Prospective study of dialysis fistulas: Problem patients and their treatment

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Abstract
A 5½-year prospective study of the fate of arteriovenous fistulas for haemodialysis is reported with particular reference to the prevention and treatment of complications. A total of 157 consecutive patients was accepted for chronic haemodialysis: 148 patients had a first attempt at a wrist fistula construction, 2 patients had a failed exploration of the wrist, 1 patient had a primary brachial fistula due to absent forearm veins and 6 patients were excluded from analysis because vascular access operations had already been performed elsewhere. Including early failures, 80 per cent of the fistulas remained patent 1 year after construction and 65 per cent remained patent at 4 years. When early thrombosis and technical failures were excluded, the 1-year patency rate was 90 per cent. Of the study group of 150 patients with attempts at wrist fistula construction, 94 had no problems with their fistulas. Five were lost to follow-up and complications developed in 51 patients, including poor flow, thrombosis, venous hypertension and false aneurysm. These patients constituted a problem group and 107 further procedures were required to re-establish satisfactory access. Analysis of variables including age, sex, smoking habit, pre-dialysis time and operative factors showed only vein size to exert a significant effect on fistula survival. Discriminant analysis failed to separate the two groups. There were 42 salvage operations and 65 new access procedures. The latter included 49 wrist or brachial fistulas, 9 ankle shunts and only 4 loop grafts. It is suggested that with careful management of wrist fistulas and their complications, the place of autogenous or artificial grafts is strictly limited.