|Year : 2019 | Volume
| Issue : 3 | Page : 127-130
Prospective analysis of arteriovenous fistula in hemodialysis patients
Anuradha J Patil, Aakanksha Vichare, Avinash Yelikar, Jiten Kulkarni
Department of Plastic Surgery, MGM Medical College, Aurangabad, Maharashtra, India
|Date of Submission||20-Jan-2020|
|Date of Acceptance||21-Jan-2020|
|Date of Web Publication||16-Mar-2020|
Dr. Anuradha J Patil
Dr. Anuradha J Patil, Department of Plastic Surgery, MGM Medical College, N-6, CIDCO, Aurangabad 431003, Maharashtra.
Source of Support: None, Conflict of Interest: None
Introduction: Patients of end-stage renal disease (ESRD) are dependent on lifelong dialysis for which an arteriovenous fistula (AVF) is the preferred vascular access. Aim: The aim of this study was to evaluate the site, results, and postoperative complications of AVF creation. Materials and Methods: A prospective study involving 100 patients of ESRD was conducted from July 1, 2015 to August 30, 2017. Cimino–Brescia radiocephalic fistulae were created just proximal to the wrist joint of the nondominant hand. In patients with prior failed attempts of wrist fistulae creation, a brachiocephalic fistula was constructed. Results: Of 100 patients, 77 male and 23 female (M:F = 3.52:1) were studied. Twenty-three patients were diabetic and 40 were hypertensive. Ninety-three patients underwent surgery for radiocephalic fistula, and brachiocephalic fistulae were constructed in seven patients. The dominant side was used in 5% of patients and the nondominant side in 95%. Technical success was 87% after 6 weeks, and at 6 months, a higher (cubital) fistula was performed for the 13% unsuccessful cases. Conclusion: An AVF in patients with an ESRD requiring long-term vascular access for hemodialysis remains the procedure of choice if performed by experienced hands.
Keywords: Arteriovenous fistula, hemodialysis, steal syndrome, thrombosis, vascular access
|How to cite this article:|
Patil AJ, Vichare A, Yelikar A, Kulkarni J. Prospective analysis of arteriovenous fistula in hemodialysis patients. MGM J Med Sci 2019;6:127-30
|How to cite this URL:|
Patil AJ, Vichare A, Yelikar A, Kulkarni J. Prospective analysis of arteriovenous fistula in hemodialysis patients. MGM J Med Sci [serial online] 2019 [cited 2020 Mar 28];6:127-30. Available from: http://www.mgmjms.com/text.asp?2019/6/3/127/280745
| Introduction|| |
The incidence of renal failure and the need for renal replacement therapy, in the form of dialysis and renal transplant, is gradually increasing in India. Before starting hemodialysis, patients must have a vascular access inserted or created in the form of an arteriovenous fistula (AVF) (fistula), arteriovenous graft (AV graft), or central venous catheter (catheter). Central venous catheters and AV grafts may be complicated by infection and thrombosis, and therefore are not first choices for long-term vascular access.
AVF can be made over the cubital fossa, forearm (proximal, mid, and distal), or in the “anatomical snuffbox.” AVFs provide the best outcome, making it the preferred vascular access due to its higher patency or survival rate and lower complication rates. Use of a fistula is also associated with lower mortality compared to the AV graft and catheter.,,, The changing patient demographics and the increasing proportion of the frail, elderly patients in recent decades, may further decrease fistula performance. Estimates of primary fistula failure, as well as primary and secondary patency, vary considerably in the literature. The effect of fistula location (lower vs. upper arm), age (the elderly vs. non-elderly), and comparative preoperative vein and artery diameters on primary failure, primary, and secondary patency rates has been examined.
The aim of this study was to identify predictors of patency in AVF formation.
| Materials and methods|| |
A prospective study was conducted at the MGM Medical College Hospital, Aurangabad, Maharashtra, India, between July 1, 2015 and August 30, 2017. A total of 100 patients with end-stage renal disease (ESRD), requiring a long-term vascular access for hemodialysis, were included in the study. Data on age, sex, surgical site, complications, and patency of the fistula at 6 weeks and after 6 months were obtained. Physical examination of the arterial and venous system of the upper limb was carried out preoperatively using color Doppler of upper limb veins and arteries.
