Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 269-273

Distal forearm radiocephalic arteriovenous fistula creation in calcified vessels: Technical challenges in anastomosis and early outcome


1 Department of Plastic Surgery, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
2 Dezire Clinic, Sir Gangaram Hospital, New Delhi, India
3 Department of Plastic and Reconstructive Surgery, Sir Gangaram Hospital, New Delhi, India

Date of Submission31-Aug-2019
Date of Acceptance27-Oct-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Sudipta Bera
Department of Plastic Surgery, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_56_19

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  Abstract 


Background: Calcified vessels are frequently encountered during arteriovenous fistula (AVF) creation in aged patients and outcome is negatively implicated. However, fistula creation in calcified artery is an entity without much technical clarity and guidance. We present our experience and several modifications of standard radiocephalic (RC) AV fistula creations adopted during anastomosis on calcified vessels depending on our experience of fistula creation over the last 7 years. Objective: The objective was to assess the outcome of our technical modifications for RC AVF creation in distal forearm on atherosclerotic radial artery. Methodology: Twelve cases of calcified radial artery noted intraoperatively between July 2017 and 2018 and the first-time RC AVF created at the distal forearm were included in the study. Operative steps with modifications and early outcome were assessed prospectively. Results: All cases were male, with a mean age of 63.08 years. The average external diameter of the radial artery and cephalic vein was 2.74 mm and 2.21 mm, respectively. Venous bifurcation was available for creating “venous branch patch” and utilized for anastomosis in all cases. The mean operative time was 36.25 min. The functional maturation rate was 12/12. The mean maturation time was 34 days (standard deviation 5.74, standard error of mean 1.66). Fistula patency at 6 months and 1 year was 9/12 and 7/12, respectively. One vascular blow out was noted as complication. Conclusion: Some simple adaptations in vessel handling and suturing techniques and the use of “venous branch patch” for anastomosis may improve functional outcome in calcified vessels in distal RC AVF creation. This observation needs more number of cases and longer follow-up to predict the outcome in more assertive way.

Keywords: Anastomosis, calcified artery, distal forearm, radiocephalic arteriovenous fistula, venous branch patch


How to cite this article:
Sharma S, Bera S, Kumar A, Gupta V. Distal forearm radiocephalic arteriovenous fistula creation in calcified vessels: Technical challenges in anastomosis and early outcome. Indian J Vasc Endovasc Surg 2019;6:269-73

How to cite this URL:
Sharma S, Bera S, Kumar A, Gupta V. Distal forearm radiocephalic arteriovenous fistula creation in calcified vessels: Technical challenges in anastomosis and early outcome. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Sep 27];6:269-73. Available from: http://www.indjvascsurg.org/text.asp?2019/6/4/269/273598




  Introduction Top


Calcified vessels are frequently encountered during arteriovenous fistula (AVF) creation in aged patients with comorbidities such as diabetes or hyperlipidemia. Calcification of vessel in chronic renal failure (CRF), its etiology, implications, and management is a matter of much discussion and studies are going on.[1],[2]

Although radiocephalic AVF (RC AVF) is the procedure of choice as per the Kidney Disease Outcome Quality Initiative (K/DOQI) of National Kidney Foundation recommendation, distal forearm RC AVF creation in the elderly and diabetic patients raises lots of doubts due to reported poor outcome in the presence of calcification.[3],[4] Fistula creation in calcified artery is an entity without much technical clarity and guidance. Although it is technically challenging and outcome is not satisfactory, establishment of fistula still remains essential in these patients.

Several research works were done earlier to improve anastomosis in calcified vessel which is encountered during AVF creation, limb salvage in peripheral vascular disease, or vascular bypass procedure.[5],[6] We present our experience and several modifications of standard RC AVF creations we adopted during anastomosis on calcified vessels depending on our experience of AVF creation over the last 7 years.

Aims and objectives

This study aimed to assess the outcome of technical modification and distal forearm RC AVF creation in calcified radial artery.


  Methodology Top


Twelve cases were included in this study where severe atherosclerosis and calcification of radial artery were noted intraoperatively.

