41 Lavainne NECKLACE GRAFT.pptx [Lecture seule] - SFAV

F.Lavainne, Nephrology Unit, CHU Nantes
JC Pillet, Vascular Surgery Unit, NCN Clinic, Nantes
S.Coupel, ECHO Haemodialysis Center, Nantes
A.Paris, ECHO Haemodialysis Center, Nantes
C.Delcroix, Nephrology Unit, CHU Nantes

- Vascular access has become a major problem
in dialysis
Increasing number of patients with
exhausted vascular access options
No other possibilities than complex grafts
(or tunneled catheters?)
-We report here our experience in 3 haemodialysis
centers in Nantes, France (CHU = 1 / ECHO = 2):
Our surgeon performed 12 necklace grafts
From axillary artery to controlateral axillary
vein
2006 to now

- Question : how nurses and patients felt about
this atypical access ?
- Methods : questionnaires (nurses/patients)
- 44 nurses
6 patients
All actually using necklace

NURSES
-Experience with necklace :
> 6 months : 87 %
-Difficulties for first puncture ?
YES = 70 %
Experience did not make any difference (mean =
6,5 years whatever the group )
-Did you feel trained enough before first use?
YES = 16 % …

EVOLUTION
Did you experience an improvement with
time ?
YES, completely : 33 %
YES, a lot : 48 %
YES, Somewhat: 14 %
NO, not at all : 5 %
1/3 have no more difficulties and 4/5 feel a
significant improvement
96 % of dialysis sessions with double
puncture

Correlation between frequency of use and
improvement ?
Improvement
YES
completely
YES
A lot
YES
somewhat
NO
Not at all
Once a week
(24 %)
60 % 20 % 20 % 0 %
Every 2 weeks
(37 %)
40 % 47 % 6,5 % 6,5 %
Every 3 weeks
(12 %)
Once a month
(15 %)
Less often
(12 %)
20 % 80 % 0 % 0 %
0 % 83 % 17 % 0 %
0 % 60 % 20 % 20 %

Necklace vs other fistulas
Level of difficulty
(puncture)
As compared
to native
fistula
As compared
to other graft
Less difficult 11,4 % 6,8 %
Same difficulties 20,5 % 43,2 %
A little harder 59 % 38,6 %
Much more difficult 6,8 % 9,1 %
Do not answer 2,3 % 2,3 %

What about stress?
Level of stress
As compared
to native fistula
As compared
to other graft
Less stress 2 % 0 %
Same stress 52 % 61,4 %
More stress 46 % 38,6 %
66 % of the nurses experience stress when using necklace
(no difference whatever the seniority in the job)

A question of time…
Necklace
Vs native
fistula
Vs another
graft
Vs catheter
Less time 4,5 % 0 % 56,8 %
Same time 45,5 % 50 % 15,9 %
More time 41 % 41 % 20,5 %
Didn’t answer 9 % 9 % 6,8 %

Comments : selected pieces
- Depth (obesity)
- The graft rolls under the fingers
- The fear to get through the graft
- 20 % of nurses found that the graft change their contact with
the patient = unwanted proximity with the patient(too close)
-To touch the chest = an intimate act (for a woman)
- Uncomfortable position (back ++)
-How can the patient compress the graft if bleeding at home ?
-Necklace considered as “the ultimate access”

PATIENTS
Did you experience difficulties to accept the graft
(as compared to previous access)?
NO, not at all: 4/6
YES, somewhat : 0/6
YES, a lot: 2/6
Currently, are you adapted to your graft ?
YES, completely : 6/6

Did this graft change the way your family look at you
(and the way you look at yourself) ?
NO, not at all: 3/6
YES, a little bit : 3/6
YES, a lot : 0/6
For what reasons ?
- “When seeing my chest, they look away”
- I use something to hide the scars (headscarf)
- Scars are too obvious
- I can’t touch the graft directly (I use a towel)

PAIN
Level of pain Evaluated by nurses Reported by patients
Less than fistula 9 % 3/6
Same level 50 % 0/6
More than fistula 36,4 %
3/6
( 1 :just at the
beginning)

SATISFACTION
To date, are you satisfied with your graft :
TOTALLY SATISFIED: 5 /6
( 1 patient did not answer…)

Age
(y)/sex
Nb of
procedure
Time in dialysis
before graft (d)
Nb of access
before graft
Previous
access
59, M 1 111 2 Cath. (jug)
59, F 1 252 4 Cath. (jug)
54, M 1 236 5 Cath. (jug)
25, F 2 840/1190 6/9 Cath. (jug)
63, F 1 120 1 Cath .(jug)
85, F 1 793 9 Cath .(fem)
91, M 1 1587 5 Cath. (jug)
58, F 1 NA = kidney graft
1
(fistula failure)
None
36, M 1 1555 5 Cath. (jug)
74, M 1 1843 5 Cath. (jug)
80, M 1 1075 5 Cath. (jug)
62 1,1 873 4,8

Age
(y)/sex
Cause of graft
failure
Rescue success
Primary
patency
59, M Died 293 N/A
59, F 1342 Yes
54, M Died 608 N/A
25, F Car accident
Thrombosis
NO (perforation)
YES (thrombectomy)
256/321 No
Yes
63, F Thrombosis Thrombectomy 242 Yes
85, F 355 Yes
91, M Thrombosis/died Thrombectomy 1 N/A
58, F 258 Yes
36, M Died
(after surgery)
N/A
74, M 192 Yes
80, M Thrombosis Thrombectomy 56 Yes
Functional
access
N/A

RESULTS
-Average primary patency : 357 days (1-1342)
Median 259 days
Primary patency at M6 : 82 %
- 2 patients deceased with functional access
- 1 patient deceased after the procedure (sickle-cell
anemia)
- 5/11 patients had thrombosis (one was definitive
after a car accident)
-Secondary patency at M6 : 100 %
- Initial average flow rate : 1423 ml/min (900-2500)
- Last flow rate (average) : 1510 ml/min (276-2200)

CONCLUSION
-A need for more information (patients)
and formation (nurses)
- A necessary time for adaptation
(both for nurses and patients…)
- More concern for caregivers than for patients ?
- Finally well accepted and tolerated
- Pretty good result
- But no easy surgery (1 death after the procedure…)
SO, A PLACE TO DEFINE, OPEN TO DISCUSSION