Invited commentary

Abstract

In this series of patients receiving an initial, autogenous arteriovenous fistula (AVF), the reported primary patency at 1 year (36%) is low relative to other series. The authors attribute this to an aggressive approach to the placement of autogenous fistulas. In concluding, they note that adherence to the Kidney Disease Outcomes Quality Initiative (K/DOQI) strategy may not result in increased AVF utilization and may prolong catheter dependence. While the manuscript describes their experience after publication of the K/DOQI guidelines, not all elements of the guidelines were followed. For the placement of an AVF to occur in a timely manner: (1) patients must have access to the healthcare system; (2) chronic kidney disease must be recognized by primary providers; (3) patients must be referred to nephrologists for pre-dialysis care; and (4) nephrologists must make timely referral for hemodialysis access assessment and placement. For the patients in this series, there was a breakdown in one or more of these elements, as 78% of those referred for placement of first time vascular access were already dialyzing via central venous catheters. Once surgical referral occurs, K/DOQI emphasizes the importance of preoperative vein mapping, arterial assessment, and the preferred order of access placement to optimize the chance of maturing a functional fistula. Based on current literature and K/DOQI guidelines, arteries should be at least 2 mm and veins at least 2.5 mm, in diameter.1National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines and Clinical Practice Recommendations.http://www.kidney.org/PROFESSIONALS/kdoqi/guideline_upHD_PD_VA/va_guide1.htmGoogle Scholar, 2Silva Jr, M.B. Hobson 2nd, R.W. Pappas P.J. Jamil Z. Araki C.T. Goldberg M.C. et al.A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation.J Vasc Surg. 1998; 27 (discussion 307-8): 302-307Abstract Full Text Full Text PDF PubMed Scopus (479) Google Scholar The order of preferred AVF placement is radiocephalic > brachiocephalic > brachiobasilic > arteriovenous grafts.1National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines and Clinical Practice Recommendations.http://www.kidney.org/PROFESSIONALS/kdoqi/guideline_upHD_PD_VA/va_guide1.htmGoogle Scholar The authors are to be commended for a critical review of their experience, which highlights opportunities for change that may ultimately impact long-term functional patency. The study indicates that there is, perhaps, a role for a unified approach to dialysis access. It is possible that patency may have been adversely impacted by the disparate approach of the 15 surgeons in this group and their lack of adherence to K/DOQI guidelines. Some of the surgeons proceeded directly to use of a prosthetic graft when patients were not candidates for radiocephalic or brachiocephalic fistulas, instead of attempting a brachiobasilic fistula. Only 76% of patients in this study underwent preoperative mapping. Despite mapping, veins with diameters as small as 1.3 mm were used for fistulas. Even after access had been placed, times to cannulation seem prolonged. While we have a limited understanding of why fistulas fail, we do know that fistulas are more likely to fail when minimum requirements are not met. A standardized approach is crucial not only for clinical outcomes, but for our ability to study access outcomes. The goal is not to simply place an AVF, but to place an access that can be utilized for hemodialysis. The natural history of autologous fistulas as first-time dialysis access in the KDOQI eraJournal of Vascular SurgeryVol. 47Issue 2PreviewPatients on hemodialysis depend on durable, easily maintained vascular access. The autologous arteriovenous fistula (AVF) has been the gold standard since the introduction of the Brecia-Cimino fistula in 1966 and is echoed in the current Kidney Disease Outcomes and Quality Initiative (KDOQI) guidelines. The purpose of this study is to determine the natural history of AVF in patients requiring first-time permanent access in a large academic vascular surgery practice. Full-Text PDF Open Archive