Assessment of Proximal Radio-median Cubital/Radio-Cephalic Arterio-venous Fistula

The present study aims to conducted the Assessment of Proximal radio-median cubital/radiocephalic Arterio-venous Fistula. Arterio-venous Fistula is life line for long-term hemodialysis for end stage renal disease patients. The order of preference as per National Kidney Foundation/ Kidney Disease Out Come Quality Initiative (KDOQI) is distal Radio Cephalic fistula is considered as gold standard followed by elbow Brachio Cephalic Fistula, transposed Brachio-Basilic Fistula, forearm arterio-venous graft. This is a cross sectional-prospective interventional study, 05/2017 to 04/2019, JNMC, Wardha, MH, with sample size of 66 cases. Out of 66 cases 25 % patients had diabetes mellitus, 48% cases were suffering from chronic glomerulonephritis, 15 % cases were suffering hypertension, 6 % cases had COPD and another 6 % cases had some cardiovascular disease. About 54 % cases had previous access failure. In our study the mean flow volume for AV fistula in Original Research Article Akther et al.; JPRI, 33(58A): 612-619, 2021; Article no.JPRI.67573 613 proximal forearm was 485± 291 ml/minon postoperative day1, 695 ± 298 on postoperative day 7 and 755± 347 ml/min. Overall postoperative complications in 12% cases was reported in our case study though Yilmiz et al reported postoperative complications in 15% cases.


INTRODUCTION
The native arteriovenous fistula (AVF) is recommended as the best vascular access for hemodialysis by the National Kidney Foundation / Kidney Dialysis Outcomes Quality Initiative (NFK/DOQI) clinical practice guideline. Patients with AVFs have the lowest risks of death, infections, and cardiovascular events and also the lowest costs to the health care system [1][2][3][4][5][6]. Arterio-venous Fistula is life line for long-term hemodialysis for end stage renal disease patients. The order of preference as per National Kidney Foundation/ Kidney Disease Out Come Quality Initiative (KDOQI) is distal Radio Cephalic fistula is considered as gold standard followed by elbow Brachio Cephalic Fistula, transposed Brachio-Basilic Fistula, forearm arterio-venous graft. There appears increase in failure rates of distal arterio venous fistulas created over wrists in recent years as a result of poor vein quality in distal veins and arteries combined with history of intravenous catheterizations, diabetes mellitus, peripheral vascular disease (PVD) and old age [7].
Arterio-Venous Fistulas using proximal Radio Cephalic have excellent patency rate, allowing multiple access sites in proximal forearm [7] The latest KDOQI guidelines recommend newly created fistulas to be physically examined within 4-6 weeks and additional imaging studies if the fistula is not adequately matured by the sixth week [8]. Arterio-Venous Fistula maturation becomes apparent as early as 2-4-wks after creation. Arterio-Venous Fistula is considered sono-graphically matured if its Vein internal diameter ≥ 4 mm and flow volume (FV)≥ 500 ml/min. (UAB) [9] Brachial artery flow volume predicts arterio-venous fistula maturation for both forearm & arm [10].
Low FV and small Vein Internal Diameter at 2wks are predictive of arterio-venous fistulas that may not develop optimally at 6-wks. Michelle L. Robbin et al. [9] in his study with 602 patients in 2016 suggested that Early (USD) identification of causal lesions and problem-directed interventions shortens the time of fistula maturation & minimizes complications of central venous catheter use [8].

RESULTS
Total 66 cases were studied between 05/2017 to 04/2019. Out of 66 cases 6 cases failed at 3 months (primary failure). Remaining 60 cases were mature at 1 year.
In present study we had male to female ratio of 0.94 with mean age as 43 years. Out of 66 cases 25 % patients had diabetes mellitus, 48% cases were suffering from chronic glomerulonephritis, 15 % cases were suffering hypertension, 6 % cases had COPD and another 6 % cases had some cardiovascular disease. About 54 % cases had previous access failure. In present study mean operative time was observed as 85 min ±10 min, out of all the cases operated 10 cases were operated on nondominant upper limb i.e., left upper limb. Technical success was 100 percent. Distal radial pulse was palpable in 100 % cases. There were 1.5 % patients who had primary failure. The preferred access for cannulation was cephalic in about 88% cases.
In our study mean venous internal diameter preoperatively was 3.47 ± 1.41. postoperatively on day 7 and day 14 it was about 5.28 ± 1.39 and 5.54 ± 1.68 respectively.
In our study the mean flow volume for AV fistula in proximal forearm was 485± 291 ml/minon postoperative day1, 695 ± 298 on postoperative day 7 and 755± 347 ml/min. In present study the primary patency at postoperative day 14 was 98.5 %, at 3 months 94 %, at 6 months it was 91 % and at 1 year it was 91%.
In this study none of the patients developed acute thrombosis, bleeding, wound infection, wound dehiscence, thrombophlebitis or Dialysis Associated Steal Syndrome though there were 4.5% cases who developed hematoma. 7.5 % cases developed arm edema and 3 % cases developed pseudo-aneurysm.

DISCUSSION
In present study we had male to female ratio of 0.94 with mean age as 43 years. Out of 66 cases 25 % patients had diabetes mellitus, 48% cases were suffering from chronic glomerulonephritis, 15 % cases were suffering hypertension, 6 % cases had COPD and another 6 % cases had some cardiovascular disease. About 54 % cases had previous access failure. Gruidah et al did a case study on 30 patients in 2019 in which 9 patients were males and 21 were females, the mean age was 52.7 years. [11] Table 2) [2].
In our study mean venous internal diameter preoperatively was 3.47 ± 1.41. postoperatively on day 7 and day 14 it was about 5.28 ± 1.39 and 5.54 ± 1.68 respectively.
Toregeani et al. [2]  .37 mm as mean VID pre operatively in upper arm which was increased to 5.84±1.23mm on post-operative day 7 and 6.02±1.38mm on post-operative day 14.the above findings were consistent with our study(see Table 3).
In present study the primary patency at postoperative day 14 was 98.5 %, at 3 months 94 %, at 6 months it was 91 % and at 1 year it was 91%. Gruidah et al. [11] reported primary patency of arterio venous fistula was 63.  Table 5).
In this study none of the patients developed acute thrombosis, bleeding, wound infection, wound dehiscence, thrombophlebitis or Dialysis Associated Steal Syndrome though there were 4.5% cases who developed hematoma. 7.5 % cases developed arm edema and 3 % cases developed pseudo-aneurysm. Gruidah et al. [11] reported 13.3% cases had developed acute thrombosis of cephalic vein. Ehsan et.al. reported 6.2% cases developing cephalic vein thrombosis. In our study none of cases developed the same. Yilmiz [12] reported 1.5% cases developed hematoma but, in our study, higher rate of 4.5% was noted. Arm edema was developed in 6.7 % cases reported by Gruidah et al. [11] whereas 3% was noted in study done by Yilmiz el al. [ Table 6).
• Intra-operative options for another artery & vein.
• Number of surgical failures was low comparable to elbow fistula.

• Timely increment of FV & Vein Internal
Diameter of proximal forearm fistula were better than distal forearm.

CONCLUSIONS
Proximal forearm arterio-venous fistula should be recommended as 2nd option after failed / when not fit for distal forearm arterio-venous fistula. We believe that a proximal radiocephalic approach should be used before creating a brachiocephalic fistula in patients with prior forearm arteriovenous (AV) fistula dysfunction or insufficient wrist vessels to avoid dialysis-associated steal syndrome.

CONSENT AND ETHICAL APPROVAL
Informed consent was taken patients and take institutional ethical committee approval.