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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2015  |  Volume : 26  |  Issue : 6  |  Page : 1210-1214
Outcome of upper limb vascular access for hemodialysis

1 Department of General Surgery, The University of Jordan, Amman, Jordan
2 Department of Internal Medicine, The University of Jordan, Amman, Jordan
3 Department of Anesthesia, The University of Jordan, Amman, Jordan

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Date of Web Publication30-Oct-2015


The aim of this study was to investigate the outcome of vascular access procedures for hemodialysis and factors affecting access survival and complication rates. A retrospective review was carried out on 276 patients who underwent 404 consecutive vascular access operations performed over seven-years. The overall primary failure rate was 9.2%, while the oneand five-year cumulative access patency rates were 63.8% and 40.6%, respectively. Diabetes mellitus status significantly influenced access survival (P = 0.022). Autogenous arteriovenous fistulas (AVFs) are reliable procedures with access sites often available in the upper limb proximally and distally. Patients with diabetes mellitus have significantly worse patency rates of upper limb AVFs.

How to cite this article:
Alsmady M, Shahait AD, Alawwa IA, Riziq MG, Abusba AA, Al-qudah A. Outcome of upper limb vascular access for hemodialysis. Saudi J Kidney Dis Transpl 2015;26:1210-4

How to cite this URL:
Alsmady M, Shahait AD, Alawwa IA, Riziq MG, Abusba AA, Al-qudah A. Outcome of upper limb vascular access for hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Nov 29];26:1210-4. Available from: https://www.sjkdt.org/text.asp?2015/26/6/1210/168626

   Introduction Top

Patients suffering from end-stage renal disease (ESRD) need to receive hemodialysis (HD) through a durable long-term arteriovenous fistula (AVF). [1] Despite significant evolutions in vascular access techniques, creation of a durable vascular access for HD continues to be a challenge for vascular surgeons. [2]

The National Kidney Foundation/Disease Outcomes Quality Initiative practice guidelines state the preferences for vascular access, which include (1) radial artery-cephalic vein native arterio-venous fistula (NAVF) at the wrist (Brescia-Cimino fistula), (2) brachial artery-cephalic vein NAVF (upper arm NAVF), transposed brachial artery-basilic vein fistula, followed by (4) prosthetic grafts and (5) cuffed tunneled central venous catheters. [1]

The possibility of inadequate AVF patency remains a major issue. [3] Recent trends in HD include recruiting an increased number of geriatric patients, higher number of diabetic patients, concerns regarding lack of appropriate pre-operative assessment and a substantial number of patients with initial and unplanned long-term central (tunneled) lines before being referred for vascular access and expanding proportion of long-term dialysis patients. [4] These factors, combined with an increase in the proportion of patients who need HD and whose venous anatomies are not suitable or exhausted, render the creation of autogenous AVF more difficult. Furthermore, these patients are subjected to secondary vascular access complications that may result in considerable morbidity and mortality besides the increased costs. [4]

We aim in this study to investigate the outcome of vascular access procedures and factors influencing access survival and its associated complications.

   Patients and Methods Top

We retrospectively reviewed the clinical data, outpatient records and surgical reports of all the patients who underwent vascular access procedures at our hospital from January 2002 to June 2009. The operations were performed exclusively by two surgeons.

Detailed information included age, sex, medical co-morbidities, previous vascular access, type of operation, complications, follow-up period, date and cause for fistula failure and patient death, if applicable. Primary failure was defined as failure either immediately after the creation of the access or before using it for dialysis. Secondary access failure was defined as access failure following its use for dialysis.

The patients who underwent transplantation or who died with a functioning access were considered as lost to follow-up. Edema was defined as at least a 20% increase in forearm circumference of the limb containing the vascular access when compared with the opposite normal one. Steal syndrome was defined as a persistent coldness of the limb with the vascular access and pain while working or during dialysis. Bleeding was defined as any hematoma requiring wound exploration or any access rupture. Infection was defined as redness of the skin surrounding the vascular access that either resolved after starting antibiotics or required an intervention (pus drainage, prosthetic graft removal, etc.).

The study was approved by our hospital ethical committee. Informed consent was obtained from all the study patients.

Pre-operative vein mapping was not routinely performed. General, local or regional anesthesia was used depending on the general anesthesia risk as well as the preferences of the anesthetist, surgeon and patient. When creating the fistula, multiple factors were regarded including prominence of superficial veins, previous history of thrombophlebitis, segmental stenosis in the proximal vessel, atherosclerosis of the radial artery and blood flow.

