Proximal radial artery as inflow site for native arteriovenous fistula

Proximal Radial Artery as Inflow Site for Native Arteriovenous Fistula Stephen D Bruns, MD, William C Jennings, MD, FACS Most vascular surgeons favor an initial radial-cephalic anastomosis at the wrist for dialysis access when possible. As populations age and more chronically ill patients are offered dialysis, this native arteriovenous fistula (NAVF) is less frequently available. A brachial-cephalic anastomosis is generally considered to be the second choice for NAVF site. We report our experience in a series of patients where the proximal radial artery (PRA) serves as the primary inflow vessel. STUDY DESIGN: We reviewed 139 consecutive dialysis access operations performed by the senior author. One hundred fourteen had an NAVF constructed. Seventy-three of these procedures in 71 patients involved the PRA as arterial inflow and are the subject of this report. RESULTS: Mean age was 57 years. Thirty-six of the 71 were men. Seventy-one percent of the patients were diabetic and more than half had previous access surgery. Twenty-nine patients underwent preoperative ultrasonographic evaluation for feasibility and planning of the NAVF fistula. The 1-month patency rate for patients undergoing PRA fistula was 98%. Cumulative patency was 80% during the followup period of up to 42 months. No infectious or ischemic complications were noted during the study period. CONCLUSIONS: We find the anterior position and mobility of the PRA offers a simple and tension-free anastomosis to the median antebrachial vein or one of its tributaries. This anastomotic site frequently allows dialysis in both the forearm and upper arm. The PRA allows for adequate arterial inflow while avoiding the risk of steal syndrome found with brachial artery fistulas. More extensive procedures or use of prosthetic grafts can be avoided. ( J Am Coll Surg 2003;197:58–63. © 2003 by the American College of Surgeons) BACKGROUND:

Selection of anastomotic site preference for permanent access is outlined in the National Kidney Foundation Dialysis Outcomes Quality Initiatives Clinical Practice Guidelines for Vascular Access,1 representing extensive literature review and input from 1,200 experts. The primary recommendation is for a radial-cephalic arteriovenous (AV) fistula at the wrist. If not successful or possible, then an elbow (brachial-cephalic) AV fistula is recommended. AV grafts of synthetic material (eg, polytetrafluoroethylene) and basilic vein transposition fistulas are recommended as third choices.2,3 Several authors have noted an increase in synthetic

graft use and a decrease in the construction or use of native arteriovenous fistulas (NAVF),4,5 despite general consensus that NAVFs represent best vascular access.1,4,6 Creating a successful native fistula has been more difficult as dialysis is offered to older and increasing numbers of diabetic patients.5-7 It is estimated that only 25% to 30% of current dialysis patients are maintained by NAVFs.5,7 Synthetic conduits are used more often in patients with multiple medical illnesses and in various geographic areas.8 Other countries report higher success rates with native fistulas.9 One-fourth of the cost of caring for patients with end-stage renal disease is devoted to vascular access.10 Several reports find dialysis by synthetic graft conduit increases morbidity and associated cost when compared with NAVFs.4,6,7 This article describes our use of the proximal radial artery (PRA) for arterial inflow in establishing NAVFs for hemodialysis. This is part of a continuing effort to establish dialysis access by NAVF in as many patients as possible.

No competing interests declared.

Presented at the Vascular Access for Hemodialysis VIII Symposium, Rancho Mirage, CA, May 2002. Received September 13, 2002; Revised January 21, 2003; Accepted February 13, 2003. From the University of Oklahoma, College of Medicine-Tulsa, Tulsa, OK. Corresponding address: William C Jennings, MD, Department of Surgery, 4502 E 41st St, The University of Oklahoma College of Medicine, Tulsa, OK 74135-2512.

© 2003 by the American College of Surgeons Published by Elsevier Inc.

