A 10-YEAR EXPERIENCE OF BRESCIA-CIMINO ARTERIOVENOUS-FISTULA IN CHILDREN - TECHNICAL EVOLUTION AND REFINEMENTS

Purpose: The arteriovenous fistula (AVE) of Brescia-Cimino fulfills ne arly all of the criteria for an optimal access for chronic hemodialysi s, such as long-term patency rate, low complication rate, and respect of vascular morphologic features. Alternative dialytic methods (i.e., external shunts and vascular grafts) cannot easily be applied to pedia tric patients, and in addition, these methods are responsible for high er complication rates. Methods: From January 1985 to December 1994, 11 2 Brescia-Cimino AVFs were performed in 90 children (average age, 5.5 years; range, 5 months to 18 years). The average weight of the childre n was 28 kg (range, 6.5 to 54 kg); 16% of AVFs were performed in child ren who were less than 5 years old, and 18% in children who were less than 15 kg in body weight. Results: Chronic renal failure was caused b y a nephropathy in 53 cases (14 with a nephrotic syndrome), and 37 cas es had a uropathy. In all cases a phlebography was performed before th e microsurgical treatment. Since 1994 an inflatable tourniquet has bee n placed on the selected upper arm because of an optimal exsanguinatio n of the operating field. The primary patency rate was obtained iu all but six of the children; 35% of AVFs had either immediate or late com plications. Thrombosis was the most frequent complication that we obse rved. In comparison with 79% of late thrombosis, 60% of early thrombos is was cured. Of the 80 AVFs, 63.5% with a 4-year follow-up are still patent. Conclusion: We emphasize the following two conclusions: first, microsurgery is essential to create AVFs with good results in childre n as well as in adult patients; and second, the results improved after the adoption of an upper-arm exsanguination and ischemia (pressure ra nge, 400 mm Hg to 600 mm Hg) that avoided spasm of the vessels with a final 35% reduction in surgical time.