Surgical Treatment of Cephalic Arch Problems in Arteriovenous Fistulas: A Center Experience.

BACKGROUND: Cephalic arch problems, mainly stenosis, are a common cause of arteriovenous fistulas (AVFs) failure, and the most effective treatment is yet to be clearly defined. Restenosis usually occurs soon, and multiple interventions become necessary to maintain patency and functionality. The authors present the experience of their center with cephalic vein transposition in a group of patients with different problems involving the cephalic arch.

METHODS: After consultation of the medical records, an observational retrospective analysis was performed to evaluate the outcomes of surgical treatment in cephalic arch problems of AVFs treated at the author's center between January 2013 and December 2015. The considered outcomes were endovascular intervention rate, thrombosis rate, and primary and secondary patencies.

RESULTS: Seven patients were treated by venovenostomy with transposition of the cephalic arch and anastomosis to the axillary vein. The average patient age was 72 years (59-81), and most patients were female (71%) and diabetic (71%). All accesses were brachiocephalic AVFs with a mean duration of 4 years (1-7). The underlying problems were intrinsic cephalic arch stenosis (n = 5), entrapment of the cephalic vein (n = 1), and clinically significant vein tortuosity at the cephalic arch (n = 1). These last 2 problems conducted to a surgical approach as first-line therapy instead of endovascular intervention, the initial treatment in the other 5 cases (all with high-pressure balloons, with cutting balloon in one case). Previous thrombotic episodes were reported in 57% of the patients. The mean access flow before surgical intervention was 425 mL/min (350-1,500). No complications related with the surgical procedure were reported. One patient underwent surgical thrombectomy after AVF thrombosis, followed by transposition of the vein. In another case, a simultaneous flow reduction was performed. Most of the patients on dialysis (5/6) used the AVF after surgery. After a mean follow-up period of 9 months (1-22), surgical treatment was associated with a reduction in endovascular intervention rate (1.9 interventions per patient-year presurgery versus 0.4 postsurgery; P < 0.05) and thrombosis rate (0.93 thrombotic episodes per patient-year presurgery versus 0.17 postsurgery; P < 0.05). The problems leading to endovascular reintervention were as follows: new venous anastomosis stenosis (57%), axillary vein stenosis (29%), and swing-point stenosis (14%). Primary and secondary patencies at 6 months were 57% and 71%, respectively.

CONCLUSIONS: In this group of patients with cephalic arch problems and multiple previous procedures, surgical treatment was associated with a reduction in endovascular intervention and thrombosis rate but did not avoid reintervention. Facing the complexity and multiplicity of the cephalic arch complications, treatment should be individually decided.