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Use Of A Small Arteriovenous Anastomosis In Dialysis Access Creation
Asma Mathlouthi, MD, Michael Turner, MD, Mahmoud Malas, MD, MHS, Omar Al-Nouri, DO.
University of California, San Diego, San Diego, CA, USA.

OBJECTIVES: Size selection of the arteriovenous (AV) anastomosis in access creation requires careful thought. AV anastomosis diameter must be large enough to accommodate sufficient flow, but small enough to minimize the complication of steal syndrome. Steal syndrome affects up to 10% of patients after creation of AV fistula (AVF) with sometimes devastating complications. Conventional teaching recommends an 8-10 mm anastomosis. We sought to assess the efficacy of using a smaller (5-6 mm) anastomosis in new arteriovenous fistula creation. METHODS: We conducted a comparative retrospective analysis of patients undergoing fistula creation with a small versus regular size anastomosis at any upper extremity anatomic site between January of 2019 and April of 2020. Anatomic sites included radiocephalic, brachiocephalic and brachiobasilic. All anastomoses were measured intra-operatively to be 5-6 mm in diameter for the small size groups and 8-10 mm for the regular size group. Endpoints included steal syndrome, functional patency, primary patency and secondary patency.
RESULTS: 86 patients underwent AVF creation; 50% received a 5-6 mm anastomosis. Mean follow-up was 126 months. Patients demographics and comorbidities were similar between the two groups. Patients in the small size group were more likely to undergo a radiocephalic fistula when compared to their regular size counterparts (40.5% vs. 9.3%, P<0.001). During follow-up, none of the patients in the small group developed a steal syndrome (0% vs. 9.3%, P=0.04). At 6 months, patients in the regular size group achieved higher rates of primary patency (78.8% vs. 58.6%, P=0.05). However, no difference was seen in 6-month secondary patency (89.5% vs. 86.8%, P=0.7) nor in functional patency (75% vs. 74.2%, P=0.9) between the small and regular size groups, respectively. CONCLUSIONS:
The use of a 5-6 mm anastomosis in the creation of new arteriovenous fistulas of the upper extremities appears to be a technically safe option for dialysis access. Our experience suggests that smaller anastomosis still creates enough flow to maintain a functional AV access while minimizing the incidence of steal syndrome. However, smaller anastomosis fistulas were associated with lower rates of primary patency and increased incidence of secondary interventions. No difference was seen in secondary or functional patency. Larger studies with longer follow-up are needed to evaluate long-term outcomes of small anastomosis fistulas.


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