Although native radiocephalic arteriovenous fistula (RCAVF) is the best vascular access for hemodialysis (HD), a major obstacle to increase its use is high frequency of fistulas that fail to mature. The aim of this study was to investigate and define cut-off values of morphologic and functional vessel parameters influencing successful RCAVF maturation using ultrasound.
Methods
A prospective, observational study was performed on 122 patients (66 men) who underwent primary RCAVF creation. Internal diameters of cephalic vein (CVd) and radial artery (ARd), venous distensibility (VD), resistance index (RI) and endothelial function by flow mediated dilatation (FMD) were determined by ultrasound examination before AVF placement. AVF maturation was observed by measuring blood flow (Qa) and CVd 0, 14 and 28 days after creation. Depending on the time when AVFs attained maturity (Qa ≥500 mL/min, CVd ≥5 mm), patients were divided into three groups: (i) successful maturation (after four weeks), (ii) prolonged maturation (within eight weeks) and (iii) failure to mature.
Results
Only 11% of patients failed to achieve a mature RCAVF. Successful AVF maturation occurred in 53% of patients and prolonged maturation in 36% of patients. ROC analysis defined the limits of variables relevant for RCAVF success (CVd >1.8 mm, ARd >1.6 mm, VD >0.4 mm). Female sex was associated with prolonged maturation (OR 0.35, 95% CI=0.17-0.72; P=0.005) having a significantly smaller ARd (1.83 vs. 2.01 mm, P=0.01) but better FMD (2981.5 vs. 2689.5, P=0.02) compared to men.
Conclusions
ARd ≤1.6 mm, CVd ≤1.8 mm and VD ≤0.4 mm are exact cut-off points, which best predict nonmaturation of RCAVF. Women need extended time for adequately matured AVF.
WangW., MurphyB., YilmazS., TonelliM., MacraeJ., MannsB.J.Comorbidities do not influence primary fistula success in incident hemodialysis patients: a prospective study.Clin J Am Soc Nephrol.2008; 3(1): 78–84.
2.
MillerP.E., TolwaniA., LuscyC.P.Predictors of adequacy of arteriovenous fistulas in hemodialysis patients.Kidney Int.1999; 56(1): 275–280.
OwensC.D., WakeN., KimJ.M., HentschelD., ConteM.S., SchanzerA.Endothelial function predicts positive arterial-venous fistula remodeling in subjects with stage IV and V chronic kidney disease.J Vasc Access.2010; 11(4): 329–334.
8.
AllonM., LockhartM.E., LillyR.Z.Effect of pre-operative sonographic mapping on vascular access outcomes in hemodialysis patients.Kidney Int.2001; 60(5): 2013–2020.
9.
FerringM., ClaridgeM., SmithS.A., WilminkT.Routine pre-operative vascular ultrasound improves patency and use of arteriovenous fistulas for hemodialysis: a randomized trial.Clin J Am Soc Nephrol.2010; 5(12): 2236–2244.
10.
SaranR., DykstraD.M., PisoniR.L.Timing of first cannulation and vascular access failure in haemodialysis: an analysis of practice patterns at dialysis facilities in the DOPPS.Nephrol Dial Transplant.2004; 19(9): 2334–2340.
11.
SaranR., PisoniR.L., YoungE.W.Timing of first cannulation of arteriovenous fistula: are we waiting too long?Nephrol Dial Transplant.2005; 20(4): 688–690.
12.
RaynerH.C., PisoniR.L., GillespieB.W.Dialysis Outcomes and Practice Patterns Study. Creation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study.Kidney Int.2003; 63(1): 323–330.
13.
MalovrhM.Non-invasive evaluation of vessels by duplex sonography prior to construction of arteriovenous fistulas for haemodialysis.Nephrol Dial Transplant.1998; 13(1): 125–129.
14.
GokceN., HolbrookM., HunterL.M.Acute effects of vasoactive drug treatment on brachial artery reactivity.J Am Coll Cardiol.2002; 40(4): 761–765.
15.
CorrettiM.C., AndersonT.J., BenjaminE.J.International Brachial Artery Reactivity Task Force. Guidelines for the ultrasound assessment of endothelial-dependent flow-mediated vasodilation of the brachial artery: a report of the International Brachial Artery Reactivity Task Force.J Am Coll Cardiol.2002; 39(2): 257–265.
16.
