Jeremy Crane (London, UK) discusses the topic of vein preservation—including its central importance to successful dialysis access creation, and practical measures for achieving it in clinical practice.
The presence of patent peripheral key veins in the arm is an obvious central tenet underpinning the creation of a successful arteriovenous fistula (AVF) for dialysis—the gold-standard form of vascular access. A well-functioning AVF allows for a durable vascular access, associated with reduced infection risk and mortality compared with central venous catheters, translating into a superior long-term outcome for a dialysis patient. Paradoxically, preserving these key veins (vein preservation) is practiced poorly in many renal failure programmes.
In this context, what is vein preservation? It is the practice of avoiding blood tests and indiscriminate insertion of intravenous (IV) lines into key veins in the arms—the anterior elbow crease and the cephalic vein at the lateral wrist—that are fundamental in creating an AVF.
Repeated venepuncture and IV-line insertion has the potential to injure veins and render them useless for AVF creation by causing thrombosis, stenosis and phlebitis. It stands to reason that a practical and effective vein preservation policy is integral in the management of all patients with kidney disease. Effective implementation of such a policy can be a major contributing factor in improving incidence and prevalence of the gold standard AVF in haemodialysis programmes across the board.
A concise guideline that can be shared with healthcare professionals and patients for them to practice simple and effective vein preservation is as follows:
- Always take blood from the back of the hand whenever possible
- If the back of the hand is not an option, the elbow crease can be used, but rotate arms
- After examination of the arm veins, a specific directive can be given to inform which arm needs to be preserved
- Avoid unnecessary or duplicate blood tests
One initiative to improve vein preservation knowledge and practice at a large, UK-based healthcare organisation is the “Save Your Vein” campaign. To summarise initial results of the campaign, a baseline assessment of knowledge and practice of vein preservation for both patients and healthcare professionals was carried out before and after an awareness campaign. This initial survey demonstrated only 31.5% of patients and 3% of healthcare staff were aware of the concept of vein preservation.
On this basis, the second phase of the campaign was implemented in 10 renal units. Approximately 2,000 patients and healthcare staff were involved. Patients were issued alert cards and leaflets, while staff were given lanyards and attended teaching sessions. Posters were placed in key healthcare areas. A post-intervention survey performed three months after the baseline assessment showed a marked improvement in knowledge, with 94% of patients and 92% of staff showing awareness of vein preservation.
What was demonstrated was that the ‘Save Your Vein’ campaign was highly effective in increasing knowledge and awareness amongst patients and healthcare groups. It also resulted in improved practice and adherence to best practice guidelines, and was well-received by those involved and other stakeholder groups. With this validation, the campaign was incorporated into the 2019 Kidney Disease Outcomes Quality Initiative (KDOQI) guideline update and there is a website solely dedicated to vein preservation for patients with kidney disease.
Jeremy Crane is a consultant transplant and vascular surgeon at Imperial College Healthcare NHS trust in London, UK. His practice involves kidney and pancreas transplantation, and he is the lead for vascular access surgery, having set up the vascular access surgical programme for West London. Crane is also the co-founder of the Save Your Vein campaign.
The author declared no relevant disclosures pertaining to this article.