Primary forearm arteriovenous fistula for hemodialysis access - an integrated approach to improve outcomes

Purpose: Maximizing the ratio of primary arteriovenous fistula (PAVF) over bridge graft fistula (BGF) for hemodialysis access is a primary recommendation of the National Kidney Foundation published as Dialysis Outcomes Quality Initiative (DOQI). Imaging, anesthetic and surgical techniques were taken into account to achieve this and other goals, including extensive use of forearm vessels to lower immediate and early failure rates and prolong the useful life of PAVFs. Design: Prospective non-randomized study. Methods: High-resolution duplex ultrasonography (DUS) was added to careful clinical assessment in planning and follow-up of the dialysis access. Brachial plexus block, which allowed the use of an arterial tourniquet and gave a postoperative sympathectomy type effect, was used for anesthesia, and together with meticulous surgical technique, prevented spasm. Access puncture, post-operative follow-up and surgical revisions were planned in close cooperation with the nephrology team. Findings: Ninety (57.3%) of the 157 fistulas constructed for new hemodialysis access between August 1998 and March 2000 were PAVFs. Seventy-three (81.1%) of these were confined to the forearm and comprise the study population, with a mean follow-up of 8.4 +/- 4.4 months. There were no immediate failures in the study group. The early failure rate (1 month) was 6.8% and revisions based on DUS were easily accomplished in all cases. The one year assisted primary patency rate was 81.8% and the secondary patency rate at 18 months was 98.6%. Conclusions: DUS for planning and follow-up of PAVF along with careful surgical technique under a brachial plexus blockade can achieve a PAVF/BGF ratio well above 50% with a low early failure rate and a high secondary patency rate. Algorithms are presented to achieve these goals. (C) 2003 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved.