Patients Characteristics and Outcome of 518 Arteriovenous Fistulas for Hemodialysis in a Sub-Saharan African Setting

doi:10.1016/j.avsg.2011.07.019

Annals of Vascular Surgery

Volume 26, Issue 5, July 2012, Pages 674-679

Presented at the 7th Congress of the Cameroon Cardiac Society, Yaounde, Cameroon, March 18, 2010. Abstract in Cardiovasc J Afr 2010;21.

https://doi.org/10.1016/j.avsg.2011.07.019 Get rights and content

Background

To present the particular aspects of arteriovenous fistula (AVF) for hemodialysis in sub-Saharan Africa in terms of patients’ characteristics, patency and complication rates, as well as factors influencing them.

Methods

From November 2002 to November 2009, 518 fistulas were constructed on adults. Demographic data, patency, and complications were analyzed. The association between age, sex, and comorbidities (HIV, hypertension, diabetes) on one hand and complications as well as AVF patency on the other was sought.

Results

Males represented 73.7% of the patient population, and the mean age of the population was 45.3 years. As far as etiologies of end-stage renal disease (ESRD) and comorbidities are concerned, chronic glomerulonephritis was the leading cause of ESRD (134; 25.9%), followed by hypertension (22.3%), although prevalent in 83.2% of patients, and diabetes (20.1%), although prevalent in 22.2%. No cause for the ESRD could be identified in 89 patients (17.2%). Only 20.64% had AVF as the initial vascular access. The main types of AVF constructed were radiocephalic (68%) and brachiocephalic (24.9%). The median follow-up period was 275 days. The cumulative patency rate at 1 year and 2 years was 76% and 51%, respectively. Altogether, 188 complications occurred in 16% of the AVFs. Aneurysms, failure to mature, and thrombosis were the most frequent complications occurring in 27.65%, 14.89%, and 10.63% of cases, respectively. The management options for the complications included the creation of a new access for 63 complications (33.51%) and nonoperative management in 44.14% of the cases. We found no adverse effect of comorbid factors like diabetes mellitus (χ² = 3.58, P > 0.05) and HIV-positive status (χ² = 0.64, P > 0.05) on the complications rate.

Conclusion

According to our patients’ characteristics, there is a possibility of constructing AVF on nearly every hemodialysis patient with a good outcome.

Introduction

Since the advent of hemodialysis in 1944, and the subsequent use of arteriovenous fistulae (AVFs) as a long-term vascular access,¹ there has been a drastic increase in both the availability of hemodialysis and long-term survival of patients with chronic renal failure. This has resulted in permanent vascular access procedures in dialysis (AVFs, prosthetic arteriovenous grafts, and autologous vein grafts) becoming the most common operations performed by vascular surgeons. Because of data illustrating superiority of AVF in terms of patency rates, lower complication rate, and lower costs, it has been recommended in countries such as United States that AVF should be constructed in at least 50% of patients on chronic hemodialysis.² This goal has even been raised to 65% in recent guidelines.³

In developing countries and particularly in sub-Saharan Africa, there are very few reports concerning vascular access surgery4, 5 compared with North Africa6, 7, as hemodialysis is not yet widespread in these areas. In Cameroon, since the year 2000, hemodialysis is accessible to many. Therefore, construction and maintenance of vascular accesses has become a challenge.

In this report, we present the particularities of AVF for hemodialysis in our setting. Specifically, we sought to audit the patients’ characteristics, the complications, patency rates, and to determine factors that affect these outcomes. To the best of our knowledge, this is the largest published report concerning vascular access surgery in sub-Saharan Africa.

Section snippets

Methods

We retrospectively evaluated upper-limb AVFs performed between November 2002 and 2009 at the Yaoundé General Hospital—a university teaching hospital with most modern facilities for vascular surgery and hemodialysis—in Cameroon. The cases included in the study were consecutive adult patients with end-stage renal disease (ESRD) referred for the creation of AVF (8 patients aged <16 years were not considered for this study). Primary (firstly created) and secondary (all subsequently constructed)

Sociodemographic Data

During the 7-year study period, 518 upper-arm vascular accesses were created on 492 limbs on 478 patients. Of these, 382 were males, representing 73.7% of the population. Two patients who relocated overseas for kidney grafting were not included in this analysis. The mean age of the patients at time of surgery was 45.33 (range: 17–74) years.

