Effect of Perioperative Management on 1 Year Patency of Internal Arteriovenous Fistula

Park, Jisoon; Cho, Wonhyun; Sohn, Changyong; Kim, Hyoungtae; Park, Sungbae; Kim, Hyunchul

Abstract

PURPOSE: Early arteriovenous fistula (AVF) failure especially during the first several months after fistula creation makes the patient, physician and surgeon frustrated. To evaluate the patency rate of arteriovenous fistulas which were made for hemodialysis, we analyzed three different protocols pre- and peri-operatively in our hospital. METHOD: From January 1983 through December 1998, total 2,078 cases of AVF were done in 1,711 patients. During the first period (from 1983 to 1988, n=280), all of the AVFs were performed with naked eyes but during the second period (from 1989 to 1993, n=770), we used surgical loupe and microvascular anastomosing technique. During the third period (from 1994 to 1998, n=1,028), besides using surgical loupe, patients were treated peri-operatively with certain volumes of fluid to maintain the systolic blood pressure above 100 mmHg, venogram and duplex sonogram to identify an available vein before AVF creation, aggressive salvage procedures and use of aspirin after fistula creation. RESULT: There were no differences between each periods in their age distribution, sex ratio, serum creatinine level, associated diabetes mellitus and hemoglobin level except significantly low incidence of hypotension at the time of operation in period 3. The early fistula failure rate at 3 months decreased in period 2, 3 than period 1 (6.9%, 6.7% vs 12.7%) and showed statistical significance (p<0.05). The rate of fistulas that is patent more than 3 months and continued at the end of 12 months were no difference between the periods. Frequency of re-AVF within 3 months in period 1 was significantly higher than period 2, 3 which suggested improved early patency in later periods. The center ability to manage the created AVF checked by rate of re-AVF showed significant difference between our hospital and other local dialysis centers. The patency of primary AVF in each period was 69.7%, 75.2%, 77.5% at one year but that of re-AVF were 77.7%, 86.3% and 80.2%. CONCLLUSION: Microsurgical technic under surgical loupe improved primary AVF patency and decreased early failure rate. Also a protocoled perioperative management, improved management skill and experiences of dialysis center might decrease the re-AVF rate.