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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2012  |  Volume : 23  |  Issue : 1  |  Page : 152-157
Outcomes of arteriovenous fistula for hemodialysis in Sudanese patients: Single-center experience

1 Department of Surgery, Faculty of Medicine, University of Gezira, Gezira, Sudan
2 Department of Surgery, Faculty of Medicine, University of Gezira; Department of Urology, Gezira Hospital for Renal Diseases and Surgery, Gezira, Sudan
3 Department of Biochemistry and Nutrition, Faculty of Medicine, University of Gezira, Gezira, Sudan

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Date of Web Publication3-Jan-2012


A well-functioning arteriovenous fistula (AVF) is essential for the maintenance of hemodialysis (HD) in patients with chronic renal failure. Our aim is to review our experience of creating AVF and to asses its success rate and common complication. A prospective, hospital-based study was conducted on 73 patients (48 males and 25 females) on chronic HD in Gezira Hospital for Renal Diseases and Surgery, from January to July 2007. Their mean age was 43.9 years (range from 18 to 72 years). Seventy-one (97.3%) of the study subjects had been dialyzed before creation of the AVF, 67 (91.8%) of them having undergone HD with temporary access. All patients (n=73) had a native AVF as the permanent vascular access (VA). A primary radiocephalic AVF was created in 78.1% of the patients, cubital fossa in 20.5% and one case had left snuff box AVF (1.4%). Percentage of AVF maturation was reported in 67.1% of the cases within the first six weeks and in 9.6% of the cases AVF never matured. Failure of AVF function occurred in 26% of the cases, due to thrombosis in 20.5% (n=15) and aneurysm in 5.5% of the cases. We conclude that an optimum outcome is likely when there is a multidisciplinary team approach, and early referral to vascular surgery is paramount.

How to cite this article:
Ahmed GM, Mansour MO, Elfatih M, Khalid KE, Mohammed Ahmed ME. Outcomes of arteriovenous fistula for hemodialysis in Sudanese patients: Single-center experience. Saudi J Kidney Dis Transpl 2012;23:152-7

How to cite this URL:
Ahmed GM, Mansour MO, Elfatih M, Khalid KE, Mohammed Ahmed ME. Outcomes of arteriovenous fistula for hemodialysis in Sudanese patients: Single-center experience. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2022 Aug 16];23:152-7. Available from: https://www.sjkdt.org/text.asp?2012/23/1/152/91411

   Introduction Top

In the United States, approximately 320,000 patients had end-stage renal disease (ESRD) in 1998; 72% of these patients were treated with maintenance hemodialysis (HD). [1] During the past five years, the number of patients receiving HD has continued to increase. [2]

Native arterio-venous fistula (AVF) is the gold standard of vascular access (VA) for HD as it is associated with less infection and offers good dialysis adequacy. Therefore, the creation of an AVF in patients with ESRD remains one of the good practice measures, as recommended by the K/DOQI1guidlines. [3]

A large group of patients who suffer from both acute and chronic renal failure require HD. In patients with ESRD, hemoaccess by means of an AVF is the most appropriate, because frequent access to the vascular system, a high-flow system and the ability to withstand needle puncture are required. The most frequently used fistula and the standard one, by which all other fistulas are compared, is the Brescia-Cimino fistula. [4],[5]

Both physicians and patients encounter frequent problems with AVF. This simple procedure requires well-experienced surgeons and ensuring of adequate collateral flow from the ulnar artery by performing Allen's test before surgery in order to minimize the problem of hand ischemia. In addition, evaluating superficial veins and distal arteries must be done for selecting the best site for fistula. Even then, the two main reasons for failure of AVF are the surgeons inexperience and improperly selected vessels. [6]

As regards importance of AVF implantation in patients with ESRD, in this study, we review our experience of creating AVF and to analyze the patency rate complication.

   Patients and Methods Top

In this prospective, randomized, hospital-based study, we analyzed 73 patients who attended Gezira Hospital for Renal Diseases and Surgery (GHRDS) since January to July 2007. All were patients of ESRD or chronic kidney disease (CKD). The causes of renal failure were glomerular disease in the majority (26%), followed by the groups of unrecognizable causes (20%), hypertension (18%), obstructive uropathy (16%), systemic lupus erythematosis (9%), reflux disease (7%) and diabetes mellitus (4%).

