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A Six-Year Experience with the Proximal Radial Artery Fistula - Does a Previous Access Matter?
Michael F Amendola1, John Pfeifer2, Francisco Albuquerque3, Mark Levy3, Luke Wolfe3, Marcela Woogen-Fisher2, Ronald Davis2
1VA Medical Center/VCU, Richmond, VA;2VA Medical Center, Richmond, VA;3VCU Medical Center, Richmond, VA

BACKGROUND:
The proximal radial artery fistula has been established as a viable early surgical option for arteriovenous fistula creation. The overall assisted primary patency reported in the literature approaches 100% at one year. We speculate that this excellent assisted primary patency does not represent the functional results when seen in light of successful cannulation and fistula utilization.
METHODS:
We retrospectively queried our Veterans Administration Hospital operative database to identify 284 male patients who had 571 access procedures preformed by a single senior vascular surgeon attending from January 1, 2003 to December 31, 2008. Operative details, co-morbidities, maturation time (time to first cannulation), functional utilization time (successful usage on dialysis), and total duration (creation to occlusion or revision to another type of fistula) were collected and analyzed.
RESULTS:
A total of 144 proximal radial artery fistulas were placed during the study period. 87 patients underwent primary proximal radial artery fistula (P-PRA) placement in a limb without previous access. 57 patients had a secondary proximal radial artery fistula (S-PRA) after a failed previous fistula or graft in the same limb. There were no differences between the two groups in terms of age, co-morbidities, and operative details. Overall assisted primary patency rate of accessed fistulas at 12 months was 79.8%. 91 patients (63.2%) were receiving hemodialysis at the time of P-PRA or S-PRA placement. Outcomes of P-PRA and S-PRA populations on hemodialysis were examined:
P-PRA (n=46) S-PRA (n=45) p value*
Successful
Cannulation
15 patients (33%)25 patients (55%)0.00354*
Maturation Time (mean +/-SD)111.4 +/- 59.1 days104 +/- 95.9 days0.3212
Functional Utilization
(mean +/-SD)
405.4 +/- 531.9 days755.2 +/- 661.2 days0.0220
Total Duration
(mean +/-SD)
516.8 +/- 547.2 days859.5 +/- 650.7 days0.0361

*Fisher’s Exact Test Wilcoxon Rank Sum
Subgroup analysis (ANOVA) of the S-PRA group indicated that a failing previous access in the same arm was not superior in terms of successful cannulation, utilization or duration when compared to a failed previous access.
CONCLUSIONS:
The proximal radial artery fistula remains a viable first access procedure undertaken at our institution. We have found a similar 12-month assisted primary patency of this fistula type compared to the literature; however, our percentage of fistulas actually being accessed for successful hemodialysis treatment was surprisingly low. The S-PRA appears to have a significantly higher cannulation rate as well as functional and total duration time most likely secondary to a dilated venous system from previous access. Interestingly, when a previous access was either thrombosed or patent it did not predict successful cannulation, utilization, or total duration of a S-PRA in the same arm at a future date.


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