All the patients were first-time candidates of RC AVF creation at distal forearm, operated between July 2017 and 2018 and followed up till July 2019. All the surgeries were performed by the senior author in the same center. Operative steps with modifications were assessed prospectively, and early outcome was noted. Data were tabulated and subjected to statistical analysis.

Operative steps

Patients were selected for fistula creation after clinical assessment, color Doppler study, and Allen's test. All the surgeries were done under local anesthesia as day-care procedure. Distal RC AVF was created with a venous bifurcation whenever available. On suspicion of an atherosclerotic vessel after clinical and color Doppler study, the cephalic vein was exposed and venous bifurcation was traced, identified, and preserved in the distal forearm. The radial artery was exposed next to the bifurcation point. If the major branch was available, a “venous branch patch”[7] was prepared from the bifurcation point and used for anastomosis [Figure 1]. If bifurcation is not available, fistula was planned to be created at proximal forearm with usual method with a larger caliber vein proximally. On finding the radial artery's consistency to be hard and calcified, necessary adjustment was made for fistula creation [Figure 2]. The radial artery was elevated between a pair of “Bulldog” hemostatic clamp as we noted that that conventional clamp pressure is usually inadequate to occlude the lumen completely. In most of the cases, adventitia is seen densely adhered to the inner layers, and adventitial clearing at the proposed anastomotic segment is avoided as much as possible. Arteriotomy is made with making a nick in the wall with a stab knife and extended to a length of 8–10 mm with a large curved micro scissors. Plaques are the usual finding at the margin and medial layer of arteriotomy, and loose plaques are removed trying to keep them undisturbed as much as possible. Anastomosis is done with 7-0 prolene instead of 8-0 prolene needle which is prone to be distorted. The first bite is taken to approximate arteriotomy and venotomy margin keeping the knot outside and then the needle is taken to the arterial luminal side. Subsequently, wide bites are taken from the luminal side of the artery to venous margin. Posterior wall anastomosis was completed within the arterial luminal side under vision. Then, anterior wall anastomosis was completed, with bite taken on the venous wall followed by the arterial wall inside outward. End-to-side anastomosis was done with continuous running suture. The needle is inserted between jewelers' forceps, and bites are taken staying away from the arteriotomy margin. Plaques that are dislodged with each bite are removed gently [Figure 3]. On completion of anastomosis, the margin is checked removing clamp from one end and on satisfactory finding, the clamp is removed from the other end [Figure 1] and [Figure 2]. Hemostasis is checked. Palpable thrill and venous dilatation were noted. Any additional branch was ligated. Incision was closed with a nonabsorbable suture.
Figure 1: Demonstration of “venous branch patch” for fistula creation on calcified artery. (a) Exposure of artery and vein. (b) Venous bifurcation is exposed and both branches are divided. (c) The common branch wall is divided to prepare a venous patch. (d) Venous patch. (e) Anastomosis before releasing vascular clamps. (f) Establishment of fistula and venous dilatation

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Figure 2: Distal forearm RC AVF creation in a calcified radial artery and our modifications. (a) Exposure of artery and vein. (b) Artery is kept elevated between a pair of “Bulldog” clamp and prepared for arteriotomy (c). Arteriotomy (d). Anastomosis with placement of suture from intimal side to outward on the arterial wall (e). Anastomosis with sealing of arteriotomy with a cuff of venous tissue (f). Establishment of fistula. Venous dilatation without any leakage and arterial fracture. Use of rubber band (1), bulldog clamp (2), curved scissors (3), and 7-0 prolene suture (4) are demonstrated in different steps

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Figure 3: Suturing technique on calcified vessel. (a) Arteriotomy and vein patch approximated and diameter matched. (b) Suturing of posterior wall. (c) Suturing of anterior wall and removal of loose outer wall plaques after placement of suture. Plaque is indicated with an arrow

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Follow-up

The patients were observed in the postoperative recovery room. Palpable thrill and audible bruit were noted after ½ hour before discharge. The patients were followed up on days 3, 7, and 12, and sutures were removed. The patients were reviewed for progression of thrill and bruit clinically. On palpable thrill in a segment of 5-cm vein, the patients were reviewed with color Doppler study and cannulated. The flow rate was measured and observing a flow rate >250 ml/min, the patients were taken for dialysis. Maturation time was noted. The patients were followed up as and when required subsequently and patency was noted.


