Clifford Sales, MD

[Editor's Note: Dr. Sales presents us with both points of view]

POINT: Fistula First for everyone? Sounds good to me

While “do no harm” may be a motto, the truth is, we strive to deliver the best care possible at every moment we interact with patients. There is no argument that an autogenous Arteriovenous Fisutla (AVF) is the best access available for patients—in terms of patency, freedom from intervention and resistance to infection. Thus, providing any other type of access—excluding the bridge catheter—is clearly a “second best” operation.

Other countries boast AVF rates in the upper 80% range and ESRD Network 16 (Alaska, Idaho, Montana, Oregon and Washington) in the U. S. has rates approaching 70%.

If that is the case, why then, does the U. S. still have an overall AVF rate of 63%? It is unlikely that the technical ability of surgeons outside the U. S. or in the upper left corner of our country differs from that of the remainder of the country. Fistula First embarked on a journey to bring this issue to the forefront. Following Drs. Larry Spergel and Tip Jennings advice, many surgeons took to the operating room in an effort to improve the AVF rates in the U. S. In fact, the numbers improved dramatically—but not to the 80+% mark.

Dr. Larry Scher assures us that every arm can have a fistula created and if you are a good interventionalist (or have a good one with whom to work) you can get all of these to mature.

Therefore, all of those 2-2.5mm veins that might not seem “usable,” should be anastomosed carefully to the radial or brachial artery—much as one would perform a distal anastomosis—and coax them into maturing to functional AVFs. If balloon assistance is needed for maturation, make certain the “balloon operator” has a good working knowledge of AV access, lest a nice, big hematoma will greet you, destroying your nicely created AVF. Those of us who cannot achieve the near 100% AVF rate must be technically challenged!

COUNTERPOINT: Fistula First is a bit overdone

Great idea, good execution, too much!

As an early ideologue in the Fistula First movement, I am proud of what we accomplished—education. We got the word out that AVFs were a better option than Arteriovenous Grafts! At the introductory meeting, I did have a rather animated “discussion” with a social worker who was convinced that the reason AVGs outnumbered AVFs was because AVGs reimbursed higher and therefore the surgeons were choosing the AVG for financial reasons (Sometimes it is really hard to maintain your composure!) While it may be true in some quarters, I would venture that was not the real reason affecting the inability of us, as a profession, to deliver the AVF rate that we should.

My alter ego above mentions Drs. Larry Spergel and Tip Jennings—both of whom should be given great credit for opening our eyes to the need for reform. They lead us and we improved. However, the number of AVFs that are being done that are NOT maturing has increased. Just as in any “cult phenomena,” when adherence to a concept supersedes rational thought, the endpoint is blurred. This is what has occurred in the Fistula First.

There are some patients who will never mature an AVF—irrespective of the competence of the vascular surgeon! Many of the veins are simply phlebitic from years of intravenous or venipuncture attacks—now that the PICC teams have learned where the basillic vein is, that vein is often problematic. Additionally, one factor that has never been adequately measured or characterized is skin turgor. Many of our older patients have awful skin turgor and any access (AVF or AVG) will be accompanied by ongoing post-dialysis hematomas with problems.

Our experience has been that octogenarians tend to do better with AVGs than AVFs—heresy to the Fistula First pundits. The number of catheter days is markedly reduced and the long-term outcomes do not vary much in this age group. And guess what, there are some patients who actually do well with a catheter!

Perhaps, two topics are worth mentioning in closing this self-debating article! Fistula First has, appropriately, been renamed Fistula First, Catheter Last! This recognizes the fact that maybe not everyone is a candidate for an AVF—but at the least we should avoid the catheter! The second, much larger issue is whether everyone that is dialyzed should, indeed, be dialyzed! I suspect all readers have been pressured into placing a catheter (or worse) in a patient who has no real chance for a meaningful survival. Additionally, maybe some patients would benefit from nutritional therapy that could delay the onset of dialysis by 6-18 months—imagine how much that would save to an already overburdened system!

Dr. Sales is President, The Cardiovascular Care Group, Westfield , N.J., chief, division of vascular surgery, Overlook Medical Center, Summit, N.J., and clinical assistant professor of Surgery, Mount Sinai School of Medicine, New York, N.Y. Both versions of Dr. Sales are an associate medical editor for Vascular Specialist.

