Prospective study of dialysis fistulas: Problem patients and their treatment

Abstract

With an increasing number of patients on maintenance haemodialysis treatment, providing satisfactory, long-lasting vascular access becomes critically important. There are a large number of reports of the relative success rates of various forms of vascular access, but there is general agreement that the Brescia-Cimino wrist fistula ( I ) is the most satisfactory. For the patient whose wrist fistula has failed, the surgeon has a choice of reconstructing the fistula when possible, constructing another fistula in the contralateral wrist, a brachial fistula (2) or inserting a graft of biological or synthetic origin. Grafts can be autologous (3) or allogeneic vein (4), umbilical vein ( 5 ) , bovine carotid artery (6) or synthetics such as polytetrafluoroethylene (PTFE) (7) and Dacron (8). Experience has shown that long term results are poor for vein loops (9, 10) and bovine heterografts ( 1 I), although with aggressive treatment of the frequent complications of bovine grafts, it is possible to achieve a 2-year patency rate of 77 per cent (12). Umbilical vein is relatively untried, though a I-year patency rate of 50 per cent has been reported (13). Patency rates for PTFE vary from 62 per cent at I year (14) to 83 per cent (15). Reports of long term patency for PTFE are harder to find; a 2-year patency rate of 76 per cent has been reported (10) and a 3-year patency rate of 63 per cent (10).The difficulty in drawing any conclusions from these studies is that the selection criteria are unknown-grafts have a greater patency rate if inserted as a primary procedure rather than in patients whose access sites are nearing exhaustion. The first aim of the present study was to examine the need for more complex procedures than simple arteriovenous fistulas in a population without previous surgery. Thus, all patients undergoing firsttime fistula operations have been studied, rather than all fistulas, regardless of whether they were first, second or subsequent procedures. The second aim of the study was to attempt to correlate fistula failure with possible aetiological factors, in the hope of predicting those likely to have subsequent thrombotic problems. Patients and methodsBetween January 1976 and May 1981 157 consecutive patients in chronic renal failure requiring access procedures were accepted on to the dialysis programme. Six patients were excluded from analysis because of previous fistula operations elsewhere. One hundred and forty-eight patients had a first-time wrist fistula constructed, 2 patients had an exploration of the wrist revealing no suitable vessels and 1 patient had a primary brachial fistula due to bilateral cephalic cutdowns in the past. Five patients with functioning fistulas were excluded due to inadequate data; 3 were transferred to other units and 2 died. Using actuarial analysis (16). fistula patency curves were calculated for the remaining 145 patients undergoing an attempt at a first-time wrist fistula. This included the two patients undergoing an exploration of the wrist to avoid biasing the results favo...

Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months

“…It has been suggested that differences in vessel diameter may account for the increased access-related morbidity experienced by women (1). Consistent with this notion, it was found that arterial size was a significant predictor of subsequent AVF survival (17), although gender was not (18), and that vessel size predicted fistula failure in the first 3 months after surgery (24). Our study did not have data on baseline vessel diameter or size.…”

“…Smoking history has been examined in a few studies of vascular access morbidity with inconsistent results (15,18,19). Previous peripheral vascular damage in former and active smokers may lead to acute access thrombosis, which may partially explain the inconsistency in results.…”

Comorbidities Do not Influence Primary Fistula Success in Incident Hemodialysis Patients

“…In addition to previous reports, Feldman and colleagues (13,21) demonstrated that vessels Ͼ3 mm in diameter are associated with higher rates of primary fistula success. Although Feldman et al reported that a history of cerebrovascular disease and cardiovascular disease, increasing age, and dependence on dialysis at the time of fistula creation predicted primary fistula success, it should be noted that whether to attempt an AVF in the study by Feldman et al was not based on vessel size measurement (as it was in our study for surgeons who used approach 1).…”

Cumulative Patency of Contemporary Fistulas versus Grafts (2000–2010)

“…Once functional, fistulas exhibit greater longevity than grafts, but because new fistulas have a higher primary failure rate than grafts, excluding failed attempts will inflate estimates of cumulative patency for fistulas (6)(7)(8). Thirty years ago, the primary failure rate for fistulas was relatively low, around 10% (8)(9)(10)(11); however, as fistula creation increased after the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendations (12)(13)(14)(15)(16), so have their primary failure rates, which are now as high as 30%260% (16)(17)(18)(19)(20). Primary access failure has numerous attendant consequences: It may delay dialysis initiation, increase catheter dependence, restrict the number of anatomic sites for subsequent accesses, and require additional interventions to salvage the failing access and attempt a new one; all of these put patients at risk of poor health outcomes and increase health care costs (21)(22)(23).…”