AV SHUNT FAILURE

31 Mei 2020

HENRY SINTORO, dr, Sp.BTKV

RS Mitra Keluarga Waru
RSUD Ibnu Sina Gresik
RS Petrokimia Gresik
FK Univ Hang Tuah Surabaya
 Hemodialysis (HD) is one of major modality of renal
replacement therapy (RRT), and approximately 1.5 million
patients worldwide have end-stage renal disease (ESRD) and
require HD.

 Vascular access failure (VAF) is a critical problem in patients

undergoing hemodialysis (HD).
 Importantly, VAF impairs the quality of life in patients
undergoing HD while imposing high medical costs. A variety of
strategies (e.g., endovascular therapy and surgical
reconstruction) for treating VAF have been established.
The arteriovenous fistula (AVF) is the preferred type of
permanent vascular access (VA) in maintenance hemodialysis
(HD) patients. AVFs are associated with a lower incidence of
patency-related procedures than arteriovenous grafts (AVGs)
and less infectious complications than both AVGs and central
venous catheters (CVC).
Wedgewood et al. measured flow rates in the radial
artery before and immediately subsequent to the
creation of an end-to-side fistula. Flow increased from
21.6 ± 20.8 ml/min to 208 ± 175 ml/min immediately after
operation. In well-developed fistulae, flow rates may
ultimately reach values of 600 to 1200 ml/min

Flow increases as a result of both vasodilation and

vascular remodeling
DEFINITION VAF

Accordingly, VA was indicated in more than 50% stenosis

or thrombosis along with one or more of the following
clinical medical abnormalities:
(i) decreased blood flow (< 500 ml/min in AVFs or
< 650 ml/min in AVGs),
(ii) increased venous pressure,
(iii) abnormally high blood urea nitrogen level, and
(iv) unexplained reduction in dialysis efficiency
RISK FACTORS VAF
1. AGE
 A recent review focusing on VA in elderly patients undergoing
HD demonstrated that older age is one of the risk factors
for AVF maturation failure

 However, there are conflicting data on whether older age is a

risk factor for AVF maturation.

 In addition, a prospective study on 422 patients, aiming to

identify patient profiles associated with the failure of AVF
maturation, revealed that an age of ≥ 65 years was an
independent risk factor of VAF [odds ratio (OR) 2.23; 95%
confidence interval (95% CI), 1.25–3.96]
2. SEX
 The role of sex as a risk factor of VAF is controversial. A
multicenter prospective study on 395 patients undergoing HD
revealed that sex was not associated with primary functional AVF
patency loss (HR 1.52, 95% CI 0.99–2.34) . However, several
reports showed that female sex is one of the risk factors
of VAF.

 Although the reasons for these differences based on sex have

not been clarified, a review on VA noted that vessel
diameter is generally smaller in females than that in
males and that this difference may be associated with AVF
maturation failure in females
3. ETHNIC
 Race and ethnicity differences may be significant risk factors of
AVF maturation failure. According to the USRDS 2018 data
regarding race differences, black population had the highest
rate of AVF maturation failure (42.0%).

 Here are some reasons to consider in racial differences such as

racial differences in :
 prevalence of arteriosclerosis,
 gene expression differences regarding hypertension,
 racial differences in oxidative stress and inflammation
 racial difference in endothelial function .
4. COMORBID CONDITION

Clinical comorbidities such as

 coronary artery disease (CAD),
 peripheral arterial disease (PAD),
 diabetes mellitus,
 Obesity
have been reported as risk factors of VAF in patients
undergoing HD.
4.1. Comorbid : PAD
 PAD can increase the risk of VAF by interfering with the increase
in blood volume to AVF because arteries affected by PAD can
fail to sufficiently dilate due to intimal hyperplasia and
arterial calcification.

 Furthermore, a retrospective study on 111 patients undergoing

HD showed that an ankle–brachial index (ABI) of < 0.9 was
significantly associated with VAF and that ABI could
potentially identify patients at a high risk of VAF
4.2. Comorbid : Diabetes Melitus

 Patients’ glycemic states should be evaluated before VA

construction because glycemic state abnormality can
cause wound infection or delayed wound healing.
 Moreover, diabetes mellitus is generally considered a risk
factor of CVDs. However, several studies regarding VA
have suggested that diabetic state alone does not affect
VAF when adjusted for potential confounders, such as
CAD, PAD, and obesity
4.3. Comorbid : Obesity

 Particularly, obese patients typically exhibit a thick

subcutaneous adipose tissue layer in their extremities; thus,
VAF or AVF maturation failure can occur in such patients
due to the venous depth
 A salvage operation to retrieve the AVF could be useful in
obese patients when AVF is located deep in the skin.
 Alternatively, several studies have suggested that
lipectomy or liposuction can prove useful to allow a
functional AVF construction in obese arms
4.3. Comorbid : Obesity

