SUPERIOR MATURATION AND PATENCY OF PRIMARY BRACHIOCEPHALIC AND TRANSPOSED BASILIC VEIN ARTERIOVENOUS-FISTULAS IN PATIENTS WITH DIABETES

Purpose: Primary radiocephalic arteriovenous fistulas (RCAVFs) have cl assically been used for the initiation of dialysis. If a suitable fore arm cephalic vein can be demonstrated, it is used to construct such a fistula. However, we have noted a tendency for RCAVF in patients with a history of diabetes mellitus (type I and type II) to remain patent b ut not mature to the point of cannulation. Therefore, the present stud y was undertaken. Methods: Fifty-eight consecutive patients with diabe tes who required initial access for hemodialysis at an urban medical c enter and tertiary Veterans Medical Center underwent creation of an RC AVF (n = 10), brachiocephalic arteriovenous fistula (BCAVF; n = 22), o r transposed basilic vein arteriovenous fistula (TBAVF; n = 26). The v ein used was determined by physical examination with tourniquet compre ssion. If neither forearm or upper-arm cephalic veins were 2 mm in dia meter, a TBAVF was created after venography. Patency was determined by Kaplan-Meier estimate; differences between groups were assessed by Fi sher's exact test. Results: The 70% rate of nonmaturation of RCAVFs wa s significantly greater than the 27% rate for BCAVFs and 0% for TBAVFs (p < 0.05). The 33% cumulative primary patency rate at 18 months for RCAVFs was significantly less than 78% for BCAVFs and 79% for TBAVFs ( p < 0.001). Within and between groups, there were no significant diffe rences in age, gender, aspirin use, history of congestive heart failur e, erythropoietin use, hematocrit level, history of peripheral vascula r disease, or mortality rate. Conclusions: In patients with renal fail ure and a history of diabetes, both primary BCAVFs and TBAVFs demonstr ate significantly greater maturation and increased primary cumulative patency rates compared with RCAVFs; therefore, these autogenous condui ts are considered to be optimal in this group of patients. Whether the discrepancy in lower-arm vein maturation is a result of a lack of com pensatory increase in radial arterial flow or an intrinsic defect in t he lower-arm cephalic vein is currently under investigation.