Arteriovenous Fistulas and Their Characteristic Sites of Stenosis
Abstract
OBJECTIVE. In the United States, more than 250,000 patients with end-stage renal disease are dialyzed through arteriovenous fistulas (AVFs). The three most common AVFs are the radiocephalic fistula, the brachiocephalic fistula, and the brachial artery–to–transposed basilic vein fistula. Although many potential access site stenoses can and do occur within any given fistula, each fistula has a characteristic site of stenosis. This article will discuss the characteristic site of stenosis for each type of fistula including the effects of stenosis at that site on fistula function, and their treatment.
CONCLUSION. The characteristic sites of stenosis in AVFs used for dialysis share in common significant angulation, which likely causes stenosis by leading to turbulent flow and intimal injury. While balloon dilation is considered first-line therapy, further interventions such as stent placement or surgical revision are sometimes needed to treat these recalcitrant areas of stenosis.
For the approximately 640,000 patients in the United States with end-stage renal disease (ESRD), the majority (64.2%) undergo renal replacement therapy via hemodialysis. Less frequently used renal replacement therapy treatments are renal transplant (29.3%) and peritoneal dialysis (6.4%) (2012 data) [1] (Fig. 1). The methods of delivering hemodialysis include tunneled and nontunneled catheters, arteriovenous grafts (AVGs), and arteriovenous fistulas (AVFs) (Fig. 2).
Central venous hemodialysis catheters, although often necessary, should be avoided whenever possible. Among the hemodialysis delivery options, central venous catheters have the highest rates of thrombosis [2] and infection [3]. They can also cause central vein stenosis [4], especially when inserted from a subclavian vein [5, 6] or via a left-sided jugular [7, 8] approach. Additionally, blood flow rates from hemodialysis catheters are typically the lowest of all hemodialysis access types [9]. Finally, hemodialysis catheters are associated with greater mortality than AVGs or AVFs [3].
AVFs are preferred over AVGs [10, 11]. The rationale for this preference includes that fistulas have lower rates of thrombosis [12], have longer access lifespans [13], and maintain their patency with fewer secondary interventions and a lower cost [12, 14] compared with grafts. Infection rates [3, 15], rates of steal syndrome [16], and rates of symptomatic central venous stenosis [17] are lower in patients with fistulas than in those with grafts. Most importantly, there is an approximate 20% decreased mortality rate [3, 18] in ESRD patients dialyzed through fistulas compared with those dialyzed through grafts. The National Kidney Foundation therefore strongly recommends that fistulas be the preferred vascular access for long-term hemodialysis [11].
There are three main types of AVFs. The radiocephalic fistula (Fig. 3) is a forearm fistula created by anastomosing the side of a radial artery to the end of a cephalic vein. It is also referred to as the Brescia-Cimino fistula. The brachiocephalic fistula (Fig. 4) is an upper arm fistula created by connecting the side of a brachial artery to the end of a cephalic vein at or slightly central to the level of the elbow. Finally, the brachial artery–to–transposed basilic vein (BTB) fistula (Fig. 5) is another upper arm fistula. This fistula is created by anastomosing the side of a brachial artery to the end of a basilic vein that has been transposed laterally and elevated superficially to make it amenable to dialysis cannulation.
Certain characteristic locations within each type of fistula are prone to stenosis. For the radiocephalic fistula, it is the juxtaanastomotic segment; for the brachiocephalic fistula, it is the cephalic arch; and, for the BTB fistula, it is the proximal swing segment (Table 1). This article will discuss the advantages and disadvantages of each type of fistula and examine the characteristic site of stenosis for each type of fistula including the causes of stenosis at that site, the effects of stenosis at that site on fistula function, and various treatment options.