As far as etiologies of ESRD and comorbidities are concerned, chronic glomerulonephritis was the leading cause of ESRD (134; 25.9%), followed by hypertension

Discussion

The proportion of patients commencing dialysis with an AVF was only 20.65%, whereas 79.35% initiated dialysis with temporary central venous catheter. The late presentation of patients with ESRD for specialized care (owing to late referral from nonspecialized centers, geographical distance, ignorance, and low income) has been described earlier in our setting.⁸ This late presentation at end stage with uremic complications requires emergency renal replacement therapy.8, 9 Therefore, central venous

Conclusion

In this study, we reported our 7-year experience in vascular access surgery in a setting where access to prosthetic graft is seldom, and showed that in nearly every patient with the same characteristics, it is possible to construct an AVF in the course of dialysis with a good outcome. There were no effects of HIV status on the outcome of the fistula. Although not specifically analyzed, we think there is a positive effect of low income and insurance status in the effort to always try to

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Cited by (11)

Model and online calculator for prediction of fistula maturation based on vein dilation and age: A retrospective cohort study in a single-center
2023, Asian Journal of Surgery
A model that considers the characteristics of dialysis patients may help predict successful fistula maturation. We evaluated factors associated with radiocephalic arteriovenous fistula (RCAVF) maturation at 3 months in dialysis patients with end-stage renal disease (ESRD).
A total of 184 patients who received an initial RCAVF at Beijing Haidian Hospital (Haidian Section of Peking University Third Hospital) were recruited. Fistula maturation was assessed within 3 months. Patient characteristics and preoperative vascular assessment indices were examined. Factors associated with fistula maturation were analyzed using logistic regression and least absolute shrinkage and selection operator (LASSO) binary logistic regression. Boostrapping was used for internal validation.
The development data consisted of 184 ESRD patients receiving an initial RCAVF, 140 (76%) of whom achieved fistula maturation. The main predictors of RCAVF maturation in the final model were sex, age-adjusted vein dilation (eVD), radial artery volume (V_artery), and diastolic blood pressure. The difference of vein diameter with and without a tourniquet was significantly larger in the mature RCAVF group (3.0 ± 0.5 vs. 2.2 ± 0.5 mm). The area under receiver operating characteristic (AUROC) curve for prediction of fistula maturation was 0.77, and the Hosmer-Lemeshow statistic indicated agreement between observed and predicted values (P = 0.792). Analysis of internal validation using bootstrapping indicated the C-index was 0.75.
The ratio of vein dilation and age were the major predictors of fistula maturation at 3 months in our patients. The resulting online prediction model may help in clinical decision-making for patients receiving a RCAVF.
Interest of surgical vascular reconstructions aiming at preserving hemodialysis access
2022, JMV-Journal de Medecine Vasculaire
Citation Excerpt :
The morbidity rate in our reconstruction series was 41.8%, comparable to the few studies that have reported this outcome. It varies from 11.4% to 64% in the literature [6–8]. This rate is essentially related to the high number of comorbidities and the use of prosthetic material for the creation or reconstruction of the AVF [4].
Vascular hemodialysis access is a very precious asset for patients with end-stage renal failure. Ideally complications in these accesses should be detected early in order to treat them in time. The aim of this study was to evaluate the effectiveness of vascular reconstructions to preserve the vascular access for hemodialysis and to examine their benefits in terms of conserving the venous network, using hemodialysis catheters, time of cannulation after surgery, patency and postoperative morbi-mortality, by comparing them to those of newly created arterio-venous fistula (AVF).
This was a retrospective, descriptive and comparative study, performed from September 2012 to February 2015. It concerned patients operated for complications of their native AVF. Two groups were compared: reconstructed AVF (group 1) and newly created AVF (group 2). Demographic characteristics, comorbidities, preoperative clinical and paraclinical data, surgical techniques and outcomes were recorded. This data was analyzed and compared between the two groups.
