist over catheters. As part of a strategy to preserve thoracic venous sites and reduce internal jugular (IJ) vein catheter use, we inserted tunneled femoral vein catheters in incident "urgent start" dialysis patients while facilitating a more appropriate definitive dialysis access. METHODS: "Urgent start" dialysis patients between January 15, 2013 and January 15, 2014 who required chronic dialysis, and did not have prior modality and vascular access plans, had tunneled femoral vein catheters inserted. We determined the femoral vein catheter associated infections rates, thrombosis, and subsequent dialysis access. Eligible patients were surveyed on their femoral vein catheter experience. RESULTS: Twenty-two femoral vein catheters were inserted without complications. Subsequently, one catheter required intraluminal thrombolytic locking, while all other catheters maintained blood flow greater than 300 ml/min. There were no catheter-related infections (exit site infection or bacteremia). Six patients continued to use their tunneled catheter at report end, one transitioned to peritoneal dialysis, thirteen to an arteriovenous graft, and two to a fistula. One patient received a tunneled IJ vein catheter. Of the patients who completed the vascular access survey, all indicated satisfaction with their access and that they had minimal complaints of bruising, bleeding, or swelling at their access sites. Pain/discomfort at the exit site was the primary complaint, but they did not find it interfered with activities of daily living. CONCLUSIONS: Femoral vein tunneled catheters appear to be a safe, well tolerated, and effective temporary access in urgent start dialysis patients while they await more appropriate long-term access.

Seeing eye to eye: the key to reducing catheter use.

PURPOSE: Hemodialysis central venous catheters (CVCs) are increasingly used, despite a prevalence target of <10%. The primary aim of our study was to understand why patients persistently use their CVCs. METHODS: A multicenter prospective observational study surveyed 322 patients and their vascular access coordinators (VACs) to determine the reasons patients use CVCs. Their responses were compared using multirater kappa statistics. An 18-month follow-up survey was applied to a subgroup of patients consistently using their CVCs, and correlated with the VACs' and patients' previous responses. Predictive associations for specific reasons for CVC use were explored. RESULTS: Patients indicated "non-medical" reasons (34.8%), having previously failed fistulas/grafts (25.8%), and fear of disfiguration (11.5%) as the main reasons for CVC use. The VAC was in agreement with the patient 16.5% of the time, in partial agreement 37.0%, and in disagreement 46.5%. Twelve percent of patients indicated a desire to change their CVC, yet the VAC was unaware of this 78% of the time. CONCLUSIONS: The primary reasons patients use CVCs are "non-medical" followed by concerns with the complications and esthetic appearance associated with fistulas/grafts. The significant discordance between the reasons the patients give and the VAC's view of patient reasons for CVC use suggests a gap in knowledge, understanding, or communication between patients and their VACs. Timely predialysis education to address this gap and realistic targets are necessary to reduce CVC prevalence.

Long-term follow-up of the Hemodialysis Infection Prevention with Polysporin Ointment (HIPPO) Study: a quality improvement report.

BACKGROUND: Infection is a common and serious complication in hemodialysis patients accessed using central venous catheters (CVCs). Previously, a randomized double-blinded trial (HIPPO [Hemodialysis Infection Prevention With Polysporin Ointment] Study) showed that application of a topical polyantibiotic ointment at the CVC exit site decreased CVC-related infections, including bacteremias and their adverse consequences. Based on this study's results, our institution implemented a policy of routine topical polyantibiotic ointment application for CVC-related infection prophylaxis. The main purpose of this prospective observational study was to determine whether the low rate of CVC-related infection achieved by topical polyantibiotic ointment use during a randomized controlled trial would be observed during long-term prophylaxis as part of routine clinical care. STUDY DESIGN: Quality improvement report. SETTING & PARTICIPANTS: All adult long-term hemodialysis patients using a tunneled cuffed CVC in a large university-affiliated outpatient hemodialysis program in 2004-2009 were included. QUALITY IMPROVEMENT PLAN: To prospectively monitor the impact of a policy-wide strategy of topical polyantibiotic ointment application at CVC exit sites (1 time/wk) as infection prophylaxis. A multidisciplinary team approach to the surveillance, prospective tracking, and management of hemodialysis CVC-related infection was used. OUTCOMES & MEASUREMENTS: Rates of CVC-related infections (exit-site infections and bacteremias), percentages of contributing organisms, and consequences of CVC-related infections. RESULTS: After 6 years, CVC exit-site infection and bacteremia rates remained low (<1.0/1,000 catheter-days). Gram-positive organisms accounted for 61.2% of exit-site infections and 72.1% of bacteremias. LIMITATIONS: A center effect of the same institution conducting the randomized trial and the quality improvement study may limit the study's generalizability to other centers. The impact of possible unmeasured cointerventions cannot be excluded. CONCLUSION: Long-term use of topical antibiotic application at CVC exit sites resulted in a sustained decrease in all CVC-related infections. A multidisciplinary effort to monitor and track outcomes allowed safe and effective implementation of a new prophylactic strategy.

Hemodialysis catheter care: current recommendations for nursing practice in North America.

Vascular access is essential for hemodialysis (HD). Many patients require a catheter for HD, either long-term or short-term, if they do not have a functional fistula or graft. Catheter-related complications, such as bacteremias and catheter dysfunction, can be reduced with consistent use of recommended practices for catheter management. This article will detail the complications, challenges, and the need for best practices. It will describe current recommended practices of catheter care and how they are integrated into the care of patients on HD in North America.

