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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 151-153

Patency and complication rates of arteriovenous fistula created for renal replacement therapy


Department of General Surgery, Government Medical College, Kozhikode, Kerala, India

Date of Submission03-Aug-2020
Date of Acceptance13-Aug-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. Yalini Palaniswamy
30/1, Kempaih Gowder Colony, Karamadai, Coimbatore - 641 104, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_16_20

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  Abstract 


Introduction: There are many choices for an areteriovenous (AV) access such as central venous catheters used in emergency basis, arteriovenous fistula (AVF), prosthetic AV grafts and vein interposition. Of these, AVF are used the most. It is very essential for surgeon to know about the merits and demerits of the same. Hence, this study was undertaken as a humble attempt to study the patency and complication rates of AVF. Materials and Methods: Eighty patients with chronic kidney disease who had an AV access created for dialysis in the given time period were included. They were assessed for fistula patency following the surgery at 1st month and 6 months clinically and correlated with pre-operative parameters and demographic profile. Results: Patency of AVF at 1 month was 88% and at 6 months was 85%. There was a negative correlation between diabetics and patency which is statistically significant. There was a positive correlation between gender and patency. Males (90%) had patency, whereas 30% of females did not have patency. There was a strong association between diabetics and infection which was statistically significant. Conclusions: Autogenous AVFs are a safe durable option for renal replacement therapy and with due care, complication rates and patency can be maintained with international standards.

Keywords: Arteriovenous fistula, brachiocephalic, patency, radiocephalic


How to cite this article:
Palaniswamy Y, Gopi E V, Sukumaran C. Patency and complication rates of arteriovenous fistula created for renal replacement therapy. Kerala Surg J 2020;26:151-3

How to cite this URL:
Palaniswamy Y, Gopi E V, Sukumaran C. Patency and complication rates of arteriovenous fistula created for renal replacement therapy. Kerala Surg J [serial online] 2020 [cited 2020 Dec 2];26:151-3. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/151/300225




  Introduction Top


End-stage renal disease (ESRD) is a tremendous public health problem. It is the last stage of chronic kidney disease (CKD). It is the stage in which glomerular filtration rate is <15 ml/min/1.73 m2. Renal replacement therapy (RRT) can be executed by renal transplantation or dialysis for the ESRD with a frequency or incidence rate of 15%. There are various techniques in the starting dialysis. They are central venous catheters, arteriovenous fistula (AVF), arteriovenous (AV) grafts or even peritoneal dialysis.

Even though central venous catheters are used for the emergency purpose in initiating dialysis in patient without prior access, they have the high rates of complications than AVF or grafts. Nowadays, for patients requiring long-term dialysis, a permanent AV access created in the form of radiocephalic or brachiocephalic fistulas. Native AVFs are preferable to prosthetic AV grafts as they have higher patency, low complication rates, require fewer revisions and are associated with slightly lower mortality, especially in diabetics.

AVFs once created should be given maturation period of minimum 4–6 weeks after which maturation status is assessed by a skilled examiner. There are many factors influencing the patency such as age, gender, obesity, smoking, drugs, vessel size and access position. Not only the patency, the complications such as infection, seroma, bleeding, pseudoaneurysm, steal syndrome, venous hypertension and neuropathy are also less with AVFs.

The primary patency rates of upper limb AVF are usually 65%. Revision rates are low when compared to AV grafts. Salvage angioplasty for failing fistulas has a technical success rate of 73%–90%. For Stage 3 and Stage 4 ischemic steal syndrome, surgical management is done otherwise managed conservatively. The article aims to study the patency and complication rates of AVF created for RRT in its 1st and 6th month after creation.


  Materials and Methods Top


It was an observational study conducted during February 2018–January 2019. All patients with CKD who had an AV access created for the dialysis in given time period were included. Sample size was calculated as 80. The preoperative workup involved fundamental investigations such as renal function test, complete blood count and liver function test. A note on pre-operative status of the vessel and its calibre and type of anastomosis was made. Patients were followed up on a monthly basis following surgery. All patients were assessed for fistula patency following surgery at 1st month and 6 months clinically. We for the presence of thrill and dialysability. At each visit, patients were examined for complications such as infection, thrombosis, haemorrhage, stenosis and steal syndrome.


