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Retrospective analysis of 271 arteriovenous fistulas as vascular access for hemodialysis


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This report describes our experience of arteriovenous fistula (AVF) creation as vascular access for hemodialysis (HD). Study has been carried out in Deenanath Mangeshkar Hospital, Pune from January 2004 to December 2009. A total of 271 AVFs were created in 249 patients. Maximum follow up was 7 years and minimum was 1 year. In this study of 271 cases of AVFs, there were 196 (72.3%) successful cases and 75 (27.7%) failures. Basilic vein was used in 77 (28.4%) cases, cephalic vein in 186 (68.6%), and antecubital vein in 8 (3%) cases. End (vein) to side (artery) anastomosis was done in 170 (63%) cases. Side to side anastomosis was done in 100 (37%) cases. On table bruit was present in 244 (90%) and thrill in 232 (85.6%) cases. During dialysis, flow rate >250 ml/min was obtained in 136 (50.4%) cases. In complications, 16 (5.9%) patients developed distal edema, 32 (11.8%) developed steal phenomenon. Presence of on table thrill and bruit are indicators of successful AVF. If vein diameter is <2 mm, chances of AVF failure are high. During proximal side to side fistula between antecubital/basilic vein and brachial artery, breaking of first valve toward wrist helps to develop distal veins in forearm by retrograde flow. This technique avoids requirement of superficialization of basilic vein in arm.
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ISSN 0971-4065
Vol 23, No. 3, May - June 2013
Indian Journal of Nephrology • Volume 23 • Issue 3May-June 2013 • Pages 159-***
Highlights of the Issue
Noninvasive assessment of bone health in
Spectrum of glomerular disease
CCR5 in renal allograft rejection
Indian Journal of Nephrology May 2013 / Vol 23 / Issue 3 191
presence of on table bruit and thrill, role of postoperative
anticoagulants and suture used to postoperative outcome
and patency.
Materials and Methods
This retrospective observation study was carried out in
our institute in patients who underwent surgical AVF
creation between January 2004 and December 2009.
During this period, AVF was created in 421 patients but
we could follow up only 249 patients during January to
July 2011. Follow up was obtained in collaboration with
dialysis unit staff by telephonic calls and personal visits
to the patients. The data extracted from hospital records
included patient demographics, co‑morbidities, details
of previous access, location and type of AVF, operative
details, patency, morbidity, and mortality. The data
collection was difficult and took time of 6 months as some
patients were taking dialysis at some other centers. Some
were lost to follow up and others could not be reached.
A total of 271 AVFs were placed in 249 patients. Maximum
follow up was 7 years and minimum follow up was 1 year.
Twenty‑two patients required repeat procedure due to
failure of previous fistula.
End stage renal disease (ESRD) patients depend on
lifelong renal replacement therapy (dialysis or renal
transplant) to sustain their lives. After Scribner shunt
in 1960, Cimino and Brescia described the creation of
subcutaneous arteriovenous fistula (AVF) constructed
between the radial artery and an adjacent vein in 1966.
Cimino fistulas are currently accepted as the best mode
of vascular access for hemodialysis (HD).[1]
This is single center, single surgeon retrospective study
comparing preoperative vein and artery diameters,
Original Article
Retrospective analysis of 271 arteriovenous stulas as
vascular access for hemodialysis
P. Sahasrabudhe, T. Dighe1, N. Panse2, S. Patil
Departments of Plastic Surgery and 1Nephrology, Deenanath Mangeshkar Hospital and Research Center, Erandwane, 2Plastic Surgery,
Sassoon Hospitals, Pune, Maharashtra, India
This report describes our experience of arteriovenous stula (AVF) creation as vascular access for hemodialysis (HD). Study
has been carried out in Deenanath Mangeshkar Hospital, Pune from January 2004 to December 2009. A total of 271 AVFs were
created in 249 patients. Maximum follow up was 7 years and minimum was 1 year. In this study of 271 cases of AVFs, there
were 196 (72.3%) successful cases and 75 (27.7%) failures. Basilic vein was used in 77 (28.4%) cases, cephalic vein in 186
(68.6%), and antecubital vein in 8 (3%) cases. End (vein) to side (artery) anastomosis was done in 170 (63%) cases. Side to
side anastomosis was done in 100 (37%) cases. On table bruit was present in 244 (90%) and thrill in 232 (85.6%) cases. During
dialysis, ow rate >250 ml/min was obtained in 136 (50.4%) cases. In complications, 16 (5.9%) patients developed distal edema,
32 (11.8%) developed steal phenomenon. Presence of on table thrill and bruit are indicators of successful AVF. If vein diameter is
<2 mm, chances of AVF failure are high. During proximal side to side stula between antecubital/basilic vein and brachial artery,
breaking of rst valve toward wrist helps to develop distal veins in forearm by retrograde ow. This technique avoids requirement
of supercialization of basilic vein in arm.
Key words: Arteriovenous stula, chronic kidney disease, hemodialysis, vascular access
Address for correspondence:
Dr. Parag Sahasrabudhe, Plot 82, Lane 2, Natraj Society, Karvenagar,
Pune ‑ 411 052, Maharashtra, India.
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Sahasrabudhe, et al.: Hemodialysis vascular access in Indian scenario
192 May 2013 / Vol 23 / Issue 3 Indian Journal of Nephrology
Patients were advised surgery for AVF when their
Modified Diet for Renal Disease estimated Glomerular
Filtration Rate (MDRD eGFR)[2] was below 15 ml/min.
HD catheter was inserted only in cases who presented late
and required HD before maturation of fistula.
History of diabetes mellitus, anticoagulant therapy for
coagulation disorder, cardiovascular disease, heart valve
disease or prosthesis, previous dialysis access, previous
central venous or peripheral catheter were noted. Physical
exam of the arterial system (peripheral pulses, Allen test,
bilateral upper extremity blood pressure) was performed
along with physical exam of the venous system (edema,
arm size comparability, collateral veins, tourniquet venous
palpation with vein mapping, examination for previous
central or peripheral venous catheters, evidence of arm,
neck, or chest surgery/trauma). Dominance of hand was
examined and preference was given to nondominant hand
for vascular access creation.
