Radiocephalic Arteriovenous Fistula Research Articles

Preoperative Cardiac Index as a Predictor of Maturation and Primary Patency of Radiocephalic Arteriovenous Fistula in Hemodialysis

Background: Radiocephalic arteriovenous fistula (RCAVF) is the best access modality to be considered initially when planning arteriovenous fistula (AVF) for maintenance hemodialysis. Considering the higher incidence of RCAVF failed maturation (M), it is important to perform proper preoperative evaluation and identification of high-risk patients. There has been no study on the influence of preoperative cardiac function on the M and patency of AVFs. The purpose of this investigation is to determine whether preoperative cardiac index (CI) is a predictor of M and primary patency of RCAVF. Method: A total of 365 end-stage renal disease patients undergoing RCAVF surgery were consecutively enrolled with a median follow-up time of 20 months in this prospective cohort study. Demographics, vascular diameters measured by duplex ultrasound examination, and CI measured by echocardiography, were analyzed for effect on RCAVF primary functional M and primary patency. Result: Patients in the group achieving primary RCAVF functional M had a significantly larger mean CI than the group with early RCAVF failure (2.93 ± 0.77 vs. 3.57 ± 0.76 L/min/m², p < 0.001). The receiver operating characteristic curve was plotted and demonstrated that preoperative vein diameter and CI can predict failure of RCAVF M. The AUC of CI was higher (0.745 vs. 0.666). Multivariate regression analysis, adjusted for age, sex, diabetes, preoperative dialysis status and vessel diameters, showed that decreased CI remained associated with increased risk of failure of M (FM) and worse primary unassisted patency. The Kaplan-Meier survival analysis suggested that patients with CI <3 L/min/m² had a worse primary unassisted patency rate at all time points compared with patients with CI ≥3 L/min/m². Conclusion: This study demonstrated that preoperative CI was associated with RCAVF M and long-term patency. A decreased CI may be a possible predictor of an increased risk of FM and a shorter primary patency time.

Outcome after early thrombotic occlusion of arteriovenous fistulas.

Arteriovenous fistulas (AVFs) are considered the first choice for venous access in end-stage renal disease patients, however, they are also known to have a high primary failure rate (early thrombosis and maturation failure). Of these, the outcome of thrombosed immature AVFs is not well known. This study aimed to investigate the outcome of AVFs with early thrombosis. Patients who underwent AVF creation from January 2009 to December 2019 at Seoul National University Hospital or Seoul Metropolitan Government - Seoul National University Boramae Medical Center were retrospectively reviewed. Patients who received salvage operations due to early thrombosis within 30 days after access creation were analyzed. During the study period, a total of 45 patients (radiocephalic 26; brachiocephalic 19) developed early thrombosis and underwent salvage operations. The median age of patients was 61.0 (54.5-69.5) years, and 51.1% were male. The first salvage operation was performed on the median 1.0 (0.0-4.5) day after AVF creation. The most common cause for early thrombosis was venous stenosis (64.4%) and followed by poor arterial inflow (28.9%), especially in radiocephalic AVFs. About 20 AVFs were salvaged to maturation (46.5%). Post-salvage primary patency and secondary patency at 1 year was 72.6% and 100%. In a multivariate logistic regression, significant risk factors for maturation failures were minimum venous outflow diameter ⩽2.5 mm (OR, 4.433; 95% CI, 1.039-18.921; p = 0.044) and lower in patients with hypertension (OR, 0.064; 95% CI, 0.006-0.637; p = 0.019). Thrombosed immature AVFs are associated with a high failure rate after salvage operation. However, if the salvage operation is successfully performed, it is associated with an acceptable 1-year outcome.

