Graft for immediate use as first stage of a native fistula
The majority of patients in the United States begin hemodialysis with a catheter. Many have immature or inadequate fistulae. At 90 days 77% of these patients are still using a catheter or a graft. The morbidity and mortality from prolonged catheter use have been well delineated. Although most of us adhere to the DOQI and Fistula First tenets, a fistula at all costs can seem counterproductive. A new paradigm is needed. The techniques described in this paper offer a novel approach to circumvent the problems of increasing catheter use and long fistula maturation times. The graft for immediate use is placed in the forearm and allows the proximal vessels to mature while providing dialysis access without a catheter. When these vessels meet maturation guidelines, or when surveillance indicates impending graft failure, a native fistula can be constructed and used in a 2-3 week period. This approach minimizes or circumvents catheter use altogether.
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