The effect of implementation of an optimized care protocol on the outcome of arteriovenous hemodialysis access surgery

Article Outline

• Abstract
• Methods
  • Patient demographics
  • Study period and follow-up
  • The Optimized Care Protocol
  • Preoperative workup
  • Arteriovenous hemodialysis access surgery
  • Postoperative surveillance
  • Definitions of patency and success of the AVF/AVG
  • Registration and statistical analysis
• Results
  • Patient demographic, AVFs, and AVGs
  • Group I: historical control group
  • Group II: study group
  • Group comparison
• Discussion
• Conclusions
  • Author contributions
• References
• Copyright

Background

The long-term patency of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) suffers from a high incidence of primary failure due to early thrombosis, myointimal hyperplasia at the venous access site, or failure to mature. A multidisciplinary meeting in vascular access surgery was initiated to optimize the timing, indication, type of intervention, and the logistics of AVFs/AVGs during the preoperative and postoperative period. This study evaluated the influence of the new optimized care protocol on the incidence of revisions (surgical and endovascular) and patency rates.

Methods

This protocol for vascular access surgery of AVFs/AVGs for hemodialysis was introduced in January 2004. It was initiated with the presence of the vascular surgeons, nephrologists, interventional radiologists, dialysis nurses, and the ultrasound technicians. Every patient who needed an AVF/AVG because of long-term treatment of chronic renal failure or awaiting kidney transplantation, or who needed a revision of an AVF/AVG, was discussed. Two groups were compared. Group I patients were treated with an AVF/AVG before the introduction of the new protocol (2001 and 2002). Group II patients were treated with an AVF/AVG after the introduction of the new optimized care protocol (2004 and 2005). Both groups were followed up after 12 months.

Results

During the study period, 146 AVFs/AVGs were attempted, and 111 postoperative revisions were performed to restore primary and secondary patency: 63 in group I (60 surgical, 3 radiology) and 48 in group II (23 surgical, 25 radiology). Significantly more segmental access replacements (P < 0.027) occurred in group I than in group II. Significantly fewer surgical revisions (P < 0.019) and more endovascular balloon angioplasties (P < 0.001) occurred in group II. Significantly higher cumulative primary and secondary patency rates of all AVFs/AVGs (P < 0.001), radial-cephalic direct wrist AVFs (P < 0.001), and brachial-cephalic forearm looped transposition AVGs (P < 0.001) were achieved in group II after follow-up.

Conclusion

The new protocol outlined in a bimonthly multidisciplinary meeting for vascular access surgery of AVFs/AVGs for hemodialysis resulted in more effective logistics according to preoperative diagnostics and operation. More importantly, a significant increase in endovascular balloon angioplasties and a significant decrease in surgical revisions was observed, resulting in less patient morbidity. Also, higher primary and secondary patency was achieved after the introduction of the new optimized care protocol.

Arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) are the methods of long-term hemodialysis access for patients with from end-stage renal disease (ESRD). The ideal AVFs/AVGs should be durable, pose minimal risk for infection, and require few revisions to maintain ongoing functional patency. However, AVFs and AVGs have a high incidence of primary failure due to early thrombosis, myointimal hyperplasia, or failure to mature. Vascular access complications substantially contribute to morbidity and hospitalization in hemodialysis patients. Estimates of primary failure, primary patency, and secondary patency vary considerably. Early thrombosis and failure to mature are significant problems, occurring in 20% to 50% of AVFs.¹

The prospective identification of patients who are prone to early AVF/AVG failure is of high clinical importance. These patients may especially benefit from a multidisciplinary approach in which all factors contributing to access graft failure are assessed. Moreover, a standardized preoperative diagnostic work-up, specific treatment guidelines considering graft type and location, and predetermined postoperative follow-up with a standardized surveillance protocol could be of value in optimizing access graft patency and thereby reduce patient morbidity.

