Although European Best Practice Guidelines on vascular access recommend universal pre-operative duplex scan in patients receiving brachio-cephalic (BC) arteriovenous fistulae (AVF), this is not widespread practice. Furthermore, cadaveric and angiographic studies suggest that variation in upper limb arterial anatomy is common. Our aim was to investigate the prevalence of high brachial artery bifurcation and its impact on BC AVF patency.
Methods
A prospective analysis of consecutive autologous BC AVF procedures over an 18 month period (January 2007-June 2008). Patients with high bifurcations identified at duplex scan were compared with a randomly selected age and sex matched population of those with normal bifurcations. Patients were followed up at 1, 6 and 12 weeks post operatively. The study endpoint was AVF failure.
Results
258 procedures were performed on 239 patients (male: female ratio 150:89, median age 64, range 29-88). 29 (12%, of whom 57% were male) had high brachial bifurcations. The bifurcation was axillary in 6 patients and at the proximal, middle and distal third humerus level in 9, 7 and 7 patients respectively. At 12 months, the actuarial risk of AVF failure was greater in those with high than those with normal bifurcations (45% (95% CI 26-69%) vs. 23% (95% CI 14-37%). Neither gender nor cause of renal failure predicted either aberrant upper limb arterial anatomy or AVF failure.
Conclusions
These data show that aberrant brachial artery anatomy is both common (12%) and a powerful independent predictor of AVF failure. These data support the universal use of pre-AVF duplex scanning.
King's College Hospital, London, United Kingdom
Author Disclosures: D. Valenti, None; H. Mistry, None; C. Junghans, None; N. Haughey, None; B. Freedman, None; M. Tyrrell, None.
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