New approach in creating an arteriovenous fistula: First year of experience implementing the new method in R. N. Macedonia

Abstract

Introduction. Arteriovenous fistula (AVF) for Hemo-dialysis (HD) is a surgical anastomosis between the native blood vessels, and it has become a symbol for superior vascular access (VA) for patients on HD. The aim our study was to compare the successful creation and adequate maturation of AVF using vessel loops instead of arterial bulldogs (small metallic vascular clamp) during surgical intervention. Methods. The study was retrospective, analyzing the outcome of AVF in patients with Chronic Kidney Disease (CKD) stage 4/5 who underwent AVF creation after hospitalization at our clinic. In 2016 we used ar-terial bulldogs, and in 2018 we used vessel loops du-ring surgical intervention. Three different types of AVF were created: the distal (radial-cephalic), middle-forearm (radial-cephalic) and proximal (brachial-ce-phalic). The successful creation and adequate matura-tion of AVF was defined as successful cannulation of AVF for efficient HD treatment, and AVF blood flow of ≥600 ml/min measured by Doppler ultrasound (DUS). Results. We analyzed 341 created fistulas during the period from January to December 2016, and 367 fis-tulas created during the period from January to De-cember 2018 in patients with CKD stage 4/5. In 2016 the average age was 62.2±11.2 years, mean HD vintage was 12.8±23.2 months, and 57.5% (196/341) were males. The successful creation and adequate maturation was achieved in 58.65% (200/341), but in preventive fistulas successful creation and adequate maturation was 69.8%. In 2018 the average age was 61.4±14.2 years, mean HD vintage was 14 months, and 64.85% (238/367) were males. The successful creation and adequate maturation were achieved in 74.11% (272/367), but in preventive fistulas successful creation and adequate maturation was 82.69%. In both years the distal location of AVF was predominate site with higher percentage of successful creation and adequate maturation. The smallest percentage of successful creation and adequate maturation of AVF was found in middle-forearm location, and it correlates with deep location of radial artery that lead to kinking of the anastomosis. Conclusion. The surgical technique during the AVF creation plays important role. Our analysis showed that creation of AVF was better in 2018 when we used vessel loops, in comparison to 2016 when we used ar-terial bulldogs. The atraumatic needles, microsurgical instruments and vascular loops decreased mechanical stress in the blood vessels. Use of the vessel loops pro-vides lower mechanical trauma of blood vessels than metallic vascular clamp, with adequate bleeding control.