- Email: [email protected]
Creating Radiocephalic Arteriovenous Fistulas: Technical and Functional Success
Creating Radiocephalic Arteriovenous Fistulas: Technical and Functional Success William C Jennings, MD, FACS, Michael G Kindred, MD, Thomas A Broughan, MD, FACS The radiocephalic arteriovenous fistula (RC-AVF) at the wrist is the recommended first choice for hemodialysis access. Several authors have reported early thrombosis or failure of RC-AVFs to mature in up to 20% to 57% of patients. We report a consecutive series of individuals in whom physical and ultrasonography (US) examinations predicted success with RC-AVFs. STUDY DESIGN: Records of all patients who underwent vascular access operations by the communicating author from June 2003 through June 2008 were reviewed to identify those individuals with RC-AVF procedures. Physical examination and US screening criteria for creating a RC-AVF included a continuous and uninterrupted outflow vein diameter ⱖ 2.5 mm and a normal radial artery inflow examination with vessel diameter ⱖ 2.0 mm. A venous branching point at the wrist was identified to create a broad patch for the RC-AVF anastomosis. RESULTS: We reviewed 796 consecutive vascular access operations, identifying 75 RC-AVFs created in 74 patients. Patient ages were 20 to 82 years (mean 57 years). Eighteen were women and 42 were diabetic. Mean followup was 14.5 months. Primary, primary-assisted, and cumulative (secondary) patency were 58.3%, 96.2%, and 100%, respectively, at 12 months and 48.1%, 91.5%, and 95.7%, respectively, at 24 months. CONCLUSIONS: RC-AVF at the wrist remains our first choice for vascular access in the subset of patients meeting specific preoperative criteria by physical and United States examinations. Cumulative patency was 100% at 12 months and 95.7% at 24 months. Although RC-AVF construction technique is important, careful patient selection is believed to be the critical element in creating functional and durable RC-AVFs. (J Am Coll Surg 2009;208:419–425. © 2009 by the American College of Surgeons) BACKGROUND:
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guideline and the National Vascular Access Improvement Initiative, “FistulaFirst,” recommend radiocephalic arteriovenous fistula (RCAVF) as the first choice in establishing vascular access, when feasible.1,2 Several authors have reported early thrombosis or failure of RC-AVFs to mature in up to 20% to 57% of patients.3-9 Particular patient groups have been reported to have lower success rates with a RC-AVF, including diabetics, older patients, patients with peripheral vascular disease, women, and individuals with previous failed access procedures.4,5,10-17
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative and FistulaFirst have emphasized the importance of dialysis by native AVF. Patients requiring renal replacement therapy suffer fewer complications, require fewer procedures, and have better overall survival rates when vascular access is achieved by an AVF as opposed to catheter or graft.3,18-22 In addition, dialysis access costs are dramatically less when access is supplied by an AVF, as opposed with a catheter or graft.23,24 Although new patients in need of renal replacement therapy in 2004 made up only 0.03% of the US population, patients with end-stage renal disease consumed 6.7% of the total Medicare expenditures in the US.25 Vascular access and complications of vascular access can account for ⬎ 20% of these costs. The dialysis population is expected to double by 2010, exceeding 600,000 individuals and emphasizing the increasing need for efficient vascular access care.26 Venous mapping and arterial evaluation by ultrasonography (US) have been demonstrated to be key elements in successful AVF creation, leading to improved fistula rates, patency, and functionality.16,27-31 We believe US examination before fistula creation is critical for success and yields
Disclosure Information: Nothing to Disclose. Abstract presented at Vascular Access for Hemodialysis X Symposium, Phoenix, AZ, May 2006. Received September 16, 2008; Revised November 20, 2008; Accepted November 21, 2008. From the Department of Surgery, University of Oklahoma College of Medicine, Tulsa, Tulsa, OK. Correspondence address: William C Jennings, MD, FACS, Department of Surgery, University of Oklahoma College of Medicine, Tulsa, 4502 E 41st St, Tulsa, OK 74135-2512. email: [email protected]
© 2009 by the American College of Surgeons Published by Elsevier Inc.
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the most useful information when performed by the operating surgeon.32 Our surgical goal has been to construct a functional and durable autogenous vascular access for all of our patients. We report a consecutive series of individuals in whom physical and US examinations predicted success with RC-AVFs when specific preoperative selection criteria were applied. The vessels and surgical site were marked by US mapping, and a median antebrachial or cephalic vein to radial artery end-to-side anastomosis was constructed using a venous bifurcation site, the “branch patch” technique.33,34 Historic context
The first AVF constructed for hemodialysis access was created by Kenneth Appell in February 1965 at the Bronx Veterans Administration Hospital in collaboration with James Cimino, Chief of Nephrology, and nephrologists Michael Brescia and Baruch Hurwich. They reported their initial series of 12 patients in 1966 using the radial artery and cephalic vein at the wrist, the RC-AVF.35 Before this landmark publication, dialysis access was possible only by direct needle cannulation of large vessels or by a Scribner external vascular shunt. An enthusiastic reception to this new and durable access procedure was found in Europe and the US. During the following decades, various vascular access procedures have been used, such as variations of more proximal and complex fistulas, snuff-box fistulas, transpositions, vascular grafts (both synthetic and biologic), implantable access devices, shunts, catheters, and more.19,36-38 Several names have become associated with this first-ever AVF constructed for dialysis access, including Cimino fistula, Brescia-Cimino fistula, and wrist fistula. The most commonly used term is now radiocephalic arteriovenous fistula.
METHODS A database of consecutive patients undergoing vascular access operations by a single surgeon was reviewed for all procedures from June 2003 through June 2008. In addition to physical examination, US evaluation by the surgeon during the initial visit was used in every patient’s vascular access evaluation to select the best site and access procedure. RC-AVF selection criteria included a continuous forearm vein with diameter ⱖ 2.5 mm, as measured by US.27 The outflow vein demonstrated distensibility without stenotic segments after application of a tourniquet. Criteria for arterial inflow at the wrist included a normal pulse with intraluminal diameter ⱖ 2 mm by US and an intact palmar arch. When radial artery inflow was questionable, arterial compliance was evaluated by the
Figure 1. Venous anatomy where a slightly more proximal skin incision allows use of a venous branching site for an end-to-side anastomosis and recruitment of a larger outflow vein. The median antebrachial vein is often larger than the more laterally positioned cephalic vein. Most extremities require ultrasonography to identify and mark these vessels. AVF, arteriovenous fistula.
