Years ago, I was asked if I would be willing to see children who needed dialysis access. I was reluctant, as you could imagine, but eventually came to the conclusion that I didn’t know who else to send them to. I was stuck, and thus began a challenging but rewarding aspect of my practice and development as a surgeon.
Children have small blood vessels. The rules I had practiced by with adults had to be thrown out the window. Arteries and veins I would never have touched in an adult were all I had to work with in children, so I had to learn to work with these tiny vessels. To my surprise and pleasure, most of what I did worked.
Seventeen patients from age 3 to 18 years were seen and all received fistulas (see table below). One wrist fistula failed in the 3 year old, and was followed by a transposed basilic fistula. There were two functional wrist fistulas and one forearm fistulas – all three of which required inflow revision. The rest were complex procedures requiring transposition or superficialization. Eleven of the 17 patients (65%) received some form of basilic or brachial vein transposition. Fourteen out of seventeen required two procedures in the process, either as planned staged procedures, or revisions within the first year.
These are complex patients, and require a surgeon adept at advanced fistulas. This is no place for beginners.
Then I started applying the lessons I learned in children to adults with smaller vessels and difficult anatomy – using finer suture, higher magnification, and low-voltage needle point electrocautery. I found that cases I thought to be impossible in the past were actually doable, and that I had gained new abilities and understandings from working with the children. They had made me a better surgeon.
Life-threatening illnesses in children are tragic and upsetting. Good results are impossible to guarantee. It would be easy enough to avoid getting involved. But children are also grateful and genuine. Successes can be extremely gratifying, and I have found that I’ve gained more than I’ve given.
Table of pediatric cases
| DOB | Age | sex | description |
| 8/31/2007 | 3 | F | Wrist fistula – failed |
| 8/31/2007 | 3 | F | Basilic transposition, one stage |
| 7/31/2006 | 5 | M | Brachiocephalic by lateral branch transposition |
| 9/29/2006 | 6 | M | Wrist fistula |
| 8/4/2008 | 7 | M | Basilic/brachial transposition |
| 3/12/2006 | 9 | F | Basilic transposition, two stages |
| 5/22/2004 | 11 | M | Basilic transposition, two stages |
| 6/2/2000 | 12 | M | Brachial vein transposition |
| 1/8/1998 | 12 | F | Basilic transposition, one stage |
| 8/16/1997 | 13 | F | Superficialized brachiocephalic fistula |
| 6/30/1997 | 13 | M | Basilic transposition, two stages |
| 11/29/1996 | 14 | F | Wrist fistula |
| 3/8/1998 | 14 | M | Forearm fistula |
| 12/9/1996 | 14 | F | Basilic transposition, two stages |
| 11/4/1996 | 15 | M | Superficialized brachiocephalic fistula |
| 9/18/1994 | 16 | M | Basilic transposition, one stage |
| 3/15/1994 | 17 | F | Basilic transposition, two stages |
| 2/25/1994 | 18 | M | Basilic transposition, one stage |
