Change Concept 6: Secondary AV Fistula Placement in Patients with AV Grafts

Evaluate graft patients for placement of a secondary AV fistula. Staff should consider every graft patient a candidate for an AV fistula and should evaluate each patient for an AV fistula before the graft fails. In this way, a plan will be in place for providing the patient with an AV fistula when the graft begins to fail. This avoids the need for a catheter or missing an AV fistula opportunity when the graft fails and there is urgency for an immediate usable access. Note particularly that the outflow vein from a graft is an already matured arterialized vein that could be connected and used right away.

• Nephrologists evaluate every AV graft patient for possible secondary AV fistula conversion, including mapping as indicated, and document the plan in the patient’s record.
• Dialysis facility staff and/or rounding nephrologists examine outflow vein of all graft patients (“sleeves up”) during dialysis treatments (minimum frequency, monthly). Identify patients who may be suitable for elective secondary AVF conversion in upper arm and inform nephrologist of suitable outflow vein.
• Nephrologists refer to surgeon for placement of secondary AVF before failure of AVG.

Changes for Improvement

Evaluate Every AV Graft Patient for Possible Secondary AVF

Nephrologists should evaluate every arteriovenous (AV) graft patient for possible placement of a secondary AV fistula, including mapping as indicated, and document the plan in the patient’s record. AV fistula evaluation of graft patients should include an updated history relevant to vascular access, physical exam with tourniquet, and vessel mapping if suitable vessels are not identified on physical exam. A secondary AV fistula plan should be documented in the chart and discussed with the patient, family, staff, and nephrologists and surgeon in anticipation of AV fistula construction on the earliest evidence of graft failure.

Examine the Outflow Vein of All Forearm Graft Patients to Identify Suitable Veins for Secondary AVF

Dialysis facility staff and/or rounding nephrologists should examine the outflow vein of all forearm graft patients during dialysis treatments (with a recommended minimum frequency of at least monthly) to identify patients who may have a suitable upper outflow vein for elective secondary AV fistula conversion in the upper arm. If such a suitable vein is found, dialysis facility staff and/or rounding nephrologists should inform the patient’s nephrologist and surgeon of the need to evaluate the identified outflow vein for AV fistula conversion.

Refer to the Surgeon for Evaluation/Placement of Secondary AVF before the Graft Fails

Patients with an AV graft should be evaluated (including vessel mapping) for an AV fistula when the graft shows evidence of dysfunction by monitoring and surveillance. The timing of such surgical intervention to convert the outflow vein of an existing AV graft to an AV fistula, or to construct a new AV fistula in a new location, assuming suitable vessels, should be as soon as feasible but not later than following an intervention for thrombosis or clinically significant stenosis. Any delay in conversion beyond this point is likely to result in loss of the window of opportunity for an AV fistula, since further graft interventions, especially if done as an emergency, are likely to damage or utilize the outflow vein, or the graft will eventually be abandoned (usually after a failed intervention), resulting in a catheter and a new graft in a different location.

Resources 

“Sleeves Up” Protocol to Convert Forearm AV Graft to Upper-Arm AV Fistula

From: Fistula First Breakthrough Initiative Tools and Resources Working Group with assistance from Lawrence M. Spergel, MD, FACS, Dialysis Management Medical Group

This protocol is used to identify a suitable outflow vein to convert a forearm arteriovenous (AV) graft to an upper-arm AV fistula, in anticipation of secondary AV fistula construction by the surgeon.

An effective strategy for increasing arteriovenous (AV) fistula prevalence is the planning and construction of AV fistulae in existing AV graft patients prior to graft failure. Although the primary access may currently be a graft, all graft patients should be evaluated and considered (where feasible) for an AV fistula as their next permanent access (secondary AV fistula).

Although evaluation for a secondary AV fistula may require bilateral vessel mapping to identify a suitable vein and artery for AV fistula construction, the simplest opportunity to convert a graft patient to a fistula patient, when present, is the conversion of an arterialized (mature) upper-arm outflow vein of a forearm graft to a direct upper-arm AV fistula. Such a conversion opportunity should be looked for and considered in all forearm graft patients.

“Sleeves Up” Checklist

Checklist for Access Managers