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The importance of age in terms of fistula patency in chronic hemodialysis patients: 7-year follow-up
*Corresponding author: Bilgehan Erkut
Mailing address: Department of Cardiovascular Surgery, Medical
Faculty, Atatürk University, Erzurum, Turkey.
Email: bilgehanerkut@yahoo.com
25 November 2020 / Accepted: 14 December 2020
DOI: 10.31491/CSRC.2020.12.063
Abstract
Background: Patients with kidney failure need dialysis until transplant or die. Hemodialysis is one of the preferred methods for these patients. Many studies have been conducted on the factors affecting the patency of arteriovenous fistulas, which are frequently used for hemodialysis. In this study, we investigated the importance
of age.
Methods: 442 patients (256 men, 186 women) who underwent arteriovenous fistula operation between May
2013 and Oct 2020 were retrospectively analyzed. Surgical operations were performed by 5 different cardiovascular surgeons for hemodialysis in two different institutions in our region. The patients were divided into
two groups, Group I (number of patients under 40 years old; n = 201) and Group II (number of patients over
40 years old; n = 241). The primary patency was the time interval between the formation of arteriovenous
fistula and any intervention for initial thrombosis and recanalization. Secondary patency was not evaluated in
this study. The effects of age on primary exposure rates were investigated for both groups.
Results: Primary arteriovenous fistula patency rates were lower in patients over 40 years of age. For this reason, more care should be taken in surgery to create fistulas in patients over the age of 40, and the follow-up of
patients should be done more tightly.
Conclusion: Complicated external hernias occur in all age groups but are more common in older age and show
preponderance in males. All patients present with irreducible swelling with no cough impulse. The indirect
inguinal hernia is the most common type and herniorrhaphy is the most preferred operative procedure in the
complicated hernia. Wound sepsis was the most common complication. Morbidity and mortality may be attenuated with proper surgical and post-operative management.
Keywords
Arteriovenous fistula; hemodialysis; age; surgery; patency
Introduction
The number of patients undergoing hemodialysis is
gradually increasing due to prolonged life span, imbalances in socio-economic conditions, increases in drug
consumption, and infectious diseases. It is important
to ensure that arteriovenous fistulas remain open
without any complications due to reasons such as high
comorbid conditions and the need for long-term durability in dialysis patients. Creating an autogenous arteriovenous fistula in patients with chronic renal failure
Research Article
facilitates hemodialysis and increases the patient’s
quality of life. An ideal vascular access method to be
created for hemodialysis applications is long-lasting
and should have low complication rates, adequate
should allow blood flow to pass.
Many patients who need dialysis cannot be kidney
transplant candidates and die in the waiting phase of
the transplant [1-3]. These patients need to be hospitalized many times a year, which increases the average
number of hospital days per year. After the first AVF creation process of Brescia et al. in 1966 [4], hemodialysis procedures became easier and complications
decreased and patients’ lifespan increased. Even if AVF
creation is performed in different localizations and
using different products over the years, this fistula application is still used as the first option [3,4].
Any intervention and application to the vascular structures used in fistula formation will disrupt the fistula
vascular structure and will cause problems in both fistula function and problems in patient psychology and
stability over time [2, 3]. Due to the repeated interventions for hemodialysis patients, limitations appear over
time in the vascular access site. Over the years, existing
vascular structures have become completely devastated and unusable to perform dialysis in patients.
The crucial factor for hemodialysis patients is to ensure the patency of AVFs as long-term as possible without complications. In arteriovenous fistulas opened for
hemodialysis, in addition to hemodynamic changes,
complications such as bleeding, thrombosis, extremity
ischemia, local infection, edema, venous hypertension,
and venous aneurysm are frequently encountered.
Complications lead to increased morbidity and prolonged hospital stay and negatively affect patients’
quality of life and duration. Several factors are related
to or not related to the patient, affecting the patency or
occlusion of AVFs. In this study, we tried to determine
whether post-middle age affects primary fistula patency.
Methods
From May 2013 through Oct 2020, 442 patients underwent arteriovenous access for hemodialysis in
Atatürk University Cardiovascular Surgery Clinic. Of
the patients operated for AVF, 256 (57,9 %) were male
and 186 (42,1 %) were female. Their mean age was
63,8 years (range 31 to 77 years). The patients were
divided into 2 groups. Patients under 40 years of age
were considered as Group I (n=201) and patients over
40 years of age were considered as Group II (n=241).
We collected the following parameters at the time of
creating the AVF: demographics (age and gender),
comorbidities (hypertension, diabetes, peripheral
arterial disease, hypercholesterolemia, obesity, smoking, etc.). All preoperative data are shown in Table 1.
The patients were prospectively followed up for 6.5 ±
1.3 years (mean 5.1 years). Patients were followed up
for kidney transplantation or death. The effects of age
for primary patency rates were investigated. Primary
patency was the interval from the time of access placement until any intervention designed to maintain or
re-establish patency, until access thrombosis, or until
the time of measurement of patency.
