![clinicsofsurgery.com 2
Volume 8 Issue 1 -2022 Research Article
exhibit the best patency rates with lower frequency of infection,
thrombotic and non-thrombotic complications, compared to arte-
riovenous graft or tunneled central venous catheter [1, 2, 3]. Al-
though there is no minimum diameter threshold to AVF creation,
cephalic veins less than 2mm in diameter should be considered
meticulously, as their primary patency was only 16% compared to
76% in those with diameter greater than 2.0mm [4, 5]. In order to
facilitate the use of smaller cephalic veins, there are several stud-
ies suggesting different plausible methods such as intraoperative
Plain Balloon Angioplasty (PBA), Balloon Assisted Maturation
(BAM), accessory vein ligation, based on patient’s condition and
operator’s clinical evaluation [3, 6-11]. These studies facilitating
intraoperative Plain Balloon Angioplasty (PBA) showed satisfy-
ing AVF maturation and patency. -10 However, the effectiveness
of PBA with non-compliant balloon in retrieving cephalic veins <
2.0mm for long term functional use is still not well established in
ESRD patients. Furthermore, the risk factors related to decreased
functional primary patency rate have not been clearly identified.
Therefore, this study aimed to evaluate the efficacy of intraopera-
tive PBA with non-compliant balloon on maturation rate, primary
patency and secondary patency rate in radiocephalicAVF surgeries
while attempting to identify the risk factors that affected primary
patency rate.
3. Patients and Methods
This study was approved by the institutional review board of our
institution (IRB: 202001393B0). This was a single center retro-
spective study including all patients who received intraoperative
PBA intervention during AVF creation from June 2013 to Decem-
ber 2017 and observations of the outcome were continued to 1st of
May 2018. Inclusion criteria were all patients with cephalic vein
diameters greater than 1.0 mm, less or equal to 2.0 mm (found
intraoperatively) and with consequent plain balloon angioplasty
performed during the same operation. Patients with brachioce-
phalic AVF creation, failed intraoperative PBA, loss of follow up
or death within one month were excluded. A total of 84 patients
were included and Figure 1 is a flow chart showing patient selec-
tion. Demographic data on age, gender, and co-morbidities such as
diabetes, hypertension, cigarette smoking, stroke, coronary artery
disease and peripheral artery disease were collected.
All surgeries were performed by the same cardiovascular surgeon,
Dr. Yen. After local anesthesia with lidocaine 1%, a 3.0 cm lon-
gitudinal incision was made on the lateral side of the wrist. The
radial artery and cephalic vein were dissected and isolated. After
clamping both vessels, venotomy and arteriotomy were performed
respectively. Proximal runoff in the cephalic vein was examined
gradually using a series of coronary dilator, starting from 1.0 mm.
In cases where coronary dilator could not be passed easily (1.0
- 2.0mm) with resistance or where backflow was inadequate, ul-
trasound was used to examine possible stenosis or sclerotic site.
After stenosis site was identified, balloon angioplasty was carried
out. A non-compliant balloon catheter, 4.0 mmx150 mm (Pacific
Extreme, Medtronic, USA) was inserted from the venotomy site to
the forearm level. The balloon was over the wire and was inflated
to a pressure of 6-8 atmospheres slowly for one minute. Whilst
performing long segment balloon dilation, another hand was
placed over the balloon to palpate the balloon inflation to avoid
over expansion. After balloon angioplasty, the cephalic vein was
irrigated with heparin solution (50 IU/ml) to verify if there had
been any free rupture of the venous wall. The vein was then exam-
ined again using a coronary dilator up to elbow level. End to side
or side to side anastomosis of the artery and vein was done using
Prolene 7-0 running sutures. Immediate intraoperative success was
defined as the presence of thrill during palpation after declamping
of arteries and veins. If thrills could not be confirmed, the AVF
was considered to have failed and further vascular access creation
would be carried out according to the patient’s condition.
