New approaches to successful vascular access

Patient education, timely referrals, knowing all options for vascular access, and training frontline staff are important approaches to successful vascular access in dialysis patients.

In a session on finding success in vascular access in dialysis patients, Dr Vandana Niyyar (Emory University, GA, USA) asked: “What do we mean when we say we want success? For me, that means providing the right access to the right patient, at the right time, for the right reasons. And then, once we define it, how can we achieve it and maintain it in the long term?” [1].

Dialysis has worse survival outcomes than invasive cancers, and there is often a discrepancy between what’s most important to the patient and to the clinician. Vascular access needs to be individualised to the patient, and patients need to be active decision-makers in their care. Patient education is associated with a 2-fold increase in the patient choosing arteriovenous fistula or arteriovenous graft.

Dr Niyyar reviewed strategies to optimise functional access as a nephrologist. She highlighted vessel preservation and timely referrals. At the nephrology level, doctors must appropriately refer patients to surgery. At Emory, her team was able to institute an automatic notification system for a nephrology consult for anyone scheduled to receive a peripherally inserted central catheter (PICC) line. Understanding all line options for specific vascular access is necessary, and institutional guidelines for treatment and follow-up are recommended.

Dr Niyyar’s team trained front-line haemodialysis staff to assess fistulas for maturity and use ultrasound to guide cannulation at Emory dialysis. This included 4 outpatient units and 150 patients. Diameter measurements were at 2 cm, 4 cm, and 6 cm from the anastomosis. At 4–6 weeks, maturity was examined, and if mature, scheduled for cannulation. Overall, 40 patients were cannulated, and there was only 1 case of infiltration. Ultrasound was useful for assessing maturity and doing the procedure, but Dr Niyyar stressed this is an adjunct — not a replacement — for physical examination.

1. Niyyar VD. Keys to Success in Managing Vascular Access in Dialysis Patients. ASN Kidney Week 2023, 2–5 November, Philadelphia, PA, USA.

 

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Posted on 28 November 202327 November 2023