Precision banding offers “effective, low-morbidity approach” in high-flow haemodialysis accesses

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Rebecca Scully

A retrospective review involving nearly 300 patients has concluded that precision banding as a treatment for high-flow haemodialysis accesses offers “an effective, low-morbidity approach”. The findings of the review are published in the Journal of Vascular Access (JVA).

“This study represents the largest series of precision banding for high-flow haemodialysis accesses, and highlights the safety and versatility of the procedure,” Rebecca Scully (Brigham and Women’s Hospital, Boston, USA) and colleagues write in JVA. “High-flow accesses were successfully banded in both symptomatic patients presenting with ischaemic steal, heart failure or pulmonary hypertension, and aneurysmal degeneration as well as at-risk patients with flow imbalance.”

The authors begin their report by noting that high-flow haemodialysis accesses are a well-recognised source of patient morbidity. They also claim that, among available management strategies, inflow constriction based on real-time physiologic flow monitoring offers a “technically straightforward, data-driven approach with potentially low morbidity”—but large, contemporary series examining it are lacking, in spite of the benefits offered.

As such, Scully and colleagues undertook a retrospective review of a prospectively maintained clinical database in order to capture patients undergoing precision banding within a single tertiary care institution between 2010 and 2019. Multivariable logistic regression modelling was used to assess the review’s primary outcome measures, access circuit thrombosis within 30 days and banding failure (defined as re-banding within one year of the index banding procedure).

The researchers found that, in total, 297 patients underwent banding during the study period for a total number of 398 encounters. The median follow-up time was 157 (52–373) days, they note in their JVA report. Most arteriovenous fistula (AVF) accesses (84%) were in the upper arm of the patient with brachial artery inflow and half of the banding procedures were performed for flow imbalance based on examination, duplex ultrasound, or a fistulogram. In addition, the median, intraoperative, pre-banding flow volume—based on intraoperative thermal dilution—was 1,545ml/min, which was reduced to 640ml/min following access banding. This represented a median reduction in flow rate of 58%.

In terms of primary outcome measures, Scully and colleagues report that the 30-day thrombosis rate after banding was 3.8% (15/397) with a total thrombosis rate of 6.5% (26/368) throughout the entire study period and a median time to event of 5.5 (2–102) days. Multivariate analysis for 30-day thrombosis identified no risk factors for thrombosis including access type, indication for banding, and banding diameter.

Regarding banding failure, the authors relay that the re-banding rate within one year was 13.6% (54/398) with a median time to re-banding of 133 (56–224) days. During the entire study period, 26% of patients (76/297) needed to be re-banded at any time. Multivariate logistic regression analysis here revealed that having a forearm radiocephalic AVF—compared to all other access types—was protective against need for re-banding at one year, as was flow imbalance as an indication for banding.

“This work highlights the safety and efficacy of precision banding for both symptomatic and asymptomatic access patients with high-flow volume,” Scully and colleagues write. “There are limitations to the study. First, this is a single-centre, retrospective review performed at a high-volume teaching institution with a multidisciplinary team dedicated to haemodialysis access and maintenance. We recognise that these types of resources and clinical experience may not be available to all proceduralists and may not be generalised to other US centres. The retrospective nature infers that the findings are associative.”

In addition to noting the “excellent symptomatic relief” offered by precision banding in high-flow haemodialysis accesses, the authors conclude by stating that early thrombosis is a rare event, and that—in the long term—one in four patients may require re-banding to control flow volumes.

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