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Surgeon-Performed Intraoperative Vein Mapping Facilitates Timely Creation of New Arteriovenous Access
Jeffrey B. Edwards, BS, Zachary B. Fang, Susan M. Shafii, MD, Luke P. Brewster, MD, Shipra Arya, MD, Yazan Duwayri, MD, Ravi K. Veeraswamy, MD, Thomas F. Dodson, MD, Ravi R. Rajani, MD.
Emory University School of Medicine, Atlanta, GA, USA.
Objective:
Preoperative duplex ultrasound is routinely performed prior to upper extremity arteriovenous (AV) access creation. Socioeconomically disadvantaged patients, however, may not have the resources necessary to obtain such testing. Focusing on surgeon-performed intraoperative ultrasound, we present a streamlined algorithm to minimize the need for preoperative testing in resource-poor environments.
Methods:
All patients referred for first-time arteriovenous access creation at an urban county hospital were initially assessed with a full history and physical exam, including bilateral upper extremity blood pressure measurements. Unless an abnormality was identified, no other preoperative testing was performed. Patients were consented for creation of arteriovenous access, and all potential outcomes were explained to them. Intraoperatively, the patient’s non-dominant arm was examined by the operating surgeon using duplex ultrasound. The cephalic and basilic veins were evaluated for diameter (>2.5 mm), presence of large branches, and continuity to their draining confluences. Radial and brachial arteries were examined for size, patency, and the presence of significant calcification. Priority was given to access creation in the following order: radiocephalic, radiobasilic, brachiocephalic, brachiobasilic, and AV graft placement.
Results:
95 consecutive patients treated with this algorithm were included (age 53 ± 13 years; ESRD 56%). 87 patients (92%) received a primary AV fistula (37% brachiocephalic, 31% radiocephalic, 24% basilic transposition, and 8% arm AV graft). On average, intraoperative duplex ultrasound took an additional 6.2 minutes. Unassisted maturation was achieved in 57% of patients. The six-month assisted primary patency was 65%. There was a 14% complication rate, including an infection rate of 1% and a clinically significant steal rate of 3%.
Conclusion:
Permanent AV access creation is able to be performed at success rates similar to previously published results with no specific preoperative testing other than a thorough physical exam. Intraoperative surgeon-performed venous mapping can be performed with minimal added operative time, thus obviating the need for any preoperative studies. Such success is able to be accomplished while maintaining a very high rate of primary fistula creation.
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