Evidence - Dialysis access surgery: Brachiocephalic fistula (“direct antecubital fistula”) - Vascular Surgery - vascular surgery

Vascular access in hemodialysis

Fashioning the fistula – timing

Early presentation of potential hemodialysis patients to a surgeon or nephrologist is strongly recommended, so that there is enough time to protect the vein, fashion the access, perform any secondary procedures and allow the access to mature. [1, 2, 3, 4] Therefore, an AV fistula (AVF) should be fashioned three months before the scheduled start of hemodialysis.  Preparations for fashioning the AVF should begin as soon as the glomerular filtration rate (GFR) falls below 30 ml/min.

Preoperative ultrasonography of the veins and arteries

A clinical examination and ultrasound study of the arteries and veins of the arm should be performed prior to fashioning the vascular access. Diagnostic imaging of the central veins is useful in patients with a history of central venous implants (catheters, ports, cardiac pacemakers).

Preoperative ultrasonography of blood vessels increases the likelihood that the AVF can be fashioned successfully and increases the intermediate-term patency rate. In a randomized study, the primary occlusion rate of 25% in cases where the AVF was fashioned solely based on clinical examination was significantly reduced to 6% when the vessels underwent preoperative ultrasound assessment. [5] Other studies demonstrated that additional ultrasonography increased the AVF patency rates from 17–35% to 58–85% [6, 7, 8, 9] and reduced the early occlusion rate from 36% to 8%. [10]

Veins with a diameter of less than 1.6 mm suffer from frequent early-onset occlusion. [11] In radiocephalic AVF, good patency rates have been reported if the preoperative diameter of the cephalic vein at the wrist was greater than 2.0-2.6 mm or greater than 3 mm in brachial veins. [12]

The diameter of the radial artery is also a predictor of successfully fashioned AVFs. Fashioning radiocephalic AVFs in patients with a radial artery diameter of less than 1.6 mm almost always results in primary thrombosis or inadequate maturation of the fistula. [13, 14, 15]

A minimum diameter of 1.6 mm (better 2.0 mm) of the radial artery and the cephalic vein is recommended for AVFs fashioned at the wrist; no data that could be interpreted as a selection criterion is available for AVFs in the antecubital fossa.

Strategies for fashioning AVFs

The primary patency rates of AVFs and synthetic grafts differ significantly. After 1 and 2 years, these are 90% and 85% respectively for AVFs and 60% and 40% for synthetic grafts. [16] Approximately 0.2 interventions per patient per year are required to preserve native AVF function, and 1.0 per patient per year in synthetic grafts. Native AVF is therefore the vascular access of choice.

First-choice vascular access – fashioning native AVFs

The first choice is a radiocephalic AVF at the wrist, which will work for years with a minimum of complications, revisions, and interventions. The major shortcoming of this site is the high rate of early-onset occlusion (5–30%). [17, 18] Long-term function rates range from 65 to 90% at 1 year, and from 60 to 80% at 2 years. The incidences of thrombosis (0.2 events per patient per year) and infections (2%) are low.

If the AVF cannot be fashioned at the wrist due to inadequate vascular conditions, a more proximal anastomosis between the radial artery and the cephalic vein on the middle forearm up to the crook of the elbow or even at the level of the antecubital fossa is an option. AVFs at the level of the antecubital fossa allow highly efficient dialysis with a low incidence of thrombotic and infectious complications and good long-term outcomes. [19–27] One shortcoming of this high-flow AVF is the risk of inferior peripheral perfusion with symptomatic ischemia of the hand, hypercirculatory heart failure especially in patients with CHD, or cardiac insufficiency. [28]

Second-choice vascular access – grafts

If autologous AVF is not possible, grafts (alloplastic, xenogeneic, autologous) may be an option. Synthetic grafts are made of polyurethane, polyester (Dacron®) and polytetrafluoroethylene. [29] The primary patency rates in synthetic grafts range from 60% to 80% after 1 year, but drop to 30–40% after 2 years. [30, 31, 32, 33] While the primary patency rate is thus generally good, stenosis at the venous anastomosis often results in fistula thrombosis if left untreated. These stenoses are marked by intimal hyperplasia due to the immigration and proliferation of smooth muscle cells and increased matrix deposits. The etiology of the intima hyperplasia is multifactorial. [34, 35, 36]

The outcomes of autologous grafts utilizing the great saphenous vein have not been convincing. [37] Xenogeneic materials on the market with acceptable patency and low infection rates are bovine mesenteric veins and bovine ureters. [38]

Third-choice vascular access - central venous catheter (CVC)

There are only few indications for tunneled CVC as permanent vascular access: severe access-related ischemia of the upper extremities, severe heart failure, advanced malignancy.