The functional maturation of AVF was defined as successful can-
nulation of fistula for smooth flow hemodialysis one month after
surgery. The outcomes of the study are the duration of primary
patency and secondary patency in days. Primary patency was de-
fined as the interval from the time of AVF creation to thrombosis
or stenosis of AVF requiring Percutaneous Transluminal Angi-
oplasty (PTA) to re-establish patency or to remove a thrombus.
While the secondary patency was defined as the interval from the
time of AVF creation to either AVF abandonment or endpoint of
study which was the 1st of May 2018 [2]. Patients were further
followed up at cardiovascular surgeon outpatient department one
week after surgery to examine if arteriovenous fistula is still intact.
One month postoperatively, patients would undergo hemodialysis
as scheduled and further follow up every three months at cardio-
vascular surgeon outpatient department or whenever thrombosis or
stenosis of arteriovenous fistula was suspected.
The demographic data of patients, categorized according to wheth-
er they had received PTA or not, was examined with the chi-square
or Fisher’s exact test. Patency rate curves and univariate analysis
of risk factors related to functional primary patency were estimat-
ed using the Kaplan-Meier method while the multivariate associa-
tion of risk factors was analyzed with Cox regression. A value of P
< 0.05 was used to determine statistical significance and analysis
was carried out using IBM SPSS Version 22.](https://image.slidesharecdn.com/img124652-240923100008-85bbd50f/85/Intraoperative-Plain-Balloon-Angioplasty-to-Augment-Creation-of-Radiocephalic-Arteriovenous-Fistula-in-Those-with-Small-Cephalic-Veins-2-320.jpg)
![clinicsofsurgery.com 5
Volume 8 Issue 1 -2022 Research Article
5. Discussion
Native arteriovenous fistula is most preferred for patients with end
stage renal disease. According to various studies, size and quality
of the vessels are important predictors for functional maturation
of the fistula.3,12,13,14,15 Nonetheless, there are several methods
proposed to improve long term patency of arteriovenous fistula
with small cephalic vein and our study aimed to investigate the
effect of intraoperative PBA on cephalic veins of 1.5 -2.0mm. Bal-
loon angioplasty has a higher immediate success rate compared
to Hydrostatic Dilation (HD), which was shown by Veroux et al.6
with success rate of PBA 100% vs HD 67% and another study of
Khan et al. with success rate of PBA 100% vs HD 73%16. Chaw-
la et al supported the use of PBA with BAM and proposed that
with staged sequential dilatation of AVFs to larger vascular access,
vascular injury such as rupture could be minimized [8]. However
there are concerns with BAM, such as more contrast and radiolog-
ic exposure, patient’s discomfort, higher cost and possible repeat-
ed intimal injury causing restenosis and thrombosis [6].
In our study, we used a relative subjective and straightforward
method to evaluate the diameter of the cephalic vein intraopera-
tively by using a dilator. Whenever small veins or stenotic sites
were detected, balloon angioplasty was carried out. The advantage
of our technique is that it is an easily reproducible intervention that
does not require the use of contrast and is done by hand assisted
balloon expansion. It is rather important to avoid contrast use in
patients with ESRD as it may worsen patient’s renal function and
accelerate patient’s need for hemodialysis. Despite the small size
and fragile nature of these veins, in most of the cases the vein
could be successfully expanded and matured to functional fistula
with functional maturation rate of 95.2%. This result was com-
parable to other studies such as those by De Marco Garcia et al
[7]. with an intraoperative success rate of 85.4% and maturation
rate of 96.3%, and by Veroux 6 with an immediate success rate of
100%. Intraoperative plain balloon angioplasty over long segment
of small cephalic vein not only helps with dilation of the sclerotic
segments but also examine the distensibility of vein and finally
achieve a low resistance venous outflow [6, 12]. Although some
patients experienced regional hematoma, they resolved spontane-
ously and the AVFs were adequately functional.