  Results Top


It was found that 90% of the males had patency rate when compared to 70% in females. This difference was statistically significant (P = 0.03). The odds ratio was 3.857 at 95% confidence interval. The patency in diabetic patients was 84.2% against 90.2% in the non-diabetics (P = 0.473), which was not statistically significant. Infection rate in diabetic patients was higher (36.8%) against 4.9% in the non-diabetics, and this was statistically significant as P < 0.05.

There was no association found between patency and site of fistula brachiocephalic (87.5%) or radio cephalic (90.6%) at 1 month and 6 months (85.4% vs. 81.3%).


  Discussion Top


ESRD is an emerging public health problem worldwide. With 15% prevalence of ESRD, RRT can be accomplished by renal transplantation or dialysis. In our study of 80 patients, the mean age was 55 years (youngest 35 years and oldest 79 years). With the maximum incidence in the sixth and seventh decades which is in comparison with the standard international studies [Table 1]. Tjang et al.[1] found that the mean age of the patients in his study undergoing AVF creation was 57.2 years.
Table 1: Table of comparision

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Majority of our patients were males (75%). Al-Jaishi et al.[2] also found the same. Majority of ESRD patients are diabetics in the Indian population. In our study, out of 80 patients, 19 patients were diabetics (23.8%), which is comparable to the standard international studies. Ronald L Pisoni et al.[3] in their study conducted a study in 2002 and he found that 22% of the people in their study were diabetics. Ravani et al.[4] in their study found that 27% of the study people were diabetics. Wand et al. expressed that comorbidities did not have a meaningful association with primary failure. Furthermore, Gh et al.[5] in their study identified that comorbidities had no statistical relationship with primary patency.

In our present study, the majority of AVF were created at brachiocephalic site (48 patients) and some at radiocephalic sites (32 patients). Nguyen and colleagues identified that the outcome of brachiocephalic fistula is better when compared to radiocephalic fistula.

Patency at 1 month in our study was 88.8% (71 patients). There are no relevant data to compare 1 month patency rate. Patency at 6 months was 85% (68 patients) which is comparable to the standard international studies. Tjang et al.[1] in 2018 conducted a study and identified that 6 months patency rate was 88%. In 2012, Gh et al.[5] found that the primary patenting rate for almost 245 patients was 79.5%, 70%, 65% and 48%, respectively, in their analysis for 1, 2, 3 and 4 years. Zouaghi et al.[6] did a study on determinants of patency of AVF in haemodialysis patients. It included 111 patients. Of which, 22.5% were aged >65 years, 39.5% were diabetic patients, 68% were hypertensive and 26% had a peripheral vascular disease. The primary patenting rates for 1 year were at 78% and for 5 years at 42%.

In our study, 15.8% of the diabetic patients have no patency which is comparable to standard study. Diehm et al.[10] examined the outcome of access of diabetic female patients, and later discovered that being from the female gender and a diabetic are the risk factors in the outcome of patentability. A meta-analysis was done by Yan et al.[7] regarding the association between diabetics and AVF failure rate. Field et al. conducted a study and identified that primary patency of AVF in the wrist were 49%, 41%, and 32% at 6, 12, and 24 months and 57%, 51%, and 38% at 6, 12, and 24 for elbow fistulae, respectively. Furthermore, he found that fistula survival rates in nondiabetic patients were higher than in patients with diabetics; however, this was not significant (P = 0.11). In our study, there is a positive association between gender and patency. In our study, 90% of males had patency, whereas only 10% didn't. Whereas in females, 30% of the female patients did not have patency. Influence of gender on the patency is controversial. Gh et al.[5] in their study showed that there is a negative impact on patency in female patient.

In the present study, age and neuropathy seem to be associated with each other in AVF patients. It also seemed to be statistically significant. The association of diabetics with infection and neuropathy are done. Their P values of diabetics and neuropathy are <0.05, and they are statistically significant. There is no relevant data in the literature to compare these associations.