In 1997 the National Kidney Foundation Disease Outcome Quality Initiative (NKF-DOQI) Work Group and European Guidelines for Vascular Access represented a comprehensive consensus statement using evidence-based methods to provide guidelines to optimize care of patients with ESRD.², ³, ⁴ The National Vascular Access Improvement Initiative (NVAII) statement recommends a multidisciplinary implementation of protocol-driven surveillance programs for early detection and treatment of failing vascular access conduits.⁵ Several studies have evaluated individual aspects of these K/DOQI guidelines, such as comprehensive follow-up programs to enhance maturation or standard preoperative work-up with duplex ultrasound (DUS) examination.⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷

The implementation of a standardized protocol with emphasis on preoperative work-up and postoperative surveillance embedded in a bimonthly multidisciplinary meeting on access graft surveillance has been rarely reported. In the present study we evaluate the effectiveness of a predetermined optimized care protocol (OCP) monitored in a bimonthly multidisciplinary meeting for vascular access surgery of AVFs and AVGs for hemodialysis, which was introduced in January 2004. The objective of the present study was (1) to evaluate the incidence of surgical and endovascular revisions and (2) to compare the primary and secondary patency rates between the historical control group and the group treated using the OCP.

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Methods 

Patient demographics 

Patient characteristics and medical history (cardiac disease, pulmonary disease, cerebral disease, diabetes mellitus, hypertension, hyperlipidemia and age) were collected prospectively during the admission intake, classified according to the Society of Vascular Surgery/North American Chapter, International Society of Cardiovascular Surgery (SVS/ISCVS) standards,¹⁸, ¹⁹, ²⁰ and graded in severity. The American Society of Anesthesiologists (ASA) classification²¹ of patients was determined according to their general condition. The primary causes of ESRD (diabetic, hypertension; medications such as analgesics, cyclosporine, or lithium; obstructive nephropathy and collagen vascular diseases) were registered and are listed with the other patient characteristics in Table I.

Table I. Patient demographics, comorbidity risk factors, and primary renal disease

Characteristicsa	Total	Group Ib	Group IIc	P
Patients, No.	146	72	74
Sex				.095
Male	82(56)	35(49)	47(64)
Female	64(44)	37(51)	27(36)
Age, years				.008
<55	26(18)	13(18)	13(18)
55-69	38(26)	15(21)	23(31)
70-79	59(40)	38(53)	21(28)
>80	23(16)	6(8)	17(23)
ASA class21				.189
2	69(47)	31(43)	38(51)
3	75(51)	41(57)	34(46)
4	2(1)	0(0)	2(3)
Comorbidity
Cardiac disease	73(50)	40(56)	33(45)	.246
Pulmonary disease	30(21)	11(15)	19(26)	.152
Carotid disease	25(17)	16(22)	9(12)	.127
Diabetes mellitus	32(22)	13(18)	19(26)	.319
Hypertension	109(75)	55(76)	54(73)	.705
Hyperlipidemia	53(36)	22(31)	31(42)	.172
Dilatating arterial disease	13(9)	6(8)	7(9)	.811
Occlusive arterial disease	24(16)	11(15)	13(18)	.824
SVS-ISCVS risk, score (SD)18, 19, 20	1.27	1.34(0.44)	1.22(0.41)	.08
Primary renal disease				.173
Diabetic nephropathy	14(10)	6(8)	8(11)
Hypertension nephropathy	11(8)	5(7)	6(8)
Glomerulonephritis	20(14)	10(14)	10(14)
Polycystic renal disease	16(11)	8(11)	8(11)
Nephrosclerosis	36(25)	18(25)	18(24)
Medication	10(7)	7(10)	3(4)
Obstructive nephropathy	6(4)	1(1)	5(7)
Collagen vascular disease	6(4)	6(8)	0(0)
Miscellaneous/unknown	27(18)	11(15)	16(22)

ASA, American society of Anesthesiologists; SD, standard deviation; SVS-ISCVS, Society of Vascular Surgery/North American Chapter, International Society of Cardiovascular surgery.

Study period and follow-up 

A retrospective observational clinical review was conducted of data for patients referred for permanent hemodialysis access to the vascular surgery practice in a single major dialysis center, at the Haga Hospital of The Hague, the Netherlands. Results of dialysis access procedures were compared between two periods: January 2001 to December 2002 (follow-up until December 2003: maximum 1 year) vs January 2004 to December 2005 (follow-up until December 2006: maximum 1 year). The AVFs/AVGs initiated in the later group were after institution of a new OCP (January 2004) outlined in a multidisciplinary meeting held every other week for planning therapy for these patients.

