Radiocephalic wrist arteriovenous fistula for hemodialysis: meta-analysis indicates a high primary failure rate

AbstractObjectiveTo improve the precision of the estimates of primary failure rates and primary and secondary 1 year patency of radial-cephalic arteriovenous fistulas (RCAVF) for hemodialysis.DesignMeta-analysis.Materials and methodsA Medline search was performed of the English language medical literature between January 1970 and October 2002. Key words that were searched included radiocephalic fistula, arteriovenous shunt, Brescia-Cimino fistula and patency. Primary failure, primary and secondary patency rates were analysed using the standard mixed effects model, which allows for variability between the different studies.ResultsEight prospective and 30 retrospective studies were included. The analysis showed a pooled estimated primary failure rate of 15.3% (95% CI: 12.7–18.3%). In addition, the pooled estimated primary and secondary patency rates of 62.5% (95% CI: 54.0–70.3%) and 66.0% (95% CI: 58.2–73.0%), respectively, were calculated. Subgroup analysis concerning various study characteristics, including study year, gender and age, did not reveal statistically significant differences.ConclusionAlthough, the autogenous RCAVF is considered to be the primary choice for vascular access, this meta-analysis indicates a high primary failure rate and only moderate patency rates at 1 year of follow-up

Autogenous radial-cephalic or prosthetic brachial-antecubital forearm loop AVF in patients with compromised vessels? A randomized, multicenter study of the patency of primary hemodialysis access

ObjectiveThe construction of an autogenous radial-cephalic direct wrist arteriovenous fistula (RCAVF) is the primary and best option for vascular access for hemodialysis. However, 10%-24% of RCAVFs thrombose directly after operation or do not function adequately due to failure of maturation. In case of poor arterial and/or poor venous vessels for anastomosis, the outcome of RCAVFs may be worse and an alternative vascular access is probably indicated. A prosthetic graft implant may be a second best option. Therefore, a randomized multicenter study comparing RCAVF with prosthetic (polytetrafluoroethylene [PTFE]) graft implantation in patients with poor vessels was performed.MethodsA total of 383 consecutive new patients needing primary vascular access were screened for enrollment in a prospective randomized study. According to defined vessel criteria from the preoperative duplex scanning, 140 patients were allocated to primary placement of an RCAVF and 61 patients to primary prosthetic graft implantation. The remaining 182 patients were randomized to receive either an RCAVF (n = 92) or prosthetic graft implant (n = 90). Patency rate was defined as the percentage of AVFs that functioned well after implantation.ResultsPrimary and assisted primary 1-year patencies were 33% ± 5.3% vs 44% ± 6.2% (P = .03) and 48% ± 5.5% vs 63% ± 5.9% (P = .035) for the RCAVF and prosthetic AVF, respectively. Secondary patencies were 52% ± 5.5% vs 79% ± 5.1% (P = .0001) for the RCAVF and prosthetic AVF, respectively. Patients with RCAVFs developed a total of 102 (1.19/patient-year [py]) vs 122 (1.45/py; P = .739) complications in the prosthetic AVFs. A total of 43 (0.50/py) interventions in the RCAVF group and 79 (0.94/py) in the prosthetic graft group were needed for access salvage (P = .077).ConclusionsAlthough there were more interventions needed for access salvage in the patients with prosthetic graft implants, we may conclude that patients with poor forearm vessels do benefit from implantation of a prosthetic graft for vascular access