The Changing Face of Dialysis Access
Stephen L Hill, Ryan D Evans
Physicians Care of Virginia, Roanoke, VA
INTRODUCTION: The increased demand for autogenous fistulae has necessitated many changes in the surgery of dialysis access. In order to respond to this demand, additional locations of autogenous dialysis access, as well as the increased utilization of smaller veins becomes a necessity. The Cimino fistula must be supplemented with other forms of autogenous dialysis access which are more surgically demanding and complex.
METHODS: A retrospective analysis of one vascular surgeon’s practice over a twenty year period was performed. The number of patients, procedures, and types of dialysis access, was evaluated as well as the changes in the use of the vascular lab and the use of tunneled dialysis catheters.
RESULTS: There were a total of 2,554 procedures performed on 1,202 patients. A total of 163 Cimino, 259 brachial cephalic, 33 forearm transposition of the cephalic veins, 65 brachial/basilic transpositions and 215 primary prosthetic arteriovenous grafts were performed. Most of the primary prosthetic grafts (63%) were placed in the first ten years of the study. In the last ten years of the study the use of prosthetic grafts was relegated to the repair of both older prosthetic grafts and autogenous fistulae. In addition, it was used in individuals who had poor veins and/or had failed autogenous dialysis access. In the first period 73% of the dialysis accesses constructed used a prosthetic whereas in the last ten years studied, 86% of the dialysis access procedures used only autogenous tissue. The Cimino fistula was always the first choice but only represented 31.5% of all the autogenous fistulae constructed; brachialcephalic was the second choice and represented 50%; the third choice was transposition of the forearm cephalic vein and was 6.4% of the total. The transposition of the brachial/basilic vein was last autogenous choice due to complexity and represented 12.5% of the total autogenous fistulae constructed. A prosthetic graft was always the last choice but in the last five years of the study a more concerted effort was made by the vascular lab to find suitable veins. It was able to locate adequate cephalic forearm veins for transposition, as well as brachial veins in the upper arm - neither of which had been used in previous years. Furthermore, cephalic and brachial veins as small as 2.0 mm were used as opposed to the usually recommended 3.0 mm or greater vein size. In the last ten years of the study the increased production of autogenous fistula was accompanied by a dramatic six fold increase in the use of tunneled dialysis catheters.
CONCLUSIONS: The demand for construction of autogenous fistula has decreased the need for prosthetic grafts but required innovative techniques to develop new locations for autogenous fistulae. This has also required a more proactive role for the vascular laboratory seeking out smaller, but adequate veins, and new locations for autogenous fistulae. An unintended consequence has been the placement of more tunneled dialysis catheters for longer periods to provide dialysis while the fistulae are maturing, being revised, or being constructed.
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