Outcomes of Autogenous Radiocephalic Versus Brachiocephalic Arteriovenous Fistula Surgery Based on Transit-Time Flowmeter Assessment: A Retrospective Study

  • Yang Gi Ryu
    Department of thoracic and cardiovascular surgery, Korea University Guro Hospital, Korea University College of Medicine, Guro-gu, Seoul, Republic of Korea

    Department of thoracic and cardiovascular surgery, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu-si, Gyeonggi-do, Republic of Korea
    Search for articles by this author
  • Dong Kyu Lee
    Correspondence to: Dong Kyu Lee. Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, 27 Dongguk-ro, Ilsandong-gu, Goyang-si, 10326, Republic Of Korea.
    Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Guro-gu, Seoul, Republic of Korea

    Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Ilsandong-gu, Goyang-si, Republic of Korea
    Search for articles by this author
Published:December 19, 2021DOI:


      • Autogenous brachiocephalic arteriovenous fistula has merits from higher blood flow.
      • Flow related problem cause to be reluctant as primary arteriovenous fistula surgery.
      • Multimodal approach includes perioperative exercise, pulsatility index assessment.
      • Brachiocephalic fistula had superior hemodialysis access than radiocephalic.
      • Multimodal brachiocephalic and radiocephalic fistulas were similarly complicated.


      Despite the better operative results of autogenous brachiocephalic arteriovenous fistula (BC-AVF), it is considered secondary to autogenous radiocephalic AVF (RC-AVF) failure. Here we compared the results of our multidisciplinary management protocol of BC-AVF versus RC-AVF.


      A total of 194 matched patients who requested autogenous BC-AVF or RC-AVF surgery between 2017 and 2019 were included in this retrospective study. All patients strictly adhered to our departmental perioperative management protocol for AVF surgery, including vessel status monitoring, exercise with or without a tourniquet, intraoperative flow assessment, and antiplatelet and anticoagulant medications. AVF function and patient status data were acquired from the electronic medical records, and the final evaluation was made via outpatient department visit or phone call in October 2020.


      Patients who underwent elective BC-AVF or RC-AVF (n = 97 each) were included. The patient groups had similar preoperative clinical characteristics. Artery and vein sizes at the planned anastomosis site were larger in the BC-AVF group (P < 0.001). The mean intraoperative maximal flow rate was higher in the BC-AVF group (492.5 ± 186.9 mL/min) than in the RC-AVF group (307.3 ± 113.0 mL/min, P < 0.001). The simultaneously evaluated mean pulsatility index was 0.5 ± 0.2 in the BC-AVF group and 0.6 ± 0.2 in the RC-AVF group (P < 0.001). The median observation duration was 19.4 months (11.0‒31.3 months). The primary patency rate was higher in the BC-AVF group (88.7%) than in the RC-AVF group (62.9%, P < 0.001). Patency duration was similar between groups, and the primary patency maintenance duration was longer in the BC-AVF group. Three cases of cephalic arch stenosis were observed in the BC-AVF group, while no cases of arterial steal syndrome were observed during the indexed observation period. Mortality rates were 14.4% and 9.3% in the BC-AVF and RC-AVF groups, respectively (P = 0.267), and the cause of death did not differ significantly between groups. For mortality, the estimated hazard ratio of RC-AVF over BC-AVF was 0.47 (95% CI, 0.19‒1.17, P = 0.106) during the observation period.


      BC-AVF had good characteristics for hemodialysis without an increased risk of AVF related complications during a median 19-month observation period. BC-AVF did not feature high flow-related complications with the multimodal approach, including preoperative exercise, intraoperative flow assessment to guarantee an adequate flow rate, postoperative exercise, and medications


