FISTULA FIRST

1
Publication No. 8041-OH-009-9/2006. This
material was prepared by Ohio KePRO, the Medicare
Quality Improvement Organization for Ohio, under
contract with the Centers for Medicare Medicaid
Services (CMS), an agency of the U. S. Department
of Health and Human Services. The contents
presented do not necessarily reflect CMS policy.
2
Faculty Disclosure Statement
The speakers do not have any financial interest
or affiliation with any corporate organizations
associated with the manufacture, license, sale,
distribution or promotion of a drug or device.
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FISTULA FIRST

• A SURGEONS
• PERSPECTIVE
• Ronald A. Savrin, MD
• Medical Director

4
WHY FISTULA ?

• LASTS LONGER
• LOWER INFECTION RATE
• LASTS LONGER
• FEWER COMPLICATIONS
• LASTS LONGER

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PRIMARY SECONDARY PATENCY

• 2247 NEW ANGIOACCESS
• PROSTHETIC GRAFT (AVG) - 70
• ARTERIOVENOUS FISTULA (AVF) - 22
• VENOUS TRANSPOSITION (VTF) - 8
• FIRST ACCESS PROCEDURE - 70
• NON-SMOKER - 56
• DIABETES - 54
• MALE SEX - 53
• AFRICAN AMERICAN - 34

Gibson et.al. JVS 2001 34(4) 694-700
Gibson et al, JVS 34(4) 2001 US Renal Data
System Dialysis M M Study
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FISTULA FIRSTPRIMARY PATENCY
56
44
40
P .008
38
28
25
Plt.001
Plt .001 p.008
FISTULAS LAST LONGER THAN GRAFTS
7
FISTULA FIRSTSECONDARY PATENCY
73
72
68
64
60
60
BUT GRAFTS ARE HIGH MAINTENANCE
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FISTULA FIRSTaRR 10 FAILURE - REVISION
ALL ANGIOACCESS (AVF AVG) PROCEDURES
Plt.001
P lt .001
Plt.001
Plt.001
P .004 P .827
P .032 P .057
P .112 P .167
v NON
v NON - AA
v FEMALE
V FISTULA
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FISTULA FIRST10 FAILURE REVISION RATE

• GRAFTS FAIL--
• 41 INCREASED RISK OF FAILURE
• 91 HIGHER REVISION RATE
• FIRST CHANCE BEST CHANCE
• SUBSEQUENT PROCEDURES HAVE A
• 81 HIGHER RISK OF FAILURE
• 83 HIGHER REVISION RATE

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aRR PRIMARY FAILUREGRAFT V FISTULA
GRAFT BETTER
FISTULA BETTER
Secondary Procedure
First Procedure
DM
No
AA
Non- AA
Female
Male
gt 66
lt 66
FISTULA IS ALWAYS BETTER !
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AVF AVG META ANALYSIS

• 34 STUDIES 76 AFTER 1990
• 3,094 PRIMARY PROCEDURES
• NONE RANDOMIZED (AVF V AVG)
• LIFE TABLE OR KAPLAN MEIER
• PATENCY ABLE TO DIALYZE

Huber et al, JVS 38(5) 2003
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AVF AVG -- 10 PATENCY
6 MONTHS
18 MONTHS
13
AVF AVG -- 20 PATENCY
6 MONTHS
18 MONTHS
14
FISTULAS ARE ALWAYS BETTER THAN GRAFTS
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FISTULA FIRST TACTICS

• EARLY SURGICAL REFERRAL
• BARRIERS
• NOT READY FOR DIALYSIS -- YET
• MAY BE ABLE TO AVOID DIALYSIS
• PATIENT IN DENIAL
• IMPORTANCE
• PROTECT VEINS
• REQUIRES TIME TO MATURE
• LATE REFERRAL MAY BIAS SURGEON
• QUALITY SURGICAL REFERRAL
• DARWINIAN SELECTION PROCESS
• PAY FOR PERFORMANCE

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FISTULA FIRST - TACTICS

• FULL RANGE AVF EVALUATION / PLACEMENT
• VENOUS MAPPING
• UPPER ARM FISTULAE
• TRANSPOSITION
• EDUCATION STAFF PATIENT
• IMPORTANCE OF FISTULA FIRST
• PROTECT POTENTIAL ACCESS SITES
• VENIPUNCTURE
• IV ACCESS

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FISTULA FIRST -- TACTICS

• MONITORING
• ADEQUATE DIALYSIS
• FLOW RATE / VENOUS PRESSURES
• ULTRASOUND
• EARLY SECONDARY INTERVENTION
• OUTFLOW STENOSIS
• ANEURYSM FORMATION
• A-V ADVERSE HEMODYNAMIC CHANGES
• LOCAL -- REGIONAL -- SYSTEMIC

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FISTULA FIRST-- IT WORKS
KAISER PERMANENTE SOUTHERN CALIFORNIA
GOAL FISTULA FIRST
88
MULITDISCIPLINARY TEAM
ALGORITHMS FOLLOWED
62
EDUCATION - STAFF
38
34
Glazer, et al. Ann Vasc Surg 20 (1), 2006
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Raynell Kinney, RN, CNN, Quality Improvement
Director The Renal Network, Inc.