Practice patterns in the management of arteriovenous fistula stenosis: a northern Italian survey

Abstract

Background: Clinical practice for stenosis detection and treatment in arteriovenous fistulas (AVFs) varies widely and is largely dictated by local customs and expertise. Methods: In May 2003, a questionnaire was sent to 32 hemodialysis (HD) facilities in north-eastern Italy, to assess the prevalence of patients with an AVF; the screening criteria for stenosis; the preferred imaging technique; the timing of the intervention and the treatment modality for stenosed and thrombosed AVFs. Results: The response rate was 87%; 2895 prevalent patients were evaluated, 86% with an AVF. All facilities routinely screened for stenosis; the majority relying on clinical assessment (86%), and many on multiple surveillance methods by monitoring dialysis pressures and blood pump flow rate (75-68%), measuring access recirculation (64%), Kt/V (54%) and access blood flow rate (11%). Angiography and Doppler ultrasound were used in equal proportion for imaging. All nephrologists agreed on pre-emptive stenosis correction, 57% taking action on well functioning and 43% on failing AVFs. Forty percent of nephrologists preferred either angioplasty or surgery for pre-emptive stenosis correction, while only 18% used both. Surgery was favored over endovascular techniques (57 vs. 36%) for treating thrombosed AVFs, while only 7% of facilities used both. Conclusions: Our survey shows that, as in 2003, the vast majority of patients in north-eastern Italy were dialyzed with an AVF. Screening for stenosis was universally adopted, though most facilities relied on clinical examination and surrogate access blood flow rate markers. All nephrologists agreed to pre-emptive stenosis correction, and surgery retained a relevant role in the treatment of stenosed and thrombosed AVFs.