Autogenous Side-to-Side Brachial-Basilic Fistulas Without Vein Transposition: A Valuable Option?

Comparison of side-to-end vs. side-to-side proximal arteriovenous fistula anastomosis in chronic renal failure patients

Introduction

Anastomotic creation of autogenous arteriovenous fistulas can be performed in different ways, side-to-end or side-to-side. However, there is a paucity of evidence to recommend them. The aim of this study is to compare both anastomosis types in elbow arteriovenous fistulas.

Material and methods

A prospective observational national multicenter study (ISRCTN62033470) was designed, including patients receiving a native arteriovenous fistula in the elbow using side-to-end or side-to-side anastomosis, between September, 2016 and September, 2017, with six-month postoperative follow-up period. Patient characteristics, surgical details, and follow-up data (primary, assisted primary and secondary patency, maturation, functionality, complications) were recorded and compared between both anastomosis groups using Kaplan–Meier curves estimations, at one and six-month follow-up, and finally a multivariate analysis with Cox regression was performed.

Results

Three centers participated in the study, including 133 cases (96 side-to-end, 37 side-to-side). The cephalic vein was more often used for side-to-end (58.3%) and basilic for side-to-side (78.4%; P < 0.001). Side-to-end anastomoses were faster to create (65.1–75.1 min; P = 0.009). During follow-up, 23 cases were lost (transplanted, dead, ligated, or lost), with no differences at one month. At six months, primary patency was better for the side-to-end group (78.5 − 55.9%; P = 0.038), but it was not confirmed as an independent predictor in the multivariate analysis. Furthermore, no significant differences in assisted primary or secondary patency, maturation or functionality were seen. Patients with side-to-side anastomosis more often required vein superficialization (2.1–16.2%; P = 0.002) and presented more frequent puncture hematomas (4.9–30.0%; P = 0.015).

Conclusions

Anastomosis type was not significantly related to different outcomes in the follow-up. Even though side-to-end anastomosis showed better primary patency at six months with lower need of vein superficialization and fewer puncture hematomas during follow-up, it was not confirmed as an independent predictor in the multivariate analysis, and similar assisted primary and secondary patency, maturation, and functionality rates have been seen after arteriovenous fistula creation.

Elbow AVF configurations and indications

INTRODUCTION

Brescia-Cimino radiocephalic arteriovenous fistula (AVF) remains the first-choice vascular access procedure for patients in need of long-term hemodialysis. The average life expectancy of patients receiving hemodialysis has increased in recent years and many patients now live longer and require secondary or tertiary procedures. Elbow fistulas should only rarely be constructed as primary fistulas. The aim of the surgeon must be not only to achieve a functioning fistula, but to avoid possible complications other than failure to mature (FTM), like distal ischemia and cardiac failure and to save the vessels as much as possible for future procedures.

BACKGROUND

Both arterial and venous anatomy of the elbow and upper arm have significant variations. The surgeon must be aware of these variations during the operation, and try not to harm the vasculature of the extremity while trying to construct a functioning fistula. The main advantages of elbow fistulas are the opportunity to have multiple outflows, preservation of the major veins in their original place with no dissection and giving no harm to them, and having a longer outflow tract for cannulation.

CONCLUSIONS

In the elbow, beginning to construct an AVF with the perforating vein is the most advantageous. If the perforating vein is not available or has been used before, median cubital vein, its branches, median antecubital vein or other available nearby veins may be used depending on the anatomy. Perforating vein should be ligated if any other elbow vein is used to prevent flow to deep veins.

A modified nontransposed brachiobasilic arteriovenous fistula versus brachiocephalic arteriovenous fistula for maintenance hemodialysis access

OBJECTIVE

With the growing need for reliable and durable upper arm hemodialysis access, we sought to compare the performance of a novel modified nontransposed brachiobasilic arteriovenous fistula (mNT-BBAVF) with that of the more traditional brachiocephalic arteriovenous fistula (BCAVF).

