The first fistula: influence of location on catheter use and the influence of catheter use on maturation

The forearm location for the initial vascular access has traditionally been considered the most desirable; however, recent advances in our understanding the physiology of fistula development suggest that the larger proximal vessels with higher blood flows may be associated with increased wall stress and faster fistula development. We examined whether the location of a first fistula had any relationship to the incidence and duration of catheter use. This was an observational study of 808 patients who underwent the creation of an autologous arteriovenous fistula for their first hemodialysis access who were evaluated for the length of use of a temporary catheter. The variables studied for their effect upon catheter use included: location in the forearm or upper arm, age, the presence of diabetes, vascular disease or smoking history. Despite being younger (P < 0.0001), nondiabetics (P < 0.0001), without vascular disease (P < 0.0001), and placed longer before initiation of dialysis (P = 0.03), the patients with forearm fistulas were significantly more likely to need a catheter to start dialysis (P < 0.0001) and the length of use was significantly longer than in upper arm fistulas. Fistulas place prior to initiation of dialysis required shorter maturation time. The upper arm as the initial site for fistula creation was associated with a significantly reduced incidence and prevalence of catheter use when the patients began dialysis. Fistulas placed prior to the initiation of dialysis had significantly shorter maturation times than those created after a catheter had been inserted which might be due to delayed maturation caused by the catheter.