[Variants of reconstructions of arterio-venous fistulas disfunction in patients on programmatic hemodialysis].

Objective: The purpose of this study was to assess efficacy of original reconstructions of arteriovenous fistulas in the development of their dysfunctions related to formation of arterial and perianastomotic stenosis.

Patients and methods: Presented herein are two techniques of original reconstructions of arteriovenous fistulas for stenotic vascular changes leading to dysfunction of a vascular access: modification of side-to-side radial-cephalic fistulas and modification of Gracz-type arteriovenous fistulas. The main concept while working out these operations was to preserve the previous length of the functioning portion of an arteriovenous fistula without its shortening. The first technique (Group One) was used in 11 patients and the second technique (Group Two) in 19 patients. The duration of replacement therapy with hemodialysis averagely amounted to 6.8 years and 5.6 years for Group Oneand Group Two patients, respectively. After clinical examination the findings of ultrasonographic mapping in Group One patients revealed the following alterations: local stenosis of the radial artery and lower third of the forearm proximal to the anastomosis (n=2), anastomotic stenosis (n=3) or fistula vein stenoses (n=6) at a distance of 1 to 5 cm from the anastomosis. All Group Two patients were found to have a stenosing lesion of the radial artery along the whole length of the forearm with pronounced calcinosis, including in combination with perianastomotic stenosis (n=2).

Results: In Group One, the results were available for 10 (91%) of 11 patients within a period from 1 year to 4 years. Of these, 2 patients died with 'functioning' fistulas. The remaining patients continue receiving replacement therapy by programmed hemodialysis. One patient developed fistula vein thrombosis followed by recanalization. Primary and secondary (functional) survival of the reconstructed vascular access amounted to 90% and 100%, respectively. In Group Two, the results were known for 12 (63%) of 19 patients (over the same period of follow up). One woman died of cardiac failure, with her fistula functioning. Another woman was found to have an immature fistula and underwent creation of a loop brachiobasilic arteriovenous fistula. A further patient after creation of an arteriovenous fistula developed venous insufficiency of the limb, which was eliminated by endovasal laser coagulation of the cephalic vein on the forearm. Primary survival of the access in Group Two amounted to 83.3%.

Conclusion: The proposed variants of reconstructions for perianastomotic stenosis of arteriovenous fistula proved optimal, since they preserve (Group One) or increase (Group Two) the length of the functioning portion of the fistula.