Abstract
The number of diseases requiring maintenance hemodialysis has lately increased along with the number of patients.
Consequently, long-term survival has been steadily increasing. As the result issues, blood access-related problems have become one of the most important in hemodialysis therapy.
In the years 1984 through 1986, 115 surgical procedures were carried out at our institution to repair nonfunctioning or poorly functioning blood accesses in 105 patients.
Most of such patients were female and the peaks of repair surgery occurred during 1-2 years and from 7 years after hemodialysis initiation.
Early failure of the access was considered most likely to be due to poor condition of vessels. Even though vessels might be satisfactory for the establishment of initial blood access, vessels especially veins are-gradually damaged by continuous pressure load on arterialized veins and also by frequent puncture.
Ectopic calcification is most frequently seen in vascular walls, which also damages the vessels and causes poor blood flow and/or thrombosis; surgery to establish a vascular access may therefore be difficult.
The condition of internal AV-fistula must be evaluated in each hemodialysis procedure from findings of inspection and palpation, puncturability, obtainable blood flow and venous pressure.
Simple X-P, echo, fistulography and thermography must be undertaken thoroughly without delay if necessary; these approaches yield a lot of information for repair surgery.
Poor or decreased fistula flow due to venous sclerosis and or stenosis was the most common reason for repair surgery in this series and thrombosis due to the same cause ranked next.
In 7 out of 115 operations, only superficialization of the arteries was possible; 6 out of 7 cases were transferred to CAPD thereafter.
A graft (Gore-Tex) was used in 24 cases (20.8%). In the remaining cases repair or re-anastomosis was possible proximal to the initial AV-fistula. Techniques for repair or re-anastomosis are apt to vary because of the wide range of causes and degree of access-related problems.
The following considerations are mandatory for blood access-related surgery: (1) Is repair technically possible? (2) Is an artificial graft necessary? (3) Will repair facilitate further long-term use? (4) Will repair create new problems? (5) Will puncture be possible 1-2 days after surgery?
Early diagnosis and prompt treatment considering the above-mentioned factors can prolong blood access patency.
