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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 : 6  |  Page : 1048-1052
Does regional anesthesia influence early outcome of upper arm arteriovenous fistula?

1 Department of Surgery, King Faisal University, Al-Khobar, Saudi Arabia
2 Department of Anesthesia, King Faisal University, Al-Khobar, Saudi Arabia

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Date of Web Publication4-Nov-2010


To assess the effect of regional anesthesia on the outcome of elbow arteriovenous fistula (AVF), prospectively studied consecutive patients with end-stage renal disease referred for permanent vascular access to the Vascular Unit of King Fahd University Hospital between September 2004 and September 2007. The patients were divided into 2 groups: Group 1: patients who underwent the construction of the AVF under regional anesthesia and Group 2: patients who were operated under general anesthesia, indicated by their preferences or failure of regional anesthesia. Data including patient characteristics and type of AVF were recorded. The internal diameter of the vein and the artery and intra-operative blood flow were measured. The complications of both types of anesthesia were recorded. The patients were followed up for three months. Eighty four cases were recruited in this study. Complete brachial plexus block was achieved in 57 (68%) patients. Seven patients were converted to general anesthesia and 20 patients had AVF under general anesthesia from the start. There were no significant differences between the 2 groups with regard to basic characteristics or operative data. There were no instances of systemic toxicity, hematomas, or nerve injury from the regional block. No major complications were reported from the general anesthesia. There was no significant difference between both groups regarding early failure of AVF (Group 1, 14% vs. Group2; 11%. P= 0.80). No significant advantage of regional over general anesthesia in terms of early outcome of AVF was seen in this study.

How to cite this article:
Elsharawy MA, Al-metwalli R. Does regional anesthesia influence early outcome of upper arm arteriovenous fistula?. Saudi J Kidney Dis Transpl 2010;21:1048-52

How to cite this URL:
Elsharawy MA, Al-metwalli R. Does regional anesthesia influence early outcome of upper arm arteriovenous fistula?. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2021 Sep 22];21:1048-52. Available from: https://www.sjkdt.org/text.asp?2010/21/6/1048/72290

   Introduction Top

Arteriovenous fistulas (AVF) have been shown to have higher long-term primary and secondary patency rates when compared with prosthetic grafts. [1],[2] Most of the superficial veins of the fore­arm of hemodialysis (HD) patients usually have segmental occlusions as a result of multiple in­travenous infusions during repeated hospital ad­missions. This has resulted in an increase in the construction of upper arm AVF. These types of procedures usually take longer time, entail more dissection and require prolonged anesthesia.

Since local anesthesia is not ideal in these situations, general or regional anesthesias are usually required. The possible benefits of regio­nal anesthesia are avoidance of hemodynamic instability, stress response of general anesthesia, faster recovery, and less hypotension because only a limited vascular bed is affected by the anesthetics. [3],[4] Moreover, a recent study has shown that the use of regional anesthesia in elbow AVF causes significant vasodilatation and im­provement of blood flow. [5] However, no pros­pective study had shown that this effect can improve the outcome of the AVF.

The aim of this study is to assess if regional anesthesia can affect early success of elbow AVF.

   Patients and Methods Top

A prospective study was performed on conse­cutive patients with end-stage renal disease (ESRD) referred to the vascular unit of King Fahd university hospital between September 2004 and September 2007 for permanent vascular access and received upper arm AVF. Careful examination of the arteries and superficial veins of the upper extremity was performed on all the study patients. Patients with signs of diseased arteries (absent or diminished pulses) under­went pre-operative duplex ultrasonography.

Preoperative upper limb venography was indi­cated if: (1) superficial veins were not visible such as children, obese patients, and those with limb edema; (2) vascular access is attempted for the second time in the same arm; (3) a central vein line had been inserted previously. Based on the preoperative examination and venous map­ping, the vascular access was planned. The ves­sels were considered adequate for construction of a fistula if the diameter of the artery was more than 2 mm and that of the vein was grea­ter than 2.5 mm. The guidelines were followed for the order in which vascular access should be at­ tempted. [6]

All patients who required vascular access other than elbow AVF were excluded from the study. Data including age, gender, body mass index, smoking, diabetes, hypertension, hyperlipidemia, previous history of access surgery, and the type of AVF were recorded.

The patients were divided into 2 groups: Group 1; those who underwent the operation under re­gional anesthesia and Group 2; patients who were operated on under general anesthesia, indicated by their preferences or failure of regional anes­thesia.

