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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 17  |  Issue : 1  |  Page : 84-88

Vascular access for dialysis - A choice between brachiobasilic versus brachiocephalic arteriovenous fistula


1 Department of General Surgery, JNMC, Sawangi, Wardha, Maharashtra, India
2 Department of Biochemistry, JNMC, Sawangi, Wardha, Maharashtra, India

Date of Submission27-Jan-2022
Date of Decision18-Feb-2022
Date of Acceptance26-Mar-2022
Date of Web Publication25-Jul-2022

Correspondence Address:
Dr. Chandrashekhar Mahakalkar
Department of General Surgery, JNMC, Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_233_22

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  Abstract 


Aim: The study aims to compare the vascular access of brachiobasilic arteriovenous fistula (AVF) to that of brachiocephalic AVF for hemodialysis in patients of end-stage renal diseases (ESRDs), in terms of patency, maturation, and the time of cannulation. Objectives: (1) To analyze the patency, maturation, and surgical outcomes of two autogenous upper arms' arteriovenous accesses: brachiobasalic and brachiocephalic AVF. (2) To analyze the factors responsible for patency and maturation of the AVF. (3) To define a criterion for vascular access maturation of the AVF. Methodology: It was a randomized controlled trial done on patients of ESRD on maintenance hemodialysis. Patients were randomized into Group A – brachiobasilic AVF and Group B – brachiocephalic AVF. They were either subjected to brachiocephalic or brachiobasilic AVF according to standard surgical guidelines. Follow-up was taken at day 30, day 90, and 6 months via clinical examination and color Doppler. Results: The patency of brachiobasilic fistula was statistically significant compared to brachiocephalic (patent: −85% vs. 71%, respectively, not patent: −15% vs. 29%, respectively) (P ≤ 0.05) at 6-month follow-up. In fistula used successfully for hemodialysis, significant difference of 73% and 56%, respectively, for brachiobasilic and brachiocephalic was observed. Conclusion: From the above study, it can be concluded that brachiobasilic AVF is superior to brachiocephalic AVF in terms of patency, rate of complications, and surgical outcomes. The factors responsible for the patency and maturation of AVF were identified.

Keywords: Arteriovenous fistula, end-stage renal disease, hemodialysis


How to cite this article:
Mahakalkar C, Jajoo SN, Kaple M, Kshirsagar S. Vascular access for dialysis - A choice between brachiobasilic versus brachiocephalic arteriovenous fistula. J Datta Meghe Inst Med Sci Univ 2022;17:84-8

How to cite this URL:
Mahakalkar C, Jajoo SN, Kaple M, Kshirsagar S. Vascular access for dialysis - A choice between brachiobasilic versus brachiocephalic arteriovenous fistula. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2022 Aug 16];17:84-8. Available from: http://www.journaldmims.com/text.asp?2022/17/1/84/352219




  Introduction Top


Chronic kidney disease (CKD) is a long-term disorder that occurs when both kidneys are damaged. The epidemiology of CKD has only recently been studied in depth, with the discovery that it is more widespread than previously believed.[1] Hemodialysis's primary aim is to reestablish the intracellular and extracellular fluid environment that is typical of normal kidney function.[2] Because of its lower cost, morbidity, and mortality, arteriovenous fistula (AVF) has become the preferred vascular access for hemodialysis.[3] The three major methods of chronic vascular management for hemodialysis are natural AVF (native AVF), AV shunts with graft material, and tunneled double-lumen catheters. Because it has the highest long-term primary patency rate and requires the fewest therapies of any vascular access, the native AVF is the preferred vascular access for long-term hemodialysis, and most significantly, AVFs are associated with the lowest incidence of morbidity and mortality of any type of access.[4],[5],[6],[7],[8] While there are several different anatomic forms of AVFs, the majority of them fall into one of three categories: the anastomosis between the radial artery and the cephalic vein is known as radiocephalic fistula; the anastomosis between the brachial artery and the cephalic vein is known as brachial-cephalic; and the anastomosis between the brachial artery and the basilic vein is known as the brachial-basilic fistula.

The classic Cimino-Brescia fistula, which is made by joining the radial artery and the cephalic vein side by side, can be complicated by venous hypertension in the hand. The most popular technique is side-to-side anastomosis, which has been described as the simplest to build technically.[9]

With this context, the aim of this study was to determine the best location for the formation of an AVF, determine the success rate at different sites, and investigate the complications of AVFs.


  Methodology Top


It was a randomized controlled trial that was done in patients with end-stage renal disease (ESRD) that needed an AVF for hemodialysis or maintenance hemodialysis. It took place at JNMC's Department of Surgery and Acharya Vinoba Bhave Rural Hospital in Sawangi (Meghe) of Wardha DMIMS (DU) with a sample size of 150.

The study was carried in patients of ESRD who need hemodialysis or maintenance hemodialysis. It was done after proper informed consent was obtained from the patients and an institutional ethical committee clearance.

