Primary vascular access in diabetic patients: an audit.

Abstract

The increasing proportion of diabetic patients in the haemodialysis population, mainly elderly patients with diabetes mellitus type 2, is a challenge to nephrologists and vascular surgeons. The aim of this study was to assess different strategies in an effort to improve the commonly disappointing results of arteriovenous (a-v) fistula surgery in this group of patients. Besides the availability of a suitable vein, special attention was paid to the quality of the artery, based on clinical and recently available ultrasonographic parameters. In the case of peripheral arterial narrowing and/or calcification, the elbow region was the preferred location for creation of the first a-v fistula, taking into consideration the reduced life expectancy of the majority of diabetic patients. Furthermore, a clinical surveillance programme was established to treat the failing, not the failed fistula. To this end, elective revisions were performed prior to the onset of thrombosis to correct stenoses, aneurysms, and other signs of fistula dysfunction. Absolute priority was given to the use of native vessels. During the period January 1993 to December 1995, 347 primary Brescia-Cimino fistulae were performed out a total of 799 access procedures. No graft material was used in these first operations. The patients were followed up until 31 July 1998. Of these 347 patients, 269 were non-diabetic and 78 were diabetic. Two hundred and two of all 347 first a-v fistulae were created in the forearm/wrist region, 182 in non-diabetic patients and 20 in diabetic patients, whereas the elbow region was used in 145 patients, 87 in non-diabetic and 58 in diabetic patients. Based on the carefully planned choice of location of the first operation and the strategy of elective revisions, virtually identical results for non-diabetic and diabetic patients could be obtained with regard to revision and patency rates. Some differences were observed with regard to the types of revision. A strategy is presented that helps to reduce the vascular access problems in diabetic and elderly patients.