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cascardo S
        • Acchiardo S
        • Beven EG
        • et al.
        Proximal arteriovenous fistulae for haemodialysis when radial arteries are unavailable.
        Proc Eur Dial Transplant Assoc. 1970; 7: 42‒6
        • Dunlop MG
        • Mackinlay JY
        • Jenkins A.
        Vascular access: experience with the brachiocephalic fistula.
        Ann Royal Coll Surg Engl. 1986; 68: 203
        • Nazzal M
        • Neglen P
        • Naseem J
        • et al.
        The brachiocephalic fistula: a successful secondary vascular access procedure.
        Vasa. 1990; 19: 326-329
        • Rubens F
        • Wellington J.
        Brachiocephalic fistula: a useful alternative for vascular access in chronic hemodialysis.
        Cardiovasc Surg. 1993; 1: 128-130
        • Schenk III W
        Subclavian steal syndrome from high-output brachiocephalic arteriovenous fistula: a previously undescribed complication of dialysis access.
        J Vasc Surg. 2001; 33: 883-885
        • Kumar A
        • Jha MS
        • Singla M
        • et al.
        Radio-median cubital/radiocephalic arteriovenous fistula at elbow to prevent vascular steal syndrome associated with brachiocephalic fistula: review of 320 cases.
        Indian J Urol. 2007; 23: 261
        • Simon E
        • Long B
        • Johnston K
        • et al.
        A case of brachiocephalic fistula steal and the emergency physician” ’s approach to hemodialysis arteriovenous fistula complications.
        J Emerg Med. 2017; 53: 66-72
        • MacRae JM
        • Pandeya S
        • Humen DP
        • et al.
        Arteriovenous fistula-associated high-output cardiac failure: a review of mechanisms.
        Am J Kidney Dis. 2004; 43: e21.1-e21.6
        • Basile C
        • Lomonte C
        • Vernaglione L
        • et al.
        The relationship between the flow of arteriovenous fistula and cardiac output in haemodialysis patients.
        Nephrol Dial Transplant. 2008; 23: 282-287
        • Al-Jaishi AA
        • Liu AR
        • Lok CE
        • et al.
        Complications of the arteriovenous fistula: a systematic review.
        J Am Soc Nephrol. 2017; 28: 1839-1850
        • Nakayama N
        • Kuroda S
        • Houkin K
        • et al.
        Intraoperative measurement of arterial blood flow using a transit time flowmeter: monitoring of hemodynamic changes during cerebrovascular surgery.
        Acta Neurochirurg. 2001; 143: 17-24
        • Kim K-B
        • Kang CH
        • Lim C.
        Prediction of graft flow impairment by intraoperative transit time flow measurement in off-pump coronary artery bypass using arterial grafts.
        Ann Thorac Surg. 2005; 80: 594-598
        • Aleksic M
        • Matoussevitch V
        • Heckenkamp J
        • et al.
        Changes in internal carotid blood flow after CEA evaluated by transit-time flowmeter.
        Eur J Vasc Endovasc Surg. 2006; 31: 14-17
        • Lin C-H
        • Chua CH
        • Chiang SS
        • et al.
        Correlation of intraoperative blood flow measurement with autogenous arteriovenous fistula outcome.
        J Vasc Surg. 2008; 48: 167-172
        • Salimi F
        • Majd Nassiri G
        • Moradi M
        • et al.
        Assessment of effects of upper extremity exercise with arm tourniquet on maturity of arteriovenous fistula in hemodialysis patients.
        J Vasc Access. 2013; 14: 239-244
        • Kong S
        • Lee KS
        • Kim J
        • et al.
        The effect of two different hand exercises on grip strength, forearm circumference, and vascular maturation in patients who underwent arteriovenous fistula surgery.
        Ann Rehab Med. 2014; 38: 648
        • Fontseré N
        • Mestres G
        • Yugueros X
        • et al.
        Effect of a postoperative exercise program on arteriovenous fistula maturation: a randomized controlled trial.
        Hemodial Intl. 2016; 20: 306-314
        • Desai S
        • Mitra A
        • Arkans E
        • et al.
        Early application of an intermittent pneumatic compression device is safe and results in proximal arteriovenous fistula enlargement.
        J Vasc Access. 2019; 20: 24-30
        • Fitch C
        • Earle R
        • Sawka A
        • et al.
        Novel use of the Nexfin HD monitor for real-time physiological assessment of blood flow during creation of an upper extremity arteriovenous fistula.
        Can J Anaesth. 2015; 62: 1353-1354
        • Krairittichai U
        • Leetrakulpanich B.
        Assessment of blood flow in hemodialysis patients using buttonhole technique for arteriovenous fistula by ultrasound dilution.
        J Med Assoc Thai. 2012; 95: S62-S68
        • Gallieni M
        • Hollenbeck M
        • Inston N
        • et al.
        Clinical practice guideline on peri-and postoperative care of arteriovenous fistulas and grafts for haemodialysis in adults.
        Nephrol Dial Transplant. 2019; 34: ii1-i42
        • Von Elm E
        • Altman DG
        • Egger M
        • et al.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Ann Intern Med. 2007; 147: 573-577
        • Asa Z
        • Greenberg R
        • Ghinea R
        • et al.
        Grading of complications and risk factor evaluation in laparoscopic colorectal surgery.
        Surg Endosc. 2013; 27: 3748-3753
        • Therneau TM
        • Grambsch PM.
        The Cox model.
        Modeling survival data: extending the Cox model. Springer, NY, USA2000: 39-77
      1. Kassambara A, Kosinski M. Survminer: drawing survival curves using “ggplot2.” 2017. 2020.

