| Abstract|| |
The number of patients with end-stage renal disease maintained on chronic hemodialysis is increasing progressively. Arteriovenous fistula (AVF) is a common vascular access for hemodialysis, however, its effect on limb distal circulation has not been studied well. Palpation of pulse at the wrist is a crude method of clinical assessment. Over one year period, 26 AVFs were created; 16 at the wrist (61.5%) and ten fistulas at the elbow (38.5%). Six of the latter were through the brachio-basilic approach while the other four were performed by basilic vein transposition. Doppler measurement of both wrist-brachial index (WBI) and finger pressure was carried out for all patients pre-operatively and on the first post-operative day. Of the patients with AVF created at the elbow, there was a decrease of WBI in seven patients (70%) and a decrease of finger pressure in three (30%); one patient (14%) had steal syndrome. Creation of AVF at the wrist resulted in a decrease of WBI in one patient (6.25%) and a decrease of finger pressure in another patient (6.25%). WBI changes as a result of creation of AVF at the elbow were significantly greater than the changes of those fistulas performed at the wrist (P < 0.001). On the other hand, the difference between the effect of both procedures on finger pressure was statistically not significant. These results may help to explain the higher incidence of steal syndrome in patients with elbow fistulas compared to patients with wrist fistulas. Further studies on a larger scale are required to determine the value of non-invasive indices at which AVF creation would have future risk of compromised distal limb circulation.
Keywords: Fistula, Hemodialysis, Non-invasive tests, Limb circulation, Complications.
|How to cite this article:|
Al-Salman MM, Fares AM, Rabee HM, Ali MM. Effect of Arteriovenous Fistula for Hemodialysis on Limb Circulation. Saudi J Kidney Dis Transpl 2000;11:548-52
|How to cite this URL:|
Al-Salman MM, Fares AM, Rabee HM, Ali MM. Effect of Arteriovenous Fistula for Hemodialysis on Limb Circulation. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2022 Jan 21];11:548-52. Available from: https://www.sjkdt.org/text.asp?2000/11/4/548/36641
| Introduction|| |
The introduction of extra corporeal hemodialysis by Kolf et al in 1943 provided a means for patients with end-stage renal disease to survive for prolonged periods.  The full potential for this remarkable means of patient salvage was not realized, however, until the introduction of the external arteriovenous shunt by Quinton, Scribner et al in 1960,  and of the endogenous fistula by Brescia, Cimino et al in 1966,  which permitted repeated and routine access to the circulation.  Most of the patients with endstage renal disease are candidates for hemodialysis and a significant number of them do not receive renal transplantation because of the severity of their systemic disease, their age, absence of a cadaveric or live donor or other problems that form contraindications to transplantation. Therefore, the vascular surgeon is being asked for creation of more arteriovenous fistulas (AVFs), which can last for prolonged periods.  Undoubtedly, the radiocephalic AVF is the best long-term dialysis access. It is autogenous and relatively easy to construct, and over time, it has proved to be durable, efficient and reliable. , However, there are complications that may compromise the distal circulation of the upper limb of the patients with large fistulas including vascular steal syndrome, particularly in patients with severe peripheral arterial disease.  Palpation of pulse at the wrist is a crude method of clinical assessment for the possibility of occurrence of this syndrome. Doppler Measurement of both the wristbrachial index (WBI) and finger pressure before creation of AVF in the limb is a noninvasive, easy and objective way of assessment of limb vascularity. This may help to discover patients with severe peripheral arterial disease.  We evaluated in this study these measurements in the proximally and distally created fistulas in our population.
| Material and Methods|| |
Between November 1997 and November 1998, 26 AVFs were created in 26 patients with end-stage renal disease maintained on chronic hemodialysis at the King Khalid University Hospital in Riyadh, Saudi Arabia. Sixteen of these AVFs were performed at the wrist (61.5%) and 10 AVFs at the elbow (38.5%), six of which were brachio-basilic fistulas and four required basilic vein transposition. Patients' age ranged from 19 years to 70 years with a mean of 42 years and 18 (69%) patients were males. All vascular access procedures were performed in the non-dominant upper limb.