Long-term Results of Interwoven Nitinol Stents to Treat the Radiocephalic Anastomotic Arteriovenous Fistula Stenosis

Introduction: Juxta-anastomotic stenosis (JXAS) is a common problem afflicting the arteriovenous fistula (AVF). This study aimed to evaluate the safety and long-term efficacy of an interwoven nitinol stent (Supera, Abbott Vascular, Santa Clara, CA, USA) in the treatment of radiocephalic AVF JXAS. Methods: A single-center, retrospective, observational study was conducted of patients with failing AVF due to JXAS treated with an interwoven nitinol stent. End points included JXAS target lesion primary patency, access circuit primary patency, assisted access circuit primary patency, and endovascular intervention rate (EIR). Results: Sixty patients were treated with a Supera stent in the JXAS between February 2014 and March 2020. One patient was excluded (AVF used for illicit drug use), leaving 59 patients (67.8% male, mean age 66.9 ± 11.4 years [range: 40–84]) with typical medical comorbidities. Overall, 45.8% of patients had previous AVF intervention. The stent was inserted with a 100% technical success rate with a mean follow-up of 729.6 ± 456.0 days (range: 5–2182 days). Juxta-anastomotic stenosis target lesion primary patency was 68.2 ± 6.6%, 53.3 ± 7.5%, and 46.2 ± 8.1% at 12, 24, and 36 months, respectively. The EIR was .64 (0–3.29) procedures/patient/year, after which the assisted access circuit primary patency rate was 94.3 ± 3.2% at 12, 24, and 36 month time points. Three thrombosed circuits occurred which were all successfully salvaged with no difference in patency by indication for procedure and no AVFs lost/abandoned out to 3 years. Avoidance of stent post-dilatation and the presence of stent mal-apposition were associated with improved primary patency, and reduced EIR, which may suggest an importance in vessel preparation prior to stent implantation. Conclusion: Interwoven nitinol stent treatment of the failing AVF with JXAS results in promising 3 year JXAS patency, with a low rate of endovascular re-intervention for those circuits developing restenosis. All AVFs were maintained over 3 years, demonstrating this treatment allows for long-term radiocephalic AVF vascular access.

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.&nbsp; 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.&nbsp; Key words: Arteriovenous fistula, hemodialysis, vascular access.

Management of Arterio-Venous Fistula Side Branches During Maturation: Ligation or Coil Embolization

Failure of maturation of arteriovenous fistulae (AVF) remains an ongoing concern for dialysis access. One etiology is the presence of side branches that divert flow from the main AVF channel. This study aims to evaluate the outcomes of endovascular and open surgical interventions for AVF side branches in the setting of maturation failure. A retrospective review of all patients within a 10-year period with primary radio cephalic and brachiocephalic AVF was undertaken, and 380 cases of maturation failure related to branch diversion were selected for the study. Fifty-four percent and 48% of the AVF in the ENDO and OPEN groups respectively have concomitant stenosis further along in the flow path that required intervention by balloon angioplasty at the same time as a side branch intervention. All patients underwent duplex imaging or a fistulogram before intervention. Indications were low flow (<600 mL/min) or failure to increase in size (<6 mm diameter) in all cases. Interventions were divided into endovascular (coil embolization; ENDO) and surgical (branch ligation; OPEN) interventions. Outcomes of maturation (successful progression to hemodialysis (HD)), re-intervention, and functional dialysis (continuous HD for three consecutive months) were examined. From January 2008 to December 2018, 187 patients (49^ of all cases with side branches; 65% female, age of 57 ± 18 years; mean ± SD) with poorly maturing radiocephalic (70%) and brachiocephalic AVF (30%) underwent intervention due to the presence of accessory venous branches only. Indications were failure to mature in 54% and low flow in 46%. The average time to intervention due to failure to mature was 5 ± 4 weeks (mean ± SD) after primary access placement. Eighty-one had coil embolization and 106 had open branch ligation. Technical success was 90% in ENDO and 100% in OPEN. Technical ENDO failures had a secondary open branch ligation but were considered failures for analysis. Repeat interventions by balloon-assisted maturation were required in 45% of all the cases with no difference between ENDO and OPEN. Recannulation of the ENDO branches occurred in 10% of the cases requiring repeat intervention. Sixty one percent of isolated endovascular (n=49) and 64% of isolated open (n=68) matured to successful cannulation (P=0.84). Median functional dialysis durations remained equivalent between ENDO (2.6 years) and OPEN (2.8 years) groups (P=0.12). There is an improved maturation rate following the ENDO group compared to OPEN interventions while both ENDO and OPEN modalities demonstrated similar long-term functionality.

