Primary Balloon Angioplasty or Hydrostatic Dilatation for Arteriovenous Access: Which Technique has Better Outcomes in Poor Caliber Cephalic Veins?

Abstract

Background: The success of hemodialysis depends on a functioning vascular access. The most important factor limiting the arteriovenous fistula (AVF) growth and patency is the availability of a good caliber venous segment: Cephalic veins smaller than 2.5 mm have been reported to have increased failure rates. Unfortunately, in the Indian population, we frequently come across patients with a poor cephalic vein diameter ≤2 mm. The present study was done to evaluate if primary balloon angioplasty (PBA) of these small cephalic veins could improve the primary patency rates and maturation time of autogenous AVFs, and also to compare this technique with the standard hydrostatic dilatation technique. Materials and Methods: Sixty patients requiring arteriovenous access surgery (but having small cephalic veins (≤2 mm) were randomized into two groups of thirty patients each. All patients underwent a thorough preoperative evaluation, after which they were subjected to AVF surgery. Thirty of these patients underwent standard hydrostatic dilatation (HD) whereas the remaining thirty were offered PBA of the vein before creating the fistula. These patients were followed up for 6 months and primary patency, reintervention rates, and maturation times were recorded. Results: Immediate technical success was 100% in the PBA group, with 6-month primary patency of 93.3%, whereas HD group had 73.3% immediate success and a 6-month primary patency of 63.3%. In HD group, 36.7% patients underwent re-intervention over a follow-up of 6 months, as compared to only 6.7% in PBA group. The average maturation time for PBA group was 32.83 days, whereas in HD group, it was 52.53 days. Conclusions: PBA of very small cephalic veins (≤2 mm) is a safe and feasible procedure. The technique is associated with excellent primary patency rates and decreased maturation time, significantly decreases the need for re-intervention, and is superior to the standard hydrostatic dilatation technique. It has the potential to maximize the number of patients with autogenous AVF by including those patients who have been rejected due to small cephalic veins.