Long and short term patency of radiocephalic arteriovenous fistulas

Eighty-three radiocephalic fistulas in 71 uremic patients were retrospectively investigated. The fistulas were grouped according to construction, viz. side of radial artery to side of cephalic vein and end of cephalic vein to side of radial artery. The aim was to find and evaluate factors influencing fistula patency rate, with special emphasis on type of anastomosis. The early failure rate was significantly higher in the end-to-side group. The late failure rate was not influenced by mode of fistula construction. The fistula failure rate showed no correlation to patient age. Diabetes did not influence failure rate, but significantly shortened the mean patency time.     

A prospective study of end-to-side vs. side-to-side arteriovenous fistulas for haemodialysis

In an attempt to determine the optimum configuration of arteriovenous (A-V) fistulas for haemodialysis, 71 patients were prospectively randomized to undergo either a side-to-side or end-of-vein to side-of-artery A-V fistula. Nine months after operation, the patency rates on dialysis were almost identical in the two groups (79.2 per cent and 78.6 per cent respectively). However, 7 of the 32 side-to-side fistulas developed hyperaemia of the hand, three of which required revisional surgery. Hyperaemia of the hand has not been seen with end-to-side fistulas. In addition, peroperative measurements of fistula flow appeared to have prognostic value with end-to-side but not with side-to-side fistulas. It is suggested that the end-to-side configuration is the one of choice for the formation of A-V fistulas for haemodialysis.     

Upper arm arteriovenous fistulas as a reliable access alternative for patients requiring chronic hemodialysis.

The wrist fistula is the access procedure of choice in the hemodialysis patient. However, unavailable or unusable anatomy in this aging population has made them difficult to establish. This study retrospectively compares patency, occlusion, and complication rates of upper arm arteriovenous fistulas (AVFs) as a reliable alternative. Fifty-eight upper arm AVFs were created in 52 patients between February 1995 and August 1997 at Hermann Hospital, affiliated with the University of Texas Health Science Center in Houston, Texas. Fistulas were constructed using the brachial artery (BA) side-to-end (n = 56) or side-to-side (n = 1) with either the cephalic vein (CV; n = 39), transposed basilic vein (TBV; n = 16), or other vein [basilic vein (BV; n = 1), transposed cephalic vein (TCV; n = 1), median cubital vein (MCV; n = 1)]. One-year primary patency rates for upper arm AVFs were 66 per cent, and secondary patency rates were 22 per cent. Flow rates averaged 354.6 mL/minute. Primary and secondary patency rates for fistulas created are: BA-CV (67% and 20%), BA-TBV (63% and 25%), and other upper arm AVFs 66 per cent without revisions. Primary patencies for both BA-CV and BA-TBV fistulas were similar to previously reported studies. Secondary patencies proved to be less effective. Upper arm AVFs should be considered before graft placement when wrist and forearm anatomy does not lend itself to fistula creation.     

A retrospective review of basilic and cephalic vein-based fistulas

This study compares outcomes of basilic and cephalic vein fistulas for hemodialysis. A retrospective review of arteriovenous fistulas in a university hospital system was performed using charts and hemodialysis records. Patency and demographic data were assessed with life table analysis. One hundred fifty-six patients (88 males; 68 females) underwent creation of 172 autogenous fistulas (mean age 61 years; mean follow-up 78 weeks). There were 101 basilic vein transpositions and 71 cephalic vein fistulas. Primary patency did not differ significantly, while assisted primary patency was significantly better for basilic vein fistulas at one year (73% versus 53%: P = 0.024). Secondary patency was significantly better for basilic fistulas through three years (58% versus 52%; P = 0.027). Primary failure (thrombosis before access or failed maturation) was significantly higher for cephalic than basilic fistulas (28% versus 13%; P = 0.01). Maturation time, usage time and complications were not significantly significant. Thirty-three (33%) basilic vein-based fistulas and 12 (17%) cephalic vein fistulas required revision during follow-up. Basilic vein-based fistulas perform as well as or better than cephalic vein-based fistulas in terms of patency, maturation time, and usage time and complication rates, though requiring more re-interventions.     