Exclusion criteria
Congestive heart failure, pregnancy, chemotherapy for malignant disease, hereditary thrombotic disposition,vasculitis, upper extremity trauma, orthopedic surgeries and phlebitis, arm-related venous thrombosis and arterial embolism, ejection fraction below 30%, and vessel diameter below 2 mm (Doppler USG) were not included in the study.
Surgical procedure
The arm to be opened with the AVF was kept away from interventional procedures and trauma. For the quality of vascular structures, vascular structures, and diameters were evaluated with duplex ultrasonography and venography in addition to physical examination. Those with vessel diameters greater than 2 mm were preferred to perform AVF. A single dose of antibiotherapy was applied to all patients in the study before the procedure. All patients were operated on by the same surgical team. The non-dominant upper limb (usually the left arm) was preferably used. It was not preferred due to the risk of lower extremity infection and limitation of movement. In general, AVFs were used for hemodialysis using the patient’s own autogenic vessels and performed from distal to proximal. After the arterial and venous vessels were prepared, 0.5 ml heparin was administered to the patients. Anastomoses were done using 7/0 polypropylene (either end-to-side or side-to-side procedure). The wound was then closed in one layer and the hand was held up. The presence of trill on the venous structure after the operation was evaluated as a successful result. The patients were discharged on the first postoperative day. Anticoagulant treatment of low molecular weight heparin was administered to all patients within 10 days. Later, acetylsalicylic acid treatment was started according to the patient’s suitability. Local anesthesia or axillary block was preferred for surgical intervention.
Assessment of fistula maturation
The patients were followed primarily for fistula patency in the postoperative period. Patients who had no problem with fistula opening were discharged and wound care recommendations were made. Hand and finger exercises were said to be done in terms of AVF development. For a functional AVF, sufficient vascular space and at least 300-400 ml/min blood circulation are required. That’s why these patients were evaluated by Doppler USG after the first week and their AVF flow was measured. Patients who were found to have sufficient flow were recommended to wait for about 1 month in terms of fistula development and adequate hemodialysis.
Ethics statement
Ethical permission was given by the Erzurum Regional Training and Research Hospital ethics committee and informed written consent was obtained from all participants and/or parents or guardians. The Hospital Ethical Committee Permission was obtained before the commencement of the study. Furthermore, all procedures were carried out by the Declaration of Helsinki.
Statistical analysis
Student t-test was used to compare age between groups, and the chi-square test was used for gender comparison. Kaplan Meier survival analysis and logrank test were used to assess the obstruction status of the fistula for 7 years. Age-related data were presented with the mean ± standard deviation of the arithmetic mean. Categorical variables were expressed as counts and percentages. Statistically, 0.05 levels were accepted as significant.
Results
The pre-operative data analysis made between both
groups is presented in Table 1. There were no differences between the two groups in preoperative
patients’ characteristics, and there was no statistical
significance. There was no statistically significant difference between the groups in terms of gender. There
were no differences between the two groups in terms
of the number of patients with hypertension, diabetes
mellitus between groups. There was also no difference between the groups in terms of etiological factors
(Table 1).
In the literature, many types of surgery have been used for AVF. The most common types of surgical intervention to create AVFs were snuff-box, Brescia-Cimino,
basilic vein transposition, brachiocephalic, upper radio
cephalic (Table 2). There was no statistical difference
between the groups in terms of AVFs types. Besides,
the information about operations is also summarized
in Table 2.
In addition to the structural and functional features in
patients with AVF, complications occurring in the first
week after surgery are shown in Table 3. The most
common complication was hematoma due to bleeding. In the first week, 21 patients in group I and 26
patients in group II had no trill in AVF and obstruction
developed. As soon as occlusion was detected in these
patients, thrombectomy was performed and AVFs were
made functional. All patients were successfully included in the hemodialysis program. There was no statistically significant difference between the groups in
terms of the features and complications shown in Table
3. A hematoma evacuation procedure was performed
in patients with hematoma. The bleeding stopped with
minimal pressure in patients with bleeding. In some
patients, the incision of the patient was reopened for bleeding. Bleeding sites were found and bleeding was
stopped (ligation or cauterization).
The overall primary patency rates were 90.2%, 85.6%,
75.4%, 63.4%, 57.1%, 48.2% and 41.2% after 1, 2, 3,
4, 5, 6 and 7 years, respectively in Group I. In patients
over 40 years of age (Group II), these rates were 83.3%,
71.2%, 61.9%, 57.7%, 43.7%, 34.8%, and 28.5% after 1, 2, 3, 4, 5, 6 and 7 years, respectively (Figure 1).
There was a significant difference between under the
age of 40 and over 40 years old about primary fistula
patency (p<0.001). In patients under 40 years of age,
the rate of primary patency rates in 7 years was found
to be higher than in those aged over 40 years. Besides,
mean fistula occlusion was 41.4 months in patients
under 40 years of age; this rate was 28.7 months in patients over 40 years of age. This period was statistically
significant (p < 0.001).
