Salvage of inaccessible arteriovenous fistulas in obese patients: A review of 132 brachiocephalic fistulas

Abstract

The two main factors leading to a functional fistula are maturity and accessibility. The aim of this review was to describe a technique of superficialization for inaccessible brachiocephalic fistulas, and to identify the patients that benefit from superficialization. One hundred and thirty-two brachiocephalic arteriovenous fistulas developed from November 2003 to December 2006 were reviewed for primary maturation. In the mature group, patients were evaluated for fistula accessibility. Inaccessible fistulas were selected for superficialization via our technique of vein mobilization using small skip incisions. Analysis of superficialized and nonsuperficialized groups included age, demographics, and comorbidities. Ninety-nine patients were in the mature group, and 33 in the immature group; primary nonmaturation was 25 per cent. Analysis within the mature group was between nonsuperficialized (n = 81) and superficialized (n = 18) patients. The superficialized group had less hypertension (83% vs 98%, P<0.05), significantly higher BMI (31 vs 27, P < 0.05), and was mostly female (78% vs 49%, P < 0.05). All superficialized fistulas accommodated successful hemodialysis postoperatively. To conclude, patients with mature but inaccessible fistulas were salvaged by superficialization. This population had significantly higher BMI, less hypertension, and female prevalence. Identifying these patients is important because salvage of their fistula can prevent premature progression to alternate autogenous arteriovenous access procedures.