Increasing the proportion of diabetics with AV fistulas

Worldwide, older diabetic patients represent the most rapidly growing group of patients treated for end-stage renal disease (ESRD). Preexisting arterial as well as venous problems have led to a pessimistic view on the creation of vascular access in this population. During 1993-98 I created all primary arteriovenous (AV) accesses for a total of 181 patients with diabetes mellitus (DM) ESRD and 567 patients with ESRD due to all other causes (non-DM). The following approach led to good outcomes for both groups whether assessed by time to first intervention or time to failure: careful preoperative investigations for selection of adequate location for initial AV fistula through ultrasonographic techniques; timely surgical AV fistula creation; preference of large-diameter, "healthy" arteries and veins, frequently requiring use of the elbow region; absolute priority for use of native vessels (i.e., avoidance of initial polytetrafluoroethylene [PTFE]); meticulous surgical technique and creativity; and continuous surveillance by the nephrologist and staff allowing elective revisions and avoidance of thrombosis. With this approach AV fistulas rather than PTFE grafts can be created in most diabetic and nondiabetic patients.