Elsevier

Journal of Vascular Nursing

Volume 31, Issue 3, September 2013, Pages 111-117
Journal of Vascular Nursing

Article
A review of patients with renal disease undergoing vascular access surgery: Is gray-scale ultrasound enough?

https://doi.org/10.1016/j.jvn.2012.10.003Get rights and content

Background

An adequate fistula or graft is essential to long-term survival and quality of life for patients with end-stage renal disease (ESRD) who are receiving hemodialysis because of its lower complication rates, lower costs, and prolonged patency. Use of duplex ultrasound for preoperative planning is currently recommended by the Kidney Disease Outcomes Quality Initiative for patients with ESRD with prior fistulas or grafts, central lines, pacemakers, and prior chest or arm surgery. The preoperative evaluation consisted of gray-scale ultrasound and physical examination in all patients with ESRD in this study. The current study determined the baseline data, including the type of vascular access, functional patency of access, associated morbidity, and preoperative demographics and comorbidities, including prior dialysis access. The primary objective was to determine the frequency of revision surgery, to identify the potential cases that may indicate the need for better assessments (eg, duplex ultrasound), and to improve fistula and graft success rates.

Materials and methods

A retrospective chart review of patients with ESRD who underwent native fistula or graft access creation in a 13-month time period from 2010 to 2011 was completed. Seventy-six surgical procedures were performed on 53 subjects. Included variables were age, race, gender, smoking status, body mass index, stage of chronic kidney disease at referral, previous central lines/pacemakers, fistulas, or grafts. Comorbidities identified included diabetes mellitus (DM), hypertension (HTN), and coronary artery disease (CAD). The types of access, location, maturation, infection, failure, or revision were noted. Continuous variables are shown in frequencies and mean. Categoric data were compared using chi-square analysis.

Results

During the 13-month study period, 76 surgical procedures were performed in 53 patients, with 39.6% of patients undergoing multiple surgical procedures. The majority of patients were male (98%) and white (58.5%), with a history of HTN (96.2%) and DM (64.2%). The mean age was 68 years, with most patients presenting in stage 5 chronic kidney disease (92.5%). Some 67.9% of patients had prior central lines or pacemakers; of those, 56.6% had previous fistulas or grafts. Negative significance was determined between the comorbidities DM/HTN/CAD alone or grouped as a cohort and multiple surgeries. Positive significance was found between multiple surgical procedures and those with prior access/pacemaker/central line (chi-square [1, N = 53] = exact P = .04).

Conclusions

Patients with ESRD undergoing access creation presenting with prior central lines, pacemakers, or arm surgery (fistulas or grafts) were more likely to undergo multiple surgeries to obtain a functional graft or fistula for hemodialysis use than those patients with ESRD without prior central lines, pacemakers, or arm surgery (fistulas or grafts). Color duplex ultrasound should be considered as a standard for preoperative assessment in an effort to improve fistula or graft success rates.

Section snippets

Literature review and synthesis

The purpose of this literature review was to identify the best evidence to support a preoperative protocol development for patients with ESRD. The appraisal of evidence was evaluated using the Johns Hopkins nursing evidence-based practice appraisal tools. These tools gauge the strength of the recommendations found in the studies or articles with levels 1 to 5. Level I indicates the strongest evidence, and level V indicates the weakest. The quality is graded with an A to C system. Grade A is

Theoretic framework

Evidence-based models have been developed to move evidence into practice. Many of the models share common phases, such as identifying clinical or potential problems, gathering best evidence, and appraising and evaluating potential change in practice, with implementation and evaluation.19 In nursing, the best evidence uses findings from research that are methodologically appropriate, rigorous, and clinically relevant. The intervention must be effective, using reliable and precise nursing

Purpose

The primary objective of the study was to determine whether the preoperative workup for patients who are receiving dialysis is adequate. This chart review will identity the frequency of revision surgery.

Study design

A chart review of all adult male and female patients who consecutively underwent fistula or graft creation surgery in a 13-month period from 2010 to 2011 were retrospectively identified through surgical procedural records. These represented the patients of the 2 surgeons who perform vascular access surgery at the study site. The database was Health Insurance and Portability Act compliant. The study was approved by the human research committees at both the study site medical center and Marquette

Results

The study cohort included 53 subjects with late-stage CKD, including 92.5% presenting in stage 5 and 7.5% presenting in stage 4. Most subjects were male, with 1.9% representing the female gender, which is representative of the study center's population. A majority of the subjects were white (58.5%), with the remainder being African American (41.5%). There were no Hispanics or Asian/Pacific Americans identified. Smoking status was examined with more subjects identified as nonsmokers within 1

Discussion

The KDOQI recommends duplex ultrasound for patients with prior neck, arm, or chest surgery; current or previous central catheters; current or previous pacemakers; edema or collateral vein development.3 Prior central or peripheral venous punctures to the veins cause scarring to the vessel that interferes with dilation of the vein, causes turbulent blood flow, and predisposes the fistula to stenosis.4 This review identified a substantial percentage of subjects (67.9%) with prior central lines or

Conclusions

The establishment of a formal preoperative protocol using duplex ultrasound should be explored for patients identified in the KDOQI guidelines and supported in the retrospective review. To influence a change in practice, an association between the evidence and the problem must be the initial step. The primary objective to identify those potential cases that may indicate the need for a more extensive preoperative workup was met. The current preoperative assessment used for identifying fistula

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    • Cited by (3)

    • Expert consensus on the establishment and maintenance of native arteriovenous fistula

      2021, Chronic Diseases and Translational Medicine
      Citation Excerpt :

      1B) Physical examination, as a preliminary screening for evaluating the blood vessels, has certain limitations.26,29 For example, while visual inspection and palpation can help to identify more venous conditions, they cannot accurately assess the inner diameter of the artery or determine factors such as the speed of blood flow, and whether vascular calcification or plaques are present, which are of great significance in determining whether the internal fistula is mature.16,18,21

    • A narrative review on arteriovenous fistula for hemodialysis

      2022, Giornale Italiano di Nefrologia

    • Letter by Ozeke et al Regarding article, "risk of acute kidney injury after percutaneous coronary interventions using radial versus femoral vascular access: Insights from the blue cross blue shield of michigan cardiovascular consortium"

      2014, Circulation: Cardiovascular Interventions

    Conflicts of Interest: None.

    This manuscript has not been presented at any conference or meetings, or submitted to any other journal. Institutional review board approval was obtained from the Zablocki VA Medical Center and Marquette University.

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