Microsurgery and preventive haemostasis for autogenous radial-cephalic direct wrist access in adult patients with radial artery internal diameter below 1.6 mm

Background. Autogenous radial-cephalic direct wrist arteriovenous fistula (RCF), the gold standard for chronic dialysis, suffers from an elevated early failure rate (up to 20-50% with a pooled rate of 15.3%). Guidelines indicate that a small radial artery internal diameter (< 1.6-2 mm) is strongly predictive of this early failure. Microsurgery and preventive haemostasis have been reported to give excellent results in a paediatric population (children < 10 kg bw) and have shown a much lower early failure rate of 5-10%. Given these excellent results, we have used microsurgery along with preventive haemostasis in adult patients. We herein describe the results of RCF created in patients with a radial artery internal diameter < 1.6 mm. Methods. From November 2004 to December 2007, 28 RCFs were created in 28 patients with a distal radial artery internal diameter < 1.6 mm using microsurgery and preventive haemostasis. The median age was 68 and the male/female ratio was 6/22. The incidence of age > 65 years was 64%, hypertension 96%, diabetes 32.1%, obesity (BMI > 30) 35%, vascular disease 46%. The mean distal radial artery and cephalic vein internal diameters, measured with ultrasound examination, were 1.3 mm and 1.9 mm, respectively. Seventy-five percent of the patients were not yet on dialysis treatment; 19% of whom had a previous failed vascular access created elsewhere without microsurgery. The remaining 25% patients were on dialysis treatment with a temporary femoral catheter. Results. All interventions ended with a patent anastomosis; no thrombosis occurred within the initial 24 h. The early failure rate was 14% (4 out of 28 patients). The causes of early failure were thrombosis > 1 week after surgery in one patient, lack of maturation (patent but unfunctional fistula) due to juxta-anastomotic vein stenosis in two patients and mid-vein stenosis in one patient. Treatment for all patients was proximalization of the anastomosis at the distal/mid forearm. Primary patency and secondary patency at 1 year were 68 +/- 10% and 96 +/- 5%, respectively. Conclusions. From our findings, we have shown that it is possible to create RCF in adult patients with a radial artery internal diameter of < 1.6 mm with an acceptable risk of early failure rate using microsurgery along with preventive haemostasis.