We collected 151 surgical interventions divided into two groups: 55 surgical reconstructions and 96 new AVF. The average age was 59.9 ± 1.3 years [19.1–88.9], with a male predominance (59.6%). The two groups were comparable in terms of age, gender and comorbidities. Reconstructions were mostly indicated for stenosis (47.3%) and new vascular accesses for venous thrombosis (92.7%). Reconstruction had significantly better successful exploitation rates (95.7%) and time of cannulation (26.6 days) (respectively P = 0.025 and P = 0.000). Its primary failure rate was null. Its primary patency and primary functional patency were respectively 94.2% and 97.7% at 1 month and 82.2% and 87.1% at 2 years. Morbidity's global rates were comparable between both groups (41.8% vs. 43.8%). The rates of early morbidity and stenosis were significantly higher for reconstructions (respectively P = 0.037 and P = 0.047), while late morbidity and thrombosis’ rates were significantly higher for new AVF (respectively P = 0.021 and P = 0.023). Mid-term permeabilities were better for reconstructions, but the differences were not statistically significant.
Surgical reconstructions seem to be an effective alternative for the treatment of complicated AVF. Our results appear to be comparable to those of the literature. The benefits of these surgical techniques in terms of conserving venous network, use of hemodialysis catheters, time for cannulation after surgery, patency and postoperative morbi-mortality appear to be undeniable.
End Stage Renal Disease in Sub-Saharan Africa
2017, Chronic Kidney Disease in Disadvantaged Populations
The increasing prevalence of noncommunicable diseases (NCDs) as a major cause of morbidity and mortality in Sub-Saharan Africa (SSA), coupled with an ageing society undergoing a rapid epidemiological transition, has brought CKD into the spotlight. This is compounded by the overlap of common comorbidities, both communicable and noncommunicable, that culminate in CKD, including hypertension, diabetes, obesity and HIV infection. These risk factors may synergize with genetic susceptibilities in those of African descent to result in a more rapid progression to end stage kidney disease. As cardiovascular disease emerges as a major cause of death in Africans, it is also noteworthy that CKD, irrespective of etiology, contributes additional cardiovascular risk. Management of CKD is challenging for governments, populations and health care workers in SSA. The onset of ESRD in SSA presents a formidable problem, where the majority of patients do not have access to RRT.
Staple aneurysmorrhaphy to salvage autogenous arteriovenous fistulas with aneurysm-related complications
2015, Journal of Vascular Surgery
Aneurysm-related complications could lead to loss of a functioning arteriovenous fistula (AVF). We report our midterm and long-term results with the staple aneurysmorrhaphy technique to repair and preserve aneurysmal AVFs.
We retrospectively reviewed our surgical treatment of patients with aneurysmal autogenous AVF complicated by skin erosion, bleeding, infection, pain, and difficulty with needle access from 2007 through 2014. We identified 52 patients, 40 (77%) of whom underwent repair with the staple aneurysmorrhaphy technique. The operation involved mobilizing the entire aneurysmal segments. A TA (Covidien, Norwalk, Conn) or Endo GIA (Covidien, Mansfield, Mass) stapler was used to resect the redundant aneurysm wall to create a 6- to 8-mm-diameter conduit. A subcutaneous skin flap was created after excising compromised skin. The remodeled vein was repositioned underneath the subcutaneous flap, with the staple line rotated laterally to avoid needle puncture.
We attempted staple aneurysmorrhaphy in 40 patients with complicated AVF aneurysms, of which 38 repairs (95%) were successful. Median patient age was 66 years (range, 29-88 years). Median AVF age was 63 months (range, 12-136 months). Median follow-up was 20 months (range, 5-81 months). At 1 year, primary patency was 67%, assisted primary patency was 88%, and secondary patency was 91%. At 2 years, primary patency was 59%, assisted primary patency was 84%, and secondary patency was 91%. At 3 years, primary patency was 46%, assisted primary patency was 69%, and secondary patency was 85%. Surgery was performed under local-regional anesthesia in 28 patients (70%) and under general anesthesia in the remaining 12 (30%). Proximal venous outflow stenoses were detected in 19 of 40 AVFs (48%) preoperatively and in 11 of 38 AVFs (29%) postoperatively. Aneurysm recurrence occurred in two repaired AVFs.
