Perforating Vein Arteriovenous Fistulas: A Secondary Lifeline for Hemodialysis Patients with Forearm Vascular...

Antecubital arteriovenous fistulas (AVFs), particularly brachiocephalic AVFs at the elbow level, are commonly created when forearm options are exhausted. However, this configuration is associated with significant complications such as steal syndrome and high-output heart failure. To mitigate these risks, the perforating vein can be utilized as an alternative configuration for AVF creation (Gracz or Konner type AVF). In this study, we aimed to evaluate complication rates and compare patency outcomes between brachiocephalic AVFs and perforator vein AVFs.

This retrospective single-center study enrolled 351 patients who underwent elbow level AVF creation between January 2015 and March 2024 (111 months). The cohort's mean age was 61.2 ± 12.5 years, and 53.8% were male. AVFs were constructed using either the perforating vein (n = 48) or the brachiocephalic configuration (n = 303). The primary endpoints of the study were primary and secondary patency rates. In addition, the incidence of complications such as hand ischemia, high-output cardiac failure, and hematoma formation was evaluated. Secondary analyses examined patency differences based on surgical technique and patient comorbidities. Kaplan-Meier survival analysis, Cox regression, and the Mann-Whitney U test were used for statistical comparisons. A P value of <0.05 was considered significant.

Primary and secondary patency rates were comparable between perforator vein and brachiocephalic AVFs at 6 months, 1 year, 2 years, and 3 years (P > 0.05 for all). The median secondary patency was 374 days in the perforator group and 386 days in the brachiocephalic group (P = 0.72). However, complications such as hand ischemia, high-output cardiac failure, and aneurysm formation were significantly more common in the brachiocephalic group (P < 0.05).

Perforator vein-based AVFs demonstrated similar patency outcomes to brachiocephalic AVFs, with significantly fewer complications. Thus, the use of the perforating vein is a safe and effective alternative for AVF creation in selected patients with limited distal access options.