@article{623ab104a115471fb0eb0578bc0e8139,
title = "The difficult hemodialysis access extremity: Proximal radial arteriovenous fistulas and the role of angioscopy and valvulotomes",
abstract = "Background: Native arteriovenous (AV) fistulas (NAVF) offer significantly lower risks than grafts or catheters. Individuals with a difficult access extremity (DAE) are often viewed as unsuitable for NAVFs. The proximal radial artery (PRA) NAVF offers a safe and reliable opportunity for a direct fistula in most patients, and we find it an important surgical option in the DAE. Methods: Consecutive vascular access operations were reviewed to find individuals with DAE. We defined the DAE patient group as those individuals where a wrist (Cimino) or upper arm brachiocephalic NAVF was not possible or was predicted to fail. Results: Preoperative physical and ultrasound examinations identified 58 individuals with DAE. Mean age was 56 years (range 11 to 87), 34 were female, 29 were diabetic, and 27 had previous access surgery. NAVFs were constructed in all patients. No grafts were utilized. Forty-six patients had a PRA NAVF constructed. NAVF patency was 91%. Twenty-three patients required retrograde angioscopy or passage of a valvulotome to gain forearm access. Twenty-one of these 23 individuals maintained an open NAVF segment in the forearm. Conclusion: NAVFs were constructed in all patients. PRA NAVFs play an important role in extending hemodialysis by NAVF for this difficult patient group. Forearm access is often possible in these patients and may be successfully augmented by angioscopy or valvulotomes.",
keywords = "Angioscopy, Arteriovenous fistula, Hemodialysis, Radial artery, Valvulotome, Vascular access",
author = "Roberts, {Justin K.} and Sideman, {Matthew J.} and Jennings, {William C.}",
note = "Funding Information: Vascular access Arteriovenous fistula Angioscopy Valvulotome Hemodialysis Radial artery General consensus supported by the National Kidney Foundation Dialysis Outcomes Quality Improvement Clinical Practice Guidelines (K/DOQI) finds native arteriovenous (AV) fistulas (NAVF) to offer the best vascular access for hemodialysis [1–5] . The K/DOQI guideline recommends a NAVF at the wrist (Cimino) when possible and a brachiocephalic NAVF as second choice. When these procedures are not possible or fail, a transposed basilic vein or placement of a graft is recommended [4] . Individuals undergoing vascular access by NAVF suffer fewer episodes of steal syndrome, bleeding, and infectious complications and have lower overall mortality rates [1,2,6] . Grafts have shorter access survival time and require up to 8 times more secondary procedures [2,3,7] . Vascular access costs are significantly less when access is by NAVF as opposed to grafts or catheters [2,8,9] . Access costs exceed 1 billion dollars per year in the United States and vascular access-related hospitalizations may comprise up to 20% of all end-stage renal disease hospitalizations [2,10] . Despite these data, the National Vascular Access Improvement Initiative reports only 30% of United States hemodialysis patients use NAVFs for hemodialysis access [11] . Many European nations and Japan have NAVF rates of 80% to 90% [12] . Access surgeons struggle with those challenging individual patients who have difficult access extremities (DAE). These individuals have many common features listed in Patients with DAE have a high risk of access failure and are often viewed as unsuitable for NAVFs Table 1 . [13–15] . These patients frequently alternate between upper arm and thigh graft access sites and catheter-based dialysis. We review our approach to these patients, frequently using a proximal radial artery (PRA) NAVF and selectively adding angioscopy and the use of valvulotomes when necessary to establish forearm dialysis access. ",
year = "2005",
month = dec,
doi = "10.1016/j.amjsurg.2005.08.011",
language = "English (US)",
volume = "190",
pages = "877--882",
journal = "American journal of surgery",
issn = "0002-9610",
publisher = "Elsevier Inc.",
number = "6",
}