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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2009  |  Volume : 20  |  Issue : 5  |  Page : 872-875
Assessment of frequency of complications of arterio venous fistula in patients on dialysis: A two-year single center study from Iran


1 Department of Surgery, Besat Hospital, Hamadan University of Medical Science, Hamadan, Iran
2 Department of Nephrology , Ekbatan Hospital, Hamadan University of Medical Science, Hamadan, Iran

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Date of Web Publication2-Sep-2009
 

   Abstract 

The arterio-venous fistula (AVF) remains the ideal vascular access for patients on maintenance hemodialysis (HD). The aim of this study was to evaluate the complications associated with AVF and was conducted at the Ekbatan Hospital dialysis center in the years 2006 and 2007. In this descriptive cross-sectional study, 90 patients with AVF were enrolled. For each patient, data related to age, gender, time of AVF surgery, duration of renal failure, duration on dialysis, number of fistulas and their sites and, data related to complications of AVF were entered in a check list and analyzed with SPSS software (version :11). Majority of the study patients were in the age-group of 41-60 years and there was a male preponderance (56.7%). The mean duration from the time AVF surgery was performed was 26 ± 29.8 months, the mean duration of ESRD was 48.1 ± 45.52 months and the mean duration on dialysis was 28.6 ± 30.81 months. Most of the patients (75.6%) had undergone AVF surgery only once and in the majority (61.1%), the fistula was in the left arm. The most frequent complication seen in our patients was aneurysm (51%), followed by venous hyper­tension (16.7%), infection (4.4%), thrombosis (3.3%) and arterial steal syndrome (1.1%). Our study indicates that the prevalence of complications of AVF is high and greater attention should be paid to the prevention of these complications. Early diagnosis and appropriate treatment is essential to improve the quality of life in patients on HD.

How to cite this article:
Derakhshanfar A, Gholyaf M, Niayesh A, Bahiraii S. Assessment of frequency of complications of arterio venous fistula in patients on dialysis: A two-year single center study from Iran. Saudi J Kidney Dis Transpl 2009;20:872-5

How to cite this URL:
Derakhshanfar A, Gholyaf M, Niayesh A, Bahiraii S. Assessment of frequency of complications of arterio venous fistula in patients on dialysis: A two-year single center study from Iran. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Oct 20];20:872-5. Available from: https://www.sjkdt.org/text.asp?2009/20/5/872/55383

   Introduction Top


Long-term patency of vascular access has pro­longed survival of thousands of patients with end-stage renal disease (ESRD) on maintenance hemodialysis (HD). [1] Arterio-venous fistula (AVF) is the preferred access for patients who require regular HD and the preferred site is the wrist, preferably in the non-dependant arm. [2],[3],[4],[5],[6] A stan­dard AVF is created from anastomosis of ce­phalic vein with radial artery at the wrist. Accor­ding to anatomic relationship, fistula could be distal at the anatomical snuff box region or pro­ximal at the elbow, where the cephalic vein is anastomosed to the brachial artery. [7]

Complications of AVF include thrombosis, in­fection, bleeding, increased venous pressure, ar­terial insufficiency, aneurysm, carpal tunnel syn­drome, distal ischemia and even heart failure. [7],[8],[9],[10],[11],[12],[13] Since data on complications of AVF are scarce from the Hamadan province of Iran, this study was performed at the Ekbatan Hospital of Ha­madan city in the years 2006-2007.


   Materials and Methods Top


In this descriptive cross-sectional study, 90 pa­tients with ESRD, having AVF and referred to the dialysis center of Ekbatan hospital of Hama­dan city in the years 2006-2007, were evaluated. Data collected and documented included age, gender, date of AVF surgery, duration of renal failure, time of starting dialysis, number of ope­rated fistulas and region of fistula insertion and information about fistula-related complications. The complications looked for included infection, thrombosis (early and late), venous hyperten­sion, arterial insufficiency (arterial steal syn­drome), aneurysm (true and pseudo aneurysm) and bleeding.

The data collected were analyzed and assessed by using SPSS statistical software and descrip­tive statistics was used for presentation of results.