All were candidates for HD, and those who accepted to take part in the study were recruited. Individual data such as age, sex, residence, occupation, cardiovascular risk factors (arterio-sclerosis, diabetes and hypertension), type of dialysis before creation of vascular access, total duration on dialysis, arm used, different sites of AVF creation, state of function after creation of AVF, their respective date of maturation and surgical complications were recorded for all patients. Pre-operative clinical assessment was done for each patient and pre-operative investigations, such as complete blood count, blood urea, serum creatinine, electrolytes (Na+, K+), coagulation profile (PT, PTT and INR), human immunodeficiency virus, serology for hepatitis B surface antigen and hepatitis C, antibody and blood grouping, were done and recorded for each case. Allen's test was also performed and the best site for fistula creation was chosen. Any patient with sepsis, acquired immunodeficiency syndrome, hepatitis C virus or hepatitis B virus, small or deformed limb, uremic-associated bleeding tendency and negative Allen's test were excluded. Radio-cephalic fistula was performed whenever the cephalic vein was in good condition; otherwise, a fistula at the elbow was created. All procedures were performed by our team successfully. Post-operatively the patient was evaluated on the first day, the first week and after the fourth week for ensuring the fistula patency and performance of HD. After ensuring the patency of fistula and obtaining the thrill, the patient was discharged. During the follow-up, the patency of the fistula was assessed either by palpation for a thrill or auscultation for a bruit. The fistula complications such as hematoma and sub-cutaneous thrombosis and blood pressure during HD were assessed by using color Doppler ultrasonography and were recorded.

Parameters were expressed in percentage or mean ± SD. Comparison between qualitative variables was made using the chi-square test. A P-value <0.05 was considered significant.

   Results Top

Seventy-three fistulae were created in our study subjects, which included 48 men (65.7%) and 25 (34.2%) women, with a mean age of 43.9 years (range from 18 to 72 years) [Table 1]. Of the study subjects, 70 patients (95.9%) were diagnosed as ESRD while the rest were diagnosed as CKD. Seventy-one (97.3%) of the study subjects had been dialyzed before creation of AVF, 67 (91.8%) of them had HD with temporary access and most of these cases (n=42) had been dialyzed via a jugular catheter [Table 2]. No patients were on steroides.
Table 1: Showing age and sex distribution of patients who underwent AVF in GHRDS in the period (January– July 2007) (n=73).

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Table 2: Characteristics of the study subjects who underwent AVF in GHRDS (n=73).

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A native AVF was created in all our patients as the first permanent access. It was radiocephalic (Cimino-Brescia fistula) in 78.1% and at cubital fossa (brachial fistula) in 20.5%, and one case had left snuff box AVF (1.4%) [Table 2]. Most of the AVFs (91.8%) were end-to-side, and the condition of its function after operation varied, with 87.7% functioning immediately, 2.7% had delayed functioning and 9.6% did not function at all.

AVF maturation was seen in 67.1% of the cases within the first six weeks, followed by 13.7% within 6-8 weeks, 9.6% in more than eight weeks and 9.6% never matured. Most of the radio-cephalic (68.5%) and brachial (66.7%) fistulae matured within the first six weeks [Table 3]. The overall primary failure rate was 26% (n=19) of the cases. Color Doppler ultrasound was done for all complicated cases (19 cases = 26%) to assess the anatomical vascular features [Figure 1].
Figure 1: Result of color Doppler ultrasonography showing the percentage of patients who had complications (26%).

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Table 3: The state of AVF versus time needed for maturation in patients who underwent AVF in GHRDS (n=73).

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As shown in [Table 4], 74.0% (n=54) of the study subjects developed no complications. The most common early complication encountered with the primary AVF was thrombosis in 20.5% (n=15) of the cases, while the most common late complication was aneurysm in 5.5% of the cases. Treatment of these complications consisted of surgical intervention for aneurysm, thrombectomy for thrombosis or conservatively (antibiotics in case of infection and compression in case of bleeding).
Table 4: The state of complications in relation to the site of AVF in the study subjects (n=73).

