Program Book - Keck School of Medicine of USC - University of ...

When to Break the Guidelines in Vascular Access SurgerySamuel Eric Wilson, MD, FACSAt least eight national and professional organizations have given “Ex-Cathedra”guidelines for the performance of vascular access surgery. The Dialysis OutcomeQuality Initiative of the National Kidney Foundation, the Society of Vascular Surgery, theCanadian Society of Nephrology, Caring for Australians with Renal Insufficiency, TheBritish Renal Association and others have all issued recommendations. Theseguidelines are for the most part sensible, and as far as possible evidence based, butcannot conceivably provide the answer to every clinical situation. I will outline someimportant clinical presentations in which the patient will better be served by breakingthese guidelines.Over the last decade, the number of hospital admissions for end stage renal disease inNorth America has remained fairly stable at approximately 20,000 per year but thenumber of hospital days has dropped in half from 175,000 to approximately 60,000. Thedecreased duration of hospitalization is probably due to the shift in vascular accesssurgery to an outpatient basis and also because of better coordination of vascular carerather than a specific technical advance.Even so, one must give credit to the level of interest raised in access surgery by theattention of these various committees. In at least five situations, however, I think it is tothe patient’s benefit to vary from the guidelines.First, the brachiocephalic A V fistula should be constructed before a radiocephalic fistulawhen the success of the latter is in doubt. In a review of 155 AV fistula procedures, we62