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Original Article |

Creating Arteriovenous Fistulas in 132 Consecutive Patients:  Exploiting the Proximal Radial Artery Arteriovenous Fistula: Reliable, Safe, and Simple Forearm and Upper Arm Hemodialysis Access FREE

William C. Jennings, MD
Arch Surg. 2006;141(1):27-32. doi:10.1001/archsurg.141.1.27.
Text Size: A A A
Published online

Hypothesis  Dialysis by native arteriovenous fistula (NAVF) clearly offers lower infection rates, fewer procedures, and lower mortality risk compared with access by catheter or graft, in addition to lower cost. However, NAVFs are utilized for vascular access in only 30% of hemodialysis patients in the United States. Wrist NAVFs are not feasible or successful in many patients and upper arm brachial artery NAVFs may be impractical or lead to additional procedures or complications. Careful preoperative evaluation of all options for NAVF construction including the proximal radial artery (PRA) as an arterial inflow site will find most, if not all, patients to be candidates for successful NAVFs.

Design  Retrospective review of consecutive operations for hemodialysis access preformed by an individual surgeon from May 2003 to November 2004.

Setting  Two university-affiliated tertiary medical centers.

Patients  All patients underwent preoperative ultrasound evaluation by the operating surgeon. A wrist fistula was first choice for access when success was predicted by ultrasound and physical examination. The second choice, and most common operation, was a PRA NAVF with distal forearm (retrograde) flow established by disrupting the initial venous valve using a vessel probe.

Results  One hundred thirty-two patients aged 11 to 90 years (mean = 61) were reviewed. Sixty-eight patients had diabetes and 61 were female. Thirty-four had previous failed access surgery. Native arteriovenous fistulas were created in all patients. No grafts were used. A PRA NAVF was utilized in 105 operations. Overall (assisted) patency was 97%, with a mean follow-up of 11 months. Importantly, there were no infections or hospitalizations due to the NAVF access operations.

Conclusions  No grafts were used in this series of 132 consecutive patients. The PRA NAVF was the most common operation and an important addition to wrist, brachial, and transposition fistulas. Proximal radial artery NAVFs increase the opportunity for construction of successful NAVFs and are reliable, safe, and simple procedures with access sites often available in both the forearm and in the upper arm.

Figures in this Article

The National Kidney Foundation Kidney Dialysis Outcomes Quality Initiative (NFK/DOQI) clinical practice guideline recommends native arteriovenous fistulas (NAVFs) as the best hemodialysis access.1 The NFK/DOQI practice guideline’s order of preference for vascular access is (1) radial artery–cephalic vein NAVF at the wrist (Brescia-Cimino fistula); (2) brachial artery–cephalic vein NAVF (upper arm NAVF); (3) arterial-venous graft or transposed brachial artery–basilic vein fistula; and (4) cuffed tunneled central venous catheters should be discouraged as permanent vascular access.

Compared with grafts or catheter-based dialysis, NAVFs offer longer patency rates, fewer interventions, infections, ischemic complications, and overall lower mortality rates.28 In addition, NAVF access has significantly lower costs than grafts or catheters.3,9 Despite these clear data indicating that NAVFs offer best practice vascular access, only 30% of patients undergoing hemodialysis in the United States use a NAVF for access.10 The rates of NAVF use in Europe and Japan are generally much higher than in the United States, although some US investigators have reported significant improvement and success in NAVF construction.2,1115 With vascular access costs in excess of $1 billion per year in the United States, increasing the use of NAVFs is particularly important.3

Successful wrist NAVFs are not feasible in many patients. Several reports have found wrist fistulas often fail or fail to mature, frequently owing to previous venous catheters or issues such as diabetes, peripheral vascular disease, and advancing age.16,17 Gracz et al18 reported mid-arm NAVFs in 1977; modified by others, these procedures extended opportunities to establish NAVF access.1820 The brachial artery has generally been used as the arterial inflow site for mid-arm fistulas, usually offering upper arm access only. Establishing retrograde NAVF flow via the median cubital vein by disruption of venous valves further added to the opportunity for dialysis access, most often in the upper arm.2123 Kooner and other authors20,2427 have reported using the proximal radial artery (PRA) for NAVF inflow. In a previous report, we found the PRA NAVF to be safe and reliable.15 In those 73 patients with PRA NAVFs, 1-month patency rate was 98% and cumulative patency was 80% during follow-up of up to 42 months. Our use of preoperative ultrasound venous mapping was evolving during that time and we reported its importance in creating NAVFs.28

This current study reviews a series of consecutive patients evaluated for hemodialysis access with the intent to avoid grafts in each individual. Careful preoperative evaluation of all options for NAVF construction, including the PRA as an arterial inflow site, was important in the care of these patients.

