High flow reduction of distal radio-cephalic fistula: Description of a novel banding technique over proximal radial artery (PRAB)

Abstract

Background:

Distal radio-cephalic arteriovenous fistula (RCAVF) is the gold standard vascular access for haemodialysis (HD). A rare complication of RCAVF is high blood flow (defined as flow (Qa) >1.5 L/min). In order to reduce high flow in such RCAVF, we conceived a novel banding technique of the proximal radial artery (PRAB), as a variant of the Bourquelot’s proximal radial artery ligation (PRAL). We describe our experience, which began in 2016.

Methods:

We retrospectively examinated prospectively collected data from 20 consecutive patients treated from 2016 to 2023 in a single centre.

All patients were referred because of high-flow RCAVF and evaluated systematically by colour Doppler ultrasound (CDU) examination preoperatively and 1, 6 and 12 months postoperatively (Qa0, Qa1, Qa6 and Qa12), with flow measurements and verification of ulnar artery and palmar arches patency.

The procedure consisted in the ligation of the juxta–juxtaanastomotic proximal radial artery over a 2 mm external tutor (proximal radial artery banding), therefore – compared to classic PRAL – preserving continuity of the proximal radial artery. The aim of this variant was to prevent involution of the radial artery proximally to ligation.

Patient characteristics (means): age 69 years, comorbidities (hypertension 85%, diabetes 0%), HD vintage 21 months, AVF vintage 31.5 months, Qa0 2650 mL/min.

Primary and secondary patency following PRAB were calculated at 6 and 12 months (PP6, PP12, SP6, SP12).

Results:

At T1, T6 and T12, AVF mean flow reduction rates were 52%, 52% and 51%, respectively, proximal radial artery patency was verified in all patients by CDU. Primary and secondary patency rates at 6 and 12 months were 100%, 83.3%, 100% and 100%, respectively. Three patients (16.6%) necessitated of iuxta-anastomotic vein revision because of low flow within 12 months after flow reduction, one patient died 5 months postoperatively unrelated to the procedure, one patient was lost to follow-up. No thrombosis or hand ischaemia occurred postoperatively.

Conclusions:

PRAB is as safe and effective as PRAL for surgical reduction of high-flow RCAVF with satisfying mid- and long-term patency results. The potential of preserving the patency of radial artery could represent an added value especially in younger patient. Further studies are needed to better define these results.