All patients were subjected to Doppler measurement of both brachial and radial pressures with calculation of the WBI in both sides. Finger pressure was measured pre-operatively in the thumb on both sides. All these non-invasive tests were repeated on the first post-operative day to assess the effect of AVF creation on limb circulation in the form of changes occurring in both WBI and finger pressure in both groups (wrist AVF and elbow AVF).
The radio-cephalic AVFs were created after documentation of a negative Allen test result and demonstration of a cephalic vein of at least two mm diameter with tourniquet compression at the antecubital fossa. A longitudinal incision under regional anesthesia was made more towards the radial artery, lying between it and the cephalic vein. Anastomosis was performed side to side using six-zero polypropylene suture in a continuous fashion. After arterialization of the cephalic vein, the distal part of the vein was ligated using three-zero silk suture. Fistulas were allowed to mature for 6-8 weeks before cannulation.
The brachio-basilic AVFs were created after documentation of a negative Allen test result and demonstration of a cephalic vein of at least two mm in diameter with tourniquet compression at the axillary fold.
We created the brachio-basilic AVFs as previously described in the literature.  The size of the fistula did not exceed four mm in diameter. Patients who did not have adequate upper arm cephalic veins underwent preoperative or intra-operative venogram to evaluate the patency of basilic and brachial veins. The surgical technique used was as described by LoGerfo et al.  The size of the brachial arteriotomy did not exceed four mm. The fistula was allowed to mature for 3-6 weeks before cannulation.
In all the above procedures, the size of the fistula was not more than one and a half times of the size of the vein at the site of the anastomosis.
| Statistical analysis|| |
Comparison of estimates was performed with Will-Cox on rank test. Fisher's exact test was used to compare categorical variables.
| Results|| |
For the entire series, there was no operative mortality. The follow-up period extended to 22 months. Fistula thrombosis occurred in a single case of radio-cephalic approach (3.8%), while subcutaneous hematoma occurred around another radiocephalic fistula (3.8%) managed by operative drainage of the hematoma five days post-operatively with salvage of the fistula.
[Table - 1] shows that creation of AVFs at the elbow resulted in a decrease of WBI in seven patients (70%) and a decrease of finger pressure in three patients (30%). WBI of a single patient from the elbow fistula group was 0.6 pre-operatively and did not change post-operatively. A single case of post-operative steal phenomenon occurred after creation of a fistula at the elbow with drop of the WBI by 0.6 (normal pre-operative WBI with post-operative WBI of 0.4).
[Table - 2] shows that creation of an AVF at the wrist resulted in a decrease of WBI in one patient (6.25%) and a decrease of finger pressure in another patient (6.25%). There were no cases of steal syndrome in this group of patients.
WBI changes as a result of creation of AVFs at the elbow were significantly greater than the changes seen amongst those fistulas performed at the wrist (P < 0.001). On the other hand, the difference between the effect of both procedures on finger pressure was statistically not significant.
| Discussion|| |
Autogenous AVF of the Brescia-Cimino type is the hemodialysis access procedure that provides the longest-term complication free patency. ,,, On the other hand, Palder et al showed that there was no difference between patency of autogenous fistulas placed at the wrist and those at the antecubital fossa when followed-up for as long as 45 months.  In case of failure of Brescia and Cimino fistula, it can be replaced either with a new fistula at a more proximal location or with a synthetic graft. In the study done by Zibari et al,  vascular steal syndrome occurred in 8% of patients with autogenous elbow fistulas, compared with 1.7% of patients with wrist fistulas. The syndrome is seen occasionally in patients with large fistulas or in patients with severe peripheral arterial disease. In the previous series,  three extremity amputations were required to treat ischemic complications, all of which occurred in patients with severe peripheral vascular disease in whom errors in judgement in the placement of the fistulas were acknowledged. In our study, there was one case (14%) of post-operative steal phenomenon that occurred after creation of a fistula at the elbow, while none occurred in those created at the wrist.