Dialysis fistulae patency and preoperative diameter ultrasound measurements.

BACKGROUND: This study was designed to investigate the possibility of defining a vascular diameter with a practical cut-off point, which predicts a successful patency for radiocephalic arteriovenous fistulae in dialysis patients. METHODS: This is a retrospective analysis of prospectively gathered data. Consecutive patients (n=148) with chronic renal failure, needing vascular access for haemodialysis, were included if they underwent duplex ultrasound examination to evaluate preoperatively the vascular status and diameters for radiocephalic arteriovenous fistulae (RCAVF) construction. The associations between the diameter of the radial artery and cephalic vein and primary failure at six weeks, primary and secondary patency at one year were investigated. RESULTS: There was no significant association between either radial artery diameter or dilated cephalic vein diameter and primary failure. There was an association between radial artery diameter and primary patency (Overall P=0.042). Males had a significantly larger mean radial artery diameter than females (P=0.005). Gender did not influence primary patency. CONCLUSION: We recommend using radial artery diameters of > or = 2.1 mm and < or = 2.5 mm for RCAVF construction, this diameter category having the highest patency at 1 year. A single cut-off guideline cannot be recommended.     

两种桡动脉切口端侧吻合动静脉内瘘近端静脉流出道狭窄的研究

目的 比较采用桡动脉前壁正中切口与前侧壁切口建立端侧吻合动静脉内瘘近端瘘静脉狭窄发生率的差异,探讨端侧吻合动静脉内瘘的桡动脉切口位置.方法 前瞻性纳入桂林医学院附属医院肾内科2017年3月至2018年2月新建立自体端侧吻合动静脉内瘘的患者160例,随机分为桡动脉前壁正中切口组(正中切口组,80例)及桡动脉前侧壁切口组(...     

Prospective long-term study of patency and outcomes of 505 arteriovenous fistulas in patients with chronic renal failure: Authors experience and review of literature

Background:

This study describes our experience of arteriovenous fistula (AVF) creation as vascular access for haemodialysis.

Materials and Methods:

This study has been carried out in our hospital from January 2004 to December 2012. A total of 505 AVFs were created in 443 patients. Maximum follow-up was 8 years, and minimum was 6 months.

Observations and Results:

In this study of 505 cases of AVFs, primary patency rates by Kaplan — Meier analysis showed 78.81% patency of fistulas at the end of 1 year and patency dropped to 14.81% at the end of 5 years. Our primary failure rate was 21.2%. Basilic vein was used in 26.35% cases, cephalic vein in 63.5%, and antecubital vein in 9.75% cases. On table, bruit was present in 459 (90.9%) and thrill in 451 (89.3%) cases. During dialysis, flow rate >250 ml/min was obtained in 150 (29.9%) cases. In complications, 2 (0.4%) patients developed distal oedema, 33 (6.5%) developed steal phenomenon.

Conclusions:

Presence of on table thrill and bruit are indicators of successful AVF. If vein diameter is <2 mm, chances of AVF failure are high. Flow rates in patients with vein diam. >2 mm were significantly higher as compared with patients with vein diam. <2 mm (P < 0.001). Flow rates are higher in non-diabetic patients as compared to diabetic patients (P < 0.001). Average blood urea and serum creatinine values are significantly lesser in patients undergoing dialysis through successful fistulas as compared to patients with failed fistulas. Correspondingly, incidence of deaths is significantly lesser in patients with successful fistulas. During proximal side-to-side fistula between antecubital/basilic vein and brachial artery, dilating of the first valve toward wrist helps to develop distal veins in the forearm by retrograde flow. This technique avoids requirement of superficialization of basilic vein in the arm.KEY WORDS: Arteriovenous fistula, chronic kidney disease, haemodialysis, vascular access     

Improved patency of prosthetic arteriovenous grafts with an acute anastomotic angle and flow diffuser

