title: Correlation of pre-existing radial artery macrocalcifications with late patency of primary radiocephalic fistulas in diabetic hemodialysis patients.
abstract: OBJECTIVE
  The aim of this study was to evaluate the impact of pre-existing radial artery macrocalcification (Mönckeberg type of arteriosclerosis) on patency rates of radiocephalic fistulas (RCFs) in diabetic end-stage renal disease (ESRD) patients undergoing hemodialysis.
  
  
  METHODS
  In this observational prospective study, the long-term patency rates (primary outcome measures) of RCFs in ESRD diabetics who had Mönckeberg radial (±brachial) artery disease (calcified [C] group) were compared with those obtained in ESRD diabetics who had healthy, noncalcified vessels before RCF construction (healthy [H] group). Vessel calcification was assessed by plain two-dimensional radiography. For inclusion in the C-group, uniform linear railroad track-type macrocalcifications of at least 6 cm in length, in the medial wall of the radial artery ipsilateral to RCF creation, were required. Patients were included in the H-group if the radial artery ipsilateral to the RCF creation was free of any macrocalcification, of either intima or media type. Any intimal-like plaque with irregular and patchy distribution was an exclusion criterion for both groups. Patients in both groups also were required to have suitable upper limb vascular anatomy on the basis of ultrasound imaging before RCF creation (cephalic vein of minimum diameter of 1.6 mm, without stenosis or thrombosis in all outflow areas, and radial artery of minimum diameter of 1.5 mm, without proximal hemodynamically significant stenosis). Secondary outcome measures included all-cause mortality. Kaplan-Meier statistics were used for comparison between groups.
  
  
  RESULTS
  The arm radiograph at the site of possible fistula construction showed abnormality in 39 patients (C-group, 47 RCFs), whereas 33 patients had noncalcified ("healthy") vascular anatomy (H-group, 40 RCFs). Mean duration of the diabetic disease at the time of RCF creation was 8.9 ± 5.6 years (range, 2-25 years) for the H-group and 14 ± 9.9 years (range, 1-40 years) for the C-group (P = .018). The mean follow-up period for H-group and C-group was 51.9 ± 35.9 months (range, 0.1-126 months) and 26.1 ± 31.6 months (range, 0.1-144 months), respectively (P = .0006). Forty-four patients died during the follow-up period. Primary patency rates at 12, 24, 36, and 48 months for C-group vs H-group were 50.2% vs 80%, 36.5% vs 72.3%, 32.4% vs 67.9%, and 29.1% vs 59.3% (P = .0019). Respective values for secondary patency rates were 52.4% vs 87.5%, 40.9% vs 82.4%, 36.6% vs 78.1%, and 33.2% vs 72.8% (P = .00064). Patient survival rates at 24 and 48 months were 56.1% and 46.4% for C-group and 92.4% and 67.4% for H-group, respectively (P = .05).
  
  
  CONCLUSIONS
  ESRD diabetics with radial artery Mönckeberg calcifications receiving RCFs had worse late clinical outcomes compared with ESRD diabetics with healthy distal arm vessels receiving the same access. The long-term benefit of RCFs may be lost in diabetics with extensively calcified vessels, and preferably the brachial artery should be used instead.
authors.affiliation: Department of Vascular Surgery, Demokritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece. Electronic address: ggeorgia@med.duth.gr.
authors.forename: George S
authors.initials: GS
authors.lastname: Georgiadis
authors.affiliation: Department of Vascular Surgery, Demokritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece.
authors.forename: Efstratios I
authors.initials: EI
authors.lastname: Georgakarakos
authors.affiliation: Department of Vascular Surgery, Demokritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece.
authors.forename: George A
authors.initials: GA
authors.lastname: Antoniou
authors.affiliation: Department of Nephrology, Demokritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece.
authors.forename: Stelios
authors.initials: S
authors.lastname: Panagoutsos
authors.affiliation: Department of Vascular Surgery, Demokritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece.
authors.forename: Christos
authors.initials: C
authors.lastname: Argyriou
authors.affiliation: Department of Nephrology, Demokritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece.
authors.forename: Efthimia
authors.initials: E
authors.lastname: Mourvati
authors.affiliation: Department of Nephrology, Demokritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece.
authors.forename: Ploumis
authors.initials: P
authors.lastname: Passadakis
authors.affiliation: Department of Vascular Surgery, Demokritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece.
authors.forename: Miltos K
authors.initials: MK
authors.lastname: Lazarides
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects* / Q000401:mortality; D016009:Chi-Square Distribution; D003928:Diabetic Nephropathies / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D005260:Female; D006083:Graft Occlusion, Vascular / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D050380:Monckeberg Medial Calcific Sclerosis / Q000150:complications* / Q000401:mortality / Q000503:physiopathology; D011446:Prospective Studies; D017534:Radial Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D011859:Radiography; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography; D034941:Upper Extremity / Q000098:blood supply*; D014654:Vascular Patency