  Results and Analysis Top


Twelve patients were operated with RC AVF at distal forearm with a calcified radial artery within the study period. The age of the patients ranged between 56 and 72 years, with a mean age of 63.08 years, standard deviation of (SD) 5.71, and standard error of mean (SEM) of 1.65. All of them were male.

The average external diameter of radial artery and cephalic vein was 2.74 (SD 0.31 and SE 0.09) and 2.21 mm (SD 0.37 and SEM 0.1), respectively. Venous bifurcation was available for creating a “venous branch patch” and utilized for anastomosis in all cases. The mean operative time was 36.25 min (SD 4.83 and SEM 1.39).

The functional maturation rate was 12/12 with flow rate >250 ml/min. The mean maturation time was 34 days (SD 5.74 and SEM 1.66). Primary fistula patency rates were 9/12 and 7/12 at 6 months and 1 year, respectively.

Blowout at the anastomotic junction was noted as a major complication in one patient, which occurred on the 10th postoperative day. The patient was managed with ligation of radial artery both proximal and distal to the fistula and ligation of vein as an emergency procedure. Hand edema, vascular steal phenomenon, and distal gangrene were not seen in any case.


  Discussion Top


Incidence

Vascular calcification in CRF is a subject of much research and ongoing studies. Published research works suggests that severe atherosclerosis is related to vascular calcifications though the nature of vascular calcification is much diverse. Intimal and medial calcifications are separate entities and implications though they are encountered during fistula creation in an indistinguishable manner.[1],[2],[8]

RC AVF has been established as the gold standard after the recommendation of K/DOQI and “FistulaFirst Initiative.” Vascular calcification has major influences on fistula creation as it makes the vessel caliber narrow; makes the wall stiff and fragile; and has much negative impact on fistula patency and maturation.[4],[9],[10] It has worse influence on smaller vessels on location such as wrist and preference to proximal fistula is suggested in these cases.[11],[12] However, proximal fistulas on large caliber vessels are known for their own complications such as hand edema and vascular steal phenomenon, leading to the need for the review of the feasibility of distal RC AVF creation on calcified artery.

Anastomosis on calcified vessel poses major challenges to the surgical team. Several improvisations and modifications of anastomotic strategy have been adopted earlier to tackle vascular calcification. Semel et al.[5] described the method of traumatic control with a sling.[5] Carpenter and Berkowitz described a method of creating hole on the vascular wall with a handheld drill and 23G hypodermic needle to facilitate suture placement for anastomosis.[13] Use of “venous branch patch” was described by Jennings et al. to prevent anastomotic stenosis.[7] Gołębiowski et al. described a “sleeve method” preferring end-to-end anastomosis in AVF creation.[14] Kim et al. mentioned end-to-side anastomosis with a venous conduit to calcified vessel for the purpose of limb salvage.[6] White et al. discussed CO2 laser fusion vascular anastomosis and suture through adventitia and media.[15] Hosein et al. described the use of interpositional venous graft for anastomosis between calcified arteries.[16]

Distal AVF became a standard after the FistulaFirst Initiative by K/DOQI, and fistula creation is evolving with improvement in both creation rate and success. Vascular calcification during AVF creation became an interesting entity due to certain anastomotic challenges. We observed a calcified vessel for first-time fistula creation in distal forearm, an occasional entity with an incidence rate of approximately 42/1000 in our last 7-year experience. Depending on our initial experiences for distal forearm RC AVF creation, we have adopted certain modifications of our standard end-to-side anastomosis and observed 12 cases prospectively during anastomosis in the last 2 years and summarized our experiences.

Problem with atherosclerotic vessels

  1. Misleading or inconclusive Allen's test. Doppler is more conclusive to suspect a calcified vessel before exploration
  2. Very hard wall produces difficult occlusion by placing regular vascular hemostatic clamps and prone to fracture
  3. Hard wall prevents wall penetration for clean arteriotomy or microvascular suture placement
  4. Luminal narrowing with plaques is prone to anastomotic occlusion and thrombosis
  5. Less distensible, more prone to anastomotic stenosis, and early failure[9],[17],[18]
  6. Poor maturation, risk of blowout, and vascular events
  7. Smaller diameter vessels are prone to difficulty to mature and large diameter vessels are prone to vascular steal phenomenon.


