A Meta-analysis of Preoperative Duplex Ultrasound Vessel Diameters for Successful Radiocephalic Fistula Placement

Abstract

Background The Kidney Dialysis Outcomes Quality Initiative (K/DOQI) guidelines for vascular access recommend the use of radiocephalic wrist arteriovenous fistulas (RCAVFs) as the initial option for dialysis access. The survival rate of a successfully placed fistula is excellent. However, 10–24% of RCAVFs fail to reach functional status as the result of early thrombosis or maturation failure. Many authors have investigated the utility of preoperative vascular mapping by Duplex ultrasound to predict adequate vessel size for successful fistula placement. This meta-analysis is the first in which preoperative radial arterial (RAD) and cephalic venous diameters (CVD) required for favorable fistula outcomes are reviewed. Methods A literature search was performed by use of the MEDLINE electronic base for “arteriovenous, fistula, ultrasound, and hemodialysis.” The analysis yielded 166 studies, of which 20 studies included preoperative duplex data. Meta-analysis was performed by applying the statistical test of comparing two proportions, assuming equal variances. Results A total of 433 patients were duplexed for preoperative evaluation of the RAD and 386 for CVD. The total number of subjects ranged from 21 to 91, mean age 58.7 years. The subjects were 55.5% male, 39.0% with diabetes mellitus. Meta-analysis yielded 2.0 mm for RAD and 2.0 mm for CVD as designated cutoff vessel diameters. Our study showed the mean fistula success rate was significantly different between RAD >2.0 mm (59%) and RAD >2.0 mm (40%). The mean fistula success rate was also significantly different between CVD > 2.0 mm (71%) and >2.0 mm (29%). Successful fistula placement was defined as a functional fistula at least 4–6 weeks after creation. Conclusion On the basis of our study, the use of Duplex ultrasound is important in determining preoperative vessel diameter size, and subsequent functional success rate of fistula placement.

Factors affecting the patency of arteriovenous fistulas for dialysis access

“…This minimal value is evidenced by meta-analysis findings of the fistula success rate being significantly different between radial artery diameters Ͼ2.0 mm (59%) and Ͻ2.0 mm (40%). 28 Atherosclerosis. The presence of peripheral vascular disease has been associated with an increased risk of AVF failure.…”

“…27 These measures have been evidenced by meta-analysis demonstrating significant differences in fistula success rates between cephalic vein diameter Ͼ2.0 (71%) and Ͻ2.0 mm (29%). 28 Distensibility. Venous diameters are variable with position, hydration status, temperature, and various provocation methods.…”

Impact of surgeon factor on radiocephalic fistula patency rates

“…Artery, vein and anastomosis diameter can also affect patency rates. Since vessel diameter ≤2 mm in distal arm is not recommended [16] , [17] , average artery and vein diameters for experienced surgeon group are 2.45 ± 0.59 and 2.35 ± 0.64 mm in the current study that is significantly different with other surgeons. This may be due to experienced surgeon preformed AVF creation in patients with non-visible vein on physical examination whereas others preferred preoperative imaging or patients with visible vein on physical examination.…”

Irreversible sequela in an arterial venous fistula with steal syndrome: A case study

“…With a reported specificity of 97% and sensitivity of 81% for detecting central vein occlusion, duplex ultrasound can identify areas of stenosis both anatomically by arterial or venous flow velocity, as well as vein or artery diameter, thickness, compressibility, and depth below the skin, which has been reported as nearly doubling the success rate of fistula placement. 1,[15][16][17][18] The gray-scale ultrasound, used in the pre-operative planning in this case, was not able to detect flow-limiting stenosis or deep perforating side branches, all of which can contribute to steal syndrome. Although the definitive cause of steal in this case was not documented due to the emergent need to ligate the fistula, duplex ultrasound with vein mapping may have prevented this patient from developing steal, as it has the ability to identify competing collateral venous or arterial branches, as well as detecting possible arterial stenosis or central venous occlusion, which may have altered the operative plan.…”