Hemodialysis access creation in a resource-limited conflict zone: outcomes of a localized surgical training initiative

Abstract Background Reliable vascular access is essential for patients with end-stage kidney disease. In conflict-affected Yemen, limited access to vascular surgical expertise poses challenges to hemodialysis access care. A WHO-supported vascular trauma training program in Al-Hodeida incorporated selected hemodialysis access procedures to address local needs while providing practical surgical training. This study describes the access procedures performed, distinguishes pre-existing access complications from postoperative complications, and evaluates short-term outcomes of newly created vascular access. Methods We conducted a retrospective descriptive study of hemodialysis vascular access procedures performed from October 2017 through December 2021 at Al-Thawrah General Hospital and Al-Olofi Hospital in Al-Hodeida, Yemen. The primary descriptive outcome was the proportion of operations involving access-complication management across three study periods (2017–2019, 2020, and 2021). A chi-square test for trend was used to assess temporal association. Early postoperative complications following procedures performed by the training team were assessed separately. During the program, the senior vascular surgeon performed procedures with the trainee surgical team; in 2021, selected trained surgeons began performing AV fistula creation under direct supervision. Newly created accesses were followed clinically for 30 days and until maturation/use for hemodialysis when documented. Results A total of 193 operations were performed in 193 ESRD patients, including 151 native AVFs, 6 AVGs, 34 operations for access-complication management, and 2 surgical explorations. Of the 34 complication-management operations, 25 involved complications originating from procedures performed before the training program and 9 involved management of postoperative access complications during the program. The proportion of operations involving access-complication management decreased from 18/53 (34.0%; 95% CI, 22.7–47.4%) in 2017–2019 to 9/50 (18.0%; 95% CI, 9.8–30.8%) in 2020 and 11/90 (12.2%; 95% CI, 7.0–20.6%) in 2021 (chi-square test for trend, χ²(1) = 9.446, p = 0.002). Among 157 AV access creations, 13 early postoperative complications occurred (8.3%; 95% CI, 4.9–13.7%). One death occurred among the 193 operations during emergency surgery for a pre-existing thrombosed/dilated AVF. Conclusion In this single-center retrospective series, supervised hemodialysis access surgery was integrated into a vascular surgical training program in a conflict-affected, resource-limited setting. The findings describe short-term outcomes, including four AVF failures among 157 procedures and nine postoperative complications, seven of which were repaired within 24 h. Although temporal changes were observed, the absence of a control group precludes causal inference. Prospective studies with standardized long-term measures of maturation, patency, and access survival are warranted.