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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 534-538

Evaluation of the proximal radio cephalic arteriovenous fistula for hemodialysis


1 Vascular Surgery Unit, General Surgery Department, Faculty of Medicine, Menoufia University Hospital, Shebin El-Kom, Egypt
2 Vascular Surgery Department, El-Bagour General Hospital, Menoufia, Egypt

Date of Submission23-Dec-2017
Date of Acceptance04-Feb-2018
Date of Web Publication25-Jun-2019

Correspondence Address:
Mohamed A Haridy
Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_881_17

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  Abstract 

Objective
To evaluate the proximal radiocephalic arteriovenous fistula (pRCF) as a hemodialysis access.
Background
The gold standard arteriovenous fistula is the distal radiocephalic fistula at wrist. If distal vessels are not suitable, a brachiocephalic fistula is a good vascular access, but many cases were reported to have dialysis access steal syndrome, so doing pRCF is a good alternative option.
Patients and methods
A prospective study was conducted on 30 patients who were in need for hemodialysis access between May 2016 to November 2016 and follow-up of patients was carried out until May 2017 at Menoufia University Hospital. The data for primary success rate, primary patency, secondary patency rates, and complications were collected and analyzed.
Results
Thirty patients underwent pRCF. Primary fistula failure was seen in 0%, whereas six (20%) fistulas failed later, four of them owing to thrombosis, one owing to anastomotic aneurysm, and one owing to extensive edema. Two (6.7%) patients were lost (censored) to follow-up. No patients developed steal syndrome, and the incidence of it was 0%. One (3.3%) fistula showed weak flow. Primary patency rate was 63.3%, whereas secondary patency rate was 73.3%.
Conclusion
For patients with prior forearm arterio-venous (AV) fistula dysfunction, or inadequate wrist vessels, we believe that a proximal radiocephalic approach should precede creation of brachiocephalic fistula to avoid the risk of dialysis-associated steal syndrome.

Keywords: arteriovenous fistula, hemodialysis, proximal radiocephalic approach


How to cite this article:
Abu-Gruidah HS, Abd El-Haleim MS, Haridy MA. Evaluation of the proximal radio cephalic arteriovenous fistula for hemodialysis. Menoufia Med J 2019;32:534-8

How to cite this URL:
Abu-Gruidah HS, Abd El-Haleim MS, Haridy MA. Evaluation of the proximal radio cephalic arteriovenous fistula for hemodialysis. Menoufia Med J [serial online] 2019 [cited 2019 Sep 17];32:534-8. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/534/260935




  Introduction Top


Arteriovenous fistulas are the preferred type of vascular access (VA) for hemodialysis. As compared with grafts, they have longer survival and require fewer interventions to maintain the long-term patency, once they are cannulated successfully for dialysis[1]. Compared with prosthetic grafts, autogenous fistulas demonstrate superior patency rates, lower infection rates, and fewer postoperative complications[2] The distal radiocephalic arteriovenous fistula (dRCF) at wrist is the gold standard venous access for patients who require long-term hemodialysis[3]. Placement of the dRCF at the wrist reduces the risk of steal syndrome compared with elbow fistulas and preserves more proximal vessels for future access placement. However, dRCF at wrist has been reported to have a high primary failure rate because of early thrombosis or failure to mature to permit adequate dialysis[4]. A substantial proportion (20–60%) of new fistulas fail to mature after their creation[5],[6]. The nonmaturation rate is greater for dRCF placed at the wrist than for brachiocephalic fistulas placed in the upper arm[7],[8]. The nonmaturation rate of dRCF is particularly poor in women and older patients[9]. When a dRCF fails to mature or when preoperative mapping indicates there are no suitable vessels for creation of a wrist fistula, current guidelines recommend placement of upper arm brachiocephalic fistula[1]. Dialysis access-associated steal syndrome (DASS) is a serious complication associated with autogenous proximal arm fistulas, reported in up to 10% of patients[10],[11]. Age greater than 60 years, female sex, concomitant peripheral vascular diseases, operations on the same limb, formation of proximal fistula, or use of synthetic graft have been identified as risk factors predisposing to DASS[12]. The incidence of DASS is rising in direct relation to the increase in number of diabetics with autogenous fistula and the use of proximal forearm veins. Approximately 25–81% of patients with DASS have been reported to have these risk factors[13]. An alternative option, which is used infrequently in such patients, is to create a proximal radiocephalic arteriovenous fistula (pRCF) between the proximal radial artery and the cephalic vein[14].

