Long-term outcomes of lateral tunneled transposed brachiobasilic arteriovenous fistulas in elderly hemodialysis patient

Evaluation of the relationship between proximal upper-extremity arteriovenous fistula patency and atherogenic index of plasma

BACKGROUND

The continuity of arteriovenous fistula (AVF) patency is essential for effective hemodialysis. In the present study, we aimed to investigate the relationship between AVF patency and atherogenic index of plasma (AIP) in patients with native proximal upper-extremity AVF.

METHODS

A total of 143 patients with native proximal upper-extremity AVF created in our clinic between January 2014 and April 2022 were analyzed retrospectively. Those with at least 24 months of follow-up and intact AVF were defined as "Group 1" (n = 97), and those with AVF thrombosis were defined as "Group 2" (n = 46).

RESULTS

The primary patency rates of the patient groups included in the study were found to be 88.1% at 6th month, 79% at 12th month, and 67.8% at 24th month. The mean AIP values that were calculated in Group 2 were found to be statistically significantly higher than the mean value calculated in Group 1 (0.30 ± 0.12 vs 0.20 ± 0.10, p < 0.001). In a multivariate logistic regression analysis made to identify the predictors of proximal upper-extremity AVF thrombosis development, total cholesterol (OR [odds ratio] = 2.259, 95% CI [confidence interval] = 1.468-3.475, p < 0.001), and triglyceride (OR = 13.777, 95% CI = 3.740-50.750, p < 0.001) were identified as independent predictors.

CONCLUSION

A significant relationship was detected in the analyses between the easily calculated AIP values and the development of AVF thrombosis. The AIP is a remarkable preoperative parameter regarding proximal upper-extremity AVF patency.

Association of glomerular filtration rate slope with timely creation of vascular access in incident hemodialysis

The factors associated with the timely creation of distal vascular access for hemodialysis initiation are unclear. We aimed to explore the association between the slope of estimated glomerular filtration rate (eGFR) and the successful usage of vascular access upon hemodialysis initiation. This single center retrospective cohort study enrolled chronic kidney disease patients who undertook a multidisciplinary care program from 2003 to 2016. Using eGFR slope as predictor, we evaluated the vascular access created timely upon hemodialysis initiation. Among the 987 patients, vascular access was created at a median eGFR of 5.8 min/ml/1.73 m², with a median duration of 3.1 months before hemodialysis. The proportions of vascular access created timely, created not timely (vascular access immature), and not created were 68.5%, 8.8%, and 22.7%, respectively. There was a significant negative association of eGFR upon vascular access creation with eGFR slope (r = − 0.182, P < 0.001). The fastest eGFR slope patients (the first quartile or < − 10 min/ml/1.73 m²/year) had the lowest percentage of vascular access created timely. In the multivariable logistic regression analysis, only higher eGFR upon vascular access creation (P = 0.001) and eGFR slope (P = 0.009) were significantly associated with vascular access created timely. The adjusted odds ratios of each quartile of eGFR slopes for vascular access created timely were 0.46 (95% confidence interval 0.27–0.86), 1.30 (0.62, 2.72), 1.00 (reference), and 0.95 (0.48–1.87), respectively. eGFR slope is associated with the timely creation of vascular access for the initiation of hemodialysis in a reverse-J-shaped pattern and may help determine the time of vascular access creation.

Transposition of brachiobasilic arteriovenous fistulas: One-stage or two-stage technique and factors affecting the early maturation

The brachiobasilic transposition (BBT) arteriovenous fistula (AVF) is a valuable option especially for dialysis patients with previously failed vascular access. We aim to report factors affecting the maturation of BBT-AVF created with either one-stage or two-stage technique. BBT-AVF procedures between January 2015 and May 2019 by a dedicated vascular access team were investigated retrospectively. A total of 122 patients (63 males, 59 females), with 6 to 12 weeks of follow-up after the BBT-AVF procedure were included in the study. Patients of one-stage and two-stage techniques were compared for maturation rates. Patients with successful and failed maturation were compared for baseline characteristics and anatomic factors. Of 122 BBT-AVF procedures, 54 were created with the one-stage and 68 were created with the two-stage technique. The mean age of the patients was 58.2 ± 13.8, the mean brachial artery and basilic vein diameters were 3.91 ± 1.02 mm, and 3.39 ± 1.16 mm. Of 122 included patients, 88 (72.1%) had mature AVFs at follow-up. The AVF maturation rates were similar between the one- and two-stage groups (70.4% vs 73.5%; P = .699). Lower age (62.8 ± 12.5 vs 56.5 ± 13.9; P = .023) and greater brachial artery diameter (3.09 ± 0.84 mm vs 4.23 ± 1.76 mm; P < .048) were the only factors affecting the AVF maturation in univariate analysis. Gender, extremity side, diabetes mellitus, hypertension, and targeted vein diameter were not found to affect the AVF maturation (P = .301, P = .084, P = .134, P = .858, P = .127). Target artery diameter (P = .049) was the only significant factor affecting BBT-AVF maturation in multivariate analysis. One-stage and two-stage BBT-AVFs are similar in terms of maturation rates. Targeted artery diameter was the only factor important in BBT-AVF maturation in our study group. The two-stage technique can be preferred considering smaller incision size and lower complication rate in patients with suitable anatomy.

