The effect of implementation of an optimized care protocol on the outcome of arteriovenous hemodialysis access surgery

Background: The long-term patency of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) suffers from a high incidence of primary failure due to early thrombosis, myointimal hyperplasia at the venous access site, or failure to mature. A multidisciplinary meeting in vascular access surgery was initiated to optimize the timing, indication, type of intervention, and the logistics of AVFs/AVGs during the preoperative and postoperative period. This study evaluated the influence of the new optimized care protocol on the incidence of revisions (surgical and endovascular) and patency rates. Methods: This protocol for vascular access surgery of AVFs/AVGs for hemodialysis was introduced in January 2004. It was initiated with the presence of the vascular surgeons, nephrologists, interventional radiologists, dialysis nurses, and the ultrasound technicians. Every patient who needed all AVF/AVG because of long-term treatment of chronic renal failure or awaiting kidney transplantation, or who needed a revision of an AVF/AVG, was discussed. Two groups were compared. Group I patients were treated with all AVF/AVG before the introduction of the new protocol (2001 and 2002). Group 11 patients were treated with all AVF/AVG after the introduction of the new optimized care protocol (2004 and 2005). Both groups were followed tip after 12 months. Results. During the study period, 146 AVFs/AVGs were attempted, and 111 postoperative revisions were performed to restore primary and secondary patency: 63 in group 1 (60 surgical, 3 radiology) and 48 in group 11 (23 surgical, 25 radiology). Significantly more segmental access replacements (P < 0.027) occurred in group I than in group II. Significantly fewer surgical revisions (P < 0.019) and more endovascular balloon angioplasties (P < 0.001) occurred ill group II. Significantly higher cumulative primary and secondary patency rates of all AVFs/AVGs (P < 0.001), radial-cephalic direct wrist AVFs (P < 0.001), and brachial-cephalic forearm looped transposition AVGs (P < 0.001) were achieved in group 11 after follow-up. Conclusion: The new protocol outlined ill a bimonthly multidisciplinary meeting for vascular access surgery of AVFs/AVGs for hemodialysis resulted in more effective logistics according to preoperative diagnostics and operation. More importantly, a significant increase in endovascular balloon angioplasties and a significant decrease in surgical revisions was observed, resulting in less patient morbidity. Also, higher primary and secondary patency was achieved after the introduction of the new optimized care protocol.