ABSTRACT
In the past 5 years, some clinical trials have questioned the value of surveillance in managing vascular accesses. Although prolongation of access life span is an important end point, reduction of thrombotic events reduces patient risks resulting from loss of access patency. Most of the available evidence suggests that detection of stenosis and prevention of thrombosis is valuable. When a test indicates the likely presence of a stenosis, then venography or fistulography should be used to definitively establish the presence and degree of the stenosis. In most but not all cases, angioplasty should be performed if the stenosis is greater than 50% by diameter. The value of routine use of any surveillance technique for detecting anatomic stenosis alone, without concomitant functional assessment by measurement of access flow, venous pressure, recirculation or other physiologic parameters, has not been established. Stenotic lesions should not be repaired merely because they are present. If such correction is performed, then intraprocedural or periprocedural measurement of access flow (QA) or intra-access pressure should be conducted to demonstrate a functional improvement with a successful percutaneous transluminal angioplasty.
Subject(s)
Arteriovenous Shunt, Surgical/adverse effects , Catheters, Indwelling/adverse effects , Graft Occlusion, Vascular/diagnosis , Blood Flow Velocity , Constriction, Pathologic/diagnosis , Constriction, Pathologic/therapy , Graft Occlusion, Vascular/physiopathology , Graft Occlusion, Vascular/therapy , Humans , Monitoring, Physiologic , Renal Dialysis/adverse effectsABSTRACT
Several research questions are open in the field of vascular access for hemodialysis. The present paper reviews both prognostic issues, such as the identification of factors for patient stratification before access insertion, and intervention questions, such as comparison of the advantages and disadvantages of different surgical solutions, the effects of different medications on vascular pathology, the different cannulation practices to prevent vessel wall lesions and technologies for early diagnosis of access dysfunction. Given that the quality of the available literature in nephrology is often suboptimal, nephrologists need to pay special attention to methodology issues before embarking on expensive multicenter studies.
Subject(s)
Arteriovenous Shunt, Surgical/adverse effects , Catheters, Indwelling/adverse effects , Randomized Controlled Trials as Topic , Arteriovenous Shunt, Surgical/methods , Constriction, Pathologic/diagnosis , Constriction, Pathologic/therapy , Graft Occlusion, Vascular/diagnosis , Graft Occlusion, Vascular/physiopathology , Humans , Monitoring, Physiologic , Prognosis , Renal Dialysis/adverse effects , Risk Assessment , Vascular PatencyABSTRACT
This comprehensive, proactive, multidisciplinary team approach to access management has enabled the achievement of center-specific best-demonstrated clinical practiCes for vascular access care. It has also resulted in significant cost savings to the health care delivery process. It has not been an easy task; if it were, access care outcomes would be better nationally than they are today. The VACP approach to vascular access care improvement employs four key implementation principles that ensure the success of Gambro's program and form the infrastructure supporting any successful team approach to care. These core processes, known as the four "C's, include: 1. Commitment, 2. Continuous Quality Improvement, 3. Core Competency, and 4. Communication.
Subject(s)
Arteriovenous Shunt, Surgical/standards , Guideline Adherence , Practice Guidelines as Topic/standards , Total Quality Management/organization & administration , Arteriovenous Shunt, Surgical/economics , Arteriovenous Shunt, Surgical/psychology , Boston , California , Clinical Competence/standards , Communication , Cost Savings , Evidence-Based Medicine , Georgia , Health Maintenance Organizations/standards , Humans , Patient Care Team/organization & administration , Program Development , Quality of Life , Renal Dialysis/economics , Renal Dialysis/instrumentation , Renal Dialysis/psychology , Treatment OutcomeABSTRACT
Implementing a CQI program for vascular access can seem an overwhelming task. It encompasses many areas that are not in the nephrologists' or dialysis facilities' control. However, involving the right multidisciplinary team members in the process and aligning the goals and objectives creates an environment conducive to success. Ongoing communication is critical. Everyone needs to be a part of the change process.