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Abbreviations and Acronyms

AV ⫽ arteriovenous NAVF ⫽ native arteriovenous fistula PRA ⫽ proximal radial artery

METHODS From June 1998 through 2001, we performed 146 vascular access procedures involving 134 patients. Fifteen patients underwent revision of an existing prosthetic graft or NAVF. Twenty patients required a new prosthetic graft and 111 had a new NAVF constructed. When a radial-cephalic fistula at the wrist was not feasible, an NAVF was created in the mid-arm with the PRA as arterial inflow site (Fig. 1). This NAVF has been rarely reported11-13 and was performed in 73 extremities, forming the basis of this article. NAVFs using the PRA were routinely constructed with local anesthesia and sedation through a longitudinal incision in the upper forearm overlying the origin of the radial artery. These operations were performed as outpatient procedures unless hospitalization was required for other reasons. The brachial and ulnar arteries were left undisturbed, and the radial artery was mobilized, accentuating its more anterior position. Local venous anatomy and acquired venous occlusions dictated the choice of outflow vessel(s) for the anastomosis. A side-to-side anastomosis was usually possible to the median antebrachial vein; otherwise, the perforating vein would often permit an end-to-side anastomosis that would function in the same manner, allowing flow and dialysis in both the upper arm and the forearm (Fig. 2). Retrograde flow into the forearm was established through the median antebrachial vein by disruption of the first valve with a small dilator under direct vision. If the perforating vein was not used for an anastomosis, it was ligated to maximize flow into the superficial venous system. The basilic vein was usually ligated if flow into the cephalic and median antebrachial veins was judged sufficient for dialysis. Continuous CVA Gortex (Gore & Associates) suture was used routinely. Selective use of preoperative ultrasonography performed by the operating surgeon in 29 of these patients predicted feasibility and best location for creation of a NAVF. We have generally required an unobstructed arterial inflow vessel of 2 mm diameter or greater and vein size of 2.5 mm diameter or greater with compressible

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and unobstructed outflow path as minimal requirements for creation of an NAVF. RESULTS Seventy-three NAVFs were constructed in 71 patients using the PRA for arterial inflow. Thirty-six patients were men. The mean age was 57 years (Fig. 3). Diabetes was the cause of renal failure in 71%. More than half had previous access surgery and 22% had two or more previous access operations. No patient new to dialysis required a prosthetic graft. The combination of older patients, a high percentage of individuals with diabetes, and frequent previous access surgery in our patient group suggests a significant risk for surgical access failure. But only one of these NAVFs had early thrombosis. No infections or ischemic complications developed during the study period. Thrombosis occurred in eight NAVFs during the followup period. Five of these NAVFs closed in patients with previous access surgery. Three patients were transplanted with functioning fistulas. Two individuals refused use of open NAVFs and were maintained by catheter hemodialysis. Eighteen patients died with open NAVFs during the followup period. No deaths were related to dialysis access. These complex patency data are best displayed as a time/life analysis (Table 1). Only 16% of those patients evaluated by preoperative ultrasonography were found to be candidates for an NAVF at the wrist. Thrombosis occurred in three patients evaluated by preoperative ultrasonography and in five patients without ultrasonographic evaluation.

Figure 1. Anastomotic site by arterial inflow in 146 hemodialysis access operations. NAVF, native arteriovenous fistula.

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Figure 2. Native arteriovenous fistula: proximal radial artery anastomosis to perforating vein providing inflow to the superficial veins of the upper arm and forearm (distal forearm is to the left in this photograph).

Three patients had fistulas ligated during the study period, one for venous hypertension, one was ligated by another surgeon during revision to a prosthetic graft, and one patient with diabetes and chronic peripheral vascular disease underwent ligation of her fistula after traumatic injury to the hand. A fourth individual with diabetes and severe peripheral vascular disease in all extremities had her fistula ligated after the study period because of progression of ischemic changes in all extremities. She had previously been placed on peritoneal dialysis and had threatened digit loss in all extremities except for the arm with the AV fistula, but progressive neuropathy was judged sufficient indication to ligate her fistula.

Figure 3. Distribution by age decade in patients with proximal radial artery native arteriovenous fistulas.

