Transposition of radial artery for reduction of excessive high-flow in autogenous arm accesses for hemodialysis.

OBJECTIVE

All surgical methods published to date for the reduction of excessive high-flow in native elbow fistulas for dialysis have limitations. We report a new surgical approach to flow reduction by transposition of the radial artery to the elbow level.

METHODS

From 1992 to 2008, 47 consecutive patients (22 women) with brachial artery to elbow vein autogenous fistula underwent flow reduction via replacement of brachial artery by transposed distal radial artery inflow. Fistulas were side-to-end either brachial-cephalic (19) or brachial-basilic (28). The indications were hand ischemia (4), cardiac failure (13), concerns about future cardiac dysfunction (23), and chronic venous hypertension resulting in aneurysmal degeneration of the vein (7). Mean patient age was 44 years, 11% were diabetic, 17% were smokers, and mean BMI was 22. Mean fistula age before flow reduction was 2.5 years.

RESULTS

Technical success was 91% (43 of 47). The mean flow rate dropped by 66% +/- 14%. Clinical success in symptomatic patients was 75% (18 of 24). The fistula eventually had to be ligated in three cases of cardiac failure because of insufficient clinical improvement. All four patients with hand ischemia were cured, with no recurrence during follow-up. Primary patency rates at one and three years were 61% +/- 7% and 40% +/- 8%. Secondary patency rates at one and three years were 89% +/- 5% and 70% +/- 8%.

CONCLUSION

Transposition of the radial artery, a safe and effective technique, might now be considered in the surgical armamentarium of flow reduction techniques.