;]km8{ sn]h, PdPd6L gjf}+ Aofr, lk|G6 ;d"xsf] k|sfzgJCMS | Vol-19 | No 1 | Jan-Mar 2023 123 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 Sah et al. Retrospective Study of Autologous Arteriovenous Fistula Creation as Vascular... ;]km8{ sn]h, PdPd6L gjf}+ Aofr, lk|G6 ;d"xsf] k|sfzgJCMS | Vol-19 | No 1 | Jan-Mar 2023 125 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%) Sah et al. Retrospective Study of Autologous Arteriovenous Fistula Creation as Vascular... ;]km8{ sn]h, PdPd6L gjf}+ Aofr, lk|G6 ;d"xsf] k|sfzgJCMS | Vol-19 | No 1 | Jan-Mar 2023 127 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 Sah et al. Retrospective Study of Autologous Arteriovenous Fistula Creation as Vascular... 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. Sah et al. Retrospective Study of Autologous Arteriovenous Fistula Creation as Vascular... ;]km8{ sn]h, PdPd6L gjf}+ Aofr, lk|G6 ;d"xsf] k|sfzgJCMS | Vol-19 | No 1 | Jan-Mar 2023 129 REFERENCES 1. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. 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American Journal of Kidney Diseases 2018; 71: 793-801.https:// d o i . o r g / 1 0 . 1 0 5 3 / j . a j k d . 2 0 1 7 . 1 1 . 0 2 0 PMID:29429750 34. Kritayakirana K, Narueponjirakul N, Uthaipaisanwong A, et al. The Effect of Artery and Vein Size on Forearm Hemodialysis Arteriovenous Graft Patency. Annals of Vascular Diseases 2019; 12: 21-24.https://doi.org/10.3400/ avd.oa.18-00105 PMID:30931052 Sah et al. A Retrospective Study of Autologous Arteriovenous Fistula Creation as Vascular...