Since then, all patients with indication of vascular access surgery (primary surgery or a revision) were evaluated according to this protocol and assessed in this meeting to optimize patient outcome. Important to stress is that the same number of patients was dependent on dialysis at the time of access placement during both periods. AVFs/AVGs performed in 2003 were excluded because during this year the new protocol was not in practice; therefore, this year was used as independent follow-up year of the AVFs/AVGs performed in January 2001 to December 2002.

The Optimized Care Protocol 

Every patient who was to receive an AVF/AVG because of long-term treatment of chronic renal failure or awaiting kidney transplantation, or who was to receive a revision of an AVF/AVG, was evaluated according to our new protocol outlined in a bimonthly multidisciplinary meeting of vascular access surgery of AVFs/AVGs for hemodialysis. In this meeting the vascular surgeons, nephrologists, interventional radiologists, the ultrasound technicians and dialysis nurses participated and assessed the medical records and dialysis charts of these patients in a structured standardized manner using a prefixed individual patient work sheet. The purpose of this protocol was (1) to optimize and standardize preoperative work-up with emphasis on access site selection, (2) to optimize postoperative surveillance to detect and treat potential access graft failure early, and (3) to optimize communication among all specialist involved in the treatment of vascular access graft patients.

Preoperative workup 

The preoperative standardized workup included careful assessment of the vascular anatomy. Arterial examination included pulse assessment, performance of the Allen test, and bilateral upper extremity blood pressure measurement. Venous examination included inspection and palpation of the cephalic vein at the wrist and upper arm and the basilica vein at the elbow, with a tourniquet in place.

Both arms were evaluated with DUS by an experienced sonographer. The diameter of the radial artery at the wrist and the brachial artery immediately above the antecubital fossa were determined. Veins were assessed on the adequacy of the superficial vein, on ease of compressibility, thickness, continuity, and depth below the skin. The evaluation of stenosis or occlusion of the deep venous system (axillary and subclavian veins) was registered. The minimum acceptable threshold for internal diameters for arteries and veins were set at ≥2.0 mm according to the NKF-DOQI guidelines,², ³, ⁴ the Vascular Access Society,²², ²³ and overall hemodialysis literature.⁶, ⁷, ²⁴

Measurements of vein diameter were recorded at representative sites, including wrist, distal forearm, middle forearm, proximal forearm, antecubital fossa, distal upper arm, middle upper arm, and proximal upper arm. In case of a suspected inflow stenosis or occlusion, contrast angiography was used to optimize preoperative work-up. Venography was performed selectively if no suitable vein was identified at DUS. There was more thorough preoperative evaluation concerning standardized DUS and angioplasty.

The protocol we used for access site and type is autogenous before prosthetic and distal arm before proximal to conserve sites. If technically possible, the nondominant extremity was used for construction of the AVF/AVG; however, the final decision was ultimately determined according to the size and quality of the vessels on the basis of results of clinical examination and DUS examination.

Important to be mentioned about the later period is that there was no timelier referral. Patients were not referred earlier for hemodialysis access in their disease course, and the waiting time from referral to operation was the same.

Arteriovenous hemodialysis access surgery 

The AVF procedures were autogenous radial-cephalic direct wrist access, brachial-cephalic direct access, and brachial-basilic transpositions. An end-to-side anastomosis was made with a running 6-0 or 7-0 monofilament suture between the vein and artery. The AVG procedures were brachial-cephalic looped transpositions with polytetrafluoroethylene (PTFE) grafts. Also ProCol shunts (Hancock Jaffe Laboratories, Irvine, Calif) were used. All operations were performed by or under the supervision of a vascular surgeon, and there was no change in surgeons or quality of surgeons during the study period.

A surgical revision of a failed AVF/AVG could be a thrombectomy, a segmental access replacement, a surgical percutaneous transluminal angioplasty (PTA), or a correction of a postoperative hemorrhage or aneurysm. A PTA could also be an endovascular revision performed by the interventional radiologist. Percutaneous thrombectomy, stenting, or placement of stent grafts were not part of the protocol; however all thrombectomies were performed surgically. All operations were performed under local, regional, or general anesthesia. AVFs were allowed at least 6 weeks to develop before puncture for hemodialysis. An AVF was considered to have matured when the diameter of the vein was sufficient to provide adequate dialysis.

Data of the surgical interventions are listed in Table II, Table III. Because the same experienced vascular surgeons operated in both periods, the quality of surgeons and executed operations did not change during this study period. The same holds for the interventional radiologists and the quality of their expertise. Also no differences existed in type of referral patterns, operation room facilities, and reimbursement patterns.

Table II. Total revisions of 111 arteriovenous fistulas in group I and group II

Proceduresa	Total	Group Ib	Group IIc	P
Total revisions	111(0,0,9)	63(0,0,9)	48(0,0,6)	.894
Surgical revisionsd
Thrombectomy	36(0,0,4)	25(0,0,4)	11(0,0,3)	.087
Segmental access replacement	18(0,0,4)	15(0,0,4)	3(0,0,2)	.026
Balloon angioplasty	25(0,0,4)	16(0,0,4)	9(0,0,3)	.261
Bleeding	1(0,0,1)	1(0,0,1)	0(0,0,0)	.311
Aneurysm	3(0,0,2)	3(0,0,2)	0(0,0,0)	.151
Total	83(0,0,9)	60(0,0,9)	23(0,0,6)	.019
Endovascular revisionse
Balloon angioplasty	28(0,0,5)	3(0,0,2)	25(0,0,5)	.001

Table III. Summary of arteriovenous access procedures in groups I and II

Arteriovenous access surgerya	Total	Group Ib	Group IIc	P
Patients, total	146	72	74
Hemodialysis access				.063
AVF
Brachial-cephalic upper arm direct access	2(1)	0(0)	2(3)
Brachial-basilic upper arm transposition	6(4)	0(0)	6(8)
Radial-cephalic direct wrist accessd	83(57)	41(57)	42(57)
AVG
Brachial-cephalic looped transposition	53(36)	30(42)	23(31)
ProCol shunte	2(1)	1(1)	1(1)
Material used				.409
PTFE	53(36)	30(42)	23(31)
ProCol	2(1)	1(1)	1(1)
Autogenous	91(62)	41(57)	50(68)

AVF, Arteriovenous fistula; AVG, arteriovenous graft; PTFE, polytetrafluoroethylene.

Postoperative surveillance 

As listed in Fig 1, a more intensive use of surveillance occurred in the new OCP study period. The first postoperative visit was at the dialysis center for examination, suture removal, and patient education after 1 week. The patient underwent a directed physical examination for signs of impending thrombosis or lack of maturation during regular visits at the dialysis center 3 times a week. The problems that would initiate an urgent assessment were: (1) high venous pressures (>250 mm Hg at a 400 mL/min pump speed), (2) difficult cannulation, (3) an AVF flow rate <400 to 500 mL/min or an AVG flow rate <600 mL/min, (4) minimal thrill with low flow suspected, (5) minimal increase in vein dilatation, (6) increasing arm edema, (7) barely audible or highly pitched bruit, or (8) physical signs of suspected stenosis after careful palpation of the entire length of the AVF/AVG.

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• Fig 1. 

  Flow chart shows protocol for treatment, multidisciplinary meeting, and follow-up of patients with arteriovenous hemodialysis access with arteriovenous fistulas (AVF) and arteriovenous grafts (AVG). PTA, percutaneous transluminal angioplasty.

When AVF/AVG failure was suspected, DUS imaging was performed to evaluate stenosis before occlusion, and the AVF/AVG was automatically evaluated according to the OCP and earlier reintroduced at the multidisciplinary meeting for a possible surgical or endovascular revision. The DUS results were not validated by fistulography in all cases as specified by the protocol. Criteria for a hemodynamically significant stenosis (≥50% reduction in luminal diameter) were based on guidelines of previously published reports.¹³, ²⁴, ²⁵ If stenosis in case of maturation failure, conduit stenosis, and native arterial stenosis was detected in the region of the venous anastomosis or anywhere along the draining vein or the central veins, PTA was the treatment of choice. It was performed with a 5- to 8-mm-diameter balloon catheter.