“clenched fist” resistance index, indicating an adequate vessel.39 An end-to-side venoarterial anastomosis was routinely constructed to prevent venous hypertension in the hand, to direct all access flow into the functional AVF segment, and to minimize the opportunity for torsion of the mobilized venous segment occasionally seen with a side-to-side anastomosis. Importantly, US was used again briefly in the operating suite to mark the outflow vein and venous branches at or near the wrist. The median antebrachial vein was the most commonly used outflow vein, often larger than the more laterally positioned cephalic vein. A longitudinal skin incision was used between the selected venous branch site and radial artery at the wrist. Occasionally, a slightly more proximal incision was needed to use a branch site for recruitment of a larger outflow vein (Fig. 1). After mobilization and division of the vein branches, the venous bifurcation was opened to create a broad flare or “branch patch.” This technique avoids placement of sutures directly in the orifice of the outflow vein during construction of the anastomosis, minimizing the chance for stenosis (Figs. 2A, 2B). This is a variation of QuinonesBaldrich’s branch patch technique and the original work of Alexis Carrel, reported in his Nobel Prize⫺winning research in vascular surgery. It is still used by many transplantation surgeons (Figs. 3A, 3B).33,40 This technique has been described for vascular access by Davidson.34 Other successful methods for creating a broad AVF anastomosis include the straight-line overlay technique and bifurcation advancement techniques (Sidney M Glazer, personal com-
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Figure 3. (A) Alexis Carrel (1873⫺1944) was the first to report success with vessel anastomosis. (B) The original “Carrel patch” is commonly used in vascular surgery and is similar to the branch patch technique.
and pulsatile when occluded proximally. Mature AVFs had accessible access sites, a diameter ⱖ 6 mm, and US flow volumes ⱖ 400 mL/min. We generally allowed initial access use after 4 to 6 weeks. If the AVF was not mature or nearing maturation at that time, a fistulogram was obtained and an angioplasty was performed, if indicated. Survival curves were created with GraphPad Prism software (version 4.00) using the Kaplan-Meier method, calculating a 95% confidence interval for fractional survival at any particular time (GraphPad Software; www.graphpad. com). This study was approved by our institutional review board. Figure 2. Radiocephalic arteriovenous fistula. (A) The branching segment is mobilized and opened to create a broad flair for the end-to-side anastomosis. This technique avoids placing sutures in the orifice of the outflow vein. (B) The branch patch technique at the venous bifurcation site creates a broad anastomosis.
munication, May, 2008; ref.41). Operations in this report were performed with local anesthetic and sedation. Prophylactic antibiotics were not used.42 Primary patency was defined as time (months) with uninterrupted patency and without intervention. Primaryassisted patency was time of uninterrupted patency from the original AVF construction, where any interventional procedure was necessary. Cumulative (secondary) patency was the period from the original AVF construction, regardless of interventions or thrombosis, until abandonment of the access or until completion of the study period.43 Patients were followed postoperatively in the surgery clinic by physical examination and US evaluation until the RC-AVF was judged ready for use. We expected the fistula to be soft with a continuous bruit when not compressed
RESULTS Seven hundred ninety-six consecutive patients had vascular access operations during the 60-month period of the study. Seventy-five RC-AVFs were created in 74 individuals. Ages ranged from 20 to 82 years, with a mean age of 57 years. Fifty-six of the RC-AVF patients (74.7%) were men, and 16 (21.3%) of the individuals were obese. Forty-two (56.0%) were diabetic. Nineteen (25.3%) individuals had chronic renal failure secondary to hypertension. Ten (15.0%) patients had undergone previous access operation, with six of these previous operations in the same arm as the new fistula reported here. Six patients had at least one previous failed AV graft placement. Radial artery diameter was 2.0 to 4.5 mm (mean 3.0 mm) and was larger in men than women. The new AVF outflow vein was 2.5 to 5.2 mm (mean 3.0 mm) and was also larger in men (Fig. 4 shows vessel sizes overall and by gender). Twenty-eight patients required a fistulogram with at least one angioplasty site. Gender did not affect likelihood
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Figure 5. (A) Intervention sites required for maturation and to maintain patency. (B) Major outflow vein(s) noted at maturation of the arteriovenous (AV) fistula. Figure 4. Preoperative vessel diameter for all patients and for men and women. Shown as range in millimeters and (mean).
of intervention. Figure 5 shows intervention site locations for these patients in addition to the dominant outflow vein, which developed in all 75 RC-AVFs. Two patients had surgical interventions. Twelve patients (16%) required intervention by fistulogram and angioplasty before initial AVF use. Time from operation to intervention for these 12 patients was 1 to 3 months (mean 1.5 months). All AVFs in this subgroup remained functional throughout the study period. Patients were not entered into a longterm access monitoring program. Access problems, such as recirculation, prolonged postcannulation bleeding, poor inflow, or high access pressures resulted in a surgical evaluation for physical and US examinations, with a fistulogram obtained and interventional angioplasty if indicated. Followup for all patients was 1 to 47 months (mean 14.5 months). Primary patency, primary-assisted patency, and cumulative (secondary) patency were 58.3%, 96.2%, and
Figure 6. Radiocephalic⫺arteriovenous fistula (AVF) Kaplan and Meier vascular access patency curve. Solid line, cumulative patency; dotted line, assisted patency; dashed line, primary patency.
100%, respectively, at 12 months and 48.1%, 91.5%, and 95.7%, respectively, at 24 months (Fig. 6). Mean time to initial use was 1.5 months. Five patients had mature fistulas and had not yet started dialysis. Two of the 75 RC-AVFs failed. One patient required proximal revision of the RCAVF with later thrombosis. Another patient’s RC-AVF thrombosed after 28 months. It had been occluded for 2 months when we learned of it, and the fistula could not be salvaged. A successful RC-AVF was created in the patient’s opposite arm. A third individual had an occluded venous segment after prolonged pressure postdialysis. This fistula was immediately salvaged by interventional techniques and remains functional. Steal syndrome developed in one patient 18 months postoperatively and had a revision with flow restriction. Three patients regained renal function, and three individuals have had successful transplantations. Thirteen deaths have occurred; none related to dialysis access. One of the patients who died was not able to make followup visits from her home in another state because of multiple medical problems, although her fistula remained patent. One patient was lost to followup at 19 months with a functional AVF. No complications were related to the dialysis access surgical procedure. No grafts were used in any of the 796 consecutive patients during this study period.
