Retrospective analysis of 271 arteriovenous fistulas as vascular access for hemodialysis

Abstract

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
INDIAN JOURNAL OF
NEPHROLOGY
Vol 23, No. 3, May - June 2013
Indian Journal of Nephrology • Volume 23 • Issue 3 • May-June 2013 • Pages 159-***
Highlights of the Issue
■Noninvasive assessment of bone health in
CKD
■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.
Introduction
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
ABSTRACT
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.
E‑mail: drparags@gmail.com
Access this article online
Quick Response Code:
Website:
www.indianjnephrol.org
DOI:
10.4103/0971-4065.111845

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
thrombophlebitis.
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
193
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.
Results
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.
Discussion
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
195
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.
Acknowledgment
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).
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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.