The radiocephalic arteriovenous fistula (RC-AVF) has significant failure rates due to occlusions and failure to mature. The size and quality of the veins are considerable limiting factors for the procedure. The aim of this pilot study was to describe the No-Touch technique (NTT) to create RC-AVF and present the results up to 1 year of follow-up.
Thirty-one consecutive patients who were referred for surgery for a RC-AVF were included (17 men, mean age 63 years, range 35-84) and operated by NTT where the vein and artery were dissected with a tissue cushion around it. Twenty-two patients had small veins or arteries (≤2 mm), 12 patients had a small cephalic vein (≤2 mm), and the mean distal cephalic vein diameter was 2.4 mm (range 1.0-4.1 mm).
Technical surgical success and immediate patency were obtained in all patients. Clinical success was achieved in 23 of the 27 (85%) patients who required hemodialysis. The proportion of primary patency at 30 days and 6 months was 84% and 64%, respectively. Secondary patency at 30 days and 6 months was 97% and 83%, respectively. At 1-year follow-up, primary patency was 54% and secondary patency was 80%. There was no major difference in patency due to preoperative vein diameter.
The results of this study indicate that NTT can be used for primary radio-cephalic fistula surgery with very good results. This method offers the potential to create a RC-AVF in patients who are not usually considered appropriate for a distal arm fistula due to a small cephalic vein.
J Vasc Access 2016; 17(1): 6 - 12
Article Type: ORIGINAL RESEARCH ARTICLE
AuthorsTal M. Hörer, Per Skoog, Robin Quell, Kristofer F. Nilsson, Thomas Larzon, Domingos R. Souza
- • Accepted on 24/06/2015
- • Available online on 19/09/2015
- • Published in print on 28/01/2016
This article is available as full text PDF.
Radiocephalic autogenous arteriovenous fistulas (RC-AVFs) are the first choice for the vascular dialysis access (1-2-3-4-5). This is a logical choice, as further fistulas can be created proximally if needed (i.e. brachio-cephalic/basilic fistula) and the risk of steal syndrome is reduced (2, 4, 6, 7). Autogenous fistulas demonstrate higher patency and lower infection rates as well as fewer general complications than fistulas created with synthetic material (8). Even so, the primary and secondary failure rates of the conventional RC-AVF may be high due to thrombosis and occlusion, failure to mature, and low fistula flow. Primary patency at 1 year is described to be around 58-63% in several studies but varies widely (9-10-11-12-13). Vein size is considered to be an important prognostic value for patency and eventual functional fistula. Former studies have shown that cephalic veins diameter of 2.0 mm or less have very high failure rates and should not be considered for RC-AVF (5, 10, 14-15-16-17). Some authors as well as a recent review recommend that patients selected for RC-AVF should have cephalic veins of at least 2.0-2.5 mm or greater in diameter (13, 14, 16, 18). Heavily calcified radial arteries as well as peripheral atherosclerotic disease, diabetes, and obesity are also considered to have a negative impact on the prognosis of new fistulas, but there is a lack of data regarding the artery quality as well as the effect of pre-procedural Doppler ultrasound (DUS) investigation on patency (2, 7, 14).
The ‘No-Touch technique’ (NTT) for vein harvesting was developed by Souza et al to increase patency in coronary bypass surgery (19-20-21). By using vein grafts dissected with the adherent fat and connective tissue (vein pedicle or fat vein), direct contact with the vein is avoided and sterile water flush is not used, thereby preventing potential damage to the vein wall as well as spasm (19). A long-term follow-up study on the use of NTT in cardiac surgery showed increased graft patency compared with standard techniques (22). It is postulated that the NTT preserves the vein endothelium, cause minimal damage to the vein wall and the feeding vessels (vasa-vasorum), and prevents vessel spasm during surgery (19, 22, 38).
The aim of this pilot study was to investigate the feasibility of NTT in RC-AVF creation and to present the early and mid-term results of 31 consecutive patients who received an RC-AVF using the NTT.
Patients and methods
We report a single-center prospective study. Between February 2011 and April 2012, 45 patients had surgical procedures to create a vascular access for hemodialysis at Örebro University Hospital (
Flow chart of the study.
At 2 and 5 weeks, all patients were examined clinically and underwent a DUS with flow measurements to evaluate the fistula flow. Patients were followed until fistula failure or patient death. In our institute usually, a failure to mature or a decreasing flow rate in a fistula detected at the dialysis center leads to a DUS examination and if needed, fistulography. Percutaneous transluminal angioplasty (PTA) interventions were made to maintain the flow in the fistula when the flow was insufficient for dialysis or showed tendency to decrease over time as recommended in the KDOQI guidelines (2, 6). The same guidelines were followed with regard to target flow, function, and general management.
