Ounali Jaffer1, Paul Gibbs2, Matthew Gibson3, James Gilbert4, Jennifer Hanko5, Praveen Jeevaratnam6, Robert Jones7, Johann Nicholas8, Raymond Ramnarine9, Rajesh Sivaprakasam10, Kate Steiner6, Richard Tippett11, Jason Wilkins12. 1. Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London, E1 1BB, UK. ounali.jaffer@nhs.net. 2. Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK. 3. Royal Berkshire Hospital, Royal Berkshire NHS Foundation Trust, Reading, UK. 4. Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. 5. Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK. 6. Lister Hospital, East and North Herts NHS Trust, Stevenage, UK. 7. University Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK. 8. Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK. 9. Gloucestershire Royal Hospital, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK. 10. Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London, E1 1BB, UK. 11. Dorset County Hospital, Dorset County Hospital NHS Foundation Trust, Dorchester, UK. 12. King's College Hospital NHS Foundation Trust, London, UK.
Abstract
PURPOSE: Stenoses in mature arteriovenous fistulas (AVFs) are common and can negatively impact on the quality of haemodialysis, the longevity of the AVF and lead to debilitating symptoms. Multiple treatment options exist; however, management can vary between different centres. We aimed to establish multidisciplinary consensus on the optimal stepwise application of interventions based on evidence and consensus. METHODS: A modified Delphi process was conducted with 13 participants from hospitals across the UK, all of whom have high-volume dialysis access practice. RESULTS: The usual intervention to rectify de novo stenoses of mature AVFs is fistuloplasty, although surgery for inflow segment stenoses is also clinically acceptable. Appropriate first-line interventions include plain old balloon angioplasty or high-pressure balloon angioplasty; if these fail during the fistuloplasty, consider upsizing the balloon, prolonged balloon inflation or using alternative interventions, such as cutting or scoring balloons and ultra-high-pressure balloons. Alternative or subsequent interventions vary by anatomical site and may require additional multidisciplinary team input. For a stenoses recurring between 3 and 12 months, it is appropriate to consider interventions used de novo, but with a lower threshold for using drug-coated balloons (DCBs) in all regions and for using stent grafts in all regions but inflow segment. Recurrence after 12 months should be treated as a de novo lesion, with DCBs considered if they have been used successfully during previous interventions. CONCLUSIONS: These recommendations aim to provide a practical guide to multidisciplinary teams in order to optimise the use of multiple interventions for rectifying AVF stenoses and provide unified evidence-based practice guidelines.
PURPOSE: Stenoses in mature arteriovenous fistulas (AVFs) are common and can negatively impact on the quality of haemodialysis, the longevity of the AVF and lead to debilitating symptoms. Multiple treatment options exist; however, management can vary between different centres. We aimed to establish multidisciplinary consensus on the optimal stepwise application of interventions based on evidence and consensus. METHODS: A modified Delphi process was conducted with 13 participants from hospitals across the UK, all of whom have high-volume dialysis access practice. RESULTS: The usual intervention to rectify de novo stenoses of mature AVFs is fistuloplasty, although surgery for inflow segment stenoses is also clinically acceptable. Appropriate first-line interventions include plain old balloon angioplasty or high-pressure balloon angioplasty; if these fail during the fistuloplasty, consider upsizing the balloon, prolonged balloon inflation or using alternative interventions, such as cutting or scoring balloons and ultra-high-pressure balloons. Alternative or subsequent interventions vary by anatomical site and may require additional multidisciplinary team input. For a stenoses recurring between 3 and 12 months, it is appropriate to consider interventions used de novo, but with a lower threshold for using drug-coated balloons (DCBs) in all regions and for using stent grafts in all regions but inflow segment. Recurrence after 12 months should be treated as a de novo lesion, with DCBs considered if they have been used successfully during previous interventions. CONCLUSIONS: These recommendations aim to provide a practical guide to multidisciplinary teams in order to optimise the use of multiple interventions for rectifying AVF stenoses and provide unified evidence-based practice guidelines.