Preoperative color Doppler of upper limb veins and
arteries was done in selected patients to look for size and
patency. It was done in patients with insufficient clinical
examination like in cases with obesity, absent or feeble
pulses, multiple previous access surgeries, indwelling
dialysis catheter on same side, and history suggestive of
Subclavian vein catheterization was avoided for
temporary access in all patients due to the risk of central
venous stenosis, which compromises entire ipsilateral arm
for vascular access. Arm veins suitable for vascular access
placement were preserved, and patients and dialysis staff
were instructed not to prick selected arm.
Operative technique
All patients were admitted on the day of surgery. All cases
were done under local anesthesia using 10 cc 2% Xylocaine
by single surgeon under loupe magnification using
microvascular instruments. ‘S’ shape 2.5‑3 cm. long incision
was used. Vein and artery were mobilized adequately.
Arteriotomy size in all cases was 7‑8 mm. Anastomosis
was done by taking continuous running suture using 7‑0
polypropylene or 8‑0 ethilon depending upon vessel wall
thickness [Figure 1]. For distal and mid forearm fistula, end
of cephalic vein to side of radial artery anastomosis was
performed [Figure 2]. For proximal fistula, we performed
side to side anastomosis between anticubital or basilic
vein and brachial artery [Figure 3]. Before anastomosis
was completed, we dilated distal vein using venous dilator
to break the first valve toward the wrist end to allow
retrograde flow into forearm veins. This technique avoided
requirement of superficialization of basilic vein in arm in
cases where forearm veins fail to develop in spite of good
bruit and thrill. In cases where antecubital vein was used,
both cephalic and basilic veins got arterialized and could
be cannulated. Skin closure was done with 3‑0 ethilon in
single layer. Noncompressive dressing was given. Bruit was
heard and thrill was felt on operation table end of dressing.
In cases where bruit was absent but there was good venous
filling, we started anticoagulation with low molecular
weight heparin subcutaneously for 3‑5 days, (doses
according to creatinine clearance), and tablet aspirin 75 mg.
once a day for 3‑5 days. Patient was discharged on same day
Figure 1: Intraoperative picture postwall complete with 8 0 ethilon
Figure 2: End to side radiocephalic stula
Figure 3: Proximal AVF side to side anast brachiobasilic
Sahasrabudhe, et al.: Hemodialysis vascular access in Indian scenario
Indian Journal of Nephrology May 2013 / Vol 23 / Issue 3
or next day. Relevant instructions about care of operated
side arm were given to the patients and their relatives.
They were told to avoid AVF arm vein blood collection,
avoid blood pressure cuffs, not to use tight clothing or
jewellery, and avoid prolong pressure on operated arm.
Written instructions about how to feel for thrill were given
and patients were asked to report any coldness, numbness,
ulcers, discoloration at fingertips. Hand ball exercises were
taught to patients before discharge.
Fistula maturation and its cannulation for use of dialysis
was decided by nephrologist based on visible enlarged
vein and well felt thrill which required 4‑6 weeks after
construction. We considered 250 ml/min as a flow rate
obtained on HD machine during HD, which was sustained
for minimum of 3 hours as acceptable flow during HD.
We followed the NKF‑K/DOQI Vascular Access Clinical
Practice Guidelines 2000.[3] However, few guidelines could
not be followed, for example, early reference, timing of
access placement (1‑4 months before anticipated HD),
Doppler ultrasound in all cases and early intervention in
failing fistulas. Above limitations were due to poor patient
compliance and affordability in Indian scenario.
The data was analyzed using SPSS (statistical package
for social sciences) version 20. Student’s t‑test was used
to find the differences. Chi square test was used to look
at the association. Regression was used to find predictors
or risk factors.
In the present series of 271 fistulas (baseline characteristics
of patients are given in Table 1), 86 were proximal fistulas,
180 were distal fistulas, and 5 were mid forearm fistulas.
Eighty‑one fistulas were done on right side and 190 were
done on left side. Basilic vein was used in 77 cases, cephalic
vein was used in 186 cases, and antecubital vein was used
in 8 cases. Vein anastomosis was done with radial artery in
187 cases and brachial artery in 84 cases. End (vein) to side
(artery) anastomosis was done in 171 cases. Side (vein)
to side (artery) anastomosis was done in 100 cases. In 17
cases vein diameter was <2 mm and in 18 cases arterial
diameter was <2 mm. Bruit was heard in 244 cases and
thrill was felt in 232 cases on operation table.
During HD, flow rate >250 ml/min was obtained in 136
cases. It was sufficient to perform successful HD in these
patients as it sustained for period of at least 3 hours
during 4 hours of HD. The flow rate >250 ml/min was
not flow across fistula, as measured by radiological or
any other means, but actual flow rate obtained on blood
pump during HD.
In complications, 16 patients developed distal edema
[Figure 4], 32 developed steal phenomenon. We did
not find aneurysm, operative site infection, and major
bleeding requiring intervention during follow up period.
There were 69 deaths during follow up period and none
were attributable to a direct complication of vascular
access operations.
Fistula is six times more likely to be successful when thrill
was felt on operation table. This result is significant at
P = 0.004 when adjusted with bruit, vein <2 mm, artery
<2 mm, suture, age, and site of fistula. Also more cases
were successful when bruit (P = 0.003) was present on
operation table.
The result also showed that vein <2 mm is significantly
(P = 0.008) less likely to be successful [Table 2]. Artery
and vein ≥2 mm showed success in about three-fourth
of the patients as compared with artery and vein
Table 1: Baseline characteristics of patients
No. of AVFs 271
No. of cannulated AVFs (successful) 196
Age 55±14
Male gender 178 (65.7%)
Female gender 093 (34.3%)
Diabetes 132 (48.7%)
Atherosclerosis 012 (4.4%)
Coagulopathy 002 (0.7%)
Figure 4: Venous hypertension.
Table 2: Logistic regression test for predictor
Variables in
the equation
SE P value OR 95% CI for OR.
