We studied the efficacy of preoperative noninvasive assessment of the upper extremity
to identify arteries and veins suitable for hemodialysis access to increase our use
of autogenous fistulas (AF).
From Sep. 1, 1994, to Apr. 1, 1997, 172 patients who required chronic hemodialysis
underwent segmental upper extremity Doppler pressures and duplex ultrasound with mapping
of arteries and veins. The following criteria were necessary for satisfactory arterial
inflow: absence of a pressure gradient between arms, patent palmar arch, and arterial
lumen diameter 2.0 mm or more. The criteria necessary for satisfactory venous outflow
were venous luminal diameter greater than or equal to 2.5 mm for AF and greater than
or equal to 4.0 mm for synthetic bridging grafts (BG) and continuity with distal superficial
veins in the arm. Intraoperative and duplex ultrasound measurements were compared.
Contemporary experience was compared with the 2-year period (1992 to 1994) before
implementation of the protocol.
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 rates were 83% for AF and 74%
for BG at 1 year (p < 0.05), with a mean clinical follow-up of 15.2 months. No postoperative
infections were observed with AF, whereas six infections (12%) were observed with
BG and two (17%) with PC insertion. During the period from June 1, 1992, to Aug. 31,
1994, 183 procedures were performed with a distribution of 14% AF, 62% BG, and 24%
PC. In this earlier period the AF early failure rate was 36%, and the patency rates
were 48%, 63%, and 48% for AF, BG, and PC, respectively (mean follow-up, 13.8 months).
A protocol of noninvasive assessment increased use of AFs. The cumulative patency
rate of AFs was improved, and early failure rates were reduced when compared with
the preceding institutional experience. Routine noninvasive assessment is recommended
to document adequacy of arterial inflow and delineate venous outflow to maximize opportunities
for AF.