The Arteriovenous Fistula

Abstract

The ground-breaking article by Brescia and Cimino in 1966 (1) revolutionized the creation of the vascular access, and the Cimino fistula was soon used in almost all dialysis patients. Unfortunately, subsequent wide-spread use of PTFE grafts instead of AV fistulae occurred because of the ease of the surgical technique, the immediate availability of the graft for puncture, the need of high blood flow for high-efficiency, short-duration hemodialysis sessions, and because of financial disincentives against the AV fistula. PTFE grafts currently account for 80% of primary vascular accesses created in the United States (2,3), but they are less frequently used in other countries. It has been increasingly recognized that outcomes of PTFE grafts are poorer. In the DOQI guidelines (4), this has led to the recommendation that AV fistulae should be the first option; however, this advice has not been followed uniformly. One impediment may be the astonishingly high rate of primary failures of AV fistulae, up to 50% in some centers (4). The DOPPS study (Figure 1) documented substantial differences between survival of PTFE grafts and AV fistulae and differences of survival of AV fistulae between the United States and other countries (3). On the basis of our experience, we are of the opinion that primary failure rates can be substantially improved by attention to small but important details of surgical technique. The DOQI guidelines state that AV fistulae are feasible only in 50% of the patients, but we (5) and others (6) found that construction of native AV fistulae is feasible in up to 90%.It is the purpose of this article (a) to provide some insights into the fascinating cellular biology and pathophysiology underlying the vascular adaptation to the creation of an AV fistula and (b) to describe some small, often neglected, but important technical details that determine the success of the procedure. It is the intention to improve results and to influence patterns of practice.

Non-Imaging Acoustical Properties in Monitoring Arteriovenous Hemodialysis Access. A Review

“…[11], Kumbar, et al [30], Nishitani & Inada [31], and Allon & Robbin [34] also confirmed that blood flow is highly correlated with stenosis and thrombosis issues [12,13,20,28] that alter the frequency spectral characteristics.…”

“…Most of the studies demonstrated that significant changes in vascular diameter affect the blood flow-rate [28,29] and change the sound characteristics, which can be identified as higher pitch (frequency) and higher intensity (amplitude) [12,19], and also increase venous pressure [28,30]. A few experimental studies presented different sensor positions or locations for auscultation of the fistula area (arterial and venous side), and showed a limited effect on the sound characteristics.…”

“…In more severe cases, the occlusion that develops has a very low sound and sometimes no sound is produced at all because no or very little blood is flowing [20,28]. Statistical analysis showed that certain parameters correlate well with PDC (R = 0.98, p < 0.001).…”

Vascular Access for Hemodialysis

“…Regular hemodialysis treatments were possible in 1950s through the use of a medical apparatus (Kolff 's twin-coil kidney [14] ), thus projecting the problem of a reliable, capable of repeated use vascular access. Nowadays, the artery-side-to-vein-end-anastomosis has become a standard procedure [15]. In 1952, Aubaniac had described the puncture of the subclavian vein [16].…”

“…After anastomosis was performed, the radial artery was ligated distal to the anastomosis, thus resulting in a functional end-to end-anastomosis. Today, the artery-side-to-vein-endanastomosis has become a standard procedure [15]. In 1970, Girardet R. [26] and Brittinger W.D.…”