Impact of the Surgeon on the Prevalence of Arteriovenous Fistulas

Abstract

Decreased use of native arteriovenous fistulas and an increased reliance on synthetic grafts as permanent dialysis access have accompanied the growth of the dialysis population in the United States, but not at our institution. Possible reasons for this difference were studied in a cross-sectional analysis in August of 2000. There were 51 chronic dialysis patients, all of whom had their access placed by the same surgeon; 75% of them were dialyzed through an arteriovenous fistula, which compares well with the 23% prevalence at the national level. Among our patients, 57% were diabetic, 98% had a history of hypertension, 35% had amputations or arterial bypass surgery, 37% had coronary artery disease, 12% had suffered a stroke, 35% were active smokers, and 22% had a history of intravenous drug use. The high prevalence of arteriovenous fistulas, despite so many comorbid conditions, suggests that the presence of a skilled and experienced surgeon may be more predictive of better dialysis access than other factors.

Pathogenesis and Prevention of Vascular Access Failure

“…A pertinent factor affecting the anastomosis and therefore the outcomes of AVFs includes both the experience of the surgeon in creating the fistula, as well as the technical issues associated with utilizing and managing the fistula. The formation of AVFs is difficult, with numerous studies indicating that there is a higher incidence of successful AVFs if the surgery is performed by an experienced vascular surgeon [45][46][47][48][49], with the emphasis being placed on the number of AVFs created over the total years of training [48,50].…”

“…Other strategies, including vein preservation policies, patient education regarding vein protection and access care, preoperative vein mapping and timely access creation have been found to increase fistula prevalence, decrease primary vascular access failure and increase cumulative patency [152][153][154]. The literature suggest that superior arteriovenous access success is achieved when the AVF is created by a skilled vascular surgeon, [45][46][47][48][49], with the emphasis being placed on the number of AVFs created over the total years of training [48,50]. In the post-operative setting, timely assessment of arteriovenous access at 4 weeks is recommended to ensure access function is adequate, and to enable early surgical or endovascular intervention to prevent or treat primary access failure.…”

American Society of Diagnostic and Interventional Nephrology Section Editor: Stephen Ash: Arteriovenous Fistula Surgery: An American Perspective from Italy

“…Some have suggested other factors that limit AVF creation in the United States, including decreased compensation for the surgery compared with arteriovenous grafts and fewer teaching programs, may also contribute (45–47). One might argue that American surgeons’ familiarity with grafts and Italian nephrologists lack of familiarity with graft surgery (except for a few individuals) may contribute to the prevalence of fistulas in these Italian centers.…”

The Advantages of Using Vascular Dilators in Angioaccess Surgery

“…There are 3 mo- dalities of VA for HD: arteriovenous fistula (AVF) as the first choice, arteriovenous graft as the second and central venous catheter as the last option. The presence of a skilled and experienced surgeon is very important in achievement of better outcomes: more AVFs and durable VAs [9,10]. Preoperative duplex ultrasonography (USG) and vessel mapping significantly help a surgeon to choose the right site for anastomosis and creation of an access that has a good chance of becoming functional [11][12][13].…”