Prognosis post AVF

Patient-related factors impacting the AVF patency rate

Patient-related characteristics can have a significant impact on the choice and prognosis of vascular access. Age may affect blood flow in an AVF, resulting in a slightly increased occlusion rate compared with young patients (18.9% vs. 13.6%). [29] The combination of age and diabetes results in a significantly higher AVF failure rate (28.6%). Epidemiologic studies have revealed a higher share of synthetic grafts in elderly patients. In Europe, for example, the use of synthetic grafts rose from 5% in patients younger than 45 years to almost 9% in patients older than 75 years. [39, 40] Since synthetic grafts are second-line vascular access devices, the frequency of revisions was correspondingly higher. [41, 42, 43]

In women with their more delicate vessels, AVFs nevertheless do not manifest poorer maturation and functional rates than in men. [44] However, studies have demonstrated that female sex was associated with increased use of synthetic grafts and a correspondingly greater number of vascular access revisions. [40, 42, 43, 45, 46, 47] 

Impact of concomitant diseases on AVFs and patency rates

The most important causes of end-stage renal failure and dialysis are diabetes and arteriosclerosis. Affected patients usually have poor, thickened, and calcified arteries with proximal and/or distal obstructions [48], complicating the fashioning of vascular access and increasing the risk of access-related symptomatic limb ischemia. Patients with diabetes also suffer from a higher incidence of AVF thrombosis. [49]

Native AVFs with good outcomes have also been described in diabetic patients, but unlike in patients without diabetes more proximal forearm and antecubital fistulae were fashioned. [27] In patients without diabetes primary patency rates were comparable, but secondary rates were better at 2 years. Ischemia was significantly more common in diabetic patients (7 vs. 0.6 per 100 patient-years).

Hemodialysis Access Surveillance Evaluation Study (HASE)

Drug Eluting Balloon for the Prevention of Hemodialysis Access Restenosis (DEB)

Safety and Efficacy of a Vascular Prosthesis for Hemodialysis Access in Patients With End-Stage Renal Disease

Drug Eluting Balloon Venoplasty in AV Fistula Stenosis (DeVA)

Comparing Catheters to Fistulas in Elderly Patients Starting Hemodialysis (ACCESS HD)

1. Allon M, Ornt DB, Schwab SJ et al (2000) Factors associated with the prevalence of arteriovenous fistulas in hemodialysis patients in the HEMO study. Hemodialysis (HEMO) Study Group. Kidney Int 58:2178–2185

2. Jungers P, Massy ZA, Nguyen-Khoa T et al (2001) Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients. Nephrol Dial Transplant 16:2357–2364

3. Ortega T, Ortega F, Diaz-Corte C et al (2005) The timely construction of arteriovenous fistulae: a key to reducing morbidity and mortality and to improving cost management. Nephrol Dial Transplant 20:598–603

4. Schwenger V, Morath C, Hofmann A et al (2006) Late referral-a major cause of poor outcome in the very elderly dialysis patient. Nephrol Dial Transplant 21:962–967

5. Mihmanli I, Besirli K, Kurugoglu S et al (2001) Cephalic vein and hemodialysis fistula: surgeon’s observation versus color Doppler ultrasonographic findings. J Ultrasound Med 20:217–222

6. Robbin ML, Gallichio MH, Deierhoi MH et al (2000) US vascular mapping before hemodialysis access placement. Radiology 217:83–88

7. Allon M, Lockhart ME, Lilly RZ et al (2001) Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients. Kidney Int 60:2013–2020