  • Group A: Patients of ESRD with brachiobasilic AVF; n = 75
  • Group B: Patients of ESRD with Brachiocephalic AVD; n = 75.


After initial clinical evaluation, blood investigations, color Doppler of the upper limb for fistula creation for the evaluation of caliber (diameter of vessel from intima to intima), Vmax (velocity of blood flow in the vessel), Qmax (volume of blood flow in the vessel), condition of the vessel (atherosclerotic changes, thrombophlebitis, and wall calcification), and depth from the skin were done. The surgical procedure for the creation of AVF was standardized for all the patients of brachiocephalic or brachiobasilic AVF.

Based on the findings of clinical examinations and color Doppler on follow-up, patients were subjected to cannulation for dialysis. The cannulation was done on superficial veins as far away as possible from the AVF. The patient was followed for 6 months after AVF creation at day 30, day 90, and 6 months. The patient was examined clinically at every visit, and color Doppler was done at day 30, day 90, and 6 months [Figure 1].
Figure 1: Comparison of age (years) between brachiobasilic and brachiocephalic

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  Results and Observations Top


Mean ± standard deviation (SD) of age (years) in brachiobasilic was 48.89 ± 14.17 and brachiocephalic was 45.96 ± 13.34, with no significant difference between them (P = 0.194).

All the patients had side-to-side anastomosis, and prolene suture material was used in all patients.

Distribution of patency of fistula on 30-day follow-up was comparable between brachiobasilic and brachiocephalic (patent: −88% vs. 88%, respectively; not patent: −12% vs. 12%, respectively; P = 1).

The patency of brachiobasilic fistula was statistically significant compared to brachiocephalic (patent: −85% vs. 71%, respectively, not patent: −15% vs. 29%, respectively) (P ≤ 0.05) at 6-month follow-up.

Analysis of vascular access maturation was comparable between brachiobasilic and brachiocephalic.

Immediate vascular access failure was seen in 0% of both brachiobasilic and brachiocephalic.

In fistula used successfully for hemodialysis (FUSH), significant difference of 73% and 56%, respectively, for brachiobasilic and brachiocephalic was observed.

Distribution of time of cannulation was comparable between brachiobasilic and brachiocephalic (mean: −47.61 vs. 52.64, respectively, not patent: −52.64 vs. 2.98%, respectively) (P = 0.0001). The difference was statistically significant [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6].
Table 1: Comparison of operative details between brachiobasilic and brachiocephalic

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Table 2: Comparison of intraoperative findings between brachiobasilic and brachiocephalic

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Table 3: Comparison of patency of fistula on 30-day follow-up between brachiobasilic and brachiocephalic

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Table 4: Comparison of patency at all follow-ups between brachiobasilic and brachiocephalic

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Table 5: Analysis of vascular access maturation between brachiobasilic and brachiocephalic

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Table 6: Analysis of time of cannulation between brachiobasilic and brachiocephalic

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  Discussion Top


The purpose of this study was to compare of the vascular access of brachiobasilic AVF to brachiocephalic AVF for hemodialysis in patients of ESRD. Our study depicted that the mean ± SD of age in brachiobasilic was 48.89 ± 14.17 years and brachiocephalic was 45.96 ± 13.34 years, with no significant difference between them (P = 0.194). Moreover, gender was also comparable between brachiobasilic and brachiocephalic (female: 32.0% vs. 37.3%, respectively; male: 68.0% vs. 62.7%, respectively) (P = 0.493). Our study noted that the distribution of preoperative color Doppler of upper limb (brachial artery) was comparable between brachiobasilic and brachiocephalic. Atherosclerotic changes in 22.67% versus 36.0%, respectively (P = 0.073), wall calcification in 8.0% versus 4.0%, respectively (P = 0.494), and tortuosity in 5.33% versus 9.33%, respectively (P = 0.533). There was no significant difference seen in caliber (mm) (P = 0.962), Vmax (cm/s) (P = 0.056), and depth from the skin (mm) (P = 0.854) between brachiobasilic and brachiocephalic. Median (25th–75th percentile) of caliber (mm), Vmax (cm/s), depth from the skin (mm) in brachiobasilic was 4.1 (3.9–4.2), 84 (83–85), 4.4 (4.2–4.6), respectively, and in brachiocephalic was 4.1 (3.9–4.2), 84 (82–85), 4.4 (4.2–4.6), respectively. However, the significant difference was seen in Qmax (mL/min) between brachiobasilic and brachiocephalic (P < 0.05). Median (25th–75th percentile) of Qmax (mL/min) in brachiobasilic was 131.88 (101.14–169.63) which was significantly higher compared to brachiocephalic (103.86 [72.17–140.52] P = 0.021).

