Radiocephalic, Brachiocephalic, and Brachiobasilic Fistula

Introduction

Hemodialysis continues to be the predominant form of renal replacement. Arteriovenous fistulas (AVFs) are the preferred hemodialysis (HD) vascular access. Compared with arteriovenous grafts (AVGs) and tunneled central venous catheters (CVCs), they have lower complication and infection rates, reduced rates of vascular access thrombosis and access-related hospitalizations, and reduced overall health care costs.

Both the 2006 Kidney Disease Outcomes Quality Initiative (KDOQI) and the 2008 Society of Vascular Surgery (SVS) guidelines suggest upper-extremity autogenous access be considered first. Although the “Fistula First” initiative has resulted in a significant increase in the number of autogenous dialysis access created, an unintended consequence has been failure of maturation of up to 50% of AVFs, which in turn has resulted in an increase in concomitant CVC use. This prompted the amendment of the original initiative to “fistula first and catheter last.”

Preoperative Evaluation

Preoperative evaluation of patients for dialysis access requires a multidisciplinary approach including the patient, the nephrologist, surgeon, and dialysis provider and is best performed with a patient-centered approach to planning.

Timely referral is essential to allow for adequate maturation as well as potential revisions if the access fails to mature. Patients with a glomerular filtration rate (GFR) less than 25 mL/min who opt for HD should be referred for surgical planning and instructed to avoid blood-pressure checks, venipuncture, or peripheral intravenous (IV) placement to preserve vein integrity in the nondominant arm. The preservation of the arm with the most ideal venous anatomy is preferred, hand dominance notwithstanding.

Thorough preoperative planning is essential to creation of a functional dialysis access.

This begins with a detailed history and physical examination. Hand dominance, prior central catheters or pacemakers, history of congestive heart failure, prior chest or arm trauma, and a history of thrombotic episodes should be noted. Diabetes mellitus is more frequently associated with nonmaturation and steal syndrome because of fixed, calcified macrovascular and microvascular disease. Heart failure, particularly diastolic dysfunction, increases the risk of high output failure after access creation. The presence of transvenous pacemakers can create central stenosis, even in the absence of radiographic evidence of such.

The physical exam should assess functionality of the upper extremities, prior failed access, overlying skin conditions, and the strength and symmetry of the brachial, radial, and ulnar pulses. Blood pressure should be measured in both upper extremities. A significant discrepancy may indicate inadequate inflow. Dilated chest wall veins and arm edema should raise suspicion for central venous stenosis or occlusion.

Vein mapping, usually via Doppler ultrasound, is useful in directing the surgical approach and should be performed in all patients before access creation. The diameter of the artery and veins should be more than 2.0 and 2.5 mm, respectively. A comprehensive assessment should note vein diameter, patency, depth, tributaries, and areas of stenosis or thrombosis.

Vein wall fibrosis increases nonmaturation, notwithstanding absolute vein size.