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Collaborative Approach to the Creation of an Arteriovenous Fistula on a U.S. Navy Hospital Ship
Kimberly A. Thompson, MD1, Amrish Krishnan, MD2, Charles Stehman, MD1, Steven Hanling, MD1, Kevin Casey, MD1.
1Naval Medical Center San Diego, San Diego, CA, USA, 2Colonial War Memorial Hospital, Suva, Fiji.

OBJECTIVES: The creation of arteriovenous fistulas (AVF) decreases morbidity and mortality in patients with chronic kidney disease on hemodialysis compared to catheters. However, this surgery may not be available in low- and middle-income countries. We present the first reported case of a successful AVF creation as part of a humanitarian assistance mission (HAM).
METHODS: Multiple global health initiatives have recently been proposed, focusing on the need for universal access to surgical and anesthesia care, provided safely through a collaborative approach between surgeons, anesthesiologists, and host nation (HN) partners. Navy hospital ships have been participating in HAMs for over a decade. The patient was a 51 year old male with diabetes and poorly controlled hypertension on hemodialysis via a left internal jugular venous catheter for 6 months. Preoperative assessment and patient selection were closely coordinated with the HN nephrologist and dialysis team. Vein mapping was performed by the visiting vascular surgeon.
RESULTS: A right brachiocephalic AVF was created under regional block performed by the visiting team. There were no complications and the patient was discharged from the hospital ship on the first post-operative day. The surgical team provided formal didactic education on AVF anatomy, complications, and cannulation techniques to the HN dialysis team. The AVF matured and was successfully cannulated by the HN dialysis team 7 weeks after creation.
CONCLUSIONS: Through careful patient selection, preoperative planning, and close collaboration between the surgical team and HN physicians and nurses, AVFs can be created safely and effectively in an austere environment. This inaugural experience demonstrates that performing AVFs as part of HAMs has the potential to significantly reduce morbidity and mortality in low- and middle-income countries.

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