Autologous arteriovenous fistula is gold standard to maintain vascular access for hemodialysis patients. As per the Kidney Disease Outcomes Quality Initiative guidelines, distal veins are preferred as the first choice. In this study, a total of patients and fistulas were evaluated from April to March Demographic factors and clinical factors were taken into consideration. Our study showed that age, sex, diabetes, and type of construction end-to-side vs. Intradialytic hypotension was one of the risk factors for loss of fistula patency.
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The survival of patients on long-term hemodialysis has improved. End-stage renal disease patients now need maintenance of their vascular access for much longer periods. Arteriovenous fistulae formed at the wrist are the first choice for this purpose, but, in many patients, these fistulae fail over time or are not feasible because of thrombosed veins.
We searched the Pubmed database to evaluate the various options of vascular access in this group of patients based on the published literature. It is quite evident that, whenever possible, autogenous fistulae should be preferred over prosthetic grafts. Use of upper arm cephalic and basilic veins with transpositions wherever required can enhance autogenous fistula options to a large extent. Upper arm grafts should be used when no autogenous fistula is possible.
Lower limb and body wall fistula sites are to be considered at the end, when all options in both upper limbs are exhausted. Autogenous arteriovenous fistulas AVF are the preferred mode of vascular access for maintenance hemodialysis HD in patients with end-stage renal disease ESRD because of their good long-term patency and low complication rate.
As the life expectancy of patients on long-term HD has improved with better healthcare facilities, most of them now stay on maintenance HD for much longer periods of time. Their vascular access also needs maintenance and management of various related complications. There is a large group of patients in whom Brescia-Cimino AVF has either failed in both upper limbs or is not feasible because of unsuitable veins. The best possible approach in the management of these patients to get a good long-term vascular access has been a matter of debate and discussion over the years.
The aim was to review the literature on the subject that is of prime importance in the care of patients with ESRD. Our main focus was on autogenous fistulae and grafts either in the upper or in the lower limbs.
After failure or nonfeasibility of distal radiocephalic AVF, consideration should be given to more proximal sites in the forearm. Direct radiocephalic fistula at a more proximal site in the forearm can be constructed. Heavily calcified or atherosclerosed arteries are responsible for the high rate of nonmaturation of distal radiocephalic fistulae in diabetic patients.
Asif et al. If the cephalic vein is not available, the forearm basilic vein is the next option. But, owing to its posteriomedial position, transposition is almost always required. Recently, Son et al. The secondary patency rates were Clearly, fistulae created by basilic vein transposition have acceptable patency rates. Moreover, thromboses and infectious complications are less than grafts.
Weyde et al. The primary patency rate was They concluded that basilic vein AVF was a valuable option where radiocephalic fistula has failed. The authors also felt that the forearm transpositions for AVF formation were underutilized. Antecubital vein is another option for formation of autogenous AVF in the forearm. The median antecubital vein may be used directly or its perforator branch may serve that purpose, as described by Gracz. They also concluded that proximal radial artery-perforating vein fistulas have an acceptable survival rate and do not produce circulatory complications.
The advantage of this type of an AVF is that it provides multiple outflows for cannulation as both cephalic and basilic veins get arterialized in the arm. The main veins in the arm remain preserved for future AVF construction.
Once the forearm veins are exhausted, the focus shifts to the upper arm. As in the forearm, the cephalic vein is preferred over the basilic vein for AVF because of its lateral position, which makes cannulation easy. In addition, the cephalic vein is relatively superficial and transposition is seldom required. Arterial inflow may come from either brachial or proximal radial artery, with the latter having the advantage of less chance of limb ischemia.
Elcheroth et al. If the cephalic vein is not available in the upper arm, the basilic vein is selected for fistula creation. Only a small part of the basilic vein above the antecubital crease is superficial, while the rest of it is running deep to the fascia.
This position protects the basilic vein from frequent venipunctures and, hence, it is usually patent and available for AVF formation. At the same time, the sub-fascial position of this vein makes its transposition to a more superficial and anterior position mandatory while formation of AVF to facilitate cannulation during HD access.
Some authors have tried simple elevation of basilic vein in its anatomical position instead of transposition. Humphries et al. In case of elevation, it is better to raise a flap of the skin and position the basilic vein somewhat away from the incision so that surgical scar does not hinder palpation and cannulation of the vein later on. The brachiobasilic AVF can be created in a single stage or in a two-staged manner. In the two-stage method, the first stage involves anastomoses of the basilic vein to brachial artery in antecubutal fossa without mobilizing its proximal part.
In the second stage, after 4—8 weeks, the arterialized vein is mobilized up to the axilla and transposed to the desired position. The idea is to avoid extensive dissection of the thin-walled vein in the first stage to prevent injury and decrease the chance of thrombosis.
Francis et al. El Mallah reported better outcomes with the staged procedure in a prospective randomized trial comparing single-stage and two-stage brachiobasilic transposition AVF. In a similar study, Kakkos et al. Arroyo et al. Many workers have tried to make the procedure less morbid. One option is to make two or three small skip incisions instead of a long incision to dissect the basilic vein from its bed.