Comparison Between Transposed Brachiobasilic Fistula and Arteriovenous Graft for Upper Limb Arteriovenous Access in Patients on Hemodialysis

BACKGROUND

Creating and maintaining a functioning arteriovenous access is essential for long-term hemodialysis patients. Transposed brachiobasilic fistula (BBF) or arteriovenous graft (AVG) becomes an option when radiocephalic or brachiocephalic fistula cannot be created or fails. This study compared the patency and complications between BBFs and AVGs among patients on hemodialysis.

METHODS

A retrospective study was performed in Shuang Ho Hospital, Taiwan, from November 2015 to May 2020. All the operations were done by a single surgeon. Primary outcomes were primary patency, primary-assisted patency, and secondary patency of the BBF and AVG groups. Secondary outcomes were incidence of complications and reinterventions.

RESULTS

Of the 144 consecutive patients, 20 and 124 patients underwent BBF and AVG creation, respectively. Median follow-up time was 19.2 months. Primary patency at 1 and 2 years were 67% and 19% in the BBF group and 44% and 16% in the AVG group (P = 0.126). Primary-assisted patency at 1 and 2 years were 82% and 54% in the BBF group and 54% and 30% in the AVG group (P = 0.012). Secondary patency at 1 and 2 years were 100% and 82% in the BBF group and 81% and 67% in the AVG group (P = 0.078). The incidence of complication was significantly higher in the AVG than in the BBF group (1.7 per patient-year vs 0.93, P < 0.001).

CONCLUSION

Compared with the AVG group, BBF group showed better primary-assisted patency, less complication and intervention rates. Therefore, BBF is a reliable option for patients with exhausted cephalic veins if basilic vein is available for reconstruction.

Proximal Arteriovenous Fistulas in Hemodialysis Patients: Advantages and Disadvantages

Introduction: The main objective of the present study is to investigate the advantages and disadvantages of proximal arteriovenous native fistulas. Hemodialysis is indispensable for patients with end-stage renal disease. For this purpose, arteriovenous fistulas (AVFs) are used. Among the native fistulas, distal radiocephalic AVF is the most preferred. However, brachiocephalic AVF (BCAVF) and brachiobasilic AVF with basilic vein transposition (basilic vein transposition arteriovenous fistula [BVTAVF]) can be used for a long time in dialysis patients whose distal vascular bed is depleted.

Methods: This is a retrospective study of 117 AVFs (BCAVF and BVTAVF), in patients with end-stage chronic renal disease, that were opened with a surgical technique (2012-2018). The postoperative two-year patency rates, AVF locations, complications, and the advantages and disadvantages of these fistulas are reviewed and recorded in the light of the literature.

Results: The mean age of the patients (52 men and 65 women) was 60.6 ± 13.6 years. The percentages of primary patency rates at 3, 6, 9, 12, and 24 months were 96.6%, 93.1%, 92%, 87.4%, and 82.8% in BCAVF patients, and 96.7%, 93.3%, 90%, 86.7%, and 80% in BVTAVF patients, respectively. The percentages of secondary patency rates at 6, 12, and 24 months were 100%, 93.3%, and 86.7% in BCAVF patients, and 100%, 100% and 87.7% in BVTAVF patients, respectively. Fistula thrombosis was seen as the most common complication. The early complication was bleeding/hematoma. As late complications, we encountered steal syndrome, ischemic pain in the relevant extremity, pseudoaneurysm, and high-output heart failure.

Conclusion: Proximal AVFs are preferable fistulas with early maturation and high primary patency rates. We believe that relatively high complications can be avoided by opening fistulas with an appropriate surgical technique.