Abstract
Juxta-anastomotic stenosis (JAS) is one of the predominant causes of arteriovenous fistula (AVF) failure, with the reported incidence as high as 65%. We hypothesized that technical modification to alter the outflow vein configuration using the novel piggyback Straight Line Onlay Technique (pSLOT) would prevent JAS and improve AVF maturation. Intention-to-treat analysis of the outcomes of consecutive distal radiocephalic (RC) fistulas performed by a single operator with three different anastomotic techniques using a prospectively maintained database. Traditional end-to-side technique (ETS), side-to-side straight-line onlay technique (SLOT, STS) and pSLOT in RC AVF created in 125 consecutive patients between 1/2004 and 12/2007 were compared. AVF maturation was evaluated by ultrasonography at 4 to 6 weeks and use for dialysis. The mean age of the study group was 53.1 ± 20.7 years, the male-to-female ratio was 61:64, and the races studied were African American (66; 52.8%) and Caucasian (54; 43.2%). The primary disease for renal failure was hypertension (54; 43.2%) and diabetes (51; 40.8%). Brachial artery flow at maturation was 1103 ± 531 mL/min. Incidence of early JAS was 9.8% and late 14.6%. The clinico-demographic variables between ETS (n = 57), STS (n = 12), and pSLOT (n = 54) were similar. The median follow-up between three groups: ETS (19 months), STS (12 months), and pSLOT (19 months; P =.1), was similar. There was a significant decrease in JAS development in pSLOT patients (P =.04). pSLOT patients also revealed decreased overall fistula failure (ETS 40.3%, STS 33.3%, pSLOT 16.7%; P =.01). There was significant reduction in JAS and improvement in AVF maturation with pSLOT. This study provides evidence highlighting the role of outflow vein configuration in AVF maturation. Minimal alteration of vein wall configuration and avoidance torsion using pSLOT technique improves AVF maturation.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 274-280 |
| Number of pages | 7 |
| Journal | Journal of Vascular Surgery |
| Volume | 55 |
| Issue number | 1 |
| DOIs | |
| State | Published - Jan 2012 |
Funding
The improved mortality rate associated with hemodialysis 1 has produced a critical need for a reliable vascular access. Based on the superior patency and lower morbidity associated with arteriovenous fistula (AVF), the recent practice guidelines of the American Society for Vascular Surgery 2 as well the Kidney Disease Outcomes Quality Initiative 3 propose creation of AVF before placement of prosthetic grafts or use of central venous catheters. With the inception of the “Fistula First” initiative ( http://www.fistulafirst.org ), the current prevalence of AVF in the U.S. is 56% and is continuing to increase. 4 Despite this, the early thrombosis and failure to mature continues to be a major problem with AVF creation. A recent multicenter controlled randomized trial conducted by the Dialysis Access Consortium (DAC) and sponsored by the National Institutes of Health (NIH) reported a 60% failure to maturation in AVF. 5 Many other studies have reported similar high rates of primary failure with AVF. 4,6-8 Juxta-anastomotic stenosis (JAC) with a variable reported incidence of 43% to 65% is a major cause for early AVF failure and arrested maturation. 9 Although factors including handling of the tissues, suture technique, physiological changes related to increasing blood flow, rheologic factors, shear stress, and patient- and surgeon-related variables have been implicated, the exact etiology of JAS still remains unclear. 10-13
ASJC Scopus subject areas
- Cardiology and Cardiovascular Medicine
- Surgery