DISCUSSION Several authors have reported high failure rates with RC-AVFs, with some questioning its role as the first-line access operation.5,7,8,10,16 We found fewer women and diabetics, as noted by others, to be good candidates for a RC-AVF.12,13,15 Older age has been another factor suggested to predict RC-AVF failure.11,14,15 In our study, we found diabetes, age, and female gender did not preclude a successful RC-AVF, if our preoperative selection criteria were met.
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Requiring the specific preoperative physical and US examination criteria we outline in this report limits the number of RC-AVFs created. We believe this vascular access strategy is particularly valid and useful, as our other AVF options have proved to be successful.44-46 Otherwise, one might accept less-stringent preoperative evaluation criteria, expecting more operative and maturation failures, before proceeding to more proximal or complex access operations. We believe that creating RC-AVFs in less-promising situations leads to substantial failure rates, maturation delays, and associated prolonged catheter use.8 The relatively low percentage of patients we identified as candidates for successful RC-AVF is likely a result of two factors: the strict and specific criteria outlined here as our necessary requirements for a successful operation and longterm patency, and the nature of our surgical vascular access practice involving out-of-region and out-of-state difficult-access extremity patient referrals, in addition to complex local referrals. When our evaluation finds that a RC-AVF is not feasible or not expected to be successful, our second choice for vascular access is a proximal radial artery fistula. We have previously reported this simple operation to be reliable, safe, and durable.44,45 These AVFs frequently offer both upper-arm and forearm access sites. More complex access procedures in our patients with difficult-access extremities are less commonly needed, but have also been used successfully.46 We find these complex-access patients, including those individuals with a failed or failing arteriovenous graft, to be candidates for a successful proximal radial artery fistula, brachial AVF, or primary or staged transposition procedure.47,48 US evaluation of both the arterial inflow and venous outflow segments is a key element in selecting patients for RC-AVF success. US is important in operative planning for AVF construction and identifying the optimal surgical site.5 Skilled use of US among surgeons is increasingly common, with the American College of Surgeons offering an array of topics and levels of instruction. We believe use of US by the surgeon is particularly helpful in vascular surgery. Prompt and skilled AVF intervention by fistulogram with angioplasty, when indicated, is important for timely maturation and access maintenance in a substantial percentage of successful AVFs.49,50 We believe that AVF-assisted maturation should not be considered an access failure and promptly obtain a fistulogram if there is a question of adequacy. We expect AVFs to be functional within 4 to 6 weeks. This expectation of timely maturation and prompt intervention is reflected in the assisted patency rates in this report. We use a branch patch technique for end-to-side RCAVF construction.33,34 This avoids sutures and potential stenosis in the ostium of the outflow vein by creating a
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broad vein hood at the anastomosis. The short segment of cephalic vein mobilized to the radial artery anastomosis, “the juxta-anastomatic segment,” is a site known to be at risk for stenosis.49 Selecting an outflow vein bifurcation point for the RC-AVF ensures use of a larger vein segment and can moderate the risk or degree of stenosis at this site. A normal radial artery is also an important component of success. A small, calcific, or sclerotic vessel will not have the needed compliance to enlarge and accommodate the roughly 20-fold increase in flow needed for a functional AVF. Although we believe our RC-AVF operative technique is important, it is our opinion that careful patient selection by physical and US examination is the most important element in our outcomes reported here. Perhaps the greatest issue with RC-AVF failure is not the fistula that promptly thromboses, but the patent and nonmaturing AVF that is observed for months, generating frustration for patient, nephrologists, dialysis nurse, and surgeon alike. This study has the many limitations of a retrospective review but demonstrates that successful outcomes are feasible in creating RC-AVFs when using careful patient selection. Prospective studies focusing on AVF success and maturation will likely be forthcoming with the organization of the National Institutes of Health multicenter vascular access study “RFADK-07-007: Identification of Factors Associated with Failure of Arteriovenous Fistulas to Mature in Hemodialysis Patients.” Autogenous vascular access is widely recommended and attainable in most patients. Konner and others28,51,52 have reported successful efforts toward an all AVF access practice. Our practice has similarly evolved to autogenous vascular access creation for all patients. No grafts were placed for dialysis access during this 5-year study period. RC-AVF at the wrist remains our first choice for vascular access in the subset of patients meeting specific preoperative criteria by physical and US examinations. Only 8.9% of the patients in this study met these requirements. US vein mapping is a key element in patient selection and in choosing the specific surgical site. An end-to-side venoarterial anastomosis using a branch patch technique has proved useful in the operations reported here. Cumulative patency was 100% at 12 months and 95.7% at 24 months. Although RC-AVF construction technique is important, careful patient selection is believed to be the critical element in creating functional and durable RC-AVFs. Author Contributions Study conception and design: Jennings, Kindred, Broughan Acquisition of data: Jennings Analysis and interpretation of data: Jennings, Kindred, Broughan
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Drafting of manuscript: Jennings, Kindred, Broughan Critical revision: Jennings, Kindred, Broughan