In our study, 8.8% of the patients had an infection. Ravani et al.[4] reported an event rate of 3, 1.7, and 0.9 infections per 1000 patient days in the first 1–3, 3–6, and 6–12 months of starting dialysis, respectively. Several factors can affect infection risk for access procedures. Repeated cannulation, poor personal hygiene, increased number of hospitalisations, increased duration of prosthetic AV access use, increased age, diabetes mellitus and ambulatory limitations have been reported to contribute to prosthetic AV access site infections. Patients with ESRD have an increased risk of bleeding due to the defects in haemostatic mechanisms secondary to uraemia or acquired or inherited coagulation abnormalities. Bleeding can be a problem during AV haemodialysis access creation or revision as well as during other major operations. In our study, bleeding was found to be present in only two patients. There is relevant data to compare the result. In our study, only two patients developed pseudoaneurysm. It accounts for 2.5% of the patients. As such pseudoaneurysm is rare in autogenous AVFs. It is more common in AV access grafts. Van Loon et al.[8] reported the highest rate of aneurysm (3.01/1000 patient days) among patients using rope ladder cannulation. The next highest rate was reported by the same study for buttonhole cannulation at a rate of 0.13 events/1000 patient days. Susan et al. in their study published in 2018 showed that second common late complication was pseudoaneurysm 4.23%. In [Table 1] the comparison between current study and related studies are done.


  Conclusions Top


The knowledge of AVF its patency and complications are very important for a surgeon before the creation of AVF for haemodialysis. AVFs should be created as distally as possible more preferably in the nondominant arm. Patency at 1 month was 88% and at 6 months was 85%. There was a negative correlation between diabetics and patency which is statistically significant. There was a positive correlation between gender and patency. Males (90%) had patency, whereas 30% of females did not have patency. There was a strong association between diabetics and infection which was statistically significant. Autogenous AVFs are a safe durable option for RRT and with due care, complication rates and patency can be maintained with the international standards.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tjang YS, Sumadi GJ. Primary patency rate of arteriovenous fistula created for hemodialysis patients: The Indonesian experience. J Assoc Vasc Access 2018;23:229-33.  Back to cited text no. 1
    
2.
Al-Jaishi AA, Oliver MJ, Thomas SM, Lok CE, Zhang JC, Garg AX, et al. Patency rates of the arteriovenous fistula for hemodialysis: A systematic review and meta-analysis. Am J Kidney Dis 2014;63:464-78.  Back to cited text no. 2
    
3.
Pisoni RL, Gillespie BW, Dickinson DM, Chen K, Kutner M, Wolfe RA. The dialysis outcomes and practice patterns study: Design, data elements, and methodology Am J Kidney Dis 2004;44 Suppl 2:S7-15.  Back to cited text no. 3
    
4.
Ravani P, Marcelli D, Malberti F. Vascular access surgery managed by renal physicians: The choice of native arteriovenous fistulas for hemodialysis. Am J Kidney Dis 2002;40:1264-76.  Back to cited text no. 4
    
5.
Kazemzadeh GH, Modaghegh MH, Ravari H, Daliri M, Hoseini L, Nateghi M. Primary patency rate of native AV fistula: Long term follow up. Int J Clin Exp Med 2012;5:173-8.  Back to cited text no. 5
    
6.
Zouaghi MK, Lammouchi ML, Hassan M, Rais L, Krid M, Smaoui W, et al. Determinants of patency of arteriovenous fistula in hemodialysis patients. Saudi J Kidney Dis Transpl 2018; 29:615-22.  Back to cited text no. 6
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7.
Yan Y, Ye D, Yang L, Ye W, Zhan D, Zhang L, et al. A meta-analysis of the association between diabetic patients and AVF failure in dialysis. Ren Fail 2018;40:379-83.  Back to cited text no. 7
    
8.
van Loon MM, Goovaerts T, Kessels AG, van der Sande FM, Tordoir JH. Buttonhole needling of haemodialysis arteriovenous fistulae results in less complications and interventions compared to the rope-ladder technique. Nephrol Dial Transplant 2010;25:225-30.  Back to cited text no. 8
    
9.
Susan Johny, Basant Pawar. Complications of arteriovenous fistula for haemodialysis access. Int Surg J. 2018;5:439-44.  Back to cited text no. 9
    
10.
Diehm N, van den Berg JC, Schnyder V, Bühler J, Willenberg T, Widmer M, et al. Determinants of haemodialysis access survival. Vasa 2010;39:133-9.  Back to cited text no. 10
    



 
 
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