Achieving vascular access success in the quality outcomes era

Background In 1997 the National Kidney Foundation put forth guidelines for hemoaccess through its Dialysis Outcomes Quality Initiative (DOQI). Some centers have been able to meet these standards; most have not. Methods A retrospective review was made of our database of more than 3,500 hemoaccess procedures from 1986 to 2003. Results Our approach, increased use of transposed fistulas and preoperative duplex mapping, has led to a fistula incidence (84%) and prevalence (54%) exceeding DOQI criteria. Meeting the DOQI guideline for thrombectomy rate (0.5 per year) is mostly achieved by increased use of fistulas. Additionally, access monitoring, as well as intraoperative angiography, angioplasty, stenting, and surgical revision, can aid in decreasing the frequency of occlusions (0.45 per year). This operative approach has led to a 98% success rate for surgical thrombectomy, exceeding the DOQI guideline of 85%. Earlier referrals from nephrologists have lowered the catheter use prevalence to 9%. Conclusions An aggressive approach to placing fistulas, maintaining the access, and receiving prompt referrals can lead to success in meeting DOQI criteria.