Tailoring the initial vascular access for dialysis patients

Background. Creating a functioning initial arteriovenous (AV) access for aging and diabetic end-stage renal disease (ESRD) hemodialysis patients has been a challenge. Methods. This study describes 748 consecutive primary AV access creations and their primary (unassisted) and secondary (assisted) access survival at a single center. Twenty-four percent of the patients had diabetes as their cause of ESRD and the average age was 59.6 years. No patient receiving an initial AV access required synthetic graft material. All received an AV fistula. Three types of fistulae were created and their distribution varied significantly for diabetic and non-diabetic patients (respective percentages): forearm AV fistula (24%, 62%). perforating vein fistula (PVF) at the elbow (48%, 21%) and non-PVF at the elbow (29%, 17%). Results. Results of access survival for age groups <65 and 65+ years, male and female, diabetic and non-diabetic subgroups ranged from 51 to 75% for unassisted and from 75 to 96% for assisted two year access survival. PVF appeared to be advantageous over non-PVF access at the elbow. First intervention for peripheral steal syndrome was required at a rate of 7 and 0.6 per 100 patient-years at risk for diabetic and nondiabetic patients, respectively. The thrombosis rates per patient year of 0.03 for non-diabetics and 0.07 for diabetics are superior to previously published results for AV fistulae or for a combined AV fistula-AV graft approach. Conclusions. Potential explanations for these excellent results among elderly and diabetic patients include preoperative evaluation, exclusive use of native vessels, a variable surgical approach including PVF. and the experience of a single operator.