3-year patency and revision in AVF
Patients with upper arm arteriovenous fistulas (AVF) occasionally develop high flow. In these cases, revision using distal inflow (RUDI) will lead to an effective reduction of high flow accesses (HFA) in the short-term, report Dutch surgeons (Gerrickens MWM et al, Three Year Patency and Recurrence Rates of Revision Using Distal Inflow with a Venous Interposition Graft for High Flow Brachial Artery Based Arteriovenous FistulaEur J Vasc Endovasc Surg. 2018; doi: 10.1016/j.ejvs.2018.03.014).
In addition, RUDI is also increasingly used for the treatment of hemodialysis access induced distal ischemia (HAIDI). However, RUDI’s long-term efficacy is as yet unknown, which is why the authors investigated 3-year RUDI patency and recurrence rates for HFA with and without HAIDI.
The retrospective cohort study included 21 patients (average age: 54 years) with a HFA with or without HAIDI, who underwent RUDI using greater saphenous vein (GSV) interposition. AVFs were defined as HFA if flow volumes exceeded 2 L/min on two consecutive measurements using dilution techniques; HAIDI was diagnosed “as recommended”.
14 patients had uncomplicated HFA, and seven had additional HAIDI. Immediately after the operation, flows were threefold lower (3,120 mL/min vs. 1,170 mL/min; p < .001). Overall, the 3 year primary patency was 48 percent; HFA: 55 percent, HAIDI/HFA: 29 percent (p = 0.042). Both groups had the same rates of secondary patency (overall, 84%). Regarding interventions, twelve percutaneous transluminal angioplasties were performed in nine patients; seven thrombectomies were performed in three patients; and three patients underwent revision with new interposition grafts.
After three years, 51 percent of patients were free of high flow (HFA 32% vs. HAIDI/HFA 100%, p = 0.018). High immediate post-operative access flow predicted recurrence with an OR of 1.004 (p = 0.044). A further interesting finding: Patients with recurrence were 12 years younger than those without (p = 0.055).
The authors conclude that RUDI with GSV interposition for HFA offers “acceptable patency rates” after three years, even though they also concede that re-interventions are required fairly often. The two main factors associated with recurrent high flow are high immediate post-operative flows and young age.
Link to the study: https://www.ejves.com/article/S1078-5884(18)30154-0/fulltext