Following exploration and dissection of the arteries and veins, and before placing vascular clamps, heparin was routinely administered intravenously to every patient. After sufficient vein mobilization, an end-to-side or side-toside fashion anastomosis was performed with a continuous suture technique using 6-0 and 70 polypropylene sutures. No immediate postoperative studies, such as duplex ultrasonography or radiography, were performed to assess access patency. At the completion of the anastomosis, a palpable thrill or an audible bruit should be felt on top of the outflow limb.

Expanded polytetrafluoroethylene (PTFE) grafts with an internal diameter of 6 mm were placed in a subcutaneous fashion with the use of a tunneler device either in the forearm (fPTFE, basilic vein-to-brachial artery) or in the upper arm (u-PTFE, axillary vein-to-brachial artery). Venous (end-to-end) and arterial (endto-side) anastomosis were performed with a continuous suturing technique using a 6-0 polypropylene suture.

   Statistical Analysis Top

Continuous variables were presented as mean ± standard error of the mean (mean ± SEM). The log rank test was used to test for equality of survival distribution for patient age groups (<50, 51-70 and >71 years). The mean cumulative access survival was calculated for the different age groups, diabetic versus non-diabetic patients and pre-dialysis versus dialysis patients. Differences in the means were tested using the F-statistic. A P-value <0.05 was considered statistically significant.

   Results Top

There were 276 patients with ESRD who underwent 404 vascular access procedures to create AVF over the seven-year period. The study population included 152 (55.1%) males and 124 (44.9%) females, with a mean age of 44.4 ± 18.8 years.

Diabetes mellitus (42.5%) was the most common cause of ESRD among our patients, followed by hypertension (35.3%). Of the 404 AVFs performed, 37.1% received a radiocephalic AVF, 51.0% received a brachiocephalic AVF and a transposed brachial basilic vein fistula and 11.9% received an e-PTFE graft. The site of AVF created was on the left upper extremity in 68% of patients and on the right upper extremity in 32% of patients. The distribution of procedures according to age group did not show any statistically significant differences (Pearson Chi-square = 0.749; DF = 2; P = 0.547).

Early patency was found in 91.5% of the created AVFs [Table 1]. Patients with a wrist (radio-cephalic) AVF had 10.0% early failure and 7.8% had early failure of an elbow (brachio-cephalic) AVF; this difference was not statistically significant (P >0.05). In total, 15% of patients were subjected to more than one surgical intervention because of early AVF thrombosis and failure. Early AVF failure affected females (60%) more often than males (40%, P <0.05).
Table 1: Access patency in 404 AVFs.

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The most common complication was thrombosis [Table 2], occurring in 28% of the procedures, and was responsible for access failure in 25% of the procedures. Steal syndrome complicated 2.2% of the procedures (radio cephalic and brachiocephalic AVFs) and was severe enough to end with access ligation in 0.7% of the patients.
Table 2: Complication of AVF in the study patients.

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The mean follow-up duration was 5.3 ± 0.7 years. By the end of the follow-up period, 21.7% of the patients died with a functioning access and 5.8% patients received renal transplants. The overall cumulative survival probability of access at one and five years was 65.6% and 43.5%, respectively. There was no statistically significant difference in survival distribution according to sex (log rank = 0.08; DF = 1; P = 0.617) or age group (log rank = 2.45; DF = 2; P = 0.389). There was no significant difference between the mean cumulative access survival for the different age groups (<50, 51-70 and >70 years) (f = 0.269; P = 0.719). Patients with diabetes mellitus had a significantly lower mean access survival than non-diabetic patients (2.1 ± 0.3 years vs. 1.5 ± 0.2 years; f = 1.889; P = 0.022).

   Discussion Top

Our approach to create AVF for patients requiring renal replacement therapy followed the NFK\DOQL guidelines, i.e. an initial effort to create an autologous AVF at a peripheral site, advancing from the distal to the proximal part of the extremity when revisions are needed. Grafts are reserved for patients whose venous vascular beds were not suitable.

Our initial AVF attempts were systematically with the radiocephalic AVF because of its technical advantages for implantation and high function rate. [5] In our study, the patency rates of this type of AVF were comparable to that reported in the literature, i.e. 90% in the first long-term observations showed that more than half of the patients in this study have a patent access at more than five years post-operatively. One of the main disadvantages of the radiocephalic AVF is that maturation failure may be due to insufficient vein diameter.

