“Early cannulation grafts” (ECGs) can be used for dialysis within hours to days after implantation. Compared with the nearly one month of waiting that a conventional graft requires, this markedly shortens the time and effectively reduces or avoids the duration of central venous catheter (CVC) use (dialysis through a tube in the neck). However, in pursuing immediacy, early cannulation grafts also face challenges in “long-term stability.”
Auntie Lin’s concern
Let us look at a real case recently encountered clinically by the Hemodialysis Access Care Team: Auntie Lin.
Because her own vessels were in poor condition, Auntie Lin underwent surgery with Acuseal, a new type of early cannulation graft. She said happily: “Wonderful! At last I can get rid of the tube in my neck!”
The first few months of dialysis went quite smoothly, but the good times did not last. Within half a year of use, this new graft began to “clog” repeatedly. A session would go well, and then a few days later it would suddenly block again; each time it blocked, she had to go to hospital for a procedure to remove the clot and widen the graft with a balloon, which left Auntie Lin very troubled and exhausted.
Auntie Lin was puzzled: “This is the newest product. How can it be so unstable?”
The dialysis unit’s medical team was also puzzled that a newly created graft kept having problems. After a detailed examination, the root cause was finally identified: the inner layer of the graft had undergone “delamination / dissection.”
Further imaging showed severe “delamination / dissection” of the inner wall of the graft. This kind of structural damage easily leads to clot formation. Auntie Lin’s case highlights the challenge of “long-term stability” that early cannulation grafts must face while pursuing “immediacy.”
Ultrasound: the blocked Acuseal graft shows inner-layer delamination. Left: longitudinal view. Right: transverse view.
Ultrasound: after the graft was reopened, the inner-layer delamination of the Acuseal graft had improved. Left: longitudinal view. Right: transverse view.
Case reports published in overseas academic journals have found the same situation.
Image source: AVG delamination: a cause of early cannulation arteriovenous graft dysfunction in hemodialysis patients. (Annals of Medicine 2024, Vol. 56, no. 1, 2424444)
Examining the evidence: comparing two early cannulation grafts, Flixene and Acuseal
Two “early cannulation grafts” are currently available in Taiwan: the Flixene, reimbursed by national health insurance, and the Acuseal, which is self-paid. Both use a three-layer graft design, and the main difference lies in the material of the innermost layer.
A study from Taiwan published in August this year in the US Journal of Vascular Surgery carried out a retrospective analysis of how the two early cannulation grafts perform in real-world use.
Data source: PubMed
In Taiwan, both Flixene and Acuseal have been approved by the Food and Drug Administration. In the past, however, there were not enough data to compare their real-world differences: for example, which is more prone to complications, which stays patent longer, and how many interventional procedures are needed to keep the access usable.
The research team reviewed data on patients who underwent surgery at their center between August 2021 and September 2023. In total, 82 patients received a Flixene graft and 70 patients received an Acuseal graft. The team compared in detail the early complications, the time to first cannulation for dialysis, the proportion and duration of CVC use, and graft patency at different time points between the two groups.
| Measure (study result) | Flixene Graft | Acuseal Graft | Main difference in conclusions |
| Time to first cannulation | 17.5 days | 17.3 days | No significant difference (P = .67) |
| Early puncture-site bleeding | 0% | 10% | Bleeding rate significantly higher with Acuseal (P < .001) |
| Graft delamination | Low incidence | High incidence | Delamination was a serious problem with Acuseal (P < .001) |
| Secondary patency (SP) | Better | Significantly worse | Flixene’s long-term lifespan was more stable (P < .001) |
| Main cause of worsening SP | – | Severe recurrent stenosis and delamination | Acuseal faces serious structural challenges |
| Study summary | Performed better than Acuseal | Did not show superior hemostasis or patency | Acuseal showed no advantage |
The study concluded that the Acuseal graft was not better than Flixene in hemostasis or patency. In particular, graft delamination and severe recurrent stenosis posed a major challenge to the long-term use of Acuseal. The article also noted that experience with Acuseal in Taiwan is still limited, that it is not yet reimbursed by national health insurance, and that staff proficiency in handling it may still need to improve; any of these factors could potentially affect Acuseal’s performance.
Reflections on Early-Cannulation Grafts
Early cannulation grafts give dialysis patients another option. When choosing, patients and care teams should consider not only the immediate convenience after implantation but also the graft’s structural stability (for example, the risk of delamination) and its patency. At present, Flixene appears to have more solid clinical evidence for long-term stability.