 According to the results of a retrospective cohort study

that used the USRDS Dialysis Morbidity and Mortality Wave
II dataset, obesity was associated with poor AVF
maturation in patients in the highest body mass index (BMI)
quartile (≥ 35 kg/m2)

 Furthermore, in another study on 183 AVFs comparing

obese patients with non-obese patients, the likelihood of
AVF construction and primary patency rates were almost
equal between the groups.
 A case report suggested that in the adducted position, soft
tissue compression of the venous outflow of the upper
extremity causes reduced secondary patency that is
observed in obese patients
3. ETHNIC
 Race and ethnicity differences may be significant risk factors of
AVF maturation failure. According to the USRDS 2018 data
regarding race differences, black population had the highest
rate of AVF maturation failure (42.0%).

 Here are some reasons to consider in racial differences such as

racial differences in :
 prevalence of arteriosclerosis,
 gene expression differences regarding hypertension,
 racial differences in oxidative stress and inflammation
 racial difference in endothelial function .
PREVENTION FAILURE STRATEGIES
Three aspects for developing strategies for preventing VAF:
(i) early identification of risk factors of VAF (e.g.,
preoperative vascular conditions, age, sex, ethnicity,
and clinical backgrounds),
(ii) prophylactic drugs to reduce the risk of VAF, and
(iii) early VAF detection through monitoring and surveillance
of vascular access, particularly at frequent stenotic sites.
Physical Examination

 Before surgery, any history of any central venous catheters or

pacemaker should be confirmed.
 In addition, clinicians should carefully assess for signs of venous
hypertension, such as prominent and tortuous collateral veins
around the shoulder and upper limb edema, in the limb
undergoing surgery.
 To check for arterial stenosis, the difference in the blood
pressures of the two upper arms can be useful because arterial
inflow insufficiency is a risk factor of VAF or AVF maturation
failure; this difference in blood pressures was suggested to be
useful by a review.
Preoperative Vascular Imaging

 The low quality of the available vessels for VA construction is

reportedly the most critical risk factor of VAF. Thus, preoperative
arterial and venous evaluation, known as “vascular imaging,” is
crucial for predicting VAF or AVF maturation failure.
 JSDT guidelines recommend that an ultrasound examination is
preferred to preoperatively evaluate vessels rather than to rely on
physical examination alone.
 Non-invasive ultrasound examination can provide detailed
preoperative information regarding vascular qualities, vessel
diameters, and vessel depth.
 Maintenance of VA

 Maintenance of VA plays an important role for

preventing VAF after VA construction.
 Hypotension is one of risk factors of VA occlusion , and
several studies indicated the association between
hypotension and VAF.
 Episodes of hypotension were defined as systolic
pressure of < 110 mmHg and diastolic pressure of
< 70 mmHg before the start of HD.
 In patients with hypertension, a decrease by > 30% of
blood pressure was defined as relative hypotension.
 Maintenance of VA

 Monitoring : Physical examinations are useful for early

detection of VAF. Three components for VA examination
are recommended by guidelines: inspection, palpation,
and auscultation.
 Abnormalities of physical examination, such as extremity
edema, alterations in the pulse, thrill, or bruit, may be
associated with impending VAF.
 Maintenance of VA
USG Monitoring :
 VAF should be suspected when blood flow is less than
500 ml/min (JDST, ESVS) or less than 400–500 ml/min (K/DOQI)
in AVFs although there is no clear definition of maturation.
 Besides, an observational study of 101 AVFs was performed to
evaluate the association between adequate AVF rates and
risk factors of VAF. In this study, AVF was defined as adequate
for HD when the AVF was successfully cannulated over a
period of at least six HD sessions in a month, and AVF was
required a blood flow of at least a consistent 350 ml/min .
 This study was cited in ESVS guidelines; this guidelines suggest
that cannulation of VA is not preferred when the quantity of
blood flow is less than 350 ml/min, although the levels of
evidence are not high
 Regular Fistula Visits
 Nurses should be trained to recognize fistula problems
and to pay attention to a progressive increase of venous
inflow pressure and post-puncture bleeding time.
 Regular “fistula visits” are advisable, i.e., inspection and
physical examination of the fistula every 6 or 8 wk. The
main purpose is to detect development and progression
of stenoses in time to prevent eventual thrombosis, so
that one is not forced to surgically correct an established
thrombosis.
 The pathophysiology underlying stenosis formation is
turbulence of blood flow , which activates platelets and
endothelial cells. In this context, a particular role has
been postulated for platelet-derived growth factor
(PDGF)
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