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Fistula First - Catheters Last: A CMS-sponsored Break-though Initiative

By Susan Eymann, MS17 Nov 2015

Centers for Medicare and Medicaid Services (CMS) Fistula First logo

The success of the Centers for Medicare and Medicaid Services (CMS) Fistula First Break-through Initiative has transformed a hemodialysis access in the United States from a “graft-oriented culture” to a “fistula-oriented culture” in less than 10 years. When the Fistula First Initiative took off in 2005, The United States lagged far behind their European counterparts in utilizing a fistula as a vascular access of choice for appropriate hemodialysis patients. An arteriovenous fistula (AVF) is the optimal vascular access for hemodialysis because it is associated with longer survival, fewer infections, lower hospitalization rates, and reduced costs. Now more than 60% of American hemodialysis patients have AV fistulas. The Fistula First goal is to reach 68%.

How Does Transonic Flow-based Surveillance Fit In?

With the dramatic increase in the number of AV fistulas in hemodialysis patients to over 61%, surveillance of the fistulas for stenosis formation is even more important. Transonic ultrasound dilution technology can detect possible stenosis formation at any site within the vascular access: inflow, outflow or between the needles. With routine measurements, access flow can be trended over time.  A decrease in access flow per KDOQI Guidelines will foreshadow stenosis formation.

Non-maturing Fistulas

Yet, the underside of the Fistula First initiative is that the number of fistulas that do not mature is high, estimated to be between 28-50%. When a fistula fails to mature, the patient has to be placed on or return to a CVC and be susceptible to its risks of infection and morbidity. Thus, any action that will help ensure the future maturation of a fistula is worth consideration. One strategy is measure flow intraoperatively during fistula creation. Several publications (see references below) suggest threshold flow rates that correlate with eventual maturation of a fistula.

And Catheters Last

In the past couple of years, the mission of the Fistula First Initiative expanded to include the reduction in tunneled catheter use. Its goal is to improve the survival and quality of life of hemodialysis patients and lower the infection, hospitalization and mortality rates associated with prolonged use of central venous catheters (CVC). Dovetailing on its success with initiating fistulas, the group has now morphed into FistulaFirstCatheterLast (FFCL) to underscore the inherent dangers of CVCs. CVC usage in the first 90 days of hemodialysis remains unacceptably high at nearly 80%. KDOQI Guidelines recommend that not more than 10% of the hemodialysis population be maintained on chronic dialysis with catheters. Current FFCL goals are to:

  • Increase AV fistula utilization in all appropriate hemodialysis patients to 68%
  • Decrease the use of long term catheters (>90 days) to < 10%
  • Engage all stakeholders to work together to achieve the goals

For patients that have initiated hemodialysis with a catheter or whose prevalent access is a catheter, Transonic ultrasound dilution technology’s recirculation and delivered blood flow measurements are used to optimize catheter placement and dialysis delivery.


1 Johnson CP et al, "Prognostic Value of Intraoperative Blood Flow Measurements in Vascular Access Surgery," Surgery 1998; 124: 729-38. 

2 Berman SS et al, “Predicting Arteriovenous Fistula Maturation with Intraoperative Blood Flow Measurements,”  J Vasc Access 2008; 9(4): 241-7.

3 Won T et al, “Effects of Intraoperative Blood Flow on the Early Patency of Radiocephalic Fistulas,”  Ann Vasc Surg 2000; 14(5): 468-72. 

4 Asif A et al, “Early arteriovenous fistula failure: a logical proposal for when and how to intervene,” Clin J Am Soc Nephrol 2006; 1(2): 332-9.

5 Lin CH et al, “Correlation of Intraoperative Blood Flow Measurement with Autogenous Arteriovenous Fistula Outcome,”  J Vasc Surg. 2008; 48(1): 167-72. 

6 Wong, V et al, “Factors Associated with Early Failure of Arteriovenous Fistulae for Haemodialysis Access,”  Eur J Vasc Endovasc Surg 1996; 12(2): 207-13.

7 Usta E et al, “Risk factors predicting the successful function and use of autogenous arteriovenous fistulae for hemodialysis,” Thorac Cardiovasc Surg 2013; 61(5): 438-44

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