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| Journal of Vascular Access 2005; 6: 92 - 92 |
| Radial artery transposition as an alternative to upper arm arterio-venous fistula: Outcome of 5 cases |
H. Tokgoz1, S. Sert2
1Department of Urology, Ankara Cankaya Hospital, Ankara - Turkey
2Transplantation Unit, Faculty of Medicine, Gazi University Ankara - Turkey
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ABSTRACT
No abstract
Dear Editor,
We read with interest the article by Dr. Barama et al (1). The authors compared long-term patency rates of wrist arterio-venous fistula (AVF), upper arm AVF, basilic vein transposition, forearm prosthetic graft and upper arm prosthetic graft operations performed by 2 different surgeons. We agree with Dr. Barama that creation of wrist AVF, prolongs the option of hemodialysis access in the same arm. However, it has a high rate of early failure. Prosthetic grafts do not seem a good second choice after failure of a wrist AVF. One and two year patency rates of prosthetic AVF were lower than native grafts in the study of Dr. Barama. Upper arm fistula is a reasonable alternative for maintenance hemodialysis access when radio-cephalic AVF is not possible. Last year, Dr. Fitzgerald and associates reported their results with brachiocephalic, brachiobasilic and brachial artery-to-median antecubital vein AVF (2). Their overall primary and assisted primary patency rates at the end of 1 year were, 50% and 74%, respectively. Actually, these results were lower than we had expected.
As an alternative to these widely used techniques, we performed end-to-end anastomosis between radial artery and cephalic vein in 5 cases. We dissected radial artery from the forearm, divided at the wrist and then turned upwards to reach the vein at the elbow. We transposed radial artery, because it was impossible to approach the artery and the vein for side-to-side anastomosis in the wrist region. With Allen test and colour-flow ultrasonography done preoperatively, we were sure that ulnar artery was patent in all cases. During early postoperative period, we did not observe any complications like bleeding, hematoma formation or infection. At the follow up examination 3 months later, no late complications were seen like thrombosis and inability to access. All fistulas achieved maturity at the end of 3 months. But, one main problem during construction of end-to-end anastomosis, is kinking of artery after transposition. To prevent this, the artery should be turned with a wide angle to the vein site. Finally, we would like to mention that failure rate of radiocephalic AVF may decrease if end-to-end anastomosis could be created in problematic cases. Also, the stenoses at the anastomosis site and on the inner wall of the curved region of the cephalic vein which were previously defined in end-to-side radiocephalic AVF, could be prevented by this way (3). So, the AVF will mature earlier and the risk of thrombosis in the anastomotic site would decrease. By this way, native AVF with higher patency rates than wrist AVF should be achieved, and the use of brachial artery as an early alternative would be prevented. We thank Dr. Barama for this insightful and interesting article.
Hüsnü Tokgöz1, Sevki Sert2
1Department of Urology, Ankara Cankaya Hospital
2Faculty of Medicine, Transplantation Unit, Gazi University, Ankara - Turkey
Address for correspondence:
Dr. Hüsnü Tokgöz
Çukuranbar Mah. 41. Cad. No: 2/ 35 Balgat Ankara - Turkey h_tokgoz@hotmail.com
REFERENCES
1. Barama AA. Evaluating the impact of an aggressive
strategy to create wrist arterio-venous fistula
in patients on hemodialysis. Journal of Vascular
Access 2003; 4: 140-5.
2. Fitzgerald JT, Schanzer A, Chin AI, McVicar JP,
Perez RV, Troppmann C. Outcomes of upper arm
arteriovenous fistulas for maintenance hemodialysis
access. Arch Surg 2004; 139: 201-8.
3. Sivanesan S, How TV, Bakran A. Sites of stenosis
in AV fistulae for haemodialysis access. Nephrol
Dial Transplant 1999; 14: 118-20.
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H. Tokgoz
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