| Access Type | Common Site of Stenosis | Advantages | Disadvantages |
|---|---|---|---|
| Radiocephalic fistula | Juxtaanastomotic segment [26, 34, 73] | Ease of creation, upstream vein is preserved for future access creation [11, 74], low rate of steal syndrome, rare ischemic monomelic neuropathya | Low rate of maturation [21–23], low flow rate |
| Brachiocephalic fistula | Cephalic arch [26, 52, 54] | Ease of creation, high flow rates, high rate of maturation | Increased steal syndrome [19, 75], increased ischemic monomelic neuropathya [76, 77], higher rates of symptomatic central venous stenosis [17] |
| Brachial artery–to–transposed basilic vein fistula | Proximal swing segment [68, 70] | High flow rates, high rate of maturation | Difficult surgery with increased perioperative morbidity; increased steal syndrome [19, 75], increased ischemic monomelic neuropathya [76, 77], higher rates of symptomatic central venous stenosis [17] |
Note—Boldface highlights advantage shared by radiocephalic and brachiocephalic fistulas, and italics show advantages and disadvantages shared by brachiocephalic and brachial artery–to–transposed basilic vein fistulas.
a
Ischemic monomelic neuropathy is characterized by the sudden onset of excruciating hand pain and motor and sensory loss immediately after AVF creation likely secondary to ischemia of the vasa nervorum. It is seen almost exclusively in upper arm fistulas [77].
Radiocephalic Fistula
The 2006 guidelines proposed by the National Kidney Foundation as part of the Kidney Disease Outcomes Quality Initiative (KDOQI) recommend that a radiocephalic fistula (Fig. 3) be the first choice for fistula creation [11]. This recommendation is because of the lower rates of steal syndrome with the radiocephalic fistula compared with the upper arm fistulas [19] and because creation of this forearm fistula preserves the future option for the creation of a more proximal fistula when this access fails [20]. However, the maturation rate for radiocephalic fistulas is poor [21, 22], with one study showing that up to two thirds of radiocephalic fistulas failed to mature [23]. A major cause of fistula nonmaturation is juxta-anastomotic stenosis (JAS) (Fig. 6). JAS is variably defined in the literature as a more than 50% reduction of the luminal diameter of the outflow vein within 2 cm [24] or 5 cm [25] from the arteriovenous anastomosis. The JAS is the most frequent stenosis seen in radiocephalic fistulas [26] and is more commonly seen in radiocephalic fistulas than in any other type of AVF. JAS is not exclusive to radiocephalic fistulas and hemodynamically significant JAS is present in up to 22% of brachiocephalic fistulas [26, 27] (Fig. 7).
Causes of Juxtaanastomotic Stenosis
The etiologic mechanism of JAS is unclear, but multiple hypotheses exist. These hypotheses include the loss of the vasa venosum during skeletonization for mobilization of the most peripheral part of the vein [27], low and fluctuating shear stress at this location [28], kinking, increased turbulence of the vein just downstream from the anastomosis [29], and torsional stress [30]. A combination of some or all of these stresses on this segment of vein leads to intimal injury with a subsequent cascade of proinflammatory cytokines. This cascade of proinflammatory cytokines leads to the proliferation of smooth-muscle cells, myofibroblasts, and an extracellular matrix that result in neointimal hyperplasia and subsequent stenosis [31].
An alteration in the technique of creating an artery-to-vein anastomosis can impact the rate of JAS. The typical creation of a radiocephalic fistula necessitates moving the peripheral portion of the cephalic vein in three different directions to meet the radial artery: from superficial to deep, from lateral to medial, and from laying horizontal to laying vertical. According to Bharat et al. [30], these movements create torsional stress within the juxtaanastomotic segment. By altering how the anastomosis is created, they found a significant reduction in JAS. They propose that this reduction in JAS was because of a reduction in torsional wall strain. Specifically, by using a piggyback straight onlay technique, in which the anastomosis is formed between the underside of the more superficial cephalic vein and the anterior aspect of the deeper radial artery, they reduced the rate of primary radiocephalic fistula failure from 40.3% to 16.7% and reduced the 1-year rate of JAS from 18.5% to 5.1% [30]. The results of another study suggested that a steeper anastomotic angle (< 30°) might lessen the disturbed flow and the incidence of subsequent JAS [28].