Cephalic arch stenosis in the arteriovenous fistula: A retrospective analysis of predisposing factors.

Cephalic Arch Stenosis (CAS) is a frequently observed complication in brachiocephalic and radiocephalic arteriovenous fistulae (AVF) associated with high morbidity and healthcare expenditure. The predisposing factors and preventative strategies for CAS remain unclear. Our aim was to examine predisposing factors for CAS development in the AVF. A retrospective case-control study was performed at Gold University Coast Hospital on patients with AVFs created from 2009 to 2018 with ⩾18 months follow-up. CAS was defined as a >50% narrowing on angiographic assessment with clinically significant symptoms (dialysis dysfunction, arm swelling, prolonged bleeding after access). About 187 patients with AVF were included in the analysis (36 brachiocephalic, 151 radiocephalic). CAS developed in 22 of 36 (61%) of brachiocephalic AVF and 9 of 151 (6%) of radiocephalic AVFs. Brachiocephalic AVF were ⩾12 times more likely to develop CAS than radiocephalic AVF (Hazard Ratio (HR) 12.7, 95% CI [5.6-28.3], p < 0.001). Each 1 mL/min increase in flow rate through the AVF, correlated with a 0.07% increase in the probability of development of CAS (HR 1.0007, 95% CI [1.0001-1.0012], p = 0.011). Brachiocephalic AVFs with CAS were associated with a higher number of interventional procedures per access-year compared with their non-CAS counterparts (Median [Interquartile range]: 1.76 [0.74, 3.97] vs 0.41 [0.27, 0.67], p = 0.003). Brachiocephalic AVF with higher access flow rates are more likely to develop CAS and earlier than radiocephalic AVF, and in a dose dependent fashion. AVF flow rate is a major factor in CAS development within brachiocephalic AVF and has potential utility in surveillance thresholds for prophylactic blood flow reduction procedures. AVFs with CAS are associated with a greater number of interventional procedures per access-year, heralding higher patient morbidity and healthcare expenditure. Further prospective studies will help define an AVF access flow rate threshold in the implementation of prophylactic strategies for CAS.

Atypical presentation of fistula dysfunction due to brachial arterial embolization mimicking stroke.

Vascular access thrombosis is an important complication with great impact on access patency and, consequently, on a patient's quality of life and survival. We report the case of a 73-year-old woman with chronic kidney disease on hemodialysis with a radiocephalic arteriovenous fistula on the right arm that was brought to the emergency department with decreased strength in her right arm, ipsilateral hypoesthesia and facial hemi-hypoesthesia. The patient was given a brain computed tomographic scan that did not confirm suspicion of stroke. On re-examination, the patient had new-onset pain at arteriovenous fistula level, and her right arm was cold and pale. The nephrology department was called for arteriovenous fistula evaluation. On physical examination, her forearm fistula had a decreased thrill and arm elevation exacerbated its paleness. A bedside ultrasound was performed for arteriovenous fistula assessment. Doppler ultrasound revealed: partial thrombosis at brachial bifurcation, a flow of 80-105 mL/min at brachial artery level and a radial artery with a damped waveform. Anastomosis and draining vein were permeable. In this case, the diagnosis of acute embolic brachial artery occlusion was made by a fast bedside ultrasound evaluation. The patient underwent thromboembolectomy with Fogarty technique, recovering fistula thrill, radial and cubital pulses. Thromboembolism of the fistula feeding artery is a rare cause of vascular access thrombosis and it is rarely mentioned in the literature. In this report, failure to recognize the upper limb ischemia would have led to delayed treatment, potentially resulting in the fistula's complete thrombosis and further limb ischemia. We highlight the importance of a diagnosis method like Doppler ultrasound, which allows for rapid evaluation at the patient's bedside.

Value of a quantitative model of axillary venous blood flow spectrum for the detection of central venous stenosis in patients undergoing hemodialysis via radiocephalic arteriovenous fistula.

