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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 802-804
Vascular access surgery: Excellent success rates with the use of a vascular dilator

Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

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Date of Web Publication9-Jul-2011

How to cite this article:
Lohani K, Guleria S, Reddy VS. Vascular access surgery: Excellent success rates with the use of a vascular dilator. Saudi J Kidney Dis Transpl 2011;22:802-4

How to cite this URL:
Lohani K, Guleria S, Reddy VS. Vascular access surgery: Excellent success rates with the use of a vascular dilator. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2021 Apr 16];22:802-4. Available from: https://www.sjkdt.org/text.asp?2011/22/4/802/82709
To the Editor,

The ideal treatment for end-stage renal disease (ESRD) is renal transplantation, which is, most of the time, not possible because of the lack of a suitable donor or adequate finance. Therefore, patients have to rely on maintenance hemodialysis (HD). Several ways of ensuring vascular accesses for dialysis are available, and include native fistula, catheters, shunts and grafts. Arterio-venous fistulas (AVFs) have become the vascular access of choice. Different studies [1],[2],[3] have shown relatively fewer complications and higher patency rates of AVFs compared with the other modes of vascular access. There are very few studies available, especially from developing countries like India, on the outcome of AVF and the salvage rates achieved by the use of vascular dilators in AVFs showing immediate failure. This study was planned to assess the outcomes achieved in AVF that did not have immediate function and were salvaged by the use of a vascular dilator.

This was a prospective, longitudinal study involving 131 consecutive patients with ESRD, of whom 25 (19%) were lost to follow-up, and in three patients, AVF could not be made due to lack of suitable veins. Individual patients were followed-up prospectively for four weeks after the AVF surgery with clinical evaluation and with the help of a preformed questionnaire. Early complications were defined as those that occurred within four weeks of creation of the AVF. Secondary AVF was defined as the AVF created using the mature vein of a prior functional AVF of the same arm. No pre-operative imaging was undertaken in our patients.

Written informed consent was taken from the patients who were included in the study and the study was performed in accordance with the ethical guidelines of the ethics committee of the hospital.

Surgical technique

Prior to the surgery, clinical assessment was carried out by general examination and auscultation of the chest. All patients were advised not to take anti-hypertensive medications on the day of the surgery. All surgeries were performed under local anesthesia using 2% lignocaine.

We chose the forearm of the non-dominant hand as the first choice for AVF. After assessing the veins, Allen's test was performed to check for patency of the ulnar artery. If the forearm cephalic vein was not prominent, or was already used, the upper arm cephalic vein was assessed. If the non-dominant hand veins were not prominent or already used, then the dominant hand was examined.

The respective artery and vein were dissected for a length of 3 cm. A venotomy of 9-10 mms in case of a radial AVF and 5-7 mm in case of a brachial AVF was made. This was followed by a corresponding arteriotomy. Vascular anastomosis was made in a continuous side-to-side fashion using 6-0 Prolene. Upon release of the slings, the blood flow across the fistula was considered adequate if a thrill was felt or a bruit was heard over the fistula. If a thrill was absent, a distal venotomy of 1-2 mm was made and an appropriately sized Debakey vascular dilator was passed gently up the vein to relieve any spasm or thrombi proximally. Similarly, the dilator was passed across the anastomosis into the artery to relieve arterial spasm. In such AVFs, the vein was ligated distal to the anastomosis and proximal to the venotomy in a radial AVF. However, in a brachial AVF, such a venotomy was repaired using 6-0 Prolene. Distal venous ligation was done in all radio-cephalic AVFs (RCAVFs) that resulted in functional artery-side-to-venous-end fistula. The AVF surgery was performed on a day-care basis. Antibiotics were given to all the patients for a period of five days. Patients were instructed to perform regular hand exercises to enhance the maturation of AVFs. The initial follow-up was after ten days.

All the variables were compared with Pearson's Chi Square or Fisher's exact test. P-value was calculated using SPSS 11.5 version. Level of significance was kept at <0.05. At the end of the study period, 103 patients were followed-up. The demographic data are presented in [Table 1].
Table 1: Demography, co-morbidities and history of prior vascular access in the study patients.

