Intraoperative transit time flow measurement predicts maturation of radiocephalic arteriovenous fistulas.

OBJECTIVE: The arteriovenous fistula (AVF) is the first choice for gaining vascular access for hemodialysis. However, 20% to 50% of AVFs fail within 4 months after creation. Although demographic risk factors have been described, there is little evidence on the intraoperative predictors of AVF maturation failure. The aim of this study was to assess the predictive value of intraoperative transit time flow measurements (TTFMs) on AVF maturation failure. METHODS: In this retrospective cohort study, intraoperative blood flow, measured using TTFM, was compared with AVF maturation after 6 weeks in 55 patients. Owing to its significantly higher prevalence and risk of nonmaturation, the radiocephalic AVF (RCAVF) was the main focus of this study. A recommended cutoff point for high vs low intraoperative blood flow was determined for RCAVFs, using a receiver operating characteristic curve. RESULTS: The average intraoperative blood flow in RCAVFs was 156 mL/min. Patients with an intraoperative blood flow equal or lower than the determined cutoff point of 160 mL/min, showed a 3.03 times increased risk of AVF maturation failure after 6 weeks, compared with patients with a higher intraoperative blood flow (P < .001). CONCLUSIONS: The intraoperative blood flow in RCAVFs measured by TTFM provides an adequate means of predicting AVF nonmaturation 6 weeks after surgery. For RCAVFs, a cutoff point for intraoperative blood flow of 160 mL/min is recommended for maximum sensitivity and specificity to predict AVF maturation failure after 6 weeks.

The clinical outcome of balloon-assisted maturation procedure between autogenous radiocephalic fistula and brachiocephalic fistula in a single-center experience.

OBJECTIVE: Balloon-assisted maturation (BAM) by an endovascular method plays an important role in treating an immature arteriovenous fistula. However, the results between radiocephalic fistula and brachiocephalic fistula were rarely reported. This retrospective study aimed to investigate the effectiveness and outcome of BAM in different sites of autogenous arteriovenous fistulas. METHODS: This single-center retrospective study included patients who underwent BAM procedures from January 2015 to December 2016. Of 148 patients, 117 and 31 patients had a radiocephalic fistula (RC) and a brachiocephalic fistula (BC), respectively. The primary outcome was BAM success. Data regarding fistula lesions, balloon types and size, frequency of procedures, and maturation time were collected for BAMs. The secondary outcome was the patency of a fistula in the follow-up period. RESULTS: No difference was observed in procedure of BAM frequency between the RC and BC groups. The total success rate was 77.7%, without significant difference between the RC and BC groups (81.20% vs 64.50%; P = .055). Within the procedures, the culprit lesion of juxta-anastomosis segment (73.5% vs 25.5%; P < .001) and arterial inlet (21.2% vs 7.8%; P = .04) were more common in the RC group, whereas the venous outlet was more common in the BC group (88.2% vs 57.7%; P < .001). Both groups had an equivalent patency rate after the BAM within the follow-up period (P = .272). CONCLUSIONS: BAM was an effective procedure for immature fistulas, without significant difference between RCs and BCs. Through the procedure, the culprit lesions causing non-maturation were found to be different between the two groups. The patency rate between the two groups after surgery seems to be equivalent within the follow-up period.

Outcomes of Autogenous Radiocephalic Versus Brachiocephalic Arteriovenous Fistula Surgery Based on Transit-Time Flowmeter Assessment: A Retrospective Study.

