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October 8, 2008

Effect of Clopidogrel on Arteriovenous Fistulas for Dialysis

JAMA. 2008;300(14):1647-1649. doi:10.1001/jama.300.14.1648-a

To the Editor: The trial by Dr Dember and colleagues1 failed to show any improvement in fistula maturation for hemodialysis by using clopidrogrel, although its use decreased the frequency of early thrombosis. However, the design of the study might explain some of the results.

Successful arteriovenous fistula creation depends on many important factors. First, there must be adequate predialysis care, particularly protection of the veins from unnecessary cannulations for blood sampling or for intravenous administration of fluids and medications; this was not described. Second, there must be appropriate preoperative evaluation of the arterial and venous networks by methods such as x-rays for possible detection of calcifications of the arteries, Doppler ultrasound for arteries and veins, or venography.2 Although Dember et al report that vascular mapping was performed in almost 75% of the patients,1 they do not provide extensive data. It would be interesting to explore whether mapping presented any advantage, provided that this approach was not biased by being used only in more complicated cases.