Trial Outcomes & Findings for Graft-first Versus Fistula-first in Older Patients With End-stage Kidney Disease (NCT NCT03545113)

NCT ID: NCT03545113

Last Updated: 2022-11-21

Results Overview

Proportion of screened participants deemed eligible for randomization.

Recruitment status

COMPLETED

Study phase

NA

Target enrollment

44 participants

Primary outcome timeframe

12 months

Results posted on

2022-11-21

Participant Flow

Participant milestones

Participant milestones
Measure
Upper Extremity Arteriovenous Graft (AVG) - First
Participants randomized to receive an AVG will undergo surgery to have an AVG placed. Upper arm arteriovenous graft surgery: Creation of arteriovenous graft vascular access for hemodialysis
Upper Extremity Arteriovenous Fistula (AVF) - First
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Overall Study
STARTED
23
21
Overall Study
COMPLETED
18
21
Overall Study
NOT COMPLETED
5
0

Reasons for withdrawal

Reasons for withdrawal
Measure
Upper Extremity Arteriovenous Graft (AVG) - First
Participants randomized to receive an AVG will undergo surgery to have an AVG placed. Upper arm arteriovenous graft surgery: Creation of arteriovenous graft vascular access for hemodialysis
Upper Extremity Arteriovenous Fistula (AVF) - First
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Overall Study
Surgery Cancelled
1
0
Overall Study
Death
1
0
Overall Study
Adverse Event
2
0
Overall Study
Received different surgery
1
0

Baseline Characteristics

Graft-first Versus Fistula-first in Older Patients With End-stage Kidney Disease

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure
Upper Extremity Arteriovenous Graft (AVG) - First
n=23 Participants
Participants randomized to receive an AVG will undergo surgery to have an AVG placed. Upper arm arteriovenous graft surgery: Creation of arteriovenous graft vascular access for hemodialysis
Upper Extremity Arteriovenous Fistula (AVF) - First
n=21 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Total
n=44 Participants
Total of all reporting groups
Age, Continuous
72.8 years
n=5 Participants
78.9 years
n=7 Participants
76.3 years
n=5 Participants
Sex: Female, Male
Female
11 Participants
n=5 Participants
6 Participants
n=7 Participants
17 Participants
n=5 Participants
Sex: Female, Male
Male
12 Participants
n=5 Participants
15 Participants
n=7 Participants
27 Participants
n=5 Participants
Race (NIH/OMB)
American Indian or Alaska Native
0 Participants
n=5 Participants
0 Participants
n=7 Participants
0 Participants
n=5 Participants
Race (NIH/OMB)
Asian
0 Participants
n=5 Participants
0 Participants
n=7 Participants
0 Participants
n=5 Participants
Race (NIH/OMB)
Native Hawaiian or Other Pacific Islander
0 Participants
n=5 Participants
0 Participants
n=7 Participants
0 Participants
n=5 Participants
Race (NIH/OMB)
Black or African American
7 Participants
n=5 Participants
7 Participants
n=7 Participants
14 Participants
n=5 Participants
Race (NIH/OMB)
White
16 Participants
n=5 Participants
14 Participants
n=7 Participants
30 Participants
n=5 Participants
Race (NIH/OMB)
More than one race
0 Participants
n=5 Participants
0 Participants
n=7 Participants
0 Participants
n=5 Participants
Race (NIH/OMB)
Unknown or Not Reported
0 Participants
n=5 Participants
0 Participants
n=7 Participants
0 Participants
n=5 Participants

PRIMARY outcome

Timeframe: 12 months

Proportion of screened participants deemed eligible for randomization.

Outcome measures

Outcome measures
Measure
Total Group
n=77 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Feasibility- Eligibility for Randomization
54 Participants

PRIMARY outcome

Timeframe: 12 months

Proportion of eligible participants who consent to randomization.

Outcome measures

Outcome measures
Measure
Total Group
n=54 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Feasibility- Consent to Randomization
44 Participants

PRIMARY outcome

Timeframe: Day 90

Proportion of participants who undergo AV graft or fistula placement within 90 days of randomization.

Outcome measures

Outcome measures
Measure
Total Group
n=23 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=21 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Feasibility- AV Graft or Fistula Placement
18 Participants
21 Participants

SECONDARY outcome

Timeframe: 3 and 6 months

Population: Subject could not move hand from past stroke; Subject had joint pain; not completed due to distance

The grip-strength test will be performed twice on each hand for each assessment and the mean of the two results will be used for statistical analyses; a cut-off point \<16 kg in women and \<26 kg in men will define muscle weakness. Changes in grip strength will be compared between the two access interventions. Assessed with upper arm grip-strength test in each arm using a hand-held dynamometer.