BACKGROUND: Despite the better operative results of autogenous brachiocephalic arteriovenous fistula (BC-AVF), it is considered secondary to autogenous radiocephalic AVF (RC-AVF) failure. Here we compared the results of our multidisciplinary management protocol of BC-AVF versus RC-AVF. METHODS: A total of 194 matched patients who requested autogenous BC-AVF or RC-AVF surgery between 2017 and 2019 were included in this retrospective study. All patients strictly adhered to our departmental perioperative management protocol for AVF surgery, including vessel status monitoring, exercise with or without a tourniquet, intraoperative flow assessment, and antiplatelet and anticoagulant medications. AVF function and patient status data were acquired from the electronic medical records, and the final evaluation was made via outpatient department visit or phone call in October 2020. RESULTS: Patients who underwent elective BC-AVF or RC-AVF (n = 97 each) were included. The patient groups had similar preoperative clinical characteristics. Artery and vein sizes at the planned anastomosis site were larger in the BC-AVF group (P < 0.001). The mean intraoperative maximal flow rate was higher in the BC-AVF group (492.5 ± 186.9 mL/min) than in the RC-AVF group (307.3 ± 113.0 mL/min, P < 0.001). The simultaneously evaluated mean pulsatility index was 0.5 ± 0.2 in the BC-AVF group and 0.6 ± 0.2 in the RC-AVF group (P < 0.001). The median observation duration was 19.4 months (11.0‒31.3 months). The primary patency rate was higher in the BC-AVF group (88.7%) than in the RC-AVF group (62.9%, P < 0.001). Patency duration was similar between groups, and the primary patency maintenance duration was longer in the BC-AVF group. Three cases of cephalic arch stenosis were observed in the BC-AVF group, while no cases of arterial steal syndrome were observed during the indexed observation period. Mortality rates were 14.4% and 9.3% in the BC-AVF and RC-AVF groups, respectively (P = 0.267), and the cause of death did not differ significantly between groups. For mortality, the estimated hazard ratio of RC-AVF over BC-AVF was 0.47 (95% CI, 0.19‒1.17, P = 0.106) during the observation period. CONCLUSION: BC-AVF had good characteristics for hemodialysis without an increased risk of AVF related complications during a median 19-month observation period. BC-AVF did not feature high flow-related complications with the multimodal approach, including preoperative exercise, intraoperative flow assessment to guarantee an adequate flow rate, postoperative exercise, and medications.

Preoperative Cardiac Index as a Predictor of Maturation and Primary Patency of Radiocephalic Arteriovenous Fistula in Hemodialysis.

BACKGROUND: Radiocephalic arteriovenous fistula (RCAVF) is the best access modality to be considered initially when planning arteriovenous fistula (AVF) for maintenance hemodialysis. Considering the higher incidence of RCAVF failed maturation (M), it is important to perform proper preoperative evaluation and identification of high-risk patients. There has been no study on the influence of preoperative cardiac function on the M and patency of AVFs. The purpose of this investigation is to determine whether preoperative cardiac index (CI) is a predictor of M and primary patency of RCAVF. METHOD: A total of 365 end-stage renal disease patients undergoing RCAVF surgery were consecutively enrolled with a median follow-up time of 20 months in this prospective cohort study. Demographics, vascular diameters measured by duplex ultrasound examination, and CI measured by echocardiography, were analyzed for effect on RCAVF primary functional M and primary patency. RESULT: Patients in the group achieving primary RCAVF functional M had a significantly larger mean CI than the group with early RCAVF failure (2.93 ± 0.77 vs. 3.57 ± 0.76 L/min/m2, p < 0.001). The receiver operating characteristic curve was plotted and demonstrated that preoperative vein diameter and CI can predict failure of RCAVF M. The AUC of CI was higher (0.745 vs. 0.666). Multivariate regression analysis, adjusted for age, sex, diabetes, preoperative dialysis status and vessel diameters, showed that decreased CI remained associated with increased risk of failure of M (FM) and worse primary unassisted patency. The Kaplan-Meier survival analysis suggested that patients with CI <3 L/min/m2 had a worse primary unassisted patency rate at all time points compared with patients with CI ≥3 L/min/m2. CONCLUSION: This study demonstrated that preoperative CI was associated with RCAVF M and long-term patency. A decreased CI may be a possible predictor of an increased risk of FM and a shorter primary patency time.

Radial artery diameterand and age related functional maturation of the radio-cephalic arteriovenous fistula.