Function and patency definitions
Function start (functional fistula or fistula ready to use) was defined as three consecutive successful cannulations that achieved dialysis blood flow of at least 400 ml/min and maintained dialysis for 4 h or less (23). Primary patency was defined as the interval from the time of access placement until any intervention designed to maintain or reestablish patency, access thrombosis, or the time of measurement of patency. Secondary patency (including secondary assisted patency) was defined as the interval from the time of access placement until access abandonment, thrombosis, or the time of patency measurement, including surgical or endovascular interventions designed to maintain or reestablish functionality and follow the reporting standards of the society for vascular surgery (23).
The preoperative patient characteristics and comorbidities are described in
Patients characteristics and preoperative data
|Mean age (years), range||63 (35-84)|
|Peripheral arteriosclerosis disease||9|
|Preoperative distal vein size (mm; mean, range)||2.4 mm (1-4.1)|
|Preoperative distal artery size (mm; mean, range)||2.2 mm (1.1-3.4)|
Life table of primary and secondary fistula patencies in all patients subjected to radiocephalic fistula surgery and after dividing the patients into subgroups (preoperative vein diameter of >2 mm or ≤2 mm)
|Interval (months)||No. at risk at the beginning of interval||No. failed during interval||Lost to follow-up during interval||Interval failure rate||Cumulative patency rate||Standard error|
Vein and artery preoperative characteristics
Preoperatively, the mean distal vein diameter measured by DUS was 2.4 mm (range 1.0-4.1 mm) and the mean radial artery size was 2.2 mm (range 1.1-3.4 mm). Twelve patients had a cephalic vein size of 2 mm or less in diameter, 12 patients had a radial artery of 2 mm or less in diameter, and four patients had both a thin cephalic vein and a thin radial artery (≤2 mm in diameter). Nine patients had significant atherosclerotic changes in the radial artery as evaluated and documented by DUS.
The study was approved by the regional ethical committee and registered in a clinical trial register (Researchweb.org study nr 94021).
No touch technique: surgical aspects
A video of the No Touch method is avaliable online as supplementary material at
After a 4-5 cm skin incision in the distal arm, diathermy and scissors were used to dissect around the fat tissue. The vein located, and by diathermy dissection was isolated with a 1-3 mm tissue pedicle around it (
The radial artery was dissected by diathermy and scissors on the medial and lateral side until a pedicle of artery with its satellite veins was isolated by vessel loops for proximal and distal control (
The artery was opened by using a 3.0 mm Beaver knife (Beaver-Visitec International, Frenchs Forest, Australia). A 6-8 mm longitudinal anterior arterotomy was performed using Potts scissors. Both vessels were prepared for the anastomosis while preserving the pedicle around it (
Vein to artery anastomosis (end-to side) was created with a 7.0 or 8.0 non-absorbable, monofilament, continuous suture (
Back flow and then in-flow was restored. Flow was evaluated by using an adequate probe (5-7 mm) connected to a transit-time flowmeter (Medistim Butterfly Flowmeter; Medistim ASA, Oslo, Norway).
The wound closure done using subcutaneous separate sutures and the skin was approximated by intra-cutis absorbable sutures. The fistula was then examined for thrill both by palpation and auscultation.
Skin incision medial to the vein marked pre-operatively. The vein being exposed with the surrounding tissue in situ.
Dissection of the vein with its surrounding tissue (pedicle). Feeding vessels (vasa-vasorum) seen clearly on the pedicle.
Vein (blue vessel loop) and artery (red vessel loop) dissected by No Touch Technique. Notice the lack of vein spasm.
The vein is prepared for end-to-side anastomosis.
Anastomsosis by parachute technique.
The radiocephalic fistula completed just before flow measurement.
During the pilot study period, all RC-AVFs were created with NTT and no RC-AVF was created using the conventional technique. One patient died before the 6-month follow-up, whereas the other patients were followed up to 1 year postoperatively.
Function start was achieved in 23 of the 27 (85%) patients who required hemodialysis. The mean time to function start was 127 days (range 33-476).
Function start failure was attributed to one patient’s refusal to use the fistula, two fistulas that failed to mature, and a patient death that occurred before cannulation of the fistula was attempted. Five patients underwent kidney transplantation during this period.
In the group of patients with veins diameter of 2 mm or less, three patients occluded and four patients were kidney transplanted; one was still at predialytic stage and two fistulas abandoned due to insufficient flow (but open). Two of the occluded fistulas in this group had achieved function start before they occluded and one occluded early before the patient has started hemodialysis.