Definitions of patency and success of the AVF/AVG 

Definitions of patency were those recommended by the Committee on Reporting Standards for Arteriovenous Access of the SVS and the American Association for Vascular Surgery.¹⁷, ¹⁸, ¹⁹ Technical success was defined as the presence of a thrill on palpation or bruit on auscultation 24 hours postoperatively. The primary patency and secondary patency rates (including initial failure to mature in 6 weeks) were determined at regular intervals: 1, 3, 6, 9, and 12 months. Primary patency was described as the interval from the time of access placement until the first intervention designed to maintain or re-establish patency, access thrombosis, or the time of measurement of patency. Secondary patency was described as the interval from the time of access placement until access abandonment, thrombosis, or the time of patency measurement including intervening manipulations (surgical or endovascular interventions) designed to re-establish functionality in thrombosed access. Inadequate maturation was defined as insufficient access flow to maintain dialysis or the unavailability to cannulate an AVF, if required, at 6 weeks after surgery. AVFs that never matured were included in the patency rates.

Registration and statistical analysis 

By using Access software (Microsoft Inc, Redmond, Wash), patient information was entered on a specifically designed computerized analysis program for hemodialysis patients. Statistical analyses were performed using Excel (Microsoft) and SPSS 12.01 software (SPSS Inc, Chicago, Ill). Follow-up was complete in all patients (mean, 12 months). The Fisher exact test, Student t test, or χ² test were used to assess differences between both groups for a given variable. The postoperative revisions were analyzed with the Mann-Whitney U test. The Kaplan-Meier survival method was used to calculate the time curve of the cumulative primary and secondary patency at 1, 3, 6, 9, and 12 months after AVF/AVG creation. The log-rank test was used for comparison of the primary and secondary patency rates. For all statistical analyses, a value of P < .05 was considered to be statistically significant.

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Results 

Patient demographic, AVFs, and AVGs 

The hemodialysis population at the Haga Hospital at any time totals approximately 80 patients. During the two study periods, 146 primary access procedures—91 primary AVFs (62%) and 55 AVGs (38%)—were performed in 82 men (56%) and 54 women (44%) as well as 111 additional revisions. Fifty-six of all AVFs (62%) were created in women. There were no significant differences with regard to ASA classification, comorbidity, and causes of renal failure. Most of these patients (56%) were aged ≥70 years. In the study group (group II), patients were significantly more likely to be >80 years. Table I summarizes demographics, comorbidity, and primary renal disease. No patients were lost to follow-up.

Group I: historical control group 

Patients in group I had 72 access procedures (49%), 41 AVFs (57%) and 31 AVGs (43%), performed between January 2001 and December 2002, with follow-up until 2003. Twenty-one of all AVFs (51%) were created in women. Three radiologic PTAs (5%) and 60 surgical revisions (95%) were done to maintain function in 46 AVFs/AVGs (64%). This resulted in an 88% rate for total revision. Twenty-six AVFs/AVGs (36%) never underwent a revision by a surgeon or an interventional radiologist.

The cumulative primary patency rates by Kaplan-Meier analysis of all AVFs/AVGs at 1, 3, 6, 9, and 12 months were 69%, 50%, 40%, 36%, and 36%, respectively. The cumulative secondary patency rates of all AVFs/AVGs were 76%, 61%, 54%, 53%, and 47%, respectively. The summary of the AVFs/AVGs, postoperative revisions, cumulative primary and secondary patency results are listed in Table II, Table III, Table IV and outlined in Fig 2, Fig 3, Fig 4.

