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To the Editor: The study by Dr Dember and colleagues¹ is notable for the highest rate of failure to attain suitability for dialysis (clopidogrel, 61.8%, vs placebo, 59.5%; P = .40) that we are aware of in the published literature. The challenge of vascular access for hemodialysis patients is that success requires knowledgeable and skillful input from several disciplines, including nephrology, radiology, and vascular surgery. Although the investigators took great care in the assessment of various elements of the trial, the possible effect of surgical expertise on the outcome of fistulas was perhaps not optimally assessed.

A Department of Veterans Affairs Veterans Health Administration study suggested that there were surgeon-specific characteristics that were associated with increased arteriovenous fistula placement, such as center volume (>30 procedures per year) and specific surgeon clustering.² Furthermore, studies by Konner et al³ and Fassiadis et al⁴ demonstrated that surgeons who created more than 100 fistulas per . . . [Full Text of this Article]

Dirk M. Hentschel, MD
dhentschel@partners.org
Interventional Nephrology
Brigham and Women's Hospital
Boston, Massachusetts

Arif Asif, MD
Interventional Nephrology
Miller School of Medicine
University of Miami
Miami, Florida

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RELATED ARTICLE

Effect of Clopidogrel on Early Failure of Arteriovenous Fistulas for Hemodialysis: A Randomized Controlled Trial
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