Staged Autogenous to Prosthetic Hemodialysis Access Creation Strategy to Maximize Forearm Options.

OBJECTIVES: When an adequate cephalic vein is not available for fistula construction, surgeons often turn to basilic vein or prosthetic constructions. Single stage forearm prosthetic hemodialysis accesses are associated with poor durability, and upper arm non-autogenous access options are often limited by axillary outflow failure which inevitably drives transition to the contralateral arm or lower extremity. We hypothesized that initial creation of a modest flow proximal forearm arterial-venous anastomosis to dilate ("develop") inflow and outflow vessels, followed by a planned second stage procedure to create a cannulation zone with a prosthetic graft in the forearm, would result in reliable and durable hemodialysis access in patients with limited options.

METHODS: We performed an institutional cohort study from 2017 to 2021 using a prospectively maintained database supplemented with adjudicated chart review. Patients without traditional autogenous hemodialysis access options in the forearm underwent an initial non-wrist arterial-venous anastomosis creation in the forearm as a first stage, followed by a second stage interposition graft sewn to the existing inflow and venous outflow segments to create a useable cannulation zone in the forearm while leveraging vascular development . Outcomes included time from second-stage access creation to loss of primary and secondary patency, frequency of subsequent interventions, and perioperative complications.

RESULTS: The cohort included 23 patients; first stage radial artery based (74%) configurations were more common than brachial artery based (26%). Mean age was 63 (SD 14) years and 65% were female. Median follow-up was 340 days (IQR 169-701). Median (IQR) time to cannulation from second stage procedure was 28 days (18-53). Primary, primary assisted, and secondary patency (95% CI) at one year was 16.7% (5.3-45.8), 34.6% (15.2-66.2) and 95.7% (81.3-99.7), respectively. Subsequent interventions occurred at a rate of 3.02 (IQR 1.0-4.97) per person-year, with endovascular thrombectomy with or without angioplasty/stenting (70.9%) being the most common. There were no cases of steal syndrome. Infection occurred in two cases and were managed with antibiotics alone.

CONCLUSIONS: For patients without adequate distal autogenous access options, staged prosthetic graft placement in the forearm offers few short-term complications and excellent durability with active surveillance while strategically preserving the upper arm for future constructions.