First and foremost, big shout out to the Eastern Vascular Society for hosting and organizing a thoroughly educational and enjoyable conference at Savannah, Georgia. I am writing this article during my second day here, staying at the gorgeous Westin resort. This conference is not as big as the SVS annual meeting, but it is more intimate and definitely just as informative. The few mosquito bites here and there are no biggie (I am blood type B).
Day one was all about dialysis; topics included access, maintenance, trouble shooting, and various decision making along the way. I would like to use the topic of dialysis access to show you the power of outcome research.
Many of you reading my blog are students, and I am sure some of you find outcome research in medicine boring, and frequently don’t seem like they apply to daily practice. I will show you that this is not the case, and it is in fact important to carry out more well designed studies and trials so we can create a “bank” of statistically powerful data so we can fall back on them when necessary.
When talking about whether hemodialysis is the best option for patients who are near the end of the road, Dr. Clifford Sales from Westfield NJ cited the data that in octagenarian with ESRD going on dialysis, the mean survival is around 1 year. This has tremendous implication on decision for creating dialysis access. Many of you know, the comparison between AV fistula vs. AV graft can be put simply that AVF is more durable and has less complications such as thrombosis and infection, but takes longer to cannulate and mature (4-6 weeks), whereas AVG can be cannulated much sooner (in 24 hours in some) but has less patency with prolonged use and more complications along the way. It is still advocated to create a native AVF in patients, but what do you think is the best choice of hemodialysis access for octagenarian with the mortality outcome data I presented to you earlier?
Answer is AVG becomes a much more attractive option, perhaps the preferred option. Why? It can be used quickly compared to AVF, so it brings the patient back to a relatively better quality of life when he/she is most likely at the end of the road. With survival of around one year, many complications associated with AVG would not surface, as it is not used long enough to induce thrombosis, infection, seroma, etc. This outcome data is amenable to change, as medicine progresses and octagenarian lives longer, even with ESRD (further highlighting the importance of constantly making progresses and updating on clinical research). In addition, patient with ischemic heart disease and ESRD have poor survival on hemodialysis, so delaying surgery for dialysis access and managing them conservatively are preferred.
You see the importance of clinical research on outcome of patient receiving treatment modalities such as different hemodialysis access, with different patient characteristics and co-morbidities. This has significant applicability on our decisions as surgeons, and definitely guides treatment. This is but a small example of many important clinical trial and followup studies that are going on currently. I urge all of you to learn your basics on the journey of becoming a great surgeon and doctor, but keep updated on the current research on your interested field.