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ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 278-282

Cross-sectional study of upper-limb vessel diameters and their association with arteriovenous fistula maturation in end-stage renal disease patients


1 Department of Vascular Surgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
2 Department of Vascular and Endovascular Surgery, Care Hospital, Hyderabad, Telangana, India

Date of Submission15-Sep-2019
Date of Acceptance21-Oct-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Fayazuddin Mohammed
Department of Vascular Surgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_76_19

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  Abstract 


Introduction: For creation of upper-limb arteriovenous fistula (AVF), international guidelines recommend a minimum diameter of 2 mm for artery and 2 mm/2.5 mm for vein. However, there are no large-scale studies in Indian patients whose stature and built is different compared to Western population. The aim of this study was to understand the upper-limb vessel diameters and their effect on AVF maturation in Indian patients. Methods: All consecutive patients who underwent AVF creation between November 2018 and May 2019 were included in the study. Demographics, upper-limb vessel diameter, type of surgery, and maturation rate at 6 weeks were recorded. Results: 129 patients were included with a mean age of 44 years (range, 18–80 years). Eighty-nine out of 129 patients (69%) were men. Overall, the mean diameter was 2.5 (range, 1–4.6 mm), 4.63 (range, 1.4–8.6 mm), 2.15 (range, 1–4.8 mm), and 3.13 mm (range, 1–6.8 mm) in the radial artery, brachial artery, and cephalic vein at wrist and elbow, respectively. In the 76 patients who underwent radiocephalic (RC) fistula, the mean diameter was 2.56 (range, 1.4–4.6 mm), 4.68 (range, 2.1–8.6 mm), 2.1 (range, 1–4.8 mm), and 3.0 mm (range, 1–5.9 mm) in the radial artery, brachial artery, and cephalic vein at wrist and elbow, respectively. In the 54 patients who underwent brachiocephalic (BC) fistula, the mean diameter was 2.3 (range, 1–4.3 mm), 4.5 (range, 1.4–6.9 mm), 1.6 (range, 1–3.6 mm), and 3.3 mm (range, 1.4–6.8 mm) in the radial artery, brachial artery, and cephalic vein at wrist and elbow, respectively. At 6 weeks, the maturation rate was 89.1% and 93.2% for RC and BC, respectively. Conclusion: The mean diameter of the cephalic vein at wrist and elbow was significantly less compared to Western population. Following the international guidelines would have taken away the opportunity to have a distal AVF in majority of the Indian patients requiring renal access patients 42 out 64 patients (65%).

Keywords: Arteriovenous fistula, maturation, vessel diameter


How to cite this article:
Mohammed F, Atturu G, Mahapatra S. Cross-sectional study of upper-limb vessel diameters and their association with arteriovenous fistula maturation in end-stage renal disease patients. Indian J Vasc Endovasc Surg 2019;6:278-82

How to cite this URL:
Mohammed F, Atturu G, Mahapatra S. Cross-sectional study of upper-limb vessel diameters and their association with arteriovenous fistula maturation in end-stage renal disease patients. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Feb 20];6:278-82. Available from: http://www.indjvascsurg.org/text.asp?2019/6/4/278/273603




  Introduction Top


India being the second most populous country of the world with a population of over 1.33 billion has seen an exponential increase in the incidence of diabetes mellitus and hypertension over the last 3 decades. Consequently, the incidence of renal diseases and the patients with end-stage renal disease (ESRD) has also increased. ESRD affects both quality and longevity of life. Approximately 100,000 patients develop ESRD each year. Vascular access is considered as a lifeline for chronic kidney disease (CKD) patients requiring renal replacement therapy. It is necessary for maintenance hemodialysis. Multiple national and international guidelines recommend arteriovenous fistulas (AVFs) as the best method for providing access.[1],[2],[3] A functional radiocephalic AVF (RC AVF) in the nondominant limb is generally considered the preferred option for creating a functional autologous vascular access for hemodialysis when appropriate vessels are present.[4] However, the successful use of AVFs can be limited by a failure of the fistulas to mature sufficiently to support dialysis therapy, with cited rates of maturation failure ranging from 20% to 60%.[5],[6],[7],[8] Various factors have been shown to affect early failure of AVFs, such as advanced patient age, female gender, artery and vein diameters, and presence of diabetes mellitus.[9] Thrombosis is one of the most common complications associated with autologous AVF. To improve the success rate of AVFs, preoperative vascular mapping by ultrasonography is now recommended,[1],[2],[3] which can be interpreted in conjunction with an assessment of preoperative vessel diameter.[10],[11],[12],[13] A minimum internal vessel diameter for both radial artery and cephalic vein of 2.0 mm using a proximal tourniquet is considered to be adequate for successful fistula creation and maturation. For brachiocephalic (BCAVF) and brachiobasilic (BBAVF) AVFs, a minimum arterial and venous diameter of 3 mm is sufficient.[14] However, there are no large-scale studies in Indian patients whose stature and built is different compared to Western population. The aim of this study is to understand the upper-limb vessel diameters and their effect on AVF maturation in Indian ESRD patients.


