Changes in the practice of angioaccess surgery: Impact of dialysis outcomeand quality initiative recommendations

Purpose: Recommendations recently published by the National Kidney Foundati on-Dialysis Outcome and Quality Initiative (DOQI) included an appeal for in creased ase of native arteriovenous fistulas (NAVFs) to improve overall pat ency and contain angioaccess costs. We evaluated the impact of the DOQI rec ommendations on angloaccess surgery and its outcome at our institution. Methods From June 1996 to April 1999, 483 angioaccess procedures were perfo rmed on 247 patients. There were 133 men and 114 women, with an average age ranging from 28 to 95 years (mean age, 69 +/- 0.59 years). Risk factors in cluded smoking in 143 patients (58%), diabetes mellitus in 135 patients (55 %), hypertension in 150 patients (61%), and coronary artery disease in 98 p atients (40%). The patients were divided in two groups. Group I (pre-DOQI) included patients who had angioaccess procedures between June 1996 and Nove mber 1997, and group II (post-DOQI) included patients who had angioaccess p rocedures between December 1997 and April 1999. The types of procedures per formed included placement of arteriovenous grafts (AVGs) in 122 patients (2 5%), creation of NAVFs in 99 patients (20%), revision of AVGs in 123 patien ts (25%), and temporary access procedures in 135 patients (28%). Forty-seve n of the NAVF procedures were radial-cephalic fistulas (47%), 22 were brach ial-cephalic fistulas (23%), and 30 were brachial-basilic fistulas (30%). P atients underwent serial ultra-sasonography scanning and physical examinati ons; the mean follow-up period was 9 months. Choice of angioaccess procedur es and patency rates before and after implementation of the DOQI recommenda tions were compared. Results: There was a significant increase in the use of NAVFs after impleme nting DOQI recommendations (5% vs 68%, P < .001), The 1-year primary patenc y rate of AVGs was Less than that of art arteriovenous fistulas (54% vs 85% , P < .001). During the study period, the percentage of AVGs placed at our institution that required revision (59%; 72 of 123) was higher than that of NAVFs that required revision (4%; 4 of 99; P < .001), There was no signifi cant difference in the maturation rates of radial-cephalic fistulas (75%), brachial-cephalic fistulas (91%), and brachial-basilic fistulas (87%). Conclusion: By adopting the DOQI recommendations, we used NAVFs more often. This resulted in superior patency rates, compared with synthetic grafts. T he liberal use of preoperative duplex venous mapping further increased NAVF use, surpassing the DOQI expectations for primary arteriovenous fistulas. Additionally, fewer revisions were required.