This never gets old, the ongoing monitoring vs surveillance debate that never ends... this has been going on since I started my interventional Nephrology career exactly 20years ago to the date, and it keeps going..

I proudly say that we have conducted static pressure ("access alert"; 2 times a month) from 12/2001 through 2010 (until the small filter that was attached between the manometer and the dialysis needles was no longer produced) on all our ESRD patients with AVG/AVF and in >30 ICHD clinics with 1 single LDO. We then switched temporarily to conductivity based flow measurement for only 6months and had to abandon it d/t its taxing effect (time wise) on the HD staff... We immediately switched afterwards to continuous VAPR, again in partnership with a large LDO and now in >40 clinics ("Vascalert", with remote monitoring and analytics....) from 2010 till current and have developed a wealth of data on this. Since we operate one of the busiest Access Centers in the US and also for the last 20yrs, we can safely say that the accuracy of this surveillance tool is in the >85-90% in predicting stenoses. This positive impact in reducing thrombosis rates and HD session interruptions (when early intervention is conducted) is beyond the scope of this discussion. I wish we have the time to publish this cumulative data on a fairly large patient population... The lesions have a wide range and are not necessarily at a "late stage"... The development of risk score (1-10) along with that tool has added value...

As I argued this point in national meeting and on many occasions: yes monitoring (ie a good physical exam with proper training) is supreme, the question is always, how much control do you have on that and how sustainable is it? if you are in an academic center, with abundant resources (HD and research staff) with low turnover, you do not need to worry about surveillance. However, when you are in a large private practice and struggling with dialysis staffing issues on a daily basis, a problem that has skyrocketed since COVID, good luck finding and maintaining well trained HD staff to perform a good physical assessment on ESRD patients with AVF or AVG.

Hence, we always have to individualize (like anything else we do in the medical field) and do what is the best for your patients. If you have the staff to do monitoring in a sustainable way, do it. If you do not, then surveillance in a cost effective and least time consuming way, is equally good and DO NOT tell your local LDO to stop doing surveillance..

Happy New Year to the entire ASDIN community and best wishes on your upcoming annual meeting.

Tony Samaha, MD
Dialysis access Center of Cincinnati

Antoine
You should post this on the ASN site too. Under Dynamic Venous pressure /surveillance
Anatole Besarab