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The relationship between thrombosis of AVF and site of AVF was studied. Thrombosis occurred in 19.3% (11 out of 57) of the patients who had radio-cephalic AVFs and in 20% (3 out of 15) of brachial AVFs.

In comparison between the type of AVF versus the site of AVF, we found that most of the radio-cephalic fistulae were created end-to-side in 55 out of 57 (96.5%), and in 11 cases out of 15 (73.3%) for brachial fistulae.

   Discussion Top

Establishing and maintaining a proper VA is necessary for successfully performing HD, and a well-functioning AVF is essential for the maintenance of HD in patients with ESRD. The need for AVF is increasing with increasing number of patients and of HD centers. Gezira Hospital for Renal Diseases and Surgery (GHRDS) is the only big and specialized center in Sudan outside the capital city, Khartoum, where AVF was done as the first most common operation during the year 2007 (n=195 patients). The aim of the present study was to review our experience of creating AVF and to assess its success rate and search for common complications.

The native AVF is the optimal VA in HD. [7],[8] It was created in all advanced CKD and ESRD patients, with radio-cephalic (Cimino-Brescia) fistula being the most common (in 78.1% of cases). This was in accordance with the international recommendations (K-DOQ1 guidelines). [8]

Time to first use for AVFs is an important variable for clinical outcome. If the time to maturation was known, nephrologists could accurately gauge the timing for referral for HD access surgery. If a patient undergoes AVF creation before starting HD, the AVF may mature before its first use for HD. In our study, however, 67 (91.8%) of 73 patients were referred for vascular access (CVC) after starting HD. This percentage is high compared with the percentage reported in Australian and USA patients (28% and 79%, respectively), [9],[10] and this is due to the late referral of our patients to the nephrologists.

Upper limb AVFs are the gold standard for frequent dialysis in ESRD cases and, especially, distal (radial) fistulas are more preferred because this provides more superficial venous to cannulate and has less complications in comparison with proximal fistula, where greater and major arteries are used. [11] In the present work, most of the AVF creations were distal forearm (Brescia-Cimino; 78.1%). Our result is quit similar to that reported in Nigeria earlier, i.e. approximately 90% of the patients of HD have Brescia-Cimino fistula. [12]

In our study, the condition of the AVF after operation varies, but most of them functioned immediately, 87.7% (n=64), and the immediate failure rate in our group (26%) correlate with the literature data, which varies from 10 to 30%. [13],[14] Maturation is defined as successful cannulation for at least one complete HD session. [15] The National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI) recommends that fistula should mature for at least one month before cannulation. [16]

The overall maturation rate (67.1%) compared favorably with published results for all types of native AVFs, both in the upper and in the lower arm. [17],[18],[19] Complications are well-known to plague any type of HD procedure. In the present study, 32.9% had a complication interfering with the function of their upper arm AVF. Such complications are usually not directly life-threatening, and can often be overcome. Most re-interventions took place before first use, indicating that once matured, upper arm AVFs tended to remain functional. The most frequent cause of failure not amenable to re-intervention was thrombosis; 15 (20.5%) had this complication. Internationally, the most common complication is thrombosis before first use, which accounted for most of the failures to mature. AVF thrombosis occurred at a rate of 0.043 AVF thromboses per patient-year at risk. [20] In Italy, all failures of vascular access were reported to be due to AVF thrombosis. [21]

Results of this study indicate that the practice of AVF in GHRDS was found to be sound and comparable to the learning curve as reported in the literature. Early diagnosis of CKD allows creation of native AVF before ESRD sets in and, consequently, use of a temporary catheter can be avoided. Regular monitoring of the VA and a close working relationship between the nephrologists, surgeon, interventional radiologists and nurses can ensure prolonged survival of primary AVF and better treatment of its complications.

