Impact of surgeon selection on access placement and survival following preoperative mapping in the "Fistula First" era.

According to the "Fistula First Initiative" surgeon selection should be based on best outcomes, willingness, and ability to provide access services. This analysis presents arteriovenous access placement and outcomes in 75 patients when surgery was performed by one of two dedicated high-volume vascular access surgeons (community [surgeon I] and academic medical center [surgeon II]). Preoperative vascular mapping was performed in all the patients. Demographic characteristics were similar except that patients referred to surgeon I (n = 40) were older (52.7 +/- 16.2 years vs. 45.4 +/- 13.7 years; p = 0.04) and tended to have more previously failed accesses (50% vs. 29%; p = 0.06) and black race (65% vs. 43%; p = 0.055) including a history of previously failed accesses (50% for surgeon I and 29% for surgeon II; p = 0.06). Similarly, there was no significant difference in the size of forearm ([surgeon I: 2.0 +/- 1.0 mm], [surgeon II: 1.9 +/- 0.8 mm]; p = 0.45) or upper arm veins (cephalic vein: surgeon I = 3.2 +/- 1.4 mm, surgeon II = 2.9 +/- 1.2 mm, p = 0.34; basilic vein: surgeon I = 5.0 +/- 1.2 mm, surgeon II = 4.7 +/- 1.3 mm, p = 0.25). Fistulae placement occurred in 98% vs. 71% (p = 0.001) for surgeon I and II, respectively. Characteristics predictive of fistula placement over an arteriovenous graft were surgeon selection (odds ratio [OR] = 19.52; p = 0.01) and no history of diabetes (OR = 7.61; p = 0.016). Kaplan-Meier analysis revealed 6 and 12 months overall access survival rates of 82%, 58% and 82% and 47% for surgeon I and II, respectively (p = 0.007). This analysis demonstrates that surgeon selection can have a significant impact on the rate of fistula placement and its overall survival despite similar findings on preoperative vascular mapping.