Abstract
The oval-shaped arteriotomy technique for radiocephalic arteriovenous fistula creation was evaluated in 104 patients with end-stage renal disease from October 2023 to December 2024. Ninety-four percent had primary patency at 6 months, and 90% had maturation within 4 to 6 weeks. Early thrombosis was seen in 4%, and hematoma requiring evacuation was seen in 2%. There were no infections, steal syndrome, or aneurysmal changes. The median operative time was 42 minutes. The oval-shaped arteriotomy technique was shown to be technically feasible and effective and deserves to be compared in trials to confirm its value.
Keywords: Access, Arteriovenous fistula, End-stage renal disease, Hemodialysis, Oval arteriotomy, Primary patency
The global prevalence of end-stage renal disease (ESRD) is continuously rising, and the majority of patients depend on hemodialysis.1,2 International guidelines recommend autogenous arteriovenous fistulas (AVFs) as the preferred access, as they are more durable and have a lower risk of infection.3,4 The radiocephalic AVF described by Brescia and Cimino5 in 1966 has become a fundamental component of vascular access surgery.
Atherosclerosis causes stiffening and calcification of the arterial wall.6 In nonelastic arteries, a conventional longitudinal arteriotomy can radially collapse and cause stenosis and thrombosis.7,8 The oval-shaped arteriotomy (OSA) technique is an elliptical opening against the radial elastic recoil and provides a wider anastomotic channel.9 We report our institutional experience with OSA in a consecutive series.
Materials and methods
The study was conducted as a retrospective cohort study, according to the Strengthening the Reporting of Observational Studies in Epidemiology statement.10 The study was conducted in accordance with the Declaration of Helsinki. The study protocol was reviewed and approved by the Ethical Committee of the College of Medicine (approval no. 6/ECM/January 23) at the University of AlKafeel, Najaf, Iraq, from October 2023 to December 2024. All eligible consecutive patients aged 18 years or older with ESRD who were suitable for a radiocephalic AVF were enrolled, as shown in Fig 1.
Fig 1.
Patient flow diagram. Consolidated Standards of Reporting Trials-style flow diagram showing enrollment, follow-up completion, and outcomes for all 104 patients undergoing radiocephalic autogenous arteriovenous fistula (AVF) creation with oval-shaped arteriotomy (OSA). CI, Confidence interval.
Exclusion criteria included prior ipsilateral AVF, previous radial artery cannulation or trauma, active infection, severe coagulopathy (international normalized ratio >1.5 or platelets <50,000/μL), or unwillingness to consent. The modified Allen test confirmed palmar arch patency.11 Vein caliber was assessed by tourniquet application; acceptable veins demonstrated distention (>2.5 mm) in a straight, nontortuous course.12 Duplex ultrasound was not routinely available.
All 104 procedures were performed by a single surgeon. Under local anesthesia, a 2- to 3-cm longitudinal incision was made at the radiocarpal joint. The cephalic vein was mobilized 3 to 5 cm, ligated distally, cut obliquely, and dilated with heparinized saline. The radial artery was prepared to 2 cm and clamped. The OSA procedure comprised (1) a 2-mm initial incision with a no. 11 blade; (2) extension with microvascular scissors to create an elliptical opening (4-6 mm × 2-3 mm); (3) oblique venous division and alignment without tension; (4) end-to-side anastomosis by parachute technique with continuous 7-0 polypropylene; (5) venous clamp release for back bleeding; and (6) stepwise arterial clamp removal with thrill confirmation. Operative time was recorded from skin incision to closure, as in Fig 2, Fig 3, Fig 4.
Fig 2.
Schematic illustration of the oval-shaped arteriotomy (OSA) technique. A, Initial 2-mm longitudinal slit in the anterior radial artery wall. B, Extension into elliptical configuration using microvascular scissors. C, Final oval opening measuring 4 to 6 mm × 2 to 3 mm.
Fig 3.
Intraoperative photograph demonstrating the completed oval-shaped arteriotomy (OSA) in the radial artery, showing the broad, stable orifice resistant to elastic recoil.
Fig 4.
Intraoperative photograph showing the end-to-side anastomosis between the obliquely transected cephalic vein and the oval arteriotomy, constructed with continuous 7-0 polypropylene suture using the parachute technique.
Postoperatively, only two patients with palpable calcification received enoxaparin 40 mg for 3 days. Fistula maturation was assessed clinically at 2 weeks, 4 weeks, 3 months, and 6 months. The primary end point was 6-month patency, defined as uninterrupted patency without intervention (angioplasty, thrombectomy, or surgical revision), per Sidawy et al13 and Kidney Disease Outcomes Quality Initiative.3,4 Fistula patency was assessed clinically by palpable thrill and audible bruit; objective volume flow measurements (duplex ultrasound, transit time flowmetry, or other techniques) were not available. Secondary end points included complications, technical feasibility, maturation (defined as successful cannulation with two 16-gauge needles for two consecutive hemodialysis sessions), and operative time. Statistical analysis used descriptive statistics with exact 95% confidence intervals (Clopper-Pearson method). Continuous variables were presented as median (interquartile range [IQR]) or mean ± standard deviation.
