Does cannulation technique impact arteriovenous fistula and graft survival? Maria Teresa Parisotto CANNT 2017 Halifax October 20 th, 2017
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1 Does cannulation technique impact arteriovenous fistula and graft survival? Maria Teresa Parisotto CANNT 2017 Halifax October 20 th, 2017
2 Survival Preserving the AVF as the patient lifeline: reduced mortality with the AVF compare to Catheter 1 ANZDATA Register AVF Catheter p< Months Polkinghorne et al. J Am Soc Nephrol 15: , 2004 FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 2
3 Vascular Access Major Cause of Hospitalisation 100% DOPPS 80% 60% 40% 20% 0% France Germany Italy Spain UK CV related VA related Infection related Gastrointestinal Rayner et al. Nephrol Dial Transplant 19: , 2004 FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 3
4 Complications Associated to VA Cannulation Thrombosis 16,5% Hemorrage 7,5% Infection 5,5% Aneurysm 4,1% % of VA cannulations Yürügen and Erdogan, J Vasc Access 2001; 2: (Data from Master Thesis at Istanbul University) FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 4
5 Preserving the Vascular Access is our responsibility FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 5
6 Phases of Vascular Access Management VA creation VA surveillance Assessment and preparation Cannulation Monitoring during treatment Disconnection Haemostasis FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 6
7 Phases of Vascular Access Management VA creation VA surveillance Assessment and preparation Cannulation Monitoring during treatment Disconnection Fresenius Medical Care Survey Haemostasis FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 7
8 Vascular Access Cannulation: Study Design 1. Objective: Snapshot on the current practice of vascular access cannulation 2. Design: International, multi-centre, observational, cross-sectional survey 3. Centres: Dialysis centres of the Fresenius Medical Care network in Europe, Middle East, Africa, participation on voluntary basis 4. Procedures: Anonymous documentation of vascular access and its cannulation once per patient (Patient Questionnaire) at appointed date (April 09) FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 8
9 Vascular Access Cannulation: Inclusion criteria FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 9
10 Vascular Access Cannulation: Participating Countries and Centres 10 countries / 171 centres / 10,807 patients 34/ 3,394 2/41 44/2,097 33/1,729 4/256 4/766 5/496 31/1,048 10/870 4/110 + South Africa (Numbers: Centres/Patients by country) FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 10
11 FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 11
12 Survey results (1/2) Descriptive Statistics Type of Vascular Access: AVF: 90.9% AVG : 9.1% Location of the VA: Arm: 98.7% Leg: 1.3% Left arm: 72.2% Right arm: 21.8% Lower arm 49.6% Upper arm: 50.4% Descriptive Statistics Cannulation technique: Area: 61.0% Rope Ladder: 31.0% Buttonhole: 6.1% Missing data 1.8% FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 12
13 Survey results (2/2) Descriptive Statistics Needle sizes: 15G: 61.3% 16G : 33.2% 14G: 3.0% 17G: 2.5% Direction of arterial needle puncture: Antegrade: 63.0% Retrograde: 37.0% Direction of bevel: Upward: 72.3% Downward: 27.7% Descriptive Statistics Rotation of needle after cannulation: Yes: 43.2% No: 54.5% Nurses 'experience in dialysis > 5 years: 66.0% 2 5 years: 19.0% 1 2 years 7.0% < 1 year 8.0% FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 13
14 Analysis of the data With the data collected we did three types of evaluations: 1. The variables possibly influencing the probability of reaching an adequate dialysis dose (Kt/V 1.2) 2. The nursing practices possibly influencing the development of acute cannulation complications (multiple-cannulation, infiltration, haematoma, haemorrhage, unknown) 3. The cannulation technique vs vascular access survival (7.058 patients observed for 3 years) FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 14
15 1. Analysis of variables related to the probability of reaching an adequate dialysis dose Logistic regression on the odds ratio to reach Kt/V > 1.2 Odds ratio 95% confidence interval P-value Gender (male vs. female) <0.001 Post-dialytic body weight (per kg) <0.001 Treatment time (per min) <0.001 Treatment modality (on-line HDF vs. HD) <0.001 Direction of arterial needle (retrograde vs. antegrade) Needle size (vs. 17 G) 16 G < G < G <0.001 Fistula type (graft vs. native arterio-venous fistula) <0.001 Blood flow (vs. < 300 ml/min) < <0.001 > <0.001 Dialyser surface (vs m 2 ) <0.001 > <0.001 Gauly A, Parisotto MT, et al. Vascular Access Cannulation in Hemodialysis Patients A Survey of Current Practice and its Relation to Dialysis Dose. JVasc Access 2011; 12 (4): FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 15