[Editor's Note: Dr. Sales presents us with both points of view]

POINT: Fistula First for everyone? Sounds good to me

While “do no harm” may be a motto, the truth is, we strive to deliver the best care possible at every moment we interact with patients. There is no argument that an autogenous Arteriovenous Fisutla (AVF) is the best access available for patients—in terms of patency, freedom from intervention and resistance to infection. Thus, providing any other type of access—excluding the bridge catheter—is clearly a “second best” operation.

Other countries boast AVF rates in the upper 80% range and ESRD Network 16 (Alaska, Idaho, Montana, Oregon and Washington) in the U. S. has rates approaching 70%.

If that is the case, why then, does the U. S. still have an overall AVF rate of 63%? It is unlikely that the technical ability of surgeons outside the U. S. or in the upper left corner of our country differs from that of the remainder of the country. Fistula First embarked on a journey to bring this issue to the forefront. Following Drs. Larry Spergel and Tip Jennings advice, many surgeons took to the operating room in an effort to improve the AVF rates in the U. S. In fact, the numbers improved dramatically—but not to the 80+% mark.

Dr. Larry Scher assures us that every arm can have a fistula created and if you are a good interventionalist (or have a good one with whom to work) you can get all of these to mature.

Therefore, all of those 2-2.5mm veins that might not seem “usable,” should be anastomosed carefully to the radial or brachial artery—much as one would perform a distal anastomosis—and coax them into maturing to functional AVFs. If balloon assistance is needed for maturation, make certain the “balloon operator” has a good working knowledge of AV access, lest a nice, big hematoma will greet you, destroying your nicely created AVF. Those of us who cannot achieve the near 100% AVF rate must be technically challenged!

COUNTERPOINT: Fistula First is a bit overdone

Great idea, good execution, too much!

As an early ideologue in the Fistula First movement, I am proud of what we accomplished—education. We got the word out that AVFs were a better option than Arteriovenous Grafts! At the introductory meeting, I did have a rather animated “discussion” with a social worker who was convinced that the reason AVGs outnumbered AVFs was because AVGs reimbursed higher and therefore the surgeons were choosing the AVG for financial reasons (Sometimes it is really hard to maintain your composure!) While it may be true in some quarters, I would venture that was not the real reason affecting the inability of us, as a profession, to deliver the AVF rate that we should.

My alter ego above mentions Drs. Larry Spergel and Tip Jennings—both of whom should be given great credit for opening our eyes to the need for reform. They lead us and we improved. However, the number of AVFs that are being done that are NOT maturing has increased. Just as in any “cult phenomena,” when adherence to a concept supersedes rational thought, the endpoint is blurred. This is what has occurred in the Fistula First.

There are some patients who will never mature an AVF—irrespective of the competence of the vascular surgeon! Many of the veins are simply phlebitic from years of intravenous or venipuncture attacks—now that the PICC teams have learned where the basillic vein is, that vein is often problematic. Additionally, one factor that has never been adequately measured or characterized is skin turgor. Many of our older patients have awful skin turgor and any access (AVF or AVG) will be accompanied by ongoing post-dialysis hematomas with problems.

Our experience has been that octogenarians tend to do better with AVGs than AVFs—heresy to the Fistula First pundits. The number of catheter days is markedly reduced and the long-term outcomes do not vary much in this age group. And guess what, there are some patients who actually do well with a catheter!

Perhaps, two topics are worth mentioning in closing this self-debating article! Fistula First has, appropriately, been renamed Fistula First, Catheter Last! This recognizes the fact that maybe not everyone is a candidate for an AVF—but at the least we should avoid the catheter! The second, much larger issue is whether everyone that is dialyzed should, indeed, be dialyzed! I suspect all readers have been pressured into placing a catheter (or worse) in a patient who has no real chance for a meaningful survival. Additionally, maybe some patients would benefit from nutritional therapy that could delay the onset of dialysis by 6-18 months—imagine how much that would save to an already overburdened system!

Dr. Sales is President, The Cardiovascular Care Group, Westfield , N.J., chief, division of vascular surgery, Overlook Medical Center, Summit, N.J., and clinical assistant professor of Surgery, Mount Sinai School of Medicine, New York, N.Y. Both versions of Dr. Sales are an associate medical editor for Vascular Specialist.

