Purpose: The algorithm of treatment for dysfunctional haemodialysis vascular access (VA) varies significantly between centres, and the role of stent-grafts is not yet standardised. A multidisciplinary panel of European experts on VA was convened, with the aim of finding consensus on stent-graft strategies in symptomatic dysfunctional VA using a modified Delphi approach.
Methods: A modified 3-round Delphi study was conducted with a panel of 12 European experts from high-volume dialysis access practices across multiple specialties (5 vascular surgeons, 5 interventional radiologists, 1 transplant surgeon and 1 nephrologist). Round 1 involved semi-structured interviews to identify key parameters. Round 2 assessed extent of expert agreement to the statements or if neutral. Round 3 allowed experts to revise responses after viewing anonymised panel results. To highlight gradations of consensus, a grading system (A-D) was applied based on agreement or disagreement, with consensus defined as ≥75% agreement.
Results: Each expert voted on the 57 statements on treatment considerations relating to optimal stent-graft utilisation; patient background; vascular occlusive pathology; considerations specific to the graft-venous anastomosis, cephalic arch and thoracic central vein stenoses; general treatment considerations with stent-grafts; and a summary treatment algorithm by anatomical location. The analysis revealed strong consensus across multiple domains, with 81% of statements (46/57) achieving ≥75% agreement. An expert panel consensus (≥75% agreement) on the use of stent-graft was found for the treatment of graft-venous anastomosis, recurrent restenosis in the central venous system, in-stent stenosis in previously-placed bare metal stents, and restenosis of the cannulation zone if to be abandoned. All 12 experts completed 3 rounds (100% retention). Response stability was high with only 3 experts adjusting 11 responses (1.6%) between rounds regarding 9 statements that changed the overall consensus level of the panel.
Conclusions: Based on the elevated strength and high consistency of this international multidisciplinary expert-based Delphi consensus, most of the statements might guide the current stent-graft strategies of dysfunctional VA, including practical recommendations on best practice using stent-grafts.
Keywords: dialysis access revision; dysfunctional haemodialysis vascular access; haemodialysis; stent-graft treatment algorithm in dialysis access revision.