Surgical practice to reduce dialysis access insufficiency.
BACKGROUND
Patients who are dependant on a percutaneous central venous catheter for dialysis have an excess morbidity and mortality compared with patients with an autologous arteriovenous fistula.


METHODS
In an effort to improve outcomes related to episodes of permanent access insufficiency, defined as a patient requiring a venous catheter for haemodialysis, a 12-month prospective audit of surgery carried out to establish and maintain dialysis access was carried out at our institution.


RESULTS
Effective measures that reduced the period of time that patients required a venous catheter for dialysis included regular communication between dialysis staff, the surgical service and patients attending for treatment in the dialysis unit, liberal use of duplex ultrasound imaging, pursuing autologous access in the majority of patients, early intervention to correct failing vascular access before conduit thrombosis, using both traditional open surgical and endovascular solutions in establishing and maintaining vascular access, using peritoneal dialysis as a long-term or temporary alternative to haemodialysis and, in cases of arteriovenous polytetrafluoroethylene graft occlusion, early thrombectomy and mandatory revision to provide a conduit immediately available for effective dialysis.


CONCLUSIONS
Conducting an audit of surgical practice contributed to an improvement in outcomes for dialysis-dependant patients. Establishing an arteriovenous fistula in a greater proportion of cases before initiating renal replacement therapy may further address the problem of dialysis access insufficiency.
Freeman
Anthony J
AJ
Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia. tony.freeman@bigpond.com
Gallagher
Martin
M
Gray-Weale
Anthony
A
Lippey
Eric
E
Thursby
Peter
P
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical; D002405:Catheterization, Central Venous; D002408:Catheters, Indwelling; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D006435:Renal Dialysis / Q000379:methods*