In our series, the six-month and one-year primary patency rate was
71.6% and 55.2% while one- year secondary patency was up to
98.8% respectively. We tried to further explore factors that might
affect the primary patency rate. Univariate and multivariate analy-
ses showed that significant correlation to decreased functional pri-
mary patency was only shown in patients older than 60. This may
be associated with relatively poor artery inflow caused by throm-
bosis or calcified arterial walls [17]. These older patients might
also be weaker and were unable to perform the hand grasp exer-
cise, which is essential to enhance maturation of AVF by transfor-
mation of veins into wide fibrotic, venous conduits [18]. Without
this stimulation, expansion of the venous size will be inadequate,
and cannulation can easily fail. Though primary patency was not
favorable in our study, anyhow with timely PTA intervention, the
AVFs were long term functional with satisfactory secondary pa-
tency.
There are a few limitations of our study. First, measurement of
cephalic vein caliber was determined subjectively by the vas-
cular surgeon using a dilator. Currently, there is still no definite
answer for the best way of evaluating vascular compliance, as it
may varies according to patient’s hydration status, anesthesia used,
evaluation technique and vessel spasm [20]. However, for better
quantification, in further study measurement of vessels size will
be performed using preoperative ultrasound. Second, this is a ret-
rospective study with no control group and limited patient num-
bers. It is due to the nature of this study that we could not set up
another control group without any intervention. Nevertheless, we
can continue further study regarding intraoperative plain balloon
angioplasty by constructing prospective study with a bigger pa-
tient group and collect long term result. Another limitation of this
study was the high loss to follow up rate at 2 years, hence limiting
the interpretation of the result. The main reasons of loss to follow
up are either mortality or transferal of patient to another medical
institution for further treatment.
Our results revealed that intraoperative non-compliant balloon
angioplasty helped in the remodeling of small vein and reduced
outflow resistance, resulting in good maturation and long- term
patency with assistance of PTA. No major complications were not-
ed during these operations, with no cases of wound infection or
operation related mortality. Studies have shown that forearm loop
AVG has a one-year primary patency rate of 32.4% with a second-
ary patency rate of 83.4% which is less than we found in this study
[19]. As compared to other alternatives such as AVG and tunneled
hemodialysis catheter, this method is worth a try in patients with
small cephalic vein.
References
1. Vascular Access 2006 Work Group. Clinical practice guidelines for
vascular access. Am J Kidney Dis. 2006; 48: S176-247.
2. Schmidli J, Widmer MK, Basile C, et al. Editor’s Choice – Vascular
Access: 2018 Clinical Practice Guidelines of the European Society
for Vascular Surgery (ESVS). European Journal of Vascular and En-
dovascular Surgery. 2018; 55(6): 757-818.
3. Tordoir JHM, Zonnebeld N, van Loon MM, Gallieni M, Hollen-
beck M. Surgical and Endovascular Intervention for Dialysis Access
Maturation Failure During and After Arteriovenous Fistula Surgery:
Review of the Evidence. European Journal of Vascular and Endo-
vascular Surgery. 2018; 55(2): 240-8.
4. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline
for Vascular Access: 2019 Update. American Journal of Kidney Dis-
eases. 2020; 75(4, Supplement 2): S1-S164.](https://image.slidesharecdn.com/img124652-240923100008-85bbd50f/85/Intraoperative-Plain-Balloon-Angioplasty-to-Augment-Creation-of-Radiocephalic-Arteriovenous-Fistula-in-Those-with-Small-Cephalic-Veins-5-320.jpg)
Intraoperative Plain Balloon Angioplasty to Augment Creation of Radiocephalic Arteriovenous Fistula in Those with Small Cephalic Veins
- 1. Sng YP1 , Li Z1 , Lin CC1 and Yen HT2* 1 Department of General surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan 2 Department of Cardiovascular surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan * Corresponding author: Hsu Ting Yen, Department of Cardiovascular surgery, Kaohsiung Chang Gung Memorial Hospital, No.123 Dapi Road, Niao Song county, Kaohsiung 833, Taiwan, Tel: +886-7-731-7123; E-mail: [email protected]/ [email protected] Received: 10 Aug 2022 Accepted: 18 Aug 2022 Published: 25 Aug 2022 J Short Name: COS Copyright: ©2022 Yen HT, This is an open access article distribut- ed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Citation: Yen HT. Intraoperative Plain Balloon Angioplasty to Augment Creation of Radiocephalic Arteriovenous Fistula in Those with Small Cephalic Veins. Clin Surg. 2022; 8(1): 1-6 Intraoperative Plain Balloon Angioplasty to Augment Creation of Radiocephalic Arteriovenous Fistula in Those with Small Cephalic Veins Clinics of Surgery Research Article ISSN: 2638-1451 Volume 8 clinicsofsurgery.com 1 Keywords: Arteriovenous fistula; Plain balloon angioplasty; Cephalic vein; Patency rate; End stage renal disease 1. Abstract 1.1. Introduction: The native small cephalic vein may be over- looked during radiocephalic Arteriovenous Fistula (AVF) creation due to concerns over failure rates particularly if the diameter is small. However, native access has benefits in patency and infec- tion risk in selected patients over alternatives such as arterio- venous graft or tunneled hemodialysis catheter. The aim of this study was to review the outcomes of intraoperative Plain Balloon Angioplasty (PBA) in patients with small cephalic veins during AVF creation. We evaluated the maturation, primary and second- ary patency rate of salvaged arteriovenous fistulae and identified risk factors related to patency rate. 1.2. Methods: This study is a single center, single surgeon, retro- spective study of 94 patients with PBA during radiocephalic arte- riovenous fistula creation for small cephalic vein (> 1.0mm caliber ≤ 2.0mm). 10 patients were excluded either from failure of angio- plasty (n=5) or loss of follow up (n=5). Primary patency was de- fined as freedom from intervention while secondary patency was defined as the time from creation to abandonment. 1.3. Findings: Intraoperative success rate of plain balloon angi- oplasty was 94.7% and among 84 patients, maturation rate of ar- teriovenous fistula was 95.2%. The one year, three year and five year primary patency rates were 55.2%, 51.3% and 32.3% while secondary patency rate were 98.8%, 95.2% and 95.2% respective- ly. During the follow up period, 47.6% of the patients received percutaneous transluminal angioplasty and only 4% of the AVFs was abandoned. Univariate and multivariate analysis of risk fac- tors suggested advanced age (> 60 years) was significantly related to the patency rate. 1.4. Discussion: In this series, intraoperative plain balloon angi- oplasty was successful in facilitating the creation of a functional radiocephalic arteriovenous fistula in patients that may have other- wise not have been successful. The primary and secondary patency rate is satisfactory without any major complications. This would be important if confirmed in other series as a useful tool to improve the utility of more distal AV access. 2. Introduction In patients with End Stage Renal Disease (ESRD), vascular ac- cesses are essential for them to receive hemodialysis. According to various studies, native Arteriovenous Fistula (AVF) accesses Abbreviations: AVF: arteriovenous fistula; CAD: coronary artery disease; CKD: chronic kidney disease; DM: diabetes mellitus; ESRD: end stage renal disease, HD: hydrostatic dilatation; HTN: hypertension; PAOD: peripheral artery occlusive disease; PBA: plain balloon angioplasty; PTA: percutaneous transluminal angioplasty