BackgroundCentral venous stenosis (CVS) of radiocephalic arteriovenous fistula (RCAVF) affects RCAVF function and longevity. Ultrasound screening for CVS is limited by acoustic window. Herein, we analyzed the quantitative axillary venous (AxV) spectrum in hemodialysis patients via RCAVF, and constructed central venous stenosis index (CVSI) model based on the spectrum parameters to early detect resting asymptomatic CVS.MethodsFrom August 2017 to May 2021, stage 5 chronic kidney disease (CKD) patients dialysed via RCAVF at the First Affiliated Hospital of Fujian Medical University were included in this study. No CVS-related symptoms were found and the pulsation at the arteriovenous anastomosis was normal. However, the patients had the sensation of swelling in the ipsilateral upper limb during dialysis; the venous pressure advanced upon the completion of dialysis; or both (n=52). The inclusion criteria were as follows: (I) Ultrasound (US) showed that the temporal phases of the AxV spectrum were “normal”; and (II) CVS was confirmed by digital subtraction angiography (DSA). The exclusion criteria were as follows: (I) stent placement; (II) multiple stenosis; and (III) placement of central venous catheter. A total of 37 patients participated in the analysis. Eighteen patients were included in the CVS group, and 19 cases without CVS were included in the control group. Independent sample t-test was used to screen each parameter of the AxV spectrum, and a CVSI model was constructed by principal component analysis (PCA). The receiver operating characteristic curve (ROC) was applied to analyze the diagnostic value of CVSI.ResultsAccording to the independent sample t-test, 9 parameters were found to have statistical significance (all P<0.05); they were analyzed by PCA, and the CVSI model was constructed. The ROC showed that CVSI had diagnostic value for CVS. When the cut-off value of CVSI was 7.13, the maximum value of the Youden index was 0.842, with a sensitivity of 100% and a specificity of 84.2%.ConclusionsThe CVSI helps to early detect resting asymptomatic CVS and dramatically increases the detection rate of CVS.

A Cadaveric Study of Radial Artery and Cephalic Vein in Forearm and Hand: A Guideline for Radio-cephalic Arteriovenous Fistula Planning

Introduction: The creation and maintenance of uninterrupted Haemodialysis (HD) is dependent on the quality and reliability of vascular access. The native Radio-cephalic Arteriovenous Fistula (RCAVF) is the vascular access of choice for HD in patients with end stage renal diseases. A thorough understanding of the vascular anatomy is critical in selecting the site for the RCAVF that provides the flow rates necessary for the development of an optimal outflow vein. The widespread use of the doppler ultrasound has facilitated the identification of vessels that are suitable for fistula construction. Aim: To analyse the surgical anatomy of radial artery and cephalic vein in the front of forearm and dorsum of hand, pertinent to RCAVF planning. Materials and Methods: A cross-sectional cadaveric of 30 formalin preserved upper limbs specimens of adult human cadavers was done in the Department of Anatomy, Hamdard Institute of Medical Sciences, New Delhi, India, (n=22 limbs) from August 2016 to April 2018 and Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India (n=8 limbs) from November 2018 to November 2019. The external diameter of radial artery, cephalic vein and distance between radial artery and cephalic vein were measured at mid forearm, front of wrist and Anatomical Snuff Box (ASB). Measurements were taken with sliding vernier caliper to an accuracy of 0.01 mm. All the measurements were tabulated separately for right and left-side. The data was analysed using Microsoft excel. Descriptive statistics like mean, standard deviation (SD) and range were evaluated for all the parameters collected. The paired t-test was applied to compare the right and left-side measurements. Results: Amongst 30 formalin preserved specimens of upper limbs of human cadavers analysed, the diameter of radial artery was 3±0.26 mm on the right-side and 2.87±0.24 mm on the left- side and of cephalic vein was 2.5±0.59 mm on the right-side and 2.9±0.33 mm in ASB. The distance between radial artery and cephalic vein were 2.5 ±0.59 mm on the right-side and 2.9±0.33 mm on the left-side which was minimum in ASB. The distance between radial artery and cephalic vein was maximum at wrist (4.02±0.76 mm and 4.2±0.71 mm on the right and left hand). Conclusion: The fistula formation in ASB may give better results as the radial artery and cephalic vein are closer as compared to wrist and midforearm with reasonable diameter. Additionally, it would also provide long segment of vein for arterialization.