Anesthetic techniques

Brachial plexus block was performed by a senior and experienced anesthesiologist using a supra-clavicular approach. The patient was placed in the supine position, with the head turned away and the ipsilateral arm adducted. The inter­scalene groove and mid-point of the clavicle were identified. After an aseptic preparation of the area, at a point 1.5 to 2.0 cm posterior to the midpoint of the clavicle, a skin wheal was raised with local anesthetic. A 22-G, 4-cm "short beveled" needle with a nerve stimulator was passed through the same point in a caudal, slightly medial and posterior direction. The cu­rrent was adjusted until appropriate twitching of the hand was achieved at 0.4 mA. After a nega­tive aspiration test, 0.4mL/kg of bupivacaine 0.375% was injected over 1 min, with repeated aspiration every 5 mL. Assessment of the block and hemodynamic variables were recorded.

After 30 min, if the block was considered to be adequate, surgery was commenced. Local in­filtration of 1% Lignocaine was sometimes re­quired to cover the axilla. The patient was sedated (if requested) using i.v. bolus doses of 0.5 mg of midazolam. If the block was deemed inade­quate for surgery, the patient would be given general anesthesia after induction with propofol 1.5-2 mg/kg and 50 ug of fentanyl. Anesthesia was maintained with sevoflurane 1-2% with 30% N2O in O2 and bolus doses of 50 μg fentanyl as required.

Operative Procedure

All the study patients received a preoperative prophylactic single dose of antibiotic (coamoxi­clav 1.2 g and were operated on by the same vas­cular surgeon or his senior resident, under su­pervision. After exposure of the artery and suf­ficient mobilization of the vein, the internal dia-meter of the vein and artery was measured using a coronary dilator or a ruler. If the diameter was considered adequate, an end-to-side vein-to-ar­tery anastomosis was performed using 6-0 po­lypropylene.

All the patients received intravenous heparin during surgery to prevent thrombosis. In case of brachial basilic vein fistulas, superficialization of the basilic vein was performed before the vascular anastomosis. About five minutes after completion of the anastomosis, intra-operative blood flow (in mL/min) was measured using a handheld flow probe (Transonic System Inc. HT­207, Ithaca, USA).

Postoperative evaluation was performed by pal­pation and auscultation. The patients were fol­lowed up jointly by the nephrologists and the vascular surgeon. Dialysis was usually started by means of a central vein catheter until can­nulation of the fistula became possible. The first cannulation was performed when the vein had matured adequately, usually after six to eight weeks. Follow-up was continued for three months after the procedure or earlier if there was failure of the fistula or the patient died. Failure of the fistula was defined as fistula thrombosis or an inability to cannulate both arterial and venous needles or to obtain sufficient dialysis blood flow (> 350 mL/min) eight weeks after creation of the fistula.

   Statistical Analysis Top

Data for the two groups were summarized either as percentage of the patient characteristic or success of AVF or as mean ± standard devia­tion (SD). Differences between the groups were tested for statistical significance using t-test, chi­square test, Fisher's exact test as appropriate. Significance was set at P< 0.05 for all compa­risons. Statistical analyses were performed using SPSS 15 software (Chicago, USA).

   Results Top

During the study period, 85 patients had AVF constructed at the elbow. One patient died after a kidney transplant. Thus, the study was per­formed on 84 AVF. There were 47 (56%) males. The average age was 46 ± 14 years, with age ranging from 15 to75 years. The prevalence of diabetes mellitus in this cohort was 77% [Table 1]. Brachiobasilic fistula was the most commonly used AVF [Table 2]. Preoperative venous mapping was required in 68(81%) pa­tients. Complete brachial plexus block was achieved in 57 (68%) patients. Seven (8%) pa­tients were converted to general anesthesia and 20 (24%) patients had AVF under general anes­thesia from the start. There were no significant differences between the 2 groups with regard to basic characteristics or operative data [Table 1] and [Table 2]. Early failure was in 11 (13%) AVF. There were no significant differences (P = 0.8) between the 2 groups with regard to early out­come of the AVF [Table 3]. There were no ins­tances of systemic toxicity, hematomas, or nerve injury from the block, and no major compli­cations were encountered from the general anesthesia.
Table 1 :Baseline patient characteristics.

