Vascular access outcome with a dedicated vascular team based approach

Abstract EN

The objective of this study is to determine the impact of a dedicated vascular team in the early detection of complications and improvement of vascular access patency.

A dedicated vascular access team comprised four dialysis nurses, a vascular access coordinator and led by a physician.

They were assigned for the surveillance and care of all vascular accesses.

The team presented problematic cases in the regular quality meeting with documentation of access blood flow, dynamic venous pressure, findings of hematoma, prolonged bleeding, swelling, low arterial pressures, steal syndrome, recirculation studies and dialysis adequacy.

In case of failed recirculation or persistently elevated dynamic venous pressure, further evaluation was done either a fistulogram or review by a vascular surgeon.

A total of 226 problematic vascular access cases were detected during the study (January 2014 to October 2017).

The majority were in 41–70 years age group.

A total of 248 referrals were given.

Two hundred cases were referred for fistulogram, but it was performed in 188 patients.

Vascular access stenosis was detected in 153 patients (81.3%) and angioplasty was performed in 137 (89.5%) of these patients.

Fifteen (9.8%) patients were managed conservatively and one patient refused angioplasty.

The 15 cases managed conservatively continued to work normally.

One patient who refused to angioplasty later clotted his fistula during the follow-up period.

Out of 41 cases who were totally noncompliant to referral, nine (22%) clotted their fistula during the follow-up period.

In 12 cases in whom fistulogram was requested, but the request was declined by the primary hospital, five patients (41.6%) clotted their fistulas.

Subgroup analysis showed that in patients who had both failed recirculation and high venous pressure, the prevalence of stenosis was 90% and angioplasty was performed in 94.4%.

In patients who had failed recirculation and low arterial pressure, stenosis was detected in 85.7% and adequacy parameters, prolonged bleeding post- hemodialysis (HD), access arm swelling, high- dynamic venous pressure, and inadequate access blood flow.

All such cases were discussed with the nephrologist.

The vascular access team collected data on all vascular access.

Recirculation studies by urea dilution method were performed quarterly during the study period.

In case of failed recirculation >10% the test was repeated on two conse- cutive dialysis sessions and if results matched, further evaluation of access was planned.

This was done to avoid error due to possible varia- bility in calculated recirculation by urea dilution method.4 Persistently elevated dynamic venous pressure in excess of 150 mm Hg at 200 mL/min blood flow on three HD session were evaluated by further investigations.

The vascular team presented all data on a monthly basis in the quality meetings.

Special emphasis was given to the problematic cases, and a correction plan was devised in each case including the need for special investigations such as duplex ultrasound or fistulogram/ graftogram.

When indicated, referral for vascular surgeon opinion was given.

Records were kept of all the referrals and their outcome.