Results
Of 104 consecutive patients, 98 (94%) completed 6-month follow-up. Six were lost: four relocated and two died of unrelated causes with functioning fistulas. The cohort was predominantly female (62%) with a mean age of 52.3 ± 10.4 years. Diabetes was present in 35%, and hypertension was present in 71%. Median ESRD duration was 18 months (IQR, 12-24). Estimated radial artery diameter was 2.5 to 3.5 mm by clinical palpation (Table).
Table.
Baseline patient characteristics (N = 104)
| Characteristic | Value | n (%) or median (IQR) |
|---|---|---|
| Total patients enrolled | 104 | — |
| Patients completing 6-month follow-up | 98 | 94% |
| Lost to follow-up | 6 | 6% (4 relocated, 2 died) |
| Age, years | 52.3 ± 10.4 | Range, 28-78 |
| Female sex | 64 | 62% |
| Body mass index, kg/m2 | 26.8 ± 4.2 | — |
| Diabetes mellitus | 36 | 35% |
| Hypertension | 74 | 71% |
| Coronary artery disease | 16 | 15% |
| Peripheral vascular disease | 8 | 8% |
| Smoking history | 24 | 23% |
| Duration of ESRD, months | 18 | IQR 12-24 |
| Prior temporary dialysis catheter | 56 | 54% |
| Hemoglobin, g/dL | 9.8 ± 1.4 | — |
| Platelet count, ×103/μL | 198 ± 62 | — |
| Estimated radial artery diameter, mm | 2.5-3.5 | Clinical estimate |
| Intraoperative radial artery calcification | 16 | 15% |
ESRD, End-stage renal disease; IQR, interquartile range.
The OSA technique was completed in all 104 procedures without conversion. Median operative time was 42 minutes (IQR, 35-52). Intraoperative radial artery calcification was identified in 15% (n = 16). All patients had a palpable thrill at declamping. Ninety-two percent were discharged the same day. There were no intraoperative complications.
All 98 completers achieved primary patency at 6 months (100%; 95% confidence interval [CI], 96.3%-100%). Sensitivity analysis assuming all six lost patients as failures yielded 94% (95% CI, 87.9%-97.9%). No patients underwent angioplasty or surgical revision.
Maturation at weeks 4 to 6 was achieved in 90% (95% CI, 83.0%-95.3%). Early thrombosis developed in 4% (days 9, 12, 15, and 18); none were salvaged by thrombectomy or surgical revision. Two patients (2%) required hematoma evacuation (days 2 and 3) with preserved patency. No infections, steal syndrome, or aneurysmal changes occurred. In subgroup analysis, diabetic patients (n = 36) achieved 94% patency, and patients with radial artery calcification (n = 16) achieved 88% patency. Median follow-up was 8 months (IQR, 7-10). No late complications occurred.
Discussion
This retrospective review of 104 consecutive ESRD patients demonstrates that the OSA technique for radiocephalic AVF creation is technically feasible, with a 6-month primary patency rate of 94% and low complication rates. These results align with historical data for conventional longitudinal arteriotomy (60%-80% primary patency at 6 months).14,15
The geometrical rationale for OSA warrants examination. In atherosclerotic arteries, a longitudinal incision may collapse radially, causing stenosis.7,8 The elliptical arteriotomy spreads tension over a greater circumference and avoids collapse at the circumference.9 Subgroup data show acceptable patency in patients with risk factors for AVF failure, including diabetes (94%) and radial artery calcification (88%). The elliptical configuration could be particularly helpful in rigid, calcified vessels. However, no objective vessel sizing was made, and the minimum arterial diameter for the safe application of OSA has not been established.
A well-described alternative is the diamond anastomosis, which requires more extensive mobilization and increases the technical complexity. The vascular punch technique demands specialized equipment. The OSA approach offers an intermediate answer, geometrically favorable, instrumentally easy (only standard microvascular scissors), and technically simple. We chose OSA as the easier option in our institution.
Limitations are retrospective design, single-center single-surgeon setting, absence of concurrent control group (most important drawback), lack of preoperative duplex ultrasound, short follow-up of 6 months (minimum standard for long-term assessment is 1 year), lack of intraoperative flow measurements (would have clarified shear stress patterns), unblinded assessment of outcomes, and the absence of objective volume flow measurements and reliance on clinical assessment (palpable thrill and audible bruit) rather than duplex scan-derived information, which may have led to overestimation of patency, as clinical assessment is less reliable than objective testing. Follow-up data at 1 year are being collected on this cohort.