Similarly, dissection of the vein using an endoscopic technique has also been described but, somehow, it has not become popular. Bazan et al. Seventeen patients developed temporary edema of the forearm during the first month, in three cases the edema extended to the entire arm, but no other complications were associated with the procedure. Brachial vein is situated quite deep in the upper arm. Moreover, because of its limited available length, we suggest that formation of brachiobrachial AVF and its transposition should be undertaken only by surgeons with a good amount of experience in vascular access surgery.
This technique is relatively new and more experience is required before its wider use could be recommended. In general, lower limb AVF is created only when it becomes absolutely necessary because of exhaustion of all upper limb options.
This is because more complex surgical procedures are required in the lower limb for AVF creation. In addition, ischemic and infective complications requiring intervention are also more common in the lower limb. Saphenous or superficial femoral veins are commonly used for autogenous AVF construction in the lower limb, and arterial inflow is usually provided by either common femoral or superficial femoral arteries.
Transposition is always required. Although use of posterior and anterior tibial arteries is also mentioned for creation of AVF at the ankle, the published data about patency and complication rates is scant. The saphenous vein is transposed either straight or in a loop fashion to make AVF. There are conflicting results in the literature about the outcome of sapheno-femoral-transposed fistulae.
Lynggaard reported very poor patency rates and unacceptably high complications in their series. The fistula was functional for hemodialysis in All patients developed stenoses within the saphenous vein loop, with a mean of 3. Three secondary surgical procedures were performed two pseudoaneurysm repairs, one vein patch angioplasty.
It appears from the available data that straight transposition of saphenous vein has better outcomes compared with loop configuration. Overall, the saphenous vein does not seem to be a very reliable venous conduit for AVF creation. Just like the saphenous vein, the superficial femoral vein can also be transposed either straight or in a loop fashion to create AVF. Gradman et al. They had a high incidence of ischemic complications. One of their patients eventually had an above-knee amputation after experiencing an acute compartment syndrome.
Eight patients required a second operation to alleviate a symptomatic steal syndrome. In conclusion, although patency rates were quite good, a high incidence of limb ischemia was the major impediment.
Later, the same authors published their further experience with 55 cases of transposed femoral vein. They reported a significant reduction in ischemic complications requiring intervention with refinement of the technique. To the best of our knowledge, there are no studies comparing saphenous and superficial femoral veins directly.
Although the reported patency rates are higher for superficial femoral vein, it has a high incidence of limb ischemia. More comparative studies are required in this field. The extent of use of prosthetic material for creation of AVF has varied significantly from one part of the world to the other. Whereas most parts of Europe have used grafts only to a limited extent, in the United States, there has been a fairly high usage of grafts in AVF construction.
The graft is then tunneled subcutaneously from one incision to the other and both ends are anastomosed end-to-side to the planned vessels. Prosthetic grafts have inferior primary and secondary patency rates and higher incidence of some complications such as infections and thrombosis compared with autogenous fistulae. Prosthetic grafts can be used in the upper limb for construction of AVF in three basic configurations. In the straight variety, the distal radial artery provides inflow and venous outflow is through the antecubital vein.
Loop graft is performed between brachial artery and antecubital vein. The upper arm grafts are placed between the brachial artery in antecubital fossa and the axillary or brachial vein in axilla. Keuter et al. The rate of complications was 1. Other investigators have also confirmed the superiority of upper arm autogenous fistulae over forearm grafts.
Many studies have compared upper arm autogenous fistulas with upper arm grafts.
A Milestone in Hemodialysis: James E. Cimino, MD, and the Development of the AV Fistula
Introduction: Stenosis of the vein close to the arteriovenous anastomosis is the most frequent cause for late failure of Brescia-Cimino fistulae BCF. Although since decades proximal re-anastomosis has been regarded as the surgical standard treatment, success rates can hardly be deducted from the literature. Considering the increasing activities of interventional radiologists surgical position finding seems necessary. Methods: Over three years 30 anastomotic BCF stenoses were treated in 28 patients. In 15 patients the stenosis had caused fistula thrombosis.
Hemodialysis vascular access options after failed Brescia-Cimino arteriovenous fistula
A Cimino fistula , also Cimino-Brescia fistula , surgically created arteriovenous fistula and less precisely arteriovenous fistula often abbreviated AV fistula or AVF , is a type of vascular access for hemodialysis. It is typically a surgically created connection between an artery and a vein in the arm, although there have been acquired arteriovenous fistulas which do not in fact demonstrate connection to an artery. The procedure was invented by doctors James Cimino and M. Brescia in Between treatments, the needles were left in place and the tube allowed blood flow to reduce clotting. But Scribner shunts lasted only a few days to weeks.
[The Stenosed Brescia-Cimino Fistula: Operation or Intervention?]
A pioneering physician looks back on one of the most important achievements of his life. Cimino, MD, one recent morning, glancing down at his Mickey Mouse watch to make sure he was on schedule. Although he officially retired from his position as director of the Palliative Care Institute at CalvaryHospital in the Bronx in , Dr. Cimino, 78, is lively, engaged, and continues to meet regularly with medical students and work on special projects.