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The immediate failure rate in our study was 3.8%, and the total failure rate was 12.6% after four weeks of follow-up. Forty-two AVFs (40.8%) needed dilatation with a vascular dilator. The failure rate was significantly higher in the AVF group that needed dilatation (26.2% vs. 3.3%, P = 0.001). However, vascular dilatation was beneficial in salvaging the failing AVFs; vascular dilatation salvaged 73.8% of the 42 AVFs that needed dilatation. The failure rate was also significantly higher in AVFs, where the operating time was more than 45 min (24.2% vs. 7.1%, P = 0.024). Intraoperative complications occurred in three patients (2.9%); they included excessive bleeding in two patients and orthopnea in one patient. Complications during follow-up were seen in 32 patients (31.1%) in the form of edema (15.5%, n=16), hematoma (6.8%, n=7), stiffness (4.9%, n=5) and steal phenomenon (3.9%, n = 4).

There was no correlation between the success rate of the AVFs or complications noted and age, gender, smoking, alcoholism, diabetes and hypertension (P >0.05).

Our study showed a success rate of AVFs in a typical setting of a developing nation that was similar to the early failure rates that have been reported. [4],[5],[6],[7] Besides failure, other complications were minor and transient in our study. Dilatation with a vascular dilator helps in releasing the vessel spasm, which will not be resolved by high-blood flow alone. [8] However, there are no reports on the effect of vascular dilators on the long-term outcome of AVFs.

Seventy-six patients (73.8%) had one or more prior vascular accesses in the past, of whom only 10 patients (9.7%) had AVFs. This suggests late referral. The National Kidney Foundation [9] has recommended that patients in whom HD is anticipated should be referred early for vascular access surgery. Late referral is an independent predictor of unsuccessful utilization. [4]

Our study did not find any significant correlation between complications in general or failure of AVFs and some of the variables we studied. In contrast, available studies [6],[9],[10],[11] show AVF failure, non-patency or non-maturation to be significantly increased with advanced age in females and in patients with diabetes, forearm AVF and prior use of internal jugular vein or subclavian catheter.

The limitations of our study are that only early failure was evaluated and follow-up was only up to four weeks. Endovascular procedures to salvage an early failure were not attempted at our center.

In conclusion, our study emphasizes the importance of vascular dilatation as a means to increase the success rate of failing AVFs. In the setting of developing countries where healthcare centers are usually saturated, pre-operative imaging to assess the suitability for AVF can reliably be avoided by depending on meticulous clinical assessment.

   References Top

1.El Minshawy O, Abd El Aziz T, Abd El Ghani H. Evaluation of vascular access complications in acute and chronic hemodialysis. J Vasc Access 2004;5:76-82.  Back to cited text no. 1
2.Elseviers MM, Van Waeleghem JP. Identifying vascular access complications among ESRD patients in Europe. A prospective, multicenter study. Nephrol News Issues 2003;17:61-8,99.  Back to cited text no. 2
3.Papanikolaou V, Papagiannis A, Vrochides D, et al. The natural history of vascular access for hemodialysis: a single center study of 2,422 patients. Surgery 2009;145:272-9.  Back to cited text no. 3
4.Ravani P, Barrett B, Mandolfo S, et al. Factors associated with unsuccessful utilization and early failure of the arterio-venous fistula for hemodialysis. J Nephrol 2005;18:188-96.  Back to cited text no. 4
5.Bitker MO, Rottembourg J, Mehama R. Early failures in the creation of arteriovenous fistulas for hemodialysis in adults. Analysis of a series of 104 patients. Ann Urol (Paris) 1984;18:98-102.  Back to cited text no. 5
6.Elsharawy MA. Prospective evaluation of factors associated with early failure of arteriovenous fistulae in hemodialysis patients. Vascular 2006; 14:70-4.  Back to cited text no. 6
7.Modi GK. Vascular access service managed by a nephrologist: An audit of Arterio-venous (AVF) surgeries performed. Nephrol Dial Transplant 2005;20(Suppl05):v148-55.  Back to cited text no. 7
8.Konner K. The anastomosis of the arteriovenous fistula-common errors and their avoidance. Nephrol Dial Transplant 2002;17:376-9.  Back to cited text no. 8
9.NKF-K/DOQI Clinical Practice Guidelines for Hemodialysis Adequacy: update 2000. Am J Kidney Dis 2001;37(Suppl 1):S7-64.  Back to cited text no. 9
10.Medkouri G, Aghai R, Anabi A, et al. Analysis of vascular access in hemodialysis patients: a report from a dialysis unit in Casablanca. Saudi J Kidney Dis Transpl 2006;17:516-20.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.Prischl FC, Kirchgatterer A, Brandstatter E, et al. Parameters of prognostic relevance to the patency of vascular access in hemodialysis patients. J Am Soc Nephrol 1995;6:1613-8.  Back to cited text no. 11

Correspondence Address:
Sandeep Guleria
Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
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PMID: 21743235

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