OBJECTIVE: Conventional end-to-side anastomosis to establish venous outflow for prosthetic arteriovenous grafts often requires operative patch angioplasty within 1 year because of venous stenosis. Rather than conventional venous anastomosis, a modified end-to-side anastomosis at a 15-degree angle with a flow diffuser was constructed. Such diffusers allow decreased flow velocity and increased pressure, inhibiting boundary layer separation. METHODS: Ten brachial artery to axillary vein 6 mm straight se-polytetrafluoroethylene prosthetic arteriovenous grafts were created with this technique. Patients included 6 men and 4 women (mean age, 66.4 years; range, 54-80 years), all with renal failure and a history of diabetes. The degree of stenosis at the venous anastomosis was determined with duplex scanning at intervals of 6 months. Analysis of survival and cumulative primary patency estimates were determined with the Kaplan-Meier method. RESULTS: Primary cumulative patency estimate of 100% for the modified group at 18 and 24 months was significantly greater than that for age-matched historic control fistulas with the conventional end-to-side anastomosis (n = 20): 18 months, 32%; 24 months, 32% (P <.05). Although venous stenosis could not be quantitated for thrombosed conventional fistulas, modified anastomoses had minimal stenosis at 24 months: mean area reduction, 30% (range, 20%-45%). CONCLUSION: Incorporation of a flow diffuser and a 15-degree anastomotic angle significantly increases patency of prosthetic brachial artery to axillary vein grafts.     

球囊辅助下血透用桡动静脉内瘘术

目的 评价球囊辅助下血透用桡动静脉内瘘术的手术方法和初步疗效。方法回顾性总结2005年8～12月复旦大学附属中山医院血管外科收治的12例诊断明确的尿毒症病人行球囊辅助下桡动静脉瘘术。选择非主利手，游离头静脉和桡动脉，分别结扎头静脉和桡动脉的远端，向头静脉和（或）桡动脉近端插入Fogarty取栓导管，用1mL的注射器向球囊注入肝素盐水0．1—0．3mL，充起球囊，持续、均匀扩张头静脉和（或）桡动脉及其狭窄段，以7-0无损伤血管缝线吻合血管。结果术后即时、回病房当天、术后1d、3d和7d听诊吻合口杂音，扪及血管震颤。平均随访3个月，手术通畅率100％。已有5例病人内瘘成熟，内瘘血流量大于150mL／min，满足血透流量。结论球囊辅助下桡动静脉内瘘术成功率高，可以纠正头静脉狭窄，内瘘成熟快。短期临床效果好，中远期临床效果在进一步观察中。     

Has the in situ right internal thoracic artery been overlooked? An angiographic study of the radial artery, internal thoracic arteries and saphenous vein graft patencies in symptomatic patients.

OBJECTIVE: The right internal thoracic artery is being used infrequently despite favorable observational angiographic data. Conversely, the radial artery utilization has increased with only limited data available. The purpose of this paper is to re-evaluate the roles of the right internal thoracic artery and the radial artery grafts. METHODS: We reviewed all ischemia-directed coronary angiographic procedures from January 1996 to December 2003. A total of 219 patients had primary coronary artery bypass grafting with an internal thoracic artery and a radial artery as two of the bypass grafts. Six hundred and seventy-nine (679) graft angiograms (45 saphenous vein, 363 radial artery, 54 right internal thoracic artery and 217 left internal thoracic artery) were studied. The mean period from operation to re-angiogram was 1104+/-761 days. Angiographic outcomes were divided into groups as: (1) patent (<50% stenosis) or (2) failed (>or=50% stenosis, string sign or occluded). A generalized linear mixed model was used to analyze predictors of graft patency. Turnbull's estimates of cumulative patency were used to compare graft failure rates over time. RESULTS: A total of 632/679 (93%) grafts were patent and 47/679 (7%) grafts had failed. Empirical saphenous vein graft patency was 40/45 (89%), radial artery patency 329/363 (91%), right internal thoracic artery patency 51/54 (94%) and left internal thoracic artery patency 212/217 (98%). Pairwise comparisons of patency from the generalized linear mixed model were: LITA>RITA, OR=1.5 (P=0.5); LITA>RA, OR=5.7 (P<0.001); LITA>SV, OR=6.5 (P<0.001); RITA>RA, OR=3.9 (P=0.01); RITA>SV, OR=4.4 (P=0.01); RA>SV, OR=1.1 (P=0.7). Five-year patency estimates from the Turnbull's model were the left internal thoracic artery (95.9%), right internal thoracic artery (91.2%), the radial artery (90.6%) and the saphenous vein (81.8%). CONCLUSIONS: Consideration should be given to the routine use of both internal thoracic arteries for coronary artery bypass grafting. When additional grafts are required, there is no evidence to suggest that either the radial artery or saphenous vein is superior.     