Lower limit Upper limit
Bruit 0.745 0.243 0.419 0.097 1.807
Thrill 0.637 0.004 6.186 1.777 21.538
Vein <2 mm 0.640 0.008 0.181 0.052 0.634
Art <2 mm 0.617 0.966 0.974 0.291 3.260
Suture 0.326 0.113 0.597 0.315 1.130
Anastomosis 0.508 0.421 0.664 0.246 1.797
Siteof stula 0.864
Proximal 0.532 0.590 1.332 0.470 3.774
Distal 1.200 0.830 1.293 0.123 13.570
Constant 0.551 0.310 1.750
SE: Standard error, OR: Odds ratio, CI: Condence interval, signicant
P value <0.05, Variable(s) entered on step 1: Bruit, Thrill, Vein <2 mm,
Art <2 mm, Suture, Anasmosis, site of stula
Sahasrabudhe, et al.: Hemodialysis vascular access in Indian scenario
194 May 2013 / Vol 23 / Issue 3 Indian Journal of Nephrology
<2 mm (P = 0.028, P < 0.0001, respectively). Univariate
logistic regression showed that cases with bruit heard on
operation table were 3.2 times (P = 0.0005), thrill felt
on operation table were 4.79 times (P < 0.0001), vein
≥2 mm were 7.26 times (P < 0.0001) and artery ≥2
mm were 2.83 times (P = 0.035) likely to be associated
with success of AVF. In multivariate logistic regression,
when adjusted with all above mentioned variables, vein
≥2 mm was 5.26 times (P < 0.0001) more likely to be
associated with success of AVF.
Though the results were not statistically significant, it
was observed that proximal fistulas had high success rate
than distal (76% vs 70%), side to side than end to side
(76% vs 70%), brachial artery than radical artery (75%
vs 71%), and nondiabetic patients than diabetic (30%
vs 25%). Postoperative heparin was given in 238 cases,
of which 173 were successful. Out of 33 nonheparinized
cases 23 were successful (P value −0.719).
Causes of 75 failures were injury (1 patient), hypotension
(4 patients), thrombosis (3 patients), and not known
(reported) for 67 patients. There were significantly more
deaths in AVF failure cases (P ‑ 0.031).
In proximal fistula, bruit was heard in 97.7% cases and
thrill was felt in 94.2% cases on operation table. In distal
fistulas, bruit was heard in 86% and thrill was felt in
81.1% on operation table. Hence success rate was more
(75.6%) in proximal than in distal (70.6%) fistulas.
Complication like edema and steal phenomenon were
more (9.3% and 16.3%, respectively) in proximal than
in distal (4.4% and 10%, respectively) fistulas.
Successful HD depends on creation and maintenance
of adequate vascular access. Due to general population
aging, median age at onset of ESRD has been progressively
increased over last few decades. More than 20% of people
have diabetes as a cause of ESRD and average age is
58.8 years.[4] In our study of 271 cases, average age
of presentation was 55 years and 48.7% patients had
diabetes as a cause of ESRD.
Patients who receive dialysis across a functional AVF
have lower complication rates and longer duration of
event‑free patency than patients with catheter access[5‑8]
and arteriovenous grafts (AVGs).[6,9] Thus construction of a
native AVF on arm or forearm is considered a good practice
over prosthetic grafts and central venous catheters. There
were no AVGs created in the present series. There is
vast data proving that native AVFs are superior to grafts
as a form of vascular access for dialysis.[6] It has been
demonstrated that early referral to nephrologist and good
collaboration with microvascular surgeon reduce the
need for temporary dialysis access for first dialysis and
increase the rate of successful AVF placement.[10] However,
central venous catheters are primary method of choice for
temporary access in which there is urgent need for HD
and no other vascular access is available or has failed.[8]
However, these devices suffer from several complicating
factors as infection, thrombosis, venous stenosis, and
damage to proximal vessels.[11] We performed AVF in all
our CKD patients as first choice of vascular access.
The most common operative procedure was the creation
of the distal radio cephalic fistula, initially described by
Brescia, et al. in 1966.[1] This operation is still considered
to be the gold standard for vascular access for HD[12] and
it accounted for 180 (66.4%) of our operative procedures.
High radio cephalic (mid forearm) and brachial‑basilic
AVFs were reserved for patients with previously failed
Brescia – Cimino AVFs or where patent adequate size
vessels at wrist level were not available for anastomosis.
The outcomes of the classic Brescia – Cimino operation
were accompanied by acceptable rates of morbidity.[13,14]
Most large‑volume centers report 15‑30% primary failure
rates for distal radio cephalic AVF.[13,14] The reported
incidence of primary failure in the medical literature
varies from 9%[15] to 40%[16] and our results were
comparable with 29.4% primary failures. The NKF/DOQI
(National Kidney Foundation Disease Outcome Quality
Initiative) Work Group did not recommend the use of
primary failure as an index of quality because it would
discourage attempts at AVF construction in patients with
complex vascular anatomy.[2]
American Institute of Ultrasound in Medicine (AIUM)
Practice Guideline 2011[17,18] states that arterial diameter
<2 mm and venous diameter <2.5 mm were associated with
high failure rate. This study also proves that arterial and
venous diameters <2 mm are associated with significantly
high failure rates (P −0.028 and 0.0001, respectively).
In India, because of illiteracy, poor follow up, and poor
socioeconomic status, fistula salvage by early detection
of failing fistula and intervention by exploration,
embolectomy, or radiological intervention like
percutaneous transcutaneous angioplasty for venous
outflow stenosis[3] is not cost effective. Hence we prefer
to perform new fistula in such situations. In our series no
patients required any such salvage procedures.
Sahasrabudhe, et al.: Hemodialysis vascular access in Indian scenario
Indian Journal of Nephrology May 2013 / Vol 23 / Issue 3
AVF creation in all (100%) patients with ESRD in our
institution far exceeds the target goals of 50% set forward
by the NKF/DOQI[3] and the CMS (Centres for Medicare and
Medicaid Services) Fistula First Breakthrough Initiative.[19]
This was being achieved with acceptable rates of morbidity
(27%), no operative mortality and good primary patency
(72%). However, early detection of complications by patient
education can help to improve long‑term patency rates.
