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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 : 5  |  Page : 859-862
Interrupting connection of superficial and deep veins of the upper extremity at the elbow for creation of hemodialysis arteriovenous fistulas


Division of Vascular Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

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Date of Web Publication31-Aug-2010
 

   Abstract 

We hypothesized that interrupting the connection between superficial and deep veins of the upper extremity at the elbow for creation of hemodialysis arteriovenous fistulas (AVFs), in addition to adequate dilation of the elbow veins, will reduce the risk of steal syndrome and venous hypertension. In this prospective study over a period of one year, patients who were candidates for creation of elbow AVFs based on Doppler ultrasound findings and physical exa­mination, were enrolled into the study. For creation of AVFs, based on the anatomy of the vessels, side-to-side or end-to-side anastomosis between the brachial artery and either cephalic or median antecubital or basilic veins was performed. In some cases, Gracz AVF was created. For inter­rupting the connection between superficial and deep veins, the perforating vein was either ligated or used for anastomosis. The patients were then followed-up regarding patency rate of the AVF and complications. AVFs were created in 50 patients and the duration of follow-up varied from one to eight months. About 56% (n = 28) of the patients had history of failed AVF or arterio­venous graft and 48% (n = 24) of them had history of insertion of a dual-lumen catheter for hemo­dialysis. Neuromuscular problem (n=1) and infection (n=1) were the observed complications. None of the patients developed steal syndrome or venous hypertension. At the end of the study, 47 AVFs (94%) were patent and adequate. Our study suggests that interrupting the connection between the superficial and deep venous systems of the upper extremity can reduce the risk of development of steal syndrome and venous hypertension despite side-to-side anastomosis. These techniques provided acceptable patency rate for elbow AVFs.

How to cite this article:
Moini M, Rasouli MR, Salehirad S, Nazarinia M. Interrupting connection of superficial and deep veins of the upper extremity at the elbow for creation of hemodialysis arteriovenous fistulas. Saudi J Kidney Dis Transpl 2010;21:859-62

How to cite this URL:
Moini M, Rasouli MR, Salehirad S, Nazarinia M. Interrupting connection of superficial and deep veins of the upper extremity at the elbow for creation of hemodialysis arteriovenous fistulas. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Oct 26];21:859-62. Available from: https://www.sjkdt.org/text.asp?2010/21/5/859/68880

   Introduction Top


According to the National Kidney Foundation Kidney Dialysis Outcomes Quality Initiative (NFK/DOQI) clinical practice guidelines, native arteriovenous fistulas (AVFs) are the vascular access of choice for patients on maintenance hemodialysis (HD). [1] Among all types of AVF, radiocephalic AVF (RCAVF) is the first choice due to its reliable patency, low complication rate, and preservation of alternate future access sites. [2],[3] However, there are some reports sho­wing that wrist AVFs often fail to mature due to factors such as diabetes, peripheral vascular disease, advanced age, and frequent venipunc­ture. [4],[5] Morever, as life expectancy increases in patients with end-stage renal disease (ESRD), many will need additional vascular access pro­cedures. [6] To meet this challenge, surgeons must be able to create AVFs at other sites and also introduce new techniques for AVFs.

Modification of the elbow AVFs as introduced by Gracz et al, [7] and using proximal part of the radial artery as inflow for creation of elbow AVFs [8],[9] are examples of these attempts. We previously reported the role of the perforating vein in hemodynamics of permanent upper extremity vascular accesses (i.e. AVF and arte­riovenous graft), [10],[11] which resulted in intro­duction of side-to-side brachiocephalic AVF (BCAVF) or brachioantecubital AVF (BAAVF) with ligation of the perforating vein. [12] We hypothesized that interrupting the connection between superficial and deep venous systems of the upper extremity at the elbow region for creation of HD AVF (i.e. ligation of the per­forating vein or using it for anastomosis), in addition to adequate dilation of the elbow veins, will reduce the risk of steal syndrome and venous hypertension. In the present study, we aimed to test this hypothesis.


   Patients and Methods Top


This prospective study was carried out at the Sina hospital, affiliated to the Tehran University of Medical Sciences. The ethical committee of human research of the aforementioned univer­sity approved the protocol of the study. During a one-year period, patients who were candi­dates for creation of elbow AVF based on Doppler ultrasound examination (brachial artery diameter greater than 2.5 mm and cephalic or basilic veins diameters greater than 3 mm) and physical examination, were enrolled into the study. Patients with previous history of failed RCAVF were also included in the study, whereas those with diagnosis of subclavian vein stenosis were excluded.