Operative technique: After the infiltration of local anesthesia, a 3-cm incision was made between the cephalic vein and the radial artery of the nondominant hand. The vein and artery were mobilized adequately. The proximal segment of the vein was dilated by injecting 10mL of heparinized saline using an intravenous catheter. A 5-mm longitudinal incision was made along its posterior wall, and its ends were splayed open. Arteriotomy of 8mm was performed on the anterior wall of the artery.
Prolene 7-0 suture was used for the vascular anastomosis. All anastomosis were end to side. Skin closure was carried out with 3-0 Ethilon suture in a single layer. A non-compressive dressing was applied. Bruit was heard and thrill was felt on operation table at the end of dressing. In all cases, anticoagulation with low-molecular-weight heparin subcutaneously for 3–5 days and tablet aspirin 150mg once a day were used for 7 days after discharge. Sutures were removed on the 10th day. In patients with previously constructed (outside) nonfunctioning radiocephalic fistulae, brachial fistulae were created. Handball exercises were taught to patients before discharge. To reduce postoperative edema, elevation of the limb was advised. Fistula maturation at 6 weeks was noted. A blood flow rate of at least 250mL/min as a flow rate was obtained on the hemodialysis machine, which was sustained for a minimum of 3h as an acceptable flow.
| Results|| |
A total of 100 patients (77 males and 23 females) were studied. Statistical data of the association of gender (male:female) with patency of AV fistula were analyzed using the chi-square test of independence. The difference between males and females with respect to patency of AV fistula was not the significant p-value was 0.605757 (P-value >0.05) [Table 1]. The average age of the patients was 40 years (range, 17–77 years). When analyzed, the association of age (<40 years:>40 years) with patency of AV fistula was carried out using the chi-square test of statistical analysis. The association between those aged <40 and >40 years with respect to patency of AV fistula was not significant (P = 0.403446; P > 0.05) [Table 2]. Diabetes was present in 23 patients and hypertension in 40. Radiocephalic fistulae were created in the left forearm in 83 patients, mid-forearm in 10 patients (which arm), and brachiocephalic fistulae (which arm) for 7 patients. The dominant side was used for 5% of patients and the nondominant side for 95%of the patients.,
In 93 radiocephalic fistulae, the average diameter of artery was 2.2mm and that of vein was 1.4mm. For brachial level fistulas in 7 patient’s, the average diameter of artery was 3.8 mm and that of the vein was 3.2 mm. All the brachial level fistulae were for previously outside operated patients with nonfunctioning radiocephalic fistulae. Correlation between the diameters of the radial artery preoperatively with the patency of AV fistula was assessed using the Student t test of statistical analysis. P < 0.05 was considered significant. A significant difference was observed in the preoperative Doppler-detected diameter of the radial artery in patients with patent AV fistula (mean = 2.27mm, standard deviation = 0.57mm) versus those with nonworking AV fistula (mean = 1.68mm, standard deviation = 0.39mm), P = 0.018. Correlation between the diameter of cephalic vein preoperatively with the patency of AV fistula was assessed using the Student t test of statistical analysis, P < 0.05 was considered significant in Doppler-detected diameter of cephalic vein in patients with patent AV fistula (mean = 2.47mm, standard deviation = 0.38mm) versus those with nonworking AV fistula (Mean=1.26mm, Standard Deviation= 0.15mm), P = 0.009.
Repeat procedures were performed successfully at a higher level for 13 patients of failed primary fistulae. The average diameter of radial artery in these patients was 1.9mm and that of cephalic vein was 1.3mm. Of 13 patients, 8 patients underwent brachiocephalic fistula and 7 patients underwent radiocephalic fistula. At 6 months, 11 of these 13 patients had a working fistula. Of seven radiocephalic fistulae, fistula of two patients was not working at the end of 6 months. In one patient, the fistula had to be closed because of bleeding, another patient’s fistula was not patent because of infection and thrombosis. The AVF was successful at 6 weeks in 87% of patients; 13 patients of radiocephalic fistula had nonfunctional AVF related to thrombosis.
The total functional fistulae at the end of 6 months, including the redo performed for primary failure cases, were 97. In complications, two patients developed operative site infection and thrombosis, and one had major bleeding, requiring intervention during the follow-up period. None had distal edema, steal phenomenon, aneurysm, or death in 6 months. Follow-up after 6 months was not feasible due to poor patient compliance and transfer to other centers for treatment. Hence, secondary patency rates in the long term could not be calculated.
| Discussion|| |
The fistula has to mature before being used for dialysis and has to remain patent for long-term percutaneous interventions. Age and gender are well-known confounders in almost all published research across the globe. In this study, the mean age of the patients with chronic renal failure (CRF) was 40 years. As per Dash and Agarwal, the mean age among the patients with CRF was 42.38 (±12.54) years, which is nearly consistent. However, gender was not a significant contributor to the success rate of AVF.
