Comparison of Side-to-side Brachiocephalic Arteriovenous fistula with Ligation of the Perforating Vein with End-to-side Brachiocephalic Arteriovenous fistula
Article Outline
Abstract
Introduction
A comparison of side-to-side brachiocephalic arteriovenous fistula (BCAVF) with ligation of the perforating vein with end-to-side BCAVF.
Report
All side-to-side BCAVFs with ligation of the perforating vein and end-to-side BCAVFs that were created in two hospitals were followed up to determine complications and patency rate of arteriovenous fistulae (AVFs).
Forty-four patients (24 side-to-side BCAVFs) entered the study, but two patients were eliminated from analysis due to early mortality. Patients of both groups were free of steal syndrome and venous hypertension. There were no significant differences in maturation time and rate of complications between the two groups. Two and three failures occurred in side-to-side and end-to-side groups (P
>0.05), respectively. The 1-year patency rate was 95% and 86% for side-to-side and end-to-side groups, respectively.
Discussion
Although there was no significant difference regarding primary and secondary access failure during the follow-up period, the 1-year patency rate was higher in side-to-side group, as determined by the life table analysis. In addition, there was no significant difference with regards to complications. This result may show that end-to-side BCAVF has no superiority over our new technique.
Keyword: Arteriovenous fistula, Elbow, End-to-side, Patency rate, Perforating vein, Side-to-side
Introduction
Recently, we introduced the side-to-side brachiocephalic arteriovenous fistula (BCAVF) with ligation of the perforating vein which has an acceptable patency rate without serious complications, such as steal syndrome and severe venous hypertension.1 However, the efficacy of this technique has not yet been compared with other types of arteriovenous fistulae (AVFs). Accordingly, in the present study, we aimed to compare patency rate and complications of this technique with end-to-side BCAVF, which may be considered the standard vascular access in the elbow region.
Report
The ethical committees of human research of Tehran and Iran universities approved the study protocol. This study was conducted at two hospitals (Sina and Hasheminejad) from August 2006 to October 2007. We followed up all side-to-side BCAVFs with perforating-vein ligation and end-to-side BCAVFs created during this time period.
Local infiltration anaesthesia was used in all cases. The standard operation consisted of an oblique incision about 2cm long, 1cm distal to the antecubital crease and parallel and medial to the brachial artery. Obesity and the requirement to use a deeply situated brachial artery or cephalic vein necessitated a longer incision and, sometimes, even a transverse incision. The median antecubitalvein was identified and dissected distal to the confluence of the median antecubital and cephalic veins. Most often, the perforating vein arose at the junction of the median antecubital and cephalic veins (Fig. 1). Less commonly, it arose from the median antecubital vein near this confluence or from the cephalic vein just distal to this confluence. The brachial artery was exposed deep to the median antecubital vein. An appropriate length of the artery, about 1.5cm, was dissected and controlled. A 6-mm long longitudinal incision was made in the artery and the neighbouring vein (Fig. 2). The side-to-side anastomosis was constructed using continuous 6/0 polypropylene sutures. No attempts were made to disrupt venous valves distal to the anastomosis.1
Figure 1
The perforating vein can be approached by a small incision below the antecubital crease. The perforating vein has been shown by an arrow.
Figure 2
Side-to-side anastomosis of the brachial artery and the cephalic vein.
Statistical analysis was performed using SPSS software version 13 and P value <0.05 was considered statistically significant. Chi-square test and independent samples t-test were used to compare parameters between two groups. Life table survival analysis was used to calculate 1-year patency rates.
During this time period, 44 AVFs (24 side-to-side AVFs with ligation of the perforating vein) were created. There were two deaths in the first month in the end-to-end group, providing 18 patients for the assessment of fistular function. The AVFs were created by two surgeons. Amongst 42 AVFs, 28 AVFs, including 16 side-to-side AVFs, were created in the Sina Hospital. The remainder (n=14), including eight side-to-side AVFs, were placed by another surgeon in the Hasheminejad Hospital. There were no significant differences with regards to baseline characteristics based on the type of AVF (Table 1) or surgeons.
Table 1. Comparison of baseline characteristics did not show significant differences between the two groups
| Variable | Side-to-side AVF with ligation of the perforating vein | End-to-side AVF | |
|---|---|---|---|
| Age (mean±SD) | 57.04±11.7 | 56.25±15.9 | |
| Sex (male) | 14 (58%) | 9 (50%) | |
| DM | 12 (50%) | 9 (50%) | |
| HTN | 15 (62%) | 8 (44%) | |
| CHF | 4 (17%) | 0 (0%) | |
| History of insertion of dual-lumen cathetera | Internal jugular | 9 (37%) | 7 (29%) |
| Subclavian | 4 (17%) | 3 (17%) | |
| Previous AVF | 4 (17%) | 4 (22%) | |
aOne patient in the side-to-side group had a history of insertion of femoral dual-lumen catheter which was not noted. |
There was no significant difference (P=0.44) regarding mean follow-up periods (9±4.2 vs. 7.8±5.3 months in side-to-side and end-to-side groups, respectively). Mean maturation times were 4.6±2.6 and 4.2±2.5 weeks in side-to-side and end-to-side groups, respectively (P=0.78). There was also no significant difference in dialysis hours per week between the two groups (10.78±1.8 vs. 10.5±2.02 for end-to-side and end-to-side, respectively).