Surgical techniques

After local anesthesia, various techniques were used to create elbow AVF. In all proce­dures, for interrupting the connection between the superficial and deep venous systems, the perforating vein was either ligated or used for anastomosis. The following techniques were used:

  1. side-to-side brachiobasilic AVF (BBAVF) with ligation of the perforating vein and proximal part of the basilic vein
  2. side-to-side BAAVF with ligation of the perforating vein
  3. end-to-side BAAVF with ligation of the perforating vein
  4. at the confluence of the cephalic vein, the forearm branch was cut and anastomosed to the brachial artery in end-to-side fashion and the perforating vein was ligated
  5. end-to-side BBAVF with ligation of the perforating vein
  6. anastomosis of the perforating vein to the brachial artery was performed if there was no connection between basilic and cepha­lic veins and the diameter of the perfo­rating vein was appropriate (Gracz AVF).


Data collection and follow-up

After creation of the AVF, data including de­mographics, co-morbidities and previous his­tory of insertion of dual-lumen catheter or failed AVF were obtained. Also, patients were visited in vascular surgery clinic and progress notes were recorded.

Definitions

The primary functional patency rate of the AVF was the main end point of this study. Function was defined as the ability to perform HD with two needles with dialysis blood flow of at least 250 mL/min in at least five dialysis sessions during the past month. Other end­points were venous hypertension which graded as none, mild (hand swelling) and severe (se­vere hand swelling and pain needing elastic support) and steal syndrome which graded as none, mild (paresthesias), moderate (arm claudi­cation with exercise), and severe (poorly pal­pable radial pulse and pain requiring revision surgery). The presence of infection was also noted. [12]


   Results Top


AVF was created in 50 patients (23 males, 27 females) and follow-up duration varied from one to eight months. The mean age of the pa­tients was 52 ± 15 years. A total of 22% of the patients were diabetic, 36% hypertensive and 12% both diabetic and hypertensive. About 54% of the patients had history of failed AVF (46% for one time, 6% for two times and 2% for three times) and 2% (n=1) had history of failed arteriove-nous graft (AVG). Infection at the site of vascular access (2%) and aneurysmal change (2%) were the complications noted in the previous vascular accesses. About 48% (n=24) of the patients had history of insertion of dual-lumen catheter for HD (subclavian: 10%, internal jugular: 38%, external jugular: 2%, both subclavian and internal jugular: 2%).

Forty-four AVFs were created in side-to-side fashion and others were end-to-side. See [Table 1] for more details. The primary failure rate was 6% (n=3). During the follow-up, no steal syn­drome or venous hypertension were seen. Neu­romuscular problem (n=1, 2%) and infection of the AVF (n=1, 2%) were the main observed complications. Forty-seven AVFs were patent and adequate (primary patency rate of 94%). Four patients died during the follow-up period of which three had patent AVF.
Table 1 :Some characteristics of the created arteriovenous fistulas (AVF) in the studied patients.

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   Discussion Top


Although direct anastomosis of the perfora­ting vein to the brachial artery and side-to-side BCAVF and BAAVF with ligation of the per­ forating vein have been reported previously, [12],[13] to our knowledge other techniques (particularly BBAVF with ligation of the perforating vein) which is introduced in this paper, have not been described reported frequently. Our results showed that ligation of the perforating vein or anastomosis of the perforating vein to the bra­chial artery, not only provides appropriate pa­tency rate but also prevents development of steal syndrome and venous hypertension.

Steal syndrome and venous hypertension occurs respectively in 6% and 2.8% of BCAVFs. These numbers are respectively 4% and 7.6% in BBAVFs. [14] In our series, none of the studied patients developed steal syndrome or venous hypertension which support the hypothesis that the perforating vein has an important role in the hemodynamics of elbow fistulas and devia­tion of blood flow from superficial upper ex­tremity venous system to the deep one tho­rough the perforating vein is the cause of steal syndrome and development of venous hyper­tension. It is consistent with our previous re­port, [12] in which we did not observe the steal syndrome and severe venous hypertension in patients who underwent side-to-side BCAVF or BAAVF with ligation of the perforating vein. As described earlier, after creation of side­to-side BCAVF, ligation of the perforating vein will increase the mean radial artery blood pressure significantly. [12] This phenomenon is due to deviation of blood flow from superficial venous system of the upper extremity to the deep one through the perforating vein.

