Three Year Patency and Recurrence Rates of Revision Using Distal Inflow with a Venous Interposition Graft for High Flow Brachial Artery Based Arteriovenous Fistula.

Abstract

Upper arm arteriovenous fistulas (AVF) occasionally develop high flow. Revision using distal inflow (RUDI) effectively reduces flow of high flow accesses (HFA) in the short-term and is also popularised for treatment of haemodialysis access induced distal ischaemia (HAIDI). The long-term efficacy is unknown. The study's aim was to report on 3 year RUDI patency and recurrence rates for HFA with and without HAIDI. This was a retrospective cohort study of patients with a HFA with or without HAIDI undergoing RUDI using greater saphenous vein (GSV) interposition between March 2011 and October 2017 at three facilities. AVFs were termed HFA if flow volumes exceeded 2 L/min on two consecutive measurements using dilution techniques. HAIDI was diagnosed as recommended. Following RUDI, follow up was not different from standard care in AVF patients. Data on post-operative flows and re-interventions were extracted from electronic patient files. Loss to follow up was avoided. Rates of patency and HFA recurrence were analysed. During the observation period, 21 patients were studied (7 females, 54 years ± 3). Fourteen had uncomplicated HFA whereas seven had additional HAIDI. Immediately post-operatively, flows decreased threefold (3120 mL/min ± 171 vs. 1170 mL/min ± 87, p < .001). Overall 3 year primary patency was 48% ± 12 (HFA, 55% ± 15 vs. HAIDI/HFA, 29% ± 17, p = .042). Secondary patency was identical in both groups (overall, 84% ± 9). Interventions were percutaneous transluminal angioplasty (n = 12, 9 patients), thrombectomy (n = 7, 3 patients), and revision with new interposition grafts (n = 3). After 3 years, 51% ± 12 were free of high flow (HFA, 32% ± 13 vs. HAIDI/HFA, 100%, p = .018). High immediate post-operative access flow predicted recurrence (OR 1.004 [1.000-1.007], p = .044). Patients with recurrence were 12 years younger than those without (p = .055). RUDI with GSV interposition for HFA offers acceptable patency rates after 3 years although re-interventions are often required. High immediate post-operative flows and young age are associated with recurrent high flow.