Three Year Patency and Recurrence Rates of Revision Using Distal Inflow with a Venous Interposition Graft for High Flow Brachial Artery Based Arteriovenous Fistula

Objectives: Upper arm arteriovenous fistulas (AVF) occasionally develop high flow. Revision using distal inflow (RUDI) effectively reduces flow of high flow accesses (HFA) in the short-term and is also popularised for treatment of haemodialysis access induced distal ischaemia (HAIDI). The long-term efficacy is unknown. The study's aim was to report on 3 year RUDI patency and recurrence rates for HFA with and without HAIDI. Material and methods: This was a retrospective cohort study of patients with a HFA with or without HAIDI undergoing RUDI using greater saphenous vein (GSV) interposition between March 2011 and October 2017 at three facilities. AVFs were termed HFA if flow volumes exceeded 2 L/min on two consecutive measurements using dilution techniques. HAIDI was diagnosed as recommended. Following RUDI, follow up was not different from standard care in AVF patients. Data on post-operative flows and re-interventions were extracted from electronic patient files. Loss to follow up was avoided. Rates of patency and HFA recurrence were analysed. Results: During the observation period, 21 patients were studied (7 females, 54 years +/- 3). Fourteen had uncomplicated HFA whereas seven had additional HAIDI. Immediately post-operatively, flows decreased threefold (3120 mL/min +/- 171 vs. 1170 mL/min +/- 87, p<. 001). Overall 3 year primary patency was 48% +/- 12 (HFA, 55% +/- 15 vs. HAIDI/HFA, 29% +/- 17, p = .042). Secondary patency was identical in both groups (overall, 84% +/- 9). Interventions were percutaneous transluminal angioplasty (n = 12, 9 patients), thrombectomy (n = 7, 3 patients), and revision with new interposition grafts (n = 3). After 3 years, 51% +/- 12 were free of high flow (HFA, 32% +/- 13 vs. HAIDI/HFA, 100%, p = .018). High immediate post-operative access flow predicted recurrence (OR 1.004 [1.000-1.007], p = .044). Patients with recurrence were 12 years younger than those without (p = .055). Conclusion: RUDI with GSV interposition for HFA offers acceptable patency rates after 3 years although reinterventions are often required. High immediate post-operative flows and young age are associated with recurrent high flow. (C) 2018 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved