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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 2  |  Page : 258-261
Surgical revision of failing or thrombosed native arteriovenous fistulas:A single center experience

Chams Clinic, Sfax, Tunisia

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Date of Web Publication9-Mar-2010


This study reports our experience at the Chams Clinic, Sfax, Tunisia, with surgical revision of malfunctioning native arteriovenous fistula (AVF). The etiological diagnosis of in­adequate access flow was determined by physical examination and a variety of clinical and phy­siological parameters. Between 1990 and 2006, surgical revisions were performed on 471 patients (mean age 52.8 years, 285 men and 186 women). There was radio-cephalic distal AVF malfunction in 299 patients (63%); the causes of malfunction in these patients included thrombosis in 47 and juxta-anastomotic vein stenosis or occlusion in 248 patients. The initial clinical success rate of all interventions was 98%. Post-intervention primary patency by Kaplan-Meier analysis at one, two, three, four, five and 10 years was 96%, 91%, 88%, 86%, 83% and 63%. Eighty-five patients had involvement of the brachial-cephalic proximal AVF. The post-intervention patency at six months, one, two and three years was 89%, 74%, 61%, 54% in these patients. There were 87 patients with the brachial-basilic upper arm AVF. The post-intervention patency at six months, one, two and three years was 94%, 84%, 64% and 55%. In conclusion, by surgical techniques, which are often simple, excellent results were obtained, and were much better than those obtained with angioplasty.

How to cite this article:
Moncef G. Surgical revision of failing or thrombosed native arteriovenous fistulas:A single center experience. Saudi J Kidney Dis Transpl 2010;21:258-61

How to cite this URL:
Moncef G. Surgical revision of failing or thrombosed native arteriovenous fistulas:A single center experience. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2022 Oct 3];21:258-61. Available from: https://www.sjkdt.org/text.asp?2010/21/2/258/60063

   Introduction Top

Dysfunction of the arteriovenous fistula (AVF) is a common problem in hemodialysis patients and remains a major cause of morbidity and hospitalization. There are few reports regarding the surgical revision of failing native AVF. [1],[2],[3],[4],[5] In recent years, endovascular techniques have be­come the first-line treatment for AVF dysfunc­tion and have replaced the classic surgical ap­proach. [2],[4],[5],[6],[7] This study reports our experience with early surgical revision of malfunctioning native AVF without the interim use of central venous catheters.

   Materials and Methods Top

Between 1990 and 2006, surgical revision of native AVFs was performed in 471 patients (mean age 52.8 years, 285 males and 186 fe­males) at the Chams Clinic, Sfax, Tunisia. Of these patients, hypertension was present in 127 patients (26%) and diabetes in 84 (17%).

The diagnosis of inadequate access flow was suspected clinically and confirmed with Dop­pler-Echo or radiology. The dysfunction was fur­ther determined by a variety of clinical and phy­siological parameters including physical exami­nation, patient biochemistry, urea kinetic mo­delling, and raised venous dialysis pressures. An increase in the pressure in the segment under the anastomosis in the arterialized vein tended, sometimes, to develop an anastomotic aneu­rysm. [8] No systematic fistula surveillance prog­ram was in place during this period.

The various surgical techniques used in our pa­tients are as given under:[9]

  1. thrombectomy: surgical removal of thrombus from the AV access
  2. outflow patch angioplasty: surgical revision of the venous stenosis with a prosthetic or autogenous patch to correct a stenosed out­flow anastomosis
  3. primary repair: a stenotic area is resected and anastomosed end-to-end
  4. segmental access replacement: insertion of a short (3 to 5 cm long) interposition PTFE arte-riovenous graft or venous segment.

   Definitions of patency and success Top

For the purpose of this study, fistulas were classified as successful, never used for dialysis, or failure. Technical success was defined as pre­sence of thrill on palpation or a bruit on aus­cultation, 24-hours post-operatively. Post-inter­vention primary patency was defined as the pe­riod between performing a surgical or endovas­cular intervention and occurrence of thrombosis or re-stenosis.

   Results Top

Types of AVF revised

a.) Radial-cephalic AVF at the wrist was seen in 299 patients (63.5%). The study focused on AVFs that were functioning, mature, vir­gin (with no previous surgical or endovas­cular procedure), and located in the lower half of the forearm with significant juxta­anastomotic venous stenosis (first 5 cm of the draining vein). The causes of inadequate arterial flow were thrombosis in 47 patients (10%) and juxta anastomotic vein stenosis or occlusion in 248 patients.

