Saving Fistula in Case of Distal Ischemia or High Flow: Literature Review of Current Surgical and Endovascular Techniques with Proposal of Decisional Algorithm

Introduction

The preferred vascular access in chronic hemodialysis patients is represented by arteriovenous fistula (AVF), considering lower incidence of infectious and thrombotic complications, reduced morbidity and mortality, and longer durability compared to central venous catheters [1, 2]. However, currently, setting up AVFs with native vessels is becoming increasingly challenging due to the increasing prevalence of chronic diseases such as the leading causes of end-stage renal disease (ESRD) (diabetes, hypertension, heart diseases) coupled with the aging of the dialysis population, resulting in an increase in peripheral vascular diseases [3]. In this scenario distal fistulas are often created in patients with advanced peripheral vascular diseases or proximal fistulas. The major issues in such conditions, as known, are represented by distal ischemic syndrome associated with hemodialysis access (Hemodialysis Access-Induced Distal Ischemia – HAIDI) and high-flow AVF.

HAIDI is characterized by the onset of ischemia of varying severity at the extremities of the limb where the AVF is present due to reduced capillary perfusion caused by reduced blood arrival or resistance to its outflow [4]. This condition can occur acutely within a few hours after fistula creation (more frequently in grafts) with serious consequences up to possible loss of hand function. The chronic form (more commonly observed in AVFs with autologous vessels), albeit rare, is more common and usually of milder severity but can still result in tissue necrosis, sometimes necessitating digital amputations [5, 6]. It is estimated that about 5% of all hemodialysis patients with AVF develop distal ischemic syndrome requiring corrective treatment [7]. From an etiopathogenetic point of view, the involved mechanisms appear complex and not yet fully defined.

According to some authors, the main factor would be the drop in arterial pressures towards the hand due to a non-physiological readjustment of the arterial circulation after fistula creation (especially in patients with advanced vascular diseases due to diabetes, older age with severe atherosclerosis) with poor or absent remodeling, resulting in a progressive loss of perfusion pressures towards the periphery [8]. Healthy individuals’ arteries are sufficiently elastic and capable of initiating such remodeling, maintaining perfusion pressures downstream. Conversely, diabetic and vasculopathic patients often have high arterial wall stiffness or actual stenotic lesions, not guaranteeing adequate wall remodeling [9]. Another mechanism implicated to varying degrees in the determination of HAIDI is the “steal” phenomenon that physiologically occurs in AVFs created without terminalization of the artery. The principle underlying the determination of a retrograde (centripetal) flow from the hand to the anastomosis is related to the fact that the distal artery “prefers” to channel flow into a low-resistance district (the efferent vein) rather than a high-resistance district (the resistive arterial vessels of the hand). This mechanism occurs “physiologically” in all AVFs where the distal artery of the anastomosis is not terminalized. The steal becomes pathological, causing distal ischemia when it is quantitatively excessive, as in the case of high-flow AVFs with excessively large anastomoses (this is referred to as true steal) or in case of maladaptation of the distal arterial circulation as explained earlier [10]. Also, preexisting or subsequently formed proximal or distal arterial stenotic lesions in the AVF can be responsible for worsening distal ischemia after AVF creation [11, 12]. Finally, another cause of distal ischemia can be represented by venous blood stagnation in the hand caused by the presence of arterialized venous collaterals directed towards the hand or in the presence of venous outflow stenosis. This is referred to as stagnant venous ischemia [13]. From what has been said, the etiopathological mechanisms determining distal ischemia can be multiple and often concomitant and not always easy to identify (Table 1).

Mechanisms	Causes
Proximal or distal preexisting arterial inflow reduction	Arterial stenosis
Arterial system maladaptation	Vasculopathy with calcification and increased arterial stiffness
True steel	High flow fistula with big anastomosis
Stagnant venous ischemia	Hand directed venous collaterals, outflow stenosis

Table 1. HAIDI etiopathogenesis. This table shows the main causes with the respective mechanisms underlying the development of distal ischemia in arteriovenous fistulas.

