Distal forearm radiocephalic arteriovenous fistula creation in calcified vessels: Technical challenges in anastomosis and early outcome.

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Date: Oct-Dec 2019
Publisher: Medknow Publications and Media Pvt. Ltd.
Document Type: Article
Length: 2,973 words
Lexile Measure: 1610L

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Byline: Shobhit. Sharma, Sudipta. Bera, Ashwani. Kumar, Vivek. Gupta

Background: Calcified vessels are frequently encountered during arteriovenous fistula (AVF) creation in aged patients and outcome is negatively implicated. However, fistula creation in calcified artery is an entity without much technical clarity and guidance. We present our experience and several modifications of standard radiocephalic (RC) AV fistula creations adopted during anastomosis on calcified vessels depending on our experience of fistula creation over the last 7 years. Objective: The objective was to assess the outcome of our technical modifications for RC AVF creation in distal forearm on atherosclerotic radial artery. Methodology: Twelve cases of calcified radial artery noted intraoperatively between July 2017 and 2018 and the first-time RC AVF created at the distal forearm were included in the study. Operative steps with modifications and early outcome were assessed prospectively. Results: All cases were male, with a mean age of 63.08 years. The average external diameter of the radial artery and cephalic vein was 2.74 mm and 2.21 mm, respectively. Venous bifurcation was available for creating 'venous branch patch' and utilized for anastomosis in all cases. The mean operative time was 36.25 min. The functional maturation rate was 12/12. The mean maturation time was 34 days (standard deviation 5.74, standard error of mean 1.66). Fistula patency at 6 months and 1 year was 9/12 and 7/12, respectively. One vascular blow out was noted as complication. Conclusion: Some simple adaptations in vessel handling and suturing techniques and the use of 'venous branch patch' for anastomosis may improve functional outcome in calcified vessels in distal RC AVF creation. This observation needs more number of cases and longer follow-up to predict the outcome in more assertive way.

Introduction

Calcified vessels are frequently encountered during arteriovenous fistula (AVF) creation in aged patients with comorbidities such as diabetes or hyperlipidemia. Calcification of vessel in chronic renal failure (CRF), its etiology, implications, and management is a matter of much discussion and studies are going on.[1],[2]

Although radiocephalic AVF (RC AVF) is the procedure of choice as per the Kidney Disease Outcome Quality Initiative (K/DOQI) of National Kidney Foundation recommendation, distal forearm RC AVF creation in the elderly and diabetic patients raises lots of doubts due to reported poor outcome in the presence of calcification.[3],[4] Fistula creation in calcified artery is an entity without much technical clarity and guidance. Although it is technically challenging and outcome is not satisfactory, establishment of fistula still remains essential in these patients.

Several research works were done earlier to improve anastomosis in calcified vessel which is encountered during AVF creation, limb salvage in peripheral vascular disease, or vascular bypass procedure.[5],[6] We present our experience and several modifications of standard RC AVF creations we adopted during anastomosis on calcified vessels depending on our experience of AVF creation over the last 7 years.

Aims and objectives

This study aimed to assess the outcome of technical modification and distal forearm RC AVF creation in calcified radial artery.

Methodology

Twelve cases were included in this study where severe...

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Gale Document Number: GALE|A609725922