In conclusion, we found that
1. Vein diameter <2 mm. showed very high failure rate
(P value less than 0.05). Hence, we recommend use of
alternative method of access placement in such patients.
2. Thrill felt on operation table has direct relation with
success of fistula operation (P −0.004).
3. Postoperative anticoagulation has no major beneficial
role in eventual patency rates (P −0.719).
4. During creation of proximal fistula by side to side
anastomosis between anticubital/basilic vein and
brachial artery, dilatation of distal vein to break the
first valve helps to develop distal veins in forearm by
retrograde flow avoiding need for superficialization
of basilic vein in arm. In none of our patients with
proximal fistula superficialization of basilic vein in
arm was needed.
The author would like to thank Consultants of Department of
Medicine, Consultants and staff of Department of Nephrology,
Dr. Amit Jadhav, Dr. Sheetal Londhe (Residents, Department
of Plastic Surgery), Dr. Joshi Veena, Department of Research at
Deenanath Mangeshkar Hospital, Pune and Dr. Shaunak Sule.
(Consultants, Plastic Surgeon, Pune).
1. Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis
using venipuncture and a surgically created arteriovenous stula.
N Engl J Med 1966;275:1089‑92.
2. Levey AS, Coresh J, Greene T, Marsh J, Stevens LA, Kusek
JW, et al.; Chronic Kidney Disease Epidemiology Collaboration.
Expressing the Modication of Diet in Renal Disease Study
equation for estimating glomerular ltration rate with standardized
serum creatinine values. Division of Nephrology, Tufts‑New
England Medical Center, Boston, MA 02111, USA. Clin Chem
3. III. NKF‑K/DOQI Clinical Practice Guidelines for Vascular Access:
Update 2000. Am J Kidney Dis 2001;37:S137‑81.
4. Konner K. Primary vascular access in diabetic patients: An audit.
Nephrol Dial Transplant 2000;15:1317‑25.
5. Tordoir JH. Current topic on vascular access for hemodialysis.
Minerva Urol Nefrol 2004;56:223‑35.
6. Young EW, Dykstra DM, Goodkin DA, Mapes DL, Wolfe RA, Held
PJ. Hemodialysis vascular access preferences and outcomes in
the Dialysis Outcomes and Practice Patterns Study (DOPPS).
Kidney Int 2002;61:2266‑71.
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quality of vascular access care for hemodialysis patients. Jt Comm
J Qual Saf 2003;29:191‑8.
8. Kong NC, Morad Z, Suleiman AB. Subclavian catheters as
temporary vascular access. Singapore Med J 1989;30:261‑2.
9. Roy‑Chaudhury P, Kelly BS, Melhem M, Zhang J, Li J, Desai P,
et al. Vascular access in hemodialysis: Issues, management, and
emerging concepts. Cardiol Clin 2005;23:249‑73.
10. Chesser AM, Baker LR. Temporary vascular access for rst
dialysisis common, undesirable and usually avoidable. Clin
Nephrol 1999;51:228‑32.
11. Weiswasser JM, Kellkut D, Arora S, Sidawy AN. Strategies of
arteriovenous dialysis access. Semin Vasc Surg 2004;17:10‑8.
12. Malovrh M. Approach to patients with end‑stage renal disease
who need an arteriovenous fistula. Nephrol Dial Transplant
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stulas for hemodialysis. Arch Surg 1975;110:708-12.
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How to cite this article: Sahasrabudhe P, Dighe T, Panse N, Patil S.
Retrospective analysis of 271 arteriovenous stulas as vascular access
for hemodialysis. Indian J Nephrol 2013;23:191‑5.
Source of Support: Nil, Conict of Interest: None declared.
... A well-working vascular access is necessary for providing adequate hemodialysis. 1 The vascular route of entry can be of the following types: arteriovenous fistula (AVF), arteriovenous grafts (AVG) and central vein catheter (CVC). 1 Preferred vascular route of access for hemodialysis is the arteriovenous (AV) fistula. 2 It is associated with higher blood flow, and lesser chances of thrombosis, sepsis and stenosis. [3][4][5] It has been well postulated that early referral by a nephrologist to the microvascular surgeon moderates the requirement for temporary dialysis access for first dialysis and increases the rate of successful AVF placement. ...
... 1 The vascular route of entry can be of the following types: arteriovenous fistula (AVF), arteriovenous grafts (AVG) and central vein catheter (CVC). 1 Preferred vascular route of access for hemodialysis is the arteriovenous (AV) fistula. 2 It is associated with higher blood flow, and lesser chances of thrombosis, sepsis and stenosis. [3][4][5] It has been well postulated that early referral by a nephrologist to the microvascular surgeon moderates the requirement for temporary dialysis access for first dialysis and increases the rate of successful AVF placement. ...
... [3][4][5] It has been well postulated that early referral by a nephrologist to the microvascular surgeon moderates the requirement for temporary dialysis access for first dialysis and increases the rate of successful AVF placement. 1 However, there are unavoidable situations when a temporary central venous catheter mandates for an urgent dialysis but at the cost of infection, thrombosis, venous stenosis and damage to the proximal vessels. 1 After the construction of AV fistula, patient is advised to wait for up to 6 weeks to allow the AV fistula obtain adequate dilation allowing appropriate hemodialysis. 6 AV fistula that never matures to the point that it could allow hemodialysis is termed as early AV fistula failure. ...
Full-text available
Objective: To analyze the outcomes of arteriovenous fistula (AVF) constructed in our setup. Study Design: Retrospective observational study. Place and Duration of Study: Combined Military Hospital, Lahore, from Mar 2019 to Mar 2020. Methodology: Our study included all the patients who had their arteriovenous fistula (AVF) made during the study period. Data was collected via telephone cal s, to inquire about the status of AV fistula after one year of AV fistula construction surgery. Results: Out of 130 study participants, 97 were successfully contacted. Mean age of patients was 54.39 ± 12.75 years. Majority were male patients (71.1%) and had their first dialysis via temporary dialysis access catheter. Most of the patients (74.7%) had functional AVF. 35 (36.1%) patients were not alive at the time of contact. In 9 (9.2%) patients, AV fistula failed with the most common cause being thrombosis (77.7%). Conclusion: Current study is one of the pioneer in Pakistan where we have started to audit our performance as the dedicated access surgeons. It is high time for us to evaluate our performance so that better outcome can be offered to the dialysis dependent patients.
