More often, the veins are deep and in order to make them easily accessible requires big surgical wounds with the associated morbidity of wound infections and breakdown. Using a prosthetic graft makes the conduit accessible, often through small wounds.
Recently, with the usage of US guided preoperative venous mapping and some close surveillance and early interventions, there were no significant different of AVF maturation between obese and non-obese patient.
Lipectomy and other venous superficialization technique without big surgical wound had been reported with good result.
In addition, recent application of venous window needle guide (VWING; CardioMed, Canada) will resolve the problem of difficult cannulation. (Jennings WC et al. The Venous Window Needle Guide, a hemodialysis cannulation device for salvage of uncannulatable arteriovenous fistulas. J Vasc Surg 2014, article in press)
Therefore, I think that vein first policy is also applicable for obese patient.
It all depends on how obese the patient is and how urgent the need is for access to be established. It is possible for example to create either a radiocephalic or a brachiocephalic arteriovenous fistula in an obese patient. What I have found is that if the patient can be convinced to then lose weight whilst the fistula is maturing then accessing the fistula for dialysis may be possible. If they do not lose weight a secondary superficialization procedure is then required. Worst scenario is if the patient continues to put on weight either post superficialization of a native vein fistula or following creation of a PTFE AVF (then the dialysis staff have problems with the cannulation). An increasing challenge!
Patients requiring vascular access for haemodialysis need an individualised approach with careful assessment of the risks and benefits of each type of vascular access made on a case by case basis. Sometimes the lowest risk approach will be a graft but usually it is a vein, even in obese patients. If autologous vein is to be the approach then striving for a distal location is especially important in obese patients as the forearms tend to smaller than the upper arm and therefore the vein will be easier to access for cannulation. New developments such as the VWING may prove to be a useful adjunct for these patients in the future but have not yet been fully evaluated.
Regarding issues like higher infection rate and lower primary and secondary patency rate of prosthetic dialysis AV graft it is justifiable to do our best with vein grafts by preoperative ultrasound mapping,vein transposition , lipectomy , superfiscialization of vein , weight loss , sonoguided cannulation for dialysis. At the end I believe on case to case decision making in obese patients.
Considering infection rates and patency rates there is a vein first policy in access surgery..
Of course, in obese patients it will be more difficult to get access to the deeper lying vein, but dplex vein mapping will help in making a patient tailored decision.
Keep it simple and break the access project into two staged procedures whenever possible and your life will be much easier, I promise. Stage 1: create the fistula. Stage 2: superficialize it. Today I usually do a simple elevation, creating a 10 cm cannulation segment.
I tell you this having done 13 fistula liposuctions, 20 lipectomies, A hundred or two transpositions with new tunnels or big flaps, and 6 venous window needle guides
Keep it simple!
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