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Table 2 :Operative data of elbow arteriovenous fistulae (AVF).

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Table 3 :Effect of type of anaesthesia on the early outcome of arteriovenous fistulae.

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   Discussion Top

During the last few decades, there has been a dramatic increase in the use of regional anes­thesia instead of general anesthesia for vascular procedures. One of such procedures is vascular access for HD patients who usually have high prevalence of coronary artery disease, diabetes mellitus, and hypertension in addition to the ESRD. [7] In these situations general anaesthesia is more risky than regional anaesthesia because of the stress of induction and hypotension asso­ciated with it. [3],[4],[8] In the present study, the ratio of general to regional anesthesia was 1:2 com­pared to 1:2.5 in other studies. [7]

Many authors [9],[10],[11],[12],[13],[14],[15],[16] have studied the effect of ge­neral factors such as age, gender, body mass in­dex, smoking, diabetes, hypertension and hyper­lipidemia on the outcome of AVF. There were also extensive studies [10],[11],[14],[17],[18] about the im­pact of operative factors e.g. the internal dia­meter of the vein and artery and intra-operative blood flow on the success of AVF. However, there was only one retrospective study, which addressed the effect of the anesthetic technique on outcome in the creation of AVF. [7] Although the present study was nonrandomized, there was no significant difference between the general and regional anesthesia with regard to the pre­viously mentioned risk factors that can affect the outcome of AVF.

In the present study, aggressive measures were adopted to reduce the incidence of AVF failure. These included liberal use of venous mapping [19]­,[20] and intra-operative heparin. [21] Most of our cases exhibited optimal arterial and venous diameters. Moreover, the younger age group of our patients may explain low incidence of failure in the pre­sent study.

Despite the proven ability of the brachial ple­xus block to vasodialate the vessels feeding the AV fistula, [5],[22] the present study and others [7] sho­wed no advantage of regional over general ana­esthesia with regard to the early outcome of AVF. One possible explanation is that the factors in the days immediately after the creation of fis­tula are more important in causing thrombosis than intra-operative factors. [7] Moreover, if a sui­table artery and vein are chosen for AVF crea­tion like in this study, vasodilatation by brachial block will probably have little effect if any on the outcome of AVF.

Patients with ESRD are at increased risk of developing several serious post-anesthetic com­plications. [23] Although, there were no major com­plications from general anesthesia in the present study, it is possible that there was bias to select regional anesthesia for higher risk patients. More­over, the number of cases, which had general anesthesia was not large so that a small adverse effect could have been missed. Although, there are reports of hazards of regional anesthesia such as seizures, [24] nerve injury [25] and delayed diagno­sis of acute ischemia of the hand, [26] there were no adverse effects from regional anesthesia in the present and others studies. [7]

In conclusion, this study did not show advan­tage of regional over general anesthesia in terms of early outcome of AVF.

