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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2018  |  Volume : 29  |  Issue : 4  |  Page : 924-929
Experience with arteriovenous fistula creation for maintenance hemodialysis in a tertiary hospital in South-Western Nigeria

Department of Surgery, Urology, and Renal Transplant Unit, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria

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Date of Submission21-Mar-2017
Date of Acceptance22-Apr-2017
Date of Web Publication28-Aug-2018


End-stage renal disease (ESRD) is prevalent in our region. A major mode of treatment is by maintenance hemodialysis, and reliable vascular access is paramount for this to be successful. Arteriovenous fistula (AVF) creation offers permanent vascular access in patients with ESRD. We present our experience on AVF creation over a 10-year period. Our objective was to retrospectively review the outcome of all cases of AVF that have been created for ESRD patients at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife Nigeria between January 2006 and December 2015. The demographic characteristics, indications, clinical and intraoperative findings, operative complications and outcomes were filled into a pre-designed proforma. A total of 80 cases were reviewed. The age range was 17-80 years, with a mean of 49.03 ± 16.34 years. Males (85%) were more common than females (15%). Chronic glomerulonephritis and hypertension accounted for about 77.5% of etiology of ESRD in these patients. The left (non-dominant) upper limb was used in 88.1% of cases whereas 11.9% were created on the right upper limb. The distal radio-cephalic AVF (76.3%) was most commonly performed; with either the end (vein) to side (artery) (68.8%) or side-to-side (31.2%) anastomotic techniques employed. There was a primary failure in six patients (7.5%). Primary failure was more common in diabetics and thrombosis (7.5%) was the most common cause for primary failure. AVF creation has very good outcome in well-selected patients.

How to cite this article:
Salako AA, Badmus TA, Igbokwe MC, David RA, Laoye A, Akinbola IA, Onyeze CI, Babalola RN. Experience with arteriovenous fistula creation for maintenance hemodialysis in a tertiary hospital in South-Western Nigeria. Saudi J Kidney Dis Transpl 2018;29:924-9

How to cite this URL:
Salako AA, Badmus TA, Igbokwe MC, David RA, Laoye A, Akinbola IA, Onyeze CI, Babalola RN. Experience with arteriovenous fistula creation for maintenance hemodialysis in a tertiary hospital in South-Western Nigeria. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2022 Aug 8];29:924-9. Available from: https://www.sjkdt.org/text.asp?2018/29/4/924/239628

   Introduction Top

The prevalence of end-stage renal disease (ESRD) caused principally by chronic glomerulonephritis (CGN), hypertension, and diabetis mellitus (DM) are rapidly increasing in Nigeria.[1],[2] Indeed, it has become a health burden in our practice.[1],[3] ESRD is treated mainly by renal replacement therapy (RRT), namely: hemodialysis (HD), peritoneal dialysis and kidney transplantation. Vascular access is paramount for successful HD and can be achieved by central venous cannulation (through the jugular or femoral veins) or by arteriovenous fistula (AVF) creation. Some of the advantages of AVF over other forms of vascular access include a reduced risk of infection, faster and easier cannulation as well as better reliability due to its permanent nature.[4] Cimino-Brescia in 1966 described the distal radio-cephalic AVF which has since been considered the gold standard AVF.[5] Creation of successful AVFs require appropriate patient selection which involves knowledge of comorbidities, examination of the upper limbs, the timing of the procedure, meticulous surgery, and postoperative management.

We present a 10-year review of our experience with AVF creation in Ile-Ife, Nigeria.

   Objectives Top

To review all cases of AVF that have been created for ESRD patients at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria over a 10-year period (January 2006 to December 2015).

   Patients and Methods Top

ESRD patients who had AVF created during the study period were identified. Their hospital records were retrieved, and information such as demographic characteristics, etiology of ESRD, indications, clinical features, intra-operative details, postoperative complications, and outcomes were extracted and filled into a predesigned proforma. These data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 20.0 for Windows (SPSS Inc., Chicago, IL, USA).

Patient's preparation

All patients were referred from the nephrology unit of our hospital. They were clerked and had general physical examination done in our clinic. Examination of both upper limbs was done; assessing the patency of the radial and ulnar vessels as well as collaterals using Allen's test. Upper limb Doppler ultrasound scans and vascular mapping were requested for patients with previously failed AVF, obese, poor peripheral veins and previous internal jugular venous cannulation. Hematocrit, serum electrolytes, and clotting profile were also done. Patients who were already on maintenance HD were required to have HD 24 hours before the procedure.

Surgical technique

Patients were admitted on the day of the procedure in our day-case theater. All cases were done under local anesthesia. Longitudinal incisions along the Langer's lines were used. End-to-side or side-to-side techniques of anastomosis were employed for all the cases using Prolene 5/0 sutures on a round bodied double-ended needle and skin closure was done using nonabsorbable sutures [Figure 1], [Figure 2], [Figure 3]. Patients were placed on anti-platelets, subcutaneous heparin or other non-pharmacological postoperative treatment to reduce the risk of thrombus formation. They were followed up for one year. Patients with primary failure (6) had repeat AVF procedures done.