Transposed Basilic Vein-Brachial Arteriovenous Fistula: An Alternative Vascular Access for Hemodialysis

Twenty-five brachial-basilic arteriovenous (AV) fistulas with transposed basilic vein for alternative vascular access were created in 22 chronic hemodialysis patients. This surgical procedure was performed under brachial block or general anesthesia. After a longitudinal skin incision that was made in the inner side of the arm, the basilic vein was exposed, transposed subcutaneously, and anastomosed end-to-side to the brachial artery. The follow-up was between 7 and 24 months. Early complications were hemorrhage, thrombosis, steal syndrome, and swelling of the arm. Among the late complications were failure of the fistula because of thrombosis and multiple stenosis at the site of venipuncture. The accumulated one-year patency rate of fistulas was 81%. The complications of high-output cardiac failure or local infection were not seen in our study. On the basis of our results, the brachial-basilic AV fistula with transposed basilic vein is a useful and safe second- or third-choice vascular procedure for hemodialysis patients, in particular for women without good quality of vessels.     

Arteriovenous fistulas after cardiac catheterization

In a review of five Dayton, Ohio, area hospitals during a six-year period, seven patients who were treated for an acquired arteriovenous (A-V) fistula after cardiac catheterization were identified. Four patients had undergone cardiac studies in area hospitals, while three were studied elsewhere. The four A-V fistulas after 23,291 cardiac catheterization procedures in Dayton hospitals represented an incidence of 0.017% for this complication. Congestive heart failure and limb ischemia were the most frequent presenting symptoms that developed from two to ten months after catheterization. Intentional puncture of both the artery and vein of the ipsilateral groin for right- and left-sided heart studies was the probable cause of fistula formation in two cases. Five patients sustained inadvertent injury to both an artery and adjacent vein during percutaneous vascular access. Six A-V fistulas that involved femoral vessels were managed by division of the fistula with lateral repair of the artery and vein. An unusual communication between the right thyrocervical trunk and the internal jugular vein was handled by ligation of the affected vessels. Prompt surgical correction of this unusual complication of percutaneous vascular access is recommended as spontaneous closure is unlikely.     

Haemodynamic and metabolic consequences of reversed portal venous blood flow after side-to-side portacaval shunt in the dog

The immediate haemodynamic and metabolic effects of reversed portal blood flow after side-to-side portacaval shunt were studied in 9 normal anaesthetized dogs, and compared to those observed after end-to-side shunt in the same animals. Blood flow in the hepatic artery (HA) and portal vein (PV) was measured using electromagnetic flowmeters. The magnitude of the HA hyperaemic response to side-to-side shunt was similar to that found after end-to-side shunt, but approximately one-third of the flow left the liver via the PV. There was no significant correlation between the HA response and the magnitude of reversed PV flow after side-to-side shunt. Despite fairly well preserved total hepatic oxygen consumption in both groups, there was a statistically significant decrease in the side-to-side series; moreover, only 13% of the total hepatic oxygen consumption was derived from blood draining the liver via the PV. It is concluded that the substantial quantity of portally drained blood after side-to-side shunt traverses metabolically inefficient pathways in the liver, and may have a detrimental influence on long-term liver function.     