BACKGROUND: Previous studies have not described the relationship between reducing radial artery diameter as well as increasing age and functional maturation of the radio-cephalic arteriovenous fistula (RCAVF) and no data identify these as linear relationship. The objective of this study was to perform trend analysis to assess these aspects. METHODS: Our retrospective cohort study enrolled and analyzed 353 follow-up cases that underwent first AVF creation. The artery and vein sizes were measured by ultrasound. We performed follow-up, a minimum of 3 months after surgery. Multivariable logistic regression analysis was used to identify independent risk factors inmaturation. Participant age was categorized into four groups (age ≤ 29, 30-49, 50-69, and 70-90 years). Radial artery diameter was categorized into four groups (≤ 1.9, >1.9 and ≤ 2.1, >2.1 and ≤ 2.4, >2.4 mm) according to median and interquartile ranges. We adjusted for confounders in four logistic models, and primary analyses were based on building ordered category models and tested P values for trends to estimate the relationship of radial artery diameter and each 20-year increase in age with risk of maturation. RESULTS: The mature RCAVF group included 301 cases, and the immature group included 52 cases. Radial artery diameter, age, and diabetes were independent risk factors of maturation. Odds ratios (ORs) associated with maturation reduced with increasing age, while ORs increased with increasing radial artery diameter. P values for trends(<0.05) were observed in all four models. A reduction in radial artery diameter and higher age were significantly associated with a higher incidence of immaturity after adjusting the multivariate models. The risks of immaturation were increased by more than 1.54 fold for each 20-year increase and increased by more than 1.34 fold for the smaller radial artery diameter group. CONCLUSION: Our findings suggest that a significantly higher immaturity risk of RCAVF was associated with increasing age and a reduction in radial artery diameter. Our study identified a linear exposure-response relationship of age and radial artery diameter with immaturity incident. A careful selection of patients will be helpful in improving AVF functional maturation.

Does ligation of the dorsal branch of the cephalic vein affect the patency of a distal forearm arteriovenous fistula? A randomised study.

BACKGROUND: Whether ligation of the dorsal branch of the cephalic vein during the surgical establishment of the radiocephalic arteriovenous fistula (RCAVF) favorably or adversely affects the patency rate of the RCAVF remains controversial. We performed a randomized controlled trial to evaluate the effect of dorsal branch ligation on the patency rate of RCAVF. METHODS: A total of 115 patients who underwent surgical establishment were randomized to two groups treated with or without ligation of the dorsal branch of the cephalic vein during the surgical process. The primary patency rates of the RCAVF at 90, 270, and 360 days after the surgery and the secondary patency rates during a follow-up up to 1 year were compared. RESULTS: The patency rate did not differ significantly between the two groups at 3, 9, or 12 months after the procedure (P > 0.05). The combined primary patency rates of the RCAVF in patients from both groups at 3, 9 and 12 months after the procedure were 87.6, 82, and 74.5% respectively, while the combined secondary patency rate was 92.2% at the 1-year follow-up. The Log-rank test indicated that the initial patency rate and secondary patency rate did not differ significantly between the two groups (P = 0.674 and 0.759, respectively). CONCLUSION: This clinical study indicated that ligation of the dorsal branch of the cephalic vein does not significantly affect the patency of the arteriovenous fistula with a 1-year follow-up. TRIAL REGISTRATION: ISRCTN ISRCTN12288675, Registered 25 September 2019 in the ISRCTN registry. retrospectively registered.

A randomized trial of vonapanitase (PATENCY-1) to promote radiocephalic fistula patency and use for hemodialysis.

OBJECTIVE: Arteriovenous fistulas created in patients with chronic kidney disease often lose patency and fail to become usable. This prospective trial evaluated the efficacy of vonapanitase, a recombinant human elastase, in promoting radiocephalic fistula patency and use for hemodialysis. METHODS: PATENCY-1 was a double-blind, placebo-controlled trial that enrolled 349 patients on or approaching hemodialysis and being evaluated for radiocephalic arteriovenous fistula creation. Of these, 313 were randomized and 311 treated. Patients were assigned to vonapanitase (n = 210) or placebo (n = 103). The study drug solution was applied topically to the artery and vein for 10 minutes immediately after fistula creation. The primary and secondary end points were primary patency (time to first thrombosis or corrective procedure) and secondary patency (time to abandonment). Tertiary end points included use of the fistula for hemodialysis, fistula maturation by ultrasound, and procedure rates. RESULTS: The Kaplan-Meier estimates of 12-month primary patency were 42% (95% confidence interval [CI], 35-49) and 31% (95% CI, 21-42) for vonapanitase and placebo (P = .25). The Kaplan-Meier estimates of 12-month secondary patency were 74% (95% CI, 68-80) and 61% (95% CI, 51-71) for vonapanitase and placebo (P = .048). The proportions of vonapanitase and placebo patients were 39% and 25% (P = .035) with unassisted use for hemodialysis and 64% and 44% (P = .006) with unassisted plus assisted use. CONCLUSIONS: Vonapanitase treatment did not significantly improve primary patency but was associated with increased secondary patency and use for hemodialysis. Further research is needed to evaluate these end points.