Outcome measures

Outcome measures
Measure
Total Group
n=13 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=16 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Upper Extremity Strength
3 Months
21.3 kilograms
Standard Deviation 5.6
22.6 kilograms
Standard Deviation 6.4
Upper Extremity Strength
6 Months
19.1 kilograms
Standard Deviation 6.7
20.4 kilograms
Standard Deviation 7.2
Upper Extremity Strength
Baseline
19.6 kilograms
Standard Deviation 3.3
17.4 kilograms
Standard Deviation 3.5

SECONDARY outcome

Timeframe: 3 and 6 months

Population: Number differ form total number of randomized, 1 participant expired, not all questionnaires collected

Vascular access questionnaire will be used to assess differences in patient satisfaction with vascular access between the two access interventions using the short-form vascular access questionnaire (SF-VAQ). Mean scores obtained on SF-VAQ will be compared. SF-VAQ score range 4 -20 with higher scores indicating more satisfaction with the vascular access.

Outcome measures

Outcome measures
Measure
Total Group
n=16 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=19 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Patient Satisfaction With Vascular Access
3 months
9.75 score on a scale
Standard Deviation 3.45
8.82 score on a scale
Standard Deviation 1.53
Patient Satisfaction With Vascular Access
6 Months
7.55 score on a scale
Standard Deviation 2.74
8.75 score on a scale
Standard Deviation 1.16
Patient Satisfaction With Vascular Access
week 2
10.1 score on a scale
Standard Deviation 3.18
9.21 score on a scale
Standard Deviation 2.39

SECONDARY outcome

Timeframe: Baseline and 6 months

Population: Patients declined survey

The level of independence will be evaluated using ADLs. ADL score range 0-30, with higher scores denoting more dependence on other people to perform the usual daily activities.

Outcome measures

Outcome measures
Measure
Total Group
n=17 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=17 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Performance on Activities of Daily Living (ADLs)
Baseline
4.5 score on a scale
Standard Deviation 1.6
4.75 score on a scale
Standard Deviation 1.28
Performance on Activities of Daily Living (ADLs)
Month 6
4.2 score on a scale
Standard Deviation 1.82
5.11 score on a scale
Standard Deviation 1.16

SECONDARY outcome

Timeframe: Baseline, 3 and 6 months

Population: Patients declined survey

The level of independence will be evaluated using IADLs instruments. ADL score range 0-31, with higher scores denoting more dependence on other people.

Outcome measures

Outcome measures
Measure
Total Group
n=14 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=17 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Performance on Activities of Instrumental Daily Living ADLs (IADLs)
Baseline
5.28 score on a scale
Standard Deviation 2.49
4.5 score on a scale
Standard Deviation 1.45
Performance on Activities of Instrumental Daily Living ADLs (IADLs)
Month 6
4.4 score on a scale
Standard Deviation 2.65
6.42 score on a scale
Standard Deviation 2.64

SECONDARY outcome

Timeframe: 3 and 6 months

Depression scores assessed with the patient health questionnaire (PHQ-9) will be compared between the two vascular access arms. PHQ-9 score range 0-27. Depression Severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe.

Outcome measures

Outcome data not reported

SECONDARY outcome

Timeframe: Baseline, Month 3, and Month 6

The impact of the two types of vascular access on HRQoL will be assessed using the Kidney Disease Quality of Life Short Form (KDQOL-SF) version 1.3. which consists of a generic core (Short Form-36 \[SF-36\]) and an 11-item kidney disease-specific scale. Score range 0 to 100, with higher scores reflecting better quality of life.

Outcome measures

Outcome measures
Measure
Total Group
n=15 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=19 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Health-related Quality of Life (HRQoL) - Mental Health (MCS-12) Scores
Month 3
54.38 score on a scale
Standard Deviation 13.26
46.27 score on a scale
Standard Deviation 5.66
Health-related Quality of Life (HRQoL) - Mental Health (MCS-12) Scores
Month 6
53.79 score on a scale
Standard Deviation 17.31
58.2 score on a scale
Standard Deviation 5.91
Health-related Quality of Life (HRQoL) - Mental Health (MCS-12) Scores
Baseline
53.38 score on a scale
Standard Deviation 8.05
51.46 score on a scale
Standard Deviation 11.37

SECONDARY outcome

Timeframe: 3 and 6 months

The impact of the two types of vascular access on HRQoL will be assessed using the Kidney Disease Quality of Life Short Form (KDQOL-SF) version 1.3. which consists of a generic core (Short Form-36 \[SF-36\]) and an 11-item kidney disease-specific scale. Score range 0 to 100, with higher scores reflecting better quality of life.