The definition of high-flow AVF varies and is ambiguous. Certainly, AVFs with high flow are those in which hemodynamics are influenced by blood flow far exceeding that required for hemodialysis, compromising overall circulatory dynamics [14]. The cardiovascular tolerance of a high-flow AVF is variable, with young patients able to tolerate flows of up to 3 liters per minute without hemodynamic compromise [15]. Some authors have identified a cut-off value between 1.5 and 2 l/min to define a high-flow AVF even in the absence of symptoms [16–18]. The Vascular Access Society indicates values above 1-1.5 l/min and associates an additional parameter, the “cardiopulmonary recirculation” (CPR), which is the ratio between the flow of the AVF and the cardiac output. When this index is >20%, there may be a risk of high-output decompensation. In short, it is not the absolute value of AVF flow that defines high flow but the ratio between its flow and the cardiovascular system’s capacity of that patient to maintain adequate cardiac output to manage the increased venous return without going into failure [19].

Distal ischemia and high-flow fistula conditions represent major issues in hemodialysis patients, difficult to manage outside specialized centers. Frequently, AVF ligation is the method used to resolve the issue, but it results in the loss of access for the patient. Bearing in mind the importance of maintaining AVF as a preferred vascular access, this work will present commonly used surgical and endovascular techniques, as well as new proposals, to restore proper AVF functioning by resolving ischemic issues or excessive flow. The techniques mentioned here can be classified into techniques involving intervention on the vein or artery and techniques of “remodeling” the anastomosis.

 

Vein

Vein Ligation

With this technique, the efferent vein of the anastomosis is exposed, and a silk ligature is applied and knotted to reduce the vein diameter (Figure 1a) aiming to decrease its flow rate [20]. Some authors suggest applying multiple ligatures to achieve an effective reduction in flow rate [21]. Some authors have developed a percutaneous, ultrasound-guided procedure, without surgical incision, for reducing the diameter of the efferent vein using a silk ligature [22]. The procedure involves using two needles, one in its normal configuration and the other curved; the curved needle, under ultrasound guidance, is used to pass beneath the venous vessel to be ligated, near the anastomosis. Through this needle, a silk ligature is then passed. The straight needle is passed above the vessel; through this, the silk ligature is brought back to the initial point for knotting. In the 26 patients treated this way, the authors describe a reduction in flow rate from 2196 to 679 ml/min, with these values maintained at one year follow-up, and a procedure duration of only 8.5 minutes.

Intraoperative monitoring of flow using color Doppler in procedures for reducing the diameter of the efferent vein can guide the extent and concomitant reduction of flow to the desired value [21, 23].

Miller Technique

An improvement over the previous technique involves ligating the efferent vein with a ligature assisted by the presence of an inflated angioplasty balloon inside the lumen to define controlled ligature caliber (Figure 1b). This is referred to as minimally invasive limited ligation endoluminal-assisted revision (MILLER) [24, 25]. This technique has shown technical success close to 100%, with clinical success in 50% of patients with distal ischemia and 100% of patients with high-flow fistulas [26]. Some authors have applied the same principle of controlling the extent of ligature.

Vein Plication

In this technique, after isolating the efferent vein of the AVF, a continuous suture is performed on the vein using a Satinsky clamp, resulting in a reduction in diameter (Figure 1c). Flow monitoring using Doppler helps determine the extent of plication before venoplasty [27]. Some authors have shown technical success in all cases treated, with symptom reduction in 92% and an average flow reduction of 600 ml/min [28].

Vein Banding

Like vein ligation but using a PTFE strip to create a sleeve approximately 20-30 mm in length wrapped around the efferent vein shortly after the anastomosis (Figure 1d). This technique has shown good success rates and maintenance of access functionality at 1 year [29]. Complications reported with this technique include band migration or venous aneurysmal dilatation both pre- and post-anastomosis [30]. To avoid these issues, some authors have proposed T-banding, characterized by using a portion of a PTFE prosthesis that is longitudinally opened and trimmed to fashion a structure capable of wrapping around the anastomotic chamber with the afferent and efferent arteries and the segment of the efferent vein, reducing its diameter but avoiding the complications [31]. With this method, these authors have shown a 44% reduction in flow with a primary and secondary clinical success of 72% and 90%, respectively.

Prosthetic Graft Interposition

After surgical dissection with isolation of the efferent vein, it is sectioned and a 5 mm prosthetic segment is interposed, 5 to 2 cm away from the anastomotic chamber (Figure 1e). This technique has shown technical success in 100% of 25 patients, with clinical improvement in 96% of treated patients [32]. Advantages include a lower recurrence rate of high flow, with a higher risk of access infections or thrombosis compared to simple banding [33].

