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
KEYWORDS
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Article Info
Publication History
Published online: December 19, 2021
Accepted:
December 3,
2021
Received in revised form:
December 1,
2021
Received:
August 27,
2021
Footnotes
Identification
Copyright
© 2021 Published by Elsevier Inc.
