Balancing 'fistula first' with a 'catheter last' strategy.

Endovascular treatment, in general, is a safe and effective method to assist a fistula to maturation, although this does not mean that surgical revision is not better in some patients. An experienced interventionalist should be able to discern the most appropriate treatment modality based upon physical exam, duplex ultrasound, and/ or fistulogram. The care of a hemodialysis patient is truly a team endeavor, including the primary care physician, nephrologists, dialysis nurses and coordinators, and the interventionalists. Each must be aware that options exist to assist many slowly or non-maturing fistulas in order to establish a usable, functional fistula as soon as possible to limit the frequent complications associated with tunneled catheters. Even diffusely small veins are not beyond the reach of therapy as evidenced with the BAM procedure. Early evaluation following fistula placement (three to four weeks) with quick referral to an experienced interventionalist is crucial. There is emerging data suggesting that there is no negative effect on patency with early cannulation of fistulas, even as soon as one month. Perhaps in the near future we might see an even greater impact on the prevalence of tunneled catheters with the emergence of earlier cannulation of fistulas, along with more aggressive intervention to slowly maturing fistulas, such as the BAM procedure. As experience with the BAM procedure grows, there may be a role for BAM in patients with a suboptimal vein on preoperative vein mapping (< 2.5 mm). These patients, who traditionally would have received a prosthetic graft, might be candidates for fistula placement followed by a preplanned BAM, initiated within weeks of the initial placement. The cost effectiveness and utility of such a strategy is unstudied and would be a good subject for future trials.