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Retrospective Study of Autologous Arteriovenous Fistula 
Creation as Vascular Access for Hemodialysis 

Journal of College of Medical Sciences-Nepal, Vol-19, No 1, Jan-Mar 2023
ISSN: 2091-0657 (Print); 2091-0673 (Online) Open Access 

DOI: 10.3126/jcmsn.v18i4.50275

Bijay Sah,1 Lokesh Shekhar Jaiswal,1 Rakesh Kumar Gupta1

1Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.

Original Research Article

Correspondence: Dr. Bijay Sah, Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.  
Email: bijaysah@hotmail.com. Phone: +977-9841410061.

ABSTRACT

Introduction

An autologous arteriovenous fistula (AVF) creation is a common vascular procedure for 
hemodialysis (HD) patients. This surgical procedure aim is to design a vascular conduct that 
withstands hemodialysis for a durable period. However, the functional outcome of this procedure 
varies and depends on patients’ various predictors. .

Methods

A retrospective observational study was carried out to evaluate the functional outcome of AVF 
creation at the cardiothoracic vascular surgery unit of the surgery department of B.P Koirala 
Institute of Health Sciences from February 2019 to February 2020. The medical file of the patients 
was studied, relevant data entered and analyzed in SPSS statistical software. 

Results

There were a total of 112 autologous AVF created during the study period. The mean age of 
the patients was 48.66±15.64 years. There were 75(67%) males and 37(33%) females. The most 
common limb of fistula creation was left non-dominant upper limb 95(84.8%) and right upper limb 
17(15.2%). The most common type of AVF was radiocephalic fistula 66(58.9%) and brachiocephalic 
fistula 46(41.1%). There were 92(82.1%) mature fistula at eight weeks follow-up. These include 
54(48.2%) radiocephalic fistulas and 38(33.9%) brachiocephalic fistulas. There were 20(17.8%) 
delayed matured fistulas at 12 weeks (12 radiocephalic and 8 brachiocephalic AVF). 

Conclusions 

The creation of an autologous AVF for hemodialysis in the upper limb has fewer complications and 
the maturation of the AVF depends on the vessel’s diameter. Radio-cephalic and Brachiocephalic 
AVF usually matures between six to eight weeks duration. 

Keywords: Arteriovenous Fistula (AVF); Autologous Vascular Access; End Stage Renal Disease 
(ESKD); Haemodialysis Vascular Shunts.



JCMS | Vol-19 | No 1 | Jan-Mar 2023124

INTRODUCTION   

Autologous arteriovenous fistula (AVF) creation 
is a common procedure for hemodialysis patients 
considered as gold standard vascular access.2 
AVF is the backbone of hemodialysis patients 
and improves the  quality of life as compared 
to other forms of access.3,4 The national kidney 
foundation guidelines recommend  assessment 
and creation of autologous AVF for long-term 
hemodialysis patients with end-stage kidney 
disease (ESKD) when  eGFR is 15 to 20  mL/1.73 
min2 with progressive poor renal function.1  

AVF creation, its maturation rate, and long-term 
patency is influenced by various factors. Size of 
the vessels, its inflow and outflow rate plays an 
important role in placement and development 
of AVF.5,6 Preoperative clinical examination and 
duplex ultrasound in selected high-risk patients 
is important in selecting types and location of AV 
fistula. It also establishes  any abnormalities in 
the arterial and venous network of upper limb, 
especially in patients with vascular disease and 
diabetes where clinical examination alone can be 
inadequate .7,8 

A period of six to eight weeks after autologous 
fistula creation is a frivolous interval where 
the fistula heals and matures for hemodialysis 
procedure.6,7 The ideal fistula access must be a 
minimum of six millimeter in diameter, have 
six-millimeter depth from skin and should 
have blood flow greater than 600 ml/min. 9 
After description of  autologous AVF procedure 
by Cimino and Brescia in 1966, there has been 
lots of modifications and configurations in the 
procedure with variable outcomes.7,10  

Radiocephalic and brachiocephalic AVFs are 
the two most common  types of AVFs for 
hemodialysis.9,12,13  Aim of the article is to identify 
some of the important details that determine the 
maturation of the procedure. 

METHODS

This was a single-center, retrospective 
observational study, conducted by reviewing 
the medical files of the patients with inclusion 
criteria as end-stage renal disease (ESKD) and 
AVF creation, under cardiothoracic vascular 
surgery unit of B.P Koirala Institute of health 
sciences from February 2019 to February 2020 . 
The patients with small size vessels or unfit for 
the procedure were excluded. The study was 
conducted after obtaining clearance from the 
Institutional Review Committee of B.P. Koirala 
Institute of Health Sciences (IRC/1776/020). 

