Fistula versus catheter outcomes: the importance of surgical training

To the Editor: Blake et al.1 question current guidance indicating that fistulas provide superior outcomes compared with cuffed catheters for dialysis vascular access. They note that the high surgical failure and complication rates of fistulas in the United States would be unacceptable with most other operations, and they call for a randomized controlled trial of fistulas versus catheters among older, frail patients. They speculate that the lower mortality seen with functioning fistulas in observational studies may simply reflect exceptionally good underlying health among these patients. There is another hypothesis to consider, however: properly constructed fistulas may truly be superior to catheters, but substandard surgical technique may cause undesirable results. The Dialysis Outcomes and Practice Patterns Study has shown higher patient survival, and lower hospitalization for infection, with fistulas, when analyses are conducted at the patient or the facility level, even after extensive adjustment for demographic factors and comorbid conditions.2 In Japan and several European nations the prevalence and survival of fistulas are far greater than in the United States, after thorough adjustment for case-mix, and new fistulas are successfully used many weeks earlier after placement.3 It is very important to note that prior surgical training is significantly associated with fistula success in clinical practice, but US surgeons place far fewer fistulas during training and indicate much lower emphasis by their mentors on creating fistulas than do surgeons abroad.4 Perhaps it would be worthwhile to investigate outcomes following improved training in fistula surgery before expending resources on a trial comparing poorly created fistulas versus catheters.