8. Dalman RL, Harris EJ Jr, Victor BJ, Coogan SM (2002) Transition to all-autogenous hemodialysis access: the role of preoperative vein mapping. Ann Vasc Surg 16:624–630

9. Schuman E, Standage BA, Ragsdale JW, Heinl P (2004) Achieving vascular access success in the quality outcomes era. Am J Surg 187:585–589

10. Silva MB Jr, Hobson RW, Pappas PJ et al (1998) A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg 27:302–307

11. Wong V, Ward R, Taylor J et al (1996) Factors associated with early failure of arteriovenous fistulae for haemodialysis access. Eur J Vasc Endovasc Surg 12:207–213

12. Brimble KS, Rabbat C, Treleaven DJ, Ingram AJ (2002) Utility of ultrasonographic venous assessment prior to forearm arteriovenous fistula creation. Clin Nephrol 58:122–127

13. Wong V, Ward R, Taylor J et al (1996) Factors associated with early failure of arteriovenous fistulae for haemodialysis access. Eur J Vasc Endovasc Surg 12:207–213

14. Malovrh M (1998) Non-invasive evaluation of vessels by duplex sonography prior to construction of arteriovenous fistulas for haemodialysis. Nephrol Dial Transplant 13:125–129

15. Malovrh M (2002) Native arteriovenous fistula: preoperative evaluation. Am J Kidney Dis 39:1218–1225

16. Hodges TC, Fillinger MF, Zwolak RM et al (1997) Longitudinal comparison of dialysis access methods: risk factors for failure. J Vasc Surg 26:1009–1019

17. Rooijens PP, Tordoir JH, Stijnen T et al (2004) Radiocephalic wrist arteriovenous fistula for hemodialysis: meta-analysis indicates a high primary failure rate. Eur J Vasc Endovasc Surg 28:583–589

18. Kherlakian GM, Roedersheimer LR, Arbaugh JJ et al (1986) Comparison of autogenous fistula versus expanded polytetrafluoroethylene graft fistula for angioaccess in hemodialysis. Am J Surg 152:238–243

19. Murphy GJ, Saunders R, Metcalfe M, Nicholson ML (2002) Elbow fistulas using autogeneous vein: patency rates and results of revision. Postgrad Med J 78:483–486

20. Murphy GJ, Nicholson ML (2002) Autogeneous elbow fistulas: the effect of diabetes mellitus on maturation, patency and complication rates. Eur J Vasc Endovasc Surg 23:452–457

21. Tordoir JH, Dammers R, de Brauw M (2001) Video-assisted basilic vein transposition for haemodialysis vascular access: preliminary experience with a new technique. Nephrol Dial Transplant 16:391–394

22. Fitzgerald JT, Schanzer A, Chin AI et al (2004) Outcomes of upper arm arteriovenous fistulas for maintenance hemodialysis access. Arch Surg 139:201–208

23. Matsuura JH, Rosenthal D, Clark M et al (1998) Transposed basilic vein versus polytetrafluorethylene for brachial-axillary arteriovenous fistulas. Am J Surg 176:219–221

24. Oliver MJ, McCann RL, Indridason OS et al (2001) Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas. Kidney Int 60:1532–1539

25. Taghizadeh A, Dasgupta P, Khan MS et al (2003) Long-term outcomes of brachiobasilic transposition fistula for haemodialysis. Eur J Vasc Endovasc Surg 26:670–672

26.  Segal JH, Kayler LK, Henke P et al (2003) Vascular access outcomes using the transposed basilic vein arteriovenous fistula. Am J Kidney Dis 42:151–157

27. Konner K, Hulbert-Shearon TE, Roys EC, Port FK (2002) Tailoring the initial vascular access for dialysis patients. Kidney Int 62:329–338

28. van Hoek F, Scheltinga MR, Kouwenberg I et al (2006) Steal in hemodialysis patients depends on type of vascular access. Eur J Vasc Endovasc Surg 32:710–717

29. Glickman MH, Stokes GK, Ross JR et al (2001) Multicenter evaluation of a polytetrafluoroethylene vascular access graft as compared with the expanded polytetrafluoroethylene vascular access graft in hemodialysis applications. J Vasc Surg 34:465–472