REFERENCES 1. Fistula First: National Vascular Access Improvement Initiative. Available at: http://www.fistulafirst.org/. Accessed December 16, 2008. 2. National Kidney Foundation. K/DOQI Clinical practice guidelines for vascular access: update 2000. Am J Kidney Dis 2001; 37[Suppl 1]:S137–S181. 3. Allon M, Robbin ML. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int 2002; 62:1109–1124. 4. Golledge J, Smith CJ, Emery J, et al. Outcome of primary radiocephalic fistula for haemodialysis. Br J Surg 1999;86:211–216. 5. Tordoir JH, Rooyens P, Dammers R, et al. Prospective evaluation of failure modes in autogenous radiocephalic wrist access for haemodialysis. Nephrol Dial Transplant 2003;18:378–383. 6. Davidson I, Gallieni M, Saxena R, Dolmatch B. A patient centered decision making dialysis access algorithm. J Vasc Access 2007;8:59–68. 7. Lee T, Barker J, Allon M. Comparison of survival of upper arm arteriovenous fistulas and grafts after failed forearm fistula. J Am Soc Nephrol 2007;18:1936–1941. Epub 2007 May 2. 8. Biuckians A, Scott EC, Meier GH, et al. The natural history of autologous fistulas as first-time dialysis access in the KDOQI era. J Vas Surg 2008;47:415–421; discussion 420⫺421. 9. Pflederer TA, Kwok S, Ketel BL, Pilgram T. A comparison of transposed brachiobasilic fistulae with nontransposed fistulae and grafts in the fistula first era. Semin Dial 2008;21:357–363. Epub 2008 Jun 28. 10. Miller PE, Tolwani A, Luscy CP, et al. Predictors of adequacy of arteriovenous fistulas in hemodialysis patients. Kidney Int 1999; 56:275–280. 11. Gibson KD, Caps MT, Kohler TR, et al. Assessment of a policy to reduce placement of prosthetic hemodialysis access. Kidney Int 2001;59:2335–2345. 12. Hakaim AG, Nalbandian M, Scott T. Superior maturation and patency of primary brachiocephalic and transposed basilic vein arteriovenous fistulae in patients with diabetes. J Vasc Surg 1998;27:154–157. 13. Astor BC, Coresh J, Powe NR, et al. Relation between gender and vascular access complications in hemodialysis patients. Am J Kidney Dis 2000;36:1126–1134. 14. Geis WP, Giacchino JL, Iwatsuki S, et al. The reverse fistula for vascular access. Surg Gynecol Obstet 1977;145:901–904. 15. Lin SL, Huang CH, Chen HS, et al. Effects of age and diabetes on blood flow rate and primary outcome of newly created hemodialysis arteriovenous fistulas. Am J Nephrol 1998;18:96–100. 16. Patel ST, Hughes J, Mills JL Sr. Failure of arteriovenous fistula maturation: an unintended consequence of exceeding Dialysis Outcome Quality Initiative guidelines for hemodialysis access. J Vasc Surg 2003;38:439–445; discussion 445. 17. Rooijens PP, Burgmans JP, Yo TI, et al. Autogenous radialcephalic or prosthetic brachial-antecubital forearm loop AVF in patients with compromised vessels? A randomized, multicenter study of the patency of the primary hemodialysis access. J Vasc Surg 2005;42:481–486; discussions 487.
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18. Dhingra RK, Young EW, Hulbert-Shearon TE, et al. Type of vascular access and mortality in US hemodialysis patients. Kidney Int 2001;60:1443–1451. 19. Centers for Medicare & Medicaid Services (CMS). CMS launches breakthrough intitiative for major improvement in care for kidney patients: safe vascular access through collaborative Fistula First Initiative. March 17, 2005. Available at: http:// www.cms.hhs.gov/apps/media/press/release.asp?counter⫽1386. Accessed December 16, 2008. 20. Young E. Vascular access. Current practice and practical aspects of management. ASN RenalWeek 2000.Toronto: ASN; 2000:377–385. 21. Murphy GJ, White SA, Nicholson ML. Vascular access for haemodialysis. Br J Surg 2000;87:1300–1315. 22. Pastan S, Soucie JM, McClellan WM. Vascular access and increased risk of death among hemodialysis patients. Kidney Int 2002;62:620–626. 23. Eggers P, Milam R. Trends in vascular access procedures and expenditures in Medicare’s ESRD program. In: Henry ML, ed. Vascular access for hemodialysis. Vol. 7. Chicago: WL Gore and Precept Press; 2001. 24. Eggers P. Trends in Medicare expenditure for vascular access. Presented at the Cincinnati Hemodialysis Vascular Access Symposium. Cincinnati, OH, March 19, 2004. 25. Foley RN, Collins AJ. End-stage renal disease in the United States: an update from the United States Renal Data System. J Am Soc Nephrol 2007;18:2644–2648; Epub 2007 Jul 26. 26. Centers for Medicare and Medicaid Services. Available at: http://www.cms.hhs.gov/. Accessed December 16, 2008. 27. Silva MB Jr, Hobson RW 2nd, Pappas PJ, et al. A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg 1998;27:302–307; discussion 307⫺308. 28. Dalman RL, Harris EJ Jr, Victor BJ, Coogan SM. Transition to all-autogenous hemodialysis access: the role of preoperative vein mapping. Ann Vasc Surg 2002;16:624–630; Epub 2002 Sep 4. 29. Malovrh M. Approach to patients with end-stage renal disease who need an arteriovenous fistula. Nephrol Dial Transplant 2003;18:v50–v52. 30. Wong V, Ward R, Taylor J, et al. Factors associated with early failure of arteriovenous fistulae for haemodialysis access. Eur J Vasc Endovasc Surg 1996;12:207–213. 31. Brimble KS, Rabbat CG, Schiff D, Ingram AJ. The clinical utility of Doppler ultrasound prior to arteriovenous fistula creation. Semin Dial 2001;14:314–317. 32. Parmley MC, Broughan TA, Jennings WC. Vascular ultrasonography prior to dialysis access surgery. Am J Surg 2002;184:568– 572; discussion 572. 33. Quinones-Baldrich WJ, Memsic L, Ramming K, et al. Branch patch for arterialization of hepatic grafts. Surg Gynecol Obstet 1986;162:488–490. 34. Davidson IJA. Access for dialysis: surgical and radiologic procedures. 2nd ed. Texas: Landes Bioscience; 2002. 35. Brescia MJ, Cimino JE, Appell K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966;275:1089–1092. 36. Dagher F, Gelber R, Ramos E, Sadler J. The use of basilic vein and brachial artery as an A-V fistula for long term hemodialysis. J Surg Res 1976;20:373–376. 37. Gracz KC, Ing TS, Soung LS, et al. Proximal forearm fistula for maintenance hemodialysis. Kidney Int 1977;11:71–75. 38. Glickman MH, Stokes GK, Ross JR, et al. Multicenter evaluation of a polytetrafluoroethylene vascular access graft as compared
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with the expanded polytetrafluoroethylene vascular access graft in hemodialysis applications. J Vasc Surg 2001;34:465–472; discussion 472⫺473. Malovrh M. Native arteriovenous fistula: preoperative evaluation. Am J Kidney Dis 2002;39:1218–1225. Carrel A, Guthrie CC. Anastomosis of blood vessels by the patching method and transplantation of the kidney. JAMA 1906;XLVII:1648–1651. Shenoy S. Innovative surgical approaches to maximize arteriovenous fistula creation. Semin Vasc Surg 2007;20:141–147. Lewis CG, Wells MK, Jennings WC. Avoidance of prophylactic antibiotics in creation of native arteriovenous fistulas. Nephrol Dial Transplant 2003;32:306–308. Sidawy AN, Gray R, Besarab A, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg 2002;35:603–610. Jennings WC. Creating arteriovenous fistulas in 132 consecutive patients: exploiting the proximal radial artery arteriovenous fistula: reliable, safe and simple forearm and upper arm hemodialysis access. Arch Surg 2006;141:27–32; discussion 32. Bruns SD, Jennings WC. Proximal radial artery as inflow site for native arteriovenous fistula. J Am Coll Surg 2003;197: 58–63.