Preoperative Assessment: 

All the ESKD patients routinely underwent 
complete general examination and focused 
local assessment of veins and artery of the 
upper limbs from distal to proximal for type 
and location of AVF creation. A two-minute 
tourniquet test for venous distensibility, an Allen 
test for palmar arch patency and tests for central 
venous occlusion were carried out. Whenever in 
doubt, vessel mapping for vascular access was 
performed and vessels marked preoperatively. 

Patients having inadequate vessel size (artery 
diameter <1.5mm and vein diameter <2mm) and 
the recent prick or injury to the vessels were 
followed up later. AVF creation was planned 
after a written consent under adequate local 
anesthesia using 2% Xylocaine injection and 
follow- up at one week, and then monthly for 
three months. 

Surgical Techniques 

Once the suitable vein and artery was selected 
in the wrist or elbow, the next important step 
was to design or create the fistula. Forearm 
was preferred than arm for AVF site whenever 
suitable. The radial artery and cephalic vein in 
the wrist were exposed by a single two to three 
centimeters transverse incision. The dissection 

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Sah et al. Retrospective Study of Autologous Arteriovenous Fistula Creation as Vascular...

was confined to the cephalic vein and care taken 
not to injure the adjacent superficial radial nerve. 

The vein was looped and any side branched 
fixed. The radial artery situated deep to and 
medial to the brachioradialis tendon was then 
dissected and proximal and distal control of 
around 6 to 10- mm long taken. The distal end 
of the cephalic vein was secured and divided 
and the appropriate length was brought closer 
to the artery. After regional heparin and a 
broad-spectrum antibiotic, the radial artery 
was clamped and an arteriotomy of five to six 
millimeters was made. 

The end of the vein prepared was then 
anastomosed to the side of the artery (side to 
end anastomosis) using a running 7-0 double 
arm polypropylene suture. The soft clamp was 
then released in the order of vein clamp or 
loop, distal, and then proximal arterial clamps. 
Once the hemostasis was completed, the vein 
was palpated for a good thrill which confirms 
good fistula outflow and outcome. The skin was 
then sutured using 3-0 absorbable subcutaneous 
sutures and loose dressing was applied.  

For patients without radiocephalic AV fistula 
possibility, brachiocephalic AV fistula was the 
ideal vascular access. The transverse incision 
was given from the cephalic vein to the brachial 
artery at the elbow crease. The cephalic vein 
was dissected and adequate length to meet the 
artery was prepared. Sometimes, the median 
antecubital vein if appropriate was used, leaving 
the cephalic vein.

Exploration of the brachial artery which 
was often beneath the flexor retinaculum of 
the brachioradialis muscle was carried out 
combining electrocautry and sharp dissection. 
Major variations of the brachial artery were found 
and therefore adequate exposure of the artery 
with proximal and distal control was taken and 
prepared for arteriotomy after regional heparin 

and antibiotics. The procedure was completed 
with a 7-0 double arm polypropylene suture, 
the technique of anastomosis, hemostasis, and 
wound closure being similar to radiocephalic 
AV fistula.   

Statistical Analysis 

The statistical analysis was performed using 
SPSS Software 16 (USA). Categorical variables 
were analyzed as mean values with standard 
deviation (±SD) and continuous values were 
shown as frequency (n) and percentages (%). 

RESULTS 

There was a total of 112 autologous AVF created 
during the study period. The mean age of the 
patients was 48.66±15.64 years. There were 
75(67%) male and 37(33%) female (Table 1). The 
most common limb of AVF creation was left 
non-dominant upper limb 95(84.80%) and right 
upper limb 17 (15.20%). The most common type 
of fistula was radiocephalic fistula 66(58.9%) and 
brachiocephalic fistula 46(41.1%). 

Table 1. Demographic profile of the patients.

S. N Variables n (%)

1 Age 48.66 ± 15.642

2
Gender
Male 
Female

75 (67%)
37 (33%)

3
Limbs
Left Upper Limb AVF
Right Upper Limb AVF                                         

95(84.8%)
17(15.2%)

4
Fistula Type
Radiocephalic AVF 
Brachiocephalic AVF 

66 (58.9%)
46 (41.1%)

5

Artery size (mm)
2.0 mm                   
2.5 mm
3.0 mm

2 (1.8%)
57 (50.9%)
53 (47.3%)

6
Vein size (mm)
2.5 mm
3.0 mm

58 (51.8%)
54(48.2%)



JCMS | Vol-19 | No 1 | Jan-Mar 2023126

7

Causes of ESKD
Hypertension
Diabetes Mellitus 
Chronic Glomerulonephritis 
Hypertension +Diabetes Mellitus 
Other Causes

14 (12.5%)
17 (15.2%)
36 (32.1%)
15 (13.4%)
30 (26.8%)

8

Risk Factors
Hypertension
Diabetes Mellitus
Ischemic Heart Disease
Peripheral Vascular Disease 
Multiple factors

17(15.2%)
23(20.5%)
18(16.1%)
18(16.1%)
36(32.1%)

9 Temporary catheter use 52(46.4%)

There were 92(82.1%) mature fistula at eight 
weeks follow-up (Table 2). These include 
54(48.2%) radiocephalic fistula and 38(33.9%) 
brachiocephalic fistulas. There were 20(17.8%) 
patients with delayed maturation of AVF at 12 
weeks (12 radiocephalic and 8 brachiocephalic 
fistulas). The most common complication was 
wound infection in three fistulas (2.70%). 

