Comparative Evaluation of Radiocephalic and Brachiocephalic Fistulae and the Variables Affecting Maturation and Patency

Objective: Radiocephalic arteriovenous fistulae (RCAVF) are recommend as the primary arteriovenous fistula of choice by NKF-K/DOQI guidelines, however some evidence exists that brachiocephalic arteriovenous fistulae (BCAVF) exhibit better performance. The purpose of this study was to compare the variables that impact maturation and patency of primary RCAVF and BCAVF and to determine which fistula is most optimal as the sole site for dialysis access.
Methods: One-hundred and ninety consecutive primary arteriovenous fistulae constructed at the same university hospital in patients for chronic hemodialysis were analyzed. The ability to perform as the sole site for hemodialysis access, the time between fistula creation and maturation, the effect of prior ipsilateral and contralateral central venous catheterization, and the impact of patient clinical factors on maturation and functional patency were studied. Clinical data was reviewed retrospectively from medical records. Patency rates were analyzed using life table methods. Multivariate analysis was performed to assess independent relationships of patient factors to maturation.
Results: Sixty-two percent were male with an average age of 56.1 years. Maturation of BCAVF was higher than RCAVF (91% vs. 72% respectively, p = 0.0017). On an intent-to-treat basis, matured RCAVF resulted in a greater primary, assisted primary, secondary, and assisted secondary patency at 6, 12 and 24 months when compared to BCAVF, with two exceptions. Matured BCAVF had greater primary patency than RCAVF at 12 months in nondiabetic patients (70% vs. 64% respectively, p = 0.0256) and in patients with a positive history of smoking (48% vs. 43% respectively, p=0.00017). Prior history of ipsilateral central venous catheterization significantly decreased primary patency of both RCAVF and BCAVF.
Conclusion: RCAVFs are associated with lower maturation rates, but provide superior patency to BCAVF after maturation. Nondiabetic patients and those with a history of tobacco use may benefit from creation of a primary BCAVF. Central venous catheterization negatively impacts the primary patency of subsequent ipsilateral and contralateral fistulae.