Society For Clinical Vascular Surgery

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One Year and Long Term Results of the Fast Track Program: Expedited Surgical Dialysis Access in a Subset of Patients with Limited Access to Care
Marc Salhanick, Steven Meadors, Salu Baby, Joseph Berger, Mujtaba Ali, John Rectenwald, Alexis Jacob.
UT Southwestern, Dallas, TX, USA.

Multiple preoperative appointments create a critical barrier to long term access creation in hemodialysis patients with limited access to care. Removing this impediment could result in higher rate of successful long term dialysis access in this complex patient population.
We retrospectively reviewed charts, contacted patients and dialysis access centers for 61 patients enrolled in our Fast Track program. The program’s main components included; 1. Eliminating all preoperative visits except hemodialysis, during which Duplex Ultrasound for bilateral upper extremity vein mapping was performed and an informational handout provided. 2. A single surgeon reviewed all patient charts and if appropriate offered a surgery date. 3. The operating surgeon adjusted plans the day of surgery as necessary. The primary outcome was successful access use.
61 patients were enrolled from November 16, 2015 to June 6, 2016, and 58 (95.1%) presented for surgery. There were no cancellations on the day of surgery. 55 (94. 8%) received arteriovenous fistulas and 3 (5. 2%) had grafts. Preoperative catheter use ranged from 72 days to 5 years. 35 (57.4%) patients had a history of hospitalization for catheter associated infection, 11 (18%) suffered multiple events, and 9 (14.8%) had prior catheter associated venous thrombosis. Of the 58 accesses created, 38 (65.5%) had complete follow up data at one year, with 20 patients lost to follow up. At 1 year, perioperative complications among these patients included 4 (9.8%) access thrombosis prior to use, 2 superficial infections managed with antibiotics, 2 hematomas, and 2 same day unplanned admissions for hemodialysis. Time from access creation to successful use ranged from 43 to 309 days, more prolonged for radiocephalic than brachiocephalic or brachiobasilic (200 ± 159 days vs 128 ± 51 days or 127 ± 101 days, median ± IQR). 24 patients (58.5%) required revision, and 20 (48.8%) had fistulograms with intervention to assist maturation. At 21 months, limited data was available for an additional 10 (17.2%) patients. 40 (69%) of the grafts or fistulas were known to be functional for hemodialysis at the time of submission with 10 patients lost to follow up.
CONCLUSIONS:The Fast Track program resulted in successful long term surgical hemodialysis access creation and catheter removal in more than two thirds of these patients with limited access to care.

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