Distensibility in a Small Size Vein as a Factor for Brachiocephalic Arteriovenous Fistula Maturity: A Single-centre Experience
Ab s t r Ac t Introduction: National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines require an arterial diameter of more than 2 mm and a venous diameter of more than 2.5 mm for arteriovenous fistula (AVF) creation. The failure rate in vein diameters of less than 2 mm is as high as 40%. An audit done in Hospital Kuala Lumpur demonstrated that up to 67% of patients who are referred for AVF creation have veins smaller than 2.5 mm. So as per the NFK-KDOQI guidelines, creation of AVF is not suitable for them. Objective: The objective of this study is to demonstrate venous distensibility as a reliable assessment tool prior to fistula creation in small size veins (1.6–2.4 mm). Materials and methods: A single-center prospective study was conducted at the Vascular Unit, Department of Surgery, Hospital Kuala Lumpur (HKL). Sixty patients with cephalic veins in cubital fossa 1.5–2.4 mm were assessed per the standard care for fistula creation. A tourniquet was applied using a sphygmomanometer cuff and inflated to occlude superficial venous return. Preand post-compression readings were taken at cubital fossa at 3 cm and at 6 cm above the cubital fossa. Patients were planned for surgery per the standard care. Follow-up was done at 2 weeks for clinical assessment, at 6 weeks to determine the maturity for early access, at 3 months to identify mature fistula, and at 6 months to identify any failure of fistula maturity if any, after the intervention. Results: The mean vein diameter of selected veins was 2.1 mm. The mean percentage of vein distention preoperatively for fistula maturity with a tourniquet was 30%. Five patients did not turn up for follow-up. One fistula thrombosed, one fistula was ligated due to the steal syndrome, and three patients passed away from myocardial infarction. The total number of patients recruited was 60, five patients dropped out for reason as stated. Hence, 55 patients developed mature fistulas. Conclusion: Venous distensibility as a preoperative assessment tool in patients with smaller veins can be used to select a larger number of patients for the creation of AVF without compromising fistula patency and maturation rate.