Doppler measurement of WBI and finger pressure before creation of AV fistula in the limb is a non-invasive, easy and objective way of assessment of the limb vascularity that helps to discover patients with severe peripheral arterial disease. This may help better planning for the site of contemplated fistulas aiming at reducing the number of patients presenting with post-operative steal phenomenon. 
Zibari et al showed that the drop of the WBI with the elbow fistulas was greater than wrist fistula and that this drop was compatible with the higher incidence of steal phenomenon after elbow access procedures. 
In our study, the patient who had steal phenomenon dropped his WBI by 0.6 and finger pressure by 60 mm Hg between the pre-operative and the post-operative measurements.
On the other hand, Bahlmann et al  used venous occlusion plethysmography for noninvasive measurement of blood flow to the forearm and digits. They showed insignificant difference between the effect of both elbow and wrist fistulas on digital blood flow.
The size of the fistula is standardized in all vascular access procedures to one and a half times the size of the vein in an attempt to avoid the effect of fistula size on distal limb circulation and hence on the non-invasive indices.
The low pre-operative WBI in the single patient from the elbow fistula study group did not affect the decision of creation of the AVF in that limb. However, further study on a larger scale is required to determine the value of non-invasive indices at which AVF creation would have future risk of compromised distal limb circulation.
| References|| |
|1.||Kolf WJ, Berk H, Th J. The artificial kidney: a dialysis with a great area. Acta Med Scand 1944;117:121-31. |
|2.||Quinton WE, Dillard D, Scribner BH. Cannulation of blood vessels for pro-longed hemodialysis. Trop Am Soc Artif Int Organs 1960;6:104-13. |
|3.||Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and surgically created arteriovenous fistula. N Engl J Med 1966;275:1089-92. [PUBMED] |
|4.||Palder SB, Kirkman RL, Whittemore AD, et al. Vascular access for hemodialysis: Patency rates and results of revisions. Ann Surg 1985;202:235-9. [PUBMED] [FULLTEXT]|
|5.||Zibari GB, Rohr MS, Landreneau MD, et al. Complications from permanent hemodialysis vascular access. Surgery 1988;104:681-6. [PUBMED] |
|6.||Mandel SR, Martin PL, Blumoff RR, Mattern WD. Vascular access in a University transplant and dialysis program. Results, costs and manpower implications. Arch Surg 1977;112:1375-80. |
|7.||Crockett RE. Blood access for haemodialysis. Nephron 1974;12:338-54. [PUBMED] |
|8.||Cascardo S, Acchiardo S, Beven EG, et al. Proximal arteriovenous fistulae for hemo-dialysis when radial arteries are unavailable. Proc Eur Dial Transplant Assoc 1970; 7:42-6. |
|9.||LoGerfo FW, Menzoian JO, Kumaki DJ, Idelon BA. Transposed basilic vein-brachial arteriovenous fistula. A reliable secondaryaccess procedure. Arch Surg 1978;113:1008-10. |
|10.||Bell DD, Rosental JJ. Arteriovenous graft life in chronic hemodialysis. A need for prolongation. Arch Surg 1988;123:1169-72. |
|11.||Hakaim AG, Nalbandian M, Scott T. Superior maturation and patency of primary brachiocephalic and transposed basilic vein arteriovenous fistulae in patients with diabetes. J Vasc Surg 1998,27:154-7. [PUBMED] [FULLTEXT]|
|12.||Bahlmann J, de-Marees H, Cachovan M, Glatzel K. Forearm and digital blood flow after arteriovenous anastomosis. Med Klin 1975;70(50):2031-3. |
Mussaad M.S Al-Salman
Department of Surgery, King Khalid University Hospital, P.O. Box 59199, Riyadh 11525
[Table - 1], [Table - 2]