RobbinM.L., ChamberlainN.E., LockhartM.E.Hemodialysis arteriovenous fistula maturity: US evaluation.Radiology.2002; 225(1): 59–64.
van HoolandS., DonckJ., AmeyeF., AerdenD.Duplex Ultrasonography and haemodialysis vascular access: A practical review.Int J Nephrol Urol.2010; 2: 283–293.
19.
MetzC.E.Basic principles of ROC analysis.Semin Nucl Med.1978; 8(4): 283–298.
20.
PetersonW.J., BarkerJ., AllonM.Disparities in fistula maturation persist despite pre-operative vascular mapping.Clin J Am Nephrol.2008; 3(2): 437–441.
21.
BresciaM.J., CiminoJ.E., AppelK.I., HurwichB.J.Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula.N Engl J Med.1966; 275(20): 1089–1092.
22.
CelermajerD.S., AdamsM.R., ClarksonP.Passive smoking and impaired endothelium-dependent arterial dilatation in healthy young adults.N Engl J Med.1996; 334(3): 150–154.
23.
JacobsM.C., LendersJ.W., KapmaJ.A., SmitsP., ThienT.Effect of chronic smoking on endothelium-dependent vascular relaxation in humans.Clin Sci (Lond).1993; 85(1): 51–55.
24.
CelermajerD.S., SorensenK.E., GeorgakopoulosD.Cigarette smoking is associated with dose-related and potentially reversible impairment of endothelium-dependent dilation in healthy young adults.Circulation.1993; 88(5 Pt 1): 2149–2155.
25.
ParmarJ., AslamM., StandfieldN.Pre-operative radial arterial diameter predicts early failure of arteriovenous fistula (AVF) for haemodialysis.Eur J Vasc Endovasc Surg.2007; 33(1): 113–115.
26.
WongV., WardR., TaylorJ., SelvakumarS., HowT.V., BakranA.Factors associated with early failure of arteriovenous fistulae for haemodialysis access.Eur J Vasc Endovasc Surg.1996; 12(2): 207–213.
27.
KortenE., ToonderI.M., ShramaY.C., HopW.C.J., van der HamA.C., WittensC.H.A.Dialysis fistulae patency and pre-operative diameter ultrasound measurements.Eur J Vasc Endovasc Surg.2007; 33(4): 461–467.
28.
LockhartM.E., RobbinM.L., AllonM.Pre-Operative sonographic radial artery evaluation and correlation with subsequent radiocephalic fistula outcome.J Ultrasound Med.2004; 23(2): 161–168, quiz 169-171.
29.
MendesR.R., FarberM.A., MarstonW.A., DinwiddieL.C., KeagyB.A., BurnhamS.J.Prediction of wrist arteriovenous fistula maturation with pre-operative vein mapping with ultrasonography.J Vasc Surg.2002; 36(3): 460–463.
30.
BrimbleK.S., RabbatChG, TreleavenD.J., IngramA.J.Utility of ultrasonographic venous assessment prior to forearm arteriovenous fistula creation.Clin Nephrol.2002; 58(2): 122–127.
31.
WallL.P., GasparisA., CallahanS., van BemmelenP., CriadoE., RicottaJ.Impaired hyperemic response is predictive of early access failure.Ann Vasc Surg.2004; 18(2): 167–171.
32.
FerringM., HendersonJ., WilminkA., SmithS.Vascular ultrasound for the pre-operative evaluation prior to arteriovenous fistula formation for haemodialysis: review of the evidence.Nephrol Dial Transplant.2008; 23(6): 1809–1815.
33.
van der LindenJ., LamerisT.W., van den MeirackerA.H., de SmetAAEA, BlankestijnP.J., van den DorpelM.A.Forearm venous distensibility predicts successful arteriovenous fistula.Am J Kidney Dis.2006; 47(6): 1013–1019.
34.
KimJ.T., ChangW.H., OhT.Y., JeongY.K.Venous distensibility as a key factor in the success of arteriovenous fistulas at the wrist.Ann Vasc Surg.2011; 25(8): 1094–1098.
35.
van BemmelenP.S., KellyP., BlebeaJ.Improvement in the visualization of superficial arm veins being evaluated for access and bypass.J Vasc Surg.2005; 42(5): 957–962.
36.
TordoirJ.H., MickleyV.European guidelines for vascular access: clinical algorithms on vascular access for haemodialysis.EDTNA ERCA J.2003; 29(3): 131–136.