DISCUSSION The brachial artery bifurcates adjacent to the biceps tendon, just distal to the elbow, after entering the cubital fossa at an angle from medial to lateral. The ulnar artery is the larger of the two branches and recedes to a posterior location. The PRA emerges anteriorly at its origin where its first branch, the radial recurrent artery, arises laterally (Fig. 4a). Superficial venous structures in the cubital fossa vary but have generally consistent and surgically useful anatomy, unless obliterated by previous operation or intravenous access use. The median antebrachial vein, the largest and most common proximal forearm access site, bifurcates by way of the median cubital vein into the basilic and cephalic upper arm components. Deep venous system perforating (communicating) branches are variable in their location but are almost always present within the cubital fossa (Fig. 4b). We find the mobility and anterior position of the PRA to be the key technical factor in this procedure. A sideto-side anastomosis without tension or distortion is usually possible between the PRA and the median antebrachial vein. The perforating vein is usually adequate for an end-to-side anastomosis to the PRA if necessary but is too short to reach the brachial artery in most patients. PRA mobilization is simple, and clamping (or even disturbing) the brachial and ulnar arteries is avoided. The PRA is almost always free of significant artheromatous

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Table 1. Time/Life Table Analysis of 73 Native Arteriovenous Fistulas with Proximal Radial Artery Inflow Open NAVF Interval (mo)

NAVFs at interval risk (n)

0–1 1–3 3–6 6–9 9–12 12–15 15–18 18–21 21–24 24–27 27–30 30–33 33–36 36–39 39–42

73 72 65 54 47 42 37 30 21 14 14 7 6 6 4

Deaths (n)

Off dialysis or transplanted (n)

Lost to followup (n)

0 4 3 4 1 0 2 1 3 0 0 0 0 0 0

0 1 0 0 0 1 1 0 0 0 0 0 0 0 0

0 2 0 0 2 0 0 2 0 0 0 0 0 0 0

Change to PD (n)

NAVFs closed or ligated (n)

Interval patency (%)

Cumulative patency (%)

1 1 0 0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 2 2 2 2 0 0 0 0 0 0 0 0

99 99 98 96 96 95 97 100 100 100 100 100 100 100 100

100 99 98 96 92 88 83 80 80 80 80 80 80 80 80

NAVF, native arteriovenous fistulas; PD, peritoneal dialysis.

disease. Retrograde forearm fistula flow is established by disruption of the first venous valve with a small dilator. Venous side branches maintain patency as valves sequentially become incompetent while the newly arterialized vein dilates toward the wrist. Communicating branches to the cephalic vein in the forearm enlarge laterally, offering additional dialysis sites. Proximal flow from the NAVF is immediately present in the cephalic system of the upper arm, and this can be the first segment to mature.14 Often, both proximal and distal segments will be adequate for dialysis. If one fistula segment is lost because of thrombosis, the remaining portion of the NAVF is often usable for continued and uninterrupted dialysis. Three articles describe NAVFs with the antecubital vein using the proximal radial or brachial arteries as inflow sites. Miller and colleagues11 used an end-to-side anastomosis with upper arm access in 14 patients. Emphasizing the use of the antecubital vein, Sparks and coworkers12 reported using the PRA as inflow if the brachial artery could not be reached for anastomosis. Kliger13 reported use of “cephalic, basilic, or any large superficial vein and the brachial or proximal radial artery” in constructing 13 of 19 successful fistulas. Three of these 13 patients developed a steal syndrome. The arterial inflow site was not specified in these patients. Advantages of the Dialysis Outcomes Quality Initiatives guidelines’ second choice, the brachiocephalic AV fistula, are said to be higher blood flow compared with a

