Fistula vs. graft

[obsidianom]

This abstract got me thinking . The fistula first initiative pushes fistula but this study at least makes it questionable in cases where there is already a catheter in place. Something to think about.  Or as one article I read put it,  "Vascular Access is the Achilles Heel of Dialysis"
 


Comparison of arteriovenous fistulas and arteriovenous grafts in patients with favorable vascular anatomy and equivalent access to health care: is a reappraisal of the Fistula First Initiative indicated?

Disbrow DE, Cull DL, Carsten CG 3rd, Yang SK, Johnson BL, Keahey GP.


Source

Department of Surgery, University of South Carolina School of Medicine-Greenville, Greenville Hospital System/University Medical Center, Greenville, SC 29605, USA.


Abstract


BACKGROUND:

Initiatives to increase arteriovenous fistula (AVF) use are based on studies that show that AVFs require fewer interventions and have better patency than arteriovenous grafts (AVGs). Because patients who receive AVFs typically have more favorable vascular anatomy and are referred earlier for access placement than those who receive AVGs, the advantages of AVF might be overestimated. We compared outcomes for AVFs and AVGs in patients with equivalent vascular anatomy who were on dialysis via catheter at the time of vascular access placement.

STUDY DESIGN:

The study included patients who underwent placement of a first-time AVF or AVG between 2006 and 2009, who were on dialysis via catheter at the time of access placement, and who had favorable arterial and venous (>3 mm) anatomy. Outcomes for AVF and AVG were compared.

RESULTS:

Eighty-nine AVF and 59 AVG patients met study inclusion criteria. Similar secondary patency was achieved by AVG and AVF at 12 (72% vs 71%) and 24 months (57% vs 62%), respectively (p = 0.96). The number of interventions required to maintain patency for AVF (n = 1; range 0 to 10) and AVG (n = 1; range 0 to 11) were not different (p = 0.36). However, the number of catheter days to first access use was more than doubled in the AVF group (median 81 days) compared with the AVG group (median 38 days; p < 0.001).

CONCLUSIONS:

For patients who are receiving dialysis via catheter at the time of access placement, the maturation time, risk of nonmaturation, and interventions required to achieve a functional AVF can negate its benefits over AVG. A fistula first approach might not always apply to patients who are already on dialysis when referred for chronic access placement.

Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.


PMID: 23395157 [PubMed - indexed for MEDLINE]

[MooseMom]

I've been reading renal related abstracts like this for years now, and I have often suspected that there are too many people out there who are in intense competitions to be published.  Elsevier seems to publish anything and everything.

And then I read this

http://www.economist.com/news/briefing/21588057-scientists-think-science-self-correcting-alarming-degree-it-not-trouble

which pretty much confirmed my suspicions.

This particular abstract does not make sense to me in that it doesn't tell us anything we don't already know.  A fistula usually takes longer to become "operational" than a graft whether or not you have a catheter.  Now, if the authors are saying that the reason a graft might be better for a patient with a catheter is only because it may mean that the catheter can be removed sooner, thereby reducing the risk of infection, that's fair enough, but the authors are not saying that, are they.

Yes, the risk of non-maturation is higher in fistulas, but both patient and doctor need to weigh the pros and cons.

Everyone on dialysis knows that vascular access is the biggest bugbear.  The human body is not designed for it to be easy to access the blood system so often for so prolonged a period.

[obsidianom]

I've been reading renal related abstracts like this for years now, and I have often suspected that there are too many people out there who are in intense competitions to be published.  Elsevier seems to publish anything and everything.

And then I read this

http://www.economist.com/news/briefing/21588057-scientists-think-science-self-correcting-alarming-degree-it-not-trouble

which pretty much confirmed my suspicions.

This particular abstract does not make sense to me in that it doesn't tell us anything we don't already know.  A fistula usually takes longer to become "operational" than a graft whether or not you have a catheter.  Now, if the authors are saying that the reason a graft might be better for a patient with a catheter is only because it may mean that the catheter can be removed sooner, thereby reducing the risk of infection, that's fair enough, but the authors are not saying that, are they.

Yes, the risk of non-maturation is higher in fistulas, but both patient and doctor need to weigh the pros and cons.

Everyone on dialysis knows that vascular access is the biggest bugbear.  The human body is not designed for it to be easy to access the blood system so often for so prolonged a period.

This got me thinking as our original training nurse with over 25 years in the dialysis field had made a comment about the fistula first initiative causing more catheters due to failed fistulas and other fistula issues. She felt grafts were being underused . It seemed the pendulem had swung so much toward only fistulas , to her.
I just found it interesting that with all the negative talk about grafts , this study at least indicated they have their place and can be successful. As stated there is no perfect solution.