Table IV. Cumulative life-table primary and secondary patency rates of 83 arteriovenous fistulas and 53 arteriovenous grafts in group I^a and II^b

Patencyc	1 month	3 months	6 months	9 months	12 months
All AVFs and AVGs
Primary patency
All	146(79)	116(62)	91(51)	74(45)	66(42)
Group I	72(69)	50(50)	36(40)	29(36)	26(36)
Group II	74(89)	66(74)	55(61)	45(54)	40(49)
Secondary patency
All	146(84)	123(72)	105(66)	96(64)	93(59)
Group I	72(76)	55(61)	44(54)	39(53)	38(47)
Group II	74(92)	68(82)	61(77)	57(74)	55(70)
AVFd
Primary patency
All	83(74)	61(57)	47(45)	37(41)	34(37)
Group I	41(63)	26(44)	18(34)	14(32)	13(32)
Group II	42(83)	35(69)	29(55)	23(50)	21(43)
Secondary patency
All	83(76)	63(59)	49(51)	42(49)	41(46)
Group I	41(66)	27(46)	19(37)	15(37)	15(37)
Group II	42(86)	36(72)	30(64)	27(62)	26(55)
AVGe
Primary patency
All	53(87)	46(68)	36(59)	31(49)	26(49)
Group I	30(80)	24(60)	18(50)	15(43)	13(43)
Group II	23(96)	22(78)	18(70)	16(57)	13(57)
Secondary patency
All	53(94)	50(87)	46(85)	45(81)	43(74)
Group I	30(90)	27(80)	24(77)	23(73)	22(60)
Group II	23(100)	23(96)	22(96)	22(91)	21(91)

AVF, Arteriovenous fistula; AVG, arteriovenous graft.

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• Fig 2. 

  Summary of revisions in 63 group I patients (57%) and 48 group II (43%) patients. Group I comprised admissions because of treatment with a primary arteriovenous fistulas (AVF) or arteriovenous grafts (AVG) in the year 2001 and 2002, with follow-up from 2001 to 2003 (mean, 1 year). Group II admissions were in the year 2004 and 2005, with follow-up from 2004 until 2006 (mean, 1 year). PTA, Percutaneous transluminal angioplasty.

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• Fig 3. 

  Kaplan-Meier curves for cumulative secondary patency (SP) rates of 83 radial-cephalic direct wrist access (Brescia-Cimino fistula) arteriovenous fistulas (AVF) or grafts (AVG) in group I (n = 41) and group II (n = 42). Data are presented as number at risk (%), unless otherwise specified. Admissions were because of treatment with a primary AVF/AVG in the year 2001 and 2002 for group I, with follow-up from 2001 to 2003 (mean, 1 year), and in the year 2004 and 2005 for group II, with follow-up from 2004 to 2006 (mean, 1 year).

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• Fig 4. 

  Kaplan-Meier curves for cumulative secondary patency (SP) rates of 53 brachial-cephalic forearm looped transposition arteriovenous grafts in group I (n = 30) and group II (n = 23). Data are presented as number at risk (%), unless otherwise specified. Admissions were because of treatment with a primary arteriovenous graft or fistula in the year 2001 and 2002 for group I, with follow-up from 2001 to 2003 (mean, 1 year); and in the year 2004 and 2005 for group II, with follow-up from 2004 to 2006 (mean, 1 year).

Group II: study group 

The study group patients underwent 74 access procedures (51%), consisting of 50 AVFs (68%) and 24 AVGs (32%), performed between January 2004 and December 2005, with follow-up until 2006. Thirty-five of all AVFs (70%) were created in women. A total of 23 surgical revisions (48%) and 25 radiologic PTAs (52%) were done to maintain function in 38 AVFs/AVGs (50%), for a total revision rate of 63%. Thirty-eight AVFs/AVGs (50%) never underwent a revision by a surgeon or an intervention radiologist.

The cumulative primary patency rates, obtained by Kaplan-Meier analysis, of all AVFs/AVGs at 1, 3, 6, 9, and 12 months were 89%, 74%, 61%, 54%, and 49%, respectively. The cumulative secondary patency rates of all AVFs/AVGs were 92%, 82%, 77%, 74%, and 70%, respectively. The summary of the AVFs/AVGs, postoperative revisions, cumulative primary and secondary patency results are listed in Table II, Table III, Table IV and outlined in Fig 2, Fig 3, Fig 4.