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46. Roberts JK, Sideman MJ, Jennings WC. The difficult hemodialysis access extremity: proximal radial arteriovenous fistulas and the role of angioscopy and valvulotomes. Am J Surg 2005; 190:869–873. 47. Slayden GC, Spergel L, Jennings WC. Secondary arterial venous fistulas: converting grafts to autologous dialysis access. Semin Dial 2008;21:474–482. Epub 2008 Jun 20. 48. Arroyo MR, Sideman MJ, Spergel L, Jennings WC. Primary and staged transposition arteriovenous fistulas. J Vasc Surg 2008;47: 1279–1283. 49. Beathard GA, Arnold P, Jackson J, Litchfield T, Physician Operators Forum of RMS Lifeline. Aggressive treatment of early fistula failure. Kidney Int 2003;64:1487–1494. 50. Clark TW, Cohen RA, Kwak A, et al. Salvage of nonmaturing native fistulas by using angioplasty. Radiology 2007;242:286– 292; Epub 2006 Nov 7. 51. Konner K, Hulbert-Shearon TE, Roys EC, Port FK. Tailoring the initial vascular access for dialysis patients. Kidney Int 2002; 62:329–338. 52. Nguyen VD, Treat L, Griffith C, Robinson K. Creation of secondary AV fistulas from failed hemodialysis grafts: the role of routine vein mapping. J Vas Access 2007;8:91–96.
JACS ONLINE CME-1 PROGRAM EARN 4 CME-1 CREDITS EACH MONTH www.jacscme.facs.org
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guideline and the National Vascular Access Improvement Initiative, “FistulaFirst,” recommend radiocephalic arteriovenous fistula (RCAVF) as the first choice in establishing vascular access, when feasible.1,2 Several authors have reported early thrombosis or failure of RC-AVFs to mature in up to 20% to 57% of patients.3-9 Particular patient groups have been reported to have lower success rates with a RC-AVF, including diabetics, older patients, patients with peripheral vascular disease, women, and individuals with previous failed access procedures.4,5,10-17
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative and FistulaFirst have emphasized the importance of dialysis by native AVF. Patients requiring renal replacement therapy suffer fewer complications, require fewer procedures, and have better overall survival rates when vascular access is achieved by an AVF as opposed to catheter or graft.3,18-22 In addition, dialysis access costs are dramatically less when access is supplied by an AVF, as opposed with a catheter or graft.23,24 Although new patients in need of renal replacement therapy in 2004 made up only 0.03% of the US population, patients with end-stage renal disease consumed 6.7% of the total Medicare expenditures in the US.25 Vascular access and complications of vascular access can account for ⬎ 20% of these costs. The dialysis population is expected to double by 2010, exceeding 600,000 individuals and emphasizing the increasing need for efficient vascular access care.26 Venous mapping and arterial evaluation by ultrasonography (US) have been demonstrated to be key elements in successful AVF creation, leading to improved fistula rates, patency, and functionality.16,27-31 We believe US examination before fistula creation is critical for success and yields
Disclosure Information: Nothing to Disclose. Abstract presented at Vascular Access for Hemodialysis X Symposium, Phoenix, AZ, May 2006. Received September 16, 2008; Revised November 20, 2008; Accepted November 21, 2008. From the Department of Surgery, University of Oklahoma College of Medicine, Tulsa, Tulsa, OK. Correspondence address: William C Jennings, MD, FACS, Department of Surgery, University of Oklahoma College of Medicine, Tulsa, 4502 E 41st St, Tulsa, OK 74135-2512. email: [email protected]
© 2009 by the American College of Surgeons Published by Elsevier Inc.
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the most useful information when performed by the operating surgeon.32 Our surgical goal has been to construct a functional and durable autogenous vascular access for all of our patients. We report a consecutive series of individuals in whom physical and US examinations predicted success with RC-AVFs when specific preoperative selection criteria were applied. The vessels and surgical site were marked by US mapping, and a median antebrachial or cephalic vein to radial artery end-to-side anastomosis was constructed using a venous bifurcation site, the “branch patch” technique.33,34 Historic context
The first AVF constructed for hemodialysis access was created by Kenneth Appell in February 1965 at the Bronx Veterans Administration Hospital in collaboration with James Cimino, Chief of Nephrology, and nephrologists Michael Brescia and Baruch Hurwich. They reported their initial series of 12 patients in 1966 using the radial artery and cephalic vein at the wrist, the RC-AVF.35 Before this landmark publication, dialysis access was possible only by direct needle cannulation of large vessels or by a Scribner external vascular shunt. An enthusiastic reception to this new and durable access procedure was found in Europe and the US. During the following decades, various vascular access procedures have been used, such as variations of more proximal and complex fistulas, snuff-box fistulas, transpositions, vascular grafts (both synthetic and biologic), implantable access devices, shunts, catheters, and more.19,36-38 Several names have become associated with this first-ever AVF constructed for dialysis access, including Cimino fistula, Brescia-Cimino fistula, and wrist fistula. The most commonly used term is now radiocephalic arteriovenous fistula.
