The earliest vascular access was achieved by the introduction of intravenous glass cannulae in the early 1990; these were replaced in the 1950s by plastic cannulae which allowed prolonged intravenous infusion. Attempts to extend the duration of infusion and to use more concentrated solutions for intravenous feeding in the 1950s led to the development of central venous cannulation, made possible by the development of longer catheters and less thrombogenic plastics .This technology advanced in the 1970s with the introduction of Teflon and Silastic coated catheters.
The advent of haemodialysis, pioneered by Kolff in 1944, introduced a new requirement for repeated high volume blood flow both into and out of the circulation .Cannulation of the arteries resulted in early thrombosis. A major advance was the realization that the formation of an artificial arteriovenous fistula [avf] resulted in massive enlargement of veins sufficient to allow repeated cannulation and the Brescia-Cimino forearm fistula, first described in 1966, remains the mainstay of haemodialysis access today.
Aim of the study is to have the attention of all medical team toward patients under haemodialysis in order to better follow their disease advance, in order to improve patients’ quality of life.
Material and Methods:
This is a study done in 74 patients that underwent the operation for arteriovenous fistula creation. All patients were in end stages of chronic renal insufficiency [CRI].Median age is been 40 years old, 30 patients were males and 33 females. In 100% of the cases high stage of secondary anemia and blood hypertension were present as associated disease. In 95 % of patients a central venous catheter was inserted before arteriovenous access creation. In 28 cases radio-cephalic, 40 cases brachial-cephalic, 6 cases ulno-basilica fistulas were created.
All patients had a blood creatinine level ranging 7.5-13 mg/dl.No one of the avf exceeded 6 weeks till in the first puncture. Study is of the retrospective character.
In 50 patients avf continue to work. In 24 patients reoperation is needed.
Reoperations have consisted:
New avf 2 procedures, angioplasty 16 procedures, hemostasis due to wound bleeding 4 cases.
Reoperated cases suffered also: Diabetes mellitus, kidney abscess, phlebothrombosis, colostomy, exhausted vascular net.
Arteriovenous fistula patency is: 1 month 97%, three months 95, 6%, six months 90.2 %, one year 80 %, and two year 78,7 %.
In comparison with results referred to serious studies our results are worse .In such studies the one year patency is about 90%, in our cases is 80 %.
What we should improve?
Following the Recommendations of Dialysis Outcomes Quality Initiative [DOQI].
A patient CRI should be referred for avf creation when:
1-Creatinine clearance is < 25 ml/min.
2-Blood creatinine > 4 mg/dl.
3-Tha patient will need hemodialises within one year.
A part of the above mentioned, preservation of the venous net, a better study of the limb vascular net, are necessary. Also a better preparation of the patient who will undergo operation is needed. It is important that patients are neither fluid neither overloaded nor dehydrated. Postoperative care is important too. The patients must take care of the wound, inadvertent local pressure, dehydration, hypotension and accurate their health in proper time.
Basilic vein transposition
Intimae hyperplasia of cephalic vein
Patient with good venous net
The patency of avf can improve if:
1-The patient has no associated disease.
2-Have good vascular net.
3-The patients have their best clinic and biochemical parameters.