Introduction:
Guidelines from various renal and vascular societies recommend autogenous arteriovenous fistula (AVF) as the primary option for vascular access for hemodialysis. A well-functioning AV fistula is associated with the lowest health and economic burden for patients on hemodialysis. However, AV fistula failure rate is very high at around 50% at one year. It has been postulated that since regional anesthesia (RA) nerve blocks may increase vasodilation and blood flow during AV fistula creation, they improve fistula success.
Methods:
The prospective observational cohort study was conducted between January 2023 to June 2023(period during which the surgeries were done) and patients were subsequently followed up for a minimum of one year. All consecutive hemodialysis patients referred to a single surgeon was taken up for surgery after requisite pre-anesthetic check- up and consent. The preferred site for surgery was distal forearm. In cases where the vein in the distal forearm was deemed too small, the cephalic vein in the cubital fossa was used for an end-side AV fistula. All patients had an end-side AV fistula.
In theatre, the regional block was administered to all the patients before the surgery. Axillary brachial plexus block is indicated in surgery on elbow, forearm, and hand. It is relatively simple to perform and is associated with a lower risk of complications compared with supraclavicular brachial plexus blocks (eg, pneumothorax). The skin is disinfected, and the ultrasound transducer is positioned in the short axis orientation to identify the axillary artery. Surrounding the artery the major branches of the brachial plexus is present. Once, the artery is identified, the anesthetic agent is deposited posterior to the artery and subsequently the adjacent nerves are blocked. After adequate regional anesthesia and surgical dissection, a tension free end to side anastomosis of the radial artery and the cephalic vein is done using 7/0 or 8/0 prolene depending upon the size of the artery. Ball squeeze exercises are started the following day and patient is called for a wound review after 7 days.
On follow up, the fistula function and patency is noted. The status of the fistula at 6 months and one year was noted. Primary failure was defined as a fistula which was never used or it failed within 3 months. Secondary failure was defined as a working fistula which fails permanently.
Results:
A total of 23 AVF were constructed. There were 14 males in this cohort. The mean (sd ) age of the group was 55.20(10.92) years. The mean (sd) hemoglobin in g/dl was 9.11(1.53) and the mean(sd) serum creatinine was 8.00(3.33) mg/dl. Of the 23 fistula two were primary failures and one failed at 6 months after working well initially (secondary failure). At 6 months 20 fistulas were functioning well and at 1 year 17 were working. The one- year patency rate of this cohort was 73.9 %. This compares favorably with current success rates in AVFs constructed with local anesthesia. There was no surgical wound infection.
Conclusions:
AVF constructed with regional axillary block has better patency rates at 1 year as compared to AVFs constructed local anesthesia. The postulated mechanism of better patency rates is because of the vasodilation secondary to regional nerve block.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.