   References Top

1.Pisoni Pisoni RL, Young EW, Dykstra DM, et al. Vascular access use in Europe and the United States from the DOPPS. Kidney Int 2002; 61:305-16.  Back to cited text no. 1
2.Kherlakian GM, Roedersheimer LR, Arbaugh JJ, Newmark KJ, King LR. Comparison of auto­genous fistula versus expanded polytetrafluoro­ethylene graft fistula for angioaccess in hemo­dialysis. Am J Surg 1986;152:238-43.  Back to cited text no. 2
3.Eldredge S, Sperry RJ, Johnson JO. Regional anesthesia for arteriovenous fistula creation in the forearm: a new approach. Anesthesiology 1992;77:1230 -1.  Back to cited text no. 3
4.Weissman C. The metabolic response to stress: an overview and update. Anesthesiology 1990; 73:308-27.  Back to cited text no. 4
5.Hingorani AP, Ascher E, Gupta P, et al. Regional anesthesia: preferred technique for venodilata­tion in the creation of upper extremity arterio­venous fistulae. Vascular 2006;14:23-6.  Back to cited text no. 5
6.Tordoir J, Canaud B, Haage P, et al. EBPG on Vascular Access. Nephrol Dial Transplant 2007; 22(Suppl2):88-117.  Back to cited text no. 6
7.Solomonson MD, Johnson ME, Ilstrup D. Risk factors in patients having surgery to create an arteriovenous fistula. Anesth Analg 1994;79:694­-700.  Back to cited text no. 7
8.Seltzer JL. Is regional anesthesia preferable to general anesthesia for outpatient surgical pro­cedures on an upper extremity? Mayo Clin Proc 1991;66:544-7.  Back to cited text no. 8
9.Schild AF, Prieto J, Glenn M, et al. Maturation and failure rates in a large series of arterio­venous dialysis access fistulas. Vasc Endovasc Surg 2004;38:449-53.  Back to cited text no. 9
10.Malovrh M. Native arteriovenous fistula: pre­operative evaluation. Am J Kidney Dis 2002; 39:1218-25.  Back to cited text no. 10
11.Elsharawy MA. Prospective Evaluation of Fac­tors Associated with Early Failure of Arterio­venous Fistulae in Hemodialysis Patients. Vascular 2006;14:234-9.  Back to cited text no. 11
12.Kim YO, Yang CW, Yoon SA, et al. Access blood flow as a predictor of early failures of native arteriovenous fistulas in hemodialysis patients. Am J Nephrol 2001;21:221-5.  Back to cited text no. 12
13.Johnson CP, Zhu Y, Matt C, Pelz C, Roza AM, Adams MB. Prognostic value of intraoperative blood flow measurements in vascular access surgery. Surgery 1998;124:729-38.  Back to cited text no. 13
14.Ernandez T, Sudan P, Berney T, Merminod T, Bednarkiewicz M, Martin PY. Risk factors for early failure of native arteriovenous fistulas. Nephron Clin Pract 2005;101:39-44.  Back to cited text no. 14
15.Lin SL, Huang CH, Chen HS, et al. Effects of age and diabetes on blood flow rate and primary outcome of newly created hemodialysis arterio­venous fistulas. Am J Nephrol 1998;18:96-100.  Back to cited text no. 15
16.Roa RK, Azin GD, Hood DB, et al. Basilic vein transposition fistula: a good option for main­taining hemodialysis access site options. J Vasc Surg 2004;39:1043-7.  Back to cited text no. 16
17.Wong V, Ward R, Taylor J, et al. Factors asso­ciated with early failure of arteriovenous fistulae for hemodialysis access. Eur J Vasc Endovasc Surg 1996;12:207-13.  Back to cited text no. 17
18.Silva MB, Hobson RW, Pappas PJ. A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative non­invasive evaluation. J Vasc Surg 1998;27:302-7.  Back to cited text no. 18
19.Allon M, Lockhart ME, Lilly RZ, et al. Effect of preoperative sonographic mapping on vascular access outcome in hemodialysis patients. Kidney Int 2001;60:2013-20.  Back to cited text no. 19
20.Elsharawy MA, Moghazy KM. Impact of pre­operative venography on the planning and out­come of vascular access for hemodialysis patients. J Vasc Access. 2006;7:123-8.  Back to cited text no. 20
21.Puskar D, Pasini J, Savic I, Sonicki Z. Survival of primary arteriovenous fistula in 463 patients on chronic hemodialysis. Croat Med J 2002;43: 306-11.  Back to cited text no. 21
22.Shemesh D, Olsha O, Orkin D, Raveh D, Goldin I, Reichenstein Y, Zigelman C. Sympathectomy­like effects of brachial plexus block in arterio­venous access surgery. Ultrasound Med Biol 2006;32:817-22.  Back to cited text no. 22
23.RodrrIguez J, Quintela O, Lopez-Rivadulla M, Barcena M, Diz C, Alvarez J. High doses of mepivacaine for brachial plexus block in pa­tients with end-stage chronic renal failure. A pilot study. Eur J Anaesthesiol 2001;18:171-6.  Back to cited text no. 23
24.Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious complications related to regional anesthesia: results of a prospective survey in France. Anesthesiology 1997;87:479­-86.  Back to cited text no. 24
25.Imashuku Y, Kitagawa H, Takahashi K, Ishii T, Iwashita N. A case of nerve injury after vascular access surgery under brachial plexus block. Masui 2003;52:1224-6.  Back to cited text no. 25
26.Leonard IE, Chinappa V. Vascular access procedures for haemodialysis-potential hazard of regional anesthesia. Anesthesia 2001;56:917-8.  Back to cited text no. 26

Correspondence Address:
Mohamed A Elsharawy
Departments of Surgery, King Faisal University, P.O. Box 40081, Al-Khobar 31952
Saudi Arabia
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PMID: 21060172

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