Abstract
Cephalic arch stenosis (CAS) is critical point to maintain functional arteriovenous fistula (AVF) in patients undergoing hemodialysis with brachio-cephalic AVFs. In this study, we aimed to determine the effectiveness of dual outflow (cephalic and basilic veins) as a surgical method to prevent CAS. Between July 2016 and December 2019, 369 patients underwent upper arm AVF creation. Among them the 251 patients were enrolled in this retrospective study. Two hundred seven underwent brachio-cephalic arteriovenous fistula (BCAVF) and 44 underwent brachio-cephalicbasilic arteriovenous fistula (BCBAVF). From the 251 patients, diabetes mellitus (66.7% vs 36.4%, P < .001) and hypertension (91.3% vs 75%, P = .002) were more common in the patient group who underwent BCAVF surgery; however, the difference in volume flow to the fistula did not differ between the 2 groups. CAS (30.4% vs 9.1%, P = .004) and fistula occlusion (15.9% vs 4.5%, P = .048) were likely to occur in the BCAVF group. The primary patency rates at 12 months were 74.3% and 86.4% for the BCAVFs and BCBAVFs, respectively (P = .075). The primary-assisted patency rates at 12 months were 87.0% for BCAVFs and 93.2% for BCBAVFs, respectively (P = .145). Secondary patency rates at 12 months were 92.2% for BCAVFs and 93.2% for BCBAVFs, respectively (P = .023). Compared to BCAVF, traditional upper arm AVF, upper arm AVF with cephalic and basilic vein dual drainage can be optimal surgical method to preventing CAS.
Keywords: arteriovenous fistula, brachio-cephalic arteriovenous fistula, cephalic arch stenosis, dual outflow veins
1. Introduction
Autogenous arteriovenous fistula (AVF) is the preferred hemodialysis access because of its low infection and occlusion rates than those of prosthetic arteriovenous graft.[1] Radiocephalic arteriovenous fistulas (RCAVFs) have a lower primary maturation rate than brachiocephalic arteriovenous fistulas (BCAVFs); however, they are preferred because they are less likely to cause the steal phenomenon and have the advantage of preserving the proximal veins.[2] However, if RCAVFs are not available because of thrombotic occlusion, BCAVFs are used as a secondary option. Although Gracz-type fistula would be an alternative surgical option to prevent peripheral ischemia, BCAVFs are more commonly used as a secondary option.[3] Compared to RCAVFs, BCAVFs have higher volume flow and superior patency; however, steal syndrome and cephalic arch stenosis (CAS) are more prevalent than in RCAVFs. The incidence of CAS in BCAVFs can occur from 30% or more than that of RCAVFs, and is known to be a common cause of secondary failure of BCAVFs.[4,5]
CAS is caused by neointimal hyperplasia, attributed to numerous factors, especially turbulent blood flow, which can cause various clinical symptoms such as arm edema, prolonged bleeding control after dialysis and dialysis malfunction due to high venous pressure.[6] The 2 methods mainly used for the management of CAS are percutaneous transluminal balloon angioplasty (PTA) and surgical procedures. The kidney disease outcomes quality initiative guidelines for vascular access suggest that it is reasonable to use PTA for radiologically significant lesions in CAS, and that surgical management can be attempted if PTA is not possible.[1] However, there are no evidence-based strategies for CAS prophylaxis or treatment methods, and further studies are needed to explain the selection of appropriate approach for recurrent stenosis. This study aimed to determine the effectiveness of upper arm AVF formation using dual outflow, which both cephalic and basilic vein as outflow as a surgical method to prevent CAS.
2. Materials and methods
Between July 2016 and December 2019, we retrospectively reviewed patients with upper arm AVF at our hospital. During this period, 369 patients had upper arm AVF, and 251 patients who were followed-up participated in this study by December 2021. Among them, 207 patients underwent BCAVFs and 44 patients underwent brachio-cephalic-basilic arteriovenous fistulas (BCBAVFs). Using a retrospective review of electronic medical records, we collected the clinical data, procedural reports, demographic characteristics, treatment modalities, patency, and procedure-related complications. This study was approved by Institutional Review Board of the Jeonbuk National University Hospital (2022-01-019).