50例球囊扩张下动静脉内瘘术的临床效果评价

目的：探讨球囊扩张下血液净化用前臂动静脉内瘘术的手术方法以及临床效果。方法：总结暨南大学附属第一医院肾内科2005年7月～2012年1月收治的50例诊断明确的尿毒症患者因需要长期透析以及血管条件差而行球囊辅助下前臂动静脉内瘘术。手术选择病人的非主力手,分别游离头静脉和桡动脉,结扎头静脉的远端向头静脉和桡动脉的近端分别插入动脉取栓导管并用2ml注射器向导管内注入适量肝素生理盐水,充起球囊,根据需要持续均匀的扩张头静脉和桡动脉的狭窄段,再以7-0的血管逢线端侧吻合血管。结果：术后即时、1、2、3h、术后连续7d均能听到血管杂音以及扪及到血管震颤平均随访60个月手术的成功率90%以上。已有30例病人内瘘成熟并已使用超过3年以上,内瘘的血流量均大于250ml/min,完全能满足各种血液净化治疗的需要。结论：球囊辅助下前臂动静脉内瘘术手术成功率高,可以纠正动静脉血管条件差伴有部分狭窄的患者,内瘘成熟快,血流量大,临床效果好。     

Side-to-side arteriovenous fistula at the elbow with perforating vein ligation

OBJECTIVE: We postulated that ligation of a consistent perforating venous branch at the elbow would improve distention and flow in the superficial veins about the elbow. This would also lesson the likelihood of arterial steal enabling a favorable outcome following a brachial artery medial antecubital or cephalic vein arterio-venous fistula (AVF). METHODS: Pressure measurements were made from the radial artery after side-to-side brachial artery antecubital or cephalic vein AVF in 20 patients. Clamping of the perforating vein increased radial artery pressure significantly indicating that a considerable amount of flow from the side-to-side AVF was diverted into the deep system and away from the accessible superficial veins. Encouraged by this finding, we studied the outcome of brachial cephalic or brachial antecubital AVF with ligation of the deep branch in 134 patients who were not candidates for radio-cephalic AVF. The end point of the study was successful hemodialysis using the fistula. RESULTS: Of the 134 patients treated, 24 died, and 11 were lost to follow-up and were censored from analysis of fistula performance at that time point. The primary fistula success rate was 89.7% +/- 2.66% and 83.7% +/- 3.5% at 1 and 2 years by life table analysis. No patient developed significant arterial steal or venous hypertension. CONCLUSION: We recommend this simple one-stage procedure for patients requiring hemodialysis whose cephalic vein at the wrist is unsuitable.     

Successful creation of arteriovenous fistulas in nonuremic patients with heparin and aspirin therapy

From November 1977 through June 1979, 26 of 28 nonuremic patients had forearm arteriovenous fistulas successfully created for dialysis, lymphapheresis or vascular access. To improve patency, aspirin and heparin therapy was begun the night before operation and continued postoperatively in all except one patient. No major change in coagulation parameters resulted from this treatment. Twenty-five radial artery to cephalic vein fistulas were created in 23 patients, brachial artery to basilic vein fistulas in 3 patients, and 8 mm polytetrafluoroethylene brachial artery to basilic vein loop grafts in two patients. Early fistula failures (within 11 days) required thrombectomy once in four patients and twice in another patient. A sixth patient was not given heparin or aspirin and required multiple thrombectomies before the graft was removed because of infection. One other patient refused further surgery after two unsuccessful attempts to create an arteriovenous fistula. In the remaining 26 patients, the fistulas have been successfully maintained, and in 18 patients more than 214 dialysis or lymphapheresis treatments have been performed without problems. The successful establishment of arteriovenous fistulas in nonuremic patients has been achieved by giving aspirin and low dose heparin therapy, which appears to be an integral step in maintaining patency.     

