The Impact of Access Blood Flow Surveillance on Reduction of Thrombosis in Native Arteriovenous Fistula: A Randomized Clinical Trial

Abstract

Purpose

The usefulness of access blood flow (Q_A) measurement is an ongoing controversy. Although all vascular access (VA) clinical guidelines recommend monitoring and surveillance protocols to prevent VA thrombosis, randomized clinical trials (RCTs) have failed to consistently show the benefits of Q_A-based surveillance protocols. We present a 3-year follow-up multicenter, prospective, open-label, controlled RCT, to evaluate the usefulness of Q_A measurement using Doppler ultrasound (DU) and ultrasound dilution method (UDM), in a prevalent hemodialysis population with native arteriovenous fistula (AVF).

Methods

Classical monitoring and surveillance methods are applied in all patients, the control group (n = 98) and the Q_A group (n = 98). Besides this, DU and UDM are performed in the Q_A group every three months. When Q_A is under 500 ml/min or there is a >25% decrease in Q_A the patient goes for fistulography, surgery or close clinical/surveillance observation. Thrombosis rate, assisted primary patency rate, primary patency rate and secondary patency rate are measured.

Results

After one-year follow-up we found a significant reduction in thrombosis rate (0.022 thrombosis/patient/year at risk in the Q_A group compared to 0.099 thrombosis/patient/year at risk in the control group [p = 0.030]). Assisted primary patency rate was significantly higher in the Q_A group than in control AVF (hazard ratio [HR] 0.23, 95% confidence interval [CI] 0.05-0.99; p = 0.030). In the Q_A group, the numbers unddergoing angioplasty and surgery were higher but with no significant difference in non-assisted primary patency rate (HR 1.41, 95% CI 0.72-2.84; p = 0.293). There was a non-significant improvement in secondary patency rate in the Q_A group (HR 0.510, 95% CI 0.17-1.50; p = 0.207).

Conclusions

The measurement of Q_A combining DU and UDM shows a reduction in thrombosis rate and an increased assisted primary patency rate in AVF after one-year follow-up.

Trial registration

ClinicalTrials.gov Identifier: NCT02111655.

Keywords

Access blood flow Doppler ultrasound Hemodialysis Thrombosis Vascular access

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