Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 311 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 

RENAL DATA FROM THE ASIA - AFRICA Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 6  |  Page : 1110-1114
The effect of ligation of the distal vein in snuff-box arteriovenous fistula


1 Department of Vascular Surgery, Alzahra Hospital, Isfahan Faculty of Medicine, Isfahan, Iran
2 Department of General Surgery, Alzahra Hospital, Isfahan Faculty of Medicine, Isfahan, Iran

Click here for correspondence address and email

Date of Web Publication27-Oct-2009
 

   Abstract 

Arterio-venous fistula (AVF) in the snuff-box region is one of the current techniques used for creating a vascular access in patients undergoing dialysis. The aim of this study is to find out whether ligating the distal vein in AVF in the snuff-box will bring about any change in the efficiency and complications of the fistula. Sixty patients (30 males, 30 females) suffering from chronic renal failure, who had been admitted for creating an AVF, were randomly divided into two groups after having filled out consent forms. After the AVF was made, the distal vein was ligated in the first group, but not in the second group. The patients were discharged after being given the necessary advice on how to take care of their fistula. They were examined on post-surgical days 1, 30 and 90. Early efficiency in the ligated and non-ligated groups was 100% and 96.7% respectively while late efficiency in the two groups was 90% and 83.4%, respectively (P> 0.05). The most common complication in both groups was thrombosis (11.7%). Venous hypertension and edema were observed in two patients (both from the non-ligated group) and infection of the surgical site was observed in only one patient. Our study suggests that, considering the high efficiency level and low complication rate, AVF at the snuff-box region constitutes one of the best possible vascular accesses for patients undergoing hemodialysis. Ligation of the distal vein prevents the development of venous hypertension in the fistula.

How to cite this article:
Beigi AA, Masoudpour H, Alavi M. The effect of ligation of the distal vein in snuff-box arteriovenous fistula. Saudi J Kidney Dis Transpl 2009;20:1110-4

How to cite this URL:
Beigi AA, Masoudpour H, Alavi M. The effect of ligation of the distal vein in snuff-box arteriovenous fistula. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Jun 6];20:1110-4. Available from: http://www.sjkdt.org/text.asp?2009/20/6/1110/57279

   Introduction Top


Most patients suffering from chronic renal failure undergo hemodialysis (HD) and in order for them to have an efficient HD with a low compli­cation rate, they require a good arterio-venous fistula (AVF). Various techniques have been suggested for creating an AVF.

The first fistula to be suggested was the Brescia­Cimino fistula between the radial artery and the cephalic vein proximal to the wrist, which was introduced in 1966, [1] and is still being used due to its high efficiency and a low complication rate. Other areas of fistulization in the upper-extremities include radio-cephalic fistula in the snuff-box region, brachio-cephalic fistula in the crook of the arm, and the fistula between the ulnar artery and basilic vein in the wrist region. [2],[3]

The more distal an AVF is created, in case of a malfunction, higher are the possibilities of crea­ting an AVF in a proximal region in the same extremity. Radio-cephalic fistulization in the snuff-box region was first introduced in 1969 by Rassat and his colleagues. [4] This technique provides the possibility of fistulization in the most distal region of the upper extremity.

As suggested by some earlier studies, ligating the distal vein of an AVF reduces the risk of venous hypertension. On the other hand, in a side-to-side anastomosis, one can get good flow even without ligating the distal vein. [5] The aim of this study is to find out whether ligating the distal vein of an AVF in the snuff-box, in com­parison to not ligating it, will bring about any change in the efficiency and complications of the fistula.


   Patients and Methods Top


From April 2005 to January 2006, 60 patients (30 males, 30 females) suffering from chronic renal failure, who had been admitted to the Al­Zahra Hospital in Isfahan, Iran for fistulization, were inducted into the study. After filling out consent forms, the patients were randomly divi­ded into two groups. After the AVF was crea­ted, the distal vein was ligated in the first group, but not in the second group. The patients were advised not to take any anti-hypertensive medi­cations on the morning of their admission. They were also advised to avoid any blood-sampling and blood pressure measurement in the extre­mity to be fistulized, two weeks prior to their admission.

The patients were prepared for surgery, pro­vided their systolic blood pressure was not less than 100 mmHg. Both the upper extremities were then examined and the extremity which had an appropriate vein and preferably, the non domi­nant extremity, were chosen for the placement of the fistula. The conditions of the artery and vein were examined by the surgeon and based on the degree of arterial atherosclerosis, blood flow and the presence of thrombosis, they were divided into three types; excellent, good and average, as follows:

Excellent artery: a minimum of 2 mm in inter­nal diameter, soft and elastic vein wall with no atheroma and good flow.

Good artery: a minimum of 2 mm in internal diameter, relatively stiff vein wall but with no atheroma and average to good flow.

Average artery: a minimum of 2 mm in inter­nal diameter, hard and fragile vein wall with atheroma and average flow.

Excellent vein: a minimum of 2 mm in inter­nal diameter, normal wall, lacking any clots and thrombosis, completely open proximal, good flow, and dilates and fills well with pressure on the proximal part of the vein.