The strongest evidence would be a prospective randomized trial comparing OSA with conventional longitudinal arteriotomy with the diamond anastomosis stratified by diabetes and calcification status with intraoperative flow measurements and duplex surveillance.15 Late patency patterns need to be clarified with extended follow-up of 1 to 2 years.14 Brachiocephalic and brachiobasilic configurations of OSA may broaden applicability.
Conclusions
Technical feasibility of the OSA technique for radiocephalic AVF creation in ESRD patients with 94% primary patency at 6 months and low complication rates. In patients with atherosclerotic radial arteries, OSA may be an alternative to conventional longitudinal arteriotomy. This requires confirmation through prospective comparative trials with extended follow-up.
Funding
None.
Disclosures
None.
Footnotes
The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
References
- 1.Pisoni R.L., Young E.W., Dykstra D.M., et al. Vascular access use in Europe and the United States: results from the DOPPS. Kidney Int. 2002;61:305–316. doi: 10.1046/j.1523-1755.2002.00117.x. [DOI] [PubMed] [Google Scholar]
- 2.Allon M., Robbin M.L. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int. 2002;62:1109–1124. doi: 10.1111/j.1523-1755.2002.kid551.x. [DOI] [PubMed] [Google Scholar]
- 3.Lok C.E., Huber T.S., Lee T., et al. KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1–S164. doi: 10.1053/j.ajkd.2019.12.001. [DOI] [PubMed] [Google Scholar]
- 4.Lok C.E., Sontrop J.M., Faratro R. Fistula First Initiative: advantages and pitfalls. Clin J Am Soc Nephrol. 2007;2:1043–1053. doi: 10.2215/CJN.01080307. [DOI] [PubMed] [Google Scholar]
- 5.Brescia M.J., Cimino J.E., Appel K., Hurwich B.J. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med. 1966;275:1089–1092. doi: 10.1056/NEJM196611172752002. [DOI] [PubMed] [Google Scholar]
- 6.Roy-Chaudhury P., Sukhatme V.P., Cheung A.K. Hemodialysis vascular access dysfunction: a cellular and molecular viewpoint. J Am Soc Nephrol. 2006;17:1112–1127. doi: 10.1681/ASN.2005050615. [DOI] [PubMed] [Google Scholar]
- 7.Wong V., Ward R., Taylor J., et al. Factors associated with early failure of arteriovenous fistulae for haemodialysis access. Eur J Vasc Endovasc Surg. 1996;12:207–213. doi: 10.1016/s1078-5884(96)80108-0. [DOI] [PubMed] [Google Scholar]
- 8.Lee T., Roy-Chaudhury P. Advances and new frontiers in the pathophysiology of venous neointimal hyperplasia and dialysis access stenosis. Adv Chronic Kidney Dis. 2009;16:329–338. doi: 10.1053/j.ackd.2009.06.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Chaudhary F.A., Parvez Z. A modified technique of basilic vein transposition for haemodialysis. J Coll Physicians Surg Pak. 2014;24:47–51. [PubMed] [Google Scholar]
- 10.von Elm E., Altman D.G., Egger M., et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453–1457. doi: 10.1016/S0140-6736(07)61602-X. [DOI] [PubMed] [Google Scholar]
- 11.Malovrh M. Native arteriovenous fistula: preoperative evaluation. Am J Kidney Dis. 2002;39:1218–1225. doi: 10.1053/ajkd.2002.33394. [DOI] [PubMed] [Google Scholar]
- 12.Silva M.B., Jr., Hobson R.W., 2nd, Pappas P.J. A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg. 1998;27:302–307. doi: 10.1016/s0741-5214(98)70360-x. [DOI] [PubMed] [Google Scholar]
- 13.Sidawy A.N., Spergel L.M., Besarab A., et al. The Society for Vascular Surgery: clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access. J Vasc Surg. 2008;48(5 Suppl):2S–25S. doi: 10.1016/j.jvs.2008.08.042. [DOI] [PubMed] [Google Scholar]
- 14.Al-Jaishi A.A., Oliver M.J., Thomas S.M. Patency rates of the arteriovenous fistula for hemodialysis: a systematic review and meta-analysis. Am J Kidney Dis. 2014;63:464–473. doi: 10.1053/j.ajkd.2013.08.023. [DOI] [PubMed] [Google Scholar]
- 15.Iguidbashian J., Imran R., Yi J.A. Maintenance and salvage of hemodialysis access. Surg Clin North Am. 2023 Aug;103:685–701. doi: 10.1016/j.suc.2023.05.004. [DOI] [PubMed] [Google Scholar]