Our experience with staple aneurysmorrhaphy shows that it is an effective, safe, and durable procedure to preserve a functioning autogenous AVF with complicated aneurysmal degeneration. Key principles are to reduce the vein to normal adjacent diameter and to provide healthy skin coverage. The remodeled AVF has a low aneurysm recurrence rate and maintains the beneficial properties of superior patency and low infection. It is important to aggressively monitor for and treat proximal outflow venous stenoses to prevent aneurysm recurrence. The surgery can be done safely under local anesthesia in selected patients.
Emergency vascular access conversion to native arterio veinous fistula: A prospective study of 37 hemodialysis patients in Rwanda
2014, Nephrologie et Therapeutique
La prise en charge de patients en hémodialyse chronique au Rwanda est récente. L’accès vasculaire utilisé est le plus souvent un cathéter.
Trente-sept patients hémodialysés chroniques sur cathéter ont été recrutés sur une période de 3 ans afin de convertir leur abord vasculaire en fistule native. La sélection des patients et le choix du type de fistule ont été faits lors d’une consultation pluridisciplinaire.
Trente et un patients ont bénéficié de la création de fistule artério-veineuse (FAV). Le sex-ratio était de 1,5 et la principale cause de l’insuffisance rénale était l’hypertension artérielle (HTA). Toutes les interventions ont été réalisées sous anesthésie locale ou locorégionale. Par ailleurs, 60 % des FAV créées étaient radio-céphaliques, 35,4 % huméro-céphaliques, avec une perméabilité primaire de 77,4 %. Enfin, 64 % des interventions ont été réalisées en ambulatoire.
Ce travail prouve la faisabilité d’un programme de création de fistules au Rwanda, permettant ainsi d’éviter les diverses complications qui surviennent avec l’utilisation prolongée d’un cathéter. Cette expérience a été rendue possible par la mise en commun des ressources de 4 hôpitaux de référence au Rwanda.
Chronic hemodialysis in Rwanda is relatively recent and most of patients are treated with catheters.
Thirty-seven patients who require chronic hemodialysis with catheters were evaluated during a 3-years period in order to facilitate the creation of a permanent vascular access for hemodialysis (AVF). Patient selection were made during a multi-disciplinary consultation. The sex-ratio was 1.5 and the main cause of the nephropathy was arterial hypertension.
Thirty-one patients benefited from the creation of an arterioveinous fistula. All of the interventions were performed using local or loco-regional anesthesia. Sixty percent of these AVF were radio-cephalic, 35.4% were humero-cephalic. Sixty-four percent of the operations were performed on ambulatory patients, with a primary function for 90% of them.
This work proves the feasibility of the creation of AVF in Rwanda, thus allowing to preclude the various complications that arise with the prolonged use of a catheter. This experience was made possible by the pooling of the resources of 4 of Rwanda's leading hospitals. In an early future, the development of vascular surgery will assure the permanence of this care.
Access for renal replacement therapy
2013, Kidney Transplantation-Principles and Practice, Seventh Edition

View all citing articles on Scopus

: Presented at the Joint Congress of German, Austrian, and Switzerland Societies of Vascular Surgery, Berlin, Germany, September 10, 2010. Abstract in Ao3.3.1.4 Gefäßchirurgie 2010;15:379.

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Clinical ResearchPatients Characteristics and Outcome of 518 Arteriovenous Fistulas for Hemodialysis in a Sub-Saharan African Setting

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Sociodemographic Data

Discussion

Conclusion

Am J Kidney Dis

Kidney Int

J Vasc Surg

J Vasc Surg

J Vasc Surg

Am J Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula

N Engl J Med

Clinical practice guidelines for vascular access 2000

Am J Kidney Dis

Clinical practice guidelines and clinical practice recommendations for 2006 updates: hemodialysis adequacy, peritoneal dialysis adequacy, vascular access

Am J Kidney Dis

Practice pattern of hemodialysis vascular access in Maiduguri, Nigeria

Int J Artif Organs

Clinical Research
Patients Characteristics and Outcome of 518 Arteriovenous Fistulas for Hemodialysis in a Sub-Saharan African Setting