   Results Top


In the present study, 90 patients on mainte­nance HD with an AVF as vascular access were evaluated. There were four patients (4.4%) in the age group 0-20 years, 18 patients in the age group 21-40 years, 37 patients in the age-group 41-60 years and 31 patients (34.4%) above 60 years of age. There were 51 males (56.7%) and 39 females (43.3%). The time duration from per­forming the AVF surgery ranged between one month and 162 months with a mean of 26 ± 29.8 months. The duration of renal failure in the study patients ranged from one to 192 months with a mean of 48.1 ± 45.52 months. The dura­tion on dialysis ranged between one month and 168 months with a mean of 30.81 ± 28.6 months. Sixty-eight of the study patients (75.6%) had undergone only one AVF surgery and in 55 patients (61.1%), the AVF was made at the left elbow. Most of the study patients (n=59; 65.6%) had HD three times weekly. Co-morbid condi­tions were seen in 56.6% of the patients and included diabetes mellitus in 14.4% and hyper­tension in 42.2% of the patients.

During the study period, the most frequently encountered complication involving the AVF was aneurysm (51%), followed by venous hypertension (16.7%), infection (4.4%), thrombosis (3.3%), and arterial steal syndrome (1.1%) [Figure 1].

The frequency of occurrence of complications of AVF in our study patients according to gen­der and age is given in [Table 1] and [Table 2], respec­tively.


   Discussion Top


Complications related to vascular shunts increase with age. [14],[15] The reported fistula patency rate is 60-70% in the first year and 50-60% in the sub­sequent years, in most centers. [16],[17] Some resear­chers claim that occurrence of AVF insufficiency is mostly a result of pre-existing morphologic ab­normalities due to the underlying disease (renal failure or its cause). [18]

In the present study, the age distribution of patients showed that most dialysis patients ha­ving AVF belonged to the age-group 41-60 years (41.1%) and there was male prepon­derance (56.7%). The most common complica­tion seen in these patients was aneurysm (51%). Cavallaro et al, [19] studied 56 dialysis patients with early and late AVF complications; the most co­mmon complications reported were aneurysm (28 cases) and thrombosis (25 cases). However, in the study of Nakagawa et al, [20] thrombosis with dysfunction of AVF was the most common complication (70.8%), while aneurysm occurred in 6.6% of the patients, a prevalence that is less than in the present study.

In another study reported by Grapsa et al, [21] which included 48 patients more than 60 years and 101 patients less than 60 years of age, throm­bosis was seen in 10 of 48 cases in the first group and 14 of 101 cases in the second group. Also, infection was not seen in any patients in the first group, but occurred in two patients in second group (1.9%). In our study, the rate of fistula infection was 4.4%.

In another study on 125 cases with fistula, Glanz et al [22] determined by angiography that 13 patients had venous obstruction, and venous ste­nosis near the anastomotic region was seen in 32 cases. Also, they reported the presence of thrombosis in nine cases (7.2%) and aneurysm in 23 cases (18.4%). Thus, their prevalence of thrombosis was more and prevalence of aneu­rysm was less than our study.

The tools available for the diagnosis of fistula stenosis include venography and angiography, both of which are invasive and expensive. Thus, these tests were not performed on any of our patients due to which the prevalence of stenosis could not be determined.

The distribution of complications of AVF accor­ding to age showed that aneurysm, venous hypertension and infection occurred most com­monly in patients belonging to the age group 41-60 years. Additionally, aneurysm and venous hypertension were predominantly seen in males while thrombosis occurred more frequently in females.

Our study suggests the following:

  1. Early diagnosis and management of com­plications related to AVF is essential to pre­vent loss of the vascular access.
  2. Advanced diagnostic methods such as veno­graphy should be used more frequently to diagnose AVF-related complications.
  3. Greater attention should be paid to care of the AVF so that complications may be pre­vented.