- 2. clinicsofsurgery.com 2 Volume 8 Issue 1 -2022 Research Article exhibit the best patency rates with lower frequency of infection, thrombotic and non-thrombotic complications, compared to arte- riovenous graft or tunneled central venous catheter [1, 2, 3]. Al- though there is no minimum diameter threshold to AVF creation, cephalic veins less than 2mm in diameter should be considered meticulously, as their primary patency was only 16% compared to 76% in those with diameter greater than 2.0mm [4, 5]. In order to facilitate the use of smaller cephalic veins, there are several stud- ies suggesting different plausible methods such as intraoperative Plain Balloon Angioplasty (PBA), Balloon Assisted Maturation (BAM), accessory vein ligation, based on patient’s condition and operator’s clinical evaluation [3, 6-11]. These studies facilitating intraoperative Plain Balloon Angioplasty (PBA) showed satisfy- ing AVF maturation and patency. -10 However, the effectiveness of PBA with non-compliant balloon in retrieving cephalic veins < 2.0mm for long term functional use is still not well established in ESRD patients. Furthermore, the risk factors related to decreased functional primary patency rate have not been clearly identified. Therefore, this study aimed to evaluate the efficacy of intraopera- tive PBA with non-compliant balloon on maturation rate, primary patency and secondary patency rate in radiocephalicAVF surgeries while attempting to identify the risk factors that affected primary patency rate. 3. Patients and Methods This study was approved by the institutional review board of our institution (IRB: 202001393B0). This was a single center retro- spective study including all patients who received intraoperative PBA intervention during AVF creation from June 2013 to Decem- ber 2017 and observations of the outcome were continued to 1st of May 2018. Inclusion criteria were all patients with cephalic vein diameters greater than 1.0 mm, less or equal to 2.0 mm (found intraoperatively) and with consequent plain balloon angioplasty performed during the same operation. Patients with brachioce- phalic AVF creation, failed intraoperative PBA, loss of follow up or death within one month were excluded. A total of 84 patients were included and Figure 1 is a flow chart showing patient selec- tion. Demographic data on age, gender, and co-morbidities such as diabetes, hypertension, cigarette smoking, stroke, coronary artery disease and peripheral artery disease were collected. All surgeries were performed by the same cardiovascular surgeon, Dr. Yen. After local anesthesia with lidocaine 1%, a 3.0 cm lon- gitudinal incision was made on the lateral side of the wrist. The radial artery and cephalic vein were dissected and isolated. After clamping both vessels, venotomy and arteriotomy were performed respectively. Proximal runoff in the cephalic vein was examined gradually using a series of coronary dilator, starting from 1.0 mm. In cases where coronary dilator could not be passed easily (1.0 - 2.0mm) with resistance or where backflow was inadequate, ul- trasound was used to examine possible stenosis or sclerotic site. After stenosis site was identified, balloon angioplasty was carried out. A non-compliant balloon catheter, 4.0 mmx150 mm (Pacific Extreme, Medtronic, USA) was inserted from the venotomy site to the forearm level. The balloon was over the wire and was inflated to a pressure of 6-8 atmospheres slowly for one minute. Whilst performing long segment balloon dilation, another hand was placed over the balloon to palpate the balloon inflation to avoid over expansion. After balloon angioplasty, the cephalic vein was irrigated with heparin solution (50 IU/ml) to verify if there had been any free rupture of the venous wall. The vein was then exam- ined again using a coronary dilator up to elbow level. End to side or side to side anastomosis of the artery and vein was done using Prolene 7-0 running sutures. Immediate intraoperative success was defined as the presence of thrill during palpation after declamping of arteries and veins. If thrills could not be confirmed, the AVF was considered to have failed and further vascular access creation would be carried out according to the patient’s condition. The functional maturation of AVF was defined as successful can- nulation of fistula for smooth flow hemodialysis one month after surgery. The outcomes of the study are the duration of primary patency and secondary patency in days. Primary patency was de- fined as the interval from the time of AVF creation to thrombosis or stenosis of AVF requiring Percutaneous Transluminal Angi- oplasty (PTA) to re-establish patency or to remove a thrombus. While the secondary patency was defined as the interval from the time of AVF creation to either AVF abandonment or endpoint of study which was the 1st of May 2018 [2]. Patients were further followed up at cardiovascular surgeon outpatient department one week after surgery to examine if arteriovenous fistula is still intact. One month postoperatively, patients would undergo hemodialysis as scheduled and further follow up every three months at cardio- vascular surgeon outpatient department or whenever thrombosis or stenosis of arteriovenous fistula was suspected. The demographic data of patients, categorized according to wheth- er they had received PTA or not, was examined with the chi-square or Fisher’s exact test. Patency rate curves and univariate analysis of risk factors related to functional primary patency were estimat- ed using the Kaplan-Meier method while the multivariate associa- tion of risk factors was analyzed with Cox regression. A value of P < 0.05 was used to determine statistical significance and analysis was carried out using IBM SPSS Version 22.