... Although interrupted sutures are time-consuming, there is a theoretical risk that interrupted sutures bleed more from the gaps between the suture lines, whereas continuous sutures, while less time-consuming, carry the risk of tightening and puckering along the suture lines, making continuous sutures unsuitable for radiocephalic fistulas with vessels smaller than 2 mm [28,29]. On-table excitement and bruit are long-term indices of primary patency [30], and comparable findings were observed in this study. The life expectancy of CKD patients has increased as awareness of the disease has grown along with research in the field of hemodialysis. ...
... The goal should be to create a functional and well-functioning AVF that can provide enough dialysis with minimal problems (Figures 1, 2). The main AVF failure rates range from 20% to 60% [30], which is comparable to the current study, which had a main failure rate of 26% in both cohorts combined. In both the cohorts combined, four patients (three in the continuous arm and one in the interrupted arm) were re-explored immediately due to the absence of thrill and bruit (on-table failure). ...
Background Arteriovenous fistulas (AVFs) are considered the first and best access for patients with end-stage renal disease who need permanent vascular access for hemodialysis over arteriovenous grafts and central venous catheters for reasons that have been well-established. Poor early patency rates pose the biggest challenge in creating vascular access as they cause increased morbidity and economic/psychological concerns among patients. To minimize such effects, it is critical to use a patient-centered approach and carefully choose patients for AVF access creation. This study aimed to compare the primary patency of distal vascular access provided by continuous suturing versus that provided by interrupted suturing. Methodology This prospective study was conducted in the urology department of a superspecialty, tertiary care center from November 2021 to November 2022. Patency was assessed immediately after surgery (on the table), one month later, and six months later by palpating thrill and auscultating bruit. A total of 50 patients between the ages of 18 and 70 years who met the inclusion criteria were randomly assigned to two groups of 25 each. Results The baseline characteristics of both groups were comparable. At six months (p = 0.09), the continuous suturing group was observed to be somewhat better than the interrupted suturing group, with no significant difference in immediate and one-month patency rates. When compared to the continuous suturing group, the primary patency failure rate was significantly higher in the interrupted suturing group. Conclusions Thus, under appropriate circumstances, continuous sutures can be performed with greater ease, resulting in anastomosis that is as patent as that performed with interrupted sutures.
... 7 A recent survey on the Italian population showed no difference in fistula outcome in old age with primary patency of 73 %, 8 The currently available literature concludes that every centre has variable outcomes and optimum hemodialysis access for the elderly population is yet to be defined. 10 Therefore, the present study aimed to determine the outcome of arteriovenous-fistula in our elderly population as per the latest KDOQI guidelines and compares it with younger age groups so that the best approach to hemodialysis access can be defined. ...
... The sample size of 160 was calculated with a 95% confidence interval and 5% margin of error, and a population proportion of 50 % using a WHO calculator. 10 All surgeries were done by a single vascular surgeon, and a similar end-to-side anasto-motic technique was utilized in all cases. After taking the consent, initial data was entered on a proforma, and the follow-up data were collected on the follow-up visits or via telephone calls to inquire about the status of their AV fistula. ...
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H He em mo od di ia al ly ys si is s A Ac cc ce es ss s O Ou ut tc co om me e i in n E El ld de er rl ly y P Po op pu ul la at ti io on n a an nd d i it ts s A As ss so oc ci ia at ti io on n w wi it th h M Mo or rt ta al li it ty y ABSTRACT Objective: to determine the outcome of arteriovenous fistula in the elderly compared to the younger age group and its association with mortality so that the best approach to hemodialysis access can be defined. Study Design: Prospective longitudinal study Place and Duration of Study: Department of Vascular Surgery, CMH, Lahore Pakistan, from Jan 2020 to Aug 2021. Methodology: All the Patients who presented to access the Surgical Clinic were categorized into three groups according to their age. Outcome variables like fistula maturation, complications and mortality were compared according to age groups. Result: A total of 184 patients were recruited. We found that in the age group >70 years, there was male predominance (12, 54.5%), three-quarters of them were on hemodialysis at the time of access surgery, only half of them were functional at one year of follow-up, and 6 (27.3%) were not alive at the time of contact. In addition, the pseudo aneurysm was the most common complication in this group, which was the most dreadful of all access-related complications and further put the already frail at risk. Conclusion: No single optimal approach can be expected to meet the needs of all, and an extensive patient-centred case-based discussion is required for each patient in the hope that optimal dialysis access can be created. Age cannot be defined as an independent risk factor for access creation.
... Authors have shown that there is no proven role of long-term postoperative heparin or aspirin in long-term patency rates, where the anastomosis was satisfactory with good thrill and bruit on table. 30 ...
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Background With rising incidence and increased life expectancy of patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD), the number of patients requiring hemodialysis has increased substantially. Vascular access is the lifeline for a patient on hemodialysis (HD), and an arteriovenous fistula (AVF) is the undisputed gold standard for HD access. An effective and long-lasting fistula serves to increase the life expectancy of ESRD patients and improves their quality of life. Learning Objectives This paper aims to give a comprehensive overview of AVF creation, including the various techniques, patient selection, troubleshooting with decision-making, and common complications. Authors share their experience from previous publications and over 2000 AVF surgeries. They have not only described a new modification of the technique of proximal fistula but have also established a direct correlation between bruit and thrill on operation table and success of fistula surgery. Conclusion A standardized, protocol-driven multidisciplinary approach with careful patient and site selection, guided by outcome predictors, is vital in AVF surgery. Knowledge about the potential complications of AVFs contributes to their timely detection and allows measures to be taken that might prevent deleterious consequences that range from loss of vascular access to serious morbidity and mortality.
