Increased use of brachiocephalic arteriovenous fistulas improves functional primary patency.
OBJECTIVE
As vascular surgeons strive to meet the Fistula First Initiative, some authors have observed a decrease in arteriovenous fistula (AVF) maturation rates in association with an increase in AVF creation. In May 2012, we adopted a practice change in an attempt to maintain the same high level of AVF creation while leading to a decrease in fistula failures.


METHODS
A retrospective study was conducted of all dialysis access procedures performed by a single vascular surgeon before (period 1; before May 1, 2012) and after (period 2; after May 1, 2012) the change in practice pattern. The adopted change included favoring the brachiocephalic location unless the patient was an ideal anatomic candidate for a radiocephalic AVF, creating a larger and standardized arteriotomy, and using a large venous footplate whenever possible. The main outcome measure was primary functional patency at 1 year. Secondary outcome measures included primary patency at 1 year, time to maturation, type of fistula created, steal syndrome, and tunneled hemodialysis catheter infections.


RESULTS
Of 213 vascular access procedures performed, 191 (90%) were AVFs. There was no difference in use of AVFs between period 1 (93% AVFs) and period 2 (88% AVFs; P = .2). Use of brachiocephalic AVFs increased from 38% in period 1 to 56% in period 2 (P = .01), with a corresponding trend toward a decrease in radiocephalic AVFs in period 2 (36% in period 1 to 27% in period 2; P = .2). Primary functional patency at 1 year was 47% in period 1 and 63% in period 2 (P = .03). Primary patency at 1 year was 51% in period 1 and 70% in period 2 (P = .001). Time to reach functional maturation was decreased in period 2 (median, 76 vs 82.5 days; P = .046). There was no difference in steal syndrome (P = 1.0), and the incidence of hemodialysis catheter infections was lower in period 2 (0 vs 7 [7%]; P = .006).


CONCLUSIONS
Increasing brachiocephalic AVF creation and reducing our reliance on radiocephalic AVFs resulted in a significant increase in primary functional patency at 1 year. This was achieved while maintaining the same high percentage of fistulas, a lower rate of central catheter infections, and the same low incidence of steal syndrome.
Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif.
Jerry J
JJ
Kim
Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif.
Edward
E
Gifford
Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif.
Virginia
V
Nguyen
Division of Nephrology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, Calif; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, Calif.
Amy H
AH
Kaji
Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif.
Patrick
P
Chisum
Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif.
Annie
A
Zeng
Division of Nephrology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, Calif; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, Calif.
Ramanath
R
Dukkipati
Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, Calif. Electronic address: cdevirgilio@labiomed.org.
Christian
C
de Virgilio
D001132:Arm / Q000098:blood supply*; D001166:Arteriovenous Shunt, Surgical / Q000379:methods*; D001916:Brachial Artery / Q000601:surgery*; D005260:Female; D006083:Graft Occlusion, Vascular / Q000517:prevention & control*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000295:instrumentation*; D012189:Retrospective Studies; D014654:Vascular Patency; D014680:Veins / Q000601:surgery*