The evolution of dialysis access surgery over 38 years: One surgeon’s perspective

OBJECTIVES: The surgery for dialysis access has changed over the past 38 years. In the 1980s and 1990s, prosthetic grafts were the most common form of access. Then, autogenous fistulae had a rebirth due to their durability and decreased complications. The continued expansion of the dialysis population, coupled with the paucity of adequate superficial veins in many patients, required other techniques of dialysis access such as tunneled dialysis catheters, and more complex surgery on deeper veins. METHODS: This study of one surgeon’s practice over 38 years mirrors the extensive changes in dialysis access. The changes in surgical technique, interventional procedures, and approaches were documented and evaluated. RESULTS: During the 38-year period, there were 1531 autogenous fistulae, 409 prosthetic grafts, and 1624 tunneled dialysis catheters placed for access. The first 20 years had 130 autogenous fistulae with 302 prosthetic grafts, while in the last 10 years there were 740 fistulae and only 17 prosthetic grafts. Prosthetic grafts were not salvageable for a long term with exposure, infection, and persistent bleeding. Autogenous fistulae were best salvaged with autogenous tissue rather than prosthetic material. Interventional procedures were most valuable in stenting high-grade stenosis centrally and dilating areas of recurrent stenosis. They were not helpful in treatment of large aneurysms or as a long-term solution for persistent and/or massive bleeding. CONCLUSION: Dialysis access has progressed back to autogenous fistula. This may require longer use of tunneled dialysis catheters, and more surgical procedures, but the construction of an autogenous fistula can be achieved in many dialysis patients.