Radiocephalic Fistula Research Articles

Proximal Ulnar Artery Pseudoaneurysm in a Patient on Maintenance Hemodialysis

A 76-year-old woman was admitted to the hospital because of painful mass under her native arteriovenous fistula tract in the left forearm near the antecubital fossa. She had been diagnosed with end-stage renal disease due to hypertensive nephrosclerosis, and had been on maintenance hemodialysis treatment for 2 years. The patient was thin with a body mass index of 18.75 kg/ m2. She had mid-forearm radiocephalic arteriovenous fistula and a painful mass under the fistula. The mass was non pulsatile. Auscultation of mass was difficult due to close relationship with her native fistula but a poor murmur was detected after a careful examination. The left radial and ulnar arteries were well palpable. There was no erythema or sinus. The pain had started after a traumatic venous puncture, complicated by a large ecchymosis, during a hemodialysis session one month ago. The ecchymotic area disappeared after three weeks. A duplex scan confirmed the diagnosis of a 3 x 3 cm pseudoaneurysm of the ulnar artery. After the diagnosis, the pseudoaneurysm was treated with local excision and reconstruction. The posterior border of the fistula was dissected carefully. The vein was pulled apart. The thrombotic capsule of the pseudoaneurysm was exposed between the brachioradialis and the flexor carpi radialis muscles (Figure 1). Then we excised the aneurysm and cleared all thrombotic material. The hole on the anterior aspect of the ulnar artery was seen and closed primarily. After the operation, the patient became asymptomatic.

Access Flow Reduction for Cardiac Failure

High-flow in hemodialysis arteriovenous angioaccesses is frequent. It may result in high-output cardiac failure, which should be prevented by fistula flow reduction. The most frequently reported flow reduction procedure is banding but immediate and long-term results are questionable. Alternative techniques are related here with personal results. Juxta-anastomosis "Proximal Radial Artery Ligation" (PRAL) is a very simple and effective reduction technique for side-to-end radio-cephalic fistulas (82 patients; reduction rate [RR]: 54% ± 19%). For brachial artery-based fistulas flow reduction two variants of Revision Using Distal Inflow (RUDI) procedures are used: 1) RUDI-1 using a polytetrafluoroethylene (PTFE) graft or a greater saphenous vein, which we first described in 1989 as "Distal Report of the Arterial Inflow" (35 patients; RR: 53% ± 18%), 2) RUDI-2 procedure, "Transposition of the Radial Artery", which we described in 2009 (47 patients; RR: 66% ± 14%).

Dialysis Access Steal Syndrome: The Severity Criteria Diagnosis with Arterial Doppler Examinations

Patients with dialysis access steal phenomenon can present with pain, paresthesia, ulceration, and tissue loss of the digits. Some degree of steal is common, up to 80% of patients with a radiocephalic arteriovenous fistula have mild, asymptomatic arterial steal documented by a decreased digital blood pressure. Critical ischemia of the upper extremity is a rare condition compared with ischemia of the lower extremities. High-flow arteriovenous fistulas have a greater risk of steal than normal flow arteriovenous fistulas; however, combined with arteriosclerotic disease they may also lead to ischemia. There are several strategies to prevent arterial steal following hemodialysis access that should be used; preoperative testing to identify proximal arterial lesions, upper extremity vein mapping and sizing, Allen's test (radial artery patency), end-to-side arteriovenous anastomosis to decrease steal and distal venous hypertension, selective venous arterialization at the elbow with ligation of deep perforation branch to improve maturation and restrict flow, and stepped or tapered grafts to limit flow. A noninvasive upper extremity arterial Doppler diagnosis is of importance to determine treatment options for patients. The goal of the vascular access surgeon is to promptly recognize and treat the disorder to maximize both limb and access salvage.

