Primary Vascular Access Surgery in a Well Defined Geographical Region: Long-Term Results of Autogenous Arteriovenous Fistulas

Long-term outcomes of the 'primary extension technique' in the prevention of Steal syndrome

PURPOSE

To report our 13 years of experience with the 'primary extension technique' for the prevention of dialysis-associated steal syndrome.

METHODS

All diabetic patients undergoing upper arm autogenous elbow fistula formation using the primary extension technique between September 2001 and September 2014 at a single centre were included. At follow-up all patients were evaluated for patency, adequacy of needling and the presence or absence of steal symptoms. In primary extension technique, the fistula is formed by anastomosing the median cubital vein with the proximal radial or ulnar artery just below the brachial artery bifurcation.

RESULTS

In total, 64 operations of the primary extension technique were included in this study. All patients were diabetic. Primary failure was 5%, follow-up 23-84 months. Nine patients (14%) developed cephalic vein thrombosis. In these cases, the basilic vein was successfully transposed to the existing fistula. In eight patients (12.5%), the cephalic vein required superficialisation. In three patients, the flow was preferentially into the basilic vein with poor maturation of cephalic vein. Of these three patients, there was a small proximal cephalic vein in one patient and stenosis in the other two patients. One patient who developed dialysis-associated steal syndrome is included in the results as they were listed for primary extension technique fistula formation but in fact did not have their fistula formed using primary extension technique. Instead, the anastomosis was formed proximal to the bifurcation of the brachial artery. Symptoms improved with revision of the fistula.

CONCLUSION

Our 13-year experience demonstrates that the primary extension technique is a safe and effective procedure for fistula formation. Patency rates are comparable to brachio-cephalic and brachio-basilic fistulas and primary extension technique is effective in the prevention of dialysis-associated steal syndrome.

Outcomes of initial hemodialysis access surgery in an Asian population

PURPOSE

Access-related morbidity contributes substantially to the costs of hemodialysis. The aim of this study was to examine the outcomes of initial hemodialysis access surgery at a single center in Singapore and to analyze factors which might influence survival of the surgically-created access.

METHODS

Patients undergoing their first hemodialysis access operations between January 2003 and December 2007 were retrospectively identified. Primary and assisted primary patency rates were determined by the Kaplan-Meier method. Data on age, sex, diabetic status, and prior tunneled central venous catheter (CVC) use were analyzed against the outcome of arteriovenous fistulas (AVF).

RESULTS

During the study period, 410 primary upper limb access operations were performed: 297 forearm AVF (72.4%), 91 upper arm AVF (22.2%), and 22 arteriovenous grafts (AVG; 5.4%). Men comprised 55.4%, 271 (66.1%) had diabetes, and 316 patients (77.1%) came to surgery with pre-existing CVC. Sixty-two percent of forearm AVF and 67% of arm AVF were used successfully. Age, sex, diabetes, and prior use of a CVC did not significantly affect the ability to use an AVF. Only in the female diabetic subgroup was an earlier loss of primary assisted patency of AVF recorded.

CONCLUSIONS

In our Asian population, we have demonstrated AVF patency rates equivalent to those of international centers. We now face the challenge of achieving a higher rate of pre-emptive AVF placement with a subsequent reduction in CVC use.

Successful Access Rate and Risk Factor of Vascular Access Surgery in Arm for Dialysis

PURPOSE

Preservation of adequate vascular access is of vital importance for patients undergoing chronic dialysis in renal failure. The aim of this study is to evaluate the successful access rate and risk factors of arteriovenous fistula (AVF) in the arm for dialysis at a single center.

MATERIALS AND METHODS

Patients undergoing vascular access operation between January 2006 and December 2011 were retrospectively identified.

RESULTS

A total of 362 vascular access operations were performed. There were 338 autologous AVFs (93.4%) and 24 prosthetic grafts (6.6%). Men comprised 58.3% of all subjects. Mean age was 59.5±14.7 years. There were 187 diabetes mellitus patients (51.7%). There was a mean duration of 70.3±21.1 days between access creation to first cannulation. Overall successful access rate for dialysis was 95.9%. Of 338 autologous AVFs, 326 patients had patent AVFs for dialysis (96.4% surgical success rate), while 21 of 24 prosthetic grafts were patent (87.5% surgical success rate). A total of 141 patients (38.9%) came to surgery with preoperative central venous catheters (CVC) of which 130 (35.9%) AVFs had a patent fistula in the arm. The only risk factor related to successful access rate of AVF was preoperative CVC placement (P=0.012).

CONCLUSION

Successful vascular access rate was 95.9%. The only risk factor related to patent access of AVF was preoperative CVC placement. At least 6 months prior to expected dialysis, AVF surgery is recommended, which may overcome the challenge of co-morbid conditions from having a preoperative CVC.

Primary Vascular Access

Primary vascular access is usually achievable by a distal autogenous arterio-venous fistula (AVF). This article describes the approach to vascular access planning, the usual surgical options and the factors affecting patency.

‘Extension Technique’: A Modified Technique for Brachio-Cephalic Fistula to Prevent Dialysis Access-Associated Steal Syndrome

OBJECTIVES

To describe a modification in brachio-cephalic fistula formation for prevention of dialysis access-associated steal syndrome (DASS).

DESIGN

Short report.

MATERIALS

From September 2001 to December 2003, 32 upper arm autogenous fistulae were formed using the 'extension technique' in patients at high-risk for developing DASS i.e. diabetics.

METHODS

In this technique, the fistula is formed by anastomosing the median vein to the radial or ulnar artery just below the brachial bifurcation, thus preserving part of the blood supply to the hand, to prevent steal syndrome. All patients were evaluated for patency, adequacy of needling and the absence of steal symptoms.

RESULTS

Only 1 patient (3.1%) developed DASS. On investigation, he was found to have the fistula formed distal to the origin of a posterior branch with the bifurcation further distally. Symptoms improved with revision of the fistula. Thrombosis of the cephalic vein (6.2%), difficulty in needling (3.1%) and deep cephalic vein in upper arm that required superficialization (15.6%) were the other complications noted.

CONCLUSIONS

The 'extension technique' has been found to be a safe and effective procedure for prevention of DASS, with a good patency rate. Additional advantage of this technique is maturation of both cephalic and basilic veins.

Radial artery as a conduit for coronary artery bypass graft

Since its resurgence in the 1990s, some 30 years after its abandonment as an alternative conduit, the radial artery has rapidly gained popularity. This article describes the application of this conduit in coronary grafting and details the controversies surrounding its use. A historical account as well as technical aspects such as operative technique are also discussed.