Distal Radiocephalic Arteriovenous Fistula Research Articles

#1335 Distal radio-cephalic arteriovenous fistula survival: comorbid conditions and long-term surveillance in hemodialysis

Abstract Background and Aims With a low incidence of infection and distal ischemia, the distal radio-cephalic arteriovenous fistula (dRCF) is the reference access for hemodialysis (HD). Smaller venous diameter and obesity have been associated with poor distal arteriovenous fistula (AVF) outcomes in some studies. On the other hand, HD patients often suffer from multiple co-morbidities, resulting in an increased number of complications. The impact of all these factors on vascular access survival has not been entirely characterized. We evaluated long-term follow-up demographic and clinical data from a cohort of patients in relation to primary and secondary dRCF survival. Method The study included prevalent patients who had been receiving hemodialysis for at least 6 months at the same reference hospital. From 2008 to 2023, we retrospectively collected dRCF for HD performed by a single reference surgical team. All dRCF could be confirmed to be clinically useful for dialysis (i.e., functional patency). Socio-demographic data were collected. Our medical team (nephrologist and radiologist) periodically performs a physical examination and duplex ultrasound to identify physical signs of possible complications, understand the underlying cause and plan treatment in advance. The time to first repair is termed primary AVF survival, while secondary survival is the time after first repair. Primary and secondary survival analysis was performed using the Kaplan-Meier method. Results Of 253 prevalent patients receiving HD, 82.2% had an AVF. The mean HD vintage was 61 ± 50 months. HD was started on a planned basis in 61.4% of cases, with AVF being the initial access in 71.7% of cases. We included 145 dRCFs for HD. dRCF was the unique AVF that was placed in 74.5% of the patients. Mean age 69.5 ± 14.5 (years), women 31%, mean BMI 27.3 ± 6.08 kg/m2, non-smokers 46.9%, obesity 37.9%, diabetes mellitus 44.8%, ischemic cardiopathy 20%, peripheric vasculopathy 15.9%. Diabetic nephropathy was the most common cause of chronic kidney disease in our population, accounting for 44.8% of cases. dRCF primary failure was 11.11%, 40% of these patients were over 80 years of age. The dRCF was left-sided in 82.2%. dRCF median survival was 64.5 ± 50.4 months; survival rates at 12, 36 and 60 months were 92%, 67% and 41%, respectively. Primary and secondary dRCF median survival was 33 ± 39 months and 50 ± 45 months, respectively. Primary and secondary survival rates at 12, 36 and 60 months were 60%, 32% and 17% and 84%, 53% and 33%, respectively. With a median survival of 62 ± 44 months, 29.7% of the dRCF did not undergo repair either before or during dialysis. The dRCF requiring percutaneous intervention and/or surgical reanastomosis before dialysis was 16.7%. Factors identified as being associated with lower primary survival were obesity and peripheral vasculopathy (p=0.01 and p=0.001, respectively), as shown in Figs. 1 and 2. The percentage of salvage procedures (percutaneous, surgical or both) in obese was 78,2%; 76,7% involved surgical repair, most of which were lipectomies, superficializations with or without transposition. Although not statistically significant (p=0.056), dRCF secondary survival is decreased in diabetic patients (Fig. 3). No statistical impact was found between age, sex, smoking, or ischemic cardiopathy and either primary or secondary survival. Conclusion Our obese patients on HD are a special population with an increased need for surgical reintervention of dRCF, which impacts primary but not secondary survival. Primary dRCF survival is lower in patients with peripheral vascular disease compared to other comorbidities; however, this vasculopathy is not associated with worse secondary dRCF survival with active follow-up. It is likely that individualized and careful long-term active surveillance was a key aspect in improving the functional patency of dRCF in our patients with multiple comorbidities. Undoubtedly, these issues deserve further prospective investigation.

Assessment of volume flow rate in arteriovenous fistulas with a novel ultrasound Doppler device (earlybird): Trend analysis, comparison of methods, and inter- and intra-rater reliability.

An accessible tool is required to analyze volume flow trends in arteriovenous fistulas for hemodialysis. Earlybird, an easy-to-place ultrasound Doppler device, has shown comparable accuracy to duplex ultrasound. In this study, we compared volume flow measurements obtained with duplex ultrasound and the dilution technique to an enhanced earlybird device, featuring a dual Doppler probe system, eliminating the requirement for a known insonation angle. Nine patients with a distal radiocephalic arteriovenous fistula were monitored for 12 months with regular volume flow measurements. Correlation and inter- and intra-class reliability analyses were conducted. An overall moderate correlation was observed between earlybird and duplex ultrasound or dilution technique (intraclass correlation coefficient = 0.606 (95% confidence interval 0.064, 0.721) and 0.581 (0.039, 0.739), respectively). Duplex ultrasound compared to dilution measurements, demonstrated an overall moderate correlation (0.725 (0.219, 0.843)). Correlation between earlybird and duplex ultrasound was stronger for the arteriovenous fistula (0.778 (0.016, 0.901)) than the brachial artery (0.381 (-0.062, 0.461)). For earlybird, inter-rater reliability was excellent for the arteriovenous fistula (0.907 (0.423, 0.930)) and poor for the brachial artery (0.430 (0.241, 0.716)). Duplex ultrasound showed a good inter-rater reliability (arteriovenous fistula: 0.843 (0.610, 0.871), brachial artery: 0.819 (0.477, 0.864)). The overall intra-rater reliability was good for duplex ultrasound (rater A: 0.893 (0.727, 0.911); rater B: 0.853 (0.710, 0.891)), while excellent for earlybird (rater A: 0.905 (0.819, 0.928); rater B: 0.921 (0.632, 0.969)). We observed a weaker correlation in the measurements of volume flow rates in arteriovenous fistulas when obtained using earlybird compared to dilution technique, unlike the comparison between duplex ultrasound and the dilution technique. However, inter-rater reliability for the arteriovenous fistula was excellent with earlybird and good with duplex ultrasound, indicating the potential of earlybird as a tool for frequent measurements, enabling trend surveillance and predicting adverse outcomes.

The Role of Ultrasound Examination in the Assessment of Suitability of Calcified Arteries for Vascular Access Creation-Mini Review.

Arterial calcifications are present in 20-40% of patients with end-stage kidney disease and are more frequent among the elderly and diabetics. They reduce the possibility of arterio-venous fistula (AVF) formation and maturation and increase the likelihood of complications, especially distal ischemia. This review focuses on methods for detecting arterial calcifications and assessing the suitability of calcified arteries for providing inflow before the construction of an AVF. The importance of a clinical examination is stressed. A grading system is proposed for quantifying the severity of calcifications in the arteries of the arm with B-mode and Doppler ultrasound exams. Functional tests to assess the suitability of the artery to provide adequate inflow to the AVF are discussed, including Doppler indices (peak systolic velocity and resistive index during reactive hyperemia). Possible predictors of the development of distal ischemia are discussed (finger pressure, digital brachial index, acceleration and acceleration time), as well as the outcomes of AVFs placed on calcified arteries. It is concluded that a noninvasive ultrasound examination is probably the best tool for a morphologic and functional assessment of the arteries. An arterial assessment is of utmost importance if we are to create distal radiocephalic AVFs in our elderly patients whenever possible without burdening them with futile surgical attempts.

The association of lower peri-operative mean arterial pressure and primary failure in distal radio-cephalic arteriovenous fistula operations

The association of lower peri-operative mean arterial pressure and primary failure in distal radio-cephalic arteriovenous fistula operations

MICROSURGERY FOR THE CREATION OF ARTERIOVENOUS FISTULAS IN PATIENTS WITH RADIAL ARTERIES DIAMETER SMALLER THAN 1.6 MM

In End-stage Renal Disease patients, the distal forearm is the preferred site for hemodialysis access, however forearm vessels have small diameter and according to Guidelines a radial artery internal diameter smaller than 1.6-2 mm is strongly predictive of early failure of the arteriovenous fistula (AVF) because of stenosis and obstruction. It could happen for some patients to not be considered suitable for distal forearm AVF because of poor peripheral vessels, so in these cases the micrusurgical technique can be very helpful in handling such “inadequates” vessels for lower-arm fistula creation. This study is an investigation of long-term patency of distal radio-cephalic AVFs created under microscopic guidance by using small radial arteries (less the 1.6 mm diameter) in adult patients with chronic renal failure and without severe comorbidities. In a sample of 31 patients, at 1 year postoperatively, the mean primary patency rate was 67.7% (21 functioning AVFs out of 31) and that is quite the same result of AVFs’ made with arteries larger than 2 mm.