Outcome measures

Outcome measures
Measure
Total Group
n=15 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=19 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Health-related Quality of Life (HRQoL) - Physical Health (PCS-12) Scores
Month 3
39.02 score on a scale
Standard Deviation 8.45
39.44 score on a scale
Standard Deviation 5.23
Health-related Quality of Life (HRQoL) - Physical Health (PCS-12) Scores
Month 6
40.77 score on a scale
Standard Deviation 7.73
36.12 score on a scale
Standard Deviation 5.55
Health-related Quality of Life (HRQoL) - Physical Health (PCS-12) Scores
Baseline
29.89 score on a scale
Standard Deviation 12.09
36.75 score on a scale
Standard Deviation 10.7

SECONDARY outcome

Timeframe: 3 and 6 months

The Rapid Assessment of Physical Activity (RAPA) instrument will be used to assess habitual physical activity. RAPA test score ≤ 3 corresponded to a sedentary lifestyle or a very light activity level; values ≥4 indicated a moderate to vigorous active lifestyle.

Outcome measures

Outcome data not reported

SECONDARY outcome

Timeframe: Baseline, month 3 and 6

Population: Assessment was added on 2.4.2019 - Subjects could not walk un-assisted

The 4MGS test is a simple screening test and a useful predictor of worsening daily activity in patients with chronic respiratory diseases.

Outcome measures

Outcome measures
Measure
Total Group
n=5 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=10 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Physical Activity Level 4-meter Gait
Baseline
7.5 meters per second
Standard Deviation 3.04
5.1 meters per second
Standard Deviation 1.61
Physical Activity Level 4-meter Gait
Month 3
6.88 meters per second
Standard Deviation 2.23
6.04 meters per second
Standard Deviation 2.36
Physical Activity Level 4-meter Gait
Month 6
5.74 meters per second
Standard Deviation 1.15
6.34 meters per second
Standard Deviation 2.45

SECONDARY outcome

Timeframe: Baseline, 3 and 6 months

Population: Patient expired, some participants also declined (at times) answering questions, and some visits were not performed due to travel distance

This will be determined by using the Verbal Descriptor Scale (VDS). The Verbal Descriptor Scale (VDS) is comprised of a series of descriptive phrases that refer to different levels of pain severity or intensity. Patients select the phrase that best describes their current pain - The verbal descriptor scale asks the patient to describe her or his pain using the following descriptors: "no pain," "mild pain," "moderate pain," "severe pain," or "pain as bad as it could be."

Outcome measures

Outcome measures
Measure
Total Group
n=17 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=19 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Number of Subjects With No Pain at the AV Access Site
Baseline
6 Participants
13 Participants
Number of Subjects With No Pain at the AV Access Site
Month 3
4 Participants
10 Participants
Number of Subjects With No Pain at the AV Access Site
Month 6
7 Participants
7 Participants

SECONDARY outcome

Timeframe: Baseline, Month 3 and Month 6

Population: Patient expired, some participants also declined (at times) answering questions, and some visits were not performed due to travel distance

This will be determined by using the Verbal Descriptor Scale (VDS). The Verbal Descriptor Scale (VDS) is comprised of a series of descriptive phrases that refer to different levels of pain severity or intensity. Patients select the phrase that best describes their current pain - The verbal descriptor scale asks the patient to describe her or his pain using the following descriptors: "no pain," "mild pain," "moderate pain," "severe pain," or "pain as bad as it could be."

Outcome measures

Outcome measures
Measure
Total Group
n=17 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=19 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Number of Subjects With Mild Pain at the AV Access Site
Baseline
6 Participants
1 Participants
Number of Subjects With Mild Pain at the AV Access Site
Month 3
2 Participants
1 Participants
Number of Subjects With Mild Pain at the AV Access Site
Month 6
0 Participants
0 Participants

SECONDARY outcome

Timeframe: Baseline, Month 3 and Month 6

Population: Patient expired, some participants also declined (at times) answering questions, and some visits were not performed due to travel distance

This will be determined by using the Verbal Descriptor Scale (VDS). The Verbal Descriptor Scale (VDS) is comprised of a series of descriptive phrases that refer to different levels of pain severity or intensity. Patients select the phrase that best describes their current pain - The verbal descriptor scale asks the patient to describe her or his pain using the following descriptors: "no pain," "mild pain," "moderate pain," "severe pain," or "pain as bad as it could be."

Outcome measures

Outcome measures
Measure
Total Group
n=17 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=19 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Number of Subject With Moderate Pain at the AV Access Site
Baseline
3 Participants
5 Participants
Number of Subject With Moderate Pain at the AV Access Site
Month 3
2 Participants
0 Participants
Number of Subject With Moderate Pain at the AV Access Site
Month 6
2 Participants
1 Participants

SECONDARY outcome

Timeframe: Baseline, Month 3 and Month 6

Population: Patient expired, some participants also declined (at times) answering questions, and some visits were not performed due to travel distance

This will be determined by using the Verbal Descriptor Scale (VDS). The Verbal Descriptor Scale (VDS) is comprised of a series of descriptive phrases that refer to different levels of pain severity or intensity. Patients select the phrase that best describes their current pain - The verbal descriptor scale asks the patient to describe her or his pain using the following descriptors: "no pain," "mild pain," "moderate pain," "severe pain," or "pain as bad as it could be."