All patients operated on for dialysis access from May 2003 to November 2004 have been included in a vascular access database detailing each patient’s preoperative evaluation, operative procedure, and follow-up information. All patients underwent preoperative ultrasound during their initial clinical evaluation. Operations were performed on an outpatient basis unless the patient was hospitalized for other reasons.

A radial-cephalic NAVF at the wrist was created as first choice when basic criteria were met: (1) a normal and uninterrupted forearm cephalic or median antebrachial vein 2.5 mm or larger in diameter by clinical and ultrasound evaluation and (2) a normal radial artery by clinical examination 2.0 mm or larger in diameter by ultrasound examination. If a wrist NAVF was not predicted to be successful, a PRA NAVF was the second access choice using the same vessel criteria (Figure 1). When creating a PRA NAVF, retrograde (distal forearm) flow from the fistula was established by placing a vascular probe through the initial retrograde valve, rendering it incompetent and allowing flow through the median antebrachial vein toward the hand. Retrograde flow through the median antebrachial vein is easily accommodated by communicating branches to the deep venous system and through the cephalic and basilic veins (Figure 2). Brachial or transposition NAVFs were used when proximal or distal radial artery procedures were not possible.

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Figure 1.

Schematic representation of proximal radial artery native arteriovenous fistula.

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Figure 2.

Postoperative examination of proximal radial artery native arteriovenous fistula (PRA NAVF) showing typical outflow pattern.

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Access patency was calculated to the end of the study period, death, transplantation, change to peritoneal dialysis, or loss to follow-up. Technical success was defined as full use of the NAVF 2 months after operation for repetitive hemodialysis access, or in those patients not yet requiring hemodialysis, clinical examination finding the NAVF ready for use. Local anesthetic with sedation was used routinely for NAVF construction. Axillary blocks were used occasionally for transposition procedures. Right- or left-handedness was considered secondary to best available vessels in selecting the extremity for NAVFs. During surgical follow-up, if a NAVF was not mature or clearly progressing to maturity by 1 month, physical and ultrasound examination findings were reviewed with the interventionalist and a fistulagram was obtained. Perioperative antibiotics were used only with transposition procedures.

ANASTOMOTIC TECHNIQUE FOR PRA NAVFs

The arteriotomy and venotomy sites must be carefully chosen and aligned to guard against twisting or distortion when the anastomosis is completed. The anastomosis length is approximately 5 to 8 mm, 2 to 3 times the internal diameter of the PRA. The length of the anastomosis for a PRA NAVF is not as important as vessel quality, diameter, and technique. If the size or quality of the PRA is marginal, the anastamosis may be best constructed where the PRA is largest, directly adjacent to the brachial artery and proximal to the recurrent radial artery. Suture technique throughout the anastomosis is critical, particularly at each end, incorporating only small amounts (≤1 mm) of tissue with each needle pass and using careful radial positioning of the suture as the corners are created. When an anastomosis is constructed in smaller vessels such as these, the amount of tissue incorporated in the suture becomes exponentially important in successful outcomes.29 A “back wall first” technique is generally used in these small vessels, similar to the method described by Tellis et al.21 This involves initiating the suture in the mid portion of the back wall and, using a running suture technique, closing the back wall from the inside of the anastomosis and then completing each corner (Figure 3B and C). The front wall closure is completed with this same continuous running technique, tightening the suture except for the last 2 suture passes, which are placed but left loose to allow for introduction of an appropriate-sized vessel probe. The probe is passed through both proximal and distal venous outflow channels and proximal and distal arterial conduits. This allows flushing to remove any residual debris or clot and may relieve vessel spasm or detect a misplaced suture. Polytetrafluoroethylene suture (Gore-Tex; W. L. Gore and Associates Inc, Flagstaff, Ariz)1 is used routinely. Its handling characteristics allow precise tissue approximation, yielding a dry anastomosis without purse stringing or distortion. Clearly, other suture material and techniques such as interrupted suture, running segment suture, or vascular clips may be used successfully.

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Figure 3.

A, Vessel probe passed distally rendering the first venous valve incompetent. B, Running suture technique initiated in the mid portion of the back wall of the native arteriovenous fistula anastomosis. C, Completed proximal radial artery native arteriovenous fistula with flow into the upper arm and retrograde into the forearm.

