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Summary

We present a modified no-touch technique (MNTT) to create a radio-cephalic arteriovenous fistula (RC-AVF) in which the venous and arterial wall avoid devascularization and the radial artery does not sever.

Abstract

Autologous arteriovenous fistula (AVF) is the primary and best option to obtain vascular access for hemodialysis treatment; other options are arteriovenous graft (AVG) and central venous catheterization (CVC). The implementation of radio-cephalic autologous arteriovenous fistula (RC-AVF) in the forearm was preferred among patients with superior vascular conditions. However, there is a high rate of early fistula failure. The chosen surgical method is understood to have an effect on the maturation of the fistula. New surgical procedures such as radial artery deviation and reimplantation (RADAR) have been significantly improved for juxta-anastomotic stenosis. Nevertheless, new problems such as stenosis of arteries and narrowing of surgical indication were also found. In this report, we presented a modified no-touch technique (MNTT) to create an RC-AVF, in which the venous and arterial wall avoid devascularization and the radial artery does not sever.

Introduction

Radio-cephalic autologous arteriovenous fistula (RC-AVF) have been regarded as the primary and best choice for vascular access in hemodialysis patients1,2. However, the early failure to mature continues to be a major problem with RC-AVF creation3. Different surgical methods have different degrees of vascular injury and affect the maturation of RC-AVF. In 1996, Souza4 first proposed the use of a no-touch technique (NTT) to separate the great saphenous vein in coronary artery bypass grafting and achieved good results5

Protocol

The MNTT was conducted according to the human research protocol approved by the ethics committee of the Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University (IRB2021029).

1. Preoperative evaluation

  1. Check the medical history: Ensure that the patients have no coagulation abnormalities, valvular heart disease, congestive heart failure, peripheral vascular disease, skin disease, history of central venous catheterization, history of pac.......

Representative Results

Since January 2021, we have applied the MNTT technique in 10 patients to construct AVF. Seven of the 10 patients have been under dialysis.

None of the patients had fever or infection after surgery. Physical examination of the cephalic-vein at weeks 4 and 8 showed significant dilation. Fistula can be palpable tremor with loud murmur. Doppler ultrasonography showed obvious dilation of the cephalic vein and radial artery. The blood flow spectrum of the cephalic vein 1.5 cm away from the anastomos.......

Discussion

Venous juxta-anastomotic stenosis is one of the main factors affecting the maturation of AVF5. It is known to be closely related to intimal hyperplasia13,14,15. However, prevention strategies for intimal hyperplasia are still limited. Modified surgical procedures16 such as RADAR have been shown to have less venous juxta-anastomotic stenosis, increased maturation and patency, and fe.......

Acknowledgements

We thank doctors Zhou Feng, Ma Tiantian, and Zhu Dongming at our hospital for providing the assistance with ultrasound examination.

....

Materials

NameCompanyCatalog NumberComments
Curved hemostatic forcepsXinhua Surgical Instrument Co., Ltd.ZH131R/RN
Dissecting ForcepsXinhua Surgical Instrument Co., Ltd.ZDO25R/RN
ElectrotomeChangzhou Yanling Electronic Equipment Co., Ltd.TY21205812
Eyelld RetractorXinhua Surgical Instrument Co., Ltd.Z014602T
LidocaineHebei Tiancheng Pharmaceutical Co., Ltd.1B200612104
Halsey needleholderXinhua Surgical Instrument Co., Ltd.ZM208R/RN
Micro forceopsXinhua Surgical Instrument Co., Ltd.ZD275RN/T
Micro needle holder forcepsXinhua Surgical Instrument Co., Ltd.ZF2618RB/T
Micro scissorsXinhua Surgical Instrument Co., Ltd.ZF022T
Micro vessel knifeXinhua Surgical Instrument Co., Ltd.ZF1549RN
Non-absorbable suture 3-0Ethicon,LLCSA84G
Poly propylene 7-0Ethicon,LLCPDB601
Sharp bladeSuzhou Medical Products Factory Co., Ltd.TY21232001
scalpel handleShanghai Medical Instrument (Group) Co., Ltd. Surgical Instruments FactoryJ11030
Syringe with needle (5ml)BD medical devices (Shanghai) Co., Ltd2006116
Triangle needleHangzhou Huawei medical supplies Co., Ltd7X17
Vessel clampXinhua Surgical Instrument Co., Ltd.ZF220RN
Vessel loopShenzhen Yiman Technology Co., LtdEM-SR1

References

  1. Trerotola, S. O. KDOQI clinical practice guideline for vascular access 2019 update: Kinder, Gentler, and More Important Than Ever. Journal of Vascular and Interventional Radiology. 31 (7), 1156-1157 (2020).
  2. Schmidli, J., et al.

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