A simple technique to prevent torsion and other obstructions of autogenous vein conduits.

During a bypass or a transposed fistula, there is a risk of twisting or torsion of the vein within the tunnel, which may not be easily apparent when incomplete. When valvulotomes are used some nonobstructing leaflets or flaps may remain. These mechanical problems may go undetected at the time and may cause hemodynamic changes, act as a nucleus for thrombosis, or obstruction postoperatively. These may result in early graft failure. A simple technique to prevent and treat twisting and other obstructions in autogenous venous conduits is described. Use of this method has helped the authors to avoid acute obstructions in vein bypasses and transposed dialysis access fistulas.

An ode to Cimino.

PURPOSE: The aim of the study was to ascertain whether a Cimino First policy can be implemented successfully in tertiary practice using a standardized technique. METHODS: This is a retrospective study. All first radial-cephalic (Cimino) fistulas placed by a single surgeon in incident patients were studied. A standardized surgical technique was used paying attention to the dorsal cephalic branch. No balloon maturation or early surveillance was performed. Kaplan-Meier survival analysis using survfit function in R (Vienna) was applied. RESULTS: Fifty-seven (69%) of 83 new accesses were radial cephalic fistulas. Of these, 44 (77.2%) were men. The patients were aged 17 to 83 (mean 54.1; SD 14.6) years. Whites comprised of 21 (36.8%), maori 18 (31.6%), and pacific islanders 16 (28.1%). Comorbidities included diabetes in 32 (56.1%), hypertension in 47 (82.5%), and hyperlipidemia in 25 (46.3%; n=54). Twenty-six (45.6%) were pre-dialysis. Mean body mass index was 30.74 (SD 6.9) Kg/m² (n=56). Mean vein diameter was 3.3 mm (range 2.1-6.2 mm; n=36). Twenty-six (45.6%) had had previous central lines. Forty-four (77.2%) fistulas matured. Mean maturation time was 14.0 weeks. Thirty-six (63.2%) were used for dialysis while eight patients remained pre-dialysis with patent fistulas. Primary patency at one year and 18 months was 69.2% and 57.4% respectively. The figures for assisted primary patency were 85.6% and 72.3% respectively. Secondary patency was 87.6% and 83.9% at one and two years. CONCLUSIONS: Cimino fistulas can be performed in a majority of patients with good results using a standardized surgical technique. The importance of the dorsal cephalic branch needs to be studied.

A retrospective review of basilic and cephalic vein-based fistulas.

This study compares outcomes of basilic and cephalic vein fistulas for hemodialysis. A retrospective review of arteriovenous fistulas in a university hospital system was performed using charts and hemodialysis records. Patency and demographic data were assessed with life table analysis. One hundred fifty-six patients (88 males; 68 females) underwent creation of 172 autogenous fistulas (mean age 61 years; mean follow-up 78 weeks). There were 101 basilic vein transpositions and 71 cephalic vein fistulas. Primary patency did not differ significantly, while assisted primary patency was significantly better for basilic vein fistulas at one year (73% versus 53%: P = 0.024). Secondary patency was significantly better for basilic fistulas through three years (58% versus 52%; P = 0.027). Primary failure (thrombosis before access or failed maturation) was significantly higher for cephalic than basilic fistulas (28% versus 13%; P = 0.01). Maturation time, usage time and complications were not significantly significant. Thirty-three (33%) basilic vein-based fistulas and 12 (17%) cephalic vein fistulas required revision during follow-up. Basilic vein-based fistulas perform as well as or better than cephalic vein-based fistulas in terms of patency, maturation time, and usage time and complication rates, though requiring more re-interventions.