Ag. Hakaim et al., SUPERIOR MATURATION AND PATENCY OF PRIMARY BRACHIOCEPHALIC AND TRANSPOSED BASILIC VEIN ARTERIOVENOUS-FISTULAS IN PATIENTS WITH DIABETES, Journal of vascular surgery, 27(1), 1998, pp. 154-157
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.