Hypothesis: Dialysis by native arteriovenous fistula (NAVF) clearly offers lower infection rates, fewer procedures, and lower mortality risk compared with access by catheter or graft, in addition to lower cost. However, NAVFs are utilized for vascular access in only 30% of hemodialysis patients in the United States. Wrist NAVFs are not feasible or successful in many patients and upper arm brachial artery NAVFs may be impractical or lead to additional procedures or complications. Careful preoperative evaluation of all options for NAVF construction including the proximal radial artery (PRA) as an arterial inflow site will find most, if not all, patients to be candidates for successful NAVFs.
Design: Retrospective review of consecutive operations for hemodialysis access preformed by an individual surgeon from May 2003 to November 2004.
Setting: Two university-affiliated tertiary medical centers.
Patients: All patients underwent preoperative ultrasound evaluation by the operating surgeon. A wrist fistula was first choice for access when success was predicted by ultrasound and physical examination. The second choice, and most common operation, was a PRA NAVF with distal forearm (retrograde) flow established by disrupting the initial venous valve using a vessel probe.
Results: One hundred thirty-two patients aged 11 to 90 years (mean = 61) were reviewed. Sixty-eight patients had diabetes and 61 were female. Thirty-four had previous failed access surgery. Native arteriovenous fistulas were created in all patients. No grafts were used. A PRA NAVF was utilized in 105 operations. Overall (assisted) patency was 97%, with a mean follow-up of 11 months. Importantly, there were no infections or hospitalizations due to the NAVF access operations.
Conclusions: No grafts were used in this series of 132 consecutive patients. The PRA NAVF was the most common operation and an important addition to wrist, brachial, and transposition fistulas. Proximal radial artery NAVFs increase the opportunity for construction of successful NAVFs and are reliable, safe, and simple procedures with access sites often available in both the forearm and in the upper arm.