... A conservative approach with observation and close follow-up is acceptable in the absence of indications for surgery. Indications for surgery include hemodynamic instability, cardiac decompensation, worsening ischemia, or failure to regress spontaneously within two weeks [20]. The goal of surgical interventions is to close the AVF while maintaining essential blood flow to the tissues. ...
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Unilateral extremity swelling after trauma usually results from acute musculoskeletal or orthopedic injuries. Worsening of swelling raises concern for compartment syndrome or vascular injury. Time-sensitive diagnosis and interventions are needed to avoid life- or limb-threatening consequences. In this report, we highlight the case of a 16-year-old male who presented with unilateral lower extremity pain and swelling, one week after a motor vehicle accident. Thorough evaluation and appropriate imaging detected the presence of an abnormal communication between the muscular branch of the anterior tibial artery and the vein. Arteriovenous fistulas (AVFs) are usually acquired and caused by penetrating trauma or iatrogenic procedures. They are rarely associated with blunt trauma. It is important to determine the degree of flow within the communication, as high flow lesions are associated with severe complications such as limb ischemia and heart failure. This report highlights the evaluation and management of a patient with delayed post-traumatic unilateral extremity swelling that eventually resulted in the diagnosis of a low-flow AVF amenable to conservative management, resulting in complete resolution of his symptoms.
... In a retrospective study by Sahasrabudhe et al, STS technique showed improved maturation rate (76%) when compared to the ETS technique (70%); however, the difference was not statistically significant. 32 In our study the maturation time did not differ significantly between the two groups (5.72 weeks+ 0.22 for SE group, 5.80 weeks+ 0.25 for SS group, P value = 0.1327 ). ...
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Background: Arteriovenous Fistula creation is one of the commonly performed procedure among Plastic surgeons. There is always an argument regarding various techniques of the fistula with lack of conclusive evidences in the past literature to recommend any of the anastomosis type. With this study we aimed to compare the two different common techniques of fistula-end to side (ES) and side to side (SS). Material and Methods: Total 80 patients were included for the retrospective analysis from January 2018 to January 2020 who were divided into two groups as ES (proximal end of the transected vein to the side of the artery anastomosis) and SS (side of the artery to the side of the vein anastomosis) groups. Each group was containing 40 patients. Follow up was done at 3 and 6 months. Results: Statistical analysis of demographic, preoperative, complications and follow-up data did not show any statistically significant difference. However, post operative complications like venous hypertension and steal syndrome were found only in SS group. Conclusion: With our study we can conclude that after comparing for a follow up period of 6 months we found statistically no significant difference between the two techniques. However, possibility of better insight in regard of patency rate, complications and other parameters after a longer duration of follow up could not be ruled out.
Introduction Nonmaturation of arteriovenous fistula (AVF) is a common obstacle due to neointimal hyperplasia (NIH). The present study evaluated the clinical and histopathological factors predicting AVF nonmaturation. Methodology This prospective observational study was conducted over 18 months in 100 patients. AVF site venous tissue samples of 55 4/5 chronic kidney disease stages patients were collected. Histopathological analysis was done to detect four immunohistochemistry (IHC) markers, namely cluster of differentiation (CD68), CD31, α-SMA, and Ki67. IIntimal composition, hyperplasia, and calcification were also assessed. Fistulae were followed up at the 2 nd , 6 th , and 12 th weeks and classified into mature and nonmature groups at 12 weeks based on clinical and Doppler examination. A comparison between the two groups was done and an association of radiological, histopathological, and IHC parameters of nonmature AVF was also carried out. Results Among 55 patients, 35 (63.6%) had mature AVF and 26 (47%) had preexisting NIH. Preexisting NIH had no significant association with maturation (odds ratio: 0.44). Subjects without preexisting NIH had a significantly higher luminal diameter in 2 nd week ( P ≤ 0.05). There was a significant increase in blood flow both between the 2 nd and 6 th and between the 6 th and 12 th week ( P < 0.05). Of the four IHC markers, three markers viz., CD68 (r = 0.525), CD31 (r = 0.420), and α-smooth muscle actin (r = 0.718) correlated significantly ( P < 0.05) with the NIH. The mean AVF diameter and blood flow in the matured arm were more than that in the nonmatured arm at all the follow-ups ( P < 0.09). Conclusion The presence of CD68, CD31, and α-smooth muscle actin in the venous tissue suggests preexisting NIH which postoperative luminal diameter and blood flow may have long-term consequences in AVF functioning.