Prophylactic Ligation of the Median Cubital Vein to Improve the Patency of a Radio Cephalic Fistula

The study evaluated the prophylactic ligation of the median cubital vein to improve the patency of a radiocephalic fistula in end stage renal disease (ESRD) patients undergoing hemodialysis. The study included a total of 38 ESRD patients undergoing arteriovenous fistula (AVF) surgery. Functional outcomes of the radiocephalic fistula were studied for six months by measuring primary patency rates. Out of 38 patients, 28 patients were cannulated at 20 days because of good flow and early maturation of the fistula. Revision AVF was performed on 4 patients after 3 months because of improper cannulation resulting in thrombosis of the cephalic vein. One patient underwent balloon angioplasty to maintain patency. Five patients discontinued the study. The primary patency rates for ESRD patients undergoing hemodialysis with radio cephalic fistula were better after ligation of the median cubital vein.

A Long term study for upper limb arterio-venous fistula creation for hemodialysis at a tertiary level hospital in Eastern India

Background: There is gradual increase in need for hemodialysis, as there is gradual increase in the end stage renal disease in India. Permanent vascular access in the patient with end stage renal disease on hemodialysis is provided through a central venous catheter, arteriovenous graft, or arteriovenous fistula. The aim of this study was to evaluate the site, results and postoperative complications of arteriovenous fistula creation in our hospital. Method: It was a retrograde study conducted at Seth Sukhlal Karnani Memorial (SSKM) hospital, Institute of Post-Graduate Medical Education and Research (IPGMER), Kolkata, between 1st July 2006 and 30th August 2011. All patients, with end stage renal disease requiring long term vascular access for haemodialysis, were included in the study. In most of the patients radio-cephalic fistulae were created in the left forearm, in some on right forearm, just above the wrist joint, and in some patients brachiocephalic or brachiobasilic arteriovenous fistulae were created. Results: 375 patients were studied; 292 (77.86%) males and 83(22.14%) females, with male to female ratio of 3.52:1. Distribution of co-morbid factors showed diabetes in 225 (60.0%), hypertension in 150 (40%) patients. Radio-cephalic fistula was done in 295 patients and brachiocephalic fistula in 80 patients. In 5% dominant hand was used and for remaining 95% of the patients fistula was created on non-dominant hand. Arterio-venous fistula was successful at 6 weeks in 95%, at 2 years in 90% and at 5 years in 85% patients. In 5% cases, failure in first 6 weeks was because of primary failure or wound infections and at 2-5 years failure due to stenosis of cephalic vein by repeated punctures and thrombosis. In failed patients re-do procedure was carried out successfully at another (cubital) site. Conclusion: Radio-cephalic arteriovenous fistula in patients with end stage renal disease requiring long term vascular access for haemodialysis remains the procedure of choice if done by experienced hands.

A prospective study of arteriovenous fistula creation in chronic renal failure patients in Bhavnagar, Gujarat, western India

Background: Arteriovenous (AV) fistula is an autogenous connection between an artery and a vein, which allows adequate blood flow during hemodialysis in patients with chronic renal failure, and they have superior patency rates and lower complication rates than grafts. Objective: To study the success rate of AV fistula, postoperative complications, and factors affecting the patency rate of AV fistula. Materials and Methods: This prospective study was conducted in Department of General Surgery of Sir Takhtsinhji Hospital, Bhavnagar, Gujarat, India, during 2012–2014 in patients of all age groups and both gender with chronic kidney disease. Result: Of the 150 patients enrolled in the study, 62% revealed radiocephalic fistulas while 17% brachiocubital fistulas. In majority of the patients (81%), side-to-side anastomosis was done, while in 19% patients, end-to-side anastomosis was done. The AV fistula remained patent in 115 (77%) patients, and among them, the patency rate of radiocephalic was 60% and that of brachiocephalic was 13%. The patency rate for side-to-side fistula was 83% and that for end-to-side was 18%. Patency rate for patients with hemoglobin (Hb) > 9 g % was 94% with only 6% for patients with Hb < 9 g %. Nonsmokers were 3.6 times (95% CI: 1.58–8.23) more likely to have their fistula patent than smokers. Arterial diameter is also a predictor of patency. Conclusion: The success rate of AV fistula by conventional vascular anastomosis technique was 77%. Side-to-side anastomosis showed better patency rate than end-to-side anastomosis. Radiocephalic AV fistula showed better patency rate than other types of fistulas performed in upper limb. Anemia (Hb < 9 g %), smoking, and arterial diameter were the major factors affecting fistula patency. Thrombosis, postoperative edema, surgical site infection, steal phenomenon, and aneurysm were the complications noted in the postoperative period.