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ESTABLISHING RETROGRADE FLOW FOR PRA NAVFs

After a venotomy is made in preparation for the anastomosis, a probe is passed distally through the vein identifying the first valve, which is usually seen within the incision (Figure 3A). The vessel probe is used to engage the valve leaflets under direct vision. Gently passing the tip of the probe along the inner wall of the vein until a valve leaflet is encountered, the probe is then pushed through the leaflet, carefully applying pressure directly along the center axis of the vein to prevent perforation. The probe is then passed on the opposite wall of the vein to encounter the opposite leaflet and the process is repeated. The valve may also be disrupted by a similar process using a gently curved Titus needle, injecting heparinized saline to distend the vein and fill the valve leaflets, making engagement of the valve a bit easier. As with the probe, the blunt tip of the Titus needle is forced through the valve leaflet in line with the axis of the vein to prevent perforation. After this initial valve is rendered incompetent, heparinized saline irrigation shows in most patients that flow is now present in a retrograde fashion through the median antebrachial vein with outflow through collateral vessels. In patients for whom retrograde flow is not clearly established, angioscopy through the venotomy site may be necessary to safely pass a probe further, or a valvulotome may be used through a distal counter incision if establishing forearm (retrograde) outflow is important. A short angioscopy film clip is available for viewing at our surgery department’s Web site: http://tulsa.ou.edu/surgery/fistula/index.htm.

One hundred forty-two consecutive vascular access operations were performed on 136 patients at 2 tertiary medical centers. Four patients were excluded from the final access analysis. They had access operations performed by other surgeons elsewhere and were referred for excision of infected graft segments or NAVF problems requiring ligation or revision because of steal syndrome or change to peritoneal dialysis. Six procedures were same-site revisions yielding 134 specific access site operations in 132 patients for analysis.

Age range was 11 to 90 years (mean = 61). Table 1 shows other patient demographics. Native arteriovenous fistulas were created in all patients. No grafts were used. Table 2 lists the operations according to arterial inflow site. Overall (assisted) access patency during this period was 97% with a mean follow-up of 11 months. Fifteen successful NAVFs had occluded segments salvaged by surgical revision (n = 4) or interventional techniques/angioplasty (n = 11). Table 3 shows access patency according to type of operation. Figure 4 shows cumulative access patency.

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Figure 4.

Life-table display for primary and secondary arteriovenous fistula patency. Line numbers are fistulas at risk in a given interval.

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Table Graphic Jump LocationTable 1. Demographics of 134 Patients With NAVFs
Table Graphic Jump LocationTable 2. Vascular Access Operations According to Arterial Inflow Site
Table Graphic Jump LocationTable 3. Access Patency in 134 AV Fistulas

Four patients died with patent NAVFs of causes unrelated to dialysis access during the follow-up period. Five patients changed to peritoneal dialysis or underwent a successful transplantation with functioning fistulas. One patient was lost to follow-up with a functioning NAVF at 9 months. Forty-nine patients had a NAVF constructed in the dominant-handed extremity. Nineteen patients had a previous failed access in the same extremity as the new NAVFs reported here.

Four fistulas failed and were not salvaged during the follow-up period. Two of these patients had successful NAVFs created at different sites in the same extremity. The other 2 patients elected to maintain dialysis access with a central venous catheter. One of these was a chemotherapy patient with recurrent cancer and the other had significant congestive heart failure and several failed access attempts elsewhere.

Two patients had mild steal syndrome postoperatively. Both had complete resolution of symptoms by ligation or occlusion by coil placement of enlarged median cubital vein outflow branches, previously left open intentionally to augment flow. Both fistulas remain functional. One patient developed a benign skin lesion (angioendotheliomatosis) that was excised from the NAVF arm. Her NAVF remains functional. One patient was observed briefly for postcannulation bleeding from a mature fistula. Transfusion was not required. His fistula remains functional and no further bleeding episodes have occurred after review of cannulation sites and technique with the dialysis staff. An additional patient had a brief period of observation following successful fistulography and angioplasty. Three patients with PRA NAVFs had mild to moderate upper extremity swelling that resolved with observation, ligation of a competitive outflow vein, angioplasty of a central venous stenosis, and/or removal of central catheters. Infectious complications were not encountered with these dialysis access procedures and no hospital admissions for complications of the dialysis access operations occurred.

The PRA was the most common anastomotic site (n = 105). Overall patency for PRA NAVFs was 97.1%. The median antebrachial vein was used for venous outflow as a side-to-side anastamosis in 66 fistulas (62.8%). The deep communicating vein, median antecubital vein, median cephalic vein, or other vein was utilized for venous outflow with an end-to-side technique in the remaining 39 operations (37.2%). Establishing retrograde flow into the forearm during PRA NAVFs was done by simple passage of a vessel probe in 80 operations (76%). Disruption of multiple distal venous valves to achieve retrograde flow was augmented by angioscopy or valvulotomes in 25 patients. Seventeen PRA NAVFs were constructed with either the upper arm or the forearm venous segment as the only accessible outflow tract.

