FACTORS IN SUCCESSFUL OUTCOME IN RADIO-CEPHALIC AV FISTULA Dr. Venkateshwara Rao K, Dr. Aniruddha G, Dr.M. Ismail Dr. Sanjay Swain Dr. Sujata Patwardhan Dr Jayesh V Dhabalia Seth G S Medical College & K.E.M. Hospital, Mumbai

Introduction The distal autogenous arteriovenous fistula is the first option for permanent access for haemodialysis , permits easy repeated access to the circulation .However the primary reported failure rate is 12% to 24%

AIMS AND OBJECTIVES To assess the factors influencing the outcome of the fistula like quality of artery quality of vein patient on dialysis DM/HTN sex Type of anastamosis

MATERIALS &METHODS Retrospective analysis of 80 cases of radio-cephalic A-V fistula we operated in the last 3 years. Age-15 to 60 yrs Male /female-3:1 Left/ right-72/8

Materials & Methods Patients clinically assessed Venous –cephalic vein at wrist and arm Arterial – Allen’s test Hand exercises in pre and post op period Intra op –end-side / side-side

Materials & Methods hypertension and 14 patients diabetes mellitus. Associated co-morbidities:74 patients had hypertension and 14 patients diabetes mellitus. Etiology-CRF/ESRD secondary to various causes.

Materials & Methods Other factors analysed- condition of vessel wall End-side/side –side anastamosis DM/HTN whether patient started on dialysis prior to fistula.

RESULTS FACTORS T PATENT OCCLUDED P SEX- M 60 53 7(11.6%) NS F 20 18 2(10%) DM - NO 66 64 2(3.3%) S YES 14 7 7(50%) DIALYSIS NO 15 1(6.6%) 65 57 8(12.3%) HTN -NO 6 5 1(16.6%) 74 8(10.8%)

RESULTS FACTORS T PATENT OCCLUDED P ARTERY-G 78 71 7(8.9%) S 2 2(100%) 2(100%) VEIN- G 70 69 1(1.4%) 10 8(80%) ANAST-EE 20 18 2(10%) NS ES 60 53 7(11.6%)

RESULTS In our study predictors of poor out come were Poor quality of artery Poor quality of vein Patient on prior dialysis Presence of diabetes Sex, type of anastamosis does not seem to affect the outcome.

RESULTS There were total of 9 failures. 5 early-within 3 months 4 late-Good fistula function initially as evidenced by thrill.3 developed thrombosis with fistula closure after 6 m. 1 patient developed fistula closure following proximal vein thrombosis.

RESULTS Of 9 patients who developed failure 8 were diabetics ,8had a narrow caliber vein,8 had hypertension. Other complications wound infection- 3 patients.

DISCUSSION Patients with end-stage renal disease (ESRD) are dependent on long-term dialysis until transplantation is possible . There is consensus that the distal autogenous arteriovenous fistula is the first option for permanent access for haemodialysis (1).

DISCUSSION It was found that patients whose fistula was constructed before the start of dialysis had significantly better results than patients who were already on dialysis at the time of operation These patients were more likely to have indwelling central venous catheters as well as multiple punctures of lower arm veins during their stay in intensive care units (2,3)

DISCUSSION previous studies have associated female sex (4, 5,6), and greater age(5) with poor outcome,however our study fails to show them as poor prognostic factors.

DISCUSSION In our study patients with poor quality vein &artery had higher chances of failure ,more so if the patient was a diabetic.

CONCLUSIONS The quality of the vessels is the most important factor influencing the outcome of the fistula. If preoperative clinical evaluation of the wrist shows questionable vessel quality or caliber ,the surgeon must have a low threshold to consider a more proximal AV fistula particularly if the patient is diabetic.

CONCLUSIONS we should consider creating fistula at an early stage, preferably before dialysis has started.

REFERENCES 1) The Vascular Access Work Group. NKF-DOQI clinical practice guidelines for vascular access. National Kidney Foundation—Dialysis Outcomes Quality Initiative. AmJ Kidney Dis 1997; 30 (suppl. 3): S150–191 2)Koo Seen Lin LC, Burnapp L. Contemporary vascular access surgery for chronic haemodialysis. J R Coll Surg Edinb 1996; 41: 164–169. 3) Murphy GJ, White SA, Nicholson ML. Vascular access for haemodialysis. Br J Surg 2000; 87: 1300–1315 4)Colledge J, Smith CJ, Emery J, Farrington K, Thompson HH. Outcome of primary radiocephalic fistula for haemodialysis. Br J Surg 1998; 86: 211–216

REFERENCES 5) Enzler MA, Rajmon T, Lachat M, Largiade`r F. Longterm function of vascular access for hemodialysis. Clin Transplant 1996; 10: 511–515 6) Lazarides MK, Iatrou CE, Karanikas ID, et al. Factors affecting the lifespan of autologous and synthetic arteriovenous access routes for haemodialysis. Eur J Surg 1996; 162: 297–301

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