The mean anastomosis artery size was 2.73 ± 
0.27mm while the mean vein size was 2.74 ± 
0.25mm. The most common cause of the end-stage 
renal disease was chronic glomerulonephritis 36 
(32.1%). The most common risk factor present 
was diabetes mellitus 23(20.5%) and there 
were multiple risk factors present in 36(32.1%) 
patients. There were 52(46.4%) patients with 
previous temporary hemodialysis catheter. 

Figure 1. Shows vein section of a non-functional 
AVF.

DISCUSSION

The mature autologous AVF serves as a lifeline 
for hemodialysis patients. The national kidney 
foundation guidelines recommend the early 

creation of autologous AVF in patients with end-
stage renal disease with rapid decrease rate of 
eGFR approximately >10 mL/min/year.1 Early 
creation of autologous AVF in progressive renal 
failure patients improves in the quality of life 
and prolongs survival. 3,7

 Majority of the ESKD patients in our community 
remains on hemodialysis life long, as renal 
transplantation is not possible in most of the 
centers of the country. An autologous AVF has 
much benefit over dialysis catheters or grafts in 
terms of costs, hospital stay and mortality. 14

Table 2. Functional outcome (Maturation Rate) at 8 and 12 weeks.  

Fistula Types 
Maturation of AVF

Total 8 weeks 12 weeks

Radiocephalic AVF 54 (48.2%) 12(10.7%) 66(58.9%)

Brachiocephalic AVF 38 (33.9%) 08(7.2% 46(41.1%)

Total 92(82.1%) 20(17.9) 112(100%)

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A period of six to eight weeks after AVF creation 
is a frivolous interval where the fistula heals 
and matures for hemodialysis procedure. The 
fistula undergoes adaptation and remodeling 
due to increased flow. The ideal autologous 
fistula must be a minimum of six millimeter in 
diameter, have six-millimeter depth from the 
skin and should have blood flow greater than 
600 ml/min. 5,6,8 

Hemodialysis initiation without AVF creation 
has been seen in up to 93% of the patients and has 
major complications.11 In our study, 52(46.4%) 
patients began hemodialysis with central venous 
catheter. An ipsilateral autologous fistula was 
constructed in more than 50% of these patients 
with an internal jugular catheter. However, 
subclavian catheter and ipsilateral AVF creation 
was avoided because of the risk of hand swelling 
and acronecrosis. 

The preoperative assessment of the upper 
limbs is an essential part in selection of the type 
and location of AVF, combined with duplex 
ultrasound in selected patients.15 The vessels 
were assessed for caliber, distensibility and 
continuity.  The study done by Silva et al. 16 
showed that the maturation rate of autologous 
fistula improved fourfold with the routine 
noninvasive assessment of the arterial inflow 
and venous outflow rate. 

The size and quality of the vessels possess 
significant role in the development of the fistula. 
Our study showed that the mean artery size was 
2.73-mm and vein size was 2.74-mm which was 
small-caliber vessels. The maturation rate in the 
study was 92 (82.1%) at eight weeks and 20 (17.8%) 
at 12 weeks. Goh et al.17 showed that radiocephalic 
fistula had fewer complications like steal syndrome 
and maturation rate was only 55% with a vessels of 
small caliber (<2.5-mm). 

There were two (1.7%) fistulas which needed 
assessment with duplex ultrasound after eight 
weeks and diversion of venous flow and stenosis 
was seen in both the fistulas. The diverting 
venous branch was ligated and the stenotic vein 

was dilated to maximize flow which improved in 
fistula function. The fistula tends to mature after 
correction in few similar patients while in some, 
more proximal fistula needs to be created.12

There seems to be an international difference in 
the type and location of autologous AVF creation 
and a shift from lower arm to upper arm AVF is 
seen in many centers due to better maturation of 
upper arm AVF (34% vs 59%). 7 The upper arm 
brachiocephalic AVF has been recommended 
in diabetic, females and older hemodialysis 
patients where there is high risk of fistula failure. 