No significant difference was found in the frequency of complications between two types of AVFs (Table 2). Comparison of complications according to the surgeons did not show significant differences, except regarding infection (P=0.04).
Table 2. Complications in the two groups
| Complications | Side-to-side AVF with perforating vein ligation | End-to-side AVF | P value |
|---|---|---|---|
| Primary failure | 1 (4%) | 2 (11%) | 0.32a |
| Secondary failure | 1 (4%) | 1 (5.5%) | 0.76a |
| Severe steal syndrome | 0 (0%) | 0 (0%) | 1a |
| Severe venous hypertension | 0 (0%) | 0 (0%) | 1a |
| Pain | 1 (4%) | 0 (0%) | 0.42a |
| Swelling | 1 (4%) | 0 (0%) | 0.42a |
| Infection | 1 (4%) | 1 (5.5%) | 0.71a |
| Aneurysm | 0 (0%) | 0 (0%) | 1a |
aChi-square test. |
Life table analysis showed 1-year patency rates of 86% and 95% for end-to-side and side-to-side AVFs, respectively.
Discussion
Comparison of our technique with end-to-side BCAVF showed higher 1-year patency rate for side-to-side AVF, while there were no significant differences regarding complications. Patency rate of end-to-side BCAVF in all previous large studies is less than 80%,2, 3 and it seems that – in our study – it has been overestimated due to our small sample size. While the patency rate of side-to-side AVFs with ligation of the perforating vein was relatively close to our previous study which showed 1-year patency rate of 91%. Moreover, our study had a confounder which could not be eliminated. In some cases of end-to-side AVFs, we were obliged to cut the perforating vein to close the cephalic vein to brachial artery. We believe that this phenomenon, together with our small sample size, influenced our results, especially regarding the low rate of complications in the end-to-side group. Amongst the more than 120 cases of side-to-side BCAVF (this study plus our previous investigation)1 we did not find any steal syndrome or severe venous hypertension, given that these phenomena can complicate at least 6% and 2.8% of BCAVF, respectively.4 The low rate of complications (especially steal syndrome and severe venous hypertension) which was found in this study is due to the ligation of the perforating vein, which interrupted blood-flow deviation from the superficial to the deep veins.1
Our technique is different from that of Gracz AVF.5 In our technique, a side-to-side anastomosis is performed between the cephalic or median antecubital veins and the brachial artery, and the perforating vein is ligated. Ligation of the perforating vein interrupts the connection between the superficial and deep venous systems of the arm, and prevents blood-flow deviation to the deep venous system which has lower resistance than the superficial veins. Therefore, distal radial artery blood pressure would increase and the rate of serious complications (steal syndrome and severe venous hypertension) would decline.1
Using both, forearm and upper-arm, spaces for inserting haemodialysis needles is another advantage of the side-to-side anastomosis that has been reported for the side-to-side mid-forearm AVF by Bruns et al.6 Thus, side-to-side anastomosis will increase the chance of successful haemodialysis. In addition, the probability of aneurysm formation due to frequent cannulation of a limited area will decrease. In addition to the other advantages of side-to-side AVF with ligation of perforating vein (high patency rate and low complication rate), the increased the area for cannulation can make side-to-side AVF more favourable than the end-to-side AVF. Although proximal radial artery AVFs have an excellent patency rate and cannulation of both upper-arm and forearm regions is possible, they are associated with a higher rate of complications such as steal syndrome and severe venous hypertension than our technique.7
In conclusion, the 1-year patency rate of side-to-side AVFs was higher than end-to-side ones, while there were no significant differences with regards to primary and secondary failures and complications. Thus, this study may suggest that end-to-side BCAVF has no superiority over our technique. Moreover, simplicity of creation and possibility of below-elbow cannulation in the side-to-side AVF makes it more favourable than the end-to-side AVF. More studies with larger samples are recommended to compare the BCAVF with perforating-vein ligation to other types of AVFs.
Acknowledgements
This study was supported by a grant of the Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences.
Conflict of Interest
None.
References
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- Determinants of failure of brachiocephalic elbow fistulas for haemodialysis. Eur J Vasc Endovasc Surg. 2005 Aug;30(2):209–214
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PII: S1533-3167(08)00026-5
doi:10.1016/j.ejvsextra.2008.11.001
© 2008 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Comparison of Side-to-side Brachiocephalic Arteriovenous Fistula with Ligation of the Perforating Vein with End-to-side Brachiocephalic Arteriovenous Fistula , 23 January 2009
