A Long term study for upper limb arterio-venous fistula creation for hemodialysis at a tertiary level hospital in Eastern India

Introduction The incidence of renal failure is gradually increasing in India. These patients need renal replacement therapy. Renal replacement therapy is provided in the form of dialysis and renal transplant. As the survival after renal failure is increasing because of the availability of renal replacement therapy, there is increased demand for angio access. For temporary angio access central double lumen catheter is passed either into an internal jugular, subclavian or common femoral vein. The most frequent complications of central venous catheter include infection and thrombosis; therefore this access is not recommended. Arteriovenous fistula can be made either at the anatomical snuffbox or the distal, mid or proximal forearm. Sometimes polytetrafluorethylene grafts are placed between the artery and the vein because of the non-availability of good length veins in the superficial tissue. Arterio venous grafts have a high rate of thrombosis and infection. The fistula provides the best outcome. An arteriovenous fistula is created by a surgical anastomosis between and artery and vein. When a fistula is created the vein and artery may be in their normal positions, or the distal end of the vein is moved to a position that is better located for cannulation (vein transposition). A translocation is done when the entire vein is moved from one anatomic location to another requiring an arterial and venous anastomosis. The fistula with the best outcome is the lower arm Radiocephalic Fistula. However this access often fails to mature in the elderly patient with underlying vascular disease, particularly in diabetics [1]. The second recommended fistula is the upper arm brachiocephalic fistula [2]. This type of fistula is being placed with increased frequency because of the high failure rate of Radio cephalic Fistula. The third recommended fistula is the Brachiobasilic fistula [3]. The Radio Background: There is gradual increase in need for hemodialysis, as there is gradual increase in the end stage renal disease in India. Permanent vascular access in the patient with end stage renal disease on hemodialysis is provided through a central venous catheter, arteriovenous graft, or arteriovenous fistula. The aim of this study was to evaluate the site, results and postoperative complications of arteriovenous fistula creation in our hospital. Method: It was a retrograde study conducted at Seth Sukhlal Karnani Memorial (SSKM) hospital, Institute of Post-Graduate Medical Education and Research (IPGMER), Kolkata, between 1st July 2006 and 30th August 2011. All patients, with end stage renal disease requiring long term vascular access for haemodialysis, were included in the study. In most of the patients radio-cephalic fistulae were created in the left forearm, in some on right forearm, just above the wrist joint, and in some patients brachiocephalic or brachiobasilic arteriovenous fistulae were created. Results: 375 patients were studied; 292 (77.86%) males and 83(22.14%) females, with male to female ratio of 3.52:1. Distribution of co-morbid factors showed diabetes in 225 (60.0%), hypertension in 150 (40%) patients. Radio-cephalic fistula was done in 295 patients and brachiocephalic fistula in 80 patients. In 5% dominant hand was used and for remaining 95% of the patients fistula was created on non-dominant hand. Arterio-venous fistula was successful at 6 weeks in 95%, at 2 years in 90% and at 5 years in 85% patients. In 5% cases, failure in first 6 weeks was because of primary failure or wound infections and at 2-5 years failure due to stenosis of cephalic vein by repeated punctures and thrombosis. In failed patients re-do procedure was carried out successfully at another (cubital) site. Conclusion: Radio-cephalic arteriovenous fistula in patients with end stage renal disease requiring long term vascular access for haemodialysis remains the procedure of choice if done by experienced hands.