METHODS A database of consecutive patients undergoing vascular access operations by a single surgeon was reviewed for all procedures from June 2003 through June 2008. In addition to physical examination, US evaluation by the surgeon during the initial visit was used in every patient’s vascular access evaluation to select the best site and access procedure. RC-AVF selection criteria included a continuous forearm vein with diameter ⱖ 2.5 mm, as measured by US.27 The outflow vein demonstrated distensibility without stenotic segments after application of a tourniquet. Criteria for arterial inflow at the wrist included a normal pulse with intraluminal diameter ⱖ 2 mm by US and an intact palmar arch. When radial artery inflow was questionable, arterial compliance was evaluated by the
Figure 1. Venous anatomy where a slightly more proximal skin incision allows use of a venous branching site for an end-to-side anastomosis and recruitment of a larger outflow vein. The median antebrachial vein is often larger than the more laterally positioned cephalic vein. Most extremities require ultrasonography to identify and mark these vessels. AVF, arteriovenous fistula.
“clenched fist” resistance index, indicating an adequate vessel.39 An end-to-side venoarterial anastomosis was routinely constructed to prevent venous hypertension in the hand, to direct all access flow into the functional AVF segment, and to minimize the opportunity for torsion of the mobilized venous segment occasionally seen with a side-to-side anastomosis. Importantly, US was used again briefly in the operating suite to mark the outflow vein and venous branches at or near the wrist. The median antebrachial vein was the most commonly used outflow vein, often larger than the more laterally positioned cephalic vein. A longitudinal skin incision was used between the selected venous branch site and radial artery at the wrist. Occasionally, a slightly more proximal incision was needed to use a branch site for recruitment of a larger outflow vein (Fig. 1). After mobilization and division of the vein branches, the venous bifurcation was opened to create a broad flare or “branch patch.” This technique avoids placement of sutures directly in the orifice of the outflow vein during construction of the anastomosis, minimizing the chance for stenosis (Figs. 2A, 2B). This is a variation of QuinonesBaldrich’s branch patch technique and the original work of Alexis Carrel, reported in his Nobel Prize⫺winning research in vascular surgery. It is still used by many transplantation surgeons (Figs. 3A, 3B).33,40 This technique has been described for vascular access by Davidson.34 Other successful methods for creating a broad AVF anastomosis include the straight-line overlay technique and bifurcation advancement techniques (Sidney M Glazer, personal com-
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Figure 3. (A) Alexis Carrel (1873⫺1944) was the first to report success with vessel anastomosis. (B) The original “Carrel patch” is commonly used in vascular surgery and is similar to the branch patch technique.
and pulsatile when occluded proximally. Mature AVFs had accessible access sites, a diameter ⱖ 6 mm, and US flow volumes ⱖ 400 mL/min. We generally allowed initial access use after 4 to 6 weeks. If the AVF was not mature or nearing maturation at that time, a fistulogram was obtained and an angioplasty was performed, if indicated. Survival curves were created with GraphPad Prism software (version 4.00) using the Kaplan-Meier method, calculating a 95% confidence interval for fractional survival at any particular time (GraphPad Software; www.graphpad. com). This study was approved by our institutional review board. Figure 2. Radiocephalic arteriovenous fistula. (A) The branching segment is mobilized and opened to create a broad flair for the end-to-side anastomosis. This technique avoids placing sutures in the orifice of the outflow vein. (B) The branch patch technique at the venous bifurcation site creates a broad anastomosis.
munication, May, 2008; ref.41). Operations in this report were performed with local anesthetic and sedation. Prophylactic antibiotics were not used.42 Primary patency was defined as time (months) with uninterrupted patency and without intervention. Primaryassisted patency was time of uninterrupted patency from the original AVF construction, where any interventional procedure was necessary. Cumulative (secondary) patency was the period from the original AVF construction, regardless of interventions or thrombosis, until abandonment of the access or until completion of the study period.43 Patients were followed postoperatively in the surgery clinic by physical examination and US evaluation until the RC-AVF was judged ready for use. We expected the fistula to be soft with a continuous bruit when not compressed
RESULTS Seven hundred ninety-six consecutive patients had vascular access operations during the 60-month period of the study. Seventy-five RC-AVFs were created in 74 individuals. Ages ranged from 20 to 82 years, with a mean age of 57 years. Fifty-six of the RC-AVF patients (74.7%) were men, and 16 (21.3%) of the individuals were obese. Forty-two (56.0%) were diabetic. Nineteen (25.3%) individuals had chronic renal failure secondary to hypertension. Ten (15.0%) patients had undergone previous access operation, with six of these previous operations in the same arm as the new fistula reported here. Six patients had at least one previous failed AV graft placement. Radial artery diameter was 2.0 to 4.5 mm (mean 3.0 mm) and was larger in men than women. The new AVF outflow vein was 2.5 to 5.2 mm (mean 3.0 mm) and was also larger in men (Fig. 4 shows vessel sizes overall and by gender). Twenty-eight patients required a fistulogram with at least one angioplasty site. Gender did not affect likelihood
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Figure 5. (A) Intervention sites required for maturation and to maintain patency. (B) Major outflow vein(s) noted at maturation of the arteriovenous (AV) fistula. Figure 4. Preoperative vessel diameter for all patients and for men and women. Shown as range in millimeters and (mean).
of intervention. Figure 5 shows intervention site locations for these patients in addition to the dominant outflow vein, which developed in all 75 RC-AVFs. Two patients had surgical interventions. Twelve patients (16%) required intervention by fistulogram and angioplasty before initial AVF use. Time from operation to intervention for these 12 patients was 1 to 3 months (mean 1.5 months). All AVFs in this subgroup remained functional throughout the study period. Patients were not entered into a longterm access monitoring program. Access problems, such as recirculation, prolonged postcannulation bleeding, poor inflow, or high access pressures resulted in a surgical evaluation for physical and US examinations, with a fistulogram obtained and interventional angioplasty if indicated. Followup for all patients was 1 to 47 months (mean 14.5 months). Primary patency, primary-assisted patency, and cumulative (secondary) patency were 58.3%, 96.2%, and
Figure 6. Radiocephalic⫺arteriovenous fistula (AVF) Kaplan and Meier vascular access patency curve. Solid line, cumulative patency; dotted line, assisted patency; dashed line, primary patency.
