title: Microsurgery and preventive haemostasis for autogenous radial-cephalic direct wrist access in adult patients with radial artery internal diameter below 1.6 mm.
abstract: BACKGROUND
  Autogenous radial-cephalic direct wrist arteriovenous fistula (RCF), the gold standard for chronic dialysis, suffers from an elevated early failure rate (up to 20-50% with a pooled rate of 15.3%). Guidelines indicate that a small radial artery internal diameter (<1.6-2 mm) is strongly predictive of this early failure. Microsurgery and preventive haemostasis have been reported to give excellent results in a paediatric population (children <10 kg bw) and have shown a much lower early failure rate of 5-10%. Given these excellent results, we have used microsurgery along with preventive haemostasis in adult patients. We herein describe the results of RCF created in patients with a radial artery internal diameter <1.6 mm.
  
  
  METHODS
  From November 2004 to December 2007, 28 RCFs were created in 28 patients with a distal radial artery internal diameter <1.6 mm using microsurgery and preventive haemostasis. The median age was 68 and the male/female ratio was 6/22. The incidence of age >65 years was 64%, hypertension 96%, diabetes 32.1%, obesity (BMI>30) 35%, vascular disease 46%. The mean distal radial artery and cephalic vein internal diameters, measured with ultrasound examination, were 1.3 mm and 1.9 mm, respectively. Seventy-five percent of the patients were not yet on dialysis treatment; 19% of whom had a previous failed vascular access created elsewhere without microsurgery. The remaining 25% patients were on dialysis treatment with a temporary femoral catheter.
  
  
  RESULTS
  All interventions ended with a patent anastomosis; no thrombosis occurred within the initial 24 h. The early failure rate was 14% (4 out of 28 patients). The causes of early failure were thrombosis >1 week after surgery in one patient, lack of maturation (patent but unfunctional fistula) due to juxta-anastomotic vein stenosis in two patients and mid-vein stenosis in one patient. Treatment for all patients was proximalization of the anastomosis at the distal/mid forearm. Primary patency and secondary patency at 1 year were 68 +/- 10% and 96 +/- 5%, respectively.
  
  
  CONCLUSIONS
  From our findings, we have shown that it is possible to create RCF in adult patients with a radial artery internal diameter of <1.6 mm with an acceptable risk of early failure rate using microsurgery along with preventive haemostasis.
authors.affiliation: Department of Clinical Science, Division of Nephrology and Dialysis University La Sapienza, Rome, Italy. n.pirozzi@tiscali.it
authors.forename: Nicola
authors.initials: N
authors.lastname: Pirozzi
authors.forename: Francesca
authors.initials: F
authors.lastname: Apponi
authors.forename: Antonello M
authors.initials: AM
authors.lastname: Napoletano
authors.forename: Remo
authors.initials: R
authors.lastname: Luciani
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Pirozzi
authors.forename: Francesco
authors.initials: F
authors.lastname: Pugliese
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000379:methods; D005260:Female; D006488:Hemostasis, Surgical; D006801:Humans; D008297:Male; D008866:Microsurgery; D017534:Radial Artery / Q000033:anatomy & histology / Q000601:surgery*