Department of Surgery University Hospital Maastricht The Netherlands Email: j.tordoir{at}surgery.azm.nl
Sir,
We acknowledge the special experience and success rates of Turmel-Rodrigues in the field of radiological interventional treatment of vascular access complications. Until now, no-one has been able to equal his high percentage of successful treatment of failing or immature fistulas. In this observation lies the weakness of Turmel-Rodrigues opinions and statements. He reports from a single centre experience with patients that were referred from other hospitals for interventional treatment. In our series, a consecutive group of patients with new radiocephalic AVFs created by a single surgeon were prospectively followed with clinical examination and duplex scanning. On defined criteria, angiography and when stenoses were detected an intervention was performed. The patients treated by Turmel-Rodrigues were likely preselected and therefore experienced a higher percentage of anatomical abnormalities.
We agree that deeply located veins not accessible for cannulation are not suitable for radiological intervention, but should be surgically revised. However, we do not consider these patients to have immature fistulas, but cannulation problems. An adequate imaging of immature AVFs is of utmost importance for treatment planning. In all our patients angiography with retrograde filling of the radial artery was sufficiently accomplished in all. In fact, the anastomotic complex and outflow vein, at which side most stenoses appear, were excellently visualized. Thus, Turmel-Rodrigues may argue about misdiagnosis of stenosis, but this view is not supported by facts. In the same line as this observation, we cannot agree with the idea that all immature AVFs can be salvaged by interventional treatment. If there is no stenosis you simple cannot treat it. And we all know that in particular in diabetics or patients with peripheral sclerotic arteries, stiffness and non-compliance may hinder maturation.
Our policy in this prospective study was to treat anastomotic stenoses with surgery and outflow stenosis with PTA. It depends on local customs whether to operate or to intervene on anastomotic abnormalities and when considering this issue, many roads may lead to Rome. In patients with insufficient wrist vessels noticed during operation and in need of an alternative vascular access, it was not possible to obtain brachiocephalic AVFs, because of the poor suitability of the upper-arm cephalic vein. In these patients, prosthetic grafts were implanted, which could be cannulated within 3 weeks. Of course, we are aware of the international literature on native and prosthetic AVFs, which report different outcomes of both types of vascular accesses. We recently published on the use of prosthetic grafts with 1 year secondary patencies of 8090% and these are really better than those reported by other authors.
It may be vital to obtain autogenous fistulas in all patients, but not at any price. Better shoot yourself in the foot, than cause sepsis in the patient, due to the central vein catheters necessary because of the lack of sufficient and matured vascular access.
Conflict of interest statement. None declared.