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7. Gradman WS, Lerner G, Mentser M, Rodriguez H, Kamil ES. Expe-rience with autogenous arteriovenous access for hemodialysis in chil-dren and adolescents. Ann Vasc Surg 2005;19:609-12.

8. Kim AC, McLean S, Swearingen AM, Graziano KD, Hirschl RB. Two-stage basilic vein transposition-a new approach for pediatric dialysisaccess. J Pediatr Surg 2010;45:177-84; discussion: 184.

9. Sheth RD, Brandt ML, Brewer ED, Nuchtern JG, Kale AS,Goldstein SL. Permanent hemodialysis vascular access survival in chil-dren and adolescents with end-stage renal disease. Kidney Int 2002;62:1864-9.

10. Thompson BW, Barbour G, Bissett J. Internal arteriovenous fistula forhemodialysis. Am J Surg 1972;124:785-8.

11. Wander JV, Moore ES, Jonasson O. Internal arteriovenous fistulae fordialysis in children. J Pediatr Surg 1970;5:533-8.

12. Quinn BM, Cull DL. Hemodialysis access: complex. In: Cronenwett JL,Johnston KW, editors. Rutherford’s vascular surgery. 7th ed. MarylandHeights, MO: W.B. Saunders; 2010. p. 1119-20.

13. Sidawy AN, Gray R, Besarab A, Henry M, Ascher E, Silva M Jr, et al.Recommended standards for reports dealing with arteriovenous he-modialysis accesses. J Vasc Surg 2002;35:603-10.

14. Fistula First Breakthrough Initiative Annual Report. 2010. Available at:http://www.fistulafirst.org/LinkClick.aspx?fileticket¼dtRHh5AoBiY%3d&tabid¼86. Accessed December 30, 2013.

15. Agarwal AK. Central vein stenosis. Am J Kidney Dis 2013;61:1001-15.16. Lacson E Jr, Lazarus JM, Himmelfarb J, Ikizler TA, Hakim RM.

Balancing Fistula First with catheters last. Am J Kidney Dis 2007;50:379-95.

17. Shingarev R, Barker-Finkel J, Allon M. Association of hemodialysiscentral venous catheter use with ipsilateral arteriovenous vascular accesssurvival. Am J Kidney Dis 2012;60:983-9.

18. Teruya TH, Abou-Zamzam AM Jr, Limm W, Wong L, Wong L.Symptomatic subclavian vein stenosis and occlusion in hemodialysispatients with transvenous pacemakers. Ann Vasc Surg 2003;17:526-9.

19. Chand DH, Valentini RP, Kamil ES. Hemodialysis vascular accessoptions in pediatrics: considerations for patients and practitioners.Pediatr Nephrol 2009;24:1121-8.

20. Jennings WC, Turman MA, Taubman KE. Arteriovenous fistulas forhemodialysis access in children and adolescents using the proximalradial artery inflow site. J Pediatr Surg 2009;44:1377-81.

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Submitted Nov 18, 2013; accepted Jan 20, 2014.

DISCUSSION

Dr Robert J. Hye (San Diego, Calif). Dr Wartman and hercolleagues at the University of Southern California have presenteda 13-year experience of creating 101 arteriovenous fistulas in 93patients. The procedures were performed by only two surgeons.The bulk of the procedures were radiocephalic fistulas, but therewere a significant number of brachiocephalic and basilic transposi-tion fistulas, and a small number of femoral transpositions. Eight-two percent of the patients were already on hemodialysis at thetime of fistula creation, and 78% had a prior central venous cath-eter. Overall, their results are excellent and consistent with otherpublications, with primary patency of 83% and secondary patencyof 92%. The authors found that gender, weight, etiology of renalfailure, previous central venous catheter and their location, andwhether the patient was already on dialysis had no impact onpatency. Only age influenced fistula patency.

Strategies for management of renal failure are a little differentin the pediatric population, with preemptive transplant being thefirst preference and peritoneal dialysis also being more prevalentthan in adults. Nevertheless, >50% of pediatric patients requiringrenal replacement therapy end up on hemodialysis. Despite KidneyDisease Outcomes Quality Initiative guidelines recommendingarteriovenous fistula (AVF) as the preferred hemodialysis accessand literature showing short- and long-term success rates thatare even better than in adults, the majority of pediatric patientsreceiving hemodialysis are dialyzing via central catheters. Reviewof the manuscript does raise several questions:

The most important factor in dialysis access is usability, not fis-tula patency, yet you only report on the latter. Can you tell us howmany of these fistulas were actually used and for how long?

Can you explain why you believe that age impacted fistulapatency but not weight? It would seem that the two variablesshould track each other to some extent.

There is no apparent analysis of outcomes depending on fistulatype. I know the numbers are small, but did you evaluate whetheryour outcomes were different for different types of fistulas?

Can you tell us what proportion of your overall pediatric dial-ysis population this report represents? What percentage of patients

at your institution are dialyzing via catheters and are on peritonealdialysis?

Finally, there was little information in the manuscriptregarding the decision-making process that was used for fistulatype selection and technical details of you procedures that mighthelp others achieve these type of excellent results. Can you provideus any information regarding those issues? I enjoyed the presenta-tion and complement the authors on their results.

Dr Sarah M. Wartman. We would like to thank Dr Hye forhis thoughtful comments and questions. Indeed, pediatric end-stage renal disease patients have certain considerations that aredifferent from the adult population. As Dr Hye has mentionedin his discussion of our paper, there is a significantly higher per-centage of pediatric patients dialyzing through catheters thanadult hemodialysis patients. The question of why remains to beanswered and is outside the scope of this study. It is, nevertheless,a source of concern when studying pediatric hemodialysis, and wehave an ongoing project that is designed evaluate the decision-making process of pediatric hemodialysis patients and their par-ents when choosing a catheter vs a fistula. Because our currentpaper specifically addresses outcomes with AVF placement, wedid not expand our data collection to include all hemodialysisand peritoneal dialysis patients at our institution and, therefore,did not capture the percentage of patients that dialyzed througha catheter or with peritoneal dialysis.

In general, all fistulas were performed with a standard end-to-side anastomosis with a continuous running monofilament suture,with tourniquet occlusion in selected cases. Loupe magnificationwas used for all cases and an operating microscope was used byone of the two surgeons on a case-by-case basis. Femoral veintransposition technique is described in Rutherford’s Vascular Sur-gery and includes references to a technique described and reportedby Dr Wayne Gradman. All basilic and femoral vein transpositionswere performed in one stage. In our study, fistula patency was notaffected by the location of the fistula. Although the subset analysiswas limited by small numbers in some groups, it did not appear tochange the outcomes for patency.

JOURNAL OF VASCULAR SURGERY6 Wartman et al --- 2014

Regarding fistula patency, we defined our patency as functionalpatency where a fistula was considered patent only while being usedby the patient. For a large cohort of patients in this study, the endof fistula patency was their date of transplant, regardless of the factthat their AVF could still be accessed and was still technically pat-ent. In fact, there were some patients that actually went back to us-ing their original AVF after transplant failure, but due to theinability to follow all patients for this possible outcome, we did

not include this time period our analysis. With this in mind, ourpatency data is an accurate reflectiondif not an underestimationdof the usability of our patients’ arteriovenous fistulas.

Finally, the reason for the significant impact of age, but notweight, on fistula patency was perplexing to us. It is possible thatthe size of vessel is not reflected as much by the patient’s weightas it is by their age. In addition, only 5% of our patients weighed<20 kg, which may have impacted our analysis.