Interwoven Nitinol Stents to Treat Radiocephalic Anastomotic Arteriovenous Fistula Stenosis.

PURPOSE: To determine the clinical outcomes in hemodialysis patients after implantation of a Supera stent to treat juxta-anastomotic stenosis in radiocephalic arteriovenous fistulas (AVF). MATERIALS AND METHODS: A single-center retrospective study was conducted of 42 consecutive patients (mean age 66.7 years, range 40-84; 26 men) who had a failing AVF due to juxta-anastomotic stenosis treated with the interwoven Supera stent between February 2014 and February 2018. A third of the patients had previous juxta-anastomotic intervention (either balloon angioplasty or open surgical revision). RESULTS: The stent was inserted successfully in all patients. Overall mean follow-up was 12.2±8.2 months (range 3.8-38.3). Juxta-anastomotic segment primary patency estimates at 6 and 12 months were 92.5% and 59.8%, respectively, with assisted primary patency rates of 97.5% and 92.9%. Reintervention (elective drug-coated balloon angioplasty) occurred at a rate of 0.31 procedures/year. Two AVFs thrombosed during the 1-year follow-up and were revascularized using balloon angioplasty. Ultrasound measurements of brachial artery flow rates increased significantly from 543.5±96.72 mL/min (range 430-644) before intervention to 919.2±355.9 mL/min (range 200-1600) after intervention (p=0.047). Arterial pressures on hemodialysis improved from -142.3±24.9 mm Hg (range -100 to -180) to -123.4±21.9 mm Hg (range -100 to -184; p=0.051). No AVFs were lost or abandoned during the follow-up period. CONCLUSION: The interwoven Supera stent is a promising treatment for failing AVFs with juxta-anastomotic stenosis. Encouraging 1-year primary and assisted primary patency was demonstrated, with a low reintervention rate. This treatment facilitates long-term maintenance of AVF vascular accesses.

The Impact of Patient Demographics, Anatomy, Comorbidities, and Peri-operative Planning on the Primary Functional Maturation of Autogenous Radiocephalic Arteriovenous Fistula.

OBJECTIVES: The aim of this study was to evaluate the collective and/or independent impact of patient demographics, comorbidities, anatomical factors, and peri-operative parameters on the primary functional maturation of RCAVFs. This study also aimed to identify the range and best cut off value for each variable and evaluate the likelihood, significance and percentage of primary functional maturation of RCAVFs. METHODS: This was a prospective consecutive single centre cohort study over a 4 year period; it was conducted on patients with the intention-to-treat using a radiocephalic arteriovenous fistula (RCAVF) (Brescia-Cimino). During this period 548 vascular access procedures, inclusive of RCAVF, were performed. Variables included patient demographics (age, gender), anatomical variance (cephalic vein, radial artery diameter, laterality), comorbidities (diabetes mellitus, ischaemic heart disease, congestive cardiac failure, hypertension), aetiology of renal failure, and anaesthesia type (local versus general anaesthesia). RESULTS: Of the total, 324 patients, cephalic vein diameter > 1.5 mm (OR 4.57, 95% CI, 2.42-8.63, p < .001) (non-augmented) and radial artery diameter > 1.6 mm (OR 12.26, 95% CI, 6.27-23.97, p < .001) were found to be independently associated with the primary functional maturation of 86% in the RCAVF formation. CONCLUSION: Of all the variables, cephalic vein and radial artery diameter are independently associated with the primary functional maturation of RCAVFs.

Application of a supporting catheter in surgery for forearm arteriovenous fistula construction.

INTRODUCTION: This study explored the feasibility of a supporting catheter combined with modified end-to-side anastomosis in the operation of radio-cephalic arteriovenous fistula (RC-AVF) and evaluated the clinical application value of this technique. METHODS: Sixty patients underwent RC-AVF operations in our hospital from January 2022 to June 2022. All the patients were treated with modified end-to-side AVF anastomosis and divided into the control group or the test group depending on whether a supporting catheter was applied. The clinical data of 60 cases were analysed retrospectively. Intraoperative related indices, the first time the fistula was used, the success rate of first puncture, the blood flow of first dialysis, the maturity condition of fistula, the size of anastomosis, the diameter of radial artery and drainage vein, the blood flow of brachial artery 8 weeks after operation and the incidence of complications within 6 months after operation were compared between the two groups. RESULTS: Compared with that in the control group, the time spent on the vascular anastomosis in the test group was significantly shortened (p<0.05). The blood flow of the first dialysis, the size of the anastomosis, the diameter of the drainage vein, the blood flow of the brachial artery 8 weeks after the operation and the incidence of complications within 6 months after operation were significantly different between the two groups (p<0.05). CONCLUSION: In the RC-AVF operation, using a supporting catheter can not only increase operation efficiency by reducing surgical injury and difficulty of vascular anastomosis, but also improve postoperative prognosis. RC-AVF is worth promoting in clinical practice.