Discussion
Establishment, use, and follow-up of AVFs, which are
one of the hemodialysis methods in patients with
chronic kidney failure, affect the quality of life of patients and are an important criterion for survival. A functional AVF that can remain open without thrombosis positively affects the patient’s future life. For this
reason, patients with AVF are closely followed by nephrology and vascular surgery teams in many clinics.
For the creation of AVFs and long-term patency rates
with successful results, surgeons should be performed
with special care and followed by the same surgeons.
In our patient groups, senior surgeons took part in the
development of AVF, and the patients were followed
closely [5,6].
The use of the left or right arm is still the first preferred method to create AVFs. It is important to start
the procedure from the most distal part of the upper
extremities (snuff-box fistula) to maintain a solid vascular structure in the subsequent fistula formation processes. Although the vessel diameters in this region are
small, the use of this distal site in case of occlusion and
fistula function deterioration provides space for the
subsequent creation of a new fistula. If the distal cuts
are unsuitable or have been used before, the middle
and upper sections of the arm should be used to create
the AVF. In general, the AVFs generated for hemodialysis should be performed from the autogenous vascular
structures of the patient and the distal to the proximal
(snuff-box, Brescia-Cimino, upper radio cephalic, brachiocephalic) [7,8]. Although there was no consensus on
the difference in patency rates of distal AVFs concerning proximal AVFs, in our patients, we attempted to use
the distal site as the first choice for AVFs, considering
that there might be fistula distortions after months
and years. Many studies have shown different rates of
patency of upper extremity AVFs. Despite these differences, there was no statistically significant difference
in patency rates for upper extremity AVF types in some
studies [9,10]. Based on the hypothesis that AVF patency
rates for the upper and lower arms did not differ in
many studies, we included all upper extremity AVFs
in our study, without distinction between upper and
lower arms [11-13].
The most commonly used technique for creating AVF is
the end-to-side technique. Side-to-side or end-to-end
techniques have been used in previous years, and over time these techniques have been abandoned. Although
all 3 techniques have advantages or disadvantages
(distal ischemia, aneurysm, venous hypertension,
steal syndrome, or edema), many studies have shown
that the end-to-side technique causes fewer complications[4,13-15]. We also preferred the end-to-side technique in all our patients and we observed that there
were no differences between the groups in terms of
adverse events caused by these techniques.
There was no significant difference between the
groups in terms of characteristics, surgical procedures,
and complications in the preoperative, operative, and
postoperative periods. The differences in the age of the
patients were not significant in terms of procedural
features and complications. While these results we
found were compatible with some studies, they also
showed differences according to some studies [16,17].
Especially gender, presence of DM, smoking, and hypertension have been shown to negatively affect AVF
patency in many studies [18-21]. However, in some studies conducted with different centers, it was observed
that these factors did not affect the fistula patency [13,22].
In this study, in which the effect of the difference in the
age of the patients on AVF patency was investigated;
Fistula opening rates were found to be lower in patients older than 40 years compared to those under 40.
While this result was compatible with some studies [16],
it showed a difference with some studies [17, 23].
This study has some limitations. First of all, it is not
possible to determine exactly which group had more
mortality over the years and mortality times due to
the lack of data in the records. Secondly, the effect of
co-morbidities (such as hypertension, diabetes) and
complications that developed over the years on fistula
patency was not investigated in this study. Finally, due
to the low socio-economic factors in our country and
our region, retrospective data collection, follow-up
of patients, and hemodialysis procedures performed
in different centers were not evaluated in this study.
Therefore, it would be beneficial to carry out further
studies by re-evaluating many missing parameters in
the future.
Conclusion
For hemodialysis, arteriovenous fistulas are vital for patients with chronic kidney failure. Repetitive entryexit procedures applied to vascular structures during the hemodialysis procedure may cause vascular tissue damage and narrowing and occlusion over time. Many factors (demographic, hemodynamic, biological parameters, and comorbidity conditions) are effective in maintaining the patency of fistulas. Previous studies have stated that one of these factors is the age of the patient. In this study, we investigated the effect of middle and old age on AVF patency, and as a result, we determined that younger age (under 40 years) was effective in keeping AVFs open for longer.
Declarations
Acknowledgments
The authors would like to thank Hasan Aydın, Prof, MD for his work on the statistical analysis.
Authors’ contributions
He designed, planned and wrote the draft with the support of Bilgehan Erkut: Borulu F; collecting and analyzing data: Borulu F, Erkut B; helped audit the findings of this study: Erkut B; all authors read and approved the last article: Borulu F, Erkut B.
Conflicts of interest
All authors declared that there are no conflicts of interest.
Ethical approval and consent to participate
Not applicable.
Consent for publication
Written consent was provided by participants or their relatives.
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