Fully no-touch technique without inflating the cephalic vein increase the patency rate of arteriovenous fistulas.

One of the most important problems for patients undergoing hemodialysis due to chronic renal failure is the need for a long-lasting vascular access. The patency of vascular access is affected by many factors. Factors related to surgery are also among these factors. No-touch techniques theoretically and practically prevent endothelial damage due to minimal contact on vascular structures. It is a well-known fact that surgeries performed with these methods also increase long-term survival. Patients who underwent distal radiocephalic arteriovenous fistula (AVF) surgery for the first time between 2017 and 2021 were included in our study. The groups, whose cephalic veins were inflated conventionally and not inflated, were compared in a prospective randomized manner. There was a significant difference between both groups in terms of failure and patency rates, which is one of the study endpoints (p = 0.012). The fact that the patency period is long, and the failure rate is low stands out as the superiority of the fully no-touch technique in AVF surgery. On the other hand, no significant difference was observed in terms of failure to maturation and fistula maturation time. Fully no-touch technique in AVF surgery should be considered primarily in suitable patients due to its long patency time and low failure rate.

English

This study aim to report our experience in the fabrication of arteriovenous fistulas (AVF) by describing the operative technique and the immediate surgical results. The study carried out retrospective study of the records of 1467 patients who underwent AVF creation during the period from January 2008 to December 2020.  1396 patients (95.2%) had already been dialyzed with a central venous catheter for one month (1 and 6 months). The procedures were performed under local anesthesia. Distal radio-cephalic AVFs were performed in 92.2% of cases. The fabrication of a radio cephalic arteriovenous fistula was described. The arteriovenous fistulas were patented in 100% at the end of the procedure. We observed 3.1% complications in the immediate postoperative period. Morbidity was constituted by early thrombosis which represented 58.8% of complications followed by false aneurysms (27.5%), compressive hematomas (11.8%) and hemorrhages (1.9%). Fistulas complicated by thrombosis were reconnected. Treatment of the false aneurysm consisted of evacuation of the false aneurysm, surgical hemostasis, and removal of the AVF. The native arteriovenous fistula is the best access route for chronic hemodialysis. This procedure carries little risk. However, complications can be fatal, hence the interest of an early and adapted management of these complications.  Key words: Arteriovenous fistula, hemodialysis, vascular access.

Proximal Arteriovenous Fistulas in Hemodialysis Patients: Advantages and Disadvantages.

Introduction: The main objective of the present study is to investigate the advantages and disadvantages of proximal arteriovenous native fistulas. Hemodialysis is indispensable for patients with end-stage renal disease. For this purpose, arteriovenous fistulas (AVFs) are used. Among the native fistulas, distal radiocephalic AVF is the most preferred. However, brachiocephalic AVF (BCAVF) and brachiobasilic AVF with basilic vein transposition (basilic vein transposition arteriovenous fistula [BVTAVF]) can be used for a long time in dialysis patients whose distal vascular bed is depleted.Methods: This is a retrospective study of 117 AVFs (BCAVF and BVTAVF), in patients with end-stage chronic renal disease, that were opened with a surgical technique (2012-2018). The postoperative two-year patency rates, AVF locations, complications, and the advantages and disadvantages of these fistulas are reviewed and recorded in the light of the literature.Results: The mean age of the patients (52 men and 65 women) was 60.6 ± 13.6 years. The percentages of primary patency rates at 3, 6, 9, 12, and 24 months were 96.6%, 93.1%, 92%, 87.4%, and 82.8% in BCAVF patients, and 96.7%, 93.3%, 90%, 86.7%, and 80% in BVTAVF patients, respectively. The percentages of secondary patency rates at 6, 12, and 24 months were 100%, 93.3%, and 86.7% in BCAVF patients, and 100%, 100% and 87.7% in BVTAVF patients, respectively. Fistula thrombosis was seen as the most common complication. The early complication was bleeding/hematoma. As late complications, we encountered steal syndrome, ischemic pain in the relevant extremity, pseudoaneurysm, and high-output heart failure.Conclusion: Proximal AVFs are preferable fistulas with early maturation and high primary patency rates. We believe that relatively high complications can be avoided by opening fistulas with an appropriate surgical technique.

