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Abstract

The radial-cephalic direct wrist arteriovenous fistula (RCAVF) is the primary and best option for vascular access in patients who need long-term intermittent hemodialysis, as proposed by the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative guidelines. However, in patients with poor or questionable forearm vessels, an alternative vascular access may be considered. We agree that an antecubital brachial-cephalic fistula is a good second option, but there are still no good studies available that support this alternative access. On the other hand, before starting the current study, only few data were known on the outcome of RCAVFs in patients with poor or questionable vessels, and no information on the performance of prosthetic arteriovenous grafts in these patients were available. That is the reason why we performed this study. It is true that there is a chance that a stenosis will develop at the venous anastomosis of forearm prosthetic grafts. We agree that these stenoses can preclude the use of the cephalic or basilic vein for creation of a direct elbow fistula. However, when these stenoses are detected early and treated by percutaneous transluminal angioplasty, there is no necessity to create an upper arm arteriovenous fistula. Yes, failed autogenous fistulas leave the door open for secondary or tertiary prosthetic grafts, but is it correct to create an autogenous arteriovenous fistula in patients with poor vessels when there is still no evidence that these fistulas do better than prosthetic grafts? We all know that there is still a considerable risk for early thrombosis or non-maturation in autogenous upper arm fistulas. In addition, upper arm access has a higher incidence of peripheral ischemia and cardiac failure due to high access flow. Finally, we did not conclude, as is suggested, that forearm grafts should be placed prior to brachial-based fistulas. We only conclude that patients with poor forearm vessels may benefit from implantation of a prosthetic graft. Regarding “Autogenous radial-cephalic or prosthetic brachial-antecubital forearm loop AVF in patients with compromised vessels? A randomized multicenter study of the patency of primary hemodialysis access”Journal of Vascular SurgeryVol. 43Issue 6PreviewThe article of Rooijens et al1 promotes the placement of brachial-antecubital forearm loop prosthetic grafts when forearm arteries and veins are judged unsuitable for the creation of a native fistula in dialysis patients. They wrote in the introduction that no information was available on the performance of alternative accesses in patients with poor or questionable forearm vessels, that “an upper arm direct AVF, anastomosing the brachial artery with the cephalic or basilic vein, may be a second best option after failure of a radial-cephalic AVF, but that in K/DOQI guidelines no consensus for either this option or the implantation of a prosthetic graft implant has been outlined.” This statement is false, since DOQI guideline number 3 clearly outlines that a prosthetic graft should be placed only “if a wrist radial-cephalic fistula or an elbow brachial-cephalic fistula cannot be constructed.”2 Full-Text PDF Open Archive