Evaluation of technical success found that NAVFs were constructed in 22 patients who had not yet started dialysis. These fistulas have been determined to be technically successful. Eighty-six patients have NAVFs that have been used successfully for repeated dialysis access. Sixteen NAVFs are patent and maturing. Ten of these are within 2 months of the operative procedure and 3 await secondary transposition. All are expected to reach technical success in the next 1 to 2 months. Six patients received a transplant or died. Four NAVFs failed, and 2 of these patients are using catheters without a NAVF.

Increasingly, patients in need of dialysis access are older, chronically ill, and more likely to be obese and/or diabetic.17 The mechanics of treating their multiple medical problems leads to repeated venipunctures and intravenous therapy long before the need for a NAVF is recognized. These difficult access patients are well represented in this report as evidenced by the percentage of patients with diabetes, obesity, and previous access procedures. Several reports have found significant NAVF failure rates both overall and in these specific subgroups.3,11,16,17,3032 Wrist fistulas (Brescia-Cimino) have been found by some investigators to have particularly high failure rates.16,29,33 Guidelines from the NFK/DOQI recommend a brachial artery NAVF as the second option when a wrist fistula is not possible or fails. Brachial artery NAVFs are generally created using an end-to-side technique resulting in upper-arm fistulas without the potential for forearm hemodialysis access. They pose a risk of developing steal syndrome and some will require ligation, banding, or bypass.6,3437 Complications have been reported in up to 47% of these patients, and fistula maturation may take as long as 6 months.3840 Upper-arm NAVFs are difficult or impossible to access in obese patients and may require an exteriorization procedure.40

Ultrasound examination has become a key element in preparation for dialysis access surgery and increases the percentage of NAVFs created.28,4144 Patients in this report were evaluated preoperatively with ultrasound by the operating surgeon during their initial office visit. This direct observation of the vascular anatomy was critical in selecting the best site and strategy for creating a successful NAVF. Most patients are not suitable candidates for a classic Brescia-Cimino fistula at the wrist, as determined by physical examination and ultrasound evaluation.3,16,29,33,45 Often, the cephalic vein at the wrist has been utilized for venipuncture and intravenous therapy access sites. The vein may be too small (< 2.5 mm by ultrasound) or it may have an interrupted segment that will prevent maturation of the fistula. In addition, the radial artery at the wrist may be inadequate for a direct anastomosis.46 Frequently, one extremity may offer good access opportunity after ultrasound examination of the opposite arm was not promising. The impact of avoiding NAVFs that are destined to fail is dramatic.

After ultrasound screening, if a wrist NAVF is not possible, one proximal forearm or the other will almost always offer an opportunity for a PRA fistula. The PRA is easily mobilized to an anterior position allowing a tension-free anastomosis. Arterial inflow is reliable, and a side-to-side anastomosis to the median antebrachial vein or an end-to-side anastomosis to the communicating vein allows dialysis access both in the upper arm and, in a retrograde fashion, in the forearm. Creating a NAVF at the PRA site allows the surgeon to consider ligation of major side channels such as an unused deep communicating vein or the median cubital vein. Preventing outflow into nondialysis venous channels may lead to earlier maturation of the fistula. Retrograde flow is established into the median antebrachial vein by disruption of the first valve with a small probe. Flow into both the upper arm and forearm venous segments offers the potential for continued and uninterrupted vascular access should one of the outflow branches fail. Proximal radial artery fistulas minimize the risk of steal syndrome and are routinely accomplished with local anesthetic and sedation. Prophylactic antibiotics are not needed with these simple NAVFs.47

Finally, efforts to achieve reliable NAVF access require follow-up by the surgeon. Patients are generally evaluated 1 week postoperatively and again in 1 month, prior to initial access utilization. Most visits are brief and of little consequence. However, the later patient visits may detect a problem that results in some action. This might simply be additional short-term follow-up, a call to the dialysis nursing staff for information, or an imaging study. If there is any question about the size or location of the targeted fistula outflow segments, access sites are marked using ultrasound, prior to initial use of the fistula. Diligent follow-up is necessary to ensure that central venous catheters are removed as quickly as possible. If the NAVF is not clearly maturing, physical examination and ultrasound often localize the problem, and a fistulogram is obtained. Clear and specific communication with the vascular interventionalist is critical for success. This includes the operative procedure details, abnormal physical findings, ultrasound results, and a summary of clinical problem(s) to be solved. Most of these nonmaturing NAVFs can be successfully treated with angioplasty.

