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• W4242438089 abstract "The authors report a randomized, controlled trial comparing autogenous radiocephalic and prosthetic forearm accesses in patients with compromised vessels for the autogenous choice. They should be commended for their efforts and study design given the limited evidence in the literature to justify the choice of the various access configurations. Indeed, the paucity of level 1 evidence is staggering given the overwhelming number of patients on hemodialysis in the United States and abroad. The authors found that the primary (33% vs 44%) and secondary (52% vs 79%) annual patency rates were higher for the prosthetic accesses, although the associated complication (1.19 patients per year) and intervention (0.94 patients per year) rates were also greater. These results are not particularly surprising given the study inclusion criteria for the autogenous access (radial artery diameter between 1 and 2 mm and/or cephalic vein ≤1.6 mm) and the mean diameters for the brachial artery (3.8 mm) and the cephalic vein (3.1 mm) in the prosthetic group. It is not particularly clear how the results of the study should affect our clinical practices. Extending the indications for the autogenous radiocephalic access to patients with compromised vessels affords another access option that does not preclude a subsequent prosthetic forearm access. However, there is a significant downside to accesses that never mature sufficiently for cannulation, including the prolonged use of temporary catheters among the patients already on hemodialysis and the associated economic/psychologic effects. Indeed, the increased emphasis on autogenous accesses in the United States has resulted in the unintended consequence of increasing their primary failure rates (nonmaturation). The more pivotal question that merits a randomized, controlled trial is the choice between a prosthetic forearm loop or an autogenous brachiobasilic access given the K/DOQI that recommend the autogenous radiocephalic and brachiocephalic routes as their first and second access choices, respectively. The results of the current study can be used to reach the opposite conclusion and seem to justify extending the indications for autogenous radiocephalic access to these compromised patients. Indeed, the patency rates for the autogenous and prosthetic accesses seem to parallel each other after the initial failures are excluded, and it is conceivable that the longer-term patency rates (>1 year) for the autogenous accesses may be superior. Furthermore, the results underscore the importance of pre–end-stage renal disease care and the importance of early referral to an access surgeon before initiating dialysis to allow adequate time to achieve an effective access. It is imperative to realize that maintaining an effective hemodialysis access is a difficult problem that usually requires multiple procedures and interventions and lifelong planning. Autogenous radial-cephalic or prosthetic brachial-antecubital forearm loop AVF in patients with compromised vessels? A randomized, multicenter study of the patency of primary hemodialysis accessJournal of Vascular SurgeryVol. 42Issue 3PreviewThe construction of an autogenous radial-cephalic direct wrist arteriovenous fistula (RCAVF) is the primary and best option for vascular access for hemodialysis. However, 10%-24% of RCAVFs thrombose directly after operation or do not function adequately due to failure of maturation. In case of poor arterial and/or poor venous vessels for anastomosis, the outcome of RCAVFs may be worse and an alternative vascular access is probably indicated. A prosthetic graft implant may be a second best option. Full-Text PDF Open Archive" @default.
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• W4242438089 date "2005-09-01" @default.
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• W4242438089 title "Invited commentary" @default.
• W4242438089 doi "https://doi.org/10.1016/j.jvs.2005.05.024" @default.
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