LETTER TO THE EDITOR
Year : 2015 | Volume
: 26 | Issue : 1 | Page : 135--136
Arterovenous fistula creation using the brachial artery and cubital fossa veins: A viable option in our environment
U Abubakar1, HM Liman2, AM Makusidi2, NP Agwu3, AC Opara4, N Musa1, PA Nazish1, IR Jamalu1, OO Opara1, SI Ukwuani1,
1 Cardiothoracic Surgery Unit, Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Nephrology Unit, Department of Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
3 Urology Unit, Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
4 Plastic Surgery Unit, Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
Dr. U Abubakar
Cardiothoracic Surgery Unit,Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, P.O. Box 1601, Sokoto
|How to cite this article:|
Abubakar U, Liman H M, Makusidi A M, Agwu N P, Opara A C, Musa N, Nazish P A, Jamalu I R, Opara O O, Ukwuani S I. Arterovenous fistula creation using the brachial artery and cubital fossa veins: A viable option in our environment.Saudi J Kidney Dis Transpl 2015;26:135-136
|How to cite this URL:|
Abubakar U, Liman H M, Makusidi A M, Agwu N P, Opara A C, Musa N, Nazish P A, Jamalu I R, Opara O O, Ukwuani S I. Arterovenous fistula creation using the brachial artery and cubital fossa veins: A viable option in our environment. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Apr 15 ];26:135-136
Available from: https://www.sjkdt.org/text.asp?2015/26/1/135/148762
To the Editor,
It is customary to first create an arteriovenous fistula (AVF) at the anatomical snuffbox, or in the wrist, and then as a second choice in the cubital fossa.  The forearm and upperarm veins suitable for placement of vascular access as such should not be used for venopuncture or for the placement of intravenous catheters, subclavian catheters or a peripherally inserted central catheter. In our environment, the patients' veins are constantly used for infusions, medications and samples for routine investigations. These further cause thrombosis of the wrist and forearm veins. We present our initial experience with cubital fossa AVF creation using the brachial artery and cubital fossa veins in emerging cardiovascular and nephrology units of a tertiary teaching hospital in subSaharan Africa. This is a prospective study of patients with chronic kidney disease who had AVF creation using the brachial artery and any of the cubital fossa veins at the Usmanu Danfodiyo University Teaching Hospital Sokoto, Nigeria, for hemodialysis between January 2012 and November 2012.
To create the cubital AVF, we performed a side-to-side anastomosis between the brachial artery and any of the cubital veins. The patients were discharged on the same day.
A total of 20 patients had cubital AVF creation during the period of the study. There were 14 males and six females, and the mean age was 43.7 years. The cause of end-stage renal disease (ESRD) was chronic glomerulonephritis in ten (50%) patients, followed by hypertension in five (25%) patients and diabetes in three (15%) patients. Eight patients (40%) had previous AVF creations, which were placed on the wrist/forearm either in our hospital or in other hospitals. Fifteen patients (75%) had the fistula created on the left upper limb and five (25%) patients had the fistula created on the right upper arm. The mean duration for the maturation of our AVFs was seven weeks, with a range of four to 10 weeks. The patency rate at nine months was 55% (11 patients). The recorded complications included superficial wound infection in two patients and hematoma in one patient. Mortality included seven (35%) patients from complications of ESRD. Two (10%) patients were lost to follow-up and 11 (55%) patients remained alive and had patent and functional AV fistulae on regular hemodialysis.
Distal arm AVFs are likely to fail when the arterial diameter is < 1.6 mm.  Use of preoperative vein mapping increases the rate of AVF creation; however, it is limited in its ability to evaluate the central veins for stenosis or occlusion.  Autogenous elbow fistula utilizing the brachial artery and the cephalic or basilic veins in the upper extremities have been shown to represent a high-quality hemodialysis access. , The veins at the elbow have a wide diameter, are more in number and rarely get thrombosed. The cephalic vein has been reported to be the best available native conduit, with 90% patency at one year and 50-80% by three to five years, and its preference for AVFs had been confirmed.  Five anatomic variations of the cephalic vein have been reported.  With these anatomic variations, successful creation of AVF at the elbow is guaranteed.
Our patency rate was 55% at nine months. Our finding corresponds to that observed by Jason et al,  who reported a primary patency rate of 50% and assisted patency rate of 74%, all at 12 months. There are some reports showing that the wrist AVFs often fail to mature due to factors such as diabetes, peripheral vascular disease, advanced age and frequent venopuncture.  Diabetes mellitus and age did not affect our patency as only three patients presented with chronic kidney disease due to diabetic nephropathy and most of our patients were in their fourth decade of life. We were only able to follow-up 11 patients for a period of seven months because most of our patients succumbed to chronic kidney disease. This can be attributed to the fact that there are very few dialysis centers that could cope with the increased number of patients requiring these services. Another factor is poverty, because most patients could not afford to pay for dialysis. The average cost per session is estimated at 130-150 USD, which is beyond the reach of a common man in Nigeria. This is contrary to what is obtainable in other parts of the world where patients outlive their first hemodialysis access port and require creation at other sites. 
Conflict of interest: None
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