Which Fistula First?

By Peter Laird, MD

The Fistula First initiative is increasing the rate of fistula placement here in America, yet it has also been accompanied by a paradoxically higher primary fistula failure rate and indwelling catheter usage. Many have entered into this debate declaring that alternative sites other than the preferred radiocephalic site are a potential solution. Brachiocephalic AV Fistula is the Preferred Autogenous Fistula:

Brachiocephalic fistulas were superior to radiocephalic fistulas in time to maturity, primary patency, and functional primary patency. Not only did brachiocephalic fistulas have a greater maturation rate, they were less likely to fail once hemodialysis began.

Some have actually dubbed the Fistula First program the Fistula Worst program due to increased primary failures, increased indwelling catheter use and allegedly unproven claims of the benefits of fistulas.

Yet, this debate is primarily an ethnocentric American debate. The majority of western nations already have very successful vascular surgery programs utilizing fistulas with great benefits to their dialysis populations. Primary failure rates are reduced in these nations by an increased focus on training of their surgeons and utilization of microsurgical techniques especially for those that are elderly or have suboptimal target vessels.

Primary patency rates for radiocephalic, brachiocephalic, and brachiobasilic fistulae were 78%, 76%, and 81% at three months respectively. Secondary patency rates for radiocephalic fistulae were 91% at one year.

Creation of distal fistulae can be challenging and is associated with a high initial failure rate. Use of the microsurgical technique in this study resulted in excellent long-term patency rates and a very low incidence of ischemia.

Europe has reduced secondary failure rates with better dialysis staff training as well as the use of constant site cannulation otherwise known as the buttonhole technique.

Therefore, while many here in America question the clinical validity of the Fistula First initiative, decades of success in Japan, Europe and Australia speak to the need for America to continue to strive to equal their results here instead of expending futile energy debating the merits of this already proven modality. In other words, it is time for America to grow up, stop whining about poor initial outcomes and step up to the plate just as all these other nations have already done with advanced surgical techniques and most importantly, better trained surgeons.

Risk of primary fistula failure was 34% lower (relative risk = 0.66, P = 0.002) when placed by surgeons who created >/=25 (vs. <25) fistulae during training. CONCLUSIONS: Surgical training is key to both fistula placement and survival, yet US surgical programs seem to place less emphasis on fistula creation than those in other countries. Enhancing surgical training in fistula creation would help meet targets of the Fistula First Initiative.

From my view on the sharp end of the needle, there are two additional issues that are seldom voiced in these debates and articles. First, many American surgeons seek a higher primary success rate by switching from the preferred radiocephalic (wrist) site to the brachiocephalic and the brachiobasilic (elbow) sites as the solution to our high primary failure rate. However, the fact remains that the recommended end to side anastomosis in the brachiocephalic fistula sacrifices the distal cephalic vein for any future consideration of a radiocephalic fistula on the same side should this first fistula fail. The converse is not true, a failed radiocephalic fistula does not usually preclude the use of the more proximal elbow sites.

For patients like myself who received a left brachiocephalic fistula as my primary access due to the surgeon’s preference, I no longer have the option of a left radiocephalic fistula should my current access fail. It is my opinion that a viable distal vessel should always be chosen first for this reason alone.

Second, for those that self cannulate especially with the buttonhole technique as I do, the distal radiocephalic fistula over the forearm is covered by less moveable and thinner skin. Bill is able to self cannulate without a partner, yet due to my upper arm fistula covered over by thicker and more moveable skin, I cannot cannulate without a dedicated partner holding my buttonhole in a fixed position. Because of thicker and more mobile skin, developing buttonholes on these sites is significantly more difficult. I do not believe that many vascular surgeons consider the ease of developing constant site cannulation (buttonholes) when they are evaluating a patient for fistula placement but it should be a primary consideration whenever any CKD-5 patient is evaluated for dialysis access options.

In summary, America needs to improve vascular surgery fistula training programs, utilize microsurgical techniques more frequently, avoid sacrificing ANY viable distal vessel, adopt constant site cannulation techniques and stop divisive and egocentric debates on issues already settled in other nations. It is time for all renal care physicians to gain maturity in fistula placement and maintenance techniques enjoyed by the other nations and become once again the advocates of excellence that we were once known.

Comments

[Wallyz]

Good post, Hemodoc. Making it easier for the providers should not be an important criteria for site selection, especially when faced with the disparity of outcomes between the US and Europe/Japan.