The brachial artery-brachial vein fistula: expanding the possibilities for autogenous fistulae

Joshua I Greenberg, Susanne May, Ahmed Suliman, Niren Angle
Journal of Vascular Surgery 2008, 48 (5): 1245-50, 1250.e1-2

OBJECTIVE: The National Kidney Foundation Dialysis Outcomes and Quality Initiative recommends autogenous access for new dialysis procedures. The patient requiring hemodialysis with inadequate superficial arm veins represents a formidable challenge to the surgeon. Our objective is to describe results with an alternative access procedure, the autogenous brachial-brachial artery (ABBA) access in patients with inadequate superficial arm veins.

METHODS: One surgeon created 163 new dialysis accesses in 122 patients during 40 consecutive months at a university hospital. There was 97% patient follow-up. All patent but diminutive superficial arm veins as judged by preoperative ultrasound were explored. Arms with inadequate veins at exploration or arms with thrombosed veins on ultrasound received either prosthetic or ABBA procedures. Upper-arm access was often staged, involving a second "superficialization" procedure. This is a retrospective case series based on a comprehensive medical record review. Cox proportional hazards models were used to compare access patency for individual as well as multiple factors suspected or known to influence dialysis access outcomes. Society for Vascular Surgery reporting guidelines were used except where specifically noted and justified otherwise.

RESULTS: One hundred thirty-five autogenous and 28 prosthetic dialysis operations were performed. Primary patency for all access procedures at 12, 24, and 36 months was 58%, 50%, and 38%, respectively. Primary assisted patency for all access procedures at 12, 24, and 36 months was 97%, 91%, and 85%, respectively. Secondary patency at 12, 24, and 36 months was 99%, 97%, and 97%, respectively. Finally, functional patency at 12, 24, and 36 months was 71%, 67%, and 44.0%, respectively. Of the 122 patients, 70 patients received either ABBA or prosthetic access. ABBA out-performed prosthetic access in terms of primary patency (hazard ratio for prosthetic vs ABBA: 4.21 (95% confidence interval [CI]: 1.49, 11.91) and functional patency (hazard ratio for prosthetic vs ABBA: 6.27 95% CI: 1.24-31.72) in patients referred early. Functional patency was more likely to be compromised in elderly patients and in patients with hypercoagulable diagnoses.

CONCLUSIONS: Autogenous brachial-brachial access for dialysis out-performed prosthetic access with respect to primary and functional patency in patients referred early without differences in overall complications.

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