Introduction: Providing the appropriate device at the appropriate time based on a patient’s intravenous needs is the key to successful vascular access care. The evolution of vascular access device requirements from the prehospital environment to the intensive care unit include peripheral, intraosseous, arterial, and central catheter placement. A documented daily needs assessment of vascular access devices to downgrade, remove, insert, or consolidate will provide best outcomes with regards to vessel preservation, and the associated risks of infection and thrombosis.Case Report: The patient was an 87-year-old male with a history of congestive heart failure, asthma, diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease (CKD) brought to the hospital by the Emergency Medical Service for hypoglycemia. The paramedics placed a 20-gauge peripheral intravenous (PIV) catheter in the left forearm and treated the patient with a 50% dextrose solution. Three days later, the patient was found in his hospital room unresponsive and pulseless in asystole. The patient was intubated, and emergent central vascular access was achieved with a 15-gauge, 25-mm intraosseous needle to the left proximal tibia. The was found to be in acute renal failure and the medical team placed a dialysis catheter to the right jugular vein. Due to the difficulties in establishing central venous access, the vascular access service was consulted for central and arterial access placement. A triple lumen central venous catheter was placed to the right axillary vein in the deltopectoral groove, and an arterial catheter to the right axillary artery in the upper extremity.Conclusion: From the prehospital environment to the Intensive Care Unit, a patient’s vascular access requirements can fluctuate. Clear knowledge of the venous and arterial anatomy in conjunction with the selection of the appropriate access device will ensure best clinical outcomes.KeywordsPeripheral intravenous catheterIntraosseous catheterAcute dialysis catheterCentral venous catheterArterial catheterAxillary artery
Background To maintain the patency and longevity of arteriovenous fistula, the availability of a venous segment with adequate diameter is important. In Indian population, many chronic kidney disease patients have poor caliber veins. The study aimed to evaluate the efficacy of hydrostatic dilatation versus Primary balloon angioplasty of small caliber cephalic veins of (≤2.5 mm) preoperatively in terms of patency rate and maturation time of arteriovenous fistula. Methods Patients ( n = 80) with an end-stage renal disease requiring arteriovenous access surgery for hemodialysis with small caliber cephalic veins were randomized into two groups, i.e., hydrostatic dilatation and primary balloon angioplasty, each with 40 patients. All patients underwent a thorough clinical examination as well as duplex ultrasound vein mapping of both upper extremities. Patients were followed up for six months and primary patency, maturation time, and complications were noted. Results Immediate technical success with good palpable thrill was achieved in 97.5% of patients in the primary balloon angioplasty group and 87.5% in the hydrostatic dilatation group. The fistula maturation time in the primary balloon angioplasty group was 34.41 days and 46.18 days in the hydrostatic dilatation group. In the primary balloon angioplasty group, the primary patency of the fistula was 97.5% and 87.5% in the hydrostatic dilatation group, at six months. The arteriovenous fistula functioning rate was 77.5% in the hydrostatic dilatation group as compared to 92.5% in the primary balloon angioplasty group at six months. The incidence of surgical site infection was 5% in the primary balloon angioplasty group as compared to 10% in the hydrostatic dilatation group. Conclusion Primary balloon angioplasty of small caliber cephalic veins (≤2.5 mm) performed prior to arteriovenous fistula creation for hemodialysis is a beneficial procedure.
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Background: Arterio-Venous Fistula (AVF) is the preferred method of vascular access for long-term maintenance haemodialysis in patients with kidney failure. The aim of this study was to assess our experience and outcome of native AVF that were constructed in our center in the initial 5 years of commencing the operation in the Kidney Center, University of Maiduguri Teaching Hospital, Nigeria.
Background and Aims: Properly functioning angioaccess is essential for the provision of adequate dialysis. We present and discuss a unique vascular access experience in a Saudi Arabian Center, lasting for more than ten years. Methods: We prospectively studied all patients with end stage kidney disease, who underwent any of three vascular access procedures (cuffed central venous catheter, arteriovenous graft, or arteriovenous fistula) from 1993 to 2004 with the objective of assessing the relative rates among these three forms of angioaccess and the survival rates of arteriovenous fistula and its relation with patients' gender, weight or nationality. The survival rate of the AVF as defined by the fistula patency rate was divided into three categories: short-term patency (early AVF failure in: less than 6 weeks), medium-term patency (6 to 52 weeks) and long-term patency (more than 52 weeks). Results: There were 603 patients (386 males and 217 females). The mean age was 48.5 years (SD ± 18.6). 326 patients were Saudis. The cause of ESRD was diabetes mellitus in 2 75 patients, glomerulonephritides in 170 patients and hypertension in 158 patients. The mean BMI was 29 (SD ± 3.7). 580 of the patients had arteriovenous fistula (AVF), 44 had arteriovenous graft (AVG), and 35 patients received only central venous catheter. There was a high early failure rate of AVF 46.4%, particularly in females (61.5%, p =0.0001) and non Saudis (55%, p=0.0008). The long-term patency rate (< 52 weeks) was 38.8% with no differences seen between genders or nationalities. BMI did not have an effect on AVF survival. The incidence of other complications combined was only 5.3%. Conclusion: The vast majority of angioaccess was AVF in keeping with NKF-DOQI guidelines. There was a high early AVF failure rate in women and non-Saudis. Diabetes mellitus seems to be a strong contributing factor but not other renal disease etiologies. Further research is needed in this field in Saudi Arabia.
We studied the efficacy of preoperative noninvasive assessment of the upper extremity to identify arteries and veins suitable for hemodialysis access to increase our use of autogenous fistulas (AF). From Sep. 1, 1994, to Apr. 1, 1997, 172 patients who required chronic hemodialysis underwent segmental upper extremity Doppler pressures and duplex ultrasound with mapping of arteries and veins. The following criteria were necessary for satisfactory arterial inflow: absence of a pressure gradient between arms, patent palmar arch, and arterial lumen diameter 2.0 mm or more. The criteria necessary for satisfactory venous outflow were venous luminal diameter greater than or equal to 2.5 mm for AF and greater than or equal to 4.0 mm for synthetic bridging grafts (BG) and continuity with distal superficial veins in the arm. Intraoperative and duplex ultrasound measurements were compared. Contemporary experience was compared with the 2-year period (1992 to 1994) before implementation of the protocol. During the period from Sep. 1, 1994, to Apr. 1, 1997, 108 patients (63%) had AF, 52 (30%) had prosthetic BG, and 12 (7%) had permanent catheters (PC) placed. Early failure was seen in 8.3% of AFs. Primary cumulative patency rates were 83% for AF and 74% for BG at 1 year (p < 0.05), with a mean clinical follow-up of 15.2 months. No postoperative infections were observed with AF, whereas six infections (12%) were observed with BG and two (17%) with PC insertion. During the period from June 1, 1992, to Aug. 31, 1994, 183 procedures were performed with a distribution of 14% AF, 62% BG, and 24% PC. In this earlier period the AF early failure rate was 36%, and the patency rates were 48%, 63%, and 48% for AF, BG, and PC, respectively (mean follow-up, 13.8 months). A protocol of noninvasive assessment increased use of AFs. The cumulative patency rate of AFs was improved, and early failure rates were reduced when compared with the preceding institutional experience. Routine noninvasive assessment is recommended to document adequacy of arterial inflow and delineate venous outflow to maximize opportunities for AF.
