High brachial artery bifurcation is associated with failure of brachio-cephalic autologous arteriovenous fistulae.
OBJECTIVE
Although European Best Practice Guidelines on vascular access recommend universal pre-operative duplex scan in patients receiving brachio-cephalic (BC) arteriovenous fistulae (AVF), this is not widespread practice. Furthermore, cadaveric and angiographic studies suggest that variation in upper limb arterial anatomy is common. Our aim was to investigate the prevalence of high brachial artery bifurcation (HB) and its impact on BC AVF patency.


METHODS
A retrospective analysis of consecutive autologous BC AVF created over an 18-month period (January 2008 to June 2009). Patients with high bifurcations identified at duplex scan were compared with a control group who had normal bifurcations. All patients were followed up at 1, 6 and 12 weeks post-operatively. The study endpoint was AVF patency.


RESULTS
One hundred and five autologous BC AVF procedures were performed in our institution, of which 29 (27.6%) were identified as having a high brachial bifurcation on pre-operative duplex scan. The bifurcation was axillary in six patients and located at the proximal, middle and distal third of the humerus in nine, seven and seven patients, respectively. The actuarial functional patency rate was 53.2% (standard error = 9.6%) in the HB group and 76.2% (standard error = 4.9%) in the control group (log-rank test, p=0.027).


CONCLUSIONS
These data show that aberrant brachial artery anatomy is both common (12%) and a predictor of autologous BC AVF failure. These data support the universal use of pre-AVF duplex scanning.
Department of Vascular Surgery, King's College Hospital, London, UK.
Christos
C
Lioupis
Hiren
H
Mistry
Cornelia
C
Junghans
Niamh
N
Haughey
Ben
B
Freedman
Mark
M
Tyrrell
Domenico
D
Valenti
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D001916:Brachial Artery / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D016121:Brachiocephalic Veins / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D016009:Chi-Square Distribution; D005260:Female; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008131:London; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D006435:Renal Dialysis; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D017211:Treatment Failure; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency