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Outcomes Of Antecubital Reconstruction For Dysfunctional Forearm Arteriovenous Fistulas
Bright Benfor, MD1, Amen Kiani, MD
2, Dylan E. Brook, MD
1, Cecilia Fenelli, MD
3, Surendra Shenoy, MD
2, Eric K. Peden, MD
1.
1Houston Methodist Hospital, Houston, TX, USA,
2Washington University in St. Louis, St. Louis, MO, USA,
3Ospedale San Giovanni Di Dio, Florence, Italy.
OBJECTIVES: This study aims to evaluate the outcomes of open surgical reconstruction for venous outflow blockade in the elbow, with a focus on preserving forearm arteriovenous fistulas (AVFs).
METHODS: This retrospective review included patients presenting to two academic centers between May 2016 and December 2022, with dysfunctional forearm AVFs requiring open surgical repair of the venous outflow in the elbow. The primary endpoint was functional cumulative patency at one-year while secondary endpoints included 30-day adverse events, primary and primary-assisted patencies at 1-year.
RESULTS: The cohort comprised 32 patients with a mean age of 56±16 years, including 61% males, 75% Black individuals, and 19% with a history of kidney transplant. All patients had radiocephalic fistulas, with 26 (81%) actively used for dialysis at the time of revision. The median access age was 36 months (IQR: 17-66 months). Clinical presentations included aneurysmal changes in 41%, prolonged access bleeding in 25%, acute thrombosis in 22%, and high pressures in 19%. Surgical techniques involved direct repair with cephalic to brachial vein transposition in 53% (n=17), graft interposition in 25%, and basilic vein to cephalic vein transposition in 22%. Direct repair included patch venoplasty in 5/17 cases. Adjunct interventions were concurrently performed in 21 (66%), with thrombectomy (n=10), aneurysm repair (n=5), and inflow revision (n=5) being the most frequent. Procedures were primarily conducted under loco-regional anesthesia (62%), with a total operating time of 130±57 minutes. Twenty-three patients (72%) were discharged the same day, and 86% could use their access at 30 days. One case of hematoma was reported at 30 days, with no other adverse events. The one-year primary patency, primary-assisted, and functional cumulative patencies were 62±9%, 87±6%, and 90±6%, respectively, with target lesion reinterventions occurring in 5 (16%). The mortality rate was 3% (n=1).
CONCLUSIONS: Antecubital reconstruction of forearm fistulas is associated with minimal 30-day adverse events and patency rates that compare favorably with reported outcomes in the literature. It should therefore be considered in the treatment algorithms of dysfunctional forearm AVFs for access preservation.
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