- 3. clinicsofsurgery.com 3 Volume 8 Issue 1 -2022 Research Article Figure 1: Flow chart of patient selections and analysis * This is an analysis by treatment, failed PBA cases were excluded. 4. Results During the study period, 94 ESRD patients received intraoperative PBA during radiocephalic AVF creation and 84 patients (89.4%) were included in this study. Ten patients were excluded from anal- ysis of long-term outcomes for failed procedure (n=5), loss of fol- low up within one month (n=3) and death (n=2). The demographic data of patients are summarized in Table 1. A total of 67 (79.8%) patients had cephalic vein of 1.5mm in di- ameter while 17 (20.2%) had cephalic veins of 2.0 mm. Cephal- ic veins less than 1.0 mm were considered unsuitable for further intervention. Vein diameter of at least 1.5mm is the safe limit to proceed with balloon angioplasty dilation. There are six cases with minimal or limited injury of veins with hematoma formation but there was no major free rupture of veins noted. PBAhad high intra- operative success rate of 94.7% regardless of the small size of the veins, where thrills were detected after arteriovenous shunt forma- tion. In five cases, plain balloon angioplasty failed to expand the native cephalic vein to greater than 2.0mm. Those patients were continued with alternative hemodialysis access choices. The func- tional maturation rate of post plain balloon angioplasty treated ra- diocephalic arteriovenous fistula was 95.2% (80 out of 84). Three patients required further PTA within the first month to achieve functional status and one needed alternative access creation. The primary patency rate at six months, one year, three years, five years were 71.6%, 55.2%, 51.3% and 32.3% respectively. The one- year secondary patency rate was 98.8% while the three and five years functional cumulative patency rate were 95.2% respectively, as shown in Figure 2. 4% of the fistula was abandoned at the end point of the study. The cause of fistula failure in all three cases was attributed to occlusion of the cephalic vein. There were no major perioperative complications including infection or mortality. Dur- ing the follow up period, a total of 40 (47.6%) patients received PTA due to thrombosis or stenosis of AVF during hemodialysis and mean sessions of PTA received within a five-year study period were 1.75. Most of the first PTA sessions were carried out within the first 8 months of operation. All the patients’ data in this study underwent univariate and mul- tivariate analysis of risk factors correlating to functional primary patency rate. Univariate analysis of risk factors is shown in Ta- ble 2. Sex and underlying disease such as DM, HTN, history of smoking, CAD, PAOD and stroke had no significant correlation with functional primary patency rate in both univariate and mul- tivariate analysis. However, patients with more than 60 years of age, showed significant correlation to functional primary paten- cy rate in both univariate and multivariate analysis (p=0.023 and p=0.026). Patients more than 60 years of age displayed a hazard ratio of 2.255, with median functional primary patency of 649 days while patients 60 years old or younger had a median of 1179 days.
