Distal ulnar-basilic fistula as the first hemodialysis access

Ulnar-Basilic Arteriovenous Fistula for Hemodialysis Access: Utility as the "Second Procedure" after Radio Cephalic Fistula

Objectives: As per standard guidelines, the recommended order of arteriovenous fistula (AVF) creation for hemodialysis (HD) access is radiocephalic (RC), followed by proximal elbow fistulas and arteriovenous graft. Although ulnar-basilic (UB) fistula has been an alternative to RC-AVF, still this procedure searches clear recommendations. We present here our experience on UB-AVF as the preferred “second procedure” instead of proximal fistula after the RC-AVF.

Methods: Forty-two UB-AVF were created in nonfeasible and failed RC-AVF cases between 2016 and 2018. They were reviewed retrospectively and outcomes were compared with 480 RC-AVF constructed within the same period.

Results: The primary patency at 18 months was 73.8%, 69.6% and mean maturation time was 33.7±6.6 days, 32.1±4.7 days for UB-AVF and RC-AVF respectively (p>0.05).

Conclusion: Our altered order of preference enabled us to create all the first-time fistula in the distal forearm, providing all the advantages of distal fistula like RC-AVF and avoiding proximal fistula, improved patient convenience and short-term benefit. In an inference that may be used for references and needs support from a larger sample and longer duration study from other centers, UB-AVF may be considered as the second option after RC-AVF depending on the clinical scenario.

Long-Term Results of Ulnar-Basilic Fistula Versus Radiocephalic Fistula for Maintenance Hemodialysis Access

OBJECTIVE

The aim of this study is to compare the rate of primary patency and secondary patency achieved by ulnar-basilic arteriovenous fistula (UBAVF) and radiocephalic arteriovenous fistula (RCAVF) in the maintenance of hemodialysis access.

METHODS

This retrospective analysis consists of 365 patients who had a forearm UBAVF or RCAVF between January 2012 and December 2015. Of these patients, 44 patients were treated with UBAVF, while 321 patients were treated with RCAVF. Demographics, primary patency, and secondary patency were documented and compared.

RESULTS

Primary patency rates at 1 and 2 years were 77.2% and 63.9% in group UBAVF and 88.1% and 71.3% in group RCAVF, respectively. Secondary patency rates at 1 and 2 years were 93.0% and 78.8% in group UBAVF and 98.7% and 80.9% in group RCAVF, respectively. The Kaplan-Meier analysis showed that the primary and secondary patency rates were all without statistical difference between the 2 groups.

CONCLUSION

Given the similar patency rate between UBAVF and RCAVF, the UBAVF could be considered as a reliable alternative when an RCAVF is not possible.

Arteriovenous Access: Infection, Neuropathy, and Other Complications

Complications of vascular access lead to morbidity and may reduce quality of life. In this module, we review both infectious and noninfectious arteriovenous access complications including neuropathy, aneurysm, and high-output access. For the challenging patients who have developed many complications and are now nearing their last vascular access, we highlight some potentially novel approaches.

Efficacy of the Ulnar-Basilic Arteriovenous Fistula for Hemodialysis: A Systematic Review

BACKGROUND

The fistula first initiative has promoted arteriovenous fistulas (AVFs) as the vascular access of choice. To preserve as many future access options as possible, multiple guidelines advocate that the most distal AVF possible should be created in the first place. Generally, snuff box and radiocephalic (RC) are accepted and well-described sites for AVFs; however, the forearm ulnar-basilic (UB) AVF is seldom used or recommended. The aim of this study is to assess and systematically review the evidence base for the creation of the UB fistula and to critically appraise whether more attention should be given to this site.

METHODS

Electronic databases were searched for studies involving the creation of UB fistulas for dialysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes for this study were 1-year primary and secondary patency rates. Secondary outcomes were rates of hemodialysis access-induced distal ischemia (HAIDI) and infection.

RESULTS

After strict inclusion and/or exclusion criteria by 2 reviewers, 8 studies were included in our review. Weighted-pooled data reveal 1-year primary patency rate for UB AVFs of 53.0% (95% confidence interval [CI]: 40.1-65.8%) with a secondary patency rate of 72.0% (95% CI: 59.2-83.3). HAIDI and infection rates were low.

CONCLUSIONS

Our review has shown that the UB AVF may be a viable alternative when a RC AVF is not possible, and dialysis is not required urgently. It has adequate 1-year primary and secondary patency rates and extremely low risk of HAIDI. While it may be more challenging for both surgeons and dialysis nurses to make it a successful vascular access it offers a further option of distal access which may be overlooked.

Promising Results of the Forearm Basilic Fistula Reveal a Worthwhile Option between Radial Cephalic and Brachial Fistula

BACKGROUND

Use of the forearm basilic vein for the creation of an arteriovenous fistula has been codified as second-choice vascular access for hemodialysis in the last clinical guidelines of the Society for Vascular Surgery in 2008. Poor literature data on this technical option and on its evaluation and outcomes led us to initiate a retrospective single-center study.

METHODS

We analyzed the outcomes of every arteriovenous fistula using the forearm basilic vein created in our department. It is a retrospective study in which we collected data prospectively by contacting dialysis centers, nephrologists, and patients. Primary end point was primary patency rate at 1 year. Secondary end points were secondary patency rate at 1 year, time of maturation, and Doppler flow measurement before the first puncture.

RESULTS

From February 2004 to June 2014, 49 forearm basilic arteriovenous fistulas were created: 33 ulnar-basilic and 16 radial basilic arteriovenous fistulas. Initial technical success rate was 98%. Functional success rate was 60%. Primary and secondary patency rates at 1 year were respectively 21% and 48%. Median time of maturation was 81 days, and mean Doppler flow measurement was 678 mL/min. Ulnar-basilic fistulas had a statistically significant shorter time of maturation than radial basilic fistulas (P ≤ 0.05).

CONCLUSIONS

Despite poor primary patency rate and a long time of maturation, forearm basilic arteriovenous fistula has satisfactory secondary patency rate and keeps all the advantages of a distal-located vascular access concerning complications. It is worth its second-choice place in the current algorithm of creation of vascular access for hemodialysis.

Modified Miller Banding Procedure for Managing High-flow Access and Dialysis-associated Steal Syndrome

Purpose

Both high-flow vascular access (VA) and dialysis-associated steal syndrome are serious complications requiring a flow reduction technique. We adopted the minimally invasive limited ligation endoluminal-assisted revision (MILLER) banding procedure with some modifications to control the high blood flow and steal syndrome during VA procedures and retrospectively assessed the outcome.

Methods

Seven patients with high-flow access (access flow >1400 ml/min) and five patients with steal syndrome (with pain, coldness, or cyanosis) were treated using the MILLER banding method. Flow volume of the brachial artery was monitored using Doppler ultrasonography during the banding procedure. In patients with steal syndrome, the finger probe of a pulse oximeter was attached to a finger on the ipsilateral side, and the peripheral oxygen saturation (SpO2) was monitored.

Results

In the high-flow group, the mean access blood flow (Qa) decreased from 2043 ± 463 ml/min (mean ± SD) to 1248 ± 388 ml/min (p<0.001). In the steal syndrome group, the SpO2 value improved in all steal syndrome patients after banding. Symptoms were almost relieved in two steal syndrome patients. The Qa in the steal group decreased from 997 ± 867 to 548 ± 376 ml/min (p = 0.12). The secondary patency rates of the high-flow and steal groups at 6 months were 83.3% and 50%, respectively.

Conclusions

The MILLER banding procedure with intraoperative access flow monitoring is effective to treat high-flow VA and steal syndrome.