The operating surgeon is the major determinant for a successful arteriovenous fistula maturation

Abstract

To the Editor: In the October 2006 issue of Kidney International, Dixon published an extraordinarily excellent review on arteriovenous fistula (AVF) maturation in hemodialysis patients. When dealing with predictors of maturation, Dixon quoted correctly preoperative vascular mapping, surgical experience, gender, and evidence of extensive vascular disease. We think, however, that the crucial role of the performing surgeon in determining a successful AVF maturation was not sufficiently stressed, and here we would like to make some comments about this issue. In recent literature, between 20 and 50% of autogenous AVFs fail to mature. We believe that such a large range is mainly due to the wide spectrum of expertise in AVF surgery. Konner et al. described the technical points determining the failure of an AVF: juxta-anastomotic stenoses in failing forearm AVFs arise in the surgical hinge region where the vein is mobilized and moved into contact with the artery. This venous segment undergoes many surgical traumas, including dessication, crush injury, kinking and spasm. Now, we know that juxta-anastomotic venous stenosis is the most common cause of failure of maturation of AVFs, accounting for 65–100% of angiographicaly evaluated failing AVFs. Evidence exists in the literature that the operating surgeon is the major determinant for the continuous patency of CiminoBrescia AVFs. Prischl et al. pointed out that the training in vascular surgery and the attention and engagement directed to AVF surgery seem to be critical for the outcomes of AVFs. Furthermore, Feldman et al. using an explanatory logistic model, estimated that the mean probability of successful AVF maturation in their study population would have increased from 58 to 84% had optimal surgical technique (high-dose heparin, use of venous clamps, and use of large vessels) been applied uniformly. In conclusion, a dedicated surgeon’s individual assessment of the vascular site together with surgical expertise and a skillful technique of operation are the major determinants for a functioning, long-lasting AVF in a routine clinical setting.