Collaborative Approach to the Creation of an Arteriovenous Fistula on a US Navy Hospital Ship
Kimberly A. Thompson, MD, Amrish Krishnan, MD, Charles Stehman, MD, Steven Hanling, MD, and Kevin Casey, MD
ABSTRACT
Early creation of arteriovenous fistulas (AVFs) decreases morbidity and mortality in patients with end-stage renal disease and is the standard of care in the United States. However, this procedure is frequently not accessible in low- and middle-income countries (LMICs). We present the first reported case of successful AVF creation as part of a humanitarian assistance mission. The patient was a 51-year-old male with diabetes, hypertension, and end-stage renal disease on hemodialysis via a temporary dialysis catheter. Preoperative assessment and patient selection were coordinated with the host nation (HN) nephrologist and dialysis team. The visiting surgical team provided education on AVF anatomy, complications, and cannulation techniques to the HN dialysis team. A left brachiocephalic AVF was created under regional anesthesia performed by the visiting surgeon and anesthesiologists. There were no postoperative complications, and the AVF was matured and accessed successfully by the HN dialysis team 7 weeks after creation. Performing AVFs as part of humanitarian assistance missions has the potential to significantly reduce morbidity and mortality in LMICs.
Keywords
hemodialysis access, arteriovenous fistula, humanitarian assistance, low- and middle-income countries, Pacific Partnership
Introduction
Recent global health initiatives have been focused on the need for universal access to surgical and anesthesia care, provided safely through a collaborative approach between surgeons, anesthesiologists, and host nation (HN) partners. The United States Naval Ship (USNS) Mercy (T-AH-19) has been participating in humanitarian assistance missions (HAMs) for over a decade. Pacific Partnership is the largest annual multilateral humanitarian assistance and disaster relief preparedness mission conducted in the Indo-Pacific region. There is an increasing risk for the development and sequelae of vascular disease; however, these nations frequently lack vascular capabilities. The Kidney Disease Quality Outcomes Initiative, implemented in 1997, advocates for early arteriovenous fistula (AVF) creation in an attempt to decrease morbidity and mortality in patients with end-stage renal disease and is the standard of care in the United States. Unfortunately, these same standards are not currently attainable in low- and middle-income countries (LMICs).6 Reasons for this include low surgeon-to-patient ratios, decreased surgical subspecialties, and significant resources committed to trauma. We present the first reported case of a successful AVF creation during a HAM and argue for an increased presence of vascular surgery in HAMs.
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