Brachial artery AVF poses a risk of developing steal syndrome and requiring some veins to be ligated, banded or bypassed, and fistula maturation may take a long period reaching up to six months. Upper-arm AVFs are extremely difficult to access in obese patients and may require an exteriorization procedure. [6] In our study, 2.2% of upper arm fistulas developed the steal syndrome and required further surgical intervention, which was comparable to the reported rate by Yu et al. [3] Prosthetic material, regardless of type, had a greater tendency toward thrombosis than autogenous tissue in our study and others. [7],[8]

In our study, diabetic patients of either gender tended to have poor outcome for AVF, irrespective of whether using autogenous or prosthetic vessels. The same experience was reported in the literatue. [9],[10],[11],[12] The poor overall results in diabetics might be explained by an increased incidence of arterial disease or even impaired venous endothelial function; in addition, sclerosed arteries also make anastomotic techniques a challenging task. [11]

Early and late thrombosis was the most common cause of access failure in our study. Early thrombosis is due to technical problems while performing the anastomosis and/or poor selection of vessels, [4] while late thrombosis usually follows outflow obstruction. Thrombectomy can be achieved surgically or pharmacologically, and the latter is at higher cost. [13],[14]

Bleeding can complicate many AVF creation procedures, but meticulous surgical technique and ensuring adequacy of HD before the procedure can prevent this complication in many of these patients. [15]

Venous hypertension results from excessive retrograde flow from the venous components of the AVF due mostly to central venous stenosis. The end result is venous insufficiency in the limb presenting as edema, pigmentation, thickened skin and, in severe cases, ulceration. Percutaneous transluminal balloon angioplasty (PTA) has become the current standard of care for the treatment of venous stenosis in patients with an AVF. [15] In our study, four patients were treated with PTA with good results.

In conclusion, an ideal AVF must provide sufficient flow for HD and be associated with minimal complications. This ideal type of AVF is still not available, but autologous AVF is the closest to fulfill this requirement. In order to minimize morbidity and cost, a multidisciplinary effort should be practiced at the goal that all patients starting HD treatment have AVF ready to be punctured as time comes to undergo HD.

Conflict of interest: None declared.

   References Top

National Kidney Foundation. NKF-K\DOQI clinical practice guidelines and clinical practice recommendations. Update 2006. Am J Kidney Dis 2006;48 Suppl 1:S177-247.  Back to cited text no. 1
Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966;275:1089-92.  Back to cited text no. 2
Yu Q, Yu H, Chen S, Wang L, Yuan W. Distribution and complications of native arteriovenous fistulas in maintenance hemodialysis patients: A single-center study. J Nephrol 2011;24:597-603.  Back to cited text no. 3
Jennings WC, Landis L, Taubman KE, Parker DE. Creating functional autogenous vascular access in older patients. J Vasc Surg 2011; 53:713-9.  Back to cited text no. 4
Windus DW. Permanent vascular access: A nephrologist's view. Am J Kidney Dis 1993; 21:457-71.  Back to cited text no. 5
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. 6
Rosas SE, Joffe M, Burns JE, Knauss J, Brayman K, Feldman HI. Determinants of successful synthetic hemodialysis vascular access graft placement. J Vasc Surg 2003;37: 1036-42.  Back to cited text no. 7
Hirth RA, Turenne MN, Woods JD, et al. Predictors of type of vascular access in hemodialysis patients. JAMA 1996;276:1303-8.  Back to cited text no. 8
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.  Back to cited text no. 9
Monroy-Cuadros M, Yilmaz S, SalazarBañuelos A, Doig C. Independent prediction factors for primary patency loss in arterio-venous grafts within six months. J Vasc Access 2012;13:29-35.  Back to cited text no. 10
Windus DW, Jendrisak MD, Delmez JA. Prosthetic fistula survival and complications in hemodialysis patients: Effects of diabetes and age. Am J Kidney Dis 1992;19:448-52.  Back to cited text no. 11
Feezor RJ. Approach to permanent hemodialysis access in obese patients. Semin Vasc Surg 2011;24:96-101.  Back to cited text no. 12
Bent CL, Sahni VA, Matson MB. The radiological management of the thrombosed arteriovenous dialysis fistula. Clin Radiol 2011;66:1-12.  Back to cited text no. 13
Padberg FT Jr, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J Vasc Surg 2008;48 5 Suppl:55S-80S.  Back to cited text no. 14
Vascular Access Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48 Suppl 1:S248-73.  Back to cited text no. 15

Correspondence Address:
Moaath Alsmady
Department of Surgery, Division of Cardiovascular Surgery, Faculty of Medicine, Jordan University Hospital, P. O. Box 2086 Aljubiha, Post Code 11941, University of Jordan, Amman
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DOI: 10.4103/1319-2442.168626

PMID: 26586061

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