Management of arteriovenous fistulas
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6262 (Published 30 October 2014) Cite this as: BMJ 2014;349:g6262
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
We welcome the clinical review by Siddiky et al. of arteriovenous fistulas in haemodialysis access. However, in the article they suggest that an arteriovenous fistula (AVF) ’offers the best short, intermediate and long term options for renal replacement therapy’. AVF do have many advantages, but one of the few recent and rigorous systematic reviews in vascular access re-iterates the often overlooked complication of primary non-function, that is patients undergoing fistula creation that never work. Al-Jaishi et al. [1] suggest this occurs in around a quarter of all patients, with only 60% (CI 56%-64%) of AVF still functioning without intervention at one year following surgery. Many clinicians may see fistula surgery as a minor operation but we should not underestimate the negative effect that that these poor outcomes from surgery have on both the patient experience and morbidity.
For some patients, AVF creation is not possible or precluded by informed patient choice. With the right care both arteriovenous grafts [2] and tunnelled lines [3] can provide acceptable alternatives. This diversity of options is important when we wish to provide bespoke and individualised care for patients, rather than a ’one-size-fits-all’ approach in modern healthcare systems including the NHS [4].
This is underpinned by decision analysis work incorporating these alternative modalities to support a patient-centred approach [5]. Indeed, this well designed study suggests that in certain patient groups, particularly the elderly and those with diabetes, a position of clinical equipoise may exist between the three modalities. The absence of randomised controlled trials in vascular access modality have meant that clinical guidelines have been reliant on historic observational studies, many of which have an inherent selection bias. In particular, many of these studies fail to deal adequately with the confounding burden of co-morbidity that often precludes the creation of native vascular access.
It is important that clinicians and policy-makers do not ignore the absence of clear evidence to support vascular access decision making. Nor should they overlook the great need for work to define the causes of early arteriovenous fistula failure alongside the design of novel interventions to improve both clinical outcomes and the patient experience.
RW Corbett clinical research fellow
DR Ashby consultant nephrologist
ND Duncan consultant nephrologist
Imperial College Renal and Transplant Centre
London, UK
References
[1] Al-Jaishi AA, Oliver MJ, Thomas SM, Lok CE, Zhang JC, Garg AX, et al.Patency rates of the arteriovenous fistula for hemodialysis: a systematic review and meta-analysis. Am J Kidney Dis. 2014 Mar;63(3):464–78.
[2] Lok CE, Sontrop JM, Tomlinson G, Rajan D, Cattral M, Oreopoulos G, et al. Cumulative patency of contemporary fistulas versus grafts (2000-2010). Clin J Am Soc Nephrol. 2013 May;8(5):810–8.
[3] Power A, Singh SK, Ashby D, Cairns T, Taube D, Duncan N. Long-term Tesio catheter access for hemodialysis can deliver high dialysis adequacy with low complication rates. J Vasc Interv Radiol. 2011 May;22(5):631–7.
[4] NHS England, Public Health England, Monitor, Care Quality Commission, Health Education England. Five year forward view; 2014. October. Available from: www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf.
[5] Drew DA, Lok CE, Cohen JT, Wagner M, Tangri N, Weiner DE. Vascular Access Choice in Incident Hemodialysis Patients: A Decision Analysis. J Am Soc Nephrol. 2014 Jul;p. 1–9.
Competing interests: No competing interests
Re: Management of arteriovenous fistulas
Many thanks to the Hammersmith team for their response to our paper. It should be noted that this paper was commissioned to provide a broad overview of arteriovenous access only with a key focus on primary autologous vein fistulae and therefore no detailed discussion around secondary and tertiary access or complex access in the presence of central vein pathology took place.
Primary non-function is a recognized problem with access creation but in experienced hands no more than 10% of radio and brachiocephalic AVF’s should be failing within the first hours after surgery. By 6 weeks post fistula creation it is recognized that a further 10-15% may well have failed or will show signs of failing to mature. It is the authors view that figures below this are both unacceptable and probably reflect a combination of poor choice of access creation in the first instance along with limited pre-operative imaging, post operative surveillance programmes or an appetite to aggressively salvage access.
The view from the Hammersmith team that these poor outcomes impact on the patients experience and morbidity are certainly valid and there is no doubt that repeatedly trying to get an access creation is soul destroying for the patient and also the surgeon. What the Hammersmith team perhaps fail to recognise is the significant morbidity and mortality associated with long term central venous catheter usage. The resultant debilitating central venous pathology that occurs significantly reduces a dialysis patients access options including the use of grafts given the high incidence of venous hypertension that will develop secondary to central stenosis or occlusions. They have also failed to mention the fact that dialysis adequacy over time is significantly better if a patient dialyses off a fistula or a graft given the presence of arterial flow as a driver.
Every access team should consider all dialysis patients as individuals who require a bespoke access approach dependent on their needs and what options are available. That is certainly the case in our own centre where fistula first is not always the best for some of our patients and where graft first may be the best or the only option.
There continues to be limited high quality evidence in access however there is growling literature that early failure may be driven by the uraemic state of the patient. This is why early referral and creation of access is imperative. More work is however clearly required to better understand the development perianastomic disease in arteriovenous access.
Competing interests: No competing interests