wrist fistula and a larger venous system more easily cannulated.1 This NAVF in the cubital fossa requires an end-to-side anastomosis with dialysis limited to the upper arm.15 In addition, after a previous forearm prosthetic graft with outflow anastomosis to the antecubital vein, a brachiocephalic AV fistula might be difficult or impossible to construct. A brachiocephalic AV fistula might not be possible in the distal upper arm because of the distance between the brachial artery and cephalic vein; a bridge graft has been reported for spanning this upper arm gap but adds synthetic material and two anastomoses.16 Greater morbidity is reported for brachial fistulas, including an increase in “steal syndrome.”17,18 We have encountered several patients with profound steal syndrome and threatened digit or limb loss from late enlargement of a brachiocephalic AV fistula but have not encountered these ischemic complications with NAVFs at the PRA. We, as others, have previously used a direct anastomosis from the basilic vein to the brachial artery with retrograde flow into the cubital and cephalic systems. This procedure requires careful inspection for valves and inflow from the brachial artery.19 We have frequently seen patients with a loop prosthetic graft placed in the forearm as second-choice access in an attempt to establish a forearm dialysis site. Complications are six to seven times more frequent with prosthetic grafts than with NAVFs,7,20 including higher risk of ischemia and infection rates of 12% to 29%.20-24 Bal-

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Figure 4. Cubital fossa illustration demonstrating the anterior position of the proximal radial artery (a) and the potential venous outflow sites for native arteriovenous fistulas (b). (Modified from: Moore KL. Clinically oriented anatomy. 3rd ed. Baltimore: Williams & Wilkins; 1992; with permission).

lard and associates21 reported an increased mortality associated with prosthetic graft complications in older patients. Primary prosthetic graft patency has been reported as low as 23% at 1 year,25 though most have reported significantly higher success rates.6 Feldman and colleagues7 emphasized the huge cost associated with access morbidity and the increase in morbidity with prosthetic graft material as opposed to NAVFs. Dialysis Outcomes Quality Initiatives guidelines avoid suggesting a minimal patency rate in NAVF procedures to encourage their construction. Early NAVF failure is reported in 9% to 30% of AVFs.6,7,20 Thrombosis in the first month was seen in only one of our series of 73 NAVFs. Another reason cited for construction of fewer AV fistulas is the longer time to mature adequately for access use. Aggressive interventions to minimize this problem include ligation of side branches, angioplasty, or banding techniques.26 Preoperative ultrasonography has evolved as an important component in our evaluation of patients with uncertain vascular status by clinical examination and is the subject of a separate article.27 Our use of preoperative ultrasonography now includes those patients who lack either a normal radial pulse or a normal and intact cephalic vein identified both visually and by palpation of the forearm. We feel patients with a history of multiple IV access procedures or diabetes will likely benefit from preoperative ultrasonography. Currently, most patients

requiring dialysis access in our practice are evaluated with preoperative ultrasonography. In summary, we find the anterior position and mobility of the PRA offers a simple tension-free anastomosis to the veins within the cubital fossa. The 1-month patency rate in our group of patients was 98.6%. Cumulative patency was 80% in a followup period of up to 42 months. Dissection, manipulation, and clamping of the brachial artery are avoided. No steal complications were observed in this series of patients. This anastomotic site frequently allows dialysis in the forearm and upper arm. With prolonged access use, if either the forearm or upper arm segment of this NAVF occludes, the remaining segment is often open and available for continued and uninterrupted dialysis. More extensive procedures or use of prosthetic grafts can be avoided. When an NAVF at the wrist is not possible, the PRA allows adequate arterial inflow while avoiding the risk of ischemia found with brachial artery fistulas. Author contributions

Study conception and design: Bruns, Jennings Acquisition of data: Jennings Analysis and interpretation of data: Bruns, Jennings Drafting of manuscript: Jennings Critical revision: Bruns, Jennings Supervision: Jennings