100%, respectively, at 12 months and 48.1%, 91.5%, and 95.7%, respectively, at 24 months (Fig. 6). Mean time to initial use was 1.5 months. Five patients had mature fistulas and had not yet started dialysis. Two of the 75 RC-AVFs failed. One patient required proximal revision of the RCAVF with later thrombosis. Another patient’s RC-AVF thrombosed after 28 months. It had been occluded for 2 months when we learned of it, and the fistula could not be salvaged. A successful RC-AVF was created in the patient’s opposite arm. A third individual had an occluded venous segment after prolonged pressure postdialysis. This fistula was immediately salvaged by interventional techniques and remains functional. Steal syndrome developed in one patient 18 months postoperatively and had a revision with flow restriction. Three patients regained renal function, and three individuals have had successful transplantations. Thirteen deaths have occurred; none related to dialysis access. One of the patients who died was not able to make followup visits from her home in another state because of multiple medical problems, although her fistula remained patent. One patient was lost to followup at 19 months with a functional AVF. No complications were related to the dialysis access surgical procedure. No grafts were used in any of the 796 consecutive patients during this study period.
DISCUSSION Several authors have reported high failure rates with RC-AVFs, with some questioning its role as the first-line access operation.5,7,8,10,16 We found fewer women and diabetics, as noted by others, to be good candidates for a RC-AVF.12,13,15 Older age has been another factor suggested to predict RC-AVF failure.11,14,15 In our study, we found diabetes, age, and female gender did not preclude a successful RC-AVF, if our preoperative selection criteria were met.
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Requiring the specific preoperative physical and US examination criteria we outline in this report limits the number of RC-AVFs created. We believe this vascular access strategy is particularly valid and useful, as our other AVF options have proved to be successful.44-46 Otherwise, one might accept less-stringent preoperative evaluation criteria, expecting more operative and maturation failures, before proceeding to more proximal or complex access operations. We believe that creating RC-AVFs in less-promising situations leads to substantial failure rates, maturation delays, and associated prolonged catheter use.8 The relatively low percentage of patients we identified as candidates for successful RC-AVF is likely a result of two factors: the strict and specific criteria outlined here as our necessary requirements for a successful operation and longterm patency, and the nature of our surgical vascular access practice involving out-of-region and out-of-state difficult-access extremity patient referrals, in addition to complex local referrals. When our evaluation finds that a RC-AVF is not feasible or not expected to be successful, our second choice for vascular access is a proximal radial artery fistula. We have previously reported this simple operation to be reliable, safe, and durable.44,45 These AVFs frequently offer both upper-arm and forearm access sites. More complex access procedures in our patients with difficult-access extremities are less commonly needed, but have also been used successfully.46 We find these complex-access patients, including those individuals with a failed or failing arteriovenous graft, to be candidates for a successful proximal radial artery fistula, brachial AVF, or primary or staged transposition procedure.47,48 US evaluation of both the arterial inflow and venous outflow segments is a key element in selecting patients for RC-AVF success. US is important in operative planning for AVF construction and identifying the optimal surgical site.5 Skilled use of US among surgeons is increasingly common, with the American College of Surgeons offering an array of topics and levels of instruction. We believe use of US by the surgeon is particularly helpful in vascular surgery. Prompt and skilled AVF intervention by fistulogram with angioplasty, when indicated, is important for timely maturation and access maintenance in a substantial percentage of successful AVFs.49,50 We believe that AVF-assisted maturation should not be considered an access failure and promptly obtain a fistulogram if there is a question of adequacy. We expect AVFs to be functional within 4 to 6 weeks. This expectation of timely maturation and prompt intervention is reflected in the assisted patency rates in this report. We use a branch patch technique for end-to-side RCAVF construction.33,34 This avoids sutures and potential stenosis in the ostium of the outflow vein by creating a
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broad vein hood at the anastomosis. The short segment of cephalic vein mobilized to the radial artery anastomosis, “the juxta-anastomatic segment,” is a site known to be at risk for stenosis.49 Selecting an outflow vein bifurcation point for the RC-AVF ensures use of a larger vein segment and can moderate the risk or degree of stenosis at this site. A normal radial artery is also an important component of success. A small, calcific, or sclerotic vessel will not have the needed compliance to enlarge and accommodate the roughly 20-fold increase in flow needed for a functional AVF. Although we believe our RC-AVF operative technique is important, it is our opinion that careful patient selection by physical and US examination is the most important element in our outcomes reported here. Perhaps the greatest issue with RC-AVF failure is not the fistula that promptly thromboses, but the patent and nonmaturing AVF that is observed for months, generating frustration for patient, nephrologists, dialysis nurse, and surgeon alike. This study has the many limitations of a retrospective review but demonstrates that successful outcomes are feasible in creating RC-AVFs when using careful patient selection. Prospective studies focusing on AVF success and maturation will likely be forthcoming with the organization of the National Institutes of Health multicenter vascular access study “RFADK-07-007: Identification of Factors Associated with Failure of Arteriovenous Fistulas to Mature in Hemodialysis Patients.” Autogenous vascular access is widely recommended and attainable in most patients. Konner and others28,51,52 have reported successful efforts toward an all AVF access practice. Our practice has similarly evolved to autogenous vascular access creation for all patients. No grafts were placed for dialysis access during this 5-year study period. RC-AVF at the wrist remains our first choice for vascular access in the subset of patients meeting specific preoperative criteria by physical and US examinations. Only 8.9% of the patients in this study met these requirements. US vein mapping is a key element in patient selection and in choosing the specific surgical site. An end-to-side venoarterial anastomosis using a branch patch technique has proved useful in the operations reported here. Cumulative patency was 100% at 12 months and 95.7% at 24 months. Although RC-AVF construction technique is important, careful patient selection is believed to be the critical element in creating functional and durable RC-AVFs. Author Contributions Study conception and design: Jennings, Kindred, Broughan Acquisition of data: Jennings Analysis and interpretation of data: Jennings, Kindred, Broughan
