Functional outcomes of arteriovenous fistulas recruited with regional anesthesia

Abstract

Objective: Regional anesthesia (RA)-induced vasodilation increases the proportion of patients with vein anatomy suitable for arteriovenous fistula (AVF) creation. The functional outcomes of AVFs created with veins initially small for size on preoperative duplex ultrasound mapping (≤2.4 mm) that are recruited under RA have not been clearly defined. We aimed to evaluate freedom from revision or thrombosis, time to first cannulation, and reintervention rates of AVFs created with veins recruited after induction of RA.

Methods: A prospectively maintained quality improvement database from a single institution was queried for patients who had dialysis access created under RA. We compared AVFs created according to the original surgical plan (preoperative minimum vein diameter >2.5 mm) with AVFs recruited with RA (preoperative minimum vein diameter ≤2.4 mm). End points included freedom from revision or thrombosis, time to first cannulation, and reintervention rates.

Results: Between May 2014 and April 2018, there were 208 dialysis access cases performed under RA. Excluding grafts, revisions, patients with previous ipsilateral AVFs, and those without preoperative ultrasound vein mapping, 135 patients were included in our analysis. Induction of RA with intraoperative duplex ultrasound allowed a change in surgical plan in 55 of 135 (42%) patients (recruited with RA), including 31 patients originally scheduled for an arteriovenous graft (mean preoperative distal upper arm cephalic vein diameter of 1.8 mm [standard deviation, 0.2 mm]) who were converted to an AVF (12 brachiobasilic, 11 brachiocephalic, and 8 radiocephalic). The remaining patients in the group of AVFs recruited with RA included 13 scheduled for brachiobasilic configurations who were converted to brachiocephalic or radiocephalic AVFs and 11 scheduled for brachiocephalic AVFs who were converted to radiocephalic AVFs. Comparing AVFs created according to the original surgical plan vs AVFs recruited with RA, there were no differences in reintervention rates (48% vs 49%; P = .90) or functional outcomes at 6 months (60% vs 65% used on hemodialysis [P = .58] and 7% vs 2% primary failure [P = .19]).

Conclusions: In this series, RA increased the proportion of patients who underwent AVF creation without compromising functional outcomes. Routine use of RA in access surgery could have significant implications in meeting national guidelines for autogenous access in the prevalent hemodialysis population.

Keywords: Arteriovenous fistula; Hemodialysis access; Regional anesthesia.