Early surgical revision was undertaken by the same surgeon under local anesthesia. The treat­ment consisted of the creation of a more pro­ximal re-anastomosis of the cephalic vein to the radial artery, a few centimetres above the ste­notic venous segment (neo-anastomosis).

The initial clinical success rate of all inter­vention was 98%. For thrombosed AVF (47 ca­ses), the immediate success rates was 98% (46/47). The Kaplan-Meier method was used to calculate the post-intervention primary patency over 15 years [Table 1].

b.) There were 85 patients (18%) with the bra­chial cephalic upper arm AVF. The surgical interventions performed in these patients included the following:

  1. thrombectomy (n=11 patients)
  2. primary outflow correction (n=18)
  3. segment access replacement (n=42)
  4. anastomosis of cephalic vein to brachial vein (n=30 patients)
The post-intervention primary patency over five years in these patients is shown in [Table 2].

c.) Brachial-Basilic upper arm AVF was seen in 87 patients (18.5 %). The surgical inter-ventions performed in these patients inclu­ded the following:

  1. thrombectomy (n=14 patients)
  2. primary repair (n=23) [revision of arte­rial anastomosis (n=12), anastomosis of basilic vein to brachial vein (n=4) and aneurysmal dilatation (n=8)]
  3. segment access replacement (n=63 pa­tients; PTFE graft n=51, vein n=12)
The post-intervention primary patency rate in these patients over five years is shown in [Table 3].

   Discussion Top

The results of our study demonstrate that sur­gical revision is an excellent form of treatment for the management of failing AVF, particularly in fistulas that have developed stenoses of the draining vein within 4 cm of the anastomosis. The results of our study compare favorably with those achieved by interventional radiologists [Table 4].

Reports of primary patency after percutaneous angioplasty of stenoses in native AVFs vary widely (16%-60% one-year primary patency). [1],[11],[12],[13] Even now, many experts, including dedicated interventional radiologists, consider surgery as the preferred treatment for juxta-anastomotic stenosis in forearm AVF. [11],[14],[15],[16],[17] The surgical correction of stenosis includes creation of a more proximal neo-anastomosis, vein-to-vein re­anastomosis, vein patching, short vein or PTFE graft interposition, [15],[16],[17] or the anastomosis of the cephalic vein to the brachial vein, all of which are minimally invasive procedures in easily acce­ssible vessels. Also, surgical correction is likely to be more durable than percutaneous translu­minal angioplasty (PTA); the reported primary patency rates in surgical series are higher than after dilatation. [1],[14],[15],[16] Some investigators use PTA as the first-line treatment for these lesions be­cause it is less invasive and produces excellent immediate primary results. Percutaneous angio­plasty is less invasive than surgery; however, it carries a high re-stenosis rate (50% at 6 months) necessitating repeated angioplasty to maintain patency. [7],[18],[19] Surgery and endovascular treat­ment can extend the life of dialysis shunts. Our experience shows that surgical salvage is par­ticularly successful in the case of juxta-anasto­motic venous stenoses and we recommend sur­gical revision in such cases.

   Conclusion Top

Revision of failing native elbow fistulas by surgical technique offers excellent results, which are better than angioplasty. Because the number of vascular access sites is limited, the preser­vation of each site for as long as possible is important for the long-term management of these patients. Transluminal dilatation may be performed in appropriate cases to obviate sur­gery.[20]