AVF surveillance was performed using duplex ultrasonography at 4 and 8 weeks after vascular access creation, and further follow-up was performed in cases of suspected vascular access-related problems. Fistulography was planned when hemodynamic venous stenosis was suspected based on duplex ultrasonography. Cephalic arch stenosis was defined as > 50% stenosis of the cephalic arch diameter. Additional treatment was planned if the flow volume decreased by more than 25% compared to the previous examination, venous pressure increased, severe arm swelling with complaint of shoulder pain, poor puncture site hemostasis, or fistula thrombotic occlusion.
Both BCAVF and BCBAVF were performed under local anesthesia in a standardized manner. An incision was made in the antecubital area. The antecubital vein and brachial artery were carefully dissected, and a vessel loop was used to control these vessels. We did not routinely perform intravenous heparin administration in autologous fistula surgery. In the case of a BCBAVF, if there was an antecubital vein that could anatomically be used together with the upper arm cephalic and basilic vein as drainage veins, the antecubital vein was anastomosed end-to-side the brachial artery. If the upper arm cephalic vein was not expected to mature sufficiently for dialysis, or if the basilic vein was not available, BCAVF was performed to anastomose the cephalic vein with the brachial artery. (Figs. 1 and 2) Access patency was verified and reported according to the reporting standards of the Society for Vascular Surgery.[7]
Figure 1.
Intraoperative BCBAVF procedure. End-to side anastomosis was performed with brachial artery and antecubital vein below the junction of the cephalic and basilic vein. BCBAVF = brachiocephalicbasilic arteriovenous fistula.
Figure 2.
Schematic diagram of the selection of BCBAVF and BCAVF. BCAVF is likely to cause CAS due to high blood flow in the upper cephalic vein using single drainage vein, however, BCBAVF can prevent CAS by dual drainage with cephalic and basilic vein. BCAVF = brachio-cephalic arteriovenous fistula, BCBAVF = brachiocephalicbasilic arteriovenous fistula, CAS = cephalic arch stenosis.
Continuous data were summarized as mean ± standard deviation or median with range and compared using the t test or Mann–Whitney test. Categorical data were summarized as proportions and percentages and compared using the chi-square test or Fisher exact test. Statistical analysis was performed using SAS, version 9.4 (SAS Institute, Cary, NC). All P values of < .05 were considered statistically significant. The Kaplan–Meier analysis was used to calculate fistula survival rates.
3. Results
Of the 251 patients, 207 (82.5%) underwent BCAVF and 44 (17.5%) underwent BCBAVF creation, respectively. The baseline characteristics of the patients with upper cephalic vein AVF are outlined in Tables 1 and 2.
Table 1.
Baseline characteristics of the patients.
| Total | Brachio-Cephalic fistula | Brachio-Cephlic-basilic fistula | P value | |
|---|---|---|---|---|
| (n = 251) | (n = 207) | (n = 44) | ||
| Clinical characteristics | ||||
| Age, mean ± SD (yr) | 61 ± 12.8 | 61.8 ± 13.1 | 57.4 ± 11.2 | .015 |
| Male, n (%) | 140 (55.8) | 109 (52.7) | 31 (70.5) | .031 |
| Cormorbidities | ||||
| Diabetes mellitus, n (%) | 154 (61.4) | 138 (66.7) | 16 (36.4) | <.001 |
| Hypertension, n (%) | 222 (88.4) | 189 (91.3) | 33 (75) | .002 |
| Hyperlipidemia, n (%) | 16 (6.4) | 11 (5.3) | 5 (11.4) | .298 |
| Smoking, n (%) | 5 (2) | 5 (2.4) | 0 (0) | .590 |
| Cause of CKD | ||||
| Glomerular nephritis, n (%) | 6 (2.4) | 5 (2.4) | 1 (2.3) | 1.000 |
| Polycystic kidney disease, n (%) | 5 (2) | 2 (1) | 3 (6.8) | .039 |
| Nephrotic syndrome, n (%) | 4 (1.6) | 4 (1.9) | 0 (0) | 1.000 |
| Ig A nephropathy, n (%) | 2 (0.8) | 2 (1) | 0 (0) | 1.000 |
| Unknwon, n (%) | 15 (6) | 9 (4.3) | 6 (13.6) | .030 |
| Medication | ||||
| Aspirin, n (%) | 75 (29.9) | 62 (30) | 13 (29.5) | .957 |
| Clopidogrel, n (%) | 23 (9.2) | 20 (9.7) | 3 (6.8) | .775 |
| Cilostazol, n (%) | 10 (4) | 8 (3.9) | 2 (4.5) | .689 |
| Berasil, n (%) | 0 (0) | 0 (0) | 0 (0) | . |
| Warfarin, n (%) | 1 (0.4) | 1 (0.5) | 0 (0) | 1.000 |
CKD = chronic kidney disease, Ig A = immunoglobulin A, SD = standard deviation.
