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Change Concept #6
Secondary AVF Placement in Patients with AV Grafts
Evaluate graft patients for placement of a secondary AV fistula. In the context of the
NVAII initiative, an AV fistula placed in a patient whose initial access was a graft is considered a "secondary" AV fistula. Staff should consider every graft patient a candidate for an AV fistula and should evaluate each patient for an AV fistula before the graft fails. In this way, a plan will be in place for providing the patient with an AV fistula when the graft begins to fail. This avoids the need for a catheter or missing an AV fistula opportunity when the graft fails and there is urgency for an immediate usable access.
Note particularly that the outflow vein from a graft is an already matured arterialized vein that could be connected and used right away (see indivual change recommendation: Examine the Outflow Vein of All Forearm Graft Patients to Identify Suitable Veins for Secondary AV Fistula ).
Changes for Improvement
Frequently Asked Questions
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Changes for
Improvement:
Evaluate Every AV Graft Patient for Possible Secondary AVF
Nephrologists should evaluate every arteriovenous (AV) graft patient for possible placement of a secondary AV fistula, including mapping as indicated, and document the plan in the patient’s record. AV fistula evaluation of graft patients should include an updated history relevant to vascular access, physical exam with tourniquet, and vessel mapping if suitable vessels are not identified on physical exam. A secondary AV fistula plan should be documented in the chart and discussed with the patient, family, staff, and nephrologists and surgeon in anticipation of AV fistula construction on the earliest evidence of graft failure.
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Changes for
Improvement:
Examine the Outflow Vein of All Forearm Graft Patients to Identify Suitable Veins for Secondary AVF
Dialysis facility staff and/or rounding nephrologists should examine the outflow vein of all forearm graft patients during dialysis treatments (with a recommended minimum frequency of at least monthly) to identify patients who may have a suitable upper outflow vein for elective secondary AV fistula conversion in the upper arm. If such a suitable vein is found, dialysis facility staff and/or rounding nephrologists should inform the patient’s nephrologist and surgeon of the need to evaluate the identified outflow vein for AV fistula conversion.
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Changes for Improvement:
Refer to the Surgeon for Evaluation/Placement of Secondary AVF before the Graft Fails
Patients with an AV graft should be evaluated (including vessel mapping) for an AV fistula when the graft shows evidence of dysfunction by monitoring and surveillance. The timing of such surgical intervention to convert the outflow vein of an existing AV graft to an AV fistula, or to construct a new AV fistula in a new location, assuming suitable vessels, should be as soon as feasible but not later than following an intervention for thrombosis or clinically significant stenosis.
Any delay in conversion beyond this point is likely to result in loss of the
window of opportunity for an AV fistula, since further graft interventions,
especially if done as an emergency, are likely to damage or utilize the
outflow vein, or the graft will eventually be abandoned (usually after a
failed intervention), resulting in a catheter and a new graft in a different
location.
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