16 1. Analysis of variables related to the probability of reaching an adequate dialysis dose Logistic regression on the odds ratio to reach Kt/V > 1.2 Odds ratio 95% confidence interval P-value Gender (male vs. female) <0.001 Post-dialytic body weight (per kg) <0.001 Treatment time (per min) <0.001 Treatment modality (on-line HDF vs. HD) <0.001 Direction of arterial needle (retrograde vs. antegrade) Needle size (vs. 17 G) 16 G < G < G <0.001 Fistula type (graft vs. native arterio-venous fistula) <0.001 Blood flow (vs. < 300 ml/min) < <0.001 > <0.001 Dialyser surface (vs m 2 ) <0.001 > <0.001 Gauly A, Parisotto MT, et al. Vascular Access Cannulation in Hemodialysis Patients A Survey of Current Practice and its Relation to Dialysis Dose. JVasc Access 2011; 12 (4): FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 16
17 1. Analysis of variables related to the probability of reaching an adequate dialysis dose Logistic regression on the odds ratio to reach Kt/V > 1.2 Odds ratio 95% confidence interval P-value Gender (male vs. female) <0.001 Post-dialytic body weight (per kg) <0.001 Treatment time (per min) <0.001 Treatment modality (on-line HDF vs. HD) <0.001 Direction of arterial needle (retrograde vs. antegrade) Needle size (vs. 17 G) 16 G < G < G <0.001 Fistula type (graft vs. native arterio-venous fistula) <0.001 Blood flow (vs. < 300 ml/min) < <0.001 > <0.001 Dialyser surface (vs m 2 ) <0.001 > <0.001 Gauly A, Parisotto MT, et al. Vascular Access Cannulation in Hemodialysis Patients A Survey of Current Practice and its Relation to Dialysis Dose. JVasc Access 2011; 12 (4): FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 17
18 2. Logistic regression model evaluating nursing practice in respect to the event acute cannulation complication (multiple-cannulation, infiltration, haematoma, haemorrhage, unknown) Nursing practice aspect 95% confidence Interval OR p-value Variable Reference Category Lower limit Higher limit NS Needle gauge <0.001 Back-eye needle No Yes <0.001 Cannulation technique Rope-Ladder Buttonhole Area < st needle inserted Arterial Venous <0.001 Needle axis rotation No Yes <0.001 Needle fixation Butterfly Chevron NS U-Shape NS Others Parisotto MT et Al. Elements of dialysis nursing practice associated with successful cannulation: result of an international survey J Vasc Access 2017; 18(2): Open Access DOI: /jva FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 18
19 2. Logistic regression model evaluating nursing practice in respect to the event acute cannulation complication (multiple-cannulation, infiltration, haematoma, haemorrhage, unknown) Nursing practice aspect 95% confidence Interval OR p-value Variable Reference Category Lower limit Higher limit NS Needle gauge <0.001 Back-eye needle No Yes <0.001 Cannulation technique Rope-Ladder Buttonhole Area < st needle inserted Arterial Venous <0.001 Needle axis rotation No Yes <0.001 Needle fixation Butterfly Chevron NS U-Shape NS Others Parisotto MT et Al. Elements of dialysis nursing practice associated with successful cannulation: result of an international survey J Vasc Access 2017; 18(2): Open Access DOI: /jva FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 19
20 3. Cannulation techniques vs vascular access survival (1/3) Out of the 10,807 patients enrolled for the original survey, access survival data was available for 7,058 (65%) Primary outcome was the time of the first surgical access intervention, where survey date serves as baseline. The observation period was 3 years (from April 2009 till March 2012). To adjust for individual patient differences, the following information was extracted from the clinical database: Patient age and gender, BMI, prevalence of diabetes, use of ACE inhibitors, platelet anti-aggregants, salicylic acid and anticoagulants. Descriptive Statistics Mean age was years; 38.5% were female; 27.1% were diabetics; 90.6% had a native fistula; 9.4% had a graft; 51.2% of patients, had a distal access location; 51.1% were treated with antiaggregants; 2.8% anti-coagulant. FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 20
21 3. Cannulation techniques vs vascular access survival (1/3) Out of the 10,807 patients enrolled for the original survey, access survival data was available for 7,058 (65%) Primary outcome was the time of the first surgical access intervention, where survey date serves as baseline. The observation period was 3 years (from April 2009 till March 2012). To adjust for individual patient differences, the following information was extracted from the clinical database: Patient age and gender, BMI, prevalence of diabetes, use of ACE inhibitors, platelet anti-aggregants, salicylic acid and anticoagulants. Descriptive Statistics Needle sizes: 15G: 63.7% 16G : 32.2% 14G: 2,7% 17G: 1.4% Cannulation technique: Area: 65.8% Rope Ladder: 28.2% Buttonhole: 6% FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 21
22 3. Cannulation techniques vs vascular access survival (1/3) Out of the 10,807 patients enrolled for the original survey, access survival data was available for 7,058 (65%) Primary outcome was the time of the first surgical access intervention, where survey date serves as baseline. The observation period was 3 years (from April 2009 till March 2012). To adjust for individual patient differences, the following information was extracted from the clinical database: Patient age and gender, BMI, prevalence of diabetes, use of ACE inhibitors, platelet anti-aggregants, salicylic acid and anticoagulants. Descriptive Statistics Direction of arterial puncture: Antegrade: 57.3% Retrograde: 42.7% The prevalent combination between arterial needle puncturing and bevel direction: Antegrade with bevel upward: 43.1% Retrograde with bevel down: 27.1% Median blood flow: ml / min FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 22