Perioperative and postoperative flow measurements
At the end of the surgical procedure, the mean fistula flow rate was 170 ml/min (range 20-500 ml/min). At 2 and 5 postoperative weeks, the mean fistula flow rates were 780 ml/min (230-1500 ml/min) and 875 ml/min (270-1630 ml/min), respectively.
Primary and secondary fistula patency
In the total patient cohort (n = 31), the 30-day primary patency proportion was 84% and secondary patency proportion was 97% (
Primary and secondary patencies curves by the life table method outlined in
In one patient, an injury occurred to the back wall of the artery during the procedure and the fistula failed later the same day. Reoperation was performed the following day, but the fistula was occluded and the patient subsequently received a brachio-cephalic fistula. In total, 16 primary patency interventions (13 PTAs) were made in this cohort. Of these, five were performed in the upper arm vein (not in the surgical field), three in the lower arm vein (near anastomosis), and five in the artery or anastomosis itself. Other primary interventions included one coiling of collateral veins combined with the PTA, one open revision (neo-anastomosis), and three thrombectomies (one combined with PTA). Secondary interventions included four PTAs (one artery, one upper arm vein, one artery and anastomosis, and one artery together with lower arm vein), one open thrombectomy, and three open revisions (two neo-anastomosis and one upper arm vein revision). There were two tertiary interventions (PTA), one to the radial artery, and the other one to the radial artery as well as the upper arm vein.
There were no major complications related to the technique or surgery. Ten patients had a slight temporary paresthesia in the operative region and the medial aspect of the thumb, which had practically disappeared at 1 year of follow-up. Local skin infections treated by antibiotics occurred in two patients; one of them needed a local wound revision due to resistant infection. The revision showed no evidence of deep infection and resolved clinically over time.
The main finding of this study is that an NTT for creation of RC-AVF is feasible and can be done in patients with small veins with good short and midterm results. These results are encouraging, as the need for dialysis treatment is increasing and the reported failure rate is high (13, 24). The overall patency in this study is very good, as it should be viewed in light of the fact that this is a consecutive group of patients treated under the notion of ‘if you have a distal cephalic vein, a RC-AVF should be built’ approach. The study group includes patients with multiple comorbidities that might influence patency rates, including obesity, general atherosclerosis, hypertension, and diabetes.
Some authors recommended a minimum vein diameter of 2.0-2.5 mm, and others reported even high failure rate for veins at a size of 1.6-2.0 mm (9, 13, 16, 17). Twenty-two patients had small arteries or veins and an RC-AVF fistula creation by conventional technique in these patients is doubtful by present guidelines and common practice (2, 5, 9, 11, 13, 14, 25-26-27-28-29-30). Patients with small veins (≤2 mm) did not suffer higher failure rate (
The NTT is a well-established technique within cardiac surgery, but this trial demonstrates that it can be applied for RC-AVF. There are several differences from conventional fistula surgery in the creation of the fistula: both the vein and the artery are prepared with cushion of surrounding tissue. They are neither distended nor directly manipulated with surgical instruments. The postulated benefit of NTT might be that less vein wall damage occurs, preventing intimal hyperplasia that is considered as a major cause for failure. The technique preserves the feeding vessels, reduces the degree of spasm, and the vein remains in a natural constitution until the maturation of the fistula (19-20-21-22). One might also hypothesize that NTT causes less inflammatory impact and thus the endothelial damage is also reduced indirectly (31-36). With regard to the cephalic vein, one might think that only a limited amount of fatty tissue surrounds the vein. However, our experience is that it is possible to dissect the vessel with an intact fat pedicle, albeit significantly less fat tissue is seen compared with the great saphenous vein.
The major limitation of this study is the small number of patients. Another limitation and possible explanation of these results might be the fact that all fistulas were created by a team of at least one of two surgeons. Another explanation might be the tight control of this study group and high early intervention rates.
The results from this pilot study applying NTT on primary radiocephalic fistulas show that by using this vessel-preserving technique, a patency rate comparable to earlier literature is seen in a consecutive patient group, including forearms with small cephalic veins and small, atherosclerotic radial arteries. This method offers the potential to create a RC-AVF in patients who are not usually considered appropriate for a distal arm fistula. The method is shown feasible and should be evaluated in randomized controlled trials.
- Hörer, Tal M. [PubMed] [Google Scholar] , * Corresponding Author (firstname.lastname@example.org)
- Skoog, Per [PubMed] [Google Scholar]
- Quell, Robin [PubMed] [Google Scholar]
- Nilsson, Kristofer F. [PubMed] [Google Scholar]
- Larzon, Thomas [PubMed] [Google Scholar]
- Souza, Domingos R. [PubMed] [Google Scholar]
Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital and Örebro University, Örebro - Sweden
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