Midterm results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System, technical recommendations, and an algorithm for maintenance

ObjectiveThe aim of this study was to report our midterm results of percutaneous arteriovenous fistula (pAVF) creation using the Ellipsys (Avenu Medical, San Juan Capistrano, Calif) device and to present technical recommendations and our algorithm of pAVF maintenance. MethodsA single-center comprehensive database of all consecutive predialysis and end-stage renal disease patients who had a pAVF creation with the Ellipsys device was reviewed retrospectively. Study end points included technical success, maturation, functional patency, and required interventions. ResultsBetween May 2017 and July 2019, there were 234 patients (mean age, 64 years; 148 male [63%]) who had a pAVF created. Technical success was achieved in 232 individuals (99%), and average duration of the procedure was 15 minutes (7-35 minutes). Average follow-up was 252 days (range, 83-696 days). The 1-year primary, primary assisted, and secondary patency rates were 54%, 85%, and 96%, respectively. Average pAVF flow was 923 mL/min (range, 425-1440 mL/min). There were no significant adverse events related to the procedure. Only three patients (1%) required a later conversion of the pAVF anastomosis to a surgical fistula. Twenty-four (10%) patients required superficialization of deep outflow veins because of difficult cannulation. Average maturation time was 4 weeks (range, 1-12 weeks). Fourteen patients (6%) had early (<2 weeks after creation) cannulation of the pAVF. ConclusionsThe Ellipsys pAVF device allows the rapid and safe creation of a reliable autogenous access. Rates of technical success, patency, and maturation were excellent. For patients unsuited for a distal radiocephalic arteriovenous fistula, it should be considered the next preferred access option.

The utility of venous bifurcation for anastomosis with small-caliber veins in distal forearm radiocephalic arteriovenous fistula: Retrospective analysis of 52 fistula cases

Context: Distal forearm radiocephalic (RC) arteriovenous fistula (AVF) is the gold standard for vascular access for hemodialysis. The use of venous bifurcation to facilitate anastomoses in small-caliber vessels is well known in microvascular surgery. Small-caliber cephalic vein (CV) is frequently encountered during AVF creation in the distal forearm. We present here the utility of this technique for the creation of distal RC AVF in small-caliber CVs. Objective: The objective was to assess the utility of venous bifurcation for distal forearm RC AVF creation in small-caliber CV. Methodology: Fifty-two cases with CV diameter

ПРОФИЛАКТИКА ОСЛОЖНЕНИЙ ПРИ ФОРМИРОВАНИИ ДИСТАЛЬНОЙ АРТЕРИО-ВЕНОЗНОЙ ФИСТУЛЫ ДЛЯ ГЕМОДИАЛИЗА

В статье проанализированы осложнения в процессе формирования и реконструкции артерио-венозной фистулы для гемодиализа. Дистальная радиоцефальная артерио-венозная фистула для гемодиализа является одним из лучших известных на сегодняшний день вариантов постоянного сосудистого доступа в связи с возможностью ее длительного функционирования, отсутствие синдрома обкрадывания, относительно небольшого процента осложнений при ее формировании и функционировании. При подготовке к операции следует проводить ультразвуковое исследование проходимости артериальной системы и картирование вен недоминантного предплечья с целью определения предпочтительной из возможных конфигурации постоянного сосудистого доступа. Предложены рекомендации по улучшению результатов оперативных вмешательств и перспектив функционирования постоянного сосудистого доступа. В особенностях микрохирургической техники формирования анастомоза между разнородными сосудами (артерией и веной), следует обратить внимание на исключение натяжения венозной стенки.