Brachiocephalic Arteriovenous Fistula through the Median Antecubital Vein for Hemodialysis

Purpose: An option for patients who are unsuitable for radiocephalic fistula is brachiocephalic (BC) fistula. In such patients, we exploited the venous interconnections in the cubital fossa for median antecubital vein (MAV)-BC arteriovenous fistula (AVF) creation. In this article, we describe our experience in the creation of such technical variant of the BC fistula AVF, its success, and associated complications. Materials and Methods: A retrospective review of such AVF created between September 2014 and August 2015 was done. The data collected included demographics, comorbidities, basic disease, operative details, patency, complications, and mortality. Results: A total of 68 vascular access surgeries were done which included 26 (38.2%) BC AVF using the MAV. The mean cephalic vein diameter and mean flow rate were 7.18 mm and 1415 ml/min, respectively, 2 months after fistula creation. The primary and secondary failure rates were 3.87% and 7.69%, respectively. Complications included aneurysm (7.69%), edema (19.23%), hematoma (11.53%), and wound infection (2.5%). Conclusion: Using reverse flow in the MAV is a safe and simple way to perform BC AVF before brachiobasilic AVF and grafts.

Peer review report 1 on “Impact of surgeon factor on radiocephalic fistula patency rates”

Peer review report 1 on “Impact of surgeon factor on radiocephalic fistula patency rates”

Arteriovenous fistulas for hemodialysis in patients suffering from chronic renal failure: our experience as regards difficulties and complications

Background: The study was conducted to assess the various complications which are encountered while creating arteriovenous fistula and post operatively during the period when fistula matures. Also the study was intended to study the failure rate and the importance of physical examination to assess vessel caliber clinically. Methods: The study comprised of 83 patients suffering from chonic renal failure and requied arteriovenous fistula for carrying out hemodialysis. The arteriovenous fistulas were created under local anesthesia, observing all precautions and end to side anastomosis was made after dissecting the vein and the artery. Results: The most common difficulty encountered at surgery was when cephalic vein was of very small caliber and we had to give a small longitudinal incision in the wall of vein or do cheatle manouvre to make the anastomosis adequate. In five cases we started for radiocephalic fistula but had to convert to brachiocepphalic fistule as arteriovenous anstomoosis was not possible between the radial artery and the cephalic vein. There were no major complications except redness and inflamation in five cases and pus formation in one case. Inflamation subsided with higher antibiotics and pus had to be drained resulting in satisfactory recovery.Most of the fistulas started well with good thrill and by the end of one month 69 out 83 arteriovenous fistulas were functioning well with a patency rate of 83.13%. Conclusions: There are no major complications after creating arteriovenous fistula and it is imperitive to do physical examination preoperatively to assess the vessel wall. In doubtful cases color Doppler may be got done for this. Postoperative precautions need to be observed for maturation of AV fistula.

Impact of surgeon factor on radiocephalic fistula patency rates.

