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Medial Cephalic To Proximal Ulnar Artery Fistula Creation Enabled By A Nitinol Extravascular Support
George Blessios, MD, FACS.
Kaleida Health/Millard Fillmore Suburban Hospital, Buffalo, NY, USA.
OBJECTIVES:Brachial-based arteriovenous fistulas (AVFs) carry the highest risk of steal and potential to develop high flow that can lead to cardiovascular insult. The proximal ulnar artery is rarely used due to its depth and risk of external compression from the dense surrounding muscular tissue. Here, we evaluate a nitinol extravascular support device to prevent compression and facilitate the maturation of a medial cephalic to proximal ulnar artery fistula (proxUCF).
METHODS:Consecutive patients, not eligible for a more distal AVF, were included if they had a suitable medial cephalic vein diameter (≥2.5 mm) and proximal ulnar artery volume flow (20 ml/min) confirmed via pre-operative ultrasound. All procedures were performed by a single surgeon, under local anesthesia with sedation. Access was gained by a transverse incision at the level of the target creation site. The proximal ulnar artery and medial cephalic were surgically mobilized. The vein was dissected and threaded through a nitinol extravascular support. The anastomosis was created, and the extravascular support secured place over the anastomosis. Patients were evaluated at 2 and 4 weeks for maturation via 600 ml/min arterial flow and 6 mm vein diameter.
RESULTS:ProxUCF were created in 22 patients from March to August 2024 with a mean age of 69 years, 55% female, 65% white, 50% on dialysis, 50% diabetic, 100% hypertensive and mean BMI of 29. The mean pre-operative diameters were 4.1 arterial and 4.0 venous. The 2-week follow-up included 20 patients excluding one death and one lost to follow-up, and the 4-week follow-up included 15 patients with an additional death and the remaining four not yet scheduled. Cephalic vein outflow was the target for 82% (18/22) and basilic vein outflow in 18% (4/22), which have undergone (2/4) or are scheduled for a second-stage superficialization. Maturation at 2-weeks and 4-weeks was 75% (15/20) and 93% (14/15), respectively, with a 95% (19/20) cumulative patency. One intervention has been required, which was a percutaneous thrombectomy due to a pre-existing outflow stenosis from cannulation injury.
CONCLUSIONS:The study suggests that, in the selected patient cohort, extravascular support enables creation of a proxUCF with high maturation and patency rates in the short-term. This study could have implications for expanding the use of the proxUCF to patients who meet the criteria outlined here.
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