Primary failure was found in 6% of the studied patients compared to 20.4% (4-41.1%) and 25.2 (0-32.4%) for BCAVF and BBAVFs, respectively. [14] However, we followed-up the patients for a short period and we cannot con­clude strongly about patency rate of the crea­ted AVFs. However, in our previous report, the one-year and two-year patency rates of BCAVF and BAAVF were respectively 90% ± 2.66% and 84% ± 3.5%, which showed that ligation of the perforating vein does not inter­fere with maturation of elbow AVF or early failure. [12]

In conclusion, despite the limitations of our study such as absence of a control group and short-term follow-up, our series revealed that ligation of the perforating vein may reduce the risk of steal syndrome and severe venous hypertension in spite of side-to-side anasto­mosis while it does not interfere with matu­ration of veins around the elbow and is asso­ciated with acceptable patency rate. We there­fore, recommend ligation of the perforating vein during creation of elbow AVFs particu­larly side-to-side ones.

 
   References Top

1.NKF-DOQI clinical practice guidelines for vascular access. National Kidney Foundation­Dialysis Outcomes Quality Initiative. Am J Kidney Dis 1997;30:S150-91.  Back to cited text no. 1  [PUBMED]    
2.Harland RC. Placement of permanent vascular access devices: surgical considerations. Adv Ren Replace Ther 1994;1:99-106.  Back to cited text no. 2  [PUBMED]    
3.Palder SB, Kirkman RL, Whittemore AD, Hakim RM, Lazarus JM, Tilney NL. Vascular access for hemodialysis. Patency rates and results of revision. Ann Surg 1985;202:235-9.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.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.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Leapman SB, Boyle M, Pescovitz MD, Milgrom ML, Jindal RM, Filo RS. The arteriovenous fistula for hemodialysis access: gold standard or archaic relic? Am Surg 1996;62:652-6; dis­cussion 6-7.  Back to cited text no. 5  [PUBMED]    
6.The USRDS and its products. United States Renal Data System. Am J Kidney Dis 1998;32: S20-37.  Back to cited text no. 6  [PUBMED]    
7.Gracz KC, Ing TS, Soung LS, Armbruster KF, Seim SK, Merkel FK. Proximal forearm fistula for maintenance hemodialysis. Kidney Int 1977; 11:71-5.  Back to cited text no. 7  [PUBMED]    
8.Bruns SD, Jennings WC. Proximal radial artery as inflow site for native arteriovenous fistula. J Am Coll Surg 2003;197:58-63.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Jennings WC. Creating arteriovenous fistulas in 132 consecutive patients: exploiting the pro­ximal radial artery arteriovenous fistula: relia­ble, safe, and simple forearm and upper arm hemodialysis access. Arch Surg 2006;141:27­-32.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Moini M, Rasouli MR, Nouri M. Ligation of the perforating vein: a treatment for steal Syn­drome in side-to-side elbow arteriovenous fis­tula. Ann Vasc Surg 2008;22:307.  Back to cited text no. 10      
11.Moini M, Rasouli MR. Ligation of the perfo­rating vein for treatment of steal syndrome in arteriovenous grafts: a hypothesis. Kidney Int 2008;74:826.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Moini M, Williams GM, Pourabbasi MS, et al. Side-to-side arteriovenous fistula at the elbow with perforating vein ligation. J Vasc Surg 2008; 47:1274-8.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Gracz KC, Ing TS, Soung LS, et al. Proximal forearm fistula for maintenance hemodialysis. Kideney Int 1977;1:71-4.  Back to cited text no. 13      
14.Lock CE, Oliver MJ. Overcoming barriers to artriovenous fistula creation and use. Semin Dial 2003;16:89-96.  Back to cited text no. 14      

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Correspondence Address:
Majid Moini
Associate Professor of Vascular Surgery Sina Hospital, Hassan-Abad Square Tehran 1136933511
Iran
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PMID: 20814120

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