Table 2.
Preoperative and postoperative values of the patients.
| Total | Brachio-Cephalic fistula | Brachio-Cephlic-Basilic fistula | P value | |
|---|---|---|---|---|
| (n = 251) | (n = 207) | (n = 44) | ||
| Preoperative values | ||||
| Artery diameter, mean ± SD (mm) | 3.7 ± 0.6 | 3.7 ± 0.6 | 3.7 ± 0.6 | .949 |
| Arterial atheroma, n (%) | 167 (66.5) | 138 (66.7) | 29 (65.9) | .923 |
| Vein diameter, mean ± SD (mm) | 2.7 ± 0.4 | 2.7 ± 0.4 | 2.7 ± 0.3 | .406 |
| Postoperative values | ||||
| Flow, mean ± SD (cc/min) | 863 ± 448.3 | 878.8 ± 453.7 | 792.6 ± 421.3 | .198 |
| Cephalic arch stenosis, n (%) | 67 (26.7) | 63 (30.4) | 4 (9.1) | .004 |
| Cephalic arch occlusion, n (%) | 35 (13.9) | 33 (15.9) | 2 (4.5) | .048 |
| Cephalic vein stenosis, n (%) | 77 (30.7) | 66 (31.9) | 11 (25) | .369 |
| Steal syndrome, n (%) | 1 (0.4) | 0 (0) | 1 (2.3) | .175 |
| Immature, n (%) | 31 (12.4) | 24 (11.6) | 7 (15.9) | .430 |
SD = standard deviation.
The baseline characteristics in Table 1 demonstrate a similar cause comprising of chronic kidney disease, medication history, and preoperative vessel values. However, more patients in the BCAVFs group were treated for diabetes mellitus (66.7% vs 36.4%, P < .001) and hypertension (91.3% vs 75%, P = .002). Table 2 shows preoperative and postoperative characteristics of fistula. There was no significant difference in the blood flow rate in the AVF between the 2 groups; however, more cephalic arch stenosis (30.4% vs 9.1%, P = .004) and occlusion (15.9% vs 4.5%, P = .048) occurred in patients with BCAVF. Steal syndrome and immature fistula rates were not significantly different between the 2 groups.
A total of 207 patients with BCAVFs and 44 with BCBAVFs were analyzed to assess patency. With a mean follow-up of 35 ± 24 months, the primary patency rates at 12 months were 74.3% and 86.4% for BCAVFs and BCBAVFs, respectively (P = .075). The primary-assisted patency rates at 12 months were 87.0% for BCAVFs and 93.2% for BCBAVFs (P = .145). Secondary patency rates at 12 months were 92.2% for BCAVFs and 93.2% for BCBAVFs (P = .023). (Fig. 3.)
Figure 3.
Kaplan–Meier curves for primary patency (A), primary-assisted patency (B), and secondary patency (C) for BCAVF and BCBAVF patients. BCAVF = brachio-cephalic arteriovenous fistula, BCBAVF = brachiocephalicbasilic arteriovenous fistula.
Analysis of the postoperative progress of patients who underwent BCBAVFs revealed that 4 patients required additional procedures to start hemodialysis using AVFs after BCBAVF. These patients were able to undergo basilic vein transposition surgery and initiate dialysis because the maturation of the upper cephalic vein was incomplete after BCBAVF. In addition, 4 patients underwent PTA due to CAS during dialysis maintenance after BCBAVF, and 2 patients underwent cephalic vein transposition for fistula revision.