IntroductionHemodialysis with arteriovenous fistula (AVF) has been widely accepted treatment modality for patients with chronic renal failure (CRF). Radiocephalic fistulas are considered to be the most desirable for the initial vascular access. The aim of this study is to investigate the surgeon factor on radiocephalic fistula patency rates.MethodsA total of 186 patients with diagnosis of CRF underwent Radiocephalic fistula for hemodialysis access were included. Patients were divided into 2 groups according to operating surgeon. Patients were evaluated according to demographic characteristics, secondary patency rates, second AVF creation and complications.ResultsMean age was 57.7 ± 14.8 years. The most common etiology of CRF was idiopathic (66.6%). 40 (75.5%) patients in group 1 and 122 (91.7%) patients in group 2 were pre-dialysis patients (p < 0.05). Overall secondary patency rate was 77.4%. Patients in group 1 and group 2 have secondary patency rates of 83% and 75.2%, respectively (p = 0.458). Second AVF creation was done in 2 (3.8%) patients in group 1 and 23 (17.3%) patients in group 2 (p < 0.05). Postoperative complication rate was 9.6%.ConclusionOperating surgeon is not a major factor of secondary patency in radiocephalic arteriovenous fistulas.

A randomized controlled trial of interrupted versus continuous suturing techniques for radiocephalic fistulas

Continuous suturing techniques have conventionally been used for the end-to-side anastomoses of radiocephalic fistulas (RCFs); however, primary patency rates are poor. Only 50% to 60% of RCFs ever achieve functional patency. We hypothesized that a hybrid interrupted-continuous suturing technique (as used in many microsurgical procedures) may improve outcomes in fistulas constructed from small vessels. A randomized controlled trial comparing hybrid interrupted-continuous (n = 42) with continuous (n = 36) suturing techniques for RCF was undertaken. Patients were excluded if vessels were <1.8 mm in diameter or if previous ipsilateral fistula had been attempted. A priori power calculation indicated that a sample size of 78 patients was required to detect an improvement in patency from 50% to 80% (α = .05, β = .8). The primary end point was primary patency at 6 weeks (assessed by a blinded observer for the presence of thrill and bruit). Secondary end points were immediate patency, functional patency (assessed clinically and by ultrasound) at 6 weeks, and presence of anastomotic stenosis. Groups were comparable for basic patient demographics, operating surgeon, and vessel diameter as measured on preoperative ultrasound (mean age, 58.9 ± 13 years; 68% male). Primary patency at 6 weeks was higher in the hybrid interrupted-continuous suturing technique group (71% vs 47%; P = .01). Immediate patency was also higher in the hybrid interrupted-continuous suturing technique group (93% vs 67%; P < .001). There was no significant difference in functional patency at 6 weeks (52% vs 36%; P = .18). Three patients developed an anastomotic stenosis. All were in the hybrid interrupted-continuous suturing technique group. One patient from the interrupted suturing technique cohort required re-exploration for bleeding. A hybrid interrupted-continuous suturing technique yielded higher immediate and 6-week primary patency rates for RCF. The hybrid interrupted-continuous suturing technique may improve anastomotic compliance and reduce the narrowing and puckering that can occur on suture tightening in small-caliber vessels. Based on these findings, consideration should be given to performing hybrid interrupted-continuous anastomoses for RCFs.

Arteriovenous Fistulas and Their Characteristic Sites of Stenosis.

In the United States, more than 250,000 patients with end-stage renal disease are dialyzed through arteriovenous fistulas (AVFs). The three most common AVFs are the radiocephalic fistula, the brachiocephalic fistula, and the brachial artery-to-transposed basilic vein fistula. Although many potential access site stenoses can and do occur within any given fistula, each fistula has a characteristic site of stenosis. This article will discuss the characteristic site of stenosis for each type of fistula including the effects of stenosis at that site on fistula function, and their treatment. The characteristic sites of stenosis in AVFs used for dialysis share in common significant angulation, which likely causes stenosis by leading to turbulent flow and intimal injury. While balloon dilation is considered first-line therapy, further interventions such as stent placement or surgical revision are sometimes needed to treat these recalcitrant areas of stenosis.

No-touch technique for radiocephalic arteriovenous fistula--surgical technique and preliminary results.