  Methods Top


This is a retrospective, cross-sectional, observational study involving patients who underwent primary AVF formation in our institute from November 2018 to May 2019. All adult (aged 18 and above) CKD patients who underwent RC or BC fistula were included in the study. Patients who underwent revision surgery, arteriovenous grafts, and BB vein fistulas were excluded. The case notes of these patients including scanned copies of the ultrasound report of upper-limb vessels were retrieved. Patient demographics, comorbidities, upper-limb vessel diameter, type of surgery done, and maturation rate at 6 weeks were recorded using electronic database. The arterial and venous diameters were measured anterioposteriorly (AP) at the wrist and elbow in the proposed side of surgery. All measurements were performed by the radiologists using a multifrequency linear transducer (7-12 MHz, Logiq V5 expert, GE). The protocol included examination in the ultrasound room with the patient in sitting position and tourniquet applied above the mid-arm with moderate pressure. The ultrasound probe was placed on the skin with minimal pressure to maintain the circular image of the vein. Patency and continuity of the artery and vein were assessed from the distal forearm to the upper arm. The AP diameter of the cephalic vein was measured 3 cm proximal to the wrist and at elbow. Similarly, the AP diameter of the radial artery was measured 3 cm proximal to the wrist and brachial artery diameter was measured at elbow. The right arm was only scanned if there were no suitable veins or if the patient had failed RC and BC fistula in the left arm. For the purpose of this study, ultrasound measurements done only on the side of surgery were taken. Patients who did not attend their follow-up appointment at 6 weeks were contacted by telephone. The AVF was considered to be matured if the patient underwent hemodialysis using the fistula for a minimum of 3 h on two consecutive dialysis sessions.

Statistical analysis

The results were analyzed using IBM-SPSS software version 24 (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.). Descriptive statistics were used to describe the demographics, comorbidities, side of surgery, upper-limb vessel diameter, and maturation rate. The continuous variable of cephalic vein diameter was grouped into veins <2 mm and more than 2 mm and compared with fistula maturation.


  Results Top


Case notes of 132 patients were studied; three patients were excluded from study as they were below 18 years. A total of 129 patients were included in this study. The mean age of the patients was 44 (range, 18–80). The procedure was performed on the left side in 119 patients (92.2%) and right side in 10 patients (7.8%). Seventy-six patients underwent RC fistula (58.9%) and 53 patients underwent BC fistula (41.1%). Variables of study and their frequencies are shown in [Table 1].
Table 1: Variables of study and their frequency

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Overall, the mean diameter of radial artery was 2.5 mm (standard deviation [SD] 0.6 and range, 1–4.6 mm), brachial artery was 4.63 mm (SD 1.1 and range, 1.4–8.6 mm), and cephalic vein at wrist was fibrosed or smaller than 1 mm in 18 patients. In the remaining 111 patients, the mean diameter was 2.15 (range, 1–4.8 mm). Cephalic vein at elbow was thrombosed/fibrosed in 5 patients, and in the remaining 124 patients, the mean diameter was 3.13 mm (range, 1–6.8 mm). The normal distribution of the diameters is shown in [Figure 1].
Figure 1: Histograms showing upper-limb vessel measurements