 
   References Top

1.Braunwald E, Fauci A, Ajay KS, Barry M. Harrison's Principles of internal medicine, 15 th ed. Philadelphia: McGraw-Hill; 2005.  Back to cited text no. 1    
2.Massary SG, Glassock RJ. Massray & Glass­work's textbook of nephrology. 4 th ed. Phila­delphia: Lippincott Williams; 2001.  Back to cited text no. 2    
3.Brescia MJ, Cimino GE. Chronic hemodialysis using venipuncture and surgically created arte­riovenous fistula. J Am Soc Nephrol 1999;10: 193-6.  Back to cited text no. 3    
4.Burdick F, Maley WR. Update on vascular access for hemodialysis. Adv Surg 1996;30:223­332.  Back to cited text no. 4    
5.Veith FJ, Hobson RW, Williams RA, Wilson SE, (eds). Vascular surgery: Principles and practice. 2nd ed. New York: McGraw-Hill; 1994:1025-38.  Back to cited text no. 5    
6.Miller PE, Tolwani A, Luscy CP, et al. Predictors of adequacy of arteriovenous fistulas in hemo­dialysis patients. Kidney Int 1999;56(1):275-80.  Back to cited text no. 6    
7.Kinnaert P, Moris C. Arterivenous fistula at the elbow for maintenance hemodialysis. In Kootstra G, Jorning PJ (eds): access Surgery. Lancaster, Boston, The Hague, MTP Press, 1983, pp 25-293.  Back to cited text no. 7    
8.David C. Sabiston, JR. Text book of surgery 15 th Edition, MacGraw- Hill, 1997; 429-36.  Back to cited text no. 8    
9.Schwartz SI, Tom Shires G, Spencer FC, Daly JM. "Principles of Surgery" 7 th ed, 1999, McGraw­Hill, vol(1), p(420).  Back to cited text no. 9    
10.Levi J, Rosbon M, Rosenfeld JB. Septicemia and pulmonary embolism complicating use of arteriovenous fistula in maintenance hemo­dialysis. Lancet 1970;2:288-90.  Back to cited text no. 10    
11.Ori Y, Korzets A, Katz M, et al. The contribution of an arteriovenous access for hemodialysis to left ventricular hypertrophy. Am J Kidney Dis 2002;40:745.  Back to cited text no. 11    
12.Bosman P, Boereboom F, Smits H, et al. Pressure of flow recordings for the surveillance of hemo­dialysis grafts. Kidney Int 1997;52:1084.  Back to cited text no. 12    
13.Ikizler TA, Himmerlfarb J. Trials and tradeoffs in haemodialysis vascular access monitoring. Nephrol Dial Transplant 2006;21:3362.  Back to cited text no. 13    
14.Fan PY, Schwab SJ. Vascular access: Concepts for the 1990s. J Am Soc Nephrol 1992;3:1.  Back to cited text no. 14    
15.Hakim RM, Himmerlfarb J. Haemodialysis access failure. A call to action. Kidney Int 1998;54: 1029.  Back to cited text no. 15    
16.Palder SB, Kirkman RL, Whittemore AD, et al. Vascular access for hemodialysis. Ann Surg 1985;202:235.  Back to cited text no. 16    
17.Munda R, First MR, Alexander JW, et al. PTFE graft survival in hemodialysis. JAMA 1983;249: 219.  Back to cited text no. 17    
18.Wali MA, Eid RA, Dewan M, Al-Homrany MA. Pre-existing histopathological changes in the cephalic vein of renal failure patients before arterio-venous fistula (AVF) construction. J Smooth Muscle Res 2003;39(4):95-105.  Back to cited text no. 18    
19.Cavallaro G, Taranto F, Cavallaro E, Quatra F. Vascular complications of native arterio-venous fistulas for hemodialysis: role of microsurgery. Microsurgery 2000;20(5):252-4.  Back to cited text no. 19    
20.Nakagawa Y, Ota K, Sato Y, Fuchinoue S, Teraoka S, Agishi T. Complications in blood access for hemodialysis. Artif Organs 1994;18(4): 283-8.  Back to cited text no. 20    
21.Grapsa EJ, Paraskevopoulos AP, Moutafis SP, et al. Complications of vascular access in hemo­dialysis (HD) aged vs adult patients. Geriatr Nephrol Urol 1998;8(1):21-4.  Back to cited text no. 21    
22.Glanz S, Bashist B, Gordon DH, Butt K, Adamsons R. Angiography of upper extremity access fistulas for dialysis. Radiology 1982;143( 1):45-52.  Back to cited text no. 22    

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Correspondence Address:
A Derakhshanfar
Department of Surgery, Besat Hospital, Hamadan University of Medical Science, Hamadan
Iran
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PMID: 19736495

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    Tables

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