Functional Patency Of Autogenous Arteriovenous Fistulas For Hemodialysis

Tien H. Nguyen, MD, Trung D. Bui, MD, Ian L. Gordon, MD and Samuel E. Wilson, MD,
Orange, CA Long Beach VA and General Surgery, University of California, Irvine, Orange, CA

Background: In response to KDOQI and the CMS “Fistula First” program, we have emphasized AV fistula for hemodialysis. Although AV fistulas are the preferred access for hemodialysis and have low complication rates, failure to function remains high and time to first dialysis may be several months. We analyzed our patient database to determine which AV fistula construction functioned earliest and had longest patency.
Methods: Patients with Current Procedural Terminology codes for AV fistula from October 2000 to March of 2006 were identified. Data from the Computerized Patient Record System were reviewed for type of fistula, interval from AV fistula construction to first hemodialysis, patency period, and complication rate.
Results: 129 patients were identified who underwent 155 autogenous AV fistula constructions. All but one patient were male; average age 62.1 years. 114 radiocephalic and 41 brachiocephalic fistulas were performed. In the radiocephalic group, 57 (50%) fistulas allowed successful hemodialysis after an average length of 13 weeks. The primary patency of this group was 13 months. 24 (42%) subsequently thrombosed, 7 (12%) developed fistula stenosis, 5 (9%) transferred dialysis, and 2 (4%) developed steal syndrome. 11 (19%) of radiocephalic fistulas that reached successful hemodialysis remain patent. Of the patients who failed to reach successful hemodialysis, 40 (70%) were due to fistula thrombosis or failure to mature. 8 (14%) patients are still predialysis. Infection of the Permacath occurred in 4% and incisional wound infection in 3%. In the brachiocephalic group, 26 (63%) of fistulas reached successful first hemodialysis with an average interval length of 6 weeks from construction. The primary patency of this group was 16 months. Of those fistulas that reached successful hemodialysis, 4 (15%) subsequently thrombosed, 7 (27%) transferred hemodialysis centers. 11 (42%) of the brachiocephalic fistulas that reached hemodialysis remained patent during the study period. Of the brachiocephalic fistulas that failed to reach hemodialysis, only 2 (8%) were due to fistula thrombosis while 6 (24%) patients await hemodialysis. There were 3 incidences (7%) of steal syndrome in the brachiocephalic group and 2 (5%) Permacath infections.
Conclusion: Vascular surgeons should develop better patient selection to predict which fistulas will function successfully rather than risk complications of prolonged central catheters. In our study, direct brachiocephalic fistulas were superior to radiocephalic in both time to maturity and duration of patency. Brachiocephalic fistulas had a higher maturation rate and were less likely to fail once hemodialysis began. Steal syndrome can be severe from brachiocephalic fistula leading to tissue loss.