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For the purpose of analysis of maturation of AVF, patients who died and lost to follow-up were excluded and the remaining 108 patients were included. Ten out of the 108 fistulas failed to mature (9.3%). The remaining 98 fistulas (90.7%) fulfilled the criteria for maturation. The study characteristics are shown in [Figure 2].
Figure 2: Summary of the study

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Forty-four out of the 108 patients had BC fistula. Forty-one of them matured at 6 weeks (93.2%). The mean diameter of brachial artery in matured group was 4.5 mm whereas it was 4.2 mm in failed AVF group. The mean diameter of cephalic vein at elbow in matured group was 3.3 mm whereas it was 2.06 in failed AVF group. Chi-square test for independence (with Yates continuity correction) performed to assess the relation between cephalic vein diameter at elbow and BC fistula maturation did not show any significant difference in maturation between cephalic vein diameter at elbow <2.5 mm and more than 2.5 mm (P = 0.243). The mean vessel diameters and their association with AVF maturation are shown in [Table 2].
Table 2: Mean vessel diameters and their association with arteriovenous fistula maturation

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Sixty-four out of the 108 patients underwent radio cephalic fistula. Fifty-seven of them matured at 6 weeks (89.1%). The mean diameter of radial artery in matured group was 2.56 mm whereas it was 2.5 mm in failed AVF group. The mean diameter of cephalic vein at wrist in matured group was 2.1 mm whereas it was 1.14 mm in failed AVF group. Chi-square test for independence (with Yates continuity correction) performed to assess the relation between cephalic vein diameter at wrist and RC fistula maturation showed no significant difference in maturation between cephalic vein diameter at wrist <2.5 mm and more than 2.5 mm (P = 0.09). However, when the criteria of cephalic vein at wrist are changed to <2 mm or more than 2 mm, the association became significant with only 1 out of 38 fistulas done using cephalic vein diameter more than 2 mm failed. Similarly, there was no significant difference in maturation between radial artery <2 mm and more than 2 mm (P = 0.733).

Forty-two out 64 patients (65%) had cephalic vein <2.5 mm and/or radial artery <2 mm and following the international guidelines would have taken away the opportunity of distal AVF in these patients.


  Discussion Top


The most important factor that determines the resistance to blood flow in a vessel is the diameter of vessel. Poiseuille's equation describes that vessel resistance (R) is inversely proportional to the radius to the fourth power (r4). Diameters of artery and vein play a major role in successful outcome of AVF. The current study focused on arterial diameters and venous diameters in Indian population and their effect on maturation.

In our study, overall, the mean diameter of radial artery was 2.5 (range, 1–4.6 mm), brachial artery was 4.63 (range, 1.4–8.6 mm), cephalic vein at wrist was 2.1 (range, 1–4.8 mm), and cephalic vein at elbow was 3.1 mm (range, 1–6.8 mm).

In the present study, among 108 patients, 64 patients underwent RC fistula. In these patients, the mean diameter of radial artery was 2.56 (range, 1.4–4.6 mm) and cephalic vein at wrist was 2.07 (range, 1–4.8 mm), which is comparable to another Indian study conducted by Manne et al.,[15] in which the mean diameter of radial artery was 2.3 (range, 1.0–4.1 mm) and cephalic vein at wrist was 2.0 (range, 1.4–3.5 mm). Our study differs in these parameters from the study conducted in Western population by Kakkos et al.,[16] in which the mean cephalic vein diameter was 3.8 mm (range, 3.4–4.2 mm) and mean radial artery was 3.0 mm (range, 2.5–3.2 mm).