So in the absence of suitable vein at the wrist, a brachiocephalic fistula at elbow is usually constructed. To avoid complication of vascular steal syndrome associated with brachiocephalic fistula, an alternative operative technique involves the creation of radiocephalic, radiomedian cubital, or ulnobasilic fistula at elbow[15].

The aim of this study was to evaluate pRCF for patency and incidence of complications.


  Patients and Methods Top


A prospective study carried out between May 2016 and November 2016, with follow-up to May 2017. The following inclusion criteria were applied:

  1. Age: above 18 years old.
  2. Sex: both sexes.
  3. Wrist veins are atrophied or unsuitable for arteriovenous fistula formation.
  4. Proximal forearm vein diameter of at least 2.5 mm with no thrombosis or stenosis.
  5. Proximal forearm artery diameter of at least 2.0 mm with no concomitant arterial disease.


The study was conducted on 30 patients presented with end-stage renal disease in need for VA in Outpatient Clinic in Menoufia University Hospital. Written informed consent was obtained from all patients to be included in this study. This study was accepted and approved by ethical committee.

All patients were evaluated regarding the following:

Physical examination in all of the patients included inspection and palpation of the vessels, Tap test, upper limb pulses, Allen test, and comparison of blood pressure in both upper limbs. Duplex ultrasonography was done in all cases to assess not only venous system but also the arteries including the proximal radial artery as an arterial inflow site. It was done using duplex ultrasound machine in Radiology Department at Menoufia University Hospital, Egypt. The fistula site was chosen contralateral to existing or previously placed dual-lumen catheters in most of cases. Operations were performed on an outpatient basis unless the patient was hospitalized for other reasons. The creation of a new fistula on the contralateral arm was considered a new VA.

Operative procedure

We always ensured that the patients were not dehydrated and their systolic blood pressure were within 130–150 mmHg. The operations were performed under local anesthesia using 1% lidocaine. After proper preoperative antibiotic prophylaxis, longitudinal or oblique incision (about 3 cm long) 1 cm distal to antecubital crease was made. The median antecubital vein was identified and dissected distally to the confluence of the cephalic vein, and then we dissected the communicating cephalic vein, and the median cubital vein was ligated distally. The perforating vein of the elbow, which joins predominantly the median vein, but sometimes confluences can be found into the first section of the communicating cephalic vein, was ligated. After disconnection, the vein was distended and flushed with heparinized saline solution. An injection of 2000 IU of heparin was given. The brachial artery was exposed in the median cubital fossa and dissected distally to expose the proximal radial artery. The radial artery was clamped, and a 8–12-mm-long arteriotomy was performed ∼2 cm distal to the brachial artery bifurcation. Then the communicating cephalic vein was anastomosed to the radial artery in an end-to-side fashion using 7/0 polypropylene. The anastomosis length was ∼5–8 mm, 2–3 times the internal diameter of the PRA. If the size or quality of the proximal redial artery (PRA) is marginal, the anastomosis may be best constructed where the PRA is largest, directly adjacent to the brachial artery and proximal to the recurrent radial artery. Clamps are then released and the anastomosis is checked, Fistula patency was confirmed on table by presence of a palpable thrill and/or a bruit. The wound was closed in layers. Skin closure was done with 4/0 prolene, and aspirin was given postoperatively.