Author’s Note: Data for this article were collected more than a year ago and I have now performed more than 300 consecutive vascular access operations without using a bioprosthesis or synthetic graft.

No grafts were used in this series of 132 consecutive patients. The PRA NAVF was the most common operation and an important addition to wrist, brachial, and transposition fistulas. Proximal radial artery NAVF increase the opportunity for construction of successful NAVFs and are reliable, safe, and simple procedures with access sites often available in both the forearm and in the upper arm.

Correspondence: William C. Jennings, MD, Department of Surgery, University of Oklahoma College of Medicine, 4502 E 41st St, Suite 2E26, Tulsa, OK 74135 (William-Jennings@ouhsc.edu).

Accepted for Publication: April 12, 2005.

Acknowledgment: I thank Lin F. Peabody, LPN, CCRC, and Heather M. Vice, RN, BSN, for their contributions to this study.

 NKF-DOQI clinical practice guidelines for vascular access: National Kidney Foundation-Dialysis Outcomes Quality Initiative. Am J Kidney Dis 1997;30 ((4, suppl 3)) S150- S191
PubMed
Pisoni  RLYoung  EWDykstra  DM  et al.  Vascular access use in Europe and the United States: results from the DOPPS. Kidney Int 2002;61305- 316
PubMed Link to Article
Allon  MRobbin  ML Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int 2002;621109- 1124
PubMed Link to Article
Ascher  EPrasad  GHingorani  A  et al.  Changes in the practice of angio-access surgery: impact of dialysis outcome and quality initiative recommendation. J Vasc Surg 2000;3184- 92
PubMed Link to Article
Young  E Vascular access. Current Practice and Practical Aspects of Management, ASN Renal Week 2000. Toronto, Canada American Society of Nephrology2000;377- 385
Schwab  SJ Reducing the risk of hemodialysis access. Am J Kidney Dis 1999;34362- 363
PubMed Link to Article
Dhingra  RKYoung  EWHulbert-Shearon  TELeavey  SFPort  FK Type of vascular access and mortality in US hemodialysis patients. Kidney Int 2001;601443- 1451
PubMed Link to Article
Murphy  GJWhite  SANicholson  ML Vascular access for haemodialysis. Br J Surg 2000;871300- 1315
PubMed Link to Article
Jennings  WC My changing approach to AV fistula construction. ESRD Network 13 Newsletter. January2004; (14)
Hemphill  HAllon  MKonner  KWork  JVassalotti  JA How can the use of arteriovenous fistulas be increased? Semin Dial 2003;16214- 223
PubMed Link to Article
Gibson  KCaps  MKohler  T  et al.  Assessment of a policy to reduce placement of prosthetic hemodialysis access. Kidney Int 2001;592335- 2345
PubMed Link to Article
Sands  JMiranda  CL Increasing numbers of AV fistulas for hemodialysis access. Clin Nephrol 1997;48114- 117
PubMed
Dalman  RLHarris  EJVictor  BJCoogan  SM Transition to all-autogenous hemodialysis access: the role of preoperative vein mapping. Ann Vasc Surg 2002;16624- 630
PubMed Link to Article
Nguyen  VDGriffith  CTreat  L A multidisciplinary team approach to increasing AV fistula creation. Nephrol News Issues 2003;1754- 60
PubMed
Bruns  SDJennings  WC Proximal radial artery as inflow site for native arteriovenous fistula. J Am Coll Surg 2003;19758- 63
PubMed Link to Article
Hakaim  AGNalbandian  MScott  T Superior maturation and patency of primary brachiocephalic and transposed basilica vein arteriovenous fistulae in patients with diabetes. J Vasc Surg 1998;27154- 157
PubMed Link to Article
Leapman  SBBoyle  MPescovitz  MD  et al.  The arteriovenous fistula for hemodialysis access: gold standard or archaic relic? Am Surg 1996;62652- 657
PubMed
Gracz  KCIng  TSSoung  L  et al.  Proximal forearm fistula for maintenance haemodialysis. Kidney Int 1977;1171- 74
PubMed Link to Article
Bender  MHBruyninckx  CMGerlag  PG The Gracz arteriovenous fistula evaluated: results of the brachiocephalic elbow fistula in haemodialysis angio-access. Eur J Vasc Endovasc Surg 1995;10294- 297
PubMed Link to Article
Konner  K How can the use of arteriovenous fistulas be increased? Semin Dial 2003;16217- 219
Link to Article
Tellis  VAVeith  FJSobermann  RJFreed  SZGliedman  ML Internal arteriovenous fistula for hemodialysis. Surg Gynecol Obstet 1971;132866- 870