Figure 1: Clearly dissected (a) cephalic vein and (b) distal radial artery prior to anastomosis.

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Figure 2: (a) Radial artery anastomosed in end (vein) to side (artery) fashion to (b) Cephalic vein. (c) Distended cephalic vein following anastomosis.

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Figure 3: Three days postoperative review. Wound edges perfectly apposed and cephalic vein distended.

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   Results Top

During the study period, 80 arteriovenous fistulas were created for 74 patients. The patients were aged between 17 and 80 years, with a median age of 49 years, and mean age (±SD) of 49.03 ± 16.34 years). CGN was the most common cause of ESRD in our study [Table 1]. The nondominant upper limb was used in all of the patients; with majority being on the left side [Table 2]. Only 14 (17.5%) patients had preoperative Doppler ultrasound of the upper limbs. Fifty-four (67.5%) patients had other forms of vascular access before AVF creation.
Table 1: Basic demographics of the study population and ESRD etiology.

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Table 2: Type of arteriovenous fistula created.

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In this series, all the patients had native AVFs with no use of vascular grafts. The distal radiocephalic AVF with end-to-side anastomotic technique was most commonly performed [Table 2].

There was primary failure in six patients hence a primary failure rate of 7.5%. Primary failure was more commonly seen in diabetics and inadequately dialyzed patients. Thrombosis - six (7.5%), wound infection - three (3.75%), hematoma (1.2%), and upper limb swelling (1.2%) were the complications noted.

   Discussion Top

There is an increasing incidence of chronic kidney disease (CKD) and ESRD in Nigeria.[1],[3] AVF is a superior form of vascular access for hemodialysis.[1],[2],[6] However, only a small fraction of ESRD patients in our environment get some form of vascular access for RRT with an AVF rate of 10% compared to 30%–40% among ESRD patients in America.[1],[3],[7]

The mean age of patients with ESRD undergoing AVF in our series was 49 years which was similar to other studies done in Nigeria.[8],[9] However, the mean age in developed countries was two decades older.[2],[4],[8],[9] The occurrence in younger age groups in our series is likely related to the most common etiology of ESRD which we found to be CGN much unlike hypertension and diabetes mellitus in the western world.[1] The etiology of ESRD in this report was similar to a previous study in our facility,9. We found a male preponderance among the patients for AVF with a male:female ratio of 5:1. This is similar to previous documentation in literature which demonstrated that CKD/ESRD was more common in males.[1],[3] The left upper limb being the nondominant limb in most of the patients was used for the creation of AVF in the majority (88.9%) of our patients. The preference for the nondominant limb is as a result of the need to carry out minimal work or activities with the limb to preserve the delicate AVF, especially in the first two weeks following surgery. Similar preference for the non-dominant upper limb is also practiced in other tertiary hospitals like ours that offer AVF to patients[8],[9]

Native AVF were created in all the patients in this series, unlike in America where Konner et al reported the use of PTFE grafts in up to 80% of AVF creation mainly due to the easier surgical technique.[10] Several other studies have shown the superiority of native AVF to central lines and arteriovenous grafts especially as regards its increased durability, reduced morbidity and mortality, reduced infection rate and better graft patency.[11],[12] In addition, the cost of arteriovenous grafts is usually unaffordable to a large percentage of the Nigerian population.[7]

The distal radio-cephalic and brachio-cephalic fistulas accounted for >90% of the fistulas created in our series. This finding was also corroborated by other researchers who routinely carry out native AVF.[8],[9] Shahbaaz and Prokash in India, showed the superiority of distal radio-cephalic AVF to other forms owing to the very superficial location of the vein and preservation of the cubital fossa for future procedures.[13] The more proximal fistulas were reserved for patients with poor peripheral veins and repeat procedures. Primary failure (non-functional AVF after six weeks of maturation) rate of 7.5% in this series was lower than in most studies, though the follow-up of only one year restricted a longer-term assessment.[8],[9],[14],[15] Thrombosis, wound infection and bleeding were the most common complications observed among the study population. Other complications which have been reported in other studies such as steal phenomenon and pseudoaneurysm were not observed in this series.[16] However, we had to do a salvage evacuation of hematoma on the postoperative day 1 on two patients following a palpably reduced thrill.

As has been alluded in many studies, delayed presentation of ESRD patients to the hospital in developing countries and referral for AVF creation have provided the need for temporary vascular access to have HD.[1],[9] This need for temporary dialysis access using central venous catheters can be reduced by early referral to surgeons for AVF creation and has been shown to have a better outcome.[14],[17] We found that seven out of 10 patients in our series had a previous central venous access for emergency HD before referral for AVF creation. Bakari et al in Maiduguri reported that 100% of patients in a series of 32 had previous access with venous catheters.[9] Going forward, earlier referrals for AVF creation should go a long way in reducing the morbidity associated with multiple venous cannulations for HD.