International survey of radiocephalic arteriovenous fistula: ISRAF survey.

AIMS: The objective of this survey was to encompass the full scope of international practice, entailing all technical, non-technical, preoperative stratification and functional maturation (FM) of RCAVF. METHODS: The survey contained n = 19 questionnaires with n = 46 variables completed by n = 85 providers from n = 21 nations across n = 5 continents. The numerical values were subjected to mean with standard error whereas the nominal data to a non-parametric (Kruskal-Wallis & Spearman correlation test) and analysis of variance (ANOVA). The test of homogeneity, & probability was reported 95% confidence intervals (CI) alongside error plots. Furthermore, a decision and higher attribute tree model was constructed based on current survey for higher FM in RCAVF. RESULTS: FM is independently associated with volume of surgeon per year (procedures performed) (p < 0.01) [High Volume: 73% (95% CI, 68-77%) versus Average volume: 63% (95% CI, 59-66%) vs Low volume: 56% (95% CI, 51-61%)]. FM increased by 8% with every 20 more procedures per group of surgeons on end point of FM. Amongst continents: Australia, America, Asia and South America demonstrated higher FM to Africa & Europe (p < 0.05). UK possessed a lower FM 58% (95% CI, 48-68%) in comparison to the world & Europe respectively [65% (95% CI, 61-70%) vs 61% (95% CI, 58--65%)]. There was a positive causal link between angle of anastomosis at 30-76° (p < 0.01), longitudinal & S-shaped incision & arteriotomy length of 3 & 4 mm to higher FM (p < 0.05). CONCLUSION: FM in RCAVF is independently & incrementally associated with the volume of surgeon per year. There is a diverse inclusion, exclusion and technical approach in RCAVF creation. This survey advocates the importance of international collaboration and/or registry in assimilation, consolidate and development of consensus.

Model and online calculator for prediction of fistula maturation based on vein dilation and age: A retrospective cohort study in a single-center.

OBJECTIVE: A model that considers the characteristics of dialysis patients may help predict successful fistula maturation. We evaluated factors associated with radiocephalic arteriovenous fistula (RCAVF) maturation at 3 months in dialysis patients with end-stage renal disease (ESRD). METHODS: A total of 184 patients who received an initial RCAVF at Beijing Haidian Hospital (Haidian Section of Peking University Third Hospital) were recruited. Fistula maturation was assessed within 3 months. Patient characteristics and preoperative vascular assessment indices were examined. Factors associated with fistula maturation were analyzed using logistic regression and least absolute shrinkage and selection operator (LASSO) binary logistic regression. Boostrapping was used for internal validation. RESULTS: The development data consisted of 184 ESRD patients receiving an initial RCAVF, 140 (76%) of whom achieved fistula maturation. The main predictors of RCAVF maturation in the final model were sex, age-adjusted vein dilation (eVD), radial artery volume (Vartery), and diastolic blood pressure. The difference of vein diameter with and without a tourniquet was significantly larger in the mature RCAVF group (3.0 ± 0.5 vs. 2.2 ± 0.5 mm). The area under receiver operating characteristic (AUROC) curve for prediction of fistula maturation was 0.77, and the Hosmer-Lemeshow statistic indicated agreement between observed and predicted values (P = 0.792). Analysis of internal validation using bootstrapping indicated the C-index was 0.75. CONCLUSION: The ratio of vein dilation and age were the major predictors of fistula maturation at 3 months in our patients. The resulting online prediction model may help in clinical decision-making for patients receiving a RCAVF.

Proximalization through one incision of a wrist arteriovenous fistula and distal revascularization with interval ligation.

