The utility of venous bifurcation for anastomosis with small-caliber veins in distal forearm radiocephalic arteriovenous fistula: Retrospective analysis of 52 fistula cases.

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Date: July-Sep 2020
Publisher: Medknow Publications and Media Pvt. Ltd.
Document Type: Article
Length: 3,130 words
Lexile Measure: 1320L

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

Context: Distal forearm radiocephalic (RC) arteriovenous fistula (AVF) is the gold standard for vascular access for hemodialysis. The use of venous bifurcation to facilitate anastomoses in small-caliber vessels is well known in microvascular surgery. Small-caliber cephalic vein (CV) is frequently encountered during AVF creation in the distal forearm. We present here the utility of this technique for the creation of distal RC AVF in small-caliber CVs. Objective: The objective was to assess the utility of venous bifurcation for distal forearm RC AVF creation in small-caliber CV. Methodology: Fifty-two cases with CV diameter <2.5 mm on color Doppler study and RC AVF created in the distal forearm between January 2015 and 2019 are reviewed for operative time, fistula maturation time, and patency rate. Patients were selected for fistula creation after clinical and color Doppler assessment. Cephalic venous bifurcation in the distal forearm was used for end-to-side anastomosis whenever feasible. Patients were followed up periodically for fistula maturation and patency. Results: Venous bifurcation was used in all 52 cases with a functional maturation rate 48/52 (92.30%). Functional primary patency rate was 46/52 (88.46%) at 6 months and 20/28 (71.42%) at 1 year. The mean fistula maturation time was 37.19 days. Conclusion: A cephalic venous bifurcation is almost always available for RC AVF in the distal forearm. Its utilization improves the success rate and feasibility of fistula creation in small-caliber veins without any delay.


Native radiocephalic (RC) arteriovenous fistula (AVF) is the first choice for vascular access for hemodialysis (HD) as per the 'FistulaFirst' recommendation of Kidney Disease Outcomes Quality Initiative of the National Kidney Foundation.[1],[2]

Distal RC AVF is considered as the first choice for AVF creation for easy vascular access, technical simplicity to construct, preservation of more proximal site for future access, and less complications such as postoperative edema or steal phenomenon.[3],[4]

Construction of RC AVF in primary attempt remains critical as it initiates dialysis early, reduces catheter dialysis period and related complications, and also reduces the expenditure.[5],[6] The selection of cases depends mainly on clinical examination and ultrasound examination.[3] Usually, cephalic vein (CV) of 2-2.5 mm diameter is considered for distal AVF creation,[7],[8] but there is no strict cutoff value. In clinical practice, vascular diameter >2.5 mm poses no problem for anastomoses for AVF creation, but CV diameter is frequently found below this range in the distal forearm during the first consultation. The establishment of fistula becomes challenging in distal small-caliber veins requiring more complex techniques.

The use of venous bifurcation to facilitate anastomosis is well known in microvascular surgery. However, the utility of this method, particularly for RC AVF, is not much discussed apart from few earlier studies.[7]

Venous bifurcation is almost always available in the distal forearm. The utilization of venous bifurcation for anastomosis thus may improve fistula creation in small-caliber veins, extending the feasibility of distal RC AVF at the initial consultations and increasing early AVF creation rate.

We present here the outcome of 52 RC AVF...

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Gale Document Number: GALE|A635430134