METHODS

Briefly, to construct an mNT-BBAVF, an incision is made on the ulnar side of the elbow. The brachial artery and basilic vein are then isolated, and a side-to-side anastomosis is performed without transposition of the basilic vein. Next, the proximal basilic vein and the perforating veins within the surgical field are ligated. In this study, we retrospectively reviewed the medical records of all patients who underwent either an mNT-BBAVF or a BCAVF between January 2011 and October 2014 to compare 1-year primary unassisted patency, cumulative patency, and complications. We also examined hemodynamic parameters of vessels in each fistula type.

RESULTS

We identified a total of 84 patients: 45 had a BCAVF, and 39 had an mNT-BBAVF. The two groups were well matched for baseline characteristics. Maturation rates at 1 month were 97% for mNT-BBAVF and 96% for BCAVF. The 1-year primary unassisted patency was significantly higher in the mNT-BBAVF group than that in the BCAVF group (87% vs 67%; hazard ratio, 2.86; 95% confidence interval, 1.11-6.40; P = .03), although cumulative patency did not differ (90% vs 73%; hazard ratio, 2.80; 95% confidence interval, 0.98-6.96 ; P = .06). There were no differences in thrombosis, failure of maturation, bleeding, steal syndrome, arm swelling, aneurysm, and stenosis between the two groups during the 12-month study. Importantly, diameters and blood flow volumes of the proximal cephalic vein, distal cephalic vein, and distal basilic vein in patients who received an mNT-BBAVF increased significantly after 12 months. All three vessels met the Kidney Disease Outcomes Quality Initiative (KDOQI) criteria for fistula maturation and were available for dialysis cannulation, whereas only the proximal cephalic vein in the BCAVF group met the maturation criteria and could be used for cannulation.

CONCLUSIONS

mNT-BBAVF appeared to be an effective alternative to BCAVF for upper arm hemodialysis access.

Brachiocephalic and Basilic Fistula

Introduction

Brescia-Cimino radiocephalic arteriovenous fistula (AVF) remains the first choice vascular access procedure for patients in need of long-term hemodialysis. Brachiocephalic fistulas are considered as a secondary option in almost all published guidelines. Recently in many reports, elbow and upper arm fistulas are recommended to be used as primary fistulas especially in elderly, diabetic, hypertensive patients. Elbow fistulas (brachiocephalic and brachiobasilic) should only rarely be constructed as primary fistulas. Forearm AVFs should be tried first to give a chance to the patient, because it is not the maturation-patency rates per se but also lowering the complication rates and saving the vessels for future use are equally important.

Background

The average life expectancy of patients receiving hemodialysis has increased in recent years and many patients now live longer and require secondary or tertiary procedures.

Conclusions

When forearm fistulas have failed, brachiocephalic AVF is usually preferred first, because of cephalic vein's appropriate anatomy for easy cannulation and ease of the operation. Operative procedure is less invasive compared to brachiobasilic AVF, therefore BC should be the procedure of choice when both veins are available.

Predictors of steal syndrome in hemodialysis patients

Steal syndrome is a feared complication of dialysis vascular access in a population becoming older and frailer. The aim of this study was to determine the predictor factors of steal syndrome. All proximal arteriovenous fistulas (AVFs), patent at day 30, inserted between January 2008 and December 2009 were studied. Data on age, gender, diabetes mellitus (DM) status, presence of coronary or peripheral artery disease, date of initiation of renal replacement therapy, date of access construction, localization, type of anastomosis, previous interventions, and outcome for AVF and patients were analyzed. There were 324 AVFs placed into 309 individual patients. The mean age was 66.7 ± 15.3 years, and the majority (53.7%) of the patients was male. Mean follow-up of all 324 fistulas was 18.6 ± 8.5 months. During follow-up, steal syndrome occurred in 26 (8%) of the AVFs. Univariate analysis revealed correlations between steal syndrome and DM (P = 0.002), brachiomedian fistulas (P = 0.016), and side-to-side (STS) anastomosis (P = 0.003). However, in multivariate analysis, the presence of DM, STS anastomosis, and female gender were found to be the independent risk factors. The strongest predictive factor was DM (odds ratio: 6.7; 95% confidence interval: 2.5-17.9). Being diabetic is the factor most predictive of having steal syndrome. In diabetic women, with a proximal access, it seems preferable to construct fistulas with end-to-side anastomosis to minimize the risk.