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Hemodialysis is a life-saving treatment for patients with end-stage renal disease, but it requires a reliable vascular access.
However, many patients who enter hemodialysis have compromised veins due to multiple hospital admissions and peripheral venous catheterizations.
Therefore, they often need prosthetic grafts to create arteriovenous fistulas (AVFs) for hemodialysis.
However, prosthetic grafts have several disadvantages compared to native AVFs, such as higher rates of infection, thrombosis, and failure, as well as lower patency and durability.
Native AVFs, on the other hand, have better outcomes in terms of infection resistance, hypotension tolerance, and complication repair.
In this study, we aim to demonstrate how we attempt to achieve 100% native AVFs in our patients, using various surgical techniques and strategies.
We performed a retrospective analysis of 1,003 AVF surgeries that were done in our center from September 2019 to July 2022.
Out of these, 425 (42.3%) were new AVFs.
We used native veins in 397 (93.4%) of the new AVFs, and prosthetic grafts in 28 (6.5%).
The types and locations of the veins that we used were as follows:
-radial vein in 69 (17.3%),
-cephalic vein in 78 (19.6%),
-middle vein of the elbow fold in 104 (26.1%),
-basilic vein transposition in 110 (27.7%),
-femoral vein transposition in 25 (6.2%),
- ulnar vein transposition in 11 (2.7%).
For the basilic vein transpositions, we performed them in one or two stages, depending on the vein diameter. We preferred two stages for veins smaller than 4 mm.
For the femoral vein transpositions, we performed them in patients who had exhausted upper limb veins.
A femoral vein transposition was performed in one patient with bilateral iliac vein occlusion,
We chose this technique over saphenous vein grafts because we observed early fibrosis.
We also avoided synthetic grafts as much as possible..
Out of the 397 new AVFs with native veins, we had
-16 (4%) cases of primary failure, which occurred in 7 cephalic, 3 basilic transposition, and 6 radial veins.
-Successful in 381 surgeries 96%
-The primary patency rate at 12 months was 94%, meaning that 374 AVFs were functioning well without any intervention.
We defined a good AVF as one that had a satisfactory anastomosis, diameter, and trajectory, that could be punctured in two sites three times a week, and that could provide adequate dialysis for about four hours with a good flow and without venous resistance.
We had few complications:
- 7 postoperative hematomas
- 3 wound infection, which were resolved without losing the AVF.
- 1 case of infrapatellar deep vein thrombosis in a patient with femoral vein transposition, which was treated with anticoagulation.
We demonstrated in this study how we successfully made natural AVFs for haemodialysis in patients with difficult veins, using different surgical methods and approaches.
Our natural AVFs had a high rate of primary patency and a low rate of primary failure, as well as minor complications.
The key factor is the creativity and skill of the surgeon when dealing with a challenging case, using options such as the basilic one.
Or even the femoral vein transposition.
It is clear that natural AVFs have more benefits than prosthetic grafts in terms of infection prevention, hypotension tolerance, and complication repair.
The other key to this success is the relationship with the Nephrologist and with Nurses.
Therefore, we strongly advise that natural AVFs should be the preferred option for vascular access in haemodialysis patients, both as a first choice and as a subsequent choice when a new access is needed.