In patients undergoing chronic hemodialysis, the need for a vascular access (VA) that functions adequately for a long time and without significant complications, is a matter of critical importance for the quality of life and survival of these patients.

In the early 1960s, external shunt or Scribner shunt was originally used to perform hemodialysis in patients with end stage renal disease (ESRD). Despite the modifications and improvements made, complications such as inflammation, thrombosis and bleeding continued to occur at a high frequency. VA got its current form in 1966 by surgical construction of an internal arteriovenous fistula (AVF). Since then, various improvements and innovations have brought other types of VA into daily clinical practice, such as arteriovenous grafts AVG and various types of central venous catheters (CVC). Autologous arteriovenous fistula (AVF) is constructed by subcutaneous anastomosis of an artery with an adjacent vein, allowing blood to flow directly from the artery to the vein (bypassing the capillary circulation), resulting in a vein arterialisation due to the high flows and pressures of the arterial circulation. The most common types of AVF are:

  1. The radial-cephalic AVF, which is constructed by anastomosis of the radial artery with the cephalic vein in the wrist, resulting in the creation of a superficial arterialised vein of satisfactory length along the forearm, suitable for puncture.

  2. The brachial-cephalic AVF in the upper arm at the level of the elbow between the brachial artery and the cephalic vein, resulting in the creation of a vessel suitable for cannulation along the arm.

  3. The brachial-basilic AVF also in the upper arm, between the brachial artery and the basilic vein. Because of the formation of an arterialised vein that is not found as superficially as required for puncture (> 6 mm from the surface of the skin), the basilic vein is usually translocated to a more superficial position. This technique results in a large incision along almost the whole upper arm and is performed under local anesthesia (basilic vein transposition).

The AVF anastomosis may be either side-to-side (such as the original type described by Brescia and Cimino in radial-cephalic anastomosis) or end-to- side (side of the artery- end of the vein). In both cases, the peripheral blood flow is maintained through the artery. In the side-to-side method, the increased arterial pressure can be transmitted to the venous system of the hand with subsequent edema formation. With the end to side anastomosis, this complication is limited due to ligation of the distal part of the vein. The autologous AVFs have a primary failure rate of about 20% (varies from 10-50%) which depends on the experience of each center. Once the anastomosis has matured, the long-term patency rates are excellent and range from about 85% in the first year to 75% at 2 years, and with a low incidence of infection. Stenosis is the major cause of thrombosis of an AVF, and in case of a radial-cephalic AVF it is often located around the anastomosis area, whereas in the AVF made in the arm, stenosis is usually located more distally. After the surgical construction of the AVF, at least one month is required for cannulation, while according to the Kidney Dialysis Outcomes Quality Initiative (K/DOQI) guidelines, the first puncture should not be attempted earlier than 6-8 weeks.

 

Bibliography

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  10. Turmel-Rodrigues L, Pengloan J, Baudin S et al. Treatment of stenosis and thrombosis in hemodialysis fistulas and grafts by interventional radiology. Nephrol Dial Transplant 2000; 15(12): 2029-2036.

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Leivaditis Konstantinos MD, PhD

Demirtzi Paraskevi MD

Nephrologists

NEPHROXENIA’ Chalkidiki Dialysis Centre