title: Increased reintervention in radial-cephalic arteriovenous fistulas with anastomotic angles of less than 30 degrees.
abstract: OBJECTIVE
  Although radial-cephalic (RC) and brachial-cephalic (BC) fistulas are the recommended primary accesses for hemodialysis, access failure is frequently due to juxta-anastomotic stenosis (JAS). Because increased turbulence at the anastomosis may lead to JAS, we hypothesized that an acute angle at the arteriovenous anastomosis is associated with JAS, reduced fistula patency, and increased reinterventions.
  
  
  METHODS
  Between February 2013 and September 2014, the anastomotic angle and vessel diameters were prospectively collected for all patients who underwent RC or BC fistula creation. The primary end point was reintervention on the juxta-anastomotic segment. Secondary end points were primary and secondary patency of the fistula.
  
  
  RESULTS
  A total of 149 patients (median age, 72 years) received 73 RC and 76 BC fistulas; the median follow-up was 7 months (range, 1-22 months) for RC and 12 months (range, 2-24 months) for BC fistulas. The median anastomotic angle in RC fistulas, was 30°. Anastomotic angles of <30° were associated with reduced primary patency (38% vs 66%, P = .003) and secondary patency (84% vs 97%, P = .02) and increased numbers of reinterventions (67% vs 34%, P = .001). Cox analysis showed that an anastomotic angle of <30° was an independent factor predicting decreased primary patency (P = .009) and secondary patency (P = .03) as well as increased reinterventions (P = .004). In BC fistulas, the median anastomotic angle was 90°. Patients with anastomotic angles <90° and ≥90° had similar rates of primary patency (67% vs 67%, P = .39) and secondary patency (93% vs 94%, P = .89) at 6 months, with a similar reintervention rate at 12 months (31% vs 32%, P = .56). Vein diameter was the only factor that predicted reintervention (P < .0001).
  
  
  CONCLUSIONS
  RC fistulas with anastomotic angles of <30° have reduced primary and secondary patency and increased numbers of reinterventions, suggesting that, if possible, surgeons should avoid an anastomotic angle of <30° when creating RC fistulas. Anastomotic angles of <90° or ≥90° may not play a role in outcome of BC fistulas.
authors.affiliation: Department of Vascular Surgery, University Hospital of Nice, and the University of Nice-Sophia Antipolis, Nice, France.
authors.forename: Nirvana
authors.initials: N
authors.lastname: Sadaghianloo
authors.affiliation: Department of Vascular Surgery, University Hospital of Nice, and the University of Nice-Sophia Antipolis, Nice, France.
authors.forename: Elixène
authors.initials: E
authors.lastname: Jean-Baptiste
authors.affiliation: Department of Vascular Surgery, University Hospital of Nice, and the University of Nice-Sophia Antipolis, Nice, France.
authors.forename: Khalid
authors.initials: K
authors.lastname: Rajhi
authors.affiliation: Department of Vascular Surgery, University Hospital of Nice, and the University of Nice-Sophia Antipolis, Nice, France.
authors.forename: Etienne
authors.initials: E
authors.lastname: François
authors.affiliation: Department of Vascular Surgery, University Hospital of Nice, and the University of Nice-Sophia Antipolis, Nice, France.
authors.forename: Serge
authors.initials: S
authors.lastname: Declemy
authors.affiliation: Department of Surgery, Yale University School of Medicine, New Haven, Conn.
authors.forename: Alan
authors.initials: A
authors.lastname: Dardik
authors.affiliation: Department of Vascular Surgery, University Hospital of Nice, and the University of Nice-Sophia Antipolis, Nice, France. Electronic address: hassen-khodja@chu-nice.fr.
authors.forename: Réda
authors.initials: R
authors.lastname: Hassen-Khodja
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical; D001916:Brachial Artery / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017534:Radial Artery / Q000601:surgery; D012189:Retrospective Studies; D014654:Vascular Patency