   References Top

1.Murphy GJ, Saunders R, Metcalfe M, Nicholson ML. Elbow using autogenous vein: Patency rates and results of revision. Postgrad Med J 2002; 78:483-6.  Back to cited text no. 1      
2.Tessitore N, Mansueto G, Lipari G, et al. Lulo endovascular versus surgical preemptive fistula juxtaanastomotic stenosis: Analysis of data collected prospectively from 1999 to 2004. Clin J Am Soc Nephrol 2006;1:448-54.  Back to cited text no. 2      
3.Tordoir JH, Rooyens P, Dammers R, van der Sande FM, de Haan M, Yo TI. Prospective evaluation of failure modes in autogenous radio cephalic wrist access for hemodialysis. Nephrol Dial Transplant 2003;18:378-83.  Back to cited text no. 3      
4.Tanuma Y. Efficacy of percutaneous translu­minal angioplasty in the management of chronic hemodialysis patients. Hinyokika Kiyo 2002;48 (10):593-7.  Back to cited text no. 4      
5.Liang HL, Pan HB, Chung HM, et al. Resto­ration of thrombosed Brescia-Cimino dialysis fistulas by using percutaneous transluminal angioplasty. Radiology 2002;223:339-44.  Back to cited text no. 5      
6.Kumpe DA, Cohen MA. Angioplasty/thrombo­lytic treatment of Failing and failed hemodia­lysis access sites: Comparison with surgical treatment. Prog Cardiovasc Dis 1992;34:263-78.  Back to cited text no. 6      
7.Konner K, Daniel BN, Ritz E. The Arteriovenous fistula. J Am Soc Nephrol 2003;14:1669-80.  Back to cited text no. 7      
8.Turmel-Rodrigues L, Pengloan J, Rodrigue H, et al. Treatment of Failed native arteriovenous fistulae for hemodialysis by interventional radio­logy. Kidney Int 2000;57:1124-40.  Back to cited text no. 8      
9.Sidawy AN, Gray R, Besarab A, et al. Recom­mended standards for reports dealing with arte­riovenous hemodialysis accesses. J Vasc Surg 2002;35(3):603-10.  Back to cited text no. 9      
10.Turmel-Rodrigues L, Pengloan J, Bourquelot P. Interventional radiology in hemodialysis fistulae and grafts: A multidisciplinary approach. Cardiovasc Intervent Radiol 2002;25:3-16.  Back to cited text no. 10      
11.Mannien HI, Kaukanen ET, Ikaaaheimo R, et al. Brachial arterial access: Endovascular treatment of failling Brescia-Cimino hemodialysis fistulas -Initial success and long term results. Radiology 2001;218:711-8.  Back to cited text no. 11      
12.Sands JJ, Miranda CL. Prolongation of hemo­dialysis access survival with elective revision. Clin Nephrol 1995;44(5):329-33.  Back to cited text no. 12      
13.Glanz S, Gordon V, Butt KM, Hong J, Lipkowitz GS. The role of percutaneous angioplasty in the management of chronic hemodialysis fistulas. Ann Surg 1987;206:777-81.  Back to cited text no. 13      
14.Turmel-Rodrigues L, Mouton A, Birmele B, et al. Salvage of immature forearm fistulas haemo­dialysis by interventional radiology. Nephrol Dial Transplant 2001;16:2365-71.  Back to cited text no. 14      
15.Oakess DD, Sherck JP, Cobb LF. Surgical salvage of failed radio cephalic arteriovenous fistulae: Techniques and results in 29 patients. Am J Kidney Int 1998;53:480-7.  Back to cited text no. 15      
16.Mickey V, Cazzonelli M, Bossinger A. The stenosed Brescia-cimino fistula: Operation or intervention. Zentralbl Chir 2003;128:757-61.  Back to cited text no. 16      
17.Georgiadis GS, Lazarides MK, Lambidis CD, et al. Use of short PTFE segments (<6 cm) com­pares favourably with pure autologous repair in failing or thrombosed native arteriovenous fistulas. J Vasc Surg 2005;41(1):76-81.  Back to cited text no. 17      
18.Georgiadis GS, Lazarides MK, Lambidis CD, et al. Use of short PTFE segments (> 6cm) com­pares favorably with pure autologous repair in failing or thrombosed native arteriovenous fistulas. J Vasc Surg 2005;42:76-81.  Back to cited text no. 18      
19.Palder S, Kirkman S, Whittemore A, Hakim R, Lazarus M, Tilnay N. Vascular access for hemo­dialysis. Patency rates and results of revision. Ann Surg 1985;202(2):235-9.  Back to cited text no. 19      
20.Dapunt O, Feurstein M, Rendl KH, et al. Trans­luminal angioplasty versus conventional opera­tion in the management of haemodialysis fistula thrombosis: Results of a 5 years study. Br J Surg 1987;74:1.  Back to cited text no. 20      

Correspondence Address:
Gdoura Moncef
Avenue 7 Novembre Imm Ibn Khaldoun, E4 Sfax
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Source of Support: None, Conflict of Interest: None

PMID: 20228510

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  [Table 1], [Table 2], [Table 3], [Table 4]

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