- 4. clinicsofsurgery.com 4 Volume 8 Issue 1 -2022 Research Article No.at risk 183 365 548 730 913 1095 1278 1460 1643 1825 Primary 54 33 21 17 15 11 7 3 1 0 Cumulative 73 61 42 34 25 21 15 5 3 0 Figure 2: Cumulative Kaplan-Meier survival estimate showing primary and secondary patency of arteriovenous fistula receiving intraoperative plain balloon angioplasty in days. * This is an analysis by treatment, failed PBA cases were excluded. Table 1: Baseline characteristics of 84 patients receiving intraoperative plain balloon angioplasty during radiocephalic arteriovenous fistula creation with long term follow up and grouped according to Percutaneous Transluminal Angioplasty (PTA) intervention. Patient characteristics Total n=84 (%) PTA , n=40 (%) No PTA, n=44 (%) *p Sex Male 58(69.0) 24 (60.0) 34 (77.3) 0.087 Female 26(31.0) 16 (40.0) 10 (22.7) Age <= 60 31 (36.9) 11 (27.5) 20 (45.5) 0.089 >60 53 (63.1) 29 (72.5) 24 (54.5) Size of cephalic vein (mm) 1.5 67 (79.8) 33 (82.5) 34 (77.3) 0.551 2 17 (20.2) 7 (17.5) 10 (22.7) Diabetes mellitus 46 (54.8) 22 (47.8) 24 (52.2) 0.967 Hypertension 73 (86.9) 37 (50.7) 36 (49.3) 0.147 Smoking 27 (32.1) 10 (37.0) 17 (63.0) 0.181 Coronary artery disease 20 (23.8) 10 (50) 10 (50) 0.807 Stroke 10 (11.9) 4 (40) 6 (60) 0.741 Peripheral artery occlusive disease 9 (10.7) 4 (44.4) 5 (55.6) 1 Table 2: Univariate analysis of risk factors correlate with primary patency rate, * This is an analysis by treatment, failed PBA cases were excluded. Characteristics N(%) Median days of primary patency Primary patency rate at 6 months (%) Primary patency rate at 1 year (%) Primary patency rate at 2 years (%) p Sex Male 34 (77.3) 1148 74.5 59.6 56.5 0.196 Female 10(22.7) 225 65.4 46.2 41 Age <=60 20(45.5) 1404 86.8 69.5 69.5 **0.023 >60 24(54.5) 283 62.4 46.6 40.8 Cephalic vein size 1.5mm 34(77.3) 1148 69.3 53.8 51.2 0.588 2.0mm 10(22.7) - 80.8 60.6 51.9 DM No 20(45.5) 1148 77.9 59.8 56 0.774 Yes 24 (54.5) 420 66.5 51.6 47.6 HTN No 8(18.2) - 90.9 79.5 63.6 0.282 Yes 36(81.8) 420 68.9 51.7 49.6 Smoking No 27(61.4) 472 67.7 54.1 49.2 0.373 Yes 17(38.6) - 80.2 57.2 - CAD No 34(77.3) 1260 74.5 57 51.9 0.648 Yes 10(22.7) 283 61.5 48.9 - Stroke No 38(86.4) 1148 72.2 55.6 51.4 0.741 Yes 6(13.6) - 66.7 53.3 - PAOD No 39(88.6) 1148 72.5 54.2 52 0.77 Yes 5(11.4) 420 62.5 62.5 46.9
- 5. clinicsofsurgery.com 5 Volume 8 Issue 1 -2022 Research Article 5. Discussion Native arteriovenous fistula is most preferred for patients with end stage renal disease. According to various studies, size and quality of the vessels are important predictors for functional maturation of the fistula.3,12,13,14,15 Nonetheless, there are several methods proposed to improve long term patency of arteriovenous fistula with small cephalic vein and our study aimed to investigate the effect of intraoperative PBA on cephalic veins of 1.5 -2.0mm. Bal- loon angioplasty has a higher immediate success rate compared to Hydrostatic Dilation (HD), which was shown by Veroux et al.6 with success rate of PBA 100% vs HD 67% and another study of Khan et al. with success rate of PBA 100% vs HD 73%16. Chaw- la et al supported the use of PBA with BAM and proposed that with staged sequential dilatation of AVFs to larger vascular access, vascular injury such as rupture could be minimized [8]. However there are concerns with BAM, such as more contrast and radiolog- ic exposure, patient’s discomfort, higher cost and possible repeat- ed intimal injury causing restenosis and thrombosis [6]. In our study, we used a relative subjective and straightforward method to evaluate the diameter of the cephalic vein intraopera- tively by using a dilator. Whenever small veins or stenotic sites were detected, balloon angioplasty was carried out. The advantage of our technique is that it is an easily reproducible intervention that does not require the use of contrast and is done by hand assisted balloon expansion. It is rather important to avoid contrast use in