PubMed
Geis  WPGiacchino  JLIwatsuki  SVaz  AJHano  JEIng  TS The reverse fistula for vascular access. Surg Gynecol Obstet 1977;145901- 904
PubMed
Nghiem  DD Angioaccess by reverse brachiocephalic fistula. Am J Surg 1987;153574- 575
PubMed Link to Article
Miller  AHolzenbein  TJGottlieb  MN  et al.  Strategies to increase the use of autogenous arteriovenous fistula in end-stage renal disease. Ann Vasc Surg 1997;11397- 405
PubMed Link to Article
Sparks  SRVanderLinden  JLGnanadev  DA  et al.  Superior patency of perforating antecubital vein arteriovenous fistulae for hemodialysis. Ann Vasc Surg 1997;11165- 167
PubMed Link to Article
Kliger  ASFinkelstein  FOMcGuire  ESchiff  M The antecubital fossa fistula. Clin Nephrol 1976;5229- 231
PubMed
Gefen  JYFox  DGiangola  GEwing  DRMeisels  IS The transposed forearm loop arteriovenous fistula: a valuable option for primary hemodialysis access in diabetic patients. Ann Vasc Surg 2002;1689- 94
PubMed Link to Article
Parmley  MCBroughan  TAJennings  WC Vascular ultrasonography prior to dialysis access surgery. Am J Surg 2002;184568- 572
PubMed Link to Article
Jennings  WCWood  CD Role of vein patch angioplasty in isolated operations for profunda femoris stenosis and disabling claudication. Am J Surg 1985;150263- 265
PubMed Link to Article
Miller  PETolwani  ALuscy  CP  et al.  Predictors of adequacy of arteriovenous fistulas in hemodialysis patients. Kidney Int 1999;56275- 280
PubMed Link to Article
Woods  JDTureene  MNStrawderman  RL  et al.  Vascular access survival among incident hemodialysis patients in the United States. Am J Kidney Dis 1997;3050- 57
PubMed Link to Article
Lazarides  MKIatrou  CEKaranikas  ID  et al.  Factors affecting the lifespan of autologous and synthetic arteriovenous access routes for haemodialysis. Eur J Surg 1996;162297- 301
PubMed
Brimble  KSRabbat  CGSchiff  DIngram  AJ The clinical utility of doppler ultrasound prior to arteriovenous fistula creation. Semin Dial 2001;14314- 317
PubMed Link to Article
Valentine  RJBouch  CWScott  DJ  et al.  Do preoperative finger pressures predict early arterial steal in hemodialysis access patients? A prospective analysis. J Vasc Surg 2002;36351- 356
PubMed Link to Article
Wehrli  HChevenard  RZaruba  K Surgical experiences with the arteriovenous heaemodialysis shunt (1970-1988). Helv Chir Acta 1989;56621- 627
PubMed
Winsett  OEWolma  FJ Complications of vascular access for heaemodialysis. South Med J 1985;78513- 517
PubMed Link to Article
Knox  RCBerman  SSHughes  JDGentile  ATMills  JL Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access. J Vasc Surg 2002;36250- 256
PubMed Link to Article
Beathard  GA Strategy for maximizing the use of arteriovenous fistulae. Semin Dial 2000;13291- 296
PubMed Link to Article
Ross  J Bridging to a high flow upper arm native fistula for hemodialysis with the LifeSite hemodialysis access system. J of Vasc Access 2001;2139- 144
Huber  TSSeeger  JM Approach to patients with “complex” hemodialysis access problems. Semin Dial 2003;1622- 29
PubMed Link to Article
Silva  MBHobson  RWPappas  PJ  et al.  A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg 1998;27302- 308
PubMed Link to Article
Vassalotti  JA How can the use of arteriovenous fistulas be increased? Semin Dial 2003;16221- 223
Link to Article
Malovrh  M The role of sonography in the planning of arteriovenous fistulas for hemodialysis. Semin Dial 2003;16299- 303
PubMed Link to Article
Silva  MBHobson  RWPappas  PJ  et al.  Vein transposition in the forearm for autogenous hemodialysis access. J Vasc Surg 1997;26981- 988
PubMed Link to Article
Brescia  MJCimino  JEAppel  KHurwich  BJ Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966;2751089- 1092
PubMed Link to Article
Goldstein  LJGupta  S Use of the radial artery for hemodialysis access. Arch Surg 2003;1381130- 1134
PubMed Link to Article
Lewis  CGWells  MKJennings  WC Avoidance of prophylactic antibiotics in creation of native arteriovenous fistulas. Dial Transplant 2003;32306- 308

Figures

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Figure 1.

