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The AV Fistula for Long Term TPN Administration
Jonathan D. Woody, MD1, Megan Lovett, RN, BSN, CRNI2.
1Athens Vascular Specialists, Athens, GA, USA, 2Athens Regional Medical Center, Athens, GA, USA.

OBJECTIVE
Long term total parenteral nutrition (TPN) administration requires central venous access. Long term central venous catheter (CVC) use is problematic. The Fistula First initiative highlighted the advantages of arteriovenous fistula (AVF) over CVC for hemodialysis. AVF may be the preferred access for long term TPN.
METHODS
A database was developed to prospectively monitor patients requiring long term vascular access. We identified five patients receiving long term TPN with recurrent CVC infections. They underwent creation of AVF for long term TPN. Patient characteristics and clinical outcomes were reviewed.
RESULTS
From 2006 - 2011, five patients underwent creation of AVF for TPN. All were dependent on TPN. Four had short gut syndrome. One had severe diabetic gastroparesis. There were four females and one male in the group. Mean age at the time of AVF was 56. Of the AVF, three were brachio-cephalic, one was a basilic vein transposition (BVT) and one was a cephalic vein transposition. Mean follow up is 23.7 months (range 11-62). Two AVF required percutaneous transluminal angioplasty. All three brachio-cephalic AVF matured. Two were used for TPN. One was never used for TPN but was ultimately used for hemodialysis. The BVT matured and was used for TPN. A poor quality vein was used for the cephalic vein transposition and it failed. All AVF created with adequate veins on pre-op duplex imaging matured. Two patients expired in follow up. No CVC infections occurred in patients using AVF for TPN. We developed a successful program to educate patients and their families about AVF and home access techniques for TPN. One barrier was the reluctance of payors and home health agencies to approve administration of TPN through a non-CVC route.
CONCLUSION
AVF is a safe and effective alternative for long term TPN administration. CVC related infections can be eliminated with the use of AVF for TPN. Patients requiring long term TPN should be referred for AVF. Our protocol for training patients and their families for home access of AVF results in the safe and effective administration of TPN. Efforts should be made to educate payors and other organizations that AVF is a safe and effective method for TPN administration and may be the preferred mode of access.


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