Abstract
The present study retrospectively analyzes data from 149 primary vascular access operations to evaluate the effect of surgical approach and surgical expertise on the rates of success and of complication for this surgery. All but 10 of the 149 operations involved construction of Cimino-Brescia (C-B) fistulae, the remaining 10 were loop-shunts. All operations were performed consecutively by five different surgeons who were categorized according to skill level as expert (ES), less expert (LES), or trainee (TS) surgeons. The authors recorded the types of complications, duration of patency, types and incidence of repeat surgery, adequacy of vascularization during all surgeries, time of onset of complications, surgical technique, and surgical skill level. Early complications were defined as those occurring within 30 days of surgery and late complications as those manifested thereafter. The presence of low flow in the fistulae on postoperative dialysis prompted angiography, color-Doppler echocardiography, or fistulography to diagnose the source of complication and determine surgical management. Total complications numbered 35 (23.5%), 13 (8.7%) early and 22 (14.8%) late. Inadequate vascularization resulted in a 53% complication rate, including both stenosis and thrombosis. Expert surgeons achieved 79% patency compared with 59% patency for less expert surgeons. The success rate for correction of stenosis (91.7% primary patency) was greater than that for thrombosis (50% primary patency). To preserve vascular capability, the authors prefer construction of a new, more proximal fistula for repeat surgery or (rarely) intraoperative angioplasty. If the fistula cannot be salvaged, they recommend construction of a C-B fistula on the contralateral limb. A loop-shunt is the least preferred alternative.
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