Novembre Dicembre 2020 - Articoli originali

How to create and preserve distal fistulas in a large number of patients: the experience of a single centre


Background: Distal arterio-venous fistula (AVF) is considered the gold standard for vascular access in hemodialysis. The aim of this retrospective study is to report our experience on two innovative techniques, Intraoperative Transluminal Angioplasty (ITA) and Vessel Pre-Dilatation (VPD).
Methods: We collected data from all the consecutive patients directly admitted to our Department from January 2014 to October 2018 in order to create or repair an AVF. Early Failure (EF), Failure to Mature (FTM), Late Failure (LF), Primary and Secondary patency rate were evaluated.
Results: All patients underwent VPD; of the total 647 AFVs, 128 received an ITA for the presence of suboptimal vessels. 98.3% of AVFs were located on the forearm. EF occurred in 83 cases; in 67 of these a new AVF was successfully created upstream from the previous one. LF occurred in 100 cases; of these, the access was abandoned in 32 cases and we performed a new AVF upstream from the previous one in 68 cases. FTM occurred in 57 cases, 31 of which were treated with Percutaneous Transluminal Angioplasty (PTA) whilst 26 were resolved performing a new anastomosis upstream. Primary and secondary patency at 1, 2, 3 and 4 years were, respectively, 80%, 74%, 68%, 64% and 94%, 91%, 89%, 88%. By dividing patients into an ITA group and a control group, we did not find any difference in primary and secondary patency.
Conclusions: VPD and ITA could be useful to increase the incidence and the prevalence of distal AVF.

Keywords: intraoperative transluminal angioplasty, vessel pre-dilatation, distal arterio-venous fistula, early failure, failure to mature, late failure, patency


International guidelines such as K-DOQI support the use of distal native fistula (AVF) as the best first-line vascular access (VA) [1,2] that guarantees the least amount of complications (stenosis, overflow syndrome, thrombosis and distal ischemia) [14]. Despite these indications, all over the world except in Japan the number of AVFs in the upper arm, and related complications, is constantly increasing [5]. As suggested by Bourquelot, the prevalence of distal AVFs may be increased through additional procedures capable of incentivizing the maturation process or establishing a more reliable inflow or outflow [3]: early referral to the surgeon, precise preoperative Ultrasound Vascular Mapping (UVM) of vein and arteries, post-operative clinical and Duplex evaluation of maturation, Percutaneous Transluminal Angioplasty (PTA) of artery and vein stenosis, or surgical procedure in case of frequent relapses or failure of the PTA. To increase the incidence of distal AVFs our team has specialized in vascular access surgery from 2004 onwards, and has progressively introduced Intraoperative Transluminal Angioplasty (ITA) [710] and Vessel Pre-Dilatation (VPD) in clinical practice [8]. 

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