Schematic representation of proximal radial artery native arteriovenous fistula.

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Figure 2.

Postoperative examination of proximal radial artery native arteriovenous fistula (PRA NAVF) showing typical outflow pattern.

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Figure 3.

A, Vessel probe passed distally rendering the first venous valve incompetent. B, Running suture technique initiated in the mid portion of the back wall of the native arteriovenous fistula anastomosis. C, Completed proximal radial artery native arteriovenous fistula with flow into the upper arm and retrograde into the forearm.

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Figure 4.

Life-table display for primary and secondary arteriovenous fistula patency. Line numbers are fistulas at risk in a given interval.

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Tables

Table Graphic Jump LocationTable 1. Demographics of 134 Patients With NAVFs
Table Graphic Jump LocationTable 2. Vascular Access Operations According to Arterial Inflow Site
Table Graphic Jump LocationTable 3. Access Patency in 134 AV Fistulas

References

 NKF-DOQI clinical practice guidelines for vascular access: National Kidney Foundation-Dialysis Outcomes Quality Initiative. Am J Kidney Dis 1997;30 ((4, suppl 3)) S150- S191
PubMed
Pisoni  RLYoung  EWDykstra  DM  et al.  Vascular access use in Europe and the United States: results from the DOPPS. Kidney Int 2002;61305- 316
PubMed Link to Article
Allon  MRobbin  ML Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int 2002;621109- 1124
PubMed Link to Article
Ascher  EPrasad  GHingorani  A  et al.  Changes in the practice of angio-access surgery: impact of dialysis outcome and quality initiative recommendation. J Vasc Surg 2000;3184- 92
PubMed Link to Article
Young  E Vascular access. Current Practice and Practical Aspects of Management, ASN Renal Week 2000. Toronto, Canada American Society of Nephrology2000;377- 385
Schwab  SJ Reducing the risk of hemodialysis access. Am J Kidney Dis 1999;34362- 363
PubMed Link to Article
Dhingra  RKYoung  EWHulbert-Shearon  TELeavey  SFPort  FK Type of vascular access and mortality in US hemodialysis patients. Kidney Int 2001;601443- 1451
PubMed Link to Article
Murphy  GJWhite  SANicholson  ML Vascular access for haemodialysis. Br J Surg 2000;871300- 1315
PubMed Link to Article
Jennings  WC My changing approach to AV fistula construction. ESRD Network 13 Newsletter. January2004; (14)
Hemphill  HAllon  MKonner  KWork  JVassalotti  JA How can the use of arteriovenous fistulas be increased? Semin Dial 2003;16214- 223
PubMed Link to Article
Gibson  KCaps  MKohler  T  et al.  Assessment of a policy to reduce placement of prosthetic hemodialysis access. Kidney Int 2001;592335- 2345
PubMed Link to Article
Sands  JMiranda  CL Increasing numbers of AV fistulas for hemodialysis access. Clin Nephrol 1997;48114- 117
PubMed
Dalman  RLHarris  EJVictor  BJCoogan  SM Transition to all-autogenous hemodialysis access: the role of preoperative vein mapping. Ann Vasc Surg 2002;16624- 630
PubMed Link to Article
Nguyen  VDGriffith  CTreat  L A multidisciplinary team approach to increasing AV fistula creation. Nephrol News Issues 2003;1754- 60
PubMed
Bruns  SDJennings  WC Proximal radial artery as inflow site for native arteriovenous fistula. J Am Coll Surg 2003;19758- 63
PubMed Link to Article
Hakaim  AGNalbandian  MScott  T Superior maturation and patency of primary brachiocephalic and transposed basilica vein arteriovenous fistulae in patients with diabetes. J Vasc Surg 1998;27154- 157
PubMed Link to Article
Leapman  SBBoyle  MPescovitz  MD  et al.  The arteriovenous fistula for hemodialysis access: gold standard or archaic relic? Am Surg 1996;62652- 657
PubMed
Gracz  KCIng  TSSoung  L  et al.  Proximal forearm fistula for maintenance haemodialysis. Kidney Int 1977;1171- 74
PubMed Link to Article
Bender  MHBruyninckx  CMGerlag  PG The Gracz arteriovenous fistula evaluated: results of the brachiocephalic elbow fistula in haemodialysis angio-access. Eur J Vasc Endovasc Surg 1995;10294- 297
PubMed Link to Article
Konner  K How can the use of arteriovenous fistulas be increased? Semin Dial 2003;16217- 219
