Outcomes of Upper Arm Arteriovenous Fistulas for Maintenance Hemodialysis Access

Abstract

Hypothesis: Radiocephalic fistulas for maintenance hemodialysis access are not feasible in all patients with endstage renal disease. Our aim was to review our experience with 3 types of upper arm arteriovenous fistula (AVF) to ascertain whether they are reasonable alternatives to radiocephalic fistulas and which, if any, have superior performance. Patients and Methods: Patient medical records were retrospectively reviewed. The main outcomes were maturation rate, time to maturation, assisted maturation rate, complication rates, reintervention rates, primary and assisted primary patency rates, and effects of comorbidities. Results: Eighty-six patients with end-stage renal disease underwent creation of a brachiocephalic, brachiobasilic, or brachial artery-to-median antecubital vein AVF. Overall, 80% matured, with 23% requiring an intervention to achieve maturity. The mean time to maturation was 3.8 months; 47% had a complication (inability to access, thrombosis, and so on), and 43% required additional interventions. The overall primary patency and assisted primary patency rates at 12 months were 50% and 74%, respectively. Brachiobasilic AVFs not superficialized immediately often needed a second operation. There were no significant differences in patency rates among the 3 AVF types. The AVFs in patients with diabetes took 2 months longer to mature than did those in patients without diabetes. Conclusions: An upper arm AVF is a reasonable alternative for maintenance hemodialysis access when a radiocephalic AVF is not possible. There are 3 valid options from which to choose to best accommodate each patient's antecubital anatomy. Diabetes may adversely affect outcomes. Our data suggest that brachiobasilic AVFs should be superficialized at the initial procedure, if feasible.

Fistula First Initiative

“…Only approximately 45% of AVF are functional without intervention after creation (32); the procedure rate is 1.45 (33) to 3.3 procedures per AVF required for maturation or 1.75 procedures per access year (32). Once an AVF is matured, the revision rate ranges from 0.17 to 0.57 (20,21,(73)(74)(75) and is required in approximately 50% of AVF (32,76). This contrasts to fewer interventions for graft maturation, whereas the revisions required for grafts per access year ranges between 0.44 and 1.80 (20,21,73,75,77) (typically three to six rimes greater than for AVF).…”

Clinical profile and early outcome of arteriovenous fistula creation for haemodialysis: Integrated activity in a general surgery unit

“…This percentage is high than that reported from Australia, USA and Sudan (28%, 78% and 91.8% respectively). 9,12,13 This may be due to requirement of emergency HD on first presentation or late referral to nephrologists.…”

Endovascular Treatment of the “Failing to Mature” Arteriovenous Fistula

“…Patients were followed up for 1 yr, during which primary and secondary AVF patency rates were measured. T he low prevalence of the arteriovenous fistula (AVF) among US hemodialysis (HD) patients (1,2) has initiated nationwide measures to increase AVF creation and prevalence (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20). Among these are providing educational programs, setting forth guidelines and goals (3,4), implementing multidisciplinary approaches (4 -9), encouraging preoperative venous mapping (14 -19), and asking surgeons to create AVF instead of arteriovenous grafts (AVG) (10 -21).…”