Outcome for arterio-venous fistula at the elbow for haemodialysis

Few studies have examined the outcome of arterio-venous fistulas (AVF) at the elbow for haemodialysis.

All AVFs at the elbow created between 1994 and 1998 were identified retrospectively from case notes and the computerised database. Patients were followed until fistula failure, death, or for a minimum of 6 months until June 1999. Life table analysis and Kaplan-Meier actuarial curves with the log rank test were used to assess the influence of age, sex, diabetes, hypertension, heart disease, cerebrovascular disease, use of erythropoietin, aspirin or warfarin, previous insertion of subclavian vein catheter and the levels of haemoglobin and serum albumin on long-term AVF survival.

A total of 137 AVFs (primary procedure in 84 and as a secondary procedure in 53 cases) at the elbow were performed in 130 patients; 7 patients had AVFs attempted at both elbows. The mean age was 56.57 yr with a mean follow-up of 48.54 months. Twenty-two patients died with a functioning AVF, while 7 patients also with a functioning AVF received a renal transplant. Overall 74% of AVF were patent at the end of 1 yr, while 22.5% failed or did not mature immediately after the procedure. Two patients had their AVFs tied off due to steal syndrome. Of the various factors known to affect long-term survival of AVF in patients receiving haemodialysis, only plasma albumin > 35 g/L was associated with poorer long-term patency in our study.

Our report supports the view that AVF at the elbow may obviate the disadvantages of AVF at the wrist in elderly patients, females and in diabetics. In this group of patients it may be preferable to create a primary AVF at the elbow rather than the wrist. Patients who have a failed attempt at creating an AVF at the wrist should undergo AVF at the elbow before the placement of a synthetic graft. This strategy will result in saving time and avoid multiple operations. There may also be a reduction in the use of synthetic grafts resulting in cost savings and avoiding the complications associated with synthetic grafts.