23 Cox model with primary outcome vascular survival Parameter Category Reference HR 95% CI p value Age years years >75 years years < Marginal p value < Gender Male Female Diabetes Yes No Heart failure Yes No Vintage Platelet Antiaggregants 6-24 months 24 months Unknown 0-6 months Yes No Fistula type Graft Fistula < AV-fistula location Right Left AV-fistula location Proximal Distal < Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: /ki FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 23
24 Cox model with primary outcome vascular survival Parameter Category Reference HR 95% CI p value Needle size 14 G 16 G 17 G 15 G Marginal p value 0.01 Cannulation technique Buttonhole Rope-Ladder Area Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down Antegrade + Bevel Up Blood flow <300 ml/min ml/min >400 ml/min ml/min Venous pressure <100 mmhg mmhg mmhg >300 mmhg mmhg < < < Arm compression at time of cannulation None Tourniquet Patient assistance Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: /ki FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 24
25 Cox model with primary outcome vascular survival Parameter Category Reference HR 95% CI p value Needle size 14 G 16 G 17 G 15 G Marginal p value 0.01 Cannulation technique Buttonhole Rope-Ladder Area Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down Antegrade + Bevel Up Blood flow <300 ml/min ml/min >400 ml/min ml/min Venous pressure <100 mmhg mmhg mmhg >300 mmhg mmhg < < < Arm compression at time of cannulation None Tourniquet Patient assistance Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: /ki FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 25
26 Cox model with primary outcome vascular survival Parameter Category Reference HR 95% CI p value Needle size 14 G 16 G 17 G 15 G Marginal p value 0.01 Cannulation technique Buttonhole Rope-Ladder Area Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down Antegrade + Bevel Up Blood flow <300 ml/min ml/min >400 ml/min ml/min Venous pressure <100 mmhg mmhg mmhg >300 mmhg mmhg < < < Arm compression at time of cannulation None Tourniquet Patient assistance Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: /ki FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 26
27 Cox model with primary outcome vascular survival Parameter Category Reference HR 95% CI p value Needle size 14 G 16 G 17 G 15 G Marginal p value 0.01 Cannulation technique Buttonhole Rope-Ladder Area Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down Antegrade + Bevel Up Blood flow <300 ml/min ml/min >400 ml/min ml/min Venous pressure <100 mmhg mmhg mmhg >300 mmhg mmhg < < < Arm compression at time of cannulation None Tourniquet Patient assistance Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: /ki FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 27
28 Cox model with primary outcome vascular survival Parameter Category Reference HR 95% CI p value Needle size 14 G 16 G 17 G 15 G Marginal p value 0.01 Cannulation technique Buttonhole Rope-Ladder Area Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down Antegrade + Bevel Up Blood flow <300 ml/min ml/min >400 ml/min ml/min Venous pressure <100 mmhg mmhg mmhg >300 mmhg mmhg < < < Arm compression at time of cannulation None Tourniquet Patient assistance Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: /ki FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 28
29 Cox model with primary outcome vascular survival Parameter Category Reference HR 95% CI p value Needle size 14 G 16 G 17 G 15 G Marginal p value 0.01 Cannulation technique Buttonhole Rope-Ladder Area Bevel and needle direction Antegrade + Bevel Down Retrograde + Bevel Up Retrograde + Bevel Down Antegrade + Bevel Up Blood flow <300 ml/min ml/min >400 ml/min ml/min Venous pressure <100 mmhg mmhg mmhg >300 mmhg mmhg < < < Arm compression at time of cannulation None Tourniquet Patient assistance Parisotto MT et al. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int doi: /ki FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 29
30 Cannulation technique vs VA survival: Summary (1/2) In summary, the study revealed that area cannulation technique, despite being the most commonly used, was inferior to both rope-ladder and buttonhole for the maintenance of Vascular Access functionality. With regard to the effect of needle and bevel direction, the combination of antegrade position of arterial needle with bevel up or down was significantly associated with better access survival than retrograde positioning with bevel down. FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 30
31 Cannulation technique vs VA survival: Summary (2/2) Results referring to the type and location of access and the technical parameters (i.e. venous pressure) were as follows: There was an increased risk of access failure for graft versus fistula, proximal vs distal location, right arm vs left arm, and the presence of a venous pressure greater than 150 mmhg. The results on venous pressure are worth considering. A venous pressure of mmhg is considered acceptable by the scientific community; the results of this study put these values under discussion. However, further investigations are required to clarify the topic fully. FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 31