Our adaptations

  1. Doppler is more conclusive and suggestive of a calcified artery which guides adopting a modification of approach and explore the artery for fistula creation. Major venous bifurcations are traced and tried to be utilized for “venous branch patch.” Skin incision was planned accordingly
  2. Use of “Bulldog” hemostatic clamp instead of regular clamps [Figure 2] and [Figure 3]. We have noted that the use of “Bulldog” clamps and irrigation during suture placement were adequate to provide a clean operative field
  3. Handling the artery with an elastic rubber band minimized the trauma and breakdown of plaques. Adventitial stripping at arteriotomy and anastomotic segment is avoided to minimize further trauma and fracture of plaques
  4. Use of venous bifurcation helped in creating a “venous branch patch” in the distal forearm to have control over anastomotic diameter, particularly in small diameter vein, and provided a cuff of tissue at the anastomotic margin to prevent tear through suture and stenosis [Figure 1]. Branch patch also allowed to take thick bite through arterial wall and vein and minimized leakage
  5. Small diameter vein at distal forearm with branch patch avoided a large caliber fistula and avoided the steal phenomenon
  6. Use of 7-0 prolene instead of 8-0. 7-0 suture needle is found to be suitable to pierce but leaves no leakage use of 7-0 and placing thick bite minimized the required number of bite through the wall and subsequent chance of plaque dislodgement [Figure 2]
  7. Placing the bite from the inner to outer side of the artery with continuous suture minimized the dislodgement of intimal plaques and allowed easy removal of medial loose plaques [Figure 3].


These adaptations were simple which did not need any special requirements and effort. The mean operation time was 32 min which was similar to our conventional fistula creation time.

Outcome

On-table palpable thrill and bruit and venous dilatation were achieved in all cases, which were found to be the most important clinical guide for fistula maturation.[19] Functional maturation was obtained in all the 12 cases, with a mean maturation time of 34 days (SD 5.77 and SEM 1.66). Thrombosis was noted in two fistulas in the first 6 months and another two in the next 6 months. The primary patency rates were 9/12 and 7/12 at 6 months and 1 year, respectively. In earlier studies, primary failure rate of distal RC AVF varies from 9% to 40%,[19],[20] and 3.42 times higher chance of failure was shown in the presence of calcification.[4],[11] Our result is almost similar to the operative outcome of distal forearm RC AVF on normal vessels shown in other studies, and we have noted better outcome of fistula on calcified vessels in contemporary literature.

The most important complication we encountered is blowout of the fistula which we have seen in one case. The blowout was noted on the 10th postoperative day. The patient presented with bleeding from the operative site and was explored under local anesthesia. The radial artery was ligated both proximal and distal to the fistula. Dialysis was continued through the neck line, and the patient was lost from subsequent follow-up. Vascular steal phenomenon or hand edema was not seen in any cases.

Limitation

This is a small sample study and needs prolonged follow-up. Furthermore, the study lacks secondary patency rate as no secondary intervention was done due to lack of cost-effective radiologic intervention at our center.


  Conclusion Top


Some simple adaptations in vessel handling and suturing techniques and use of “venous branch patch” for anastomosis may improve functional outcome in atherosclerotic vessels in distal forearm RC AVF creation. This observation needs more number of cases and longer follow-up to predict the outcome in more assertive way.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
London GM, Marchais SJ, Guérin AP, Métivier F. Arteriosclerosis, vascular calcifications and cardiovascular disease in uremia. Curr Opin Nephrol Hypertens 2005;14:525-31.  Back to cited text no. 1
    
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Moe SM, Chen NX. Mechanisms of vascular calcification in chronic kidney disease. J Am Soc Nephrol 2008;19:213-6.  Back to cited text no. 2
    
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Georgiadis GS, Georgakarakos EI, Antoniou GA, Panagoutsos S, Argyriou C, Mourvati E, et al. Correlation of pre-existing radial artery macrocalcifications with late patency of primary radiocephalic fistulas in diabetic hemodialysis patients. J Vasc Surg 2014;60:462-70.  Back to cited text no. 3
    
