[Prospective monitoring of vascular access in hemodialysis by means of a multidisciplinary team].
OBJECTIVE
Nowadays, expert guidelines recommend the monitoring programs of the vascular access (VA) by a multidisciplinary team.


METHODS
We present the experience over the last five years, of a prospective VA surveillance by a multidisciplinary team. The quality indicators reached are described as the associated factors for survival of the new VA.


RESULTS
Three hundred seventeen VA have been studied, 73% were arteriovenous fistulas(AVF) and the rest were polytetrafluoroethylene (PTFE) grafts at 282 patients. The main causes of dysfunctions were elevated dynamic venous pressure (42.5%) and the decreased blood flow (36.4%) with a 88% of positive predictive value. Over the 5 years there was 88 thrombosis (24 AVF and 64 PTFE grafts), that means a hazard thrombosis global rate of 0.15 access/year, which were distributed in 0.06 for AVF and 0.38 in PTFE grafts. Two hundred and one repairs of VA were done: 66.6% were elective repair after a proper review by the multidisciplinary team and the rest of them were done after the AV thrombosis happened. Urgent rescue surgeries were done in 76% of the thrombosis. 62.5% of the patients did not need a catheter after vascular access thrombosis. The complication relation with AVF and PTFE were 11.4% of the total patients hemodialysis hospitalizations. 65.2% of the VA were new access. 57% of patients were properly reviewed in the pre-dialysis unit at least once and 80% of them start haemodialysis with a mature access. The average survival (Kaplan Meier) of the new AVF was 1,575+/-55 days vs 1,087+/-102 of the PTFE grafts (p < 0.008). The survival after 1, 2 and 3 years for the AVF was 89%, 85% and 83% and for the PTFE graft 3% 67% and 51% respectively. The Cox regression has proved that the type of vascular access is the strongest factor associated to VA survival. The survival added of VA repaired due to dysfunction was 1,062 +/- 97 days vs 707 +/- 132 due to thrombosis, log rank 5.17 (p < 0,02). The increasing risk of those repaired after a thrombosis vs dysfunction is 4.2 p < 0,01.


CONCLUSIONS
The monitoring of the vascular access by a multidisciplinary team has reached:low rate of thrombosis, high elective number of repairs of the VA, high urgent rescue surgery after a thrombosis and a few number catheter needed and hospitalizations. AVF are associated with greater survival than PTFE. The VA repair due to dysfunction vs thrombosis had a greater survival as well.
Gruss
E
E
Fundación Hospital de Alcorcón, Bidapest 1, Alcorcón, Madrid. egruss@auna.com
Portolés
J
J
Jiménez
P
P
Hernández
T
T
Rueda
J A
JA
del Cerro
J
J
Lasala
M
M
Tato
A
A
Gago
M C
MC
Martínez
S
S
Velayos
P
P
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000451:nursing / Q000706:statistics & numerical data*; D001783:Blood Flow Velocity; D002404:Catheterization / Q000009:adverse effects; D002408:Catheters, Indwelling / Q000009:adverse effects / Q000706:statistics & numerical data*; D004868:Equipment Failure / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D013502:General Surgery; D006801:Humans; D006973:Hypertension / Q000150:complications; D033183:Interdisciplinary Communication; D008297:Male; D008875:Middle Aged; D009398:Nephrology; D010348:Patient Care Team; D011138:Polytetrafluoroethylene; D011379:Prognosis; D015397:Program Evaluation; D016016:Proportional Hazards Models; D011446:Prospective Studies; D015642:Radiology, Interventional; D006435:Renal Dialysis / Q000451:nursing; D017131:Thrombectomy; D013927:Thrombosis / Q000453:epidemiology / Q000209:etiology / Q000601:surgery
D011138:Polytetrafluoroethylene