The Fistula First Breakthrough Initiative, originally known as the National Vascular Access Improvement Initiative, was launched in 2003 with a goal of increasing the use of AV fistulas (AVFs) and decreasing the use of long-term central venous catheters to improve quality of care for patients requiring maintenance hemodialysis.
Fistulas are recognized as the gold standard of vascular access because they last longer (sometimes for decades), need less rework or repairs, and are associated with lower rates of infection, hospitalization, and death. Drawbacks to fistulas are the typical waiting period of six weeks to three months before they are ready for use; they’re not an option for all people; and although they last longer, they most likely will eventually fail.
I often tell patients, “If God had intended for arteries to be sown to veins, he would have done it himself.” I also remind them that a vein is not meant to be stuck three times a week every week for the rest their lives. In looking at options for hemodialysis, however, AVFs are clearly superior to a catheter or AV graft.
The Fistula First campaign estimates that in America as many as 5,000 deaths could be prevented each year if more renal patients used AVFs. That, along with other advantages such as lower infection rates and fewer needed repairs, serves as the impetus for the campaign to have physicians make fistulas their first choice for patients requiring maintenance hemodialysis.
In March 2011, the national prevalent AVF use rate was 57.9 percent, which is short of the Fistula First goal of 66 percent but an impressive 25 percent increase since the initiative was launched. At the Premier Vascular Access & Imaging Center in Knoxville, we’re exceeding the Fistula First AVF placement goal, and we’re seeing the benefit of creating a healthier patient population.
One reason for our success is the nature of the Center. Because we have physicians and staff dedicated 100 percent to serving patients with kidney disease five days a week, we are in a position to be proactive instead of reactive. We are able to see and address potential problems with a graft before it develops serious problems, such as a thrombosis, that means it can’t be salvaged.
Successful AVF placement also requires two key components: 1) a good relationship and coordination with the nephrologist and nephrology team and 2) thorough and early education of patients. Patients don’t want to think about a fistula when they don’t yet need dialysis, but early surgery is a key for success.
Creating a fistula can be difficult and frustrating for the patient. The biggest misconception patients have with regard to AVFs is that creation of the AVF means it’s ready for dialysis. Often, these patients incorrectly believe that AVF placement requires one simple operation and 10 minutes later it’s ready for use. If a second surgery is needed or a revision is necessary, patients are unhappy.
Educating patients as to why they need the AVF and why the process is lengthy helps prepare them for potential difficulties and helps them better tolerate the necessary waiting period.
Achieving the highest AVF placement rates requires teamwork on the part of the various disciplines. Surgeons, nephrologists, dialysis clinic staff and other renal caregivers must work together to maximize the AVF opportunities for patients and optimize vascular access care and outcomes. We’re making great strides in this area, and I look forward to seeing even better patient results in the future.
Donald L. Akers Jr., MD, FACS, earned his bachelor’s degree from the University of Tennessee, Knoxville, and his medical degree from the University of Tennessee, Memphis. He completed his residency in General Surgery at Tulane University, New Orleans and fellowships in Vascular Surgery at the University of Cincinnati and Endovascular Surgery at the University of Tennessee, Knoxville. Akers joined Premier Surgical Associates in 2007, following a 16-year career as professor in Tulane University’s Department of Surgery. He practices at Premier’s Physicians Regional, North Knoxville and Jefferson City offices and at the Premier Vascular Access & Imaging Center.