The American Institute of Ultrasound in Medicine (AIUM) Practice Guidelines 2011, states that arterial diameter <2mm and venous diameter <2.5mm were associated with a high failure rate. The arterial diameter was found to be significantly higher in those with patent AVFs than those with non-patent AVFs. Arterial and venous diameters <2mm were associated with significantly high failure rates (P = 0.018 and P = 0.0009, respectively). The greater the diameter of the artery, the lesser the technical difficulties during the procedure. With a 1-mm increase in arterial diameter, the risk of AVF abandonment decreased by 30% over a median follow-up of 379 days. This effect of an artery size may be because: (1) blood flow is proportional to the fourth power of the arterial radius, and thus, small increments in size may substantially increase flow, and (2) larger arteries may show a greater vasorelaxant response, thereby accommodating greater blood flow during AVF maturation.
The flow in the cephalic vein increases from 20–30mL/min to 200–300mL/min after fistula creation and can go up to 600–1200mL/min on maturation. This is called arterialization of the vein. Venous thrombosis is said to be due to the shear stress caused by the arterial flow within. This shear stress causes intimal hyperplasia, which causes luminal narrowing, which can cause thrombosis, leading to complete occlusion.
Thrombosis was the common complication causing early failure. Primary failure includes fistulae that do not mature within 3 months. Other causes of primary failure include inadequate arterial supply, anastomotic stenosis, or outflow obstruction of the venous segment. According to literature, body mass index (BMI) and comorbid conditions such as hypertension, peripheral vascular disease, or diabetes mellitus can cause early failure. The most common cause of vascular access thrombosis is venous neointimal proliferation. Neointimal hyperplasia is the proliferation of smooth muscle cells under the influence of basic fibroblast and platelet-derived growth factors. The smooth muscle cell layer penetrates through the internal elastic lamina and then migrates into the intima. During migration, they are modified into a secretory type from a contractile type, which produces a basic substance that causes intimal fibrosis. Fibrinogen has been found in an increased concentration in patients on chronic hemodialysis, which causes platelet aggregation, which in turn decreases luminal flow., Moreover, damage to the blood vessel walls during the procedure exposes the subendothelial structures to blood flow and initiates a hemostatic reaction, resulting in the formation of a thrombus.
The dialysis outcomes–practice patterns study (DOPPS) showed that the use of aspirin, and the dialysis access consortium fistula trial (DAC) noted that the use of clopidogrel improved success rates by decreasing thrombus formation. Failure of fistula after 3 months or late failure is usually due to venous stenosis and characterized by problematic cannulation, hemorrhage, and localized edema. Late failure of the fistula is defined as a failure occurring greater than 3 months after creation and is often due to outflow stenosis. Outflow stenosis had not been noticed. The most common site for outflow stenosis in a radiocephalic fistula is 3cm from the arteriovenous anastomosis, which may be treated successfully by angioplasty.
This study had no aneurysm. The incidence of aneurysm varies in studies (5%–7%). Steal syndrome leading to hand ischemia was not noticed. It may arise from excessive reverse blood flow through a dilated blood vessel due to a bigger opening diameter of fistula than of the artery together without any compensatory collateral formation. This condition is more common with brachiocephalic fistulae. Another cause of failure at the brachial level is cephalic arch stenosis. Distal revascularization with interval ligation procedure, or as in some cases, complete ligation is the treatment of choice in patients developing hand ischemia due to stealing phenomena. Infection accounted for 2% of cases, whereas in a study by Schild et al., fistula infection rate was 0.9%. Local infection can present as cellulitis, which can be conservatively managed. However, hematomas or abscesses may require surgical intervention.
| Conclusion|| |
Patients who have a lifelong dependence on hemodialysis require reliable and long-term intravenous access. Radiocephalic AVF along with postoperative anticoagulant therapy provide excellent results for the same. Mechanical dilatation of blood vessels immediately before anastomosis improves success rates. Early detection of fistula dysfunction to prevent and adequately treat potential complications is important. Arterial and venous diameters are also predictive factors of fistula patency.
This study was approved by the institutional ethics committee and was therefore performed in accordance with the ethical standards set forth in 1964 Declaration of Helsinki and its later amendments.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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