Prospective evaluation of failure modes in autogenous radiocephalic wrist access for haemodialysis

Abstract

Introduction: Radiocephalic wrist arteriovenous fistulae (RCAVF) are the primary and best option for vascular access for haemodialysis treatment. However, 10-24% of these AVFs fail due directly to thrombosis and non-maturation. In a prospective study, the failure modes of radiocephalic AVFs and the impact of surgical and interventional treatment on fistula outcome were investigated.

Methods: The rate of thrombosis and non-maturation was evaluated in 43 RCAVFs. The selection of RCAVF creation was made on preoperatively determined duplex parameters. Fistula function was evaluated post-operatively by clinical examination and non-invasively measured AVF blood flow. A policy of a liberal use of radiological and/or surgical revision of non-functioning RCAVFs was made on the basis of duplex measured blood flow and angiographically detected vessel stenosis.

Results: Primary fistula function was achieved in 26 of 43 patients (60%). Non-maturation and thrombosis occurred in 14 (33%) and three (7%) patients, respectively. A total of 12 interventions (PTA 6; surgery 6) were needed, resulting in salvage of eight RCAVFs (47%). The blood flow in functioning AVFs was significantly higher compared to non-functioning AVFs at 1 (754 vs 440 cc/min), 7 (799 vs 524 cc/min) and 42 days (946 vs 532 cc/min) post-operatively. At the end, 34 RCAVFs (79%) became functional as vascular access for haemodialysis treatment.

Conclusion: Primary RCAVFs have a high rate of failure. An aggressive approach towards early interventional treatment of these non-functional AVFs is worthwhile and leads to a considerable salvage rate. Early post-operative AVF flow measurement indicates the chance of successful maturation of RCAVF.