Endovascular Treatment of Autogenous Radiocephalic Fistulas with the “Eighth Note” Deformity for Hemodialysis

Abstract

The purpose of this paper is to describe a unique "eighth note" deformity of the autogenous radiocephalic fistula for hemodialysis and to retrospectively evaluate the efficacy and safety of its endovascular treatment. Over 3 years, a total of 808 patients and 558 autogenous radiocephalic fistulas were treated for vascular access dysfunction or thrombosis. These included 14 fistulas in 14 patients (9 men, 5 women; mean age, 58.2 +/- 2.8 years; range 27-79 years) whose fistulograms before treatment resembled a musical note, the eighth note. Endovascular treatment sought to remodel the deformed vascular access to a classic radiocephalic fistula and increase the number of cannulation sites available for hemodialysis. The technical and clinical success rates were each 92.8% (13/14). Fistula remodeling was successful in 13 patients. The postintervention primary patency was 100% at 90 days, 91.7 +/- 0.8% at 120 days, 78.6 +/- 13.9% at 180 days, 62.9 +/- 17.9% at 360 days, 31.4 +/- 24.0% at 540 days, and 0% at 720 days. The postintervention secondary patency was 100% at 90 days, 100% at 120 days, 100% at 180 days, 85.7 +/- 13.2% at 360 days, and 85.7 +/- 13.2% at 720 days. No major complications were noted. Minor complications were found in 71.4% of patients, all of which resolved spontaneously. In conclusion, endovascular treatment of fistulas with the eighth note deformity can effectively increase the number of available cannulation sites, facilitate fistula maturation, and facilitate thromboaspiration after fistula thrombosis.

An eighth note

“…The eighth note is a deformity uniquely seen on autologous radiocephalic AVF. [3][4][5] Its incidence is low and has been reported as 1.7% (14 out of 808 patients). 3 The eighth note may not be seen if there was no collateral branch located at the proximal downstream of the anastomosis or it was ligated at the time of AVF creation surgery.…”

“…[3][4][5] Its incidence is low and has been reported as 1.7% (14 out of 808 patients). 3 The eighth note may not be seen if there was no collateral branch located at the proximal downstream of the anastomosis or it was ligated at the time of AVF creation surgery. The eighth note is composed of four parts, including (1) the note-head part as the arteriovenous anastomosis; (2) the note-stem part as a juxta-anastomotic segment of the cephalic vein; (3) the note-stump part as the distal cephalic vein (before the stenotic lesion); and (4) the note-flag part as a dilated collateral branch with retrograde blood flow (Figure 1).…”

“…Meanwhile, the eighth note sign could be reversed if the stenosis is treated timely by recanalization. 3 However, the eighth note sign is not seen frequently. Herein we report a chronic hemodialysis patient who received an angiographic examination for the juxta-anastomosis stenosis of his AVF, showing a unique feature of a collateral venous branch antecedent to the stenotic lesion.…”

Quantification of the severity of outflow stenosis of hemodialysis fistulas with a pulse- and thrill-based scoring system

“…The exclusion criteria were 1) an AVF that had failed to mature; 2) an AVF with outflow that was deep and invisible or was difficult to palpate because of an interposed graft, stent graft, or heavy calcification; 3) an AVF without a main trunk (e.g., Gracz’s fistula, eighth-note deformity [ 2 ]); and 4) an AVF for which the pulsation was weak or absent upon palpation when the AVF-bearing arm was elevated.…”

Measuring the palpable pulsatility length as a physical examination test in defining the severity of inflow stenosis for hemodialysis fistulas

“…The inclusion criteria included 1) a mature AVF (after 6 months of use for hemodialysis) with a single main trunk available for cannulation; 2) a mature AVF which was superficial and visible at least from the anastomosis to the arterial cannulation segment. The exclusion criteria included 1) a thrombotic AVF; 2) a sub-optimally treated AVF with a residual stenosis> 30% at the completion of treatment; 3) an arteriovenous graft, 4) an immature fistula; 5) a deformed AVF without a main trunk (the eighth note deformity) [4] or with more than two main trunks (the Gracz’s fistula); or 6) the AVF was too deep to be visible or was difficult to palpate because of interposition graft or heavy calcification.…”