Planning Vascular Access Creation For Hemodialysis: Is There A Role For The Nephrologist? A Single-Center Experience.

Abstract Background and Aims Vascular access planning is a crucial step in the path to dialysis treatment. Although the vascular surgeon role is of undeniable importance on vascular access creation, the nephrologist’s view may be an added advantage on vascular access planning. Method A retrospective observational study of the vascular access appointments carried out at the Centro Hospitalar de Tondela-Viseu’s nephrology department between 1/1/2017 and 13/12/2019 was performed. Of the 173 consultations reviewed, 71 patients were referred to preoperative vascular mapping, which were selected. In those selected, 38 had a vascular access built. A descriptive and statistical analysis of the population and proposed vs constructed access was performed. Results Of those patients referred to the vascular access appointment for vessel mapping, the median age was 70 years, the majority were men (59.2%), most of them had Chronic Kidney Disease (CKD) stage 5 (57.7%) and most frequently had Diabetic Nephropathy (38.6%) or Chronic Glomerulonephritis (14.9%) as the cause of kidney disease. The majority were Diabetic (62%), Hypertensive (91.5%), Obese (63.4%) and had a history of stroke, coronary or peripheral arterial disease (63.4%). The vascular mapping was performed for creation of first access in 64.8% of the patients and the nephrologist most commonly proposed a radio-cephalic fistula (63.6%) as first line access creation, followed by brachio-cephalic (30.3%) and brachio-basilic (6%) fistulas. An arteriovenous graft was suggested in only 1 case and 4 patients were not referred to the vascular surgeon as they had no vascular patrimony to autologous vascular access creation. Regarding those patients who had already a vascular access at the time of this study (n=36), 58.33% coincided with the first line access suggested by the nephrologist. We found that the nephrologist most frequently proposed a brachio-basilic fistula in older patients (median age 77.5), while younger patients had proposed other fistulas (median age 77.5 years, p=0.031). Those patients without history of stroke, coronary or peripheral arterial disease had 4.57 times more odds of being proposed to a radio-cephalic fistula (p=0.007) and those with history of atherosclerotic events had 4.36 times more odds of being proposed for a brachio-cephalic fistula (p=0.003). Patients with more vascular calcification on the vessel mapping appointment had 7 times more odds of not being proposed for a distal fistula (p=0.000) and had instead 5.56 times more odds of being proposed to a brachio-cephalic fistula (p=0.003). Gender, etiology of CKD, smoking, diabetes, hypertension, heart failure and obesity were not significantly associated with vascular access proposed by the nephrologist. Conclusion In light of the results of this study, we conclude that there is an important place for ultrasound preoperative mapping by the nephrologist on planning the vascular access for haemodialysis.