The outcome of radiocephalic after brachiocephalic and redo arteriovenous fistula.

Introduction:When created in appropriately selected patients, arteriovenous fistula requires fewer interventions and costs compared to arteriovenous graft. The outcome of radiocephalic after brachiocephalic and redo arteriovenous fistula is not studied well in the literature, and this study highlights the outcome of these arteriovenous fistulae.Methods:The retrospective, single-center study, based on patient record analysis of 1040 arteriovenous fistula, was created between January 2017 and October 2021. Thirty-nine (3.37%) patients met the inclusion criteria for radiocephalic after brachiocephalic arteriovenous fistula group, and 42 (4.04%) met the inclusion criteria for the redo arteriovenous fistula group. Preoperative Doppler ultrasound was performed by the operating surgeon in all patients. All patients were scheduled for a visit 2 months after surgery for assessment—only 34 of radiocephalic after brachiocephalic arteriovenous fistula and 35 of redo arteriovenous fistula patients presented for follow-up. The arteriovenous fistula was assessed for patency, maturation, and complications. SPSS version 22 (Chicago, USA) was used for data entry and analysis.Results:The redo arteriovenous fistula has a significantly lower maturation rate at 2 months of follow-up (62.85%) when compared to other brachiocephalic arteriovenous fistula (79.18%) (p-value = 0.0245). The radiocephalic after brachiocephalic arteriovenous fistula has no significant difference in maturation rate at 2 months of follow-up (61.67%) when compared to other distal forearms radiocephalic arteriovenous fistula (68.18%) (p-value = 0.5173). The incidence of some early complications was higher in the redo group.Conclusion:The feasibility of doing radiocephalic arteriovenous fistula after failed brachiocephalic arteriovenous fistula is generally overlooked. The redo arteriovenous fistula is more technically challenging, associated with higher complications, but it provides reliable access in a specific group of patients.

Prospective Study of Upper Limb Vessel Diameters and their Association with Arteriovenous Fistula Maturation in End Stage Renal Disease Patients

Purpose: For the creation of an upper limb arteriovenous fistula (AVF), the 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) suggest a minimum vessel diameter of 2 mm and 3 mm for radiocephalic (RCAVF) and brachiocephalic AVFs (BCAVF), respectively. However, there have been no large scale studies in Indian patients to substantiate these guidelines. The aim of this study was to estimate the upper limb vessel diameters and their association with the maturation of AVF at six weeks.

Outcomes of Autogenous Radiocephalic Versus Brachiocephalic Arteriovenous Fistula Surgery Based on Transit-Time Flowmeter Assessment: A Retrospective Study

Despite the better operative results of autogenous brachiocephalic arteriovenous fistula (BC-AVF), it is considered secondary to autogenous radiocephalic AVF (RC-AVF) failure. Here we compared the results of our multidisciplinary management protocol of BC-AVF versus RC-AVF. A total of 194 matched patients who requested autogenous BC-AVF or RC-AVF surgery between 2017 and 2019 were included in this retrospective study. All patients strictly adhered to our departmental perioperative management protocol for AVF surgery, including vessel status monitoring, exercise with or without a tourniquet, intraoperative flow assessment, and antiplatelet and anticoagulant medications. AVF function and patient status data were acquired from the electronic medical records, and the final evaluation was made via outpatient department visit or phone call in October 2020. Patients who underwent elective BC-AVF or RC-AVF (n=97 each) were included. The patient groups had similar preoperative clinical characteristics. Artery and vein sizes at the planned anastomosis site were larger in the BC-AVF group (P < 0.001). The mean intraoperative maximal flow rate was higher in the BC-AVF group (492.5 ± 186.9 mL/min) than in the RC-AVF group (307.3 ± 113.0 mL/min, P < 0.001). The simultaneously evaluated mean pulsatility index was 0.5 ± 0.2 in the BC-AVF group and 0.6 ± 0.2 in the RC-AVF group (P < 0.001). The median observation duration was 19.4 months (11.0‒31.3 months). The primary patency rate was higher in the BC-AVF group (88.7%) than in the RC-AVF group (62.9%, P < 0.001). Patency duration was similar between groups, and the primary patency maintenance duration was longer in the BC-AVF group. Three cases of cephalic arch stenosis were observed in the BC-AVF group, while no cases of arterial steal syndrome were observed during the indexed observation period. Mortality rates were 14.4% and 9.3% in the BC-AVF and RC-AVF groups, respectively (P=0.267), and the cause of death did not differ significantly between groups. For mortality, the estimated hazard ratio of RC-AVF over BC-AVF was 0.47 (95% CI, 0.19‒1.17, P=0.106) during the observation period. BC-AVF had good characteristics for hemodialysis without an increased risk of AVF related complications during a median 19-month observation period. BC-AVF did not feature high flow-related complications with the multimodal approach, including preoperative exercise, intraoperative flow assessment to guarantee an adequate flow rate, postoperative exercise, and medications.