In the setting of ischemic steal syndrome with tissue loss, patients with radiocephalic fistulas have limited options to preserve their conduit and treat their ischemic symptoms. To address this, we have proposed the technique of proximalization through one incision of a wrist arteriovenous fistula (POWR) with distal revascularization with interval ligation (DRIL) procedure. In the present retrospective, single-center, case series, we evaluated the outcomes of three patients with radiocephalic fistulas who had undergone POWR DRIL from 2017 to 2021. Their ischemic symptoms were monitored for regression. All three patients showed signs of regressing ischemia. The POWR DRIL represents an efficient procedure to address tissue loss and preserve the autogenous conduit.

Clinical characteristics and preoperative ultrasound parameters related to low patency in radio-cephalic arteriovenous fistulas.

INTRODUCTION: Our objective is to describe the clinical characteristics and preoperative ultrasound mapping parameters associated with primary and secondary patency of radio-cephalic arteriovenous fistulas (RCF). METHODS: A retrospective, single-center, descriptive study, including patients undergoing a RCF creation between 2015 and 2019. Socio-demographic data and ultrasound parameters were collected and an analysis of primary and secondary patency was performed. RESULTS: Eighty-four patients were included in this study. Mean age was 65.6 (±13.9) years; 76.6% were male. Mean preoperative ultrasound parameters: forearm cephalic vein diameter was 2.8 (±0.57) mm, radial artery diameter was 2.6 (±0.42) mm, radial artery systolic peak velocity was 68 (±14.3) cm/s radial artery resistance index was 0.76 (±0.9). At the end of the 4 years the follow-up, the mean primary and secondary patency were 47.2% and 80% respectively. Only female sex was significantly associated with a decrease in both primary patency (p = 0.043, HR = 0.48) and secondary patency (p = 0.021, HR = 0.023). Furthermore, radial artery systolic peak velocity (p = 0.007, HR = 2.6) showed a significant association with decreased primary patency and forearm cephalic vein diameter showed a borderline significant association with decreased secondary patency (p = 0.046, HR = 8.2). CONCLUSIONS: A standardized evaluation by a vascular surgeon or nephrologist represent a key in the preoperative assessment of AVF candidates. Based on our results, we will consider to avoid distal vascular access in both female patients with lower radial artery systolic peak velocity (less than 68 cm/s) and borderline forearm cephalic vein diameter (less than 2.8 mm) after initial assessment in our clinical practice. Our results could encourage new studies in order to stablish the potential role of these parameters in the RCFs patency rates.

A Case Report of a Successful Attempt to Create a Hemodialysis Vascular Access in a Patient With Recurrent Failed Arteriovenous Fistulas.

The majority of individuals undergoing hemodialysis for chronic renal insufficiency (CRI) require vascular access. The more appropriate and long-term accesses are arteriovenous fistulas (AVF). These accesses must be attempted to be salvaged even in the circumstances when they stop functioning. In this study, a case report of a 57-year-old female patient with CRI who presented with a failed brachioradial and brachiocephalic AVF in the left upper limb and who later underwent the creation of a new functional radio-cephalic AVF mid-arm on the same limb is presented.

The difference in diameter between radial artery and cephalic vein correlates with primary patency of radio-cephalic arteriovenous fistula.

INTRODUCTION: Autogenous radio-cephalic arteriovenous fistula (RCAVF) is preferred for chronic hemodialysis access. However, RCAVF still suffers from disappointing survival due to fistula dysfunction, with intimal hyperplasia (IH) as an underlying cause of this condition. The inconsistency of radial artery diameter (DRA) and cephalic vein diameter (DCV) is one of the factors affecting the shear disturbance, which is believed to trigger the onset of IH. However, there are no reports correlating the difference in DRA and DCV with RCAVF outcomes. METHODS: This was a retrospective cohort study. Consecutive patients (n = 233) with a new RCAVF created were included if they underwent duplex ultrasound examination to evaluate preoperatively the radial artery diameter (DRA) and cephalic venous diameter (DCV). We then calculated radial artery-cephalic vein diameter difference (DCV minus DRA, termed DCV-DRA hereafter) and evaluated the association of the preoperative DCV-DRA with primary patency of RCAVF at 12 months. Subgroup analysis was also performed to explore effect modification by age, gender, radial artery diameter, and cephalic vein diameter with DCV-DRA. RESULTS: After adjusting for age, gender, weight, and mean arterial pressure, the preoperative DCV-DRA was associated with primary patency of RCAVF at 12 months (adjusted Odds ratio [aOR], 1.524 per 1-mm increase; 95% confidence interval [95% CI], 1.048-2.218). The primary patency of RCAVF at 12 months was achieved in 69.4%, 71.8%,and 87.3% of patients with a preoperative DCV-DRA of ⩽-0.6 mm, (-0.5)-0.5 mm, and ⩾0.6 mm, respectively. P for trend was 0.029. Patients with DCV-DRA of ⩾0.6 mm had a much higher chance of 12-month patency than patients with DCV-DRA of ⩽-0.6 mm (aOR, 3.574; 95% CI, 1.276-10.010). Age, gender, radial artery diameter, and cephalic vein diameter did not modify the association of DCV-DRA with primary patency of RCAVF at 12 months. CONCLUSIONS: Preoperative DCV-DRA may be an under-recognized predictor of RCAVF patency.