Endovascular Vein Diameter Reduction

Several endovascular techniques have been described to reduce the diameter of the efferent vein, resulting in reduced flow. Some authors have placed a covered stent, flared at one end, at the post-anastomotic segment of the efferent vein, resulting in a reduction in the usable lumen diameter (Figure 1f), with improvement in ischemic symptoms and fistula flow reduction [34]. Other authors have used a similar technique in three patients, but in which a larger caliber, longer covered stent is inserted into a smaller caliber and shorter covered stent, creating an hourglass-shaped structure (Figure 1g), adhering at the ends to the vein wall but having an internal segment of smaller caliber, reducing flow in the AVF [35].

Management of Stagnant Venous Ischemia

In this condition, the presence of arterialized venous collateral vessels directed towards the hand, with or without obstruction in proximal outflow vessels, can result in increased pressure in the capillary venous side of the hand, resulting in “warm” ischemia, associated with edema. This condition can be resolved by ligating the vessels directed towards the hand with possible treatment of venous stenotic lesions when indicated (Figure 1h) [36].

 

Artery

Distal Artery Ligation

In distal forearm fistulas constructed with the radial artery, which is non-terminalized, distal radial artery ligation (DRAL) (Figure 2a) can be a resolving method for improving ischemic syndrome by interrupting retrograde flow from the hand to the fistula [37]. This procedure should only be performed after assessing the capacity of the ulnar artery, with the palmar arch, to provide adequate vascularization of the hand and is indicated for the treatment of distal ischemic syndrome [38].

Proximal Artery Ligation

Proximal radial artery ligation (PRAL) (Figure 2b) is used to reduce flow in AVFs with the radial artery in the distal forearm. AVF patency will be ensured by retrograde flow from the distal radial artery, through the palmar arch and the ulnar artery. In this case as well, the patency of these structures should be established before the procedure to avoid complete closure of the fistula. Burquelot et al. demonstrated a success rate of flow reduction in 92% of cases, with primary patency at 1 and 2 years of 88% and 74%, respectively, in 37 patients [39].

Distal Radial Artery Embolization

Unlike the previously described techniques, interruption of arterial flow in the distal radial artery can be performed endovascularly, using embolization coils [38, 40, 41] (Figure 2c). The endovascular approach can allow simultaneous treatment of stenotic lesions of the brachial, proximal radial, or ulnar arteries [42], reducing procedural times with less invasiveness compared to surgical approaches.

Angioplasty of Stenotic Lesions

The presence of stenotic lesions in the arterial system supplying the AVF can cause various forms of distal ischemic injury. Stenosis on the ulnar side can cause reduced blood flow to the hand in patients with distal radio-cephalic fistulas due to physiological “steal” from the radial artery [42, 43], or in proximal accesses with brachial artery stenosis and associated radial or ulnar artery lesions [44]. Endovascular treatment of such lesions with angioplasty can lead to rapid improvement in patient symptoms, with minimally invasive and rapid procedures (Figure 2d). The presence of calcified stenotic lesions can pose challenges. Recently, new techniques have been developed and used by vascular surgeons and cardiologists. Intravascular lithotripsy (IVL) allows for the fragmentation of calcium by emitting sound waves from a device placed inside the vessel [45]. We have recently begun using this equipment in the treatment of pre-existing arterial stenotic lesions at the time of fistula creation [46, 47] or in failed fistulas during maturation [48]. This opens the possibility of using this tool in the future for the treatment of calcified stenotic lesions causing distal ischemic syndrome.

Anastomosis

RUDI

Revision Using Distal Inflow (RUDI) is a surgical technique used to revise the anastomosis in fistulas with the brachial artery associated with distal ischemia with or without high flow. The technique involves isolating the anastomosis, ligating the efferent vein, and applying a prosthetic bridge between the post-ligation vein segment and the radial or ulnar artery [49, 50] (Figure 3a). This method remodels a proximal fistula with the brachial artery into a “distal” fistula by distal transposition of the inflow. This results in a reduction in access flow as well as reduced steal from the brachial artery. Variants of this technique have been described, involving ligation of the efferent vein, its sectioning with transposition and anastomosis with the radial or ulnar artery [51]. Literature reports a 50% reduction in access flow, improvement in symptoms and ischemic lesions, with primary patency at 3 and 12 months of 80% and 100% respectively [52]. Other authors described primary and secondary patency at 3 years of 48% and 84% respectively, with a postoperative flow reduction of approximately 65% [53]. Mallios recently described a new technique, performed on a patient, named endo-RUDI, in which he created an anastomosis between the proximal radial artery and the radial vein using the Ellipsys endovascular system and subsequently, during surgical time, anastomosed the basilic vein (efferent of the previous brachio-basilic access) with the radial vein, ligating the previous anastomosis. This achieved distalization of the inflow [54].

