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

  • Yang Gi Ryu
    Affiliations
    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
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  • Dong Kyu Lee
    Correspondence
    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.
    Affiliations
    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
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Published:December 19, 2021DOI:https://doi.org/10.1016/j.avsg.2021.12.001

      Highlights

      • 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.

      Background

      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.

      Methods

      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.

      Results

      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.

      Conclusion

      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

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