Technical success was defined as the presence of a thrill on palpation or a bruit on auscultation immediately and/or 24 h postoperatively. Primary patency was defined as hemodynamic patency without further intervention, and secondary (cumulative) patency when additional surgical or radiological procedures were performed to maintain fistula patency (whether on a thrombosed fistula or not).

Follow-up

Fistulas were monitored for clinical evidence of dysfunction, steal phenomena, or occurrence of complications, with follow-up weekly for the first month and then every month for another five months. Follow-up was done by clinical examination and by duplex study.

Statistical analysis

Data were collected, tabulated, and statistically analyzed using an IBM personal computer with statistical package of the social sciences (SPSS), version 23 and Epi Info 2000 programs (Released 2015, IBM SPSS Statistics for Windows, version 23.0; IBM Corp., Armnok, New York, USA), where the following statistics were applied:

  1. Descriptive statistics: in which quantitative data were presented in the form of mean, SD, range, and qualitative data were presented in the form numbers and percentages.
  2. Analytical statistics:


    1. Kaplan–Meier estimator curve is a nonparametric statistic used to estimate the survival function from lifetime data.



  Results Top


The 30 patients comprised nine males and 21 females, and the age of those patients ranged from 28 to 76 years, with a mean age of 52.7 ± 14.3 years. The comorbid conditions among the studied group were diabetes mellitus in 24 (80%) patients, cardiovascular disease in five (16.7%) patients, hypertension in nine (30%) patients, ischemic heart disease in two (6.7%) patients, and previous failed atrerio-venous fistula (AVF) in six (20%) patients [Table 1]. Early (primary) fistula failure was not seen in any patient, whereas six (20%) fistulas failed later, four of them owing to thrombosis, one owing to anastomotic aneurysm and one owing to extensive edema. Two (6.7%) patients were lost (censored) to follow-up: one of them died owing to causes unrelated to dialysis and the other was lost to follow-up. No patients developed steal syndrome, and the incidence of it was 0%. Fistula thrombosis occurred in four (13.3%) patients, and the occurrence was at second, third, fourth, and fifth month of follow-up; in all of them, thrombectomy was tried but unfortunately failed. One (3.3%) fistula showed weak flow, after being sufficient owing to anastomotic stenosis, and was salvaged by percutaneous dilation. In two (6.7%) fistulas, there was anastomotic pseudoaneurysm: in one case we succeeded to preserve the fistula by fashioning a brachiocephalic at more proximal site, and in the other case, fistula ligation was done. A pulsatile mass appears at the level of the incision to create the fistula, and this mass was tender, increasing in size, and painful. A partially thrombosed false aneurysm was found, with partial anastomosis disruption. A fragment of the pseudoaneurysm's wall was sent for a bacteriological examination, and a full course of antibiotics was given after the operation. Pseudoaneurysm proximal to the fistula was developed in one (3.3%) patient following needle trauma during hemodialysis access, and it was successfully repaired. In one (3.3%) patient, the cephalic vein was deep and required superficialization as a second stage, and the vein was then needled successfully. In two (6.7%) patients, there was upper arm extremity swelling: in one of them edema is mild to moderate, which was resolved with observation, limb elevation, and removal of central catheters, but in the other one, edema was extensive and fistula was occluded [Table 2]. Follow-up for patency was done. Primary patency rate was 63.3%, whereas secondary patency rate was 73.3% [Figure 1] and [Figure 2].
Table 1: Comorbid conditions

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Table 2: Types of complications

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Figure 1: Kaplan–Meier survival analysis in which primary patency and secondary patency were considered negative, and occluded was considered positive.

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Figure 2: Kaplan–Meier survival analysis in which primary patency was considered negative and secondary patency and occluded were considered positive.