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Acknowledgment: We wish to acknowledge Thomas A Broughan, MD, FACS; Misti L Coates, RDCS, RVT; Connie B George, LPN; Lin F Peabody, LPN, CCRC; and Heather M Vice, RN; for their contributions to this study. REFERENCES 1. National Kidney Foundation Dialysis Outcomes Quality Initiative. Clinical practice guidelines for vascular access. New York: National Kidney Foundation; 1997. 2. Humphries AL. Elevated basilic vein arteriovenous fistula. Am J Surg 1999;177:489–491. 3. Zielinski CM, Mittal SK, Anderson P, et al. Delayed superficialization of brachiobasilic fistula. Arch Surg 2001;136:929–932. 4. Hakim R. Hemodialysis access failure: a call to action. Kidney Int 1998;54:1029–104. 5. Fan PY, Schwab SJ. Vascular access: concepts for the 1990s. J Am Soc Nephrol 1992;3:1–11. 6. Windus DW. Permanent vascular access: a nephrologist’s view. Am J Kidney Dis 1993;21:457–471. 7. Feldman HI, Kobrin S, Wassenstein A. Hemodialysis vascular access morbidity. J Am Soc Nephrol 1996;7:523–535. 8. Schwab SJ. Hemodialysis vascular access: entering a new era. Am J Kidney Dis 1999;34:xxxviii–xli. 9. Besarab A, Escobar F. A glimmer of hope: increasing the construction and maturation of autologous arteriovenous fistulas. Am J Kidney Dis 1999;33:977–999. 10. Hirth RA, Turenne MN, Woods JD, et al. Predictors of type of vascular access in hemodialysis patients. JAMA 1996;276: 1303–1308. 11. Miller A, Holzenbein TJ, Gottlieb MN, et al. Strategies to increase the use of autogenous arteriovenous fistula in end-stage renal disease. Ann Vasc Surg 1997;11:397–405. 12. Sparks SR, VanderLinden JL, Gnanadev DA, et al. Superior patency of perforating antecubital vein arteriovenous fistulae for hemodialysis. Ann Vasc Surg 1997;11:165–167. 13. Kliger FO. The antecubital fossa fistula. Clinical Nephrol 1976; 5:229–231.

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14. Miller PE, Tolwani A, Luscy CP, et al. Predictors of adequacy of arteriovenous fistulas in hemodialysis patients. Kidney Int 1999; 56:275–280. 15. Cantelmo NL, LoGerfo FW, Menzoian JO. Brachiobasilic and brachiocephalic fistulas as secondary angio-access routes. Surg Gynecol Obstet 1982;155:545–548. 16. Polo JR, Vazquez R, Polo J, Sanabia J, et al. Brachiocephalic jump graft fistula: an alternative for dialysis use of elbow crease veins. Am J Kidney Dis 1999;33:904–909. 17. Dunlop MG, Mackinlay JY, Jenkins AM. Vascular access: experience with the brachiocephalic fistula. Ann R Coll Surg Engl 1986;68:203–206. 18. Harland RC. Placement of permanent vascular access devices: surgical considerations. Adv Ren Replace Ther 1994;1:99–106. 19. Nghiem DD. Angioaccess by reverse brachiocephalic fistula. Am J Surg 1987;153:574–575. 20. Kherlakian GM, Roedersheimer LR, Arbaugh JJ, et al. Comparison of autogenous fistula versus expanded polytetrafluoroethylene graft fistula for angioaccess in hemodialysis. Am J Surg 1986;152:238–243. 21. Ballard JL, Bunt TJ, Malone JM. Major complications of angioaccess surgery. Am J Surg 1992;164:229–232. 22. Rajus S. PTFE grafts for hemodialysis access. Ann Surg 1987; 206:666–673. 23. Palder SB, Kirkman RL, Whittemore AD, et al. Vascular access for hemodialysis. Ann Surg 1985;202:235–239. 24. Silva MB Jr, Hobson RW II, 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. 25. Miller PE, Carlton D, Deierhoi MH, et al. Natural history of arteriovenous grafts in hemodialysis patients. Am J Kidney Dis 2000;36:68–74. 26. Beathard GA, Settle SM, Shields MW. Salvage of the nonfunctioning arteriovenous fistula. Am J Kidney Dis 1999;33:910– 916. 27. Parmley MC, Broughan TA, Jennings WC. Vascular ultrasonography prior to dialysis access surgery. Am J Surg 2002;184:586– 572.