June 2023 Issue 08 www.renalinterventions.net
In this issue:
CX Symposium summarised
Profile:
Daniel Patel
pages 4–6
page 10
“EndoAVF 2.0” projects evaluated in CX debate
Continued on page 13
pages 12
Wei Li and Mareena Zachariah on IN training pages 14
New UKKA guideline places patient choice at the heart of vascular access care
The advent of endovascular arteriovenous fistula (endoAVF) creation with the development of the Ellipsys (Medtronic) and WavelinQ (BD) systems marks a “major innovation in dialysis access”— and a “mounting evidence base” demonstrates their high functional patency rates. So said interventional radiology lead at East and North Herts NHS Trust (Stevenage, UK) Kate Steiner, who led a discussion of the next generation of endoAVF devices at the Charing Cross Symposium 2023 (25–27 April, London, UK). Joining her was Robert Shahverdyan (Asklepios Clinic Barmbek, Hamburg, Germany) and Simon Hogan (Pathfinder Medical, London, UK), who offered a preview of the future of the technology. HOGAN OPENED PROCEEDINGS with a dive into the ePath system currently in development at Pathfinder Medical, which he explained has its roots in the work of the company’s electrical engineer CEO Sorin Popa at Imperial College London. He explained that it is a twin-catheter system with a 3Fr target that goes into the target artery, and a 5Fr crossing catheter for the target vein. Under fluoroscopic guidance, the ePath system sees the two catheters inserted “either from a parallel point of view or anti-parallel way depending on the access sites that are being used”. The target device has a basket on the end that acts as a sensor, while there are four electrodes printed into the surface of the crossing device,” Hogan outlined. These electrodes generate electrical fields in which the alignment of the target basket can be detected. “You know exactly where the needle is pointing when you rotate the handle. The display is very intuitive—it is just two arrows that point to each other, and when it turns green you know the devices are aligned. Then, the needle pops out straight into the middle of the basket. You deploy a guide wire, after which you can deploy a stent or balloon over the top of that: whatever the operator desires to create the fistula.” Hogan added that preclinical trials in cadaveric and animal models had tested the system in the wrist and other sites in the forearm. “We hope to be able to advance our clinical research in the coming months,” he said.
UK Kidney Week preview
The recent haemodialysis access guideline update from the UK Kidney Association (UKKA) comes in the run-up to the 2023 UK Kidney Week conference (UKKW; 5–7 June, Newport, UK), and marks a considerable shift in how the organisation recommends that clinicians approach choices in vascular access for patients. Two of the UKKA update’s authors, Damien Ashby (Hammersmith Hospital, London, UK) and Catherine Fielding (University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK) spoke to Renal Interventions to detail how that shift was built on a desire to better consider the patient voice in all aspects of access care.
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sked what distinguishes this version of the UKKA guideline, Fielding began by highlighting the multidisciplinary involvement in the writing of the update. The text of the guideline states that nephrologists, surgeons and radiologists were all involved—as well as nurses like herself. Explaining the reasoning behind this, Fielding said: “It sometimes feels like it is not those who perform procedures like cannulation who are writing the guidelines on them. I am not saying that they should not have their own perspectives, but it leads you to wonder how some guideline proposals can be put into clinical practice. I think that practical, pragmatic element comes strongly through in this guideline—so that it is not just doctors but other professions that can implement it.” Not only were a variety of specialties included, but there were also “three very active patient representatives” at the heart of the process. Developing this point, Ashby added: “The big thing that moves the needle with this guideline is how we constantly tried to involve the patient voice. The guideline emphasises different patient characteristics rather than just saying: ‘This is the best access for you.’” Asked what might surprise some readers about the update, Ashby said that, though it would not surprise patients or nurses, it may be unexpected for some clinicians that the update does away with the concept of targets. Other guidelines, he suggested, prescribe fistulas as the
optimum form of access and provide a percentage of patients that should receive one. “It is not consistent with making the patient voice and patient choices the centre of care that hospitals should need to reach targets for types of access,” he argued. “We are moving away from that by recognising patient characteristics and what is sometimes the uncertainty of the evidence base.” The patient voice is the fundamental difference in this guideline compared to both those issued by the UKKA in the past and those seen elsewhere, Ashby and Fielding agreed. Fielding also noted that the writing team contended with a “mushrooming” breadth of research in vascular access, which meant they were required to judge carefully what now warranted recommendation, and what still called for more research. In particular, however, they looked at qualitative data, something which they suggest may not have been included to the same degree in previous guidelines. “Once you start looking at studies of patient perspectives, it changes your own,” Ashby said. The consideration of the patient perspective meant making the guideline more readable, too. Comparing the UKKA guideline with the Kidney Disease Outcomes Quality Initiative (KDOQI) guideline on vascular access, Ashby made the case that the references “running into the thou-
“The guideline emphasises diff erent patient characteristics rather than just saying: ‘This is the best access for you.'” Damien Ashby Continued on page 2