Feasibility of a 3 mm arteriotomy for brachiocephalic fistula formation

Abstract

Background: The arteriovenous fistula is the modality of choice for long-term haemodialysis access. We describe the feasibility of routinely fashioning a brachiocephalic fistula utilising a 3 mm long arteriotomy in an attempt to reduce the incidence of symptomatic steal syndrome yet while maintaining satisfactory clinical outcomes. Methods: All patients who underwent brachiocephalic fistula formation using a routine 3 mm long arteriotomy within Hammersmith Hospital between January 2017 and March 2018 were included. Primary outcomes included primary failure, failure of maturation, secondary patency and steal syndrome. Results: Sixty-eight brachiocephalic arteriovenous fistula were fashioned utilising a 3 mm long arteriotomy during the study period. Mean age was 60.5 years with 59% having a history of diabetes mellitus. Mean followup was 368 days. Primary failure occurred in 10 (14.7%) patients. Cannulation was achieved in 67.3% of remaining fistula within 3-months, rising to 87.3% by 6-months. Primary patency at 6 and 12 months was 76% and 69%, respectively. Secondary patency at 6 and 12 months was 94% and 91%, respectively. Dialysis access steal syndrome was clinically apparent in three (4.4%) patients with all cases being managed conservatively. Conclusion: A 3 mm long arteriotomy may be routinely utilised for brachiocephalic fistula creation in an attempt to limit the incidence of steal syndrome yet while maintaining clinical patency outcomes.

Treatment of Dialysis Access Steal Syndrome with Concomitant Vascular Access Aneurysms

“…Many different techniques have been described in the literature to prevent and treat steal syndrome in high-risk patient groups, including those with diabetes, smoking, advanced age (>60 years), peripheral arterial disease, history of steal syndrome, and previous ipsilateral access, and females [ 2 , 4 ]. A non-palpable radial artery and a digital-brachial index <0.6 (especially <0.45) puts patients at increased risk [ 1 ].…”

“…This is due to the diversion of blood from the distal arteries toward the fistula, leading to a steal effect, which may affect nearly 80% of asymptomatic functional AVAs [ 1 ]. The shift from steal phenomenon to steal syndrome could result from an interplay between the volume of access flow, collateral circulation, inadequacy of arterial adaptation, and the presence of arterial stenotic lesions [ 1 , 2 ]. Excessive access flow is the most common cause [ 1 ].…”

Short interposition grafting for dialysis-access steal syndrome treatment

“…1 Several additional techniques have been reported in the literature, with ligation being the last option. [2][3][4][5][6] Prior DSA with correction of critical stenosis is mandatory and can eliminate the steal in many cases. There are little data in the literature on short interposition grafts for the treatment of dialysis access steal syndrome.…”

“…Fistulas with a normal flow have been treated with Distal Revascularisation-Interval Ligation or Proximalisation of Arterial Inflow 1. Several additional techniques have been reported in the literature, with ligation being the last option 2–6. Prior DSA with correction of critical stenosis is mandatory and can eliminate the steal in many cases.…”

Computational modeling of the cephalic arch predicts hemodynamic profiles in patients with brachiocephalic fistula access receiving hemodialysis

“…Through systematic alterations of geometric or flow parameters, this modeling technique may also be used to prevent flow conditions that deviate from steady laminar flow which contributes to endothelial dysfunction. To maintain laminar flow and endothelial health, low Re may be necessary and achieved in lower flow states by altering the anastomotic angle when the AVF is created [35,36]; banding the arterial inflow [37]; creation of an anastomosis by endovascular technique or the SLOT technique which both offer a lower flow state [38,39]; or limiting the length of the arteriotomy when the BCF is created [40]. These computational models lay the foundation for a study to determine and optimize the flow and pressure parameters which could prevent altered hemodynamics that cause AVF complications and failure.…”