Forearm brachial artery to brachial vein looped arteriovenous grafts: A single center, single surgeon observational study.

BACKGROUND: Long-term hemodialysis (HD) treatment requires the establishment of a cannulatable vascular access (VA) point. While the arteriovenous fistula (AVF) is considered the gold standard, the arteriovenous graft (AVG) is a viable alternative especially in patients with poor superficial venous anatomy. Few studies have assessed the efficacy of the brachial-brachial arteriovenous graft (BB-AVG) for long-term HD access. By analyzing one surgeon's experience in creating, surveilling and maintaining BB-AVGs, this retrospective study aims to add to the body of literature in assessing patency outcomes of BB-AVGs. METHODS: We identified 57 BB-AVGs that met inclusion criteria and were created between October 6, 2005 and May 1, 2019 by a single surgeon in 54 patients. We analyzed primary failures, patency, complications and interventions. Patency rates were calculated by the Kaplan-Meier method. The incidence of complications and interventions were expressed as number of events per person-year. RESULTS: A total of 54 patients (median age of 65 years) were analyzed. Primary patency rates at 12, 24, and 36 months were 20.4% 7.4%, and 5.0%. Primary assisted patency rates at 12, 24, and 36 months were 46.7%, 33.5%, and 15.1%. The secondary patency rates at 12, 24, and 36 months were 81.8%, 63.8%, and 60.1%, respectively. The incidence of complications and interventions was 2.164 per person-year. Most complications and interventions were due to stenosis (1.202 per person-year) or thrombosis (0.802 per person-year). CONCLUSION: In patients with poor superficial veins, the brachial vein is a reasonable alternative to use as the venous outflow. However, in order to achieve acceptable patency rates, close monitoring of the VA, as well as aggressive treatment of complications within the brachial vein is necessary. Overall, the BB-AVG should be considered in patients who lack adequate superficial veins and require preservation of the more proximal veins.

Developing Duplex Ultrasound Criteria for Diagnosis of Arteriovenous Fistula Stenosis.

BACKGROUND: The purpose of this study was to determine the best color-flow duplex ultrasound (US) criteria for the detection of significant stenoses in arteriovenous fistulas (AVFs) by comparing US with the angiographic gold standard. METHODS: Included in this retrospective study were all patients who had both US scans and angiograms of their AVFs performed from December 2008 to July 2015. Comparisons were made between the preoperative US peak systolic velocity (PSV) measurements and the angiographic images looking at the percent diameter reduction in the stenosis. The PSV ratio between the area of stenosis and the normal segment on the inflow side of the stenosis (systolic velocity ratio [SVR]) was also compared with the angiograms. Sensitivity and positive predictive values (PPV) with 95% confidence intervals were calculated. RESULTS: This study included 780 cases of stenotic accesses (47 brachiobasilic, 361 brachiocephalic, and 372 radiocephalic). PSVs of ≥500 cm/s predicted a 50% or greater stenosis with a sensitivity of 89% (95% confidence interval 87-91) and PPV of 99% (99-100). At lower PSVs, sensitivity and PPV remained high; however, there were an increased number of false positive cases compared with those at 500 cm/sec or greater. The SVR was unreliable in predicting the degree of stenosis in AVF. CONCLUSION: PSVs of ≥500 cm/sec are generally reliable in predicting stenosis of 50% or greater in AVFs.