Outcome measures

Outcome measures
Measure
Total Group
n=17 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=19 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Number of Subjects With Severe Pain at the AV Access Site
Baseline
2 Participants
0 Participants
Number of Subjects With Severe Pain at the AV Access Site
Month 3
0 Participants
0 Participants
Number of Subjects With Severe Pain at the AV Access Site
Month 6
0 Participants
1 Participants

OTHER_PRE_SPECIFIED outcome

Timeframe: 6 months

Rate of AV access primary failure between the two AV access strategies. Primary access failure is defined as permanent failure of the fistula or graft before hemodialysis suitability. This will include inadequate maturation, thrombosis, failure of first and subsequent cannulations, and/or other complications leading to nonfunctional fistula or graft.

Outcome measures

Outcome measures
Measure
Total Group
n=13 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=16 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
AV Access Primary Failure
4 Participants
5 Participants

OTHER_PRE_SPECIFIED outcome

Timeframe: 12 months

Incidence rate of AV access infection between the two AV access strategies. This will include fistula or graft cellulitis, abscess, and/or bacteremia due to AV access infection.

Outcome measures

Outcome measures
Measure
Total Group
n=13 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=16 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
AV Access Infection
3 Participants
2 Participants

OTHER_PRE_SPECIFIED outcome

Timeframe: 6 months

Will compare the proportion of patients with successful AV access cannulation between the two AV access strategies. Successful cannulation is defined by the use of the AV access as the primary vascular access for hemodialysis (the fistula or graft access has been cannulated with two 16- or 15-gauge needles for ≥3 consecutive dialysis sessions and the dialysis central venous catheter was removed).

Outcome measures

Outcome measures
Measure
Total Group
n=13 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=16 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
AV Access Successful Cannulation
8 Participants
8 Participants

OTHER_PRE_SPECIFIED outcome

Timeframe: 12 months

Rate of AV access secondary failure between the two AV access strategies. Secondary access failure is defined by permanent AV access failure after the fistula or graft met dialysis suitability criteria with subsequent abandonment.

Outcome measures

Outcome measures
Measure
Total Group
n=18 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=21 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
AV Access Secondary Failure
5 Participants
8 Participants

OTHER_PRE_SPECIFIED outcome

Timeframe: 12 months

Number of AV access procedures per 100 patient-days between the two AV access strategies. This will include angioplasty, thrombectomy, stent placement, repeat surgery, and/or surgical superficialization.

Outcome measures

Outcome measures
Measure
Total Group
n=13 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=16 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
AV Access Procedures - Number of Surgical Re-intervention on Index AV Access Procedures
3 procedures per 100 patient-days
4 procedures per 100 patient-days

OTHER_PRE_SPECIFIED outcome

Timeframe: 12 months

Number of AV access procedures per 100 patient-days between the two AV access strategies. This will include angioplasty, thrombectomy, stent placement, repeat surgery, and/or surgical superficialization.

Outcome measures

Outcome measures
Measure
Total Group
n=13 Participants
Group includes all Participants that signed Consent
Upper Extremity Arteriovenous Fistula (AVF) - First
n=16 Participants
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
AV Access Procedures - Number of Endovascular Interventions on Index AV Procedures Access
5 procedures per 100 patient-days
7 procedures per 100 patient-days

Adverse Events

Upper Extremity Arteriovenous Graft (AVG) - First

Serious events: 0 serious events
Other events: 1 other events
Deaths: 3 deaths

Upper Extremity Arteriovenous Fistula (AVF) - First

Serious events: 0 serious events
Other events: 0 other events
Deaths: 2 deaths

Serious adverse events

Adverse event data not reported

Other adverse events

Other adverse events
Measure
Upper Extremity Arteriovenous Graft (AVG) - First
n=23 participants at risk
Participants randomized to receive an AVG will undergo surgery to have an AVG placed. Upper arm arteriovenous graft surgery: Creation of arteriovenous graft vascular access for hemodialysis
Upper Extremity Arteriovenous Fistula (AVF) - First
n=21 participants at risk
Participants randomized to receive an AVF will undergo surgery to have an AVF created. Upper arm arteriovenous fistula surgery: Creation of arteriovenous fistula vascular access for hemodialysis
Infections and infestations
catheter-related infection
4.3%
1/23 • Number of events 1 • 12 months
0.00%
0/21 • 12 months

Additional Information

Mariana Murea, MD

Wake Forest University Health Sciences

Phone: 336-716-5777

Results disclosure agreements

  • Principal investigator is a sponsor employee
  • Publication restrictions are in place