[Editor's Note: Dr. Sales presents us with both points of view]

POINT: Fistula First for everyone? Sounds good to me

While “do no harm” may be a motto, the truth is, we strive to deliver the best care possible at every moment we interact with patients. There is no argument that an autogenous Arteriovenous Fisutla (AVF) is the best access available for patients—in terms of patency, freedom from intervention and resistance to infection. Thus, providing any other type of access—excluding the bridge catheter—is clearly a “second best” operation.

Other countries boast AVF rates in the upper 80% range and ESRD Network 16 (Alaska, Idaho, Montana, Oregon and Washington) in the U. S. has rates approaching 70%.

If that is the case, why then, does the U. S. still have an overall AVF rate of 63%? It is unlikely that the technical ability of surgeons outside the U. S. or in the upper left corner of our country differs from that of the remainder of the country. Fistula First embarked on a journey to bring this issue to the forefront. Following Drs. Larry Spergel and Tip Jennings advice, many surgeons took to the operating room in an effort to improve the AVF rates in the U. S. In fact, the numbers improved dramatically—but not to the 80+% mark.

Dr. Larry Scher assures us that every arm can have a fistula created and if you are a good interventionalist (or have a good one with whom to work) you can get all of these to mature.

Therefore, all of those 2-2.5mm veins that might not seem “usable,” should be anastomosed carefully to the radial or brachial artery—much as one would perform a distal anastomosis—and coax them into maturing to functional AVFs. If balloon assistance is needed for maturation, make certain the “balloon operator” has a good working knowledge of AV access, lest a nice, big hematoma will greet you, destroying your nicely created AVF. Those of us who cannot achieve the near 100% AVF rate must be technically challenged!

COUNTERPOINT: Fistula First is a bit overdone

Great idea, good execution, too much!

As an early ideologue in the Fistula First movement, I am proud of what we accomplished—education. We got the word out that AVFs were a better option than Arteriovenous Grafts! At the introductory meeting, I did have a rather animated “discussion” with a social worker who was convinced that the reason AVGs outnumbered AVFs was because AVGs reimbursed higher and therefore the surgeons were choosing the AVG for financial reasons (Sometimes it is really hard to maintain your composure!) While it may be true in some quarters, I would venture that was not the real reason affecting the inability of us, as a profession, to deliver the AVF rate that we should.

My alter ego above mentions Drs. Larry Spergel and Tip Jennings—both of whom should be given great credit for opening our eyes to the need for reform. They lead us and we improved. However, the number of AVFs that are being done that are NOT maturing has increased. Just as in any “cult phenomena,” when adherence to a concept supersedes rational thought, the endpoint is blurred. This is what has occurred in the Fistula First.

There are some patients who will never mature an AVF—irrespective of the competence of the vascular surgeon! Many of the veins are simply phlebitic from years of intravenous or venipuncture attacks—now that the PICC teams have learned where the basillic vein is, that vein is often problematic. Additionally, one factor that has never been adequately measured or characterized is skin turgor. Many of our older patients have awful skin turgor and any access (AVF or AVG) will be accompanied by ongoing post-dialysis hematomas with problems.

Our experience has been that octogenarians tend to do better with AVGs than AVFs—heresy to the Fistula First pundits. The number of catheter days is markedly reduced and the long-term outcomes do not vary much in this age group. And guess what, there are some patients who actually do well with a catheter!

Perhaps, two topics are worth mentioning in closing this self-debating article! Fistula First has, appropriately, been renamed Fistula First, Catheter Last! This recognizes the fact that maybe not everyone is a candidate for an AVF—but at the least we should avoid the catheter! The second, much larger issue is whether everyone that is dialyzed should, indeed, be dialyzed! I suspect all readers have been pressured into placing a catheter (or worse) in a patient who has no real chance for a meaningful survival. Additionally, maybe some patients would benefit from nutritional therapy that could delay the onset of dialysis by 6-18 months—imagine how much that would save to an already overburdened system!

Dr. Sales is President, The Cardiovascular Care Group, Westfield , N.J., chief, division of vascular surgery, Overlook Medical Center, Summit, N.J., and clinical assistant professor of Surgery, Mount Sinai School of Medicine, New York, N.Y. Both versions of Dr. Sales are an associate medical editor for Vascular Specialist.