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  Discussion Top


A progressive increase in the number of patients accepted for renal replacement therapy has been reported worldwide. Permanent VA is the life-line for the majority of these patients when hemodialysis is the treatment of choice. Thus, the successful creation of permanent VA and the appropriate management to decrease the complications are mandatory. A well-functional access is also vital to deliver adequate hemodialysis therapy in end-stage renal disease[16]. Few would argue that the radial artery-cephalic vein arteriovenous fistula described in 1966 by Brescia et al.[17] should be attempted first, as this clearly is the access procedure of choice followed by other potential options. However, when this access site is unavailable or has failed, unfortunately obese patients, those with poor or exhausted superficial venous system of the forearm owing to repeated venipuncture, and patients who had lost their primary fistulae are in need for alternative methods for surgical angioaccess[8]. The age of patient included in chronic dialysis program is increasing and so is mainly the number of patients affected by diabetes mellitus and peripheral vasculopathy. The creation of the arterio-venous (AV) fistula at the wrist level is often impossible in such patients[18]. Autogenous brachial artery fistulas are considered when there are poor forearm veins, calcification of the distal vessels, or failure of distal fistulas[10],[19]. However, these fistulas are more commonly associated with development of DASS than wrist fistulas[11],[20]. In this study, pRCF was done for 30 patients for hemodialysis for selected patients who had inadequate wrist veins, diabetics, previous failed distal atrerio-venous fistulas (AVFs), or atherosclerosed distal artery. The incidence of DASS is extremely rare following proximal radiocephalic AVFs[18],[21],[22],[23]. No patient in this series developed DASS. Bruns and Jennings[21] found this fistula type to be safe and reliable, with no incidence of steal after a 42-month follow-up. All the previous studies demonstrated a low incidence of steal syndrome (at 0–3%) compared with much higher (≤20%) in brachiocephalic fistulas[20]. Our results came in concordant with previous reports. In our series, the proximal radial artery was used as the inflow site, and the median cephalic vein was used for venous outflow with end-to-side technique. When the proximal radial artery is used for the fistula, the hand is still supplied with blood via the ulnar artery and the vascular arcades of the hand[24]. This can help to prevent steal syndrome. The brachiocephalic fistula, originally described by Gracz et al.[14], is created between the median cephalic vein and the brachial artery, resulting in arterialization of the cephalic vein, similar to the technique reported by Bruns and Jennings[21] and Ehsan et al.[22]. In this study, we have used a variant of Gracz fistula with an anastomosis formed between the proximal radial artery and the median cephalic vein with end-to-side technique. In this series, two (6.7%) patients developed anastomotic pseudoaneurysm. This was higher than with the 2–2.4% incidence reported by Zibari and colleagues[25],[26],[27]. The cause may be the higher incidence of infection. Other frequent complications affecting the patency of fistulas include thrombosis, stenosis, infection, bleeding, and flow problems[26]. The results of attempted surgical revision after thrombosis in native fistulas is generally low[28]. If the patients present promptly, an attempt to salvage the fistula can be made via a surgical thrombectomy with a Fogarty catheter[26],[28]. The first 24 h must be regarded as a critical period for the patency of fistulas. In our series, thrombosis of the cephalic vein was seen in four (13.3%) patients; in them, thrombectomy was tried but failed. These results compared favorably with the previous reports. In end-to-side fistula, venous hypertension may be the result of venous outflow obstruction at the regional level or central venous stenosis, and the end result is venous insufficiency in the limb presenting as edema, pigmentation, thickened skin, and in severe cases ulceration. Treatment is done by angioplasty to correct stenosis of the outflow venous channels. In our study, this occurred in two (6.7%) patients: one of them managed successfully and the other was occluded.


  Conclusion Top


For patients experiencing prior forearm AV fistula dysfunction, or having inadequate wrist vessels, we believe that a proximal radiocephalic should precede creation of brachiocephalic or barchiobasilic fistula to avoid the risk of dialysis-associated steal syndrome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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