ZBYLUT J. TWARDOWSKI

Steve Schwab, MD, Duke University Medical Center, Durham, North Carolina, reviewed the current status of hemodialysis blood access. He reiterated the need for increasing the use of primary fistulas, and decreasing the use of central vein catheters. Primary fistulas yield the best longevity and fewest complications. If a fistula cannot be created in the forearm, a primary brachiocephalic or brachiobasilic fistula should be the second choice, followed by bridge grafts in various locations. Unfortunately the trend in the United States is not consistent with the guidelines recommended by the Dialysis Outcomes Quality Initiative (DOQI) committee.

Scott Trerotola, MD, Indiana University School of Medicine, Indianapolis, Indiana, reviewed the role of interventional radiology in the placement of percutaneous access and in treatment of subcutaneous access complications for which fistulography, angioplasty, atherectomy, and stent placement are used. The most common cause of graft failure is venous outflow stenosis, which leads to access failure unless corrected by balloon angioplasty or other means. In peripheral lesions, stents are usually reserved for failures of angioplasty. In contrast, stents play a very important role in the treatment of central venous stenosis because they provide better results than angioplasty or bypass surgery. Thrombosed accesses are usually treated by pulse-spray pharmaco-mechanical thrombolysis using small aliquots of urokinase mixed with heparin, forcefully injected into the clot by multi side-slit or side-hole catheters. Recently-developed mechanical devices that pulverize the clot and allow the resulting slurry to be aspirated from the access give results similar to the pharmacomechanical methods.

Anatole Besarab, MD, Henry Ford Hospital, Detroit, Michigan, presented the development of clinical performance measures (CPMs) for permanent vascular access based on the DOQI guidelines. The project is still in the early stage. The CPMs for vascular access are targeted at timing of access placement, type of initial access, use of catheters, technology used to detect access problems, and performance standards. The initial results will be available next year.

The ensuing discussion, moderated by Umberto Buoncristiani, MD, University of Perugia, Italy, also addressed the influence of frequent dialysis on blood access malfunction and longevity. Those who are experienced in the use of fistulas for frequent dialysis, including Dr. Buoncristiani, stressed that primary fistula complication rates and longevity are better with frequent dialysis than with routine dialysis. The reason for this phenomenon is not clear. One possible explanation is that frequent dialyses improve thrombopathy and decrease the incidence of hematoma formation at the puncture sites. There are no sufficient comparative data on complication rates and survival of bridge grafts and catheters in frequent and routine dialysis.