PC134. Tunneled Catheter Placement for Hemodialysis Should Be Paired With Evaluation for Arteriovenous Fistula or Graft Creation

Permanent dialysis access with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) is the first choice for hemodialysis whenever possible. In patients who do not have a matured AVF or AVG, large-bore tunneled catheters (TCs) are placed to provide bridging access. Whereas TCs provide convenient access for hemodialysis, they are at risk for development of central line-associated bloodstream infections and can cause central vein stenoses. Ideally, TCs are used as a bridge to AVF or AVG creation for minimization of total catheter days. A multispecialty Vascular Access Service Team (VAST) was implemented to evaluate patients for permanent hemodialysis access at the time of TC placement. The objective of this study was to evaluate the efficacy of VAST in the context of identifying patients for AVG or AVF creation. The VAST provides a multidisciplinary centralized consultation service to evaluate and to implement appropriate vascular access. All inpatient TC consultations for dialysis are reviewed by nephrologists, who evaluate patients for causes of kidney failure and possibility of renal recovery. Patients who are not expected to have meaningful renal recovery are referred to the vascular surgery team for permanent dialysis access creation with a preference for distal radiocephalic AVF. A retrospective review was performed of a prospectively maintained database of patients undergoing TC placement at a large academic medical center. From January 2018 to December 2018, a total of 213 TCs were placed. The indications for TC placement included acute tubular necrosis, acute kidney injury due to hepatorenal syndrome, tubulointerstitial nephritis, chronic kidney disease due to uncontrolled hypertension, renal cell carcinoma, glomerulonephritis, polycystic kidney disease, and failed kidney transplants. The average number of days from consultation to TC placement was 1.7 business days; 43% of the patients (n = 90) undergoing TCs were expected to have renal recovery and cessation of hemodialysis. Of the remaining patients, 19% refused the procedure, 7% had contraindications to access creation, and 20% had existing AVFs or AVGs awaiting maturation; 65 patients (54%) agreed to AVF or AVG creation. Seven patients were able to have permanent access creation simultaneously with the time of TC placement. Median wait time was 8 business days, with 40% of procedures occurring within 3 business days. Around a third of patients undergoing TC placements did not have expected renal recovery and benefited from early evaluation for permanent dialysis access creation. A centralized vascular access team facilitates expedited evaluation for permanent dialysis access and may reduce the total catheter days per patient and catheter-related complications.

The effects of preoperative blood pressure on early failure rate of distal arteriovenous fistulas for hemodialysis access

The first choice of vascular access for hemodialysis in patients with end-stage renal disease is a distal radiocephalic arteriovenous fistula (AVF). Early failure rates for these AVFs vary from 10% to 53%. The effects of predialysis hypotension on failure of AVFs have been described in the literature. Weather lower blood pressures affect early AVF failure has not been extensively studied. We conducted this study to evaluate the effects of preoperative blood pressures on early AVF failure. Ours was a prospective observational study over a period of 2 years that included 224 patients who underwent distal radiocephalic AVF creation. Only those patients were included whose fistulas were made by surgeons with an experience of greater than five cases. The systolic, diastolic, and mean arterial pressures (MAPs) were recorded preoperatively. Early failure was defined as failure to achieve vascular access from the fistula within first 4 months of its creation. The overall early failure rate was 27.7%. Early failure was more common in females and diabetic patients. The systolic, diastolic, and MAPs were significantly lower in patients with early failure (P < 0.05). In a multivariable adjusted analysis, lower preoperative diastolic and MAPs were predictors for early failure of distal radiocephalic AVF. Our study shows that patients with early failure of AVFs have lower preoperative blood pressure. A larger study is required to substantiate our findings and define target preoperative blood pressure for AVF creation.