Effects of Juxtaanastomotic Stenosis
By obstructing inflow to the fistula, JAS inhibits the vein from maturing properly. JAS is a causative lesion in 25–64% of cases of fistula nonmaturation [32–34]. Competing collateral veins are another major cause of fistula nonmaturation [35]. Although JAS is often thought to be a lesion predominantly seen early in the lifespan of a fistula [36], JAS also occurs in mature fistulas (Figs. 4 and 5). For example, in a study of 94 mature dysfunctional radiocephalic AVFs, a clinically significant JAS was present in 64% of patients [26]. Physical examination of a fistula with JAS reveals poor turgor [37] and a weak bruit. During dialysis, low access flows, difficulty with cannulation, and high negative arterial pump pressures are seen (Table 2).
| Stenosis Type | Typical Lesion | Physical Examination Findings | Findings at Dialysis and Surveillance |
|---|---|---|---|
| Inflow stenosis | JAS | Fistula is flaccid fistula and shows poor turgor, weak bruit, or weak thrill | Difficulty with cannulation, high negative arterial pump pressures, poor access flows |
| Outflow stenosis | CAS | Fistula is pulsatile and tense and shows aneurysmal dilatation | Prolonged bleeding, high venous pressures, poor access flows |
Note—When one suspects an inflow stenosis, a retrograde (i.e., against flow) fistula puncture should be performed. When one suspects an outflow stenosis, an antegrade (i.e., with flow) puncture should be performed. JAS = juxtaanastomotic stenosis, CAS = cephalic arch stenosis.
Treatment of Juxtaanastomotic Stenosis
Treatment of JAS is controversial, with the surgical and endovascular approaches each having advantages and disadvantages. Some advocate the surgical creation of a new, more proximal anastomosis given that the rates of restenosis compared with endovascular treatment are 2–2.5 times lower [38–41]. However, the assisted primary patency [40] and secondary patency [38] rates are similar with endovascular and surgical treatments, but repeated endovascular procedures are needed to maintain this similar rate. The disadvantages of surgical revision include the necessary sacrifice of a portion of puncturable vein, a longer wait until the fistula is ready for use, and increased invasiveness.
For the endovascular treatment of JAS, the initial puncture should be of the fistula, near the level of the elbow in a retrograde (i.e., against flow) direction. Crossing the arteriovenous anastomosis and cannulating the proximal radial artery are often the most difficult parts of the procedure, and different techniques have been described. One method is to advance a tightly curved catheter, such as an internal mammary catheter, into the radial artery distal to the artery-to-vein anastomosis. Crossing the arteriovenous anastomosis to cannulate the proximal radial artery is often the most difficult part of the procedure, and different techniques have been described to accomplish it. One method is to advance a tightly curved catheter, such as an internal mammary catheter over a wire, into the radial artery distal to the artery-to-vein anastomosis. The wire is then removed. While the operator simultaneously injects contrast material and slowly retracts this unformed catheter, the catheter will form at the anastomosis with the tip entering the proximal radial artery. A hydrophilic wire can be advanced into the proximal radial artery and eventually can be exchanged for a nonhydrophilic wire. Over this wire, balloon angioplasty can be performed. Although dependent on the size of the nonstenotic segment of the vein and on the maturity of the fistula, a 6-mm balloon is typically the recommended size for balloon dilation of the stenosis. Under-sizing the balloon (≤ 5 mm) leads to suboptimal hemodynamic results, and oversizing the balloon (≥ 7 mm) risks rupture. An alternative approach is a brachial artery puncture in an antegrade direction [42, 43].
Brachiocephalic Fistula
An upper arm fistula is typically placed in a patient with a forearm fistula that has failed or a patient whose forearm vessels, as assessed by preoperative vein mapping, are unsuitable for the creation of a forearm fistula. Although subject to individual surgeon preference, the criteria for adequate vasculature to create a brachiocephalic fistula are an arterial diameter of more than 2 mm and a vein diameter of more than 2.5 mm while a tourniquet or blood pressure cuff is applied [44].