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Drafting of manuscript: Jennings, Kindred, Broughan Critical revision: Jennings, Kindred, Broughan
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18. Dhingra RK, Young EW, Hulbert-Shearon TE, et al. Type of vascular access and mortality in US hemodialysis patients. Kidney Int 2001;60:1443–1451. 19. Centers for Medicare & Medicaid Services (CMS). CMS launches breakthrough intitiative for major improvement in care for kidney patients: safe vascular access through collaborative Fistula First Initiative. March 17, 2005. Available at: http:// www.cms.hhs.gov/apps/media/press/release.asp?counter⫽1386. Accessed December 16, 2008. 20. Young E. Vascular access. Current practice and practical aspects of management. ASN RenalWeek 2000.Toronto: ASN; 2000:377–385. 21. Murphy GJ, White SA, Nicholson ML. Vascular access for haemodialysis. Br J Surg 2000;87:1300–1315. 22. Pastan S, Soucie JM, McClellan WM. Vascular access and increased risk of death among hemodialysis patients. Kidney Int 2002;62:620–626. 23. Eggers P, Milam R. Trends in vascular access procedures and expenditures in Medicare’s ESRD program. In: Henry ML, ed. Vascular access for hemodialysis. Vol. 7. Chicago: WL Gore and Precept Press; 2001. 24. Eggers P. Trends in Medicare expenditure for vascular access. Presented at the Cincinnati Hemodialysis Vascular Access Symposium. Cincinnati, OH, March 19, 2004. 25. Foley RN, Collins AJ. End-stage renal disease in the United States: an update from the United States Renal Data System. J Am Soc Nephrol 2007;18:2644–2648; Epub 2007 Jul 26. 26. Centers for Medicare and Medicaid Services. Available at: http://www.cms.hhs.gov/. Accessed December 16, 2008. 27. Silva MB Jr, Hobson RW 2nd, Pappas PJ, et al. A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg 1998;27:302–307; discussion 307⫺308. 28. Dalman RL, Harris EJ Jr, Victor BJ, Coogan SM. Transition to all-autogenous hemodialysis access: the role of preoperative vein mapping. Ann Vasc Surg 2002;16:624–630; Epub 2002 Sep 4. 29. Malovrh M. Approach to patients with end-stage renal disease who need an arteriovenous fistula. Nephrol Dial Transplant 2003;18:v50–v52. 30. Wong V, Ward R, Taylor J, et al. Factors associated with early failure of arteriovenous fistulae for haemodialysis access. Eur J Vasc Endovasc Surg 1996;12:207–213. 31. Brimble KS, Rabbat CG, Schiff D, Ingram AJ. The clinical utility of Doppler ultrasound prior to arteriovenous fistula creation. Semin Dial 2001;14:314–317. 32. Parmley MC, Broughan TA, Jennings WC. Vascular ultrasonography prior to dialysis access surgery. Am J Surg 2002;184:568– 572; discussion 572. 33. Quinones-Baldrich WJ, Memsic L, Ramming K, et al. Branch patch for arterialization of hepatic grafts. Surg Gynecol Obstet 1986;162:488–490. 34. Davidson IJA. Access for dialysis: surgical and radiologic procedures. 2nd ed. Texas: Landes Bioscience; 2002. 35. Brescia MJ, Cimino JE, Appell K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966;275:1089–1092. 36. Dagher F, Gelber R, Ramos E, Sadler J. The use of basilic vein and brachial artery as an A-V fistula for long term hemodialysis. J Surg Res 1976;20:373–376. 37. Gracz KC, Ing TS, Soung LS, et al. Proximal forearm fistula for maintenance hemodialysis. Kidney Int 1977;11:71–75. 38. Glickman MH, Stokes GK, Ross JR, et al. Multicenter evaluation of a polytetrafluoroethylene vascular access graft as compared
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with the expanded polytetrafluoroethylene vascular access graft in hemodialysis applications. J Vasc Surg 2001;34:465–472; discussion 472⫺473. Malovrh M. Native arteriovenous fistula: preoperative evaluation. Am J Kidney Dis 2002;39:1218–1225. Carrel A, Guthrie CC. Anastomosis of blood vessels by the patching method and transplantation of the kidney. JAMA 1906;XLVII:1648–1651. Shenoy S. Innovative surgical approaches to maximize arteriovenous fistula creation. Semin Vasc Surg 2007;20:141–147. Lewis CG, Wells MK, Jennings WC. Avoidance of prophylactic antibiotics in creation of native arteriovenous fistulas. Nephrol Dial Transplant 2003;32:306–308. Sidawy AN, Gray R, Besarab A, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg 2002;35:603–610. Jennings WC. Creating arteriovenous fistulas in 132 consecutive patients: exploiting the proximal radial artery arteriovenous fistula: reliable, safe and simple forearm and upper arm hemodialysis access. Arch Surg 2006;141:27–32; discussion 32. Bruns SD, Jennings WC. Proximal radial artery as inflow site for native arteriovenous fistula. J Am Coll Surg 2003;197: 58–63.
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46. Roberts JK, Sideman MJ, Jennings WC. The difficult hemodialysis access extremity: proximal radial arteriovenous fistulas and the role of angioscopy and valvulotomes. Am J Surg 2005; 190:869–873. 47. Slayden GC, Spergel L, Jennings WC. Secondary arterial venous fistulas: converting grafts to autologous dialysis access. Semin Dial 2008;21:474–482. Epub 2008 Jun 20. 48. Arroyo MR, Sideman MJ, Spergel L, Jennings WC. Primary and staged transposition arteriovenous fistulas. J Vasc Surg 2008;47: 1279–1283. 49. Beathard GA, Arnold P, Jackson J, Litchfield T, Physician Operators Forum of RMS Lifeline. Aggressive treatment of early fistula failure. Kidney Int 2003;64:1487–1494. 50. Clark TW, Cohen RA, Kwak A, et al. Salvage of nonmaturing native fistulas by using angioplasty. Radiology 2007;242:286– 292; Epub 2006 Nov 7. 51. Konner K, Hulbert-Shearon TE, Roys EC, Port FK. Tailoring the initial vascular access for dialysis patients. Kidney Int 2002; 62:329–338. 52. Nguyen VD, Treat L, Griffith C, Robinson K. Creation of secondary AV fistulas from failed hemodialysis grafts: the role of routine vein mapping. J Vas Access 2007;8:91–96.
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