Society For Clinical Vascular Surgery

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Patients With Prior Failed Hemodialysis Accesses: The Effect of Intraoperative Ultrasound
C. Y. Maximilian Png, Ignatius Lau, Peter L. Faries, David Finlay.
Icahn School of Medicine at Mount Sinai, New York, NY, USA.

OBJECTIVES: This study investigates the impact of post-anesthesia ultrasound mapping (PAUS) on the type of hemodialysis access chosen in patients with previously failed accesses.
METHODS: 89 of 297 consecutive patients met inclusion criteria. Within-subjects analysis was performed on patients with both an outpatient ultrasound-guided vein mapping and a PAUS using sign tests and Wilcoxon signed ranked tests. Between-subjects analysis added patients with only the outpatient vein mapping; demographic and comorbidity data were analyzed using t-tests and chi-squared tests. An ordinal logit regression was run for the type of access placed, while a bivariate logit regression was used to compare rates of autogenous access maturation.
RESULTS: 69 (78%) patients received both a standard outpatient vein mapping and a PAUS. At the outpatient vein mapping, 47 (68%) patients had suitable veins for an autogenous access compared to during PAUS, where 68 (98%) patients were found to have suitable veins for autogenous access formation. When comparing specific autogenous access configurations, Wilcoxon signed rank testing showed significantly more preferable configurations in the PAUS group compared to the outpatient mapping (P<0.001); Outpatient mapping resulted in 17 (25%) radiocephalic accesses, 2 (3%) radiobasilic accesses, 19 (28%) brachiocephalic accesses, 9 (13%) brachiobasilic accesses and 22 (32%) prosthetic accesses planned, in contrast to 41 (59%) radiocephalic accesses, 4 (6%) radiobasilic accesses, 18 (26%) brachiocephalic accesses, 5 (7%) brachiobasilic accesses and 1 (1%) prosthetic access when the same patients were analyzed using PAUS. With the analysis expanded to include the 20 (22%) patients with only the outpatient vein mapping (without-PAUS), Wilcoxon-Mann-Whitney testing showed no significant differences between the groups in terms of outpatient vein mapping plans, however when comparing the PAUS plans to the outpatient vein mapping plans, there was again a significantly increased proportion of preferred access types in the PAUS group (P<0.001). In the ordinal logit multivariate analysis, the most significant variable was the post-anesthesia ultrasound, which positively correlated with more favorable access configurations (coefficient=4.27, P<0.001). The bivariate logit regression for autogenous access maturation rates found no significant difference between the without-PAUS group and the PAUS group (P=0.28).
CONCLUSIONS: In patients with previous failed hemodialysis accesses, PAUS mapping can be used to increase the proportions of preferred access placement (autogenous vs. prosthetic and forearm vs. upper extremity) placed without compromising maturation rates.

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