Complications, while a nuisance for some types of vascular surgery, in dialysis access they can be life threatening with sepsis, bleeding and metabolic derangements.:
METHODS: I have reviewed my 35-year experience of treating dialysis access complications. There were significant changes in the types of complications and their approach due to the transition to autogenous fistulae from prosthetic grafts for dialysis access. In this study there were 4,283 procedures performed upon 2,872 patients. RESULTS: There were 1,285 autogenous fistulae constructed and 409 prosthetic grafts for dialysis access. The majority of the prosthetic grafts were performed in the earlier years with the autogenous fistula being the major dialysis access in the later years. Thrombosis was the most common complication. Autogenous fistulae had a combined patency rate of 71.51% while prosthetic grafts had a patency rate of 54.03%. Stated another way, the prosthetic grafts thrombosed over time 45.96% of the time while autogenous fistula only had a thrombosis rate of 28.48%. In reviewing other complications: there were 15 patients (1.15%), 16 occurrences over the study period with life threatening hemorrhage. These occurred primarily in autogenous fistulae (15) and were treated with ligation, repair or interposition grafts. Herald bleeds were much more common occurring 43 times (3.3%) in 29 patients. Here again they were more common in autogenous fistulae (39) but were repaired and salvaged in 33; ligated in 1, stented in 8 and two repaired with prosthetic. Infectious complications presented in several varieties. Some patients presented with cellulitis (5.6%) (59 patients and 73 occurrences), others presented with ulcers on autogenous fistulae (11 patients ,0.8%) or grafts (7 patients), and 10 (.76%) presented with exposed prosthetic grafts. There were a total of 38 (2.99%) patients (39 occurrences) with steal. Aneurysms requiring treatment occurred in 54 (4.14%) patients, 19 in autogenous fistulae and 35 in prosthetic dialysis access grafts. CONCLUSIONS:
Treatment of complications of dialysis access has become more complex and technically demanding with the increase in autogenous fistulae. Most complications in prosthetic grafts were significant and could not be resolved for the long term. Autogenous fistulae offer a better chance at ultimate repair and salvage than prosthetic grafts, in both bleeding issues and infectious problems. Interventional techniques only rarely provide more than transient results.
