Long-term durability of Oakes salvage procedure to preserve Brescia-Cimino arteriovenous fistula.

BACKGROUND: In 2002, Oakes et al described a novel procedure designed to salvage the distal cephalic venous outflow of a Brescia-Cimino fistula by placing a prosthetic graft between the brachial artery in the antecubital space and the cephalic vein at the wrist. In this fashion, the more proximal veins were saved for future procedures. Their approach was reported and found to be successful in the short term, but the long-term durability of the Oakes procedure has not been described. This study aimed to determine the long-term primary, primary-assisted, and secondary patency rates of the brachial to distal cephalic vein Oakes procedure. METHODS: This is a retrospective review of a prospective database in a large, single institution. All patients who underwent the Oakes procedure from 1998 to 2012 were followed up to 2018. We reviewed the time to intervention, type of intervention, patency rates, and mortality of this patient population. RESULTS: Over the 5-year study period, 14 patients were identified who underwent the Oakes procedure, of whom seven (50%) were female. The average age was 55.7 years (range, 38-73 years). All patients had a previously placed Brescia-Cimino that was not suitable for dialysis but was patent. The average number of days to placement of an Oakes brachial to distal cephalic graft was 396 (range, 119-1167) days. A total of 71% (10) of patients underwent an intervention to maintain the graft, of whom 50% (5) underwent an angioplasty and 50% (5) had a thrombectomy/revision procedure. The average number of days to first intervention was 367.3 (range, 21-1048) days from Oakes placement. Of this cohort, 30% (3) of patients had a second intervention, of whom one (33%) underwent an angioplasty and two (66%) had revisions. One patient had a third and a fourth intervention at 39 days and 74 days, respectively, that were both angioplasties. The overall number of days the Oakes procedure remained usable from placement was 843.6 (range, 21-3790) days or 2.3 years. CONCLUSIONS: This study concluded that the Oakes procedure may extend the use of the distal dialysis access site by 2.3 years without increasing infection and is hence a durable solution that should be considered in patients requiring dialysis access.

A new operation with inadequate Brescia fistulae for preservation of more proximal veins.

PURPOSE: The purpose of this study was to test the hypothesis that venous outflow of a Brescia fistula that is patent but unusable for one of a variety of reasons can provide adequate drainage to sustain a prosthetic arteriovenous graft based on the brachial artery, thus sparing more proximal veins for future access procedures. METHODS: The operation consists of placement of a prosthetic graft between the brachial artery in the antecubital space and the cephalic vein at the wrist. RESULTS: Between December 1998 and November 1999, 14 patients (eight male and six female; age range, 34 to 73 years; mean age, 51 years) underwent the operation. The original fistulae had been in place for 5 to 27 months (mean, 13 months). Thirteen grafts were patent at 30 days; the one early failure (24 days) was caused by infection. As of May 31, 2001, four grafts were being used (18 (1/2), 20, 23, and 28 months after placement) and four had been withdrawn in a functional state because of death (n = 3) or transplantation (n = 1). Primary functional patency rate with life-table analysis was 71%, 57%, 41%, and 41% at 3, 6, 9, and 12 months; secondary functional patency rate was 86%, 78%, 52%, and 52% at these same intervals. Three grafts had primary functional patencies greater than 18 months. CONCLUSION: Patent but unusable Brescia fistulae can provide adequate outflow to sustain arteriovenous grafts, thus sparing more proximal veins for future access procedures. The operation can extend by months or years the time during which satisfactory vascular access can be maintained in these patients, potentially increasing survival in some cases. We hope that the availability of this salvage option will encourage vascular surgeons to attempt arteriovenous fistulae at the wrist even in patients with suboptimal venous anatomy.