Comparative study between no touch technique and conventional method in the distal radio cephalic arterio venous fistula for hemodialysis

Background The distal radiocephalic arteriovenous fistula (RC-AVF) is the gold standard for hemodialysis but has significant failure rates owing to occlusions and failure to mature. The size and quality of the veins play an important role in the patency of the fistula. Objective The aim of this study was to evaluate the no-touch technique compared with the conventional method in the distal radiocephalic fistula for hemodialysis in terms of patency and complications. Patients and methods A prospective randomized study including 80 patients with ESRD in need for hemodialysis access was done between March 2016 and March 2017 and followed up to October 2017 at Menoufia university hospital. The patients were randomly categorized into two groups (no-touch group that included 40 patients where the vein and artery were dissected with the surrounding tissue cushion and conventional group that included 40 patients). Primary failure, primary and secondary patency rates, and complications of each group were collected and analyzed. Patients with vein caliber less than 2.5 mm, previous arteriovenous fistula, without venous continuity in the arm, or with severely atherosclerotic radial artery were excluded from the study. Results In the no-touch group, primary fistula failure was 7.5%, whereas three (7.5%) fistulas failed later one owing to thrombosis (one case), anastomotic pseudoaneurysm (one case), and anastomotic stenosis (one case). Primary and secondary patency rates at 6 months were 85 and 90%, respectively, whereas in the conventional group, primary fistula failure was 17.5%, whereas eight (20%) fistulas failed later owing to thrombosis (two cases), anastomotic pseudoaneurysm (two cases), anastomotic stenosis (three case), and venous hypertension (one case). Primary and secondary patency rates at 6 months were 62.5 and 67.5%, respectively Conclusion The results of this study indicate that no-touch technique can be used for primary radiocephalic fistula surgery with better patency rate and less complications compared with conventional method. This method offers the potential to create a RC-AVF in patients with distal cephalic veins 2.5 mm or more in caliber with encouraging results.

Drug-Eluting Balloon Angioplasty for Juxta-Anastomotic Stenoses in Distal Radiocephalic Hemodialysis Fistulas: Long-Term Patency Results.

To evaluate long-term primary and secondary patency results of drug-eluting balloon angioplasty for the treatment of juxta-anastomotic stenoses in distal radiocephalic arteriovenous fistulas. Thirty-eight patients with juxta-anastomotic stenotic distal radiocephalic arteriovenous fistulas who underwent endovascular treatment with drug-eluting balloons between January 2014 and August 2016 in our interventional radiology department were included in this retrospective study. Color Doppler examination for follow-up was performed 15days, 6months, 12months, 18months, 24months, 36months, and 48months after the procedure. Kaplan-Meier analysis was used to estimate primary and secondary patency rates. Totally, 42 angioplasty with drug-eluting balloons was performed in 38 patients (20 men and 18 women; mean age 66.42 ± 12.01). Technical and clinical success rate was 100% (42/42). The mean follow-up period was 27.71months ± 12.98 (range, 1-54months). The estimated primary patency rates at 6months were 94.7% (95% CI, 80.9%-99.0%), at 12months were 81.2% (95% CI, 64.6%-91.4%), at 24months were 60.7% (95% CI, 43.6%-75.7%), and at 48months were 53.1% (95% CI, 36.5%-69.1%). The estimated secondary patency rates at 6months were 97.3% (95% CI, 84.5%-99.8%), at 12months were 86.5% (95% CI, 70.7%-94.8%), at 24months were 69.0% (95% CI, 51.8%-82.4%), and at 48months were 61.7% (95% CI, 44.6%-76.5%). Drug-eluting balloon angioplasty is a useful, effective technique in dysfunctional radiocephalic fistulas due to juxta-anastomotic stenoses. We demonstrated remarkably high primary patency rates at 6, 12, 24, and 48months.

Distal forearm radiocephalic arteriovenous fistula creation in calcified vessels: Technical challenges in anastomosis and early outcome