Vein diameters appear to be most important determinant in success of in RC AVF maturation. The mean diameter of cephalic vein at wrist in matured AVF was 2.1 mm whereas it was only 1.14 mm in failed RC AVF. Thus, success rate depends on cephalic vein diameter, but its diameter is less compared to Western population. Relation between cephalic vein diameter at wrist and RC fistula maturation showed significant difference in maturation between cephalic vein diameter at wrist <2 mm and more than 2 mm. Mendes analyzed 44 consecutive patients and he concluded that venous diameter of >2.0 mm had higher successful rate.[12]

Out of 108 patients, 44 patients underwent BC fistula. In them, the mean diameter of brachial artery was 4.5 (range, 1.4–6.9 mm), and cephalic vein at elbow was 3.21 mm (range, 1.4–6.8 mm), which is comparable to the study conducted by Manne et al.,[15] in which mean diameter of brachial artery was 4.0 (range, 2.5–6.8 mm) and cephalic vein at elbow was 2.75 mm (range, 1.5–5.0 mm). Our study differs with a study conducted in Western population by Kakkos et al.,[16] in which mean diameter of brachial artery was 4.8 (range, 4.1–5.6 mm) and cephalic vein at elbow was 4.4 mm (range, 3.8–5.1 mm). In BC AVF, also, the vein diameter appears to be most important determinant in success of BC AVF maturation. The mean diameter of cephalic vein at elbow in matured AVF was 3.3 mm whereas it was only 2.06 mm in failed RC AVF.

The Vascular Access 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery[14] states that a minimum internal vessel diameter for both radial artery and cephalic vein of 2.0 mm using a proximal tourniquet is adequate for successful fistula creation and maturation. For BCAVF and BBAVF, a minimum arterial and venous diameter of 3 mm is sufficient. By applying this criterion, 27 out of 64 (42%) of our RC AVF patients were not suitable for RC AVF. Out of these 27 patients, AVFs successfully matured in 21 (77.8%). Similarly, 27 out of 44 (61.4%) BC AVF patients were not suitable for BC AVF. Out of these 27 patients, AVFs successfully matured in 24 (88.8%).

As advised by many Western studies, criteria for vein diameter and arterial diameter are 2.5 mm and 2 mm, respectively, for AVF creation. By applying this criterion, 41 out of 64 RC AVF (64%) were not suitable for AVF, out of which 34 (82.9%) were matured. [Table 3] shows analysis of our results by applying various criteria.
Table 3: Analysis of our results by applying various criteria

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As depicted by above, by considering Western criteria, most of our patients not suitable for AVF as Indian population have lesser diameter compare to western population, but successful maturation rate is still higher with lesser diameters. Large-scale studies are required to evaluate diameters in Indian ESRD population and need for establishment of criteria for minimum diameters for creation of AVF.

One limitation that needs to be considered while interpreting our study is that all the Doppler measurements were done by a team of radiologist and not the operating surgeon.


  Conclusion Top


The mean diameter of the cephalic vein at wrist and elbow of Indian population was significantly less compared to Western population. Following the international guidelines would have taken away the opportunity to have a distal AVF in majority of the Indian patients requiring renal access patients 42 out 64 patients (65%).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Schinstock CA, Albright RC, Williams AW, Dillon JJ, Bergstralh EJ, Jenson BM, et al. Outcomes of arteriovenous fistula creation after the fistula first initiative. Clin J Am Soc Nephrol 2011;6:1996-2002.  Back to cited text no. 8
    
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Saucy F, Haesler E, Haller C, Déglise S, Teta D, Corpataux JM, et al. Is intra-operative blood flow predictive for early failure of radiocephalic arteriovenous fistula? Nephrol Dial Transplant 2010;25:862-7.  Back to cited text no. 9
    
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Mendes RR, Farber MA, Marston WA, Dinwiddie LC, Keagy BA, Burnham SJ. Prediction of wrist arteriovenous fistula maturation with preoperative vein mapping with ultrasonography. J Vasc Surg 2002;36:460-3.  Back to cited text no. 12
    
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Manne V, Vaddi SP, Reddy VB, Dayapule S. Factors influencing patency of brescia-cimino arteriovenous fistulas in hemodialysis patients. Saudi J Kidney Dis Transpl 2017;28:313-7.  Back to cited text no. 15
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Kakkos SK, Kaplanis N, Papachristou EC, Papadoulas SI, Lampropoulos GC, Tsolakis IA, et al. The significance of inflow artery and tourniquet derived cephalic vein diameters on predicting successful use and patency of arteriovenous fistulas for haemodialysis. Eur J Vasc Endovasc Surg 2017;53:870-8.  Back to cited text no. 16
    


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