The radiocephalic arteriovenous fistula (RC-AVF) has significant failure rates due to occlusions and failure to mature. The size and quality of the veins are considerable limiting factors for the procedure. The aim of this pilot study was to describe the No-Touch technique (NTT) to create RC-AVF and present the results up to 1 year of follow-up. Thirty-one consecutive patients who were referred for surgery for a RC-AVF were included (17 men, mean age 63 years, range 35-84) and operated by NTT where the vein and artery were dissected with a tissue cushion around it. Twenty-two patients had small veins or arteries (≤2 mm), 12 patients had a small cephalic vein (≤2 mm), and the mean distal cephalic vein diameter was 2.4 mm (range 1.0-4.1 mm). Technical surgical success and immediate patency were obtained in all patients. Clinical success was achieved in 23 of the 27 (85%) patients who required hemodialysis. The proportion of primary patency at 30 days and 6 months was 84% and 64%, respectively. Secondary patency at 30 days and 6 months was 97% and 83%, respectively. At 1-year follow-up, primary patency was 54% and secondary patency was 80%. There was no major difference in patency due to preoperative vein diameter. The results of this study indicate that NTT can be used for primary radio-cephalic fistula surgery with very good results. This method offers the potential to create a RC-AVF in patients who are not usually considered appropriate for a distal arm fistula due to a small cephalic vein.

Distal radial artery ligation for treatment of steal syndrome in a distal radiocephalic arteriovenous fistula

Distal radial artery ligation for treatment of steal syndrome in a distal radiocephalic arteriovenous fistula

Salvage of Early-Failing Radiocephalic Fistulae with Techniques that Minimize Venous Dissection

Although radiocephalic fistulae are the preferred hemodialysis access, juxta-anastomotic stenosis is often responsible for early fistula failure. We hypothesized that wall ischemia from surgical manipulation leads to early juxta-anastomotic neointimal hyperplasia and failure of maturation and that minimal venous dissection will improve surgical salvage, increasing fistula maturation rates. For failing-to-mature radiocephalic fistulae that develop early juxta-anastomotic stenosis, we describe 3 variations to perform a new proximal anastomosis with a minimal dissection technique on the forearm cephalic vein: (1) side-to-side anastomosis, (2) radial artery deviation and reimplantation, or (3) radial artery deviation and loop reimplantation. Minimal dissection of the cephalic vein achieves fistula salvage without needing a more proximal site for access.

An unusual shunt from the pulmonary artery to the left atrial appendage

A 55-year-old man presented to the emergency room with dyspnoea, which had progressively increased after closure of his radiocephalic fistula (used for haemodialysis) in 2013. Arterial O2 saturation was 82% at admission. The patient's medical history revealed proliferative glomerulonephritis, continuous ambulatory peritoneal dialysis (CAPD), and two post-mortal kidney transplantations. CAPD was restarted due to rejection in 2003. However, due to an abdominal abscess, a radiocephalic fistula was constructed for …

Mobilization of Endothelial Progenitor Cells Following Creation of Arteriovenous Access in Patients with End-Stage Renal Disease.

A patent arteriovenous (AV) fistula induces activation of regional vascular endothelium and vascular shear force. Shear stress is an important physiological force in mobilizing endothelial progenitor cells (EPCs). This study aimed to explore the perioperative changes of circulating EPC levels for patients who require hemodialysis and underwent radiocephalic fistula operation. This prospective cohort study included patients who received a radiocephalic fistula surgery when they were between 25 and 65 years of age. The subjects were followed for 90 days postoperatively for any stenotic events or immaturity of the fistula. Blood samples were obtained on the day before surgery and at postoperation day (POD) 3 and 30. CD133+/KDR+ cells, defined as EPCs, were analyzed using flow cytometry. Blood flow of the fistula was followed on POD 3 and 30. A total of 30 patients were enrolled in the study from July 2009 to December 2011. One patient dropped out of the study and seven patients developed a stenotic (or immature) AV fistula (7/29, 24.1%). There were positive linear relationships between EPC numbers and shear rate postoperatively, which were more significant on POD 30. In addition, postoperative mobilization of EPCs was significantly higher in patients who developed a stenotic fistula than those without. The mobilization of circulating EPCs correlated with a compromised arteriovenous fistula. The biological significance of increased EPC numbers need to be determined in future studies. Arteriovenous fistula; Endothelial progenitor cells.