Background: Calcified vessels are frequently encountered during arteriovenous fistula (AVF) creation in aged patients and outcome is negatively implicated. However, fistula creation in calcified artery is an entity without much technical clarity and guidance. We present our experience and several modifications of standard radiocephalic (RC) AV fistula creations adopted during anastomosis on calcified vessels depending on our experience of fistula creation over the last 7 years. Objective: The objective was to assess the outcome of our technical modifications for RC AVF creation in distal forearm on atherosclerotic radial artery. Methodology: Twelve cases of calcified radial artery noted intraoperatively between July 2017 and 2018 and the first-time RC AVF created at the distal forearm were included in the study. Operative steps with modifications and early outcome were assessed prospectively. Results: All cases were male, with a mean age of 63.08 years. The average external diameter of the radial artery and cephalic vein was 2.74 mm and 2.21 mm, respectively. Venous bifurcation was available for creating “venous branch patch” and utilized for anastomosis in all cases. The mean operative time was 36.25 min. The functional maturation rate was 12/12. The mean maturation time was 34 days (standard deviation 5.74, standard error of mean 1.66). Fistula patency at 6 months and 1 year was 9/12 and 7/12, respectively. One vascular blow out was noted as complication. Conclusion: Some simple adaptations in vessel handling and suturing techniques and the use of “venous branch patch” for anastomosis may improve functional outcome in calcified vessels in distal RC AVF creation. This observation needs more number of cases and longer follow-up to predict the outcome in more assertive way.

Comparison of the mid-term results of proximal and distal radiocephalic arteriovenous fistulas created for hemodialysis

Comparison of the mid-term results of proximal and distal radiocephalic arteriovenous fistulas created for hemodialysis

Experience with arteriovenous fistula creation for maintenance hemodialysis in a tertiary hospital in South-Western Nigeria

End-stage renal disease (ESRD) is prevalent in our region. A major mode of treatment is by maintenance hemodialysis, and reliable vascular access is paramount for this to be successful. Arteriovenous fistula (AVF) creation offers permanent vascular access in patients with ESRD. We present our experience on AVF creation over a 10-year period. Our objective was to retrospectively review the outcome of all cases of AVF that have been created for ESRD patients at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife Nigeria between January 2006 and December 2015. The demographic characteristics, indications, clinical and intraoperative findings, operative complications and outcomes were filled into a pre-designed proforma. A total of 80 cases were reviewed. The age range was 17-80 years, with a mean of 49.03 ± 16.34 years. Males (85%) were more common than females (15%). Chronic glomerulonephritis and hypertension accounted for about 77.5% of etiology of ESRD in these patients. The left (non-dominant) upper limb was used in 88.1% of cases whereas 11.9% were created on the right upper limb. The distal radio-cephalic AVF (76.3%) was most commonly performed; with either the end (vein) to side (artery) (68.8%) or side-to-side (31.2%) anastomotic techniques employed. There was a primary failure in six patients (7.5%). Primary failure was more common in diabetics and thrombosis (7.5%) was the most common cause for primary failure. AVF creation has very good outcome in well-selected patients.

Surgical technique determines the outcome of the Brescia/Cimino AVF.

Over the past 50 years, since Dr. Appel performed the first internal vascular access procedure for hemodialysis, the distal radiocephalic arteriovenous fistula continues to be the access of choice. Over time, failure to maturation has evolved as a major problem associated with this procedure depriving its benefits to many patients with end-stage renal disease. A variable incidence of this problem within similar patients suggests that surgical technique may play an important role in the development of non-maturation. Evaluating the current surgical techniques based on the hemodynamic consequences of anatomic and physiologic alterations following this procedure highlights the role of surgical technique in mitigating or reducing complications. Piggy-back straight line on-lay, a technique that helps to tailor the blood flow and reduce the oscillatory shear stress appears to reduce the incidence of early juxta-anastomotic problems, which contribute significantly to the problem of non-maturation.

Impaired maturation of distal radio-cephalic fistula for haemodialysis: a review of treatment options.

Distal radio-cephalic arteriovenous fistula is the 'gold standard' vascular access for chronic hemodialysis. Its main drawback is early failure, which can complicate up to 50% of this surgical procedure. Two scenarios of failure are possible: early post-operative thrombosis or impaired maturation. The first is mainly due to a defective preoperative evaluation or poor surgical procedure. The latter is a patent angioaccess unable to deliver adequately hemodialysis due to a persistently low blood flowor difficult cannulation. In this article, the causes of impaired maturation will be reviewed, ranging from the stenosis causing low flow to the deep location of the vein in the obese. Treatment options will be described in thorough technical detail, in order to allow the angioaccess team to master them in daily practice.