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Jankovic A, Damjanovic T, Djuric Z, Marinkovic J, Schlieper G, Djuric P, et al. Calcification in arteriovenous fistula blood vessels may predict arteriovenous fistula failure: A 5-year follow-up study. Int Urol Nephrol 2017;49:881-7.  Back to cited text no. 4
    
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Semel L, Schu W, Aust JC, Bredenberg CE. Atraumatic control in calcified arteries. Ann Vasc Surg 1988;2:73-4.  Back to cited text no. 5
    
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Kim DY, Lee YJ, Moon SH, Oh JS, Koh YS, Kim JY, et al. Vein conduit for end-to-side anastomosis of a calcified vessel in lower extremity free flap reconstruction. J Plast Reconstr Aesthet Surg 2019;72:1100-9.  Back to cited text no. 6
    
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Jennings WC, Kindred MG, Broughan TA. Creating radiocephalic arteriovenous fistulas: Technical and functional success. J Am Coll Surg 2009;208:419-25.  Back to cited text no. 7
    
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Amann K. Media calcification and intima calcification are distinct entities in chronic kidney disease. Clin J Am Soc Nephrol 2008;3:1599-605.  Back to cited text no. 8
    
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Stehbens WE, Karmody AM. Venous atherosclerosis associated with arteriovenous fistulas for hemodialysis. Arch Surg 1975;110:176-80.  Back to cited text no. 9
    
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Stolić R, Trajković G, Perić V, Jovanović A, Subarić-Gorgieva G. Impact of arteriosclerosis on the functioning of arteriovenous fistula for hemodialysis. Vojnosanit Pregl 2007;64:13-8.  Back to cited text no. 10
    
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Allon M, Robbin ML, Umphrey HR, Young CJ, Deierhoi MH, Goodman J, et al. Preoperative arterial microcalcification and clinical outcomes of arteriovenous fistulas for hemodialysis. Am J Kidney Dis 2015;66:84-90.  Back to cited text no. 11
    
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Georgiadis GS, Argyriou C, Kantartzi K, Georgakarakos EI. Which is the most powerful adverse factor for autogenous access patency between diabetes and high arterial calcification burden? Ren Fail 2018;40:455-7.  Back to cited text no. 12
    
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Carpenter JP, Berkowitz HD. A technique for suturing anastomoses involving calcified vessels. J Vasc Surg 1992;16:494-6.  Back to cited text no. 13
    
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Gołębiowski T, Weyde W, Letachowicz K, Kusztal M, Augustyniak-Bartosik H, Penar J, et al. The sleeve method for creation of radiocephalic arteriovenous fistulas in patients with calcified vessels. J Vasc Access 2017;18:384-9.  Back to cited text no. 14
    
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White JV, Leefmans E, Stewart GJ, Katz ML, Comerota AJ. CO2 vascular anastomosis of atherosclerotic and calcified arteries. Laser Surgery: Advanced Characterization, Therapeutics, and Systems II. Proceedings SPIE 1200; 1990.  Back to cited text no. 15
    
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Hosein RC, Odobescu A, Goodwin IA. A novel technique for microsurgery on calcified arteries: Venous interposition grafting. Eplasty 2019;19:pb3.  Back to cited text no. 16
    
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Kim YO, Song HC, Yoon SA, Yang CW, Kim NI, Choi YJ, et al. Preexisting intimal hyperplasia of radial artery is associated with early failure of radiocephalic arteriovenous fistula in hemodialysis patients. Am J Kidney Dis 2003;41:422-8.  Back to cited text no. 17
    
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Kheda MF, Brenner LE, Patel MJ, Wynn JJ, White JJ, Prisant LM, et al. Influence of arterial elasticity and vessel dilatation on arteriovenous fistula maturation: A prospective cohort study. Nephrol Dial Transplant 2010;25:525-31.  Back to cited text no. 18
    
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Sahasrabudhe P, Dighe T, Panse N, Patil S. Retrospective analysis of 271 arteriovenous fistulas as vascular access for hemodialysis. Indian J Nephrol 2013;23:191-5.  Back to cited text no. 19
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Haimov M, Baez A, Neff M, Slifkin R. Complications of arteriovenous fistulas for hemodialysis. Arch Surg 1975;110:708-12.  Back to cited text no. 20
    


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