Obesity promotes forearm primary arteriovenous fistula creation in chronic haemodialyzed patients

Abstract

The increase in number of obese people seen in the general population, is also what is seen in the hemodialyzed population. It is generally believed that the location of deep forearm vessels in the subcutaneous fat tissue makes primary arteriovenous fistula (AVF) a disadvantage because of difficulties in vessel puncturing. For obese patients, it is suggested that a fistula with PTFE is created or a central catheter inserted, but these solutions increase already high morbidity rate and significantly increase mortality rate. Methods: The deep location of veins situated on the anterior part of the forearm involved 57 patients (45 female and 12 male) aged 13–87 years (mean 67 ± 15.2 years). Patients’ body mass index (BMI) ranged from 29.1 to 53.73 (mean 34.6 ± 7.8). The causes of the renal failure were diabetic nephropathy in 30 patients, chronic glomerulonephritis in 4, hypertensive nephrosclerosis in 5, lupus nephritis in 2, interstitial nephritis in 4, primary amyloidosis in 1, polycystic kidney disease in 3, and unknown in 3 patients.Two‐step surgical procedure was performed in all patients. In the first stage, the standard distal radiocephalic AVF in the wrist region was created. In case of its failure, the next attempt was performed above the point of the first intervention. In the second stage, superficialization of the venous part of AVF was performed in the mode described by us (Kidney 2002;.1:1170). Results: The first stage of the procedure was successful in 46 patients. In 6 cases it was necessary to perform a second attempt, and 2 cases required three operations. The second stage was undertaken in all of these patients (n = 54), and complete success was achieved in 51. In 3 cases, in spite of superficialization, AVF was not suitable for puncturing because of poor blood flow. The causes of failure of the first stage procedure in 2 patients were severe arteriosclerosis and venous anomaly. All patients had non‐altered cephalic veins in the wrist region, as opposed to patients with cannulated veins. In 51 pts (90%) an efficient flow of the blood through AVF was successfully obtained and allowed satisfactory dialyses. Conclusions: The primary AVF creation on the forearm is feasible in 90% of obese patients. This result is similar to the general population of chronic renal disease patients of our center (95%)(NDT 1998;13:527) and is possible thanks to the location of the veins deep in the subcutaneous fat tissue, which protects against repeated cannulation and hence mechanical destruction in the pre‐dialysis period.