Comparison between autogenous brachial-brachial upper-arm elevated direct arteriovenous fistulas and prosthetic brachial-antecubital indirect forearm arteriovenous grafts.

Kim H ，Ahn S ，Kim M ，Chung CTY ，Choi KW ，Ko H ，Han A ，Min S ，Min SK ，Ha J ... -  《-》

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 effect of location and configuration on forearm and upper arm hemodialysis arteriovenous grafts.

The arteriovenous graft (AVG) is most often used in hemodialysis patients when an autogenous fistula is not feasible. The optimal location (forearm or upper arm) and configuration (loop or straight) of AVGs are not known. To evaluate relationships of AVG location and configuration with patency, we conducted a secondary analysis using data from a randomized, placebo-controlled trial of dipyridamole plus aspirin for newly placed AVG. Participants of the Dialysis Access Consortium (DAC) Graft Study with newly placed upper extremity prosthetic grafts involving the brachial artery were studied. Multivariable analyses adjusting for trial treatment group, center, gender, race, body mass index, diabetes, current treatment with chronic dialysis, and prior arteriovenous vascular access or central venous catheter were performed to compare outcomes of forearm (fAVG) and upper arm (uAVG) grafts, including loss of primary unassisted patency (LPUP) and cumulative primary graft failure (CGF). Subgroup analyses of graft configuration and outflow vein used were also conducted. A total of 508 of the 649 participants (78%) enrolled in the trial had an upper extremity brachial artery graft placed, 255 with fAVG and 253 with uAVG. Participants with fAVG were less often male (33% vs 43%; P = .03), African American (62% vs 78%; P < .001), and receiving dialysis at the time of surgery (62% vs 80%; P < .001). Participants with fAVG had a higher mean body mass index (33 vs 29; P < .001). The LPUP (fAVG 70% vs uAVG 78%; P = .07) and CGF (33% vs 36%; P = .91) were similar between fAVG and uAVG at 1-year follow-up. In multivariable analysis, AVG location (uAVG vs fAVG) was not associated with LPUP (hazard ratio, 1.21; 95% confidence interval, 0.90-1.63; P = .20) or CGF (hazard ratio, 1.36; 95% confidence interval, 0.94-1.97; P = .10). LPUP did not differ significantly between fAVG and uAVG among subgroups based on AVG configuration (P = 1.00) or outflow vein used (P = .16). Patency was comparable between fAVG and uAVG despite the larger caliber veins often encountered in the upper arm in carefully selected patients. Our findings support the traditional view that, in order to preserve a maximal number of access sites, the forearm location should be considered first before resorting to an upper arm graft.

Farber A ，Tan TW ，Hu B ，Dember LM ，Beck GJ ，Dixon BS ，Kusek JW ，Feldman HI ，Dialysis Access Consortium (DAC) Study Group ，Dialysis Access Consortium DAC Study Group ... -  《-》

Comparison of forearm versus upper arm basilic transposition arteriovenous fistulas demonstrates equivalent satisfactory patency.

In accordance with the Kidney Disease Outcomes Quality Initiative recommendations, attaining autogenous hemodialysis access, specifically via creation of radiocephalic arteriovenous fistulas (AVF), brachial-basilic (BB)-AVF, or brachial-cephalic AVFs, is preferred for mortality and morbidity benefits over catheter access in patients with end-stage renal disease. The aim of this study is to determine the suitability of forearm basilic vein transposition (FBVT) fistulas as an alternative access option by comparing outcomes with those of BB-AVFs. All patients who underwent creation of FBVT between 2007 and 2015 were identified retrospectively in the electronic medical record and compared with a sample of patients undergoing BB-AVF placement during this time. Access patency was examined using Kaplan-Meier methods and Cox proportional hazards regression. We included 34 patients with FBVT (median age, 54 years; 67.6% male) and 49 with BB-AVF (median age, 57 years; 42.9% male) in this study. There were no significant differences in comorbid conditions between the two groups, with the exception of hyperlipidemia (29.4% FBVT vs 53.1% BB-AVF; P = .03). Although those with FBVT were more likely to have had previous permanent access attempts (70.6% vs 38.7%; P = .002), and access attempts on the same extremity (44.1% vs 24.4%; P = .04), there were no significant differences in primary patency (46.9% vs 53.3%; P = .6), primary-assisted patency (65.6% vs 73.3%; P = .5), or secondary patency (68.8% vs 82.2%; P = .2) at 1 year when compared with BB-AVF. The risk of loss of patency was not statistically different for FBVT as compared with BB-AVF (hazard ratio, 1.37; 95% confidence interval 0.65-2.88; P = .4). This risk did not vary for those who had previous access on the same arm (interaction P = .8). Four fistulas in each group failed to mature. Only one infectious complication was identified in the FBVT group. No prior studies have directly compared outcomes of FBVTs with BB-AVFs at 1 year or longer. Despite the increased difficulty of harvesting the forearm basilic vein, particularly in patients who have had prior access attempts, there was no significant difference in patency between FBVTs and BB-AVFs. FBVTs are a reasonable option for hemodialysis access, particularly in patients without adequate cephalic veins or who previously failed radiocephalic fistula attempts.

Weaver ML ，Holscher CM ，Sorber R ，Arnold MW ，Lum YW ，Reifsnyder T ... -  《-》

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 ... -  《-》