The present study observed that the distribution of preoperative color Doppler of upper limb (cephalic vein) was comparable between brachiobasilic and brachiocephalic. In this study, the distribution of preoperative color Doppler of upper limb (basilic vein) was comparable between brachiobasilic and brachiocephalic. In our study, the distribution of intraoperative findings was comparable between brachiobasilic and brachiocephalic.

The patency of brachiobasilic versus brachiocephalic was 88% each at day 30, 87% versus 83% at day 90, and 85% versus 65% at 6-month follow-up, respectively.

Brachiobasilic AVF was used successfully for hemodialysis (FUSH) in 73% of patients as compared to 56% in brachiocephalic AVF.

The rate of complication was 2.67% in brachiocephalic versus 0% in brachiobasilic AVF.

Following factors are found to be statistically significant in terms of patency:

  • Socioeconomic status (P = 0.012)
  • Duration of CKD (P = 0.099)
  • Hypertension (P = 0.012)
  • Arterial volume (P = 0.013)
  • Hemoglobin and platelet counts (P = 0.056 and 0.013)
  • Atherosclerotic changes in vessels (P = 0.073)
  • Preoperative Vmax and Qmax (P = 0.056 and 0.021)
  • Diameter of vein (P = 0.036)
  • Depth of vessels from skin (P = 0.011)


Following factors are found to be statistically significant in terms of maturation:

  • Mismatched diameter of vessels
  • Palpable veins at elbow (P = 0.013)
  • Preoperative visible veins (P = 0.013)
  • Technical issues related to vein mobilization.


The mean cannulation tine for brachiobasilic AVF was 47.61 ± 2.56 and brachiocephalic was 52.64 ± 2.98. It was statistically significant difference (0.0001).

The patency rate, maturation time, and successful use of brachiobasilic AVF were more and statistically significant as compared to brachiocephalic AVF.


  Conclusion Top


From the above study, it can be concluded that brachiobasilic is superior as compared to brachiocephalic.

Factors responsible for patency

  • Socioeconomic status
  • Duration of CKD
  • Hypertension
  • Arterial volume
  • Hemoglobin and platelet counts
  • Atherosclerotic changes in vessels
  • Preoperative Vmax and Qmax
  • Diameter of vein
  • Depth of vessels from skin.


Factors responsible for maturation

  • Mismatched diameter of vessels
  • Palpable veins at elbow
  • Preoperative visible veins
  • Technical issues related to vein mobilization.


Brachiobasilic is superior to brachiocephalic AVF for hemodialysis in patients of ESRD.

Transposed brachiobasilic fistulas may be preferred to brachiocephalic fistulas because of their lower primary failure rate. The decision about placing a brachiobasilic fistula in a given patient must be tempered; however, by the greater technical challenge of this surgical procedure. For the majority (62%) of patients in whom the brachiocephalic fistula is used successfully for dialysis, one would prefer to forego the more extensive brachiobasilic fistula surgery. The mean arterial and venous diameters were significantly lower in brachiocephalic fistulas that failed to mature than in those that were used successfully for dialysis. Unfortunately, there was substantial overlap in vessel diameters between the two groups, such that there was no satisfactory threshold diameter that would both maximize fistula placement and minimize fistula nonmaturation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
John R, Webb M, Young A, Stevens PE. Unreferred chronic kidney disease: A longitudinal study. Am J Kidney Dis 2004;43:825-35.  Back to cited text no. 1
    
2.
Himmelfarb J, Ikizler TA. Hemodialysis. N Engl J Med 2010;363:1833-45.  Back to cited text no. 2
    
3.
Hakim R, Himmelfarb J. Hemodialysis access failure: A call to action. Kidney Int 1998;54:1029-40.  Back to cited text no. 3
    
4.
Feldman HI, Kobrin S, Wasserstein A. Hemodialysis vascular access morbidity. J Am Soc Nephrol 1996;7:523-35.  Back to cited text no. 4
    
5.
Ascher E, Gade P, Hingorani A, Mazzariol F, Gunduz Y, Fodera M, et al. Changes in the practice of angioaccess surgery: Impact of dialysis outcome and quality initiative recommendations. J Vasc Surg 2000;31:84-92.  Back to cited text no. 5
    
6.
Increasing Arteriovenous Fistulas in Hemodialysis Patients: Problems and Solutions – PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/12234281/. [Last accessed on 2022 May 16].  Back to cited text no. 6
    
7.
Dixon BS, Novak L, Fangman J. Hemodialysis vascular access survival: Upper-arm native arteriovenous fistula. Am J Kidney Dis 2002;39:92-101.  Back to cited text no. 7
    
8.
Añel RL, Yevzlin AS, Ivanovich P. Vascular access and patient outcomes in hemodialysis: Questions answered in recent literature. Artif Organs 2003;27:237-41.  Back to cited text no. 8
    
9.
Desai V, Van B, editors. Vascular Diseases: Surgical & Interventional Therapy. 1st ed. New York: Churchill Livingstone; 1993. p. 1392.  Back to cited text no. 9
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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