A three years’ experience of Arteriovenous Fistula (AVF) cases in a tertiary care hospital of East Java, Indonesia: a descriptive observational study

Introduction: The incidence of end-stage renal disease (ESRD) globally is 700 million people approximately. Patients with ESRD need vascular access for hemodialysis as renal replacement therapy (RRT). Among hemodialysis access, arteriovenous fistula is considered as the most preferred form of vascular access due to its characteristics. This study aimed to to present a descriptive characteristic of arteriovenous fistula creation cases in a tertiary care hospital with a specific view of demographic parameters, fistulas' sites, type of fistulas. Methods: We conducted a descriptive study of single-center in the Department of Thoracic, Cardiac and Vascular Surgery of Dr. Soetomo Academic General Hospital Surabaya, collected data from January 1st, 2017 to December 31st, 2020. All patients who undergo arteriovenous fistula creation considered as a subject in this study. We retrieved the characteristics of the patients, the type of fistula, the site, surgical technique, and underlying disease from patients’ electronic medical data records. Results: A total of 167 patients requiring long-term hemodialysis in our center. Females were dominantly in our study with 56.9% (95). Most of AVFs were created on the left arm. Radiocephalic type of AVF was the most common arteriovenous fistula type found in 111 subjects (66.5%). The highest postoperative successful rate was found in brachiocephalic type in 78.8%, followed by radiocephalic AVF type with 66.7%. The wrist region was favorable in subjects (43.1%). Conclusions: Arteriovenous fistulas for hemodialysis are needed and in our center. Radiocephalic AVFs are the most common type. Further study to learn the different aspects of arteriovenous fistula cases is needed to fulfill queries in the local population.

Novel Use of Forearm Perforator in Vascular Access

A 65-year-old male was initiated on hemodialysis through a radio-cephalic arteriovenous fistula. He required a proximal brachiocephalic fistula due to a failing radiocephalic fistula. Both fistulae could be functionalized simultaneously due to a forearm cephalic perforator vein. The radiocephalic fistula was subsequently ligated, allowing the patient to use the mature brachiocephalic fistula instead of a bridging temporary/tunneled catheter.

Ulnar-basilic arteriovenous fistula with multilocular gigantic aneurysmal dilatation: a case report

Abstract Introduction: Arteriovenous fistula dysfunction has been associated with a range of problems such as thrombosis, stenosis, dilatation, and infection. Case presentation: We present the case of a 64-year-old patient with chronic kidney disease on hemodialysis and with aneurysmal dilatation of the ulnar-basilic arteriovenous fistula, having an increased risk of rupture. A temporary dialysis catheter is placed in the left femoral vein, an aneurysmal basilic vein is ligated at the anastomosis, aneurysmal dilatation is emptied by compression, and a right radiocephalic arteriovenous fistula is performed. The patient undergoes hemodialysis on the second day and subsequently three times a week for six weeks until the new arteriovenous fistula develops. He returns for aneurysmal sac resection. Conclusion: The purpose of this paper is the presentation and management of a 15-year-old ulnar-basilic arteriovenous fistula with multilocular aneurysmal development and an imminent rupture.

