Vascular access surveillance: Evaluation of combining dynamic venous pressure and vascular access blood flow measurements

Background/Aims: Vascular access thrombosis is one of the most morbid problems encountered by hemodialysis patients. Surveillance protocols utilizing venous pressure (Vp) and vascular access blood flow (VABF) measurements have been employed to preserve vascular access. We undertook a study to evaluate combined dynamic Vp and VABF measurements in the identification of vascular access impairment. We also assessed the effect of preventive repair on thrombosis rates in impaired vascular accesses identified by surveillance. Methods: Eighty-six chronic hemodialysis patients with a functioning vascular access were enrolled into the surveillance protocol. All vascular accesses with greater than 50% of monthly Vp readings > 120 mm Hg or VABF <500 ml/min in arteriovenous fistulas (AVFs) and VABF <650 ml/min in arteriovenous grafts (AVGs), or a decrease in VABF > 25% compared to the highest previously measured value, were considered positive. Stenosis >150% on fistulography or a thrombotic event were defined as a 'vascular access impairment episode' while a stenosis < 50% or the absence of a thrombotic event was defined as 'no vascular access impairment episode'. Thrombosis rates and intervention rates were calculated per access year at risk. Results: The sensitivity and specificity of the combined surveillance protocol for AVFs were 73.3 and 91%, respectively. In AVGs, they were 68.8 and 87.5%, respectively. The rate of thrombotic events was lower in patients who underwent early repair. The addition of dynamic Vp did not reduce the thrombosis rate any further than surveillance based on VABF alone. Conclusion: Combined monitoring for surveillance of AVFs improved sensitivity but had little benefit in AVGs over VABF monitoring alone. Raising VABF cutoff levels might increase and improve identification of vascular access risk for thrombosis, but at the expense of lower specificity.