Radial Artery Aneurysm Arising from the Stump of a Ligated Arteriovenous Fistula in a Kidney Transplant Patient.

While aneurysm and pseudoaneurysm are common complications to arteriovenous (AV) fistula, the development of aneurysm from the stump of a ligated AV fistula is unusual. The involvement of radial artery after AV fistula ligation is an extremely rare entity with only two cases reported in the literature. In this report, we describe a 40-year-old kidney transplant patient who presented with a radial artery aneurysm after radiocephalic fistula ligation which was managed by the plastic surgery team using autologous vein graft reconstruction, and we compare our case to the two cases described in the literature in the presentations, timelines, and management options.

Radiocephalic Arteriovenous Fistula Patency and Use: A Post Hoc Analysis of Multicenter Randomized Clinical Trials.

We sought to confirm and extend the understanding of clinical outcomes following creation of a common distal autogenous access, the radiocephalic arteriovenous fistula (RCAVF). Background: Interdisciplinary guidelines recommend distal autogenous arteriovenous fistulae as the preferred hemodialysis (HD) access, yet uncertainty about durability and function present barriers to adoption. Methods: Pooled data from the 2014-2019 multicenter randomized-controlled PATENCY-1 and PATENCY-2 trials were analyzed. New RC-AVFs were created in 914 patients, and outcomes were tracked prospectively for 3-years. Cox proportional hazards and Fine-Gray regression models were constructed to explore patient, anatomic, and procedural associations with access patency and use. Results: Mean (SD) age was 57 (13) years; 45% were on dialysis at baseline. Kaplan-Meier estimates of 3-year primary, primary-assisted, and secondary patency were 27.6%, 56.4%, and 66.6%, respectively. Cause-specific 1-year cumulative incidence estimates of unassisted and overall RC-AVF use were 46.8% and 66.9%, respectively. Patients with larger baseline cephalic vein diameters had improved primary (per mm, hazard ratio [HR] 0.89, 95% confidence intervals 0.81-0.99), primary-assisted (HR 0.75, 0.64-0.87), and secondary (HR 0.67, 0.57-0.80) patency; and higher rates of unassisted (subdistribution hazard ratio 1.21, 95% confidence intervals 1.02-1.44) and overall RCAVF use (subdistribution hazard ratio 1.26, 1.11-1.45). Similarly, patients not requiring HD at the time of RCAVF creation had better primary, primary-assisted, and secondary patency. Successful RCAVF use occurred at increased rates when accesses were created using regional anesthesia and at higher volume centers. Conclusions: These insights can inform patient counseling and guide shared decision-making regarding HD access options when developing an individualized end-stage kidney disease life-plan.

Fatal suicidal injury of a radiocephalic arteriovenous fistula.

A 59-year-old man was found dead in his living room. His body was covered with blood, but the only injury found was a 31-mm-long, transverse incision on the radial surface of the left forearm. Autopsy revealed that the injured vessel was an enlarged cephalic vein from a radiocephalic arteriovenous fistula (RC-AVF) that had been created 23 years before for hemodialysis. Cephalic vein injury is usually not fatal, but circumstantial evidence, autopsy, and histological findings suggested that hemorrhagic shock and death occurred within a short time after the self-inflicted incised wound. This may be explained by the blood flow rate in the RC-AVF, which can reach 12 ml/s; this is 25 times higher than the normal cephalic vein blood flow.