Comparative Study of the Effects of Two Suturing Techniques of End-to-Side Arteriovenous Anastomosis on Early Outcomes of Radio-Cephalic Fistulas

Introduction: Radiocephalic arteriovenous fistulas (AVFs) for dialysis have significantly high maturation failure rate. Many surgical technique-related factors are known to impact the outcomes of AVF surgery; anastomotic suturing technique is one such factor for which the published data is sparse. Patients and Methods: We retrospectively analyzed the data of patients who underwent end-to-side radio-cephalic AVF surgery during a 2-year period and grouped it according to the two techniques of anastomotic suturing: Anchor technique and parachute technique. Comparative analysis was done to study the effect of the technique on well-defined outcomes within the first 6 months of surgery. Results: A total of 119 AVFs (anchor technique = 65, parachute technique = 54) were included in the study. The aggregated primary patency at 6 weeks and 6 months was 85.7% and 78.1% respectively and successful use of fistula was seen in 62.2%. The parachute technique was associated with lower immediate access thrombosis (3.7% vs. 15.4%, P = 0.019) and primary failure (31.5% vs. 43%, P = 0.033) than the anchor technique. The groups did not differ statistically in outcomes like early access failure (P = 0.376), maturation failure (P = 0.105), primary patency at 6 weeks (P = 0.07) and at 6 months (P = 0.083) and successful use of fistula at 6 months (P = 0.196). Conclusion: In this retrospective single-center study, the parachute technique of anastomotic suturing was associated with lower incidence of immediate access failure of radio-cephalic AVF as compared to the anchor technique, although other early outcomes were similar with both techniques. The effects of different suturing techniques on surgical outcomes of AVF should be studied in large randomized trials.

Prospective Evaluation of Radiocephalic Arteriovenous Fistula to Determine the Causes for Non Maturity with Clinical and Ultrasonography-Doppler

Introduction: The RC-AVF is the most important tool for hemodialysis considered to be the life line of patients. In our study, we have tried to find the incidence of AVF non maturation and the physical and ultrasonological parameter which can predict its non maturation. Materials and Methods: Radio-cephalic AVF surgery was done taking into account the inclusion and exclusion criteria with a follow up period of 6 weeks. The cases were evaluated pre-operatively and post-operatively using clinical and DUS. Results: 91 cases were studied with a success surgical outcome in 54.9% (50) of patients. The mean age of 46.04 yrs, male sex and less diabetes (46%) was associated with a matured RC-AVF surgical outcome. Mean preoperative artery diameter of &gt; 0.21 ± 0.04 cm and vein diameter of &gt; 0.20 ± 0.03 cm was seen in the matured cases. Incremental test and Resistive index was normal in 62% and 80% of the matured cases respectively, while calcification of feeding artery was associated with poor outcome. Further Clinical examination showed sensitivity 88% and specificity 95% whereas Doppler studies showed a sensitivity of 100% and specificity of 92.6% to successfully diagnose matured cases. Thrombosis (51%) was the most common cause of AVF failure followed by juxta anastomosis stenosis (14%). Conclusion: In this study we found that a thorough pre-operative evaluation of the vessels of RC-AVF can predict its maturation. Also a regular follow-up and use of clinical and imaging studies can help diagnose and timely salvage a failing AVF.