Trisodium citrate 4%--an alternative to heparin capping of haemodialysis catheters.

BACKGROUND: Central venous catheters (CVCs) continue to be used at a high rate for dialysis access and are frequently complicated by thrombus-related malfunction. Prophylactic locking with an anticoagulant, such as heparin, has become standard practice despite its associated risks. Trisodium citrate (citrate) 4% is an alternative catheter locking anticoagulant. METHODS: The objective was to prospectively study the clinical effectiveness, safety and cost of citrate 4% vs heparin locking by comparing rates of CVC exchanges, thrombolytic use (TPA) and access-associated hospitalizations during two study periods: heparin period (HP) (1 June 2003-15 February 2004) and Citrate Period (CP) 15 March-15 November 2004. Incident catheters evaluated did not overlap the two periods. RESULTS: There were 176 CVC in 121 patients (HP) and 177 CVC in 129 patients (CP). The event rates in incident CVC were: CVC exchange 2.98/1000 days (HP) vs 1.65/1000 days (CP) (P = 0.01); TPA use 5.49/1000 (HP) vs 3.3/1000 days (CP) (P = 0.002); hospitalizations 0.59/1000 days (HP) vs 0.28/1000 days (CP) (P = 0.49). There was a longer time from catheter insertion to requiring CVC exchange (P = 0.04) and TPA (P = 0.006) in the citrate compared with the heparin lock group. Citrate locking costs less than heparin locking but a formal economic analysis including indirect costs was not done. CONCLUSION: Citrate 4% has equivalent or better outcomes with regards to catheter exchange, TPA use and access-related hospitalizations compared with heparin locking. It is a safe and less expensive alternative. Randomized trials comparing these anticoagulants with a control group would definitively determine the optimal haemodialysis catheter locking solution.

Arteriovenous fistula outcomes in the era of the elderly dialysis population.

BACKGROUND: The growth of patients > or =65 years on hemodialysis is increasing. Guidelines recommend arteriovenous fistula (AVF) access but their outcomes in elderly patients are controversial. This study compared the outcomes of AVF in patients <65 years old (65- group) versus those > or =65 years old (65+ group). METHODS: This retrospective analysis of prospectively collected data included 444 incident, first-time AVF created in a large dialysis center between January 1, 1995 and July 1, 2003. The primary outcome of AVF cumulative patency was evaluated using Kaplan-Meier survival analysis with log-rank test comparison. A Cox model determined factors associated with AVF loss. RESULTS: One hundred ninety-six patients (44%) were in the 65+ group. In total, there were 230 (52.2%) radiocephalic, 186 (42.2%) brachiocephalic, and 25 (5.6%) basilic vein transposed AVF. The one-year AVF cumulative survival was 75.1% (65+ group) and 79.7% (65- group); the five-year survival was 64.7% (65+ group) and 71.4% (65- group). The overall total procedure, angioplasty, thrombolysis, and revision rates per access-year were 0.83, 0.30, 0.66, and 0.16, respectively. The 65+ group had a relative risk of 1.7 of their AVF failing to mature compared with the 65- group. Multivariate analysis yielded these variables significant for AVF loss: male sex HR 0.63 (95% CI 0.44-0.91), coronary artery disease HR 2.1 (95% CI 1.5-3.0), and Caucasian ethnicity HR 0.63 (95% CI 0.44-0.91). CONCLUSION: Age should not be a limiting factor when determining candidacy for AVF creation due to equivalent survival and procedural rates. Failure of fistula maturation is a primary concern to patients of all ages and demands further study.

Reducing vascular access morbidity: a comparative trial of two vascular access monitoring strategies.

BACKGROUND: Thrombosis is the primary cause of access failure in polytetrafluoroethylene grafts and arteriovenous fistulas. It can lead to significant patient and access morbidity and mortality, and is difficult to prevent medically. Intervention is largely limited to maximizing access patency by detecting culprit lesions early and intervening with angioplasty or surgical revision. The most efficacious monitoring strategy is undetermined. METHODS: This 3 year prospective study took advantage of a change in monitoring strategy used in a large dialysis centre to compare the efficacy of two methods used to monitor grafts and fistulas in order to prevent access thrombosis. Accesses were monitored using Duplex ultrasonography in year 1, while the saline ultrasound dilution technique (Transonic) became the primary monitoring strategy in year 3 (year 2 was a transition year). Risk factors for thrombosis were determined using multivariate survival analysis, and the performance of Duplex ultrasonography and Transonic monitoring was assessed. RESULTS: A total of 303 656 access days at risk were assessed, with 344, 385 and 425 accesses in years 1, 2 and 3, respectively. The total thrombosis rate was 1.01/1000 access days in year 1 compared with 0.66/1000 access days in year 3. This was accomplished despite a reduction in procedure rates of 55% for angiograms, 13% for angioplasties and 31% for thrombolysis. CONCLUSION: Low flow rates detected using Transonic monitoring were associated with increased thrombosis, while stenosis detected using Duplex ultrasonography was not a strong predictor of incipient thrombosis; however, these different access characteristics were compared using monitoring techniques that may be ideal in different clinical situations.