A STRATEGY FOR INCREASING USE OF AUTOGENOUS HEMODIALYSIS ACCESS PROCEDURES - IMPACT OF PREOPERATIVE NONINVASIVE EVALUATION

Purpose: We studied the efficacy of preoperative noninvasive assessmen t of the upper extremity to identify arteries and veins suitable for h emodialysis access to increase our use of autogenous fistulas (AF). Me thods: From Sep. 1, 1994, to Apr. 1, 1997, 172 patients who required c hronic hemodialysis underwent segmental upper extremity Doppler pressu res and duplex ultrasound with mapping of arteries and veins. The foll owing criteria were necessary for satisfactory arterial inflow: absenc e of a pressure gradient between arms, patent palmar arch, and arteria l lumen diameter 2.0 mm or more. The criteria necessary for satisfacto ry venous outflow were venous luminal diameter greater than or equal t o 2.5 mm for AF and greater than or equal to 4.0 mm for synthetic brid ging grafts (BG) and continuity with distal superficial veins in the a rm. Intraoperative and duplex ultrasound measurements were compared. C ontemporary experience was compared with the 2-year period (1992 to 19 94) before implementation of the protocol. Results: During the period from Sep. 1, 1994, to Apr. 1, 1997, 108 patients (63%) had AF, 52 (30% ) had prosthetic BG, and 12 (7%) had permanent catheters (PC) placed. Early failure was seen in 8.3% of AFs. Primary cumulative patency rate s were 83% for AF and 74% for EG at 1 year (p < 0.05), with a mean cli nical follow-up of 15.2 months. No postoperative infections were obser ved with AF, whereas six infections (12%) were observed with BG and tw o (17%) with PC insertion. During the period from June 1, 1992, to Aug . 31, 1994, 183 procedures were performed with a distribution of 14% A P, 62% BG, and 24% PC. In this earlier period the AF early failure rat e was 36%, and the patency rates were 48%, 63%, and 48% for AF, BG, an d PC, respectively (mean followup, 13.8 months). Conclusion: A protoco l of noninvasive assessment increased use of AFs. The cumulative paten cy rate of AFs was improved, and early failure rates were reduced when compared with the preceding institutional experience. Routine noninva sive assessment is recommended to document adequacy of arterial inflow and delineate venous outflow to maximize opportunities for AF.