   References Top

1.United States Renal Data System. The USRDS and its products. Am J Kidney Dis 1998;32(2 suppl 1):S20-37.  Back to cited text no. 1
2.Kidney Disease Outcomes Quality Initiative (DOQI) update 2000. Am J Kidney Dis 2001; 34:S141-73.  Back to cited text no. 2
3.Eknoyang G, Levin NW, Eschbach JW, et al. Continuous quality improvement: DOQ1 becomes K/DOQ1and is updated. National Kidney Foundation's Dialysis Outcome Quality Initiative. Am J Kidney Dis 2001;37(1):179-94.  Back to cited text no. 3
4.Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 16th ed. Philadelphia; Saunders Company 2001;1450-62.  Back to cited text no. 4
5.Veith FJ, Hobson RW. Vascular Surgery: Principles and Practice. 2nd ed. McGraw-Hill 1994;1025-38.  Back to cited text no. 5
6.Hirth RA, Turenne MN, Woods JD, et al. Predictors of type of vascular access in hemodialysis patients. JAMA 1996;276(16): 1303-8.  Back to cited text no. 6
7.Rodríguez Hernández JA, López Pedret J, Piera L. Vascular access in Spain: Analysis of its distribution, morbidity, and monitoring systems. Nefrologia 2001;21(1):45-51.  Back to cited text no. 7
8.NKF-K/DOQ1. Clinical practice guidelines for vascular access: Update 2000. Am J Kidney Dis 2001;37(1 Suppl 1):S137-81.  Back to cited text no. 8
9.Di Iorio BR, Bellizzi V, Cillo N, et al. Vascular access for haemodialysis: the impact on morbidity and mortality. J Nephrol 2004; 17(1):19-25.  Back to cited text no. 9
10.Fitzgerald JT, Schanzer A, Chin AI, McVicar JP, Perez RV, Troppmann C. Outcomes of upper arm arteriovenous fistulas for maintenance hemodialysis access. Arch Surg 2004;139(2): 201-8.  Back to cited text no. 10
11.Kim YO, Yang CW, Yoon SA, et al. Access blood flow as a predictor of early failure of native arteriovenous fistula in hemodialysis patients. Am J Nephrol 2001;21(3):221-5.  Back to cited text no. 11
12.Bakari AA, Nwankwo EA, Yahaya SJ, Mubi BM, Tahir BM. Initial five years of arteriovenous fistula creation for haemodialysis vascular access in Maiduguri, Nigeria. Int J Cardiovasc Res 2007;4(2):1-6.  Back to cited text no. 12
13.Malovrh M. Native arteriovenous fistula: pre-operative evaluation. Am J Kidney Dis 2002;39(6):1218-25.  Back to cited text no. 13
14.Malovrh M. Approach to patients with end stage renal disease who need arteriovenous fistula. Nephrol Dial Transplant 2003;18 Suppl 5:v50-2.  Back to cited text no. 14
15.Hirth RA, Turenne MN, Woods JD, et al. Predictors of type of vascular access in haemodialysis patients. JAMA 1996;276:1303-7.  Back to cited text no. 15
16.Asif A, Roy-Chaudhury P, Beathard GA. Early arteriovenous fistula failure: A logical proposal for when and how to intervene. Clin J Am Soc Nephrol 2006;1(2):332-9.  Back to cited text no. 16
17.Murphy GJ, Saunders R, Metcalfe M, Nicholson ML. Elbow fistulas using autogeneous vein: Patency rates and results of revision. Postgrad Med J 2002;78(922):483-6.  Back to cited text no. 17
18.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. 18
19.Lin SL, Huang CH, Chen HS, Hsu WA, Yen CJ, Yen TS. 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. 19
20.Holden RM, Harman GJ, Wang M, Holland D, Day AG. Day.major bleeding in haemodialysis patients. Clin J Am Soc Nephrol 2008;(3):105-10.  Back to cited text no. 20
21.Fitzgerald JT, Schanzer A, Chin AI, McVicar JP, Perez RV, Troppmann C. Outcomes of upper arm arteriovenous fistulas for maintenance haemodialysis access. Arch Surg 2004;139(2): 201-8.  Back to cited text no. 21

Correspondence Address:
Mohammed El Imam Mohammed Ahmed
Vice Dean Faculty of Medicine, University of Gezira, Gezira Hospital for Renal Diseases and Surgery, P.O. Box 20, Gezira
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Source of Support: None, Conflict of Interest: None

PMID: 22237243

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