32 FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 32
33 Needle diameter vs blood flow and flow pattern vector Needle 17G Ø 1.5 mm Needle 15G Ø 1.8 mm FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 33
34 Effect of needle angle during the treatment Fulker D. et al. The flow field near a venous needle in hemodialysis: a computational study. Hemodial Int Oct;17(4): doi: /hdi Epub 2013 Mar 1. FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 34
35 Effect of needle depth during the treatment Fulker D. et al. The flow field near a venous needle in hemodialysis: a computational study. Hemodial Int Oct;17(4): doi: /hdi Epub 2013 Mar 1. FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 35
36 Antegrade puncturing may be fistula protective Increased risk of haematoma formation from retrograde filling Tract closure through flow force by antegrade puncture FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 36
37 Effect of bevel direction in the arterial needle position (antegrade/retrograde) Antegrade Retrograde Bevel Up Bevel Down Bionic Medizintechnick GmbH FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 37
38 Effect of bevel direction in the arterial needle position (antegrade/retrograde) Antegrade Retrograde Bevel Up Bevel Down Bionic Medizintechnick GmbH FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 38
39 Effect of bevel direction in the arterial needle position (antegrade/retrograde) Antegrade Retrograde Bevel Up Bevel Down Bionic Medizintechnick GmbH FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 39
40 Arterial needle antegrade: Effect of bevel up direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 40
41 Arterial needle antegrade: Effect of bevel up direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 41
42 Arterial needle antegrade: Effect of bevel up direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 42
43 Arterial needle antegrade: Effect of bevel up direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 43
44 Arterial needle antegrade: Effect of bevel up direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 44
45 Arterial needle antegrade: Effect of bevel up direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 45
46 Arterial needle antegrade: Effect of bevel down direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 46
47 Arterial needle antegrade: Effect of bevel down direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 47
48 Arterial needle antegrade: Effect of bevel down direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 48
49 Arterial needle antegrade: Effect of bevel down direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 49
50 Arterial needle antegrade: Effect of bevel down direction FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 50
51 Blood flow and vascular access survival, taking access blood flow into consideration, no association was found between VA failure and extracorporeal blood flow for the range of extracorporeal blood flows commonly used in routine dialysis practice. Low extracorporeal blood flow (<310 ml/min) seems to be a surrogate for poor access blood flow. Some caution appears indicated when applying particularly high extracorporeal blood flow (>390 ml/min). Ponce P. et al. Hemodialysis International Does the extracorporeal blood flow affect survival of the arteriovenous vascular access? FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 51
52 Blood flow and vascular access survival, taking access blood flow into consideration, no association was found between VA failure and extracorporeal blood flow for the range of extracorporeal blood flows commonly used in routine dialysis practice. Low extracorporeal blood flow (<310 ml/min) seems to be a surrogate for poor access blood flow. Some caution appears indicated when applying particularly high extracorporeal blood flow (>390 ml/min). Ponce P. et al. Hemodialysis International Does the extracorporeal blood flow affect survival of the arteriovenous vascular access? FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 52
53 Recommandations for an effective Vascular Access Management Rope-ladder cannulation technique as preferred option and only when there is a limited area for cannulation sites, or for the potential self-care dialysis patients choose buttonhole Arterial needle insertion in the antegrade direction (blood flow direction) and with bevel downward; In the case of arterial needle retrograde position, the direction of the bevel should be upward Avoid needle rotation! VA Survival 15 G needles are recommended Proper needle fixation Blood flow ml/min Venous pressure around 150 mmhg Correct haemostasis Patients education to care for the Vascular Access Clinical staff education on Vascular Access Management FME Copyright MTP - Does cannulation technique impact arteriovenous fistula and graft survival? Page 53
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