Autogenous Arteriovenous Access in the Morbidly Obese:
Fistula First for Large Arms

OBJECTIVE: To evaluate the results of autogenous fistula creation in the morbidly obese patient population as a sole means for hemodialysis access.
METHODS: The clinical data for thirteen consecutive patients who were determined to be obese (BMI > 25 kg/m2) and an upper extremity circumference greater than 35cm already receiving hemodialysis or with an anticipated need within six months was reviewed. Demographics, morphologic measurements, and operative techniques were all evaluated.
RESULTS: Average BMI was 47.3 kg/m2 (25.1-65.5 kg/m2), average weight 139 kg (305 lbs), and average arm circumference 47.8 cm (35-56 cm). Preoperative vein mapping identified veins most suitable for use as access. In eleven patients, primary brachial-cephalic AV fistulae were created and in two patients a brachial-basilic configuration was utilized--all of which matured-followed by a staged elevation of the outflow vein to a location to allow easy cannulation. All patients (100%) demonstrated functional patency. The average time to cannulation was 235 days (average of 46 days after the elevation procedure). All fistulae remain functionally patent as the sole means for hemodialysis access in this group of patients (mean follow-up = 15 months.)
CONCLUSION: Creation and maintenance of a functionally patent autogenous hemodialysis access in the obese patient is achievable. This requires careful planning utilizing the noninvasive vascular laboratory and the application of a staged approach to access creation. Morbid obesity, while presenting a challenge to the access surgeon, should not be a contraindication to autogenous access creation.