        • Drouven J W
        • de Bruin C
        • van Roon AM
        • et al.
        Vascular access creation in octogenarians: The effect of age on outcomes.
        J Vasc Surg. 2020; 72: 171-179
        • Cyrek AE
        • Bernheim J
        • Juntermanns B
        • et al.
        Intraoperative use of transit time flow measurement improves patency of newly created radiocephalic arteriovenous fistulas in patients requiring hemodialysis.
        J Vasc Access. 2020; 21: 990-996
        • Ryu YG
        • Lee DK
        • Baek MJ
        • et al.
        Clinical value of intraoperative transit-time flow measurement for autogenous radiocephalic arteriovenous fistula in patients with chronic kidney disease.
        Ann Vasc Surg. 2016; 35: 53-59
        • Ladenheim ED
        • Lulic D
        • Lum C
        • et al.
        First-week postoperative flow measurements are highly predictive of primary patency of radiocephalic arteriovenous fistulas.
        J Vasc Access. 2016; 17: 307-312
        • Berman SS
        • Mendoza B
        • Westerband A
        • et al.
        Predicting arteriovenous fistula maturation with intraoperative blood flow measurements.
        J Vasc Access. 2008; 9: 241-247
        • Usta E
        • Elkrinawi R
        • Salehi-Gilani S
        • et al.
        Risk factors predicting the successful function and use of autogenous arteriovenous fistulae for hemodialysis.
        Thorac Cardiovasc Surg. 2013; 61: 438-444
        • Ehsan O
        • Bhattacharya D
        • Darwish A
        • et al.
        Extension technique’: a modified technique for brachio-cephalic fistula to prevent dialysis access-associated steal syndrome.
        Eur J Vawsc Endovasc Surg. 2005; 29: 324-327
        • Moini M
        • Rasouli MR
        • Nouri M.
        Ligation of the perforating vein: a treatment for steal syndrome in side-to-side elbow arteriovenous fistula.
        Ann Vasc Surg. 2008; 22: 307
        • Dixon BS
        • Novak L
        • et al.
        Hemodialysis vascular access survival: upper-arm native arteriovenous fistula.
        Am J Kidney Dis. 2002; 39: 92-101
        • Pandeya S
        • Lindsay RM.
        Relationship between cardiac output and access flow during hemodialysis.
        Asaio J. 1999; 45: 135-138
        • Hetz P
        • Pirklbauer M
        • Müller S
        • et al.
        Prophylactic ligature of AV fistula prevents high output heart failure after kidney transplantation.
        Am J Nephrol. 2020; 51: 511-519
        • Zamboli P
        • Lucà S
        • Borrelli S
        • et al.
        High-flow arteriovenous fistula and heart failure: could the indexation of blood flow rate and echocardiography have a role in the identification of patients at higher risk?.
        J Nephrol. 2018; 31: 975-983
        • Siddiky A
        • Sarwar K
        • Ahmad N
        • et al.
        Management of arteriovenous fistulas.
        BMJ. 2014; 349: g6262
        • Sivananthan G
        • Menashe L
        • Halin NJ.
        Cephalic arch stenosis in dialysis patients: review of clinical relevance, anatomy, current theories on etiology and management.
        J Vasc Access. 2014; 15: 157-162