Huben et al. 18 demonstrated major complications 
like steal syndrome and hand ischemia in seven 
percent of diabetic, females, and peripheral 
vascular disease patients. Our study didn’t 
show any such complications as the high-risk 
patients were preoperatively carefully assessed 
by duplex ultrasound study and surgery was 
planned to minimize adverse effects. Thamer et 
al.19 in the cost analysis study of the procedure 
found that there was a financial burden when 
fistula failed to mature on time and revision 
surgery was needed.

There are complex modifiable and non-
modifiable factors that affected the long-term 
patency of the autologous AVF. 20 Modifiable 
factors like smoking, obesity, early referral, 
ultrasound imaging, anastomosis type and 
flow assessment have been found to affect the 
patency of fistulas. Non-modifiable factors 
for AVF patency were increase age, diabetes, 
hypotension, arterial diameter, arteriosclerosis, 
venous diameter and venous distensibility. 20–22 

A systematic review done by Tanner et al. 17 on 
drug treatments to increase the patency of fistula 
showed that clopidogrel of 75mg/day showed a 
beneficial effect. However, the random-effect 
meta-analysis on the use of the drug showed no 
benefit.18 There have been several modifications 
and configurations of the operative technique. 
All our procedures were done by artery side to 
vein end anastomosis with a continuous double 
arm 7-0 polypropylene suture.  This technique 

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JCMS | Vol-19 | No 1 | Jan-Mar 2023128

has less complication than interrupted suturing. 
Kanko et al. 24 described the diamond-shaped 
technique in 67 patients and found an 89% 
patency rate in six months. 

Early failure within four weeks of the procedure 
is seen in 29% of patients and emphasis has been 
made on surgical technique improvement.20,25 
The proper skin incision without crossing the 
arterialized vein, felicitous handling of the 
vessels, and correct anastomosis angle with 
minimal shear stress distribution is advised, 
with high quality instruments and surgical 
loupes.9,26 

Fistula with feeble thrill and low outflow has 
more chances of thrombosis.11 Heparin and a 
broad-spectrum antibiotic are routinely used 
in many centers and ours too as it prevents 
early thrombosis and infection. Few patients 
experience hand and finger edema after AVF 
creation which usually subsides by elevation of 
the limb.25–27 

If the swelling progress to the extent of limiting 
the mobility, central stenosis should be suspected 
especially in patients with previous central 
venous catheters and devices (pacemakers).18 A 
duplex ultrasound study or venogram should 
be performed if such symptoms persist, as it can 
lead to discoloration of the limb. Endovascular 
treatment has a high success rate and should be 
the first choice in such symptomatic patients. 20,28

Severe pain and coldness after AVF creation is 
usually rare and if present, one should consider 
steal syndrome, especially in brachiocephalic 
AVF. 11 When the arteriotomy is more than 
6-mm in the brachial artery, steal syndrome 
can develop with loss of the extremity function. 
Revision surgery is usually required.25,29 Distal 
pulses and saturation in the arms are routinely 
inspected after the procedure and any curiosity 
is confirmed by duplex scan immediately. 

Severe calcifications of the fistula especially 
in older patients can cause thrombosis and 
threaten the long-term patency of the AVF. 30 The 

study on pre-existing and postoperative intimal 
hyperplasia found no association in fistula long-
term outcome. 31  Siddiqui et al. 26 review on 
factors affecting AVF maturation recommended 
more research studies on the basic biology of 
AVF maturation. Once the fistula is created, flow 
in the AVF increases and vascular remodeling 
and vasodilatation takes place in a non-
pathological vessel. Wedgewood et al.32 studied 
flow rate in the radial artery and showed that 
flow increased immediately after the creation of 
the fistula. Endothelial cell has important role in 
remodeling and the forward blood flow elicitate 
cytoskeletal remodeling in the vessels. 2

Although, there has not been much development 
in the research of autologous AVF stenosis, it is 
thought that deposition of fibrin and thrombocyte 
activation initiated delayed stenosis of the access 
as shown in a histogram of one non-functional 
radiocephalic fistula (Figure 1). Another factor 
might be the repeated iatrogenic remodeling 
from the puncture or cannulation of the vessel 
causing thrombosis of the access. 9

An autologous radiocephalic and brachiocephalic 
fistula with end to side anastomosis provide the 
best long-term access. Occasionally, when the 
basilic or cephalic veins are not suitable, complex 
vascular access becomes necessary with brachial 
vein transposition or translocation of suitable 
veins. 25,31  An autologous AVF creation needs 
more experience and a three-dimensional picture 
of the after the procedure should be in the back 
of the mind while creating the fistula.20,34 

CONCLUSIONS

The creation of an autologous AVF for 
hemodialysis in the upper limb has fewer 
complications and the maturation of the AVF 
depends on the vessel’s diameter. Radio-cephalic 
and Brachiocephalic AVF usually matures 
between six to eight weeks duration.    

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Sah et al. A Retrospective Study of Autologous Arteriovenous Fistula Creation as Vascular...


