Increasing numbers of AV fistulas for hemodialysis access

As part of our CQI program, we initiated an effort to see if we could successfully increase the total number of native arterio-venous (AV) fistulas relative to synthetic PTFE grafts in our dialysis population. This was a combined effort of the nephrology and surgery departments. The program emphasized placement of brachial fistulas in elderly patients and diabetics. Permcaths were placed in the internal jugular position to allow adequate time for maturation of fistulas. The percentage of AV fistulas in our total dialysis population increased from 28% (93 of 328) in the base period 1990 through 1992 to 44% (170 of 386) in the period from 1993 through 1995 (p < 0.0001). Initial AV fistula insertions increased from 38% (52 of 137) in 1990-1992 to 71.8% (102 of 142) in the years 1993 through 1995 (p < 0.0001). 86.5% (45 of 52) of initial fistulas placed in 1990-1992 were useable compared to 63.7% (65 of 102) in 1993-1995 (p < 0.01). Patient demographics were unchanged throughout the study. In conclusion, the number and percentage of AV fistulas in our dialysis population was significantly increased through a coordinated CQI initiative. We expect that this will have a positive impact on decreasing future thrombosis rates and decreasing the cost of access management.