30. Barron PT, Wellington JL, Lorimer JW et al (1993) A comparison between expanded polytetrafluoroethylene and plasma tetrafluoroethylene grafts for hemodialysis access. Can J Surg 36:184–186

31. Tordoir JH, Hofstra L, Leunissen KM, Kitslaar PJ (1995) Early experience with stretch polytetrafluoroethylene grafts for haemodialysis access surgery: results of a prospective randomised study. Eur J Vasc Endovasc Surg 9:305–309

32. Lenz BJ, Veldenz HC, Dennis JW et al (1998) A three-year follow-up on standard versus thin wall ePTFE grafts for hemodialysis. J Vasc Surg 28:464–470

33. Garcia-Pajares R, Polo JR, Flores A et al (2003) Upper arm polytetrafluoroethylene grafts for dialysis access. Analysis of two different graft sizes: 6 mm and 6-8 mm. Vasc Endovascular Surg 37:335–343

34. Hofstra L, Bergmans DC, Leunissen KM et al (1995) Anastomotic intimal hyperplasia in prosthetic arteriovenous fistulas for hemodialysis is associated with initial high flow velocity and not with mismatch in elastic properties. J Am Soc Nephrol 6:1625–1633

35. Roy-Chaudhury P, Kelly BS, Narayana A et al (2002) Hemodialysis vascular access dysfunction from basic biology to clinical intervention. Adv Ren Replace Ther 9:74–84

36. Lemson MS, Tordoir JH, van Det RJ et al (2000) Effects of a venous cuff at the venous anastomosis of polytetrafluoroethylene grafts for hemodialysis vascular access. J Vasc Surg 32:1155–1163

37. Heintjes RJ, Eikelboom BC, Steijling JJ et al (1995) The results of denatured homologous vein grafts as conduits for secondary haemodialysis access surgery. Eur J Vasc Endovasc Surg 9:58–63

38. Widmer MK, Aregger F, Stauffer E et al (2004) Intermediate outcome and risk factor assessment of bovine vascular heterografts used as AV-fistulas for hemodialysis access. Eur J Vasc Endovasc Surg 27:660–665

39. Ridao-Cano N, Polo JR, Polo J et al (2002) Vascular access for dialysis in the elderly. Blood Purif 20:563–568

40. Rodriguez JA, Lopez J, Cleries M, Vela E (1999) Vascular access for haemodialysis-an epidemiological study of the Catalan Renal Registry. Nephrol Dial Transplant 14:1651–1657

41. Culp K, Taylor L, Hulme PA (1996) Geriatric hemodialysis patients: a comparative study of vascular access. ANNA J 23:583–590, 622

42. Gibson KD, Gillen DL, Caps MT et al (2001) Vascular access survival and incidence of revisions: a comparison of prosthetic grafts, simple autogenous fistulas and venous transposition fistulas from the United States Renal data system dialysis morbidity and mortality study. J Vasc Surg 34:694–700

43.  Polkinghorne KR, McDonald SP, Atkins RC, Kerr PG (2003) Epidemiology of vascular access in the Australian hemodialysis population. Kidney Int 64:1893–1902

44. Caplin N, Sedlacek M, Teodorescu V et al (2003) Venous access: women are equal. Am J Kidney Dis 41:429–432

45. Enzler MA, Rajmon T, Lachat M, Largiader F (1996) Long-term function of vascular access for hemodialysis. Clin Transplant 10:511–515

46. Hirth RA, Turenne MN, Woods JD et al (1996) Predictors of type of vascular access in hemodialysis patients. JAMA 276:1303–1308

47. Fisher CM, Neale ML (2003) Outcome of surgery for vascular access in patients commencing haemodialysis. Eur J Vasc Endovasc Surg 25:342–349

48. Kim YO, Song HC, Yoon SA et al (2003) Preexisting intimal hyperplasia of radial artery is associated with early failure of radiocephalic arteriovenous fistula in hemodialysis patients. Am J Kidney Dis 41:422–428

49. Windus DW (1993) Permanent vascular access: a nephrologist’s view. Am J Kidney Dis 21:457–471