Group comparison 

No significantly differences were found between the two groups regarding the sort of AVFs/AVGs (P < .063) and material used in AVFs/AVGs (P < .409), as listed in Table III. For surgical revisions, there was a statistically significant difference in segmental access replacements (P < .026) in favor of group II. This resulted in a decrease of the total of surgical revisions (P < .019) and an increase of endovascular PTAs performed by the interventional radiologist (P < .001). A significant difference was achieved between group I and group II in primary patency rates of all AVFs/AVGs (36% vs 49%; P < .001), the radial-cephalic direct wrist access AVFs (32% vs 43%, P < .001), and the brachial-cephalic looped transposition AVGs (43% vs 57%, P < .001) after 1 year of follow-up. A significant difference between group I and group II was achieved in secondary patency rates for the respective AVFs/AVGs (47% vs 70%, P < .001), the radial-cephalic direct wrist access AVFs (37% vs 55%, P < 0.001) and the brachial-cephalic looped transposition AVGs (60% vs 91%, P < 0.001) after 1 year of follow-up, as listed in Table II, Table III, Table IV and outlined in Fig 2, Fig 3, Fig 4.

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Discussion 

Arteriovenous hemodialysis access surgery is complex. The multidisciplinary nature, preoperative workup of the patient, timing of the operation, selection of the vascular access site, surgical technique, postoperative monitoring, and early detection of AVF/AVG failure are all important aspects to ensure an uninterrupted hemodialysis access and a good long-term survival. In this study, the effect of a newly introduced protocol outlined in a regular bimonthly multidisciplinary meeting on the long-term patency of AVFs/AVGs was assessed. After the initiation of this protocol in January 2004, all patients with an indication of vascular access placement or with undercurrent complications or access problems were discussed according to a new protocol outlined in this meeting attended by the vascular surgeons, nephrologists, interventional radiologists, the ultrasound technicians, and dialysis nurses.

To achieve the best outcome for every individual patient, the team agreed on a set of goals, to collaborate closely, and maintain good communication. The medical records and dialysis charts registered in a standardized manner were discussed and policy was made. This protocol ensured that every patient was analyzed in the most optimal way with the best interpretation of medical history, physical examination, and additional diagnostic imaging.

In this study, the overall primary and secondary 1-year patency rates improved from 36% to 49% and from 47% to 70%, respectively. The primary and secondary 1-year patency rates of the radial-cephalic direct wrist access (AVF) improved from 32% to 43% and from 37% to 55%, respectively. Furthermore, the primary and secondary 1-year patency rates of the brachial-cephalic forearm looped transposition (AVG) improved from 43% to 57% and from 60% to 91%, respectively. When primary and secondary 1-year patency rates were compared for all AVFs/AVGs, and AVFs and AVGs between the two groups, a significant difference in favor of group II was seen. The patency rates are quite reasonable, meet NKF-DOQI guidelines,², ³, ⁴ and are in accordance with and sometimes compare favorably with the results of others.²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³², ³³

The results of this study indicate that evaluating individual patients with vascular access indications or postoperative vascular access complications according to a new strict OCP in a regular bimonthly multidisciplinary meeting with all specialists surrounding the vascular access patient improves vascular access patency significantly. Although the total of all revisions, surgical and endovascular, did not differ significantly, a significant decrease of all of surgical revisions and an increase of all PTAs was achieved after the implementation of this new OCP embedded in the bimonthly multidisciplinary meeting.

The greater use of PTA may reflect changes in practice and the identification of AVF/AVG stenosis before thrombosis through better monitoring of access function in the dialysis center. These changes in revisions reduce morbidity, shorten the hospitalization period, and decrease the cost of hemodialysis treatment for the individual patient and health care in general. This is a cohort study without significant differences between both groups with regard to risk factors of AVF/AVG failure.

The improved outcome of vascular access function after the initiation of the OCP outlined in the biweekly multidisciplinary meeting in January 2004 is presumably caused by several factors:

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Conclusions 

In this study we demonstrated significant increased primary and secondary AVF/AVG patency rates after the initiation of a new OCP. Discussing patients on a regular basis in a strict manner according to a predetermined protocol resulted in significant increased endovascular revisions and significant decreased surgical revisions. Therefore, this optimized care protocol outlined in a multidisciplinary meeting with all specialists surrounding the vascular access patient reduces patient morbidity and is of value in order to strive for the highest possible quality of care.

Author contributions 

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References 

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