Intermittent claudication of the hand after creation of an arteriovenous fistula in the forearm

Eighty-five patients were followed up at least 1 year after creation of an arteriovenous fistula in the forearm. The anastomosis was side-to-side in 33 patients, end-to-side in 33 and end-to-end in 19. Trophic lesions were not observed. Intermittent claudication of the hand was more frequent in patients with a side-to-side arteriovenous fistula (42 percent) than in those with end-to-side (21 percent) or end-to-end fistulas (16 percent). Clinical and x-ray studies indicate that two different mechanisms are responsible for cramping pains: arterial steal phenomenon and venous hypertension. Their relative importance depends on multiple hemodynamic factors that may vary with time.     

End-to-end versus end-to-side arterial anastomosis patency in microvascular surgery

The patency rates of microsurgical end-to-end and end-to-side anastomosis in the rat carotid artery were studied. Seventy end-to-end and seventy end-to-side arterial anastomoses, using 10-0 nylon interrupted sutures, were performed on 140 Sprague-Dawley rats. Findings indicated 100% patency in end-to-end as well as end-to-side immediately and 1 week post-anastomosis. This investigation suggests that there is no significant advantage between the methods studied based on vessel patency alone. The decision to perform an end-to-end vs. an end-to-side arterial anastomosis should be based upon the clinical circumstances encountered, since no significant difference in patency rates exists. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:125-128 1998     

Renal autotransplantation versus bypass techniques for renovascular hypertension

From 1972 to 1983, 78 patients underwent surgical treatment for renovascular hypertension caused by a lesion limited to the trunk of the renal artery. Forty-five of these patients underwent aortorenal bypass (24 saphenous grafts and 21 arterial hypogastric grafts); 36 patients (80%) had either a relief of the hypertension or were improved. Graft closure occurred in five cases. Thirty-three patients were treated by autotransplantation of the kidney. After resection of the lesion, the renal artery was anastomosed end-to-end to the hypogastric artery or end-to-side to the common iliac artery and the renal vein and side-to-side to the iliac vein or the origin of the vena cava. In this group all patients but one (97%) had relief of the hypertension or were improved. No thrombosis was observed. Late angiography was performed 5 years after surgery in 19 patients (nine autotransplantations and 10 bypass operations): patients who underwent autotransplantation had no alteration of the renal vessels whereas four patients who underwent bypass operations had dilatation of the saphenous vein bypass. Renal autotransplantation was superior to the bypass technique in the surgical treatment of renovascular hypertension caused by lesions of the trunk of the renal artery and may represent a better alternative in the surgical treatment of this condition.     

Management of dialysis fistula thrombosis

The results of 74 operations for fistula thrombosis were analyzed by life table methods to identify aspects of operative management that were important in restoring long-term patency. Fistula patency was restored by simple thrombectomy in 14 of 15 (93 per cent) arteriovenous fistulas between the radial artery and cephalic vein and in 20 of 26 (77 per cent) bovine heterograft fistulas. However, early reocclusion was common after thrombectomy, resulting in cumulative 6 month patency rates of only 22 per cent for radiocephalic fistulas and 41 per cent for bovine heterograft fistulas.A protocol including routine intraoperative angiography and revision of identified fistula defects was employed in 33 operations (12 radiocephalic fistulas and 21 bovine heterograft fistulas). Significant defects were detected in 21 (64 per cent) and were revised concurrent with thrombectomy. Eleven lesions (52 per cent) were unsuspected and would have been undetected without routine angiographic assessment. Revision or demonstration of normal post-thrombectomy angiograms resulted in cumulative 6 month patency rates of 70 per cent for radiocephalic fistulas and 72 per cent for bovine heterograft fistulas, which are significantly better (p <0.05) than the results of thrombectomy alone. Revised defects included stenotic venous outflow intimal fibroplasia (14 instances), pseudoaneurysms (3), and anastomotic technical imperfections (4).A variety of remediable vascular lesions may contribute to recurrent dialysis fistula thrombosis. Correction of these defects is rewarded by improved maintenance of vascular access patency.