4. Discussion
Hemodialysis patients require not only proper AVF formation, but also appropriate maintenance treatment to minimize morbidity and mortality related to dialysis maintenance. BCAVF is an important secondary surgical procedure for patients with difficulty in distal AVF maturation and with small sized forearm cephalic vein. Based on previous literature, the most common cause of BCAVF malfunction is CAS, occurring in approximately 4% to 64% patients.[4,5,8] In addition, it has been reported that the primary patency rate falls to < 23% within 1 year after the occurrence of CAS.[9] However, it is not negligible, and surveillance of the cephalic arch is an important issue.
The pathophysiology of cephalic arch stenosis is poorly understood. However, several mechanisms have been proposed, incluidng altered blood flow, extrinsic compression of the cephalic vein by the fascia and pectoralis major muscles and intimal hyperplasia.[10] Changes in the blood flow are associated with an increased risk of cephalic arch malfunction. Laminar blood flow induces high shear stress, which promotes the survival of endothelial cells, prevents neointimal hyperplasia, and helps preserve AVF function.[11] In contrast, low shear stress and turbulence promotes blood vessel contraction, coagulation, platelet aggregation changes, proliferation, and apoptosis of endothelial cells. Arthur Miller et al[12] demonstrated that the rate of cephalic arch intervention per access year decreased from 3.34 to 0.9 by reducing the AVF flow rates in patients with CAS, who underwent banding procedure for this mechanism. The cephalic vein travels deep into the deltopectoral and clavipectoral fascia, compressing the cephalic arch, and preventing dilatation. This mechanism causes venous compression to interfere with proper shear stress and produce turbulent flow, thereby increasing venous pressure. These pathophysiological mechanisms ultimately lead to endothelial damage, hyperplasia, and clinically significant CAS.[6,13] Intimal hyperplasia is associated with CAS. High plasma levels of proinflammatory proteins such as interleukin 6, platelet derived growth factor and monocyte chemoattractant protein 1 in hemodialysis patients promote neointimal changes and vascular smooth muscle hyperplasia. This also explain the recurrent CAS.[14–18]
The kidney disease outcomes quality initiative guidelines provide several guidelines for CAS treatment along with the recently published paper by the American Society for Diagnostic and Interventional Neurology.[19] They recommend PTA with or without stent graft insertion, surgical repair of blood flow reduction, and cephalic vein transposition based on the AVF flow rates.[1]
Percutaneous balloon angioplasty is the first-line treatment for venous stenosis in patients undergoing hemodialysis. Many previous studies have mentioned the usefulness of conventional balloon angioplasty as a treatment for CAS,[4,20–25] and new technologies are being developed. However, this can lead to vessel wall injury, intimal hyperplasia, and venous stenosis.[26] In addition, many studies have mentioned the usefulness of stents or stent graft implantation as an additional treatment for recurrent fistula stenosis. It can be effective as a treatment methods for stenotic lesions; however, it can cause complications such as stent rupture, migration, in-stent restenosis with intimal hyperplasia, and restenosis at the edge of the stent graft, these limitations therefore prevent its widespread utility as a clear treatment modality for CAS patients.[21,22,27] In most cases, CAS treatment is clinically determined based on obvious symptoms. Even with standard treatment, CAS recurrence occurs frequently after PTA, and the primary patency rates is lower than 20%.[9]
Surgical intervention can be effective in terms of long-term patency of the fistula when PTA is limited by the recurrent nature of CAS and fistula recoiling. High blood flow in the fistula is a potential cause of CAS recurrence, and Miller et al suggested therapeutic flow reduction surgery. Arthur Miller et al[12] performed fistula banding using a balloon-assisted technique to reduce blood flow in 33 patients with recurrent CAS, and confirmed that the rate of cephalic arch intervention reduced from 3.34 to 0.9 per access year (P < .001). Another surgical strategy is cephalic vein transposition (CVT). CVT surgically ligates the cephalic vein at the deltopectoral groove and transposes the remaining segment to the distal axillary or jugular veins. Although there is a limit to the small number of patients enrolled, several retrospective studies have demonstrated that CVT can be an effective treatment method due to its higher patency rate and lower re-intervention rate than that of CAS angioplasty.[28–30] Although PTA is considered the first-line treatment for CAS, CVT should also be considered as an initial treatment for CAS, depending on the appropriate clinical aspects of patients and fistulas, owing to its low re-intervention rate.
