title: Outcomes of Vascular Access Care and Surgery Managed by Interventional Nephrologists: A Twelve-Year Experience.
abstract: BACKGROUND
  Optimizing vascular access outcomes is still a challenge, since 30-60% of arteriovenous fistulas fail or do not mature and catheters are widely used in contemporary patients.
  
  
  METHODS
  This study reports on strategies and outcomes in a single center in which access planning, surgery and maintenance are managed by a team of nephrologists. We retrospectively analyzed 305 fistulas and 61 grafts created in 270 consecutive patients between 2002 and 2013.
  
  
  RESULTS
  The percentage of patients receiving a fistula or graft who initiated hemodialysis with a mature access was 68.6%. Among prevalent patients, 71.7% used a fistula, 15.7% a graft and 12.6% a catheter. Rates of primary failure and revision before cannulation were 14.4 and 1.6% for fistulas vs. 4.9 and 3.3% for grafts. After maturation, complications (1.040 vs. 0.188 per patient-year (py)) and interventions (0.743 vs. 0.066 per py) were greater for grafts than for fistulas (p < 0.001). Secondary patency did not significantly differ between grafts and fistulas (median survival 34.8 vs. 57.3 months, p = 0.36), unless primary failures were excluded from Kaplan-Meier analysis (median survival 34.9 vs. 70.9 months, p = 0.03).
  
  
  CONCLUSIONS
  High fistula prevalence, low access-related morbidity and catheter dependence were achieved using individualized strategies, including mid-forearm or perforating vein fistula creation and selective graft placement in high risk patients. Direct involvement of nephrologists throughout all steps of access care can improve access outcomes, by promoting a patient-centered approach.
authors.affiliation: Nephrology and Dialysis Unit, USL 12 Versilia Hospital, Lido di Camaiore, Lucca, Italy.
authors.forename: Giordano
authors.initials: G
authors.lastname: Fumagalli
authors.forename: Stefano
authors.initials: S
authors.lastname: De Pietro
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Migliori
authors.forename: Francesco Paolo
authors.initials: FP
authors.lastname: Ferrandello
authors.forename: Fabio
authors.initials: F
authors.lastname: Trovato
authors.forename: Carlo
authors.initials: C
authors.lastname: Donadio
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Panichi
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000592:standards / Q000706:statistics & numerical data*; D002404:Catheterization / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D053208:Kaplan-Meier Estimate; D000072104:Nephrologists / Q000592:standards; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D019737:Transplants / Q000592:standards / Q000706:statistics & numerical data*; D016896:Treatment Outcome