Volume 2 Issue 1

 

Welcome to the third edition of Vascular Access, the official journal of the Australian Vascular Access Society (AVAS). This edition of the journal has a renal vascular access flavour. Over the past 20 years, vascular access in renal dialysis has taken centre stage. Collectively we have recognised that vascular access is the patient’s lifeline and it is imperative to provide extra care in this area to prolong the lifespan of the access. There have been innovations in surveillance and monitoring, such as the Transonic Qc™ ultrasound dilutional technique for arteriovenous fistula and arteriovenous graft surveillance¹ and the use of ultrasound for assessment and cannulation^2,3.

The Transonic Qc™ ultrasound dilutional technique is used to test the access flow of the arteriovenous fistula or graft to identify and predict any ‘slowing down’ of the blood flow through the access. Most arteriovenous fistula will have a blood flow of >1000 ml per minute; if there is a decrease of over 25% in a four-month period and/or a decrease to below 500 ml/minute, an investigation is required¹. This is done either via diagnostic Doppler ultrasound in the radiology department or via fistulography. This is to detect any narrowing of the vessel. The use of this technology allows for pre-emptive treatment of the vessel rather than reactive treatment. It is much easier to treat a stenosis via angioplasty well before the vessel has thrombosed⁴.

Point of care ultrasound is another adjunct assessment tool used in some renal units to assess the arteriovenous fistula or graft and guide cannulation. One of the issues with cannulation of arteriovenous fistula in dialysis is that for 50 years we have relied on ‘blind cannulation’ for insertion of the large bore metal needles into the vessel. Yes, we assess the overlying skin, feel the vessel, sometimes we listen for a bruit, but we really don’t know what is going on inside the arterialised vessel. Often the needle has scraped the back wall of the vessel on insertion, or is sitting up or sticking into the side wall of the vessel during the four to five hours of dialysis. This damage to the vessel encourages intimal hyperplasia, leading to scarring and narrowing of the vessel⁵. The narrowing (stenosis) is what causes the slowing down of the blood flow and encouragement of thrombosis within the vessel. Both of these things affect the quality of the dialysis that the patient receives, which has both short- and long-term effects on their health⁵.

So how can we be more proactive? Well, as Martinez-Smith, Meek and Tranter⁶ have outlined in their paper in this edition of the journal — introduction of a central coordinator, such as a vascular access coordinator can make a significant difference in vascular access outcomes. The vascular access coordinator has a complex role of monitoring, surveillance, administration, assessment, patient education, staff education, data collection, dissemination of results et cetera. This role has a positive impact on patient outcomes such as symptom management by prolonging the lifespan and the quality of the access⁷.

There are many aspects to the role of vascular access coordinator. Their role within the dialysis unit cannot be underestimated. The cost benefit to prolonging the life of the access and keeping patients out of acute hospital beds is insurmountable. The use of Transonic Qc™ monitoring by staff and reporting the data to the coordinator can result in a proactive approach to vascular access care, thus improving outcomes for patients. Ultrasound use at point of care has the potential to increase the accuracy of cannulation, therefore decreasing the amount of intimal damage to the lumen of the vessel, thus reducing stenosis and thrombosis occurance³.

Additionally, the recent introduction of plastic cannula into the renal units in Australia also works towards the aim to decrease the damage that we do to the vessels on cannulation. Smith and Schoch⁸ discuss the implementation of this in a reprint from the Journal of Vascular Access in this edition of the journal, discussing the trials of change and successes of vascular access outcomes. The journey to introduce plastic cannula, use of ultrasound for assessment and cannulation guidance and the Transonic Qc™ machine are all tools of change. It can be difficult to introduce new technologies or new processes into units without any resistance. If there is a dedicated role for someone to champion the area of vascular access within a unit, it will make the introduction of these tools smoother and more successful within a reasonable time frame.

Vascular access monitoring and surveillance methods coordinated by the vascular access coordinator are imperative to the survival of each vascular access. Without a functioning vascular access, there is no dialysis, without dialysis, there is no patient.

Postscript

This is my last edition as editor in chief of Vascular Access. I have enjoyed my time over the past 18 months, developing new skills and learning the ropes of editing a journal. I will be leaving to pursue research into renal vascular access whilst working full time and undertaking my PhD part time. Thank you to the publishers at Cambridge Publishing for your support as well as the board and members of the Australian Vascular Access Society. I wish the new editor in chief, Gillian Ray-Barruel the very best for future editions.

 

Author(s)

Monica Schoch Editor in Chief

References

1. Krivitski N. Theory and validation of access flow measurement by dilution technique during hemodialysis. Kidney Int 1995; 48(1):244–250.
2. Swinnen, J. Duplex ultrasound scanning of the autogenous arterio venous hemodialysis fistula: a vascular surgeon’s perspective. Australas J Ultrasound Med 2011; 14(1):17–20.
3. Schoch M, Du Toit D, Marticorena RM & Sinclair PM. Utilising point of care ultrasound for vascular access in haemodialysis. Renal Society of Australasia Journal 2015 Jul; 11(2):78–82.
4. Fletchman L, Pondor Z & Robinson H. The changing role of the dialysis access nurse in the vascular access multidisciplinary team. J Vasc Access 2011; 12(1):107.
5. Elseviers M & Van Waeleghem J. Identifying vascular access complications among ESRD patients in Europe. A prospective, multicenter study. Nephrol News Issues 2003; 17:61.
6. Martinez-Smith Y, Meek C & Tranter S. The impact of a dedicated renal vascular access nurse on haemodialysis access outcomes. Vascular Access 2016 April: In press.
7. Polkinghorne K, Seneviratne M & Kerr P. Effect of a vascular access nurse coordinator to reduce central venous catheter use in incident hemodialysis patients: A quality improvement report. Am J Kidney Dis 2009; 53(1):99–106.
8. Smith V & Schoch M. Plastic cannula use in haemodialysis access. J Vasc Access 2016: In press.