patients with ESRD as it may worsen patient’s renal function and accelerate patient’s need for hemodialysis. Despite the small size and fragile nature of these veins, in most of the cases the vein could be successfully expanded and matured to functional fistula with functional maturation rate of 95.2%. This result was com- parable to other studies such as those by De Marco Garcia et al [7]. with an intraoperative success rate of 85.4% and maturation rate of 96.3%, and by Veroux 6 with an immediate success rate of 100%. Intraoperative plain balloon angioplasty over long segment of small cephalic vein not only helps with dilation of the sclerotic segments but also examine the distensibility of vein and finally achieve a low resistance venous outflow [6, 12]. Although some patients experienced regional hematoma, they resolved spontane- ously and the AVFs were adequately functional. In our series, the six-month and one-year primary patency rate was 71.6% and 55.2% while one- year secondary patency was up to 98.8% respectively. We tried to further explore factors that might affect the primary patency rate. Univariate and multivariate analy- ses showed that significant correlation to decreased functional pri- mary patency was only shown in patients older than 60. This may be associated with relatively poor artery inflow caused by throm- bosis or calcified arterial walls [17]. These older patients might also be weaker and were unable to perform the hand grasp exer- cise, which is essential to enhance maturation of AVF by transfor- mation of veins into wide fibrotic, venous conduits [18]. Without this stimulation, expansion of the venous size will be inadequate, and cannulation can easily fail. Though primary patency was not favorable in our study, anyhow with timely PTA intervention, the AVFs were long term functional with satisfactory secondary pa- tency. There are a few limitations of our study. First, measurement of cephalic vein caliber was determined subjectively by the vas- cular surgeon using a dilator. Currently, there is still no definite answer for the best way of evaluating vascular compliance, as it may varies according to patient’s hydration status, anesthesia used, evaluation technique and vessel spasm [20]. However, for better quantification, in further study measurement of vessels size will be performed using preoperative ultrasound. Second, this is a ret- rospective study with no control group and limited patient num- bers. It is due to the nature of this study that we could not set up another control group without any intervention. Nevertheless, we can continue further study regarding intraoperative plain balloon angioplasty by constructing prospective study with a bigger pa- tient group and collect long term result. Another limitation of this study was the high loss to follow up rate at 2 years, hence limiting the interpretation of the result. The main reasons of loss to follow up are either mortality or transferal of patient to another medical institution for further treatment. Our results revealed that intraoperative non-compliant balloon angioplasty helped in the remodeling of small vein and reduced outflow resistance, resulting in good maturation and long- term patency with assistance of PTA. No major complications were not- ed during these operations, with no cases of wound infection or operation related mortality. Studies have shown that forearm loop AVG has a one-year primary patency rate of 32.4% with a second- ary patency rate of 83.4% which is less than we found in this study [19]. As compared to other alternatives such as AVG and tunneled hemodialysis catheter, this method is worth a try in patients with small cephalic vein. References 1. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis. 2006; 48: S176-247. 2. Schmidli J, Widmer MK, Basile C, et al. Editor’s Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). 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