Per the KDOQI guidelines [11], the preferred upper arm access is the brachiocephalic fistula (Fig. 4). Brachiocephalic fistulas are constructed by anastomosing the cephalic vein to the brachial artery in an end-to-side fashion just central to the antecubital fossa. Despite studies showing that brachiocephalic fistulas reach maturation faster than radiocephalic fistulas [45] and have better patency rates [45, 46], the placement of a brachiocephalic fistula precludes the opportunity for the subsequent creation of a more distal fistula, which is the major reason the KDOQI guidelines recommend brachiocephalic fistula placement only after radiocephalic fistula failure or in patients with unsuitable vessels [11]. Additionally, there is an estimated 5–20 times increased rate of steal syndrome in patients with brachiocephalic fistulas (5–20%) than in those with radiocephalic fistulas (1%) [47–49]; when severe, steal syndrome may result in tissue loss [47–49]. However, placement of a primary brachiocephalic fistula should be strongly considered in certain populations, such as patients with multiple medical comorbidities [50] and those with diabetes [51], because of a significantly higher proportion of brachiocephalic fistulas reaching maturation and the substantially better patency of brachiocephalic fistulas compared with radiocephalic fistulas. The cephalic arch is the most central portion of the cephalic vein as it arcs through the deltopectoral groove to join the axillary vein.
The most frequent cause of dysfunction in a brachiocephalic fistula is cephalic arch stenosis (CAS) (Figs. 8 and 9). Hemodynamically significant CAS is seen in 30–77% of dysfunctional brachiocephalic fistulas [26, 52, 53]. By comparison, CAS is rarely seen in dysfunctional radiocephalic fistulas [54].
Fig. 9A —43-year-old woman with end-stage renal disease secondary to diabetes and hypertension who was dialyzed via right upper extremity brachiocephalic fistula was referred for fistulography because of high venous pressures.
A, Initial digital subtraction angiogram shows moderate to severe cephalic arch stenosis. After balloon angioplasty, appearance did not significantly improve (not shown), and decision was made to place bare metal self-expanding stent.
Fig. 9B —43-year-old woman with end-stage renal disease secondary to diabetes and hypertension who was dialyzed via right upper extremity brachiocephalic fistula was referred for fistulography because of high venous pressures.
B, Postdeployment digital subtraction angiogram shows stent (8-mm diameter and 6-cm length; Supera, Abbott Vascular) has been placed in cephalic arch. This type of stent was chosen because of its resistance to fatigue in light of mobility of cephalic arch. Note that stent extends to junction of cephalic arch and axillary vein but not beyond it.
Fig. 9C —43-year-old woman with end-stage renal disease secondary to diabetes and hypertension who was dialyzed via right upper extremity brachiocephalic fistula was referred for fistulography because of high venous pressures.
C, Initial angiogram obtained 39 months after placement of metal stent shows moderate to severe in-stent stenosis that led to prolonged bleeding after dialysis. In 3-year period after bare metal stent placement, patient presented three more times with in-stent restenosis treated solely with balloon angioplasty.
Fig. 9D —43-year-old woman with end-stage renal disease secondary to diabetes and hypertension who was dialyzed via right upper extremity brachiocephalic fistula was referred for fistulography because of high venous pressures.
D, Given multiple repeat interventions after bare metal stent placement, in-stent stenosis was treated by placing stent-graft (Viabahn, W. L. Gore & Associates) within bare metal stent. Postdeployment conventional angiogram shows only minimal residual cephalic arch stenosis.
Causes of Cephalic Arch Stenosis
Multiple nonmutually exclusive causes of CAS have been proposed including extrinsic compression by the enclosing clavipectoral fascia [55], the sharp turn of the cephalic arch causing turbulent flow [55], and the high concentration of valves that may hypertrophy or may also lead to turbulent flow [56]. It is proposed that the higher blood flow in brachiocephalic fistulas versus that in radiocephalic fistulas explains why this lesion nearly exclusively affects the former type of fistula [54, 57]. The higher flow within the cephalic arch of brachiocephalic fistulas not only is secondary to greater arterial inflow (brachial artery vs radial artery) but also may result from alternative venous outflow seen in radiocephalic fistulas, such as through the median cubital vein to the basilic vein.
Effects of Cephalic Arch Stenosis
An outflow stenosis caused by CAS leads to aneurysmal fistula dilatation, which can become abnormally pulsatile and tense. Poor access flows and access thrombosis may subsequently occur. Increased venous pressures may be seen during surveillance (Table 2).
