The first choice for hemodialysis access in chronic renal failure (CRF) patients is native arteriovenous fistulas (AVF). In all over the world, the experience and cumulative data gained from CRF patients yielded KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines and it was revised in 2015, stating that the main goal is creating an AVF at the most distal part of the non-dominant arm. The present study aims to represent our experience in AVF operations with preliminary results.
A total of 54 native AVF surgical procedure was created, by one general surgeon experienced in kidney transplantation, between January 2014 and January 2018, as hemodialysis access surgery for 51 CRF patients referred from Nephrology Department at Umraniye Training and Research Hospital of Health Sciences University. Only patients with previously failed AVF and/or inconclusive physical exam findings were requested preoperative color Doppler ultrasound for arm mapping. All operations were done under local anaesthesia, and a standard Cimino-Brescia shunt was created at the wrist region of non-dominant arm. In case of primary non-function or improper anatomy, AVF was created at antecubital fossa. All anastomoses were done with 6/0 or 7/0 polipropylene (prolene®, Ethicon, USA) and end to side technique was preferred. Demographics, AVF localizations, primary non-function and patency rates, postoperative complications and overall results were recorded from the patient charts.
Twenty-eight were women (54.9%) and 23 were men (45%). Mean age was 61 years (range, 46-78). Thirty-three (61.1%) were radiocephalic AVF at wrist, 19 (35.1%) were brachiocephalic and 2 (3.7%) were brachiobasilic at antecubital region. In case of non-function (no thrill sound heard), a new AVF was created at more proximal region (n = 2, 3.7%), and thrill was heard. While 51 surgical procedures (94.4%) had no complication and the patients were discharged home on postoperative second hour, oozing type bleeding and/or hematoma followed the remaining 3 procedures (5.5%) and these patients were followed up for 24 hours and then discharged. Mean follow-up period was 27 months (range 10-58). One patient with radiocephalic AVF (1.8%) had early postoperative thrombosis and he underwent brachiocephalic AVF procedure. Four patients (7.4%) had arm edema and ecchymosis in the first month postoperatively, but all resolved with medical treatment. One patient (1.8%) had wall-pilication procedure due to aneurysm developed at postoperative month 44. AVF was ligated in one patient with steal syndrome (1.8%) at 36. postoperative month. Three patients (5.5%) had infections at their incision site, but all responded well to antibiotherapy. Primary non-function and early thrombosis were only seen in our patients with narrow vein lumens (below 3 mm). The patency rate of AVF was 92.5% during follow-up period.
Both nephrologists and surgeons should follow the clinical guidelines set by KDOQI. Early results of AVF procedures done in our clinic is acceptable when compared to the related English-written literature. A vein with sufficient width (usually at or above 3 mm) seems to be the most important factor for early AVF patency.