Thirty vascular complications were seen in a group of 444 patients who had 516 arteriovenous fistulas for hemodialysis: 413 standard peripheral arteriovenous fistulas and 103 modifications, which included the use of 35 autogenous vein grafts and 62 bovine heterografts. Four hundred sixty two of the fistulas were done with the radial or ulnar arteries, 53 with the brachial artery, and one with the superficial femoral artery. Symptomatic ischemia due to 'steal' developed in eight patients (1.6%). Four of these patients developed gangrene, with one requiring finger amputation and three of them hand amputation. False aneurysms developed in 14 patients, ten infectious and four traumatic. Venous aneurysm requiring surgery developed in four patients and hand venous hypertension syndrome with chronic venous stasis in the hand was seen in four patients.
We reviewed our experience with subclavian vascular catheters (SVC) as temporary vascular access in the 18 month period 1 January 1984-30 June 1985. 37 consecutive patients using 49 vascular catheters received a total of 461 haemodialyses. Only 8 patients had acute renal failure. The rest were endstage renal failure (ESRF) patients awaiting definitive vascular access. Most of these latter patients were ambulant and were generally dialysed on an outpatient basis. 27 episodes of clinical septicaemia occurred and was the ONLY significant complication encountered. All but one patient responded to empiric therapy with cloxacillin +/- gentamicin and removal of the catheter. We conclude that SVC's are safe and suitable for use on an extended short-term basis especially in ESRF patients with vascular access problems.
When technically feasible, patients with end-stage renal failure should commence regular dialysis treatment with permanent access to the circulation (by arteriovenous fistula) or peritoneum (by soft peritoneal catheter) in situ, thus avoiding the need for initial hemodialysis employing temporary vascular access. We have examined the frequency, consequences and avoidability of temporary access in such patients. 178 patients commencing regular dialysis between August 1993 and April 1995 were analysed retrospectively using case notes. Patients were divided into those who had permanent dialysis access in situ when they commenced dialysis and those who required temporary access. If temporary access was required, the patients were further analysed into those who had been first seen by a nephrologist at least 12 weeks before the first dialysis, and those who had been referred "late". It was assumed that 12 weeks was sufficient time for permanent access to be instituted. Mortality within the first 90 days of commencing dialysis was recorded. Seventy-four of 82 patients opting for regular hemodialysis and 53 of 96 opting for peritoneal dialysis required temporary vascular access. Late referral accounted for 47 and delays within the renal service for 35 of such patients. Late presentation to the medical profession or indecisiveness on the part of the patient accounted for the remainder. Twenty-five of 127 patients requiring temporary access but only one or 51 patients not requiring it died within 90 days of commencement of treatment. Late presentation to a renal unit prior to first dialysis is associated with increased mortality. Late referral or late presentation are associated with an increased need for temporary vascular access for first dialysis. Many patients who require temporary access for first dialysis could have been better managed.
The increasing proportion of diabetic patients in the haemodialysis population, mainly elderly patients with diabetes mellitus type 2, is a challenge to nephrologists and vascular surgeons. The aim of this study was to assess different strategies in an effort to improve the commonly disappointing results of arteriovenous (a-v) fistula surgery in this group of patients. STRATEGIES: Besides the availability of a suitable vein, special attention was paid to the quality of the artery, based on clinical and recently available ultrasonographic parameters. In the case of peripheral arterial narrowing and/or calcification, the elbow region was the preferred location for creation of the first a-v fistula, taking into consideration the reduced life expectancy of the majority of diabetic patients. Furthermore, a clinical surveillance programme was established to treat the failing, not the failed fistula. To this end, elective revisions were performed prior to the onset of thrombosis to correct stenoses, aneurysms, and other signs of fistula dysfunction. Absolute priority was given to the use of native vessels. During the period January 1993 to December 1995, 347 primary Brescia-Cimino fistulae were performed out a total of 799 access procedures. No graft material was used in these first operations. The patients were followed up until 31 July 1998. Of these 347 patients, 269 were non-diabetic and 78 were diabetic. Two hundred and two of all 347 first a-v fistulae were created in the forearm/wrist region, 182 in non-diabetic patients and 20 in diabetic patients, whereas the elbow region was used in 145 patients, 87 in non-diabetic and 58 in diabetic patients. Based on the carefully planned choice of location of the first operation and the strategy of elective revisions, virtually identical results for non-diabetic and diabetic patients could be obtained with regard to revision and patency rates. Some differences were observed with regard to the types of revision. A strategy is presented that helps to reduce the vascular access problems in diabetic and elderly patients.
Synthetic grafts have generally been found to exhibit lower survival rates and higher complication rates than native arteriovenous fistulae. We investigated whether survival of grafts relative to fistulae was better in facilities with a preference for grafts, hypothesizing that such facilities may place more grafts because grafts produced superior outcomes. The study was based on a national U.S. sample of 133 hemodialysis facilities participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS), a prospective, observational study of dialysis treatment practices and outcomes. Vascular access preferences were ascertained from medical directors, nurse managers, and actual practice within each facility (% graft use among prevalent patients). Logistic regression was used to model the odds ratio (OR) of graft placement (vs. fistula) and Cox regression was used to model time from access creation to initial failure. Grafts were preferred by 21% of medical directors and 40% of nurse managers. Patients in facilities in which the medical director or nurse manager expressed a preference for grafts were more than twice as likely to have a graft than a fistula (AOR = 2.3, P < 0.01; reference group = facilities that did not prefer grafts), suggesting that facility preferences influence the type of access created. Overall, grafts were more prevalent than fistulae in dialysis facilities, but displayed a higher relative risk of failure (RR 1.33, P < 0.0001). However, the risk of graft versus fistula failure did not vary by expressed preference of the medical director: the relative risk of graft versus fistula failure was 1.39 in facilities in which the medical director preferred grafts and 1.39 in facilities in which the medical director preferred fistulae. Moreover, the relative risk of graft versus fistula failure was 1.57 in facilities that used more than the median percentage of grafts and 1.19 in facilities that used less than the median percentage of grafts. No evidence was found that graft outcomes are superior in facilities that prefer grafts to fistulae. The observed variation in vascular access practice patterns suggests opportunities for quality improvement if optimal practices can be defined.