Link to Article
Tellis  VAVeith  FJSobermann  RJFreed  SZGliedman  ML Internal arteriovenous fistula for hemodialysis. Surg Gynecol Obstet 1971;132866- 870
PubMed
Geis  WPGiacchino  JLIwatsuki  SVaz  AJHano  JEIng  TS The reverse fistula for vascular access. Surg Gynecol Obstet 1977;145901- 904
PubMed
Nghiem  DD Angioaccess by reverse brachiocephalic fistula. Am J Surg 1987;153574- 575
PubMed Link to Article
Miller  AHolzenbein  TJGottlieb  MN  et al.  Strategies to increase the use of autogenous arteriovenous fistula in end-stage renal disease. Ann Vasc Surg 1997;11397- 405
PubMed Link to Article
Sparks  SRVanderLinden  JLGnanadev  DA  et al.  Superior patency of perforating antecubital vein arteriovenous fistulae for hemodialysis. Ann Vasc Surg 1997;11165- 167
PubMed Link to Article
Kliger  ASFinkelstein  FOMcGuire  ESchiff  M The antecubital fossa fistula. Clin Nephrol 1976;5229- 231
PubMed
Gefen  JYFox  DGiangola  GEwing  DRMeisels  IS The transposed forearm loop arteriovenous fistula: a valuable option for primary hemodialysis access in diabetic patients. Ann Vasc Surg 2002;1689- 94
PubMed Link to Article
Parmley  MCBroughan  TAJennings  WC Vascular ultrasonography prior to dialysis access surgery. Am J Surg 2002;184568- 572
PubMed Link to Article
Jennings  WCWood  CD Role of vein patch angioplasty in isolated operations for profunda femoris stenosis and disabling claudication. Am J Surg 1985;150263- 265
PubMed Link to Article
Miller  PETolwani  ALuscy  CP  et al.  Predictors of adequacy of arteriovenous fistulas in hemodialysis patients. Kidney Int 1999;56275- 280
PubMed Link to Article
Woods  JDTureene  MNStrawderman  RL  et al.  Vascular access survival among incident hemodialysis patients in the United States. Am J Kidney Dis 1997;3050- 57
PubMed Link to Article
Lazarides  MKIatrou  CEKaranikas  ID  et al.  Factors affecting the lifespan of autologous and synthetic arteriovenous access routes for haemodialysis. Eur J Surg 1996;162297- 301
PubMed
Brimble  KSRabbat  CGSchiff  DIngram  AJ The clinical utility of doppler ultrasound prior to arteriovenous fistula creation. Semin Dial 2001;14314- 317
PubMed Link to Article
Valentine  RJBouch  CWScott  DJ  et al.  Do preoperative finger pressures predict early arterial steal in hemodialysis access patients? A prospective analysis. J Vasc Surg 2002;36351- 356
PubMed Link to Article
Wehrli  HChevenard  RZaruba  K Surgical experiences with the arteriovenous heaemodialysis shunt (1970-1988). Helv Chir Acta 1989;56621- 627
PubMed
Winsett  OEWolma  FJ Complications of vascular access for heaemodialysis. South Med J 1985;78513- 517
PubMed Link to Article
Knox  RCBerman  SSHughes  JDGentile  ATMills  JL Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access. J Vasc Surg 2002;36250- 256
PubMed Link to Article
Beathard  GA Strategy for maximizing the use of arteriovenous fistulae. Semin Dial 2000;13291- 296
PubMed Link to Article
Ross  J Bridging to a high flow upper arm native fistula for hemodialysis with the LifeSite hemodialysis access system. J of Vasc Access 2001;2139- 144
Huber  TSSeeger  JM Approach to patients with “complex” hemodialysis access problems. Semin Dial 2003;1622- 29
PubMed Link to Article
Silva  MBHobson  RWPappas  PJ  et al.  A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg 1998;27302- 308
PubMed Link to Article
Vassalotti  JA How can the use of arteriovenous fistulas be increased? Semin Dial 2003;16221- 223
Link to Article
Malovrh  M The role of sonography in the planning of arteriovenous fistulas for hemodialysis. Semin Dial 2003;16299- 303
PubMed Link to Article
Silva  MBHobson  RWPappas  PJ  et al.  Vein transposition in the forearm for autogenous hemodialysis access. J Vasc Surg 1997;26981- 988
PubMed Link to Article
Brescia  MJCimino  JEAppel  KHurwich  BJ Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966;2751089- 1092
PubMed Link to Article
Goldstein  LJGupta  S Use of the radial artery for hemodialysis access. Arch Surg 2003;1381130- 1134
PubMed Link to Article
Lewis  CGWells  MKJennings  WC Avoidance of prophylactic antibiotics in creation of native arteriovenous fistulas. Dial Transplant 2003;32306- 308

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