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I’d like to share my experience as a vascular access surgeon at an underserved hospital, and explain why I’m a bit why I’m so skeptical about endovascular AVF tech
First I’d like to acknowledge this is cool tech, I think most people are surprised the devices work as well as they do from a purely technical stand point. The devices seem capable of safely creating a durable AVF connection which is pretty astonishing.
When I assess a new device or technology I have one question at the forefront of my mind: Who can I help with device, this who I struggle to help now? A really great new technology should be able to extend therapies to people who couldn’t get them before. EVAR certainly did that
With endo avf I cannot imagine that patient who uniquely benefits from the technology. In order to create an Eavf you need a patient with a potentially use-able basilic/ or cephalic vein and reasonable deep veins with perforators. The cephalic can’t be too deep to cannulate
By definition virtually all of these patients can get a standard avf. Unlike open AAA repair, almost anyone can tolerate avf creation under block/ or local.
So who do we struggle with now? Obese patients, patients with marginal veins with sclerosed segments, patients with multiple prior failed access, patients with poor arterial inflow. None of these patients are going to uniquely benefit from Endo avf.
Essentially the technology is another way to create an AVF in a patient with an embarrassment of good options to start
Cost. I would think this would be a no-brainer. A system requiring an expensive disposable magnet/ electrode catheter, access sheaths, needles and coils is never going to be as cheap as reusable instruments and a little prolene.
Astonishingly, early endo AVF have pointed to this study as proof of the opposite ncbi.nlm.nih.gov/pubmed/?term=Y…
Without getting too nasty, this study is flawed. The authors used dubious methodology at best, to prove that the sky is green and the grass is blue. The study compares the reinterveniton rate of prospectively selected endo avf patients to all comers in national data.
Remember those obese patients with marginal vein ? Those are compared against perfectly selected patients undergoing endo avf. The authors even counted catheter placement as a negative outcome without bothering to control for immediate need for dialysis! Yikes.
Wrapping up. We have an expensive novel technology, but maybe without a target patient who needs it. I’m definitely willing to reassess if one of the possible benefits bears out, but there is next to no data right now.
I have heard advocates say that there is something magical about a low pressure avf because of the increased avf out-flow? Maybe that will result in less re-intervention. I have also heard people have struggled with inadequate flow rates given the multiple outflows, so maybe not.
Time will tell if this tech has a future, but I’m going to focus on offering high quality standard surgical avf creation and endo intervention. I hope we continue to innovate but I’d like to see those innovations focus on my most challenging patients rather than my easiest.
