Thomas S Huber1, Brett Larive2, Peter B Imrey2, Milena K Radeva2, James M Kaufman3, Larry W Kraiss4, Alik M Farber5, Scott A Berceli6. 1. Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, Fla. Electronic address: thomas.huber@surgery.ufl.edu. 2. Department of Quantitative Health Sciences, Learner Research Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio. 3. Division of Nephrology, VA New York Harbor Healthcare System and Division of Nephrology, New York University School of Medicine, New York, NY. 4. Division of Vascular Surgery, University of Utah, Salt Lake City, Utah. 5. Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, Mass. 6. Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, Fla.
Abstract
OBJECTIVE: Access-related hand ischemia (ARHI) is a major complication after hemodialysis access construction. This study was designed to prospectively describe its incidence, predictors, interventions, and associated access maturation. METHODS: The Hemodialysis Fistula Maturation Study is a multicenter prospective cohort study designed to identify predictors of autogenous arteriovenous access (arteriovenous fistula [AVF]) maturation. Symptoms and interventions for ARHI were documented, and participants who received interventions for ARHI were compared with other participants using a nested case-control design. Associations of ARHI with clinical, ultrasound, vascular function, and vein histologic variables were each individually evaluated using conditional logistic regression; the association with maturation was assessed by relative risk, Pearson χ(2) test, and multiple logistic regression. RESULTS: The study cohort included 602 participants with median follow-up of 2.1 years (10th-90th percentiles, 0.7-3.5 years). Mean age was 55.1 ± 13.4 (standard deviation) years; the majority were male (70%), white (47%), diabetic (59%), smokers (55%), and on dialysis (64%) and underwent an upper arm AVF (76%). Symptoms of ARHI occurred in 45 (7%) participants, and intervention was required in 26 (4%). Interventions included distal revascularization with interval ligation (13), ligation (7), banding (4), revision using distal inflow (1), and proximalization of arterial inflow (1). Interventions were performed ≤7 days after AVF creation in 4 participants (15%), between 8 and 30 days in 6 (23%), and >30 days in 16 (63%). Female gender (odds ratio, 3.17; 95% confidence interval, 1.27-7.91; P = .013), diabetes (13.62 [1.81-102.4]; P = .011), coronary artery disease (2.60 [1.03-6.58]; P = .044), higher preoperative venous capacitance (per %/10 mm Hg, 2.76 [1.07-6.52]; P = .021), and maximum venous outflow slope (per [mL/100 mL/min]/10 mm Hg, 1.13 [1.03-1.25]; P = .011) were significantly associated with interventions; a lower carotid-femoral pulse wave velocity and the outflow vein diameter in the early postoperative period (days 0-3) approached significance (P < .10). Intervention for ARHI was not associated with AVF maturation failure (unadjusted risk ratio, 1.18 [0.69-2.04], P = .56; adjusted odds ratio, 0.97 [0.41-2.31], P = .95). CONCLUSIONS: Remedial intervention for ARHI after AVF construction is uncommon. Diabetes, female gender, capacitant outflow veins, and coronary artery disease are all associated with an increased risk of intervention. These higher risk patients should be counseled preoperatively, their operative plans should be designed to reduce the risk of hand ischemia, and they should be observed closely.
OBJECTIVE:Access-related hand ischemia (ARHI) is a major complication after hemodialysis access construction. This study was designed to prospectively describe its incidence, predictors, interventions, and associated access maturation. METHODS: The Hemodialysis Fistula Maturation Study is a multicenter prospective cohort study designed to identify predictors of autogenous arteriovenous access (arteriovenous fistula [AVF]) maturation. Symptoms and interventions for ARHI were documented, and participants who received interventions for ARHI were compared with other participants using a nested case-control design. Associations of ARHI with clinical, ultrasound, vascular function, and vein histologic variables were each individually evaluated using conditional logistic regression; the association with maturation was assessed by relative risk, Pearson χ(2) test, and multiple logistic regression. RESULTS: The study cohort included 602 participants with median follow-up of 2.1 years (10th-90th percentiles, 0.7-3.5 years). Mean age was 55.1 ± 13.4 (standard deviation) years; the majority were male (70%), white (47%), diabetic (59%), smokers (55%), and on dialysis (64%) and underwent an upper arm AVF (76%). Symptoms of ARHI occurred in 45 (7%) participants, and intervention was required in 26 (4%). Interventions included distal revascularization with interval ligation (13), ligation (7), banding (4), revision using distal inflow (1), and proximalization of arterial inflow (1). Interventions were performed ≤7 days after AVF creation in 4 participants (15%), between 8 and 30 days in 6 (23%), and >30 days in 16 (63%). Female gender (odds ratio, 3.17; 95% confidence interval, 1.27-7.91; P = .013), diabetes (13.62 [1.81-102.4]; P = .011), coronary artery disease (2.60 [1.03-6.58]; P = .044), higher preoperative venous capacitance (per %/10 mm Hg, 2.76 [1.07-6.52]; P = .021), and maximum venous outflow slope (per [mL/100 mL/min]/10 mm Hg, 1.13 [1.03-1.25]; P = .011) were significantly associated with interventions; a lower carotid-femoral pulse wave velocity and the outflow vein diameter in the early postoperative period (days 0-3) approached significance (P < .10). Intervention for ARHI was not associated with AVF maturation failure (unadjusted risk ratio, 1.18 [0.69-2.04], P = .56; adjusted odds ratio, 0.97 [0.41-2.31], P = .95). CONCLUSIONS: Remedial intervention for ARHI after AVF construction is uncommon. Diabetes, female gender, capacitant outflow veins, and coronary artery disease are all associated with an increased risk of intervention. These higher risk patients should be counseled preoperatively, their operative plans should be designed to reduce the risk of hand ischemia, and they should be observed closely.
Authors: Thomas S Huber; C Keith Ozaki; Timothy C Flynn; W Anthony Lee; Scott A Berceli; Christa M Hirneise; Lori M Carlton; Jeffrey W Carter; Edward A Ross; James M Seeger Journal: J Vasc Surg Date: 2002-09 Impact factor: 4.268
Authors: Angela A Kokkosis; Steven D Abramowitz; Jonathan Schwitzer; Scott Nowakowski; Victoria J Teodorescu; Harry Schanzer Journal: J Vasc Access Date: 2014-01-27 Impact factor: 2.283
Authors: Michelle L Robbin; Tom Greene; Michael Allon; Laura M Dember; Peter B Imrey; Alfred K Cheung; Jonathan Himmelfarb; Thomas S Huber; James S Kaufman; Milena K Radeva; Prabir Roy-Chaudhury; Yan-Ting Shiu; Miguel A Vazquez; Heidi R Umphrey; Lauren Alexander; Carl Abts; Gerald J Beck; John W Kusek; Harold I Feldman Journal: J Am Soc Nephrol Date: 2018-10-11 Impact factor: 10.121
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