Good vein: a minimum of 2 mm in internal diameter, appropriate wall, lacking proximal obs­truction, but having proximal stenosis, which could be removed by a dilator. The vein will appropriately fill up with blood after release of proximal pressure.

Average vein: a minimum of 2 mm in internal diameter, stiff wall, relative stenosis or obstruc­tion of the proximal, in which case a dilator of maximum size-2 will pass through. Low flow rate and by controlling the proximal part of the vein, does not fill up appropriately with blood and will not dilate desirably.

Surgical Technique

The surgery was performed with local anes­thesia using 10 mL of 2% lidocaine. A five cm long incision was made in the snuff-box region of the hand. At first, the vein and artery, which were identified prior to surgery, were located and dissected. The minimum length required for dissecting a vein and artery was 5 cm. A 7-10 mm incision was made on the vein and artery. The incision was anastomosed according to ru­nning side-to-side method with Prolan 7-0 sur­gical suture made by Ethicon Company. In pa­tients in whom there was suspicion of obs­truction or stenosis in the proximal veins, the stenosis was correceted with a vascular dilator number 2 or 3 after venotomy.

The presence of a thrill on the fistula was looked for after anastomosis. The surgery was considered successful either, when a good thrill was felt at the AVF site or, at least when there was a clear machinery souffle. Otherwise, the AVF site was re-examined. Stenosis or vascular flexure was removed, and physiotherapy of the extremity was performed by application of a tourniquet or by pressing the hand on the arm and gently tapping the AVF, or folding and un­folding the arm by the patient himself. In case of absence of thrill, a vascular dilator number 2­3 was passed through one of the branches of the distal vein. If thrill was not felt despite this, the surgery was considered unsuccessful. The distal veins of the AVF were randomly ligated with a 4-zero silk surgical suture during the surgery. Heparin and prophylactic antibiotics were not used for the surgery. The patients were advised on how to take care of their fistula and were then discharged from the hospital. They were re-examined on days 1, 30 and 90 post-surgery to assess the function of the fistula and the complications.

The SPSS version 9 statistical software was used to analyze the data. Quantitative and quali­tative data were compared in both groups using t-student and chi-square statistical tests, respec­tively.


   Results Top


Assessment of the basic variables including the distribution of sex, age, history of diabetes, hypertension, previous fistula in the opposite ex­tremity, history of dialysis for more than a year and blood pressure showed that both study groups did not have a meaningful difference in these variables and were approximately equal [Table 1].

Examination of the condition of the fistulas showed that both early and late efficiency were satisfactory in both groups, and no meaningful statistical difference was observed [Table 2].

The most common complication observed in the two groups was thrombosis, which was ob­served in 11.7% of the individuals. Venous hyper­tension and edema were observed in two pa­tients (both from the non-ligated group) and in­fection of the surgical site was observed in only one patient [Table 3].

In all, post-surgical complications in the two groups did not have a meaningful difference. Pseudo-aneurysm was not observed in any of the patients in the follow-up period.

After three months of follow-up, eight patients' fistulas became non-functional (13.3%). Of these eight patients, five (62.5%) were males and three (37.5%) were females. (P = 0.57). Six patients (75%) had a previous history of hypertension (P = 0.8). The mean age of the patients with an efficient fistula was 51 years; in the eight pa­tients with non-functioning AVF, the mean age was 49 years (P = 0.78). Examination of the con­dition of veins before the surgery showed that 32 patients (53.4%) had excellent veins, 20 (33.3%) had good veins and eight patients (13.3%) had average veins. Evaluation of the arteries prior to surgery showed that 30 patients (58.4%) had excellent arteries, 19 (31.6%) had good and six others (10%) had average arteries. Follow-up data showed that 6.3, 25 and 12.5% of the pa­tients who had excellent, good and average veins respectively, had AVF inefficiency in the long run, while 8.6, 21.1 and 16.6% of patients with excellent, good and average ratings of their arteries respectively, had AVF non-function on long-term follow-up.


   Discussion Top


Fistulas in the snuff-box region offer many ad­vantages. Firstly, the anastomosis is performed in the most distal part of the radial artery and in this region, the vein is comfortably placed next to the artery and the probability of strain on anastomosis is reduced. Secondly, with the use of this technique, in case of fistula inefficiency, more proximal vessels remain intact for the purpose of performing anastomosis. Thirdly, due to the relatively small arterial caliber, the pro­bability of occurrence of steal phenomenon and heart failure reduces. [5] However, proper selec­tion of the patients is a primary pre-requisite in achieving an efficient, low-complication, long lasting fistula.

The results of our study also show that consi­dering high efficiency and low complications, AVFs of the snuff-box region are among the best possible vascular methods for patients on HD provided adequate care is taken while selecting the patients. Ligation of the distal vein prevents the occurrence of venous hypertension in the fis­tula although, the frequency of occurrence of early thrombosis increases. However, in the long run, the rate of occurrence of thrombosis in both the methods had no meaningful difference.