Treatment of Cephalic Arch Stenosis
It is critical to be familiar with CAS not only because of its high prevalence but also because it is notoriously difficult to treat. Endovascular and surgical options exist. Endovascular treatment with balloon angioplasty is considered the first-line treatment. As with the treatment of other areas of stenosis, balloons are sized to be approximately 1 mm larger in diameter than the adjacent normal vein. For the cephalic arch, the stenosis should eventually be dilated to a diameter of 6–10 mm. The recalcitrant nature of the stenosis seen in the cephalic arch often necessitates higher inflation pressures [54], and CAS may be resistant to angioplasty in up to 5% of cases [52]. There is also a higher rate of vessel rupture with angioplasty of the cephalic arch when compared with other areas of venous stenosis [52, 54]. Even when initially successful, balloon dilation of CAS leads to only a 23% primary patency at 1 year [54].
Given this poor outcome with balloon angioplasty, many have searched for alternative treatments. Studies investigating the placement of bare metal stents are sparse and have had mixed outcomes [58, 59]. Stenting in this area also creates unique issues. One risks the stent encroaching on the axillary vein. This encroachment could occur if the initial deployment is too central or if there is subsequent stent migration. The stent would then obstruct outflow from the brachial and basilic veins, and obstruction of outflow from these veins would not only lead to arm swelling but also preclude future basilic vein access creation in that arm. Stent fracture can also occur secondary to stent fatigue given that the cephalic arch overlies the mobile glenohumeral joint [57].
The results of a small prospective randomized controlled trial of patients with recurrent CAS have shown that the use of covered stents (Fluency, Bard) results in better patency than the use of bare metal stents (Luminexx, Bard) [58]. When restenosis occurred in the stent-graft group, it occurred at the uncovered ends and secondary to kinking [58]; these results suggest that using a completely covered and more flexible stent-graft (e.g., Viabahn, W. L. Gore and Associates) could have an even higher primary patency rate, which was shown in a small subsequent study [60].
Surgical turndown, in which the cephalic vein just peripheral to the cephalic arch is dissected, tunneled subcutaneously, and anastomosed to the side of the axillary or basilic vein, is a seldom-used alternative to endovascular treatment of CAS. A small study of nine patients showed a 70% 6-month patency after this procedure [61]. However, the subsequent creation of a basilic vein fistula may be limited [57].
Because high blood flow is a risk factor for developing CAS [57, 62], one group assessed the intentional reduction of fistula flow in a small retrospective study and reported the lowest rate of restenosis among any of the treatments discussed [63]. Given the small sample sizes of these studies, the first-line treatment of CAS should remain angioplasty until further investigation, and stent-graft placement, fistula flow reduction, or surgical turndown should be considered in patients with recurrent stenosis.
Brachial Artery–to–Transposed Basilic Vein Fistula
According to the KDOQI guidelines [11], a BTB fistula (Fig. 5) should be considered if a radiocephalic or brachiocephalic fistula cannot be created or has failed. The basilic vein is deeper and more medial in location than the cephalic vein. Although this location protects the basilic vein from prior venipuncture, it also makes elevation and lateral transposition of the basilic vein necessary for it to be accessible for dialysis use [64].
Surgical Creation of Brachial Artery–to–Transposed Basilic Vein Fistula
The surgical creation of a BTB fistula is technically challenging and is associated with a relatively high perioperative morbidity: a 3.8% [64] to 13% [65] rate of operative site hematoma, a 3.6% [64] to 13% [66] rate of wound infection, and a 10% [66] to 100% [67] rate of postoperative arm swelling. These perioperative complications and the technically challenging nature of the surgery are the main reasons that the BTB fistula is the third in the order of preference according to the KDOQI guidelines [11].
A BTB fistula can be created in one or two stages. For the single-stage procedure, an incision is made in the medial bicipital groove, between the biceps and triceps muscles, from the axilla to the antecubital fossa. The basilic vein is exposed by incising the deep fascia of the arm. The side branches of the basilic vein are ligated. Then, a transverse incision is made above the antecubital fossa. The peripheral portion of the basilic vein is ligated, the basilic vein is then tunneled laterally and superficially, and the peripheral end of the basilic vein is anastomosed to the side of the brachial artery [68].