DRILL

Distal Revascularization with Interval Ligation (DRILL) is used to treat distal ischemic syndromes with or without high flow by “proximalizing” the bifurcation of the brachial artery in patients with proximal fistulas with the brachial artery. A prosthetic bridge (or using autologous veins such as the saphenous) is placed between the artery (brachial or axillary) upstream of the anastomosis and the brachial artery downstream of the anastomosis, followed by ligation of the artery between the anastomosis (with the vein) and the new distal anastomosis (Figure 3b). This remodels the pathological access as if it were a fistula with a terminalized radial or ulnar artery [55]. A challenge with this technique is that distal arterial perfusion depends on graft patency; therefore, some authors recommend not ligating the artery between the two anastomoses, although this limits the effectiveness of the procedure in reducing access flow. Literature reports an 80% technical success rate [56] with primary access patency rates at 12 and 24 months of 87% and 79% respectively [57].

PAI

Proximalization of Arterial Inflow (PAI). By placing a junctional prosthetic bridge between the brachial or axillary artery and the efferent vein of the fistula with ligation of the vein in the iuxtanastomotic tract, the access is remodeled by “recreating” a high bifurcation of the artery, eliminating the previous anastomosis (Figure 3c). In this procedure, useful for reducing symptoms related to distal ischemia in AVFs with or without high flow, the brachial artery is not ligated as in DRILL, avoiding possible complications of distal vascularization in case of graft thrombosis [58]. Graft thrombosis will result in non-functioning of the vascular access, without compromising upper limb vascularization. With this technique, primary and secondary patency rates of 87% and 90% at 1 year and 67% and 78% at 3 years are described, with a significant improvement in ischemic symptoms [59].

Radial Artery Transposition

This technique described by Bourquelot [60] reduces the flow of a pathological access with the brachial artery by dissecting the radial artery, proximally transposing it, and anastomosing it with the efferent vein of the previous AVF, suppressing the old anastomosis (Figure 3d). This creates a new end-to-end anastomosis with the radial artery, effectively reducing its flow through a modification of the inflow, which will be supplied by the radial artery. Technical success is reported in 91% of cases, with a 66% reduction in fistula flow. Primary patency at one and three years was 61% and 40% respectively, with secondary patency of 89% and 70%.

From the preceding chapters, it is evident that the techniques currently used to reduce the flow of a vascular access or to improve distal perfusion are diverse. These techniques may involve the venous compartment, the arterial compartment, or act through “remodeling” of the anastomosis. There are both surgical and endovascular techniques, some well-established and others emerging. Some of the described procedures have a greater impact on the flow of the AVF, while others focus on improving distal perfusion. As previously described, the pathophysiological aspects of high-flow fistulas and distal ischemic syndrome are often intertwined. Therefore, in practical terms, we may encounter three types of issues, which are easy to diagnose: high-flow fistulas without distal ischemic syndrome, high-flow fistulas with distal ischemic syndrome, and fistulas with distal ischemic syndrome without high flow. The aim of this review is to propose a decision-making algorithm, based on literature data, to indicate which procedures to implement for addressing these three categories (Table 2, Figure 4).

	Reducing flow	Reducing ischemia
Vein
Vein ligature	+++	+
Miller technique	+++	+
Vein plication	+++	+
Vein banding	+++	+
Prosthetic interposition	+++	+
Endovascular vein caliper reduction	+++	+
Artery
DRAL	+	++
PRAL	++	–
Distal radial artery embolization	+	++
Stenotic lesion angioplasty	–	+++
Anastomosis
RUDI	+	+++
DRILL	+	+++
PAI	+	+++
Radial artery transposition	++	+

Table 2. Available techniques. This table represents the effectiveness of the various techniques described in achieving flow rate reduction and/or improvement of ischemia in arteriovenous fistulas.

 

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