Computational Analysis of Anastomotic Angles by Blood Flow Conditions in Side-to-End Radio-Cephalic Fistulae Used in Hemodialysis

Chronic renal failure is a disease that affects a considerable population percentage that requires the hemodialysis procedure which is a blood filtration. This process is extremely stressful in many cases for the patient, because there is a continuous degradation of vessels and fistulae susceptible to this process due to the alterations of the stress at the blood vessel walls and flow patterns, leading to diseases such as intimal hyperplasia and consequent stenosis. Experimental in vivo researches in this area are very difficult to perform. In this sense computational models become interesting non invasive options to understand what happens to the blood in non viscometric geometries. In this work, we analyse blood flow, through computational modeling, in arteriovenous fistulae used in hemodialysis, using geometries with dimensions close to real ones. Discretization of the governing equations was made through a finite volume technique with the PISO—Pressure Implicit with Splitting of Operators—algorithm, using as a basis the OpenFOAM software platform. Large vessel Newtonian fluid model was used to analyze six possible anastomotic angles (20。, 25。, 30。, 35。, 40。, 45。). To analyze the possibility of stenosis formation caused by hyperplasia, results for wall shear stress, oscillatory shear index (OSI), velocity and local circulation fields were obtained, showing that higher angles presented more secondary flows and larger extensions of stagnation regions near the critical areas of the junctions. Moreover, a range around 25。was identified to be the most suitable choice for clinical applications, minimizing possibility of diseases.

Haemodialysis access: clinical and epidemiological profile of patients and their vascular access in interior of Brazil

Background: The analysis of vascular access for hemodialysis is relevant for the quality of life of patient. In this study we investigated the profile of vascular access used for hemodialysis patients in a poor place, interior of Brazil. Objectives: To identify the percentage of vascular access for hemodialysis in this unit conforms to international standards. Methods: We evaluated the reference hemodialysis service in a specific poor place in Brazil. There are 120 patients of both genders who have undergone implant or manufacture of vascular hemodialysis access; there aren´t patients on renal replacement therapy by peritoneal dialysis. Results: Associated diseases were unknown cause, diabetes mellitus and hypertension. 93(77.5) had arteriovenous fistula, with 89 held by the same dialysis and four of them were still maturing. 27 patients on dialysis used central venous catheter. 91 were indigenous and two were made using polytetrafluoroethylene prosthesis (PTFE). Among the 27 patients with central venous catheters, twenty were short-term catheter and 7 were long-term catheter. Among the fistulas for dialysis patients, the highest prevalence was radiocephalic fistula in 60 patients (50%). Among all the fistulas, the left radiocephalic was the most found, in 37 patients (39.8) and right, in 23 patients (24.7). The number of patients that they had only one fistula manufactured corresponded 60 patients (50%). and mean duration of use was 1,74 ±1,64 years, ranging from two months to 9 years. Conclusion: Our Unit of hemodialysis is above the limits established by international norms.

Fistula Diameter Correlates with Echocardiographic Characteristics in Stable Hemodialysis Patients

Aims and background Left ventricular hypertrophy (LVH) is a common finding in hemodialysis patients. The aim of the present study was to investigate if the diameter of the distal radiocephalic fistula could influence left ventricular variables in stable hemodialysis patients. Methods Nineteen patients were investigated. Measurements of the diameter of the arteriovenous (AV) fistula were performed in 4 different locations. The patients were investigated using M-mode recordings and measurements in the 2D image. Doppler ultrasound was also performed. Transonic measurements were performed after ultrasound investigation. Results Fistula mean and maximal diameter correlated with left ventricular characteristics. Fistula flow correlated neither with the left ventricular characteristics nor with fistula diameters. Conclusions The maximal diameter of the distal AV fistula seems to be a sensitive marker of LVH in stable hemodialysis patients.