The first stage of the two-stage procedure is simply creating the artery-to-vein anastomosis between the brachial artery and basilic vein just above the antecubital fossa. After a delay of 4–8 weeks, which allows arterialization of the vein to make the vein better able to withstand the mobilization and lateral transposition, a longitudinal incision is made in the bicipital groove. The basilic vein is transected just peripheral to its confluence with the brachial vein, is tunneled superficially and laterally, and is then reanastomosed to the brachial vein [65]. Although the two-step procedure has been associated with better patency [69] and lower perioperative morbidity [65], there is a extra 4- to 8-week delay until the fistula can be used compared with the single-step technique [65].
Although the creation of a BTB fistula is relatively challenging and is associated with increased perioperative morbidity, the rates of its maturation and patency are encouraging. In patients with diabetes, the maturation rate of BTB fistulas is 3 times greater than that of radiocephalic fistulas [51]. Other studies have shown BTB upper arm fistulas achieve a higher maturation rate and do so faster than brachiocephalic fistulas [70]. Once BTB fistulas are mature, the studies in the literature are divided about the relative patency of BTB fistulas compared with brachiocephalic fistulas. One study showed that BTB fistulas were more likely to thrombose than brachiocephalic fistulas [70], whereas another study showed that the median cumulative survival times were similar for BTB fistulas and brachiocephalic fistulas [71].
Proximal Swing Segment Stenosis
The proximal swing segment is the surgically created curve of the basilic vein just peripheral to its confluence with the brachial vein (Figs. 5 and 10). At this site, the basilic vein transitions from its surgically created superficial and lateral location to its naturally deeper and more medial location. From 70% to 75% of stenoses in BTB fistulas occur at this location [68, 70]. The proposed causes for stenosis at this site include kinking or compression at the tunnel site, constriction by the deep fascia of the arm, trauma during surgical manipulation, and turbulent flow in an area of significant angulation [68]. This outflow stenosis may cause prolonged bleeding after dialysis, elevated venous pressures, poor access flows, and eventual thrombosis. The standard treatment is balloon angioplasty; however, frequent reinterventions may be required after angioplasty at this site. According to one study, 29% of proximal swing segment stenoses required four or more interventions or angioplasties to maintain patency, with a median time between interventions of 75 days [68].
Conclusion
Of the more than 400,000 patients with ESRD in the United States undergoing renal replacement therapy via hemodialysis, more than 250,000 are dialyzed through AVFs. The three most common fistulas are the radiocephalic fistula, the brachiocephalic fistula, and the BTB fistula. Although any fistula can have a stenosis and sometimes multiple stenoses anywhere throughout its access circuit, each of these fistulas has a characteristic site of narrowing. For the radiocephalic fistula, it is the juxtaanastomotic segment; for the brachiocephalic fistula, it is the cephalic arch; and for the BTB fistula, it is the proximal swing segment. The former is an inflow lesion, which causes poor turgor, a weak thrill, difficulty with cannulation, poor flows, and high negative arterial pump pressures. If present shortly after fistula creation, JAS can be a contributing factor in fistula nonmaturation. The latter two stenoses are outflow stenoses, which cause the fistula to become tense, pulsatile, and aneurysmal. High venous pressures are seen during dialysis. Both inflow and outflow stenoses lead to poor access flows and can subsequently cause access thrombosis.
For the treatment of JAS, some investigators recommend surgical revision, whereas others perform endovascular dilation. CAS is difficult to treat. Balloon dilation is the first-line treatment, but primary patency is less than 25% at 1 year [54]. Stent-graft placement, surgical turndown, and intentional flow reduction are emerging treatment options. Finally, a proximal swing segment stenosis of the BTB fistula is treated with balloon dilation, but reinterventions are frequently needed.
All of these sites of stenosis share the common characteristic of significant angulation, which likely causes turbulent flow that leads to intimal injury and subsequent neointimal hyperplasia [27]. The JAS and proximal swing segment stenosis are also subject to direct surgical manipulation, which also likely plays a role in stenosis development.
Acknowledgment
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Submitted: March 1, 2015
Accepted: April 30, 2015
First published: September 23, 2015
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