Society of Vascular Surgery arteriovenous access reporting standards.

IN the March issue of the Journal of Vascular Surgery, the Society of Vascular Surgery (SVS) published a set of reporting standards for hemodialysis access (1). Although the SVS was aware of the existing SCVIR reporting standards for hemodialysis access (2), it was believed that similar standards were needed for surgical creation of permanent access. A concerted effort was made on the part of the SVS to involve the SCVIR as well as other societies in the creation of this document. To that end, several of the authors of the SCVIR standards were invited to participate throughout the process. The result is a multidisciplinary document that is, in most respects, very much in line with the SCVIR document. Although less detailed than the SCVIR version, the SVS document addresses several important deficiencies in the reporting of surgical interventions in hemodialysis access circuits. One of the most exciting aspects of the SVS document is the proposal of a new characterization system and nomenclature for permanent access, covering all forms of synthetic and native dialysis access circuits in an easy-touse algorithm, identifying conduit type, conduit location, and configuration. Using combinations of these three terms, any dialysis access described today and, one would assume, any future configurations can be described with ease and consistency. We believe that universal adoption of this system will eliminate many of the inconsistencies that currently hamper peer-reviewed publications and, equally important, routine communication in patients’ medical records. The document also provides definitions for dialysis catheters, which are similar to published definitions. Preoperative evaluation is addressed in detail with sections on arterial inflow and venous outflow. Complication grading is addressed, as is patency assessment. Nowhere is standardization more needed than for the definitions of patency in the surgical access literature. Authors have variably combined primary and secondary patency and have used varying points of reference, such that comparing the radiologic literature on access to the surgical literature, or, for that matter, even comparing papers in the surgical literature between each other has been difficult or impossible. One of the biggest difficulties has been separating the concept of access patency from the time of surgical creation from the concept of patency after an intervention (percutaneous or surgical) to treat a failing or failed access. With this document, the surgical and radiology literature will fall very much in line in terms of definitions of patency. The concept of “post-intervention patency,” used in the SCVIR document, has been carried over to the SVS document. A rigorous definition of functionality of the access is included, which distinguishes a patent access that is useful for dialysis from one that has blood flow but cannot be used for dialysis satisfactorily. The concept of intention to treat is also addressed. Definitions of primary assisted and secondary patency are provided for the access itself (ie, after access creation), separate from definitions of post-intervention patency. The document is slightly unclear as to the definition of post-intervention assisted primary patency in permanent access. It states that patency for a particular intervention ends if a different method is used to maintain patency. The example used is angioplasty failure with surgical revision. However, it is not entirely clear whether this is meant to apply to different endovascular interventions. For example, if one switches from angioplasty to atherectomy or to a stent, should assisted primary patency end? If the intent of the study is to evaluate balloon angioplasty, the answer is probably yes, as one is escalating to a more aggressive and more expensive technology. If the intent is to evaluate an algorithm of endovascular therapies or a combination of endovascular and surgical therapies, then post-intervention assisted patency would continue. As long as the intent of each study is clearly stated, the definitions probably apply equally well to endovascular interventions, changes from From the Department of Radiology (S.O.T.), University of Pennsylvania Medical Center, Philadelphia; Department of Radiology (D.S.), Reading Hospital & Medical Center, Reading, Pennsylvania; Department of Radiology (R.J.G.), Washington Hospital Center, Washington, DC; Department of Radiology (L.G.M.), Emory University Hospital, Atlanta, Georgia. Address correspondence to S.O.T., Department of Radiology, Hospital of the University of Pennsylvania, One Silverstein, 3400 Spruce Street, Philadelphia, PA 19104; E-mail: streroto@uphs.upenn.edu