Budak Ali Baran, Saba Tonguç, Yıldırım Alp, Haberal Cevahir
Cardiovascular Surgery Department, Liv Hospital Ulus, Istanbul, Turkey.
Cardiovascular Surgery Department, Başkent University Alanya Hospital, Antalya, Turkey.
Ann Vasc Surg. 2025 Jun 17;122:168-175. doi: 10.1016/j.avsg.2025.05.050.
Antecubital arteriovenous fistulas (AVFs), particularly brachiocephalic AVFs at the elbow level, are commonly created when forearm options are exhausted. However, this configuration is associated with significant complications such as steal syndrome and high-output heart failure. To mitigate these risks, the perforating vein can be utilized as an alternative configuration for AVF creation (Gracz or Konner type AVF). In this study, we aimed to evaluate complication rates and compare patency outcomes between brachiocephalic AVFs and perforator vein AVFs.
This retrospective single-center study enrolled 351 patients who underwent elbow level AVF creation between January 2015 and March 2024 (111 months). The cohort's mean age was 61.2 ± 12.5 years, and 53.8% were male. AVFs were constructed using either the perforating vein (n = 48) or the brachiocephalic configuration (n = 303). The primary endpoints of the study were primary and secondary patency rates. In addition, the incidence of complications such as hand ischemia, high-output cardiac failure, and hematoma formation was evaluated. Secondary analyses examined patency differences based on surgical technique and patient comorbidities. Kaplan-Meier survival analysis, Cox regression, and the Mann-Whitney U test were used for statistical comparisons. A P value of <0.05 was considered significant.
Primary and secondary patency rates were comparable between perforator vein and brachiocephalic AVFs at 6 months, 1 year, 2 years, and 3 years (P > 0.05 for all). The median secondary patency was 374 days in the perforator group and 386 days in the brachiocephalic group (P = 0.72). However, complications such as hand ischemia, high-output cardiac failure, and aneurysm formation were significantly more common in the brachiocephalic group (P < 0.05).
Perforator vein-based AVFs demonstrated similar patency outcomes to brachiocephalic AVFs, with significantly fewer complications. Thus, the use of the perforating vein is a safe and effective alternative for AVF creation in selected patients with limited distal access options.
当用尽前臂的造瘘选择时，常在前臂肘窝处建立动静脉内瘘（AVF），尤其是肘水平的头臂动静脉内瘘。然而，这种结构与诸如窃血综合征和高输出量心力衰竭等严重并发症相关。为降低这些风险，可利用穿支静脉作为建立AVF的替代结构（Gracz或Konner型AVF）。在本研究中，我们旨在评估并发症发生率，并比较头臂动静脉内瘘和穿支静脉动静脉内瘘的通畅结局。
这项回顾性单中心研究纳入了2015年1月至2024年3月（111个月）期间接受肘水平AVF建立的351例患者。队列的平均年龄为61.2±12.5岁，男性占53.8%。AVF采用穿支静脉（n = 48）或头臂结构（n = 303）构建。研究的主要终点是初级和次级通畅率。此外，评估了诸如手部缺血、高输出量心力衰竭和血肿形成等并发症的发生率。二级分析根据手术技术和患者合并症检查通畅差异。采用Kaplan-Meier生存分析、Cox回归和Mann-Whitney U检验进行统计学比较。P值<0.05被认为具有统计学意义。
穿支静脉动静脉内瘘和头臂动静脉内瘘在6个月、1年、2年和3年时的初级和次级通畅率相当（所有P>0.05）。穿支静脉组的中位次级通畅时间为374天，头臂动静脉组为386天（P = 0.72）。然而，头臂动静脉组中诸如手部缺血、高输出量心力衰竭和动脉瘤形成等并发症明显更常见（P<0.05）。
基于穿支静脉的动静脉内瘘显示出与头臂动静脉内瘘相似的通畅结局，并发症明显更少。因此，对于远端通路选择有限的特定患者，使用穿支静脉是建立AVF的一种安全有效的替代方法。
