European Journal of Cardiovascular Medicine

Introduction: Dialysis access procedures and complications represent a major cause of morbidity in CKD patients. Recent guidelines have encouraged a creation of AV fistula access in a CKD patient at least 6 months before first dialysis for proper maturation and to give time, if any secondary procedure is needed due to primary failure. Aggressive strategy should be taken for creation of AV Fistula to avoid sepsis and morbidity of temporary access. Objectives: To analysis various factors affecting the primary failure, secondary failure and primary patency of AV Fistula, complications of AV Fistula and its management. Methods: We evaluate the AV Fistula created in RGKMCH in Urology department in 5 years period from January 2017 to February 2022 (212 cases of AV Fistula, done by Radio- cephalic or Brachio- Cephalic end to side anastomosis). A fistula is adequate, if it provides a blood flow of at least 350 ml/min in 6 sessions of hemodialysis in one month. Various demographic factors (age, sex), clinical factors (diabetes, obesity, persistent low BP with Interstitial Nephritis, smoking), venous anatomy of upper limbs, arterial atherosclerosis are related with primary failure and complications. Results: Of 212 AV Fistulas, 178 fistulas developed for dialysis and 34 were primary failure. Primary failure rate was lower in patients aged less than 65 years, in 34 cases of primary failure 6 patients developed pseudoaneurysm and required emergency closure of AV fistula. In 178 cases, 38 patients had eventually secondary failure (mean time ~4 months after initiation of HD) and required a second procedure in upper arm (mainly Brachio- cephalic anastomosis and 12 cases required Permanent Dialysis Catheter insertion in IJV). Primary failure was higher in poorly controlled diabetics (random CBG > 200mg/ dl), in atherosclerotics, in low BP (SBP< 100) and in elderly females. Among 6 cases of pseudoaneurysm in the entire study, 4 were poorly controlled diabetics. The adequacy rate was not related with Serum albumin, Serum PTH, Surgeon, Serum Creatinine. Primary (28 out of 34) and secondary failure (22 out of 38) rate is significantly higher in forearm fistula than upper arm fistula, but complications like pseudoaneurysm (4 cases), serpentine aneurysm (4 cases), steal phenomenon (10 cases), gangrene of the limb (2 cases) are more common in upper arm fistula. The adequacy of forearm fistula is poorer in older women, diabetics and they need upper arm fistula to avoid primary failure, though complications are more common in upper arm fistula.  Conclusion: Success rate of AV Fistula is lower in certain subset of patients. To achieve best outcome, AV Fistula need to be constructed in upper arm in older, female, low BP, or in diabetics, though upper arm fistula has more complications like pseudoaneurysm, serpentine aneurysm, steal phenomenon, gangrene of limb.