   Conclusion Top

This review showed that outcome of AV-fistula creation in our center is promising. Only a small percentage of ESRD patients are referred for AVF creation due to late presentation and most have already had some prior forms of temporary central venous access. Distal radiocephalic AVF is the most common type offered in our facility and thrombosis was the most common cause of AVF failure. Diabetes and inadequate preoperative HD were associated with primary failure.

Conflict of Interest: None declared.

   References Top

Arogundade FA, Sanusi AA, Hassan MO, Akinsola A. The pattern, clinical characteristics and outcome of ESRD in Ile-Ife, Nigeria: Is there a change in trend? Afr Health Sci 2011;11:594-601.  Back to cited text no. 1
Nwankwo EA, Wudiri WW, Bassi A. Practice pattern of hemodialysis vascular access in Maiduguri, Nigeria. Int J Artif Organs 2006; 29:956-60.  Back to cited text no. 2
Ulasi II, Ijoma CK. The enormity of chronic kidney disease in Nigeria: The situation in a teaching hospital in South-East Nigeria. J Trop Med 2010;2010:501957.  Back to cited text no. 3
Al-Jaishi AA, Oliver MJ, Thomas SM, et al. Patency rates of the arteriovenous fistula for hemodialysis: A systematic review and metaanalysis. Am J Kidney Dis 2014;63:464-78.  Back to cited text no. 4
Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966;275:1089-92.  Back to cited text no. 5
Akinsola W, Odesanmi WO, Ogunniyi JO, Ladipo GO. Diseases causing chronic renal failure in nigerians – a prospective study of 100 cases. Afr J Med Med Sci 1989;18:131-7.  Back to cited text no. 6
Schon D, Blume SW, Niebauer K, Hollenbeak CS, de Lissovoy G. Increasing the use of arteriovenous fistula in hemodialysis: Economic benefits and economic barriers. Clin J Am Soc Nephrol 2007;2:268-76.  Back to cited text no. 7
Yiltok SJ, Orkar KS, Agaba EI, et al. Arteriovenous fistula for patients on long term haemodialysis in Jos, Nigeria. Niger Postgrad Med J 2005;12:6-9.  Back to cited text no. 8
Bakari A, Nwankwo E, Yahaya S, Mubi B, Tahir B. Initial five years of arterio-venous fistula creation for haemodialysis vascular access in Maiduguri, Nigeria. Internet J Cardiovasc Res 2006;4(2):1-6.  Back to cited text no. 9
Konner K, Nonnast-Daniel B, Ritz E. The arteriovenous fistula. J Am Soc Nephrol 2003; 14:1669-80.  Back to cited text no. 10
Tordoir JH. Hemodialysis vascular access preferences and outcomes in the dialysis outcomes and practice patterns study (DOPPS). Minerva Urol Nefrol 2004;56:223-35.  Back to cited text no. 11
Young EW, Dykstra DM, Goodkin DA, Mapes DL, Wolfe RA, Held PJ. Hemodialysis vascular access preferences and outcomes in the dialysis outcomes and practice patterns study (DOPPS). Kidney Int 2002;61:2266-71.  Back to cited text no. 12
Shahbaaz K, Prokash S. A long term study for upper limb arterio-venous fistula creation for hemodialysis at a tertiary level hospital in Eastern India. Clin Pract 2016;13:5-9.  Back to cited text no. 13
Sahasrabudhe P, Dighe T, Panse N, Deshpande S, Jadhav A, Londhe S. Prospective long-term study of patency and outcomes of 505 arteriovenous fistulas in patients with chronic renal failure: Authors experience and review of literature. Indian J Plast Surg 2014;47:362-9.  Back to cited text no. 14
[PUBMED]  [Full text]  
Cawich SO, Brown H, Martin A, Newnham MS, Venugopal R, Williams E. Arteriovenous fistulas as vascular access for hemodialysis: The preliminary experience at the University Hospital of the West Indies, Jamaica. Int J Angiol 2009;18:29-32.  Back to cited text no. 15
Sahasrabudhe P, Dighe T, Panse N, Patil S. Retrospective analysis of 271 arteriovenous fistulas as vascular access for hemodialysis. Indian J Nephrol 2013;23:191-5.  Back to cited text no. 16
[PUBMED]  [Full text]  
Chesser AM, Baker LR. Temporary vascular access for first dialysis is common, undesirable and usually avoidable. Clin Nephrol 1999;51: 228-32.  Back to cited text no. 17

Correspondence Address:
Dr. Martin C Igbokwe
Department of Surgery, Urology Unit, Obafemi Awolowo University Teaching Hospital, Ile-Ife
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.239628

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