Patency and Recurrence Rates of the Revision Using Distal Inflow Technique for High Flow Brachial Artery Based Arteriovenous Fistula

Introduction - High flow access (HFA; >2L/min or >1.5L/min with congestive complaints) is occasionally observed in the presence of a brachial artery based arteriovenous fistula (AVF).1 Several flow reducing techniques are available. Banding suffered from recurrence rates up to 50% within one year.2 Revision using distal inflow (RUDI) demonstrated a substantial flow reduction in the short term.3 Aim of this study was to report on the three-year patency and HFA recurrence rates of RUDI with interposition of the greater saphenous vein (GSV) in dialysis patients with a high flow access. Methods - Patients with a high flow elbow-based AVF scheduled for a RUDI procedure with use of the GSV between March 2011 and March 2017 in three facilities were followed for three years. Patency rates were defined as recommended by Sidawy.4 Recurrent high flow was defined as two consecutive high flow measurements (>2L/min) or signs of venous congestion or cardiac failure in presence of flows exceeding 1.5L/min. Patency and high flow recurrence were analysed using Kaplan-Meier analysis. Results - Twenty-one patients were studied (14 males, 54 ±3 years). RUDI was performed 44 ±12 months after the initial AVF construction. Peripheral arterial occlusive disease (5%) and diabetes mellitus (10%) were rarely observed while hypertension (52%) was more commonly present. Access flows decreased from 3220 ±204 mL/min preoperatively to 1150 ±88 mL/min postoperatively (P<0.001). Primary patency rates were 65% ±10, 54% ±12 and 54% ±12 after one, two and three years, respectively. Assisted patency rates were 79% ±9, 73% ±10 and 62% ±14, respectively. Secondary patency rates were 95% ±5, 95% ±5 and 76% ±14. In order to maintain access patency, twelve percutaneous transluminal angioplasties in eight and seven thrombectomies in four patients were conducted. Furthermore, two GSVs were replaced in a re-RUDI procedure (PTFE n=1; contralateral GSV n=1). HFA free survival was 74% ±10, 61% ±11 and 55% ±12 after one, two and three years. In the recurrence group, immediate postoperative access flow was higher when compared to the non-recurrence group (Flowrecurrence 1410 mL/min ±128, n=8 versus Flowno-recurrence 960mL/min ±87, n=11; P=0.012). The mean age in the recurrence group tended to be lower (Agerecurrence 46 ±4 years versus Ageno-recurrence 58 ±5years; P=0.082). Conclusion - A RUDI procedure with GSV interposition for HFA offers reasonably satisfactory patency rates after three years but requires maintenance. Recurrence free survival is higher when compared to rates described for banding. A relatively high immediate postoperative access flow is associated with recurrent high access flow. References1.Stern AB, Klemmer PJ. High-output heart failure secondary to arteriovenous fistula. Hemodial Int. 2011 Jan;15(1):104-7.2.Vaes RHD, Wouda R, van Loon M, van Hoek F, Tordoir JH, Scheltinga MR. Effectiveness of surgical banding for high flow in brachial artery based haemodialysis vascular access. J Vasc Surg. 2014 Mar;61(3):762-6.3.Vaes RHD, van Loon M, Vaes SMM, Cuypers PWM, Tordoir JH, Scheltinga MRM. One year efficacy of the RUDI technique for flow reduction in high flow autologous brachial artery-based haemodialysis vascular access. J Vasc Access. 2015;16 Suppl9:S96-101.4.Sidawy AN, Gray R, Besarab A, Henry M, Ascher E, Silva M, Miller A, Scher L, Treretola S, Gregory RG, Rutherford RB, Kent KC. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg. 2002 Mar;35(3):603-1