Appropriate AVF formation surgery for preventive blood flow reduction procedures above a certain threshold is performed from the beginning, and a well-defined monitoring program for AVF management is employed. It expected that avoiding additional interventional procedures or surgery and maintaining AVF patency will be possible. In this study, the primary and primary-assisted patency of BCBAVF and BCAVF showed no significant difference. While BCBAVF should not be a surgical method that can completely prevent recurrent CAS, it is an optional modality to prevent long-term AVF stenosis or occlusion to some extent because it exhibited significantly superior results over BCAVF in secondary patency (P = .023) in our study.
This study, presenting a preventive surgical method for CAS, has several limitations. The first limitation stems from the fact that it was a retrospective study conducted in a relatively small number of patients, and in particular, the small number of patients in the BCBAVF group, which is the comparison target of this study, can act as the biggest bias. There is also a limitation in that the number of female patients in the BCAVF group was significantly high (47.3% vs 29.5%, P = .031) due to selection bias of retrospective study, which may make female patients more prone to AVF failures. In future, additional research in collaboration with more patients and multiple centers is needed. In addition, owing to the anatomical diversity of cephalic vein drainage, the dual drainage procedure cannot be applied to all patients who required AVF. For the dual drainage procedure, the vein, before branching into the upper cephalic and basilic veins, must be anastomosed to the brachial artery in the antecubital area. However, this surgical method cannot be used if the veins are not available in that area because of the patient’s anatomical variation. Finally, parametric measurements such as vein diameters and blood flow for each of the drainage cephalic and basilic veins may be essential to quantitatively predict the CAS prevention effects caused by the dual drainage method. However, this study has an important limitation in that quantitative analysis is impossible because the above parameters cannot be measured intentionally owing to the vulnerability of retrospective studies.
5. Conclusion
As CAS is the main cause of AVF malfunction in upper arm AVFs, careful evaluation of the cephalic arch during follow-up is required during surveillance, and it is also necessary to consider methods to prevent it. Several treatment methods, such as PTA and surgical bypass, have been described previous studies. However, in situations where a clear method to prevent CAS is ambiguous, the dual drainage method presented in this study may be an effective surgical method to prevent CAS to some extent.
Acknowledgments
This paper was supported by Fund of Biomedical Research Institute, Jeonbuk National University Hospital.
Author contributions
Conceptualization: Hong Pil Hwang, Byeounghoon Chung.
Data curation: Byeounghoon Chung.
Investigation: Hong Pil Hwang, Mi Rin Lee.
Methodology: Hong Pil Hwang.
Project administration: Jae Do Yang.
Resources: Hee Chul Yu.
Supervision: Hee Chul Yu.
Software: Jae Do Yang.
Validation: Mi Rin Lee.
Writing – original draft: Hong Pil Hwang, Byeounghoon Chung.
Writing – review & editing: Hong Pil Hwang, Byeounghoon Chung.
Abbreviations:
- AVF
- arteriovenous fistula
- BCAVF
- brachio-cephalic arteriovenous fistula
- BCBAVF
- brachiocephalicbasilic arteriovenous fistula
- CAS
- cephalic arch stenosis
- CVT
- cephalic vein transposition
- PTA
- percutaneous transluminal balloon angioplasty
- RCAVFs
- radiocephalic arteriovenous fistulas
All data generated or analyzed during this study are included in this published article [and its supplementary information files].
The authors have no funding and conflicts of interest to disclose.
How to cite this article: Hwang HP, Yu HC, Do Yang J, Lee MR, Chung BH. Dual outflow upper arm arteriovenous fistula: An effective technique to prevent cephalic arch stenosis. Medicine 2023;102:48(e36419).
Contributor Information
Hong Pil Hwang, Email: h2p@jbnu.ac.kr.
Hee Chul Yu, Email: hcyu@jbnu.ac.kr.
Jae Do Yang, Email: hirojawa@jbnu.ac.kr.
Mi Rin Lee, Email: sofkin3732@gmail.com.
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