Weight-Based Assessment of Access Flow Threshold to Predict Arteriovenous Fistula Functional Patency

IntroductionThe 2019 Kidney Disease Outcome Quality Initiative (K/DOQI) guideline recommended evaluating arteriovenous fistula (AVF) malfunction risks primarily based on clinical monitoring, which can be assisted with the value of vascular access flow (Qa). Nevertheless, Qa thresholds recommended by different guidelines vary, ranging from 300 to 500 ml/min. This study investigated the optimal Qa threshold to predict future functional patency in AVFs with Qa <500 ml/min.MethodsBoth the clinical indicators of access dysfunction and the Qa value were monitored in patients receiving hemodialysis by the radiocephalic AVF. Routine access flow surveillance was performed by the ultrasound dilution method (HD03, Transonic Inc.). The development of clinically significant indicators of access dysfunction, which necessitated percutaneous transluminal angiography (PTA) to maintain functional patency, was analyzed in this cohort.ResultsAmong the enrolled 302 patients, Qa of 52 patients was under 500 ml/min. These 52 patients received 2 Qa measurements during the follow-up period. Of these 52 patients, serial Qa of 17 patients varied trivially and their AVF remained functional. Multivariable logistic regression analysis revealed that a low Qa per ideal body weight (IBW) is an independent predictor of AVF functional loss. Receiver operating characteristic curve analysis of Qa/IBW in predicting future AVF functional loss revealed that the best cutoff value of Qa is 7.1 times the IBW.ConclusionFor radiocephalic AVFs with Qa <500 ml/min, the minimally required Qa to maintain access function is associated with individual IBW. The IBW-based Qa threshold assessment would allow more flexibility in the treatment of patients and reduce unnecessary invasive measures.

Brachial artery aneurysm as a late complication of arteriovenous fistula.

Brachial artery aneurysm (BAA) is a rare late complication of arteriovenous fistula (AVF). It brings the risk of peripheral embolism and hand ischemia and is defined by brachial artery diameter above 10 mm or by regional dilatation by >50%. BAA is described in the literature in closed radiocephalic arteriovenous fistulas after kidney transplantation. The aim of the study was to analyze the prevalence of BAA and of their more dangerous forms. A observational one center study performed on patients after kidney transplantation with AVF or arteriovenous graft (AVG). We invited all patients followed up for kidney transplantation in our center. Arterial diameter greater than 10 mm was considered as a brachial artery aneurysm to simplify the detection and evaluation of aneurysms. About 162 patients with AVF after kidney transplantation were examined between 4/2018 and 4/2020. Brachial artery aneurysm was detected in 34 patients (21%) with AVF or AVG, of them 7 had confirmed wall thrombi. AVF flow volume of more than 1500 ml/min increased the risk of BAA development by 4.54x. Eight aneurysms were treated surgically. After this surgery, the primary patency was 87.5% in 12 months. Brachial artery aneurysm was relatively frequent in our study compare to the literature. Aneurysm or dilatation of the brachial artery is more frequent in functional AVFs. Surgical correction is necessary in cases of complicated aneurysms to prevent distal embolization.

Effect of Radiocephalic Anastomotic Length on the Maturation of Arteriovenous Fistula

A radiocephalic arteriovenous fistula (RCAVF) is associated with better long-term patency and fewer complications. However, RCAVF have lower maturation rate for hemodialysis compared with upper AVF or arteriovenous graft. We performed this study to determine the effect of the radiocephalic (RC) anastomotic length on the AVF maturation. We reviewed the patients who underwent RCAVF creation with a side-to-end manner from March 2015 to December 2018. AVF maturation was defined as successful hemodialysis (HD) in at least two consecutive sessions. We compared the possible factors including the RC anastomotic length between the initial HD success group and initial HD failure group. A total of 114 patients underwent RCAVF creation: 72 males and 42 females (63.2% and 36.8%, respectively). The mean preoperative arteriotomy length of the AVF was 14.1 mm (range 11.0-16.0 mm). Out of 114 patients, initial HD was executed successfully in 83 patients (72.8%). Among the 31 patients with initial HD failure (27.2%) balloon angioplasty was successfully performed in 17 patients, failed in 4 patients, and not performed in 10 patients. The secondary success rate after balloon angioplasty was 87.7%. After factor analysis, pre-emptive AVF (P=0.01), vein diameter (P < 0.001), and flow rate (P < 0.001) were revealed significant factors for initial HD success, but not RC anastomotic length of AVF (P=0.55). The length of the radiocephalic anastomosis does not affect the RCAVF maturation rate statistically. However, lengthening of arteriotomy on the radial artery may increase the initial success rate of HD.