The short-term efficiency of the fistulas was excellent (approximately 100%) in both the groups and after three months it was 90% in the ligated group and 83.4% in the non-ligated group, a difference that was not statistically different. In all, the efficiency of the fistulas in both the groups had no meaningful statistical difference. Neither the demographics nor the history of dialysis variables had any meaningful influence in the efficiency of the fistulas.

A point worth mentioning is that 75% of the inefficiency of the fistulas occurred early (within the first month). This shows that peri-surgical factors such as condition of the artery and vein of the patient, blood pressure, surgical technique, the surgeon himself and the care necessary for preparing the veins of the extremities, have greater influence compared to long-term factors such as underlying disease, catheterization tech­nique and the HD procedure. In one of the pre­vious studies, the surgeon and the care taken during surgery were highlighted as the most important factors in the efficiency rate of the fistulas. [6] In our study, we paid enough attention to these factors.

In earlier studies, the rate of thrombosis was reported to be 10 to 15%. [7],[8],[9],[10],[11],[12] Also, in this study, the most common complication seen in both the study groups was thrombosis. (11.6%) The rate of venous hypertension was only 3.3% and all the cases were in the control group. The other point is that despite the lack of administration of prophylactic antibiotics, only one case of in­fection at the surgical site was observed. Recent reports suggest that the occurrence of infection is not more than 2%, although previous studies reported a higher prevalence necessitating the routine use of prophylactic antibiotics. [9],[10] This indicates that if sterilization principles are properly followed, there is no reason to be con­cerned about the infection at the surgical site.

In conclusion, our study suggests that, consi­dering high efficiency and low complications, AVFs of the snuff-box region are among the best possible vascular methods for patients on HD. Ligation of the distal vein is recommended because it prevents the occurrence of venous hypertension in the fistula.

 
   References Top

1.Brescia MJ, Cimino JE, Appel K, et al. Chronic hemodialysis using venepuncture and a surgically created arteriovenous fistula. N Engl J Med 1966;275:1089-92.  Back to cited text no. 1      
2.Chen Z, Wu W, Wu QH. Operative outcome and experience in arteriovenous shunt at different sites. Zhonghula Yi Xue Za Zhi 2003;83:2111-3.  Back to cited text no. 2      
3.Bell PR, Wood RM. Surgical aspects of haemo­dialysis. 2 nd Ed, Ch. 5, pp. 35-56, Churchill Livingstone, 1983.  Back to cited text no. 3      
4.Rassat JP, Moscovtchenko JF, Perrin J, Traeger J. Artero-venous fistula in the anatomical snuff­box. Journal d'Urologie et de Nephrologie 1969; 75(Suppls 12):482.  Back to cited text no. 4      
5.National Kidney Foundation. K-DOQI clinical practice guidelines for vascular access: update 2000. Am J Kidney Dis 2001;37:S137-81  Back to cited text no. 5      
6.Wolowczyk L, Williams AJ, Donovan KL, Gibbons CP. The snuffbox arteriovenous fistulafor vascular access. Eur J Endovasc Surg 2000;19:70-6.  Back to cited text no. 6      
7.Paruk S, Koenig M, Levitt S, Hardy MA. Arteriovenous fistulas for hemodialysis in 100 consecutive patients. Am J Surg 1976;131(5): 552-5.  Back to cited text no. 7      
8.Basile C, Ruggieri G, Vernaglione L, Montanaro A, Giordano R. The natural history of autogenous radio-cephalic wrist arteriovenous fistulas of haemodialysis patients: a prospective observa­tional study. Nephrol Dial Transplant 2004;19: 1231-6.  Back to cited text no. 8      
9.Tordoir JH, Rooyens P, Dammers R, van der Sande FM, de Haan M, Yo TI. Prospective evaluation of failure modes in autogenous radio­cephalic wrist access for haemodialysis. Nephrol Dial Transplant 2003;18:378-83.  Back to cited text no. 9      
10.Wong V, Ward R, Taylor J, Selvakumar S, How TV, Bakran A. Factors associated with early failure of arteriovenous fistulae for haemo­dialysis access. Eur J Vasc Endovasc Surg 1996;12(2):207-13.  Back to cited text no. 10      
11.Giacchino JL, Geis WP, Buckingham JM, Vertuno LL, Bansal VK. Vascular access: long­term results, new techniques. Arch Surg 1979; 114(4):403-9.  Back to cited text no. 11      
12.Garcia de Cortazar L, Gutierrez E, Delucchi MA, Cumsille MA. Vascular accesses for chro­nic hemodialysis in children. Rev Med Child 1999;127(6):693-7.  Back to cited text no. 12      

Top
Correspondence Address:
Hassan Masoudpour
Department of General Surgery, Alzahra Hospital, Isfahan Faculty of Medicine, Isfahan
Iran
Login to access the Email id


PMID: 19861886

Rights and Permissions



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    References
    Article Tables
 

 Article Access Statistics
    Viewed3204    
    Printed75    
    Emailed0    
    PDF Downloaded532    
    Comments [Add]    

Recommend this journal