Arteriovenous fistula at the wrist region is the
most recommended type of vascular access, and
antecubital area fistulas created with anastomosis
of veins to particularly radial artery are good access
options.[
9] Our study showed the feasibility of AVF
construction between the antecubital perforating vein
and proximal radial artery with acceptable primary
and secondary patency rates up to 24 months. Our
patency results are consistent with other published
reports using the cubital perforating vein and radial
artery for AVF creation.[
6,
8] In the study by Weyde
et al.,[
8] the AVF between the antecubital perforating
vein and radial artery had primary patency rates of
47% at one year and 43% at two years with cumulative
patency rates of 67% at one year and 56% at two years.
In another study, Elcheroth et al.[10] reported the
cumulative patency rates of antecubital perforating
vein-brachial artery fistulas as 80.3% at one year
and 68.0% at four years. In this study, the patency
results are higher than our patency rates. The use of
brachial artery instead of radial artery is the probable
explanation of this fact and the radial artery has a
smaller diameter and slower blood flow, compared to
the brachial artery. In contrast, using brachial artery
also provoked steal syndrome and hand ischemia as
reported in the study, which did not develop in any
of our patients. In the literature, acute or chronic
ischemia symptoms have been reported in up to 20%
with brachial artery-based access procedures and
2% with radial artery procedures, and also nearly
half of the patients with the brachial artery required
interventions due to severe hand ischemia.[11,12]
The blood flow through the AVF is limited by
anastomosis width and diameter of the fistula vein,
making anastomosis with brachial artery may produce
steal syndrome or cause hyperkinetic blood flow with
a possibility of circulatory insufficiency. That is the
exact reason of why Konner[13] advised AVF creation with proximal radial artery at the antecubital region,
particularly for diabetic patients with probability of
peripheral circulatory insufficiency. In our study,
we observed no symptoms of steal syndrome even in
diabetic and older patients.
Our method for harvesting and preparing the
antecubital perforating vein was relied on ligating the
vein at the connection point with deep veins without
any damage to the deep vein circulatory system.
Using this method may prevent severe hand edema
during hemodialysis and during future vascular access
attempts.
The modest-flow AVFs constructed with the
radial artery offer a lower risk for patients with
congestive heart failure and should be preferred for
particularly in older patients.[14] These modest-flow
AVFs are also more likely to remain asymptomatic
without severe edema in patients with central venous
occlusion or stenosis, as the existing collateral
venous return is usually enough for the flow.[15] It is
speculated that the vein wall shear stress is directly
related to the high flow and turbulence and, thus,
lower flows may decrease neointimal hyperplasia in
the veins with less turbulence and pressure.[16] In our
study, stenosis and occlusion at the AVF tract were
rare and two juxta-anastomotic stenoses and one
central vein occlusion were noted.
The origin and the proximal part of the radial
artery is usually free from occlusive vascular
disease.[14] This advantage gives a few more vascular
access options via the proximal radial artery as
anastomosed with the proximal cephalic vein or
antecubital perforating vein. This type of AVFs
provide a more accessible cannulation length
compared to typical brachiocephalic fistulas. In
brachiocephalic AVFs, the possible cannulation
length may be shortened by rotating the vein to the
brachial artery.
Nonetheless, the single-center, retrospective design
with a small sample size are the main limitations to the
present study. In addition, we were unable to evaluate
the results of Gracz AVFs created with the perforating
antecubital vein and brachial artery in this study.
In conclusion, arteriovenous fistulas constructed
with the antecubital perforating vein and radial artery
is a feasible method with acceptable patency and low
complication rates, particularly for steal syndrome.
The arteriovenous fistula creation failure at the wrist region in the distal part of the forearm may cause
a dilemma regarding the second site selection for
another access. The arteriovenous fistula creation
through the antecubital vein may be the second
choice, when the forearm vasculature is exhausted. In
such cases, antecubital perforating vein-radial artery
arteriovenous fistulas should be kept in mind with
low complications before creating an arteriovenous
fistula through the brachial artery.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.