Experience With Arteriovenous Fistulas for Chronic Hemodialysis in Children: Technical Details and Refinements

Abstract

PURPOSE:The aim of this paper is to report our experience in the creation of arteriovenous fistulas in children by using microsurgical vascular techniques, with emphasis on the details of the surgical technique.METHODS: The children underwent surgery from July 1997 to March 2004. Operating loupes (magnification: 3.5X) were used by the entire surgical team. After dissection and adequate mobilization, the vein was anastomosed to the artery in an end-to-lateral fashion by using 4 separate 7/0 or 8/0 prolene running sutures.RESULTS: Twenty nine children underwent 33 fistula creations -21 radiocephalic, 6 brachiocephalic, 4 brachiobasilic, and 2 saphenofemoral. Primary patency was achieved in 17/21 (80.9%) of the radiocephalic fistulas, 5/6(83.3%) of the brachiocephalic, 3/4 (75.0%) of the brachiobasilic, and 2/2 (100%) of saphenofemoral. Two patients developed fistula occlusion and radial artery thrombosis, and in 2 others, radiocephalic fistulas became occluded in the first or second postoperative week. In the late postoperative period, the saphenofemoral fistulas were responsible for significant edema formation in the lower extremity; an aneurysm formed in a brachiocephalic fistula after a long period of utilization. As to the patency of the different sites of fistulas, the brachiocephalic and brachiobasilic fistulas had the same incidence of patency as the radiocephalic fistulas (P >.05).CONCLUSIONS: This experience indicates that the arteriovenous fistulas are a satisfactory method for providing hemodialysis in children. The utilization of microsurgical techniques and some technical refinements herein described permit the attainment of high patency rates of the fistulas.

Review of microsurgery and arteriovenous fistulae for hemodialysis

“…9 Tannuri and Tannuri also espoused the benefits of microsurgical techniques in creating AVFs for hemodialysis in children. 11 In 2003, Bourquelot et al 9 stated that the surgical teams of Lumsden et al 23 and Sheth et al 24 created AVFs without the use of microsurgery and had a 30À33% failure of AVFs, whereas the surgical teams of Bourquelot et al, 6 Sanabia et al, 22 and Bagolan et al 14 used microsurgery for angio-access in children and reported only 5À10% of fistulae that failed to mature.…”

“…14 Tannuri and Tannuri used microsurgical techniques in creating AVFs, but did not use the upper-arm ischemia technique with an inflatable tourniquet. 11 The lament of many involved in ESRD patient care is that the patients are very sick, and along with uremia and any other comorbities, another common problem involves dealing with patients who have lost precious vascular capital due to previous procedures. Tannuri and Tannuri stated that the main cause of primary patency failure, in their experience, was the poor condition of the veins and low arterial flow.…”

“…Tannuri and Tannuri stated that the main cause of primary patency failure, in their experience, was the poor condition of the veins and low arterial flow. 11 Often patients in chronic renal failure have edematous arms and thrombosed veins secondary to multiple venipunctures, adding to the difficulties in fistula creation. 11 If possible, AVFs are generally created distally on the arm in an effort to preserve a patient's vascular capital.…”

“…11 Often patients in chronic renal failure have edematous arms and thrombosed veins secondary to multiple venipunctures, adding to the difficulties in fistula creation. 11 If possible, AVFs are generally created distally on the arm in an effort to preserve a patient's vascular capital. The NFK guidelines recommend the following order of preference for placement of AVFs: 1) wrist (radial-cephalic), and 2) elbow (brachialÀcephalic).…”

“…10 In 2005, Tannuri and Tannuri stated that ''vascular access is the basis for hemodialysis and presents itself as a surgical challenge, especially for pediatric patients.'' 11 In a 20-year retrospective study conducted by Ramage et al, 304 vascular procedures were performed on 114 hemodialysis patients whose median age at initial access was 12 years; the authors concluded that there was an increased survival of autologous AVFs over cuffed central venous catheters (CVLs) and arteriovenous synthetic grafts (AVGs). 10 …”