A comparison of brachial artery-brachial vein arteriovenous fistulas with arteriovenous grafts in patients with poor superficial venous anatomy.

The autogenous arteriovenous fistula (AVF) has been shown to be superior to the arteriovenous graft (AVG) with respect to cost, complications, and primary patency. Therefore, the National Kidney Foundation Disease Outcomes Quality Initiative guidelines recommend reserving AVGs for patients who do not have adequate superficial venous anatomy to support AVF placement. The brachial artery-brachial vein arteriovenous fistula (BVAVF) has emerged as an autologous last-effort alternative. However, there are limited data comparing BVAVFs and AVGs in patients who are otherwise not candidates for a traditional AVF. Patients who received a BVAVF from July 2009 to July 2014 were compared with those who received an AVG during the same period. At our institution, BVAVF and AVG are only performed in patients with poor superficial venous anatomy. Patient demographic data, operative details, and subsequent follow-up were collected. BVAVFs were performed with a two-stage approach, with initial arteriovenous anastomosis, followed by delayed superficialization or transposition. Our primary outcome measure was primary functional assisted patency at 1 year. Patients lost to follow-up were excluded. A subgroup analysis was also performed for patients in whom the BVAVF or the AVG was their first hemodialysis access surgery. During the study period, 29 patients underwent BVAVF and 32 underwent AVG. There were no differences in age, gender, or presence of diabetes between the two groups. The median days to cannulation from the initial operation were 141 (interquartile range, 94-214) in the BVAVF group and 29 (interquartile range, 14-33) in the AVG group (P < .001). Fewer patients required interventions to maintain or re-establish patency in the BVAVF group than in the AVG group (10% v. 44%; P < .01). The 1-year primary patency was greater for BVAVF (62% vs 25%; P < .01); however, there was no difference in the functional assisted primary patency rates at 1 year (45% vs 25%; P = .1). Subgroup analysis demonstrated greater 1-year primary functional assisted primary patency (52% vs 19%; P < .05) in patients without prior access surgery. The BVAVF is a viable alternative to the AVG in patients with inadequate superficial venous anatomy, especially in access-naïve patients. The decision to perform BVAVF must be weighed against the delay in functional maturation expected compared with AVG.

Pham XD ，Kim JJ ，Ihenachor EJ ，Parrish AB ，Bleck JD ，Kaji AH ，Koopmann MC ，de Virgilio C ... -  《-》

The forearm arteriovenous graft between the brachial artery and the brachial vein as a reliable dialysis vascular access for patients with inadequate superficial veins.

The arteriovenous fistula (AVF) is recommended as the preferred hemodialysis access. However, placing an AVF in all patients may result in poor access outcomes and increased central venous catheter (CVC) use because of increased comorbid conditions, age, and suboptimal vessels. In patients with inadequate superficial veins for AVFs, the use of the brachial veins for creation of forearm arteriovenous grafts (AVGs) has received limited attention. This retrospective study aimed to evaluate outcomes of forearm brachial-brachial AVGs (BB-AVGs) placed in patients with poor superficial veins. We identified 111 BB-AVGs created in 111 consecutive patients, using standard-walled polytetrafluoroethylene grafts, between January 2010 and December 2015. After excluding 6 patients (non-dialysis initiation, missing information, and death within 1 month), we included 105 patients from 21 dialysis centers. We analyzed primary failures, time to cannulation, patency, complications, and revisions. Patency rates were calculated by the Kaplan-Meier method. The incidence of complications and revisions was expressed as number of events per person-year. A total of 105 patients (median age, 69 years) were followed up for a median time of 21.2 months (interquartile range, 9.2-36.5 months). Of the patients, 72.4% were on chronic hemodialysis and had previously undergone one or more access procedures. At the time of BB-AVG placement, prior accesses were 39 AVFs, 20 tunneled CVCs, and 17 AVGs. BB-AVG rates of primary failure and revision before cannulation were 7.6% and 5.7%, respectively. BB-AVGs were cannulated after a median time of 3.4 weeks (interquartile range, 2.8-4.1 weeks). Primary patency rates at 12, 24, and 36 months were 49.5%, 29.5%, and 19.5%. Secondary patency rates at 12, 24, and 36 months were 76.3%, 62.7%, and 54.6%. After cannulation, the incidence of complications and revisions was 1.054 and 0.649 per person-year, respectively. Most complications and interventions were due to thrombosis (0.527 per person-year) or stenosis (0.381 per person-year) and related interventions (0.490 per person-year). A minority of patients experienced AVG infections (0.052 per person-year), with only two requiring access removal. In patients with poor superficial veins, the forearm BB-AVG is a reliable access because of low access-related morbidity and considerable long-term access survival. BB-AVG placement has the advantage of preserving proximal vessels. In these patients, such an approach can delay both rapid exhaustion of vascular sites and early recourse to CVC permanent use.

Fumagalli G ，Trovato F ，Migliori M ，Panichi V ，De Pietro S ... -  《-》

Equivalent secondary patency rates of upper extremity Vectra Vascular Access Grafts and transposed brachial-basilic fistulas with aggressive access surveillance and endovascular treatment.

Kakkos SK ，Andrzejewski T ，Haddad JA ，Haddad GK ，Reddy DJ ，Nypaver TJ ，Scully MM ，Schmid DL ... -  《-》

Predicting loss of patency after forearm loop arteriovenous graft.

Although arteriovenous grafts (AVGs) for dialysis access have been applied to patients who were poor candidates for an arteriovenous fistula, durability after AVGs has been clinically suboptimal. This retrospective study investigated whether forearm AVGs based on radial artery inflow would have superior patency to those with brachial artery inflow and evaluated the operative predictors for loss of patency after AVG. This multicenter retrospective study included 156 upper limbs in 150 consecutive patients (50% male; age, 70.5 ± 12.8 years) who underwent forearm loop AVG formation from January 2010 to October 2013. The outcome measures were the primary and secondary functional graft patency rates and factors related to primary patency. Primary and secondary patency of AVGs was evaluated by Kaplan-Meier analysis, and predictors for loss of primary patency of AVGs were determined using a Cox proportional hazards model. The median observation period was 10 months (interquartile range, 6-18 months). The 1-year primary patency rate was 32.4%, and the secondary patency rate was 83.4%. Use of the radial artery as the inflow arteriovenous anastomosis (hazard ratio, 0.56; 95% confidence interval, 0.30-0.99) was independently associated as an operative predictor for primary patency after AVG. The primary patency rate was significantly different between radial artery inflow and brachial artery inflow at 1 year (53.8% vs 24.4%; P = .032). Radial artery selection as inflow artery was independently associated with primary patency after AVG.

Suemitsu K ，Iida O ，Shiraki T ，Suemitsu S ，Murakami M ，Miyamoto M ，Izumi M ，Nakanishi T ... -  《-》

Outcomes of arteriovenous fistulae compared with heparin-bonded and conventional grafts for hemodialysis access.

Charlton-Ouw KM ，Nosrati N ，Miller CC 3rd ，Coogan SM ，Safi HJ ，Azizzadeh A ... -  《-》