The impact of minimally invasive dialysis access.

Abstract

Objective: Minimal Invasive Dialysis Access (MIDA) for renal dialysis encompasses percutaneous arteriovenous fistula (pAVF) creation and the modified percutaneous Seldinger peritoneal dialysis catheter insertions (pPD). This review examines the impact of MIDA on technical success, maturation rates, patency, clinical benefits, complications, and cost.

Methods: A review was made of the literature on MIDA including pAVF creation and pPD insertion regarding technical success rates, maturation rates, patency, clinical benefits, complications, and cost. Additional benefits of pAVF such as expansion of cannulation area and reduction of steal syndrome, and associated administrative challenges was assessed.

Results: Percutaneous AVF can be performed outside the operating room by interventionalists and physicians of several specialties. Initial reports claim safe and efficacious use and equivalent patency to open surgery (sAVF). Percutaneous AVF with multiple venous outflows has the benefit of expanding the area for cannulation. The incidence of wound infection and steal syndrome is reduced. Most studies have been retrospective and there are no prospective randomized controlled trials. The cost-effectiveness of pAVF versus sAVF has been challenged. The recently modified pPD has reduced incidence of catheter misplacement with improved catheter survival. With equivalent efficacy and complication rates reported in prospective studies and without the need for surgery and general anesthesia, pPD should be cost-effective in skilled centers.

Conclusions: MIDA is an innovative approach to dialysis access that offers benefits over open surgery. MIDA advantages include widened indications to the very sick patients, being performed under ultrasound and fluoroscopic guidance with local anesthesia. New devices are being developed that may meet stricter criteria with improved efficacy. The cost of device and added procedures required for maturation and patency may prevent widespread application for now. Real-world data is needed to determine long term clinical outcomes and cost-effectiveness. Additional skills training and team collaborations are likely key factors for success.