Accepted Manuscript Efficacy of the ulnar-basilic arteriovenous fistula for haemodialysis: A systematic review J. Al Shakarchi, A. Khawaja, D. Cassidy, J.G. Houston, N. Inston PII:
S0890-5096(16)30005-X
DOI:
10.1016/j.avsg.2015.09.027
Reference:
AVSG 2664
To appear in:
Annals of Vascular Surgery
Received Date: 14 May 2015 Revised Date:
12 September 2015
Accepted Date: 20 September 2015
Please cite this article as: Al Shakarchi J, Khawaja A, Cassidy D, Houston J, Inston N, Efficacy of the ulnar-basilic arteriovenous fistula for haemodialysis: A systematic review, Annals of Vascular Surgery (2016), doi: 10.1016/j.avsg.2015.09.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1 2 3
Efficacy of the ulnar-basilic arteriovenous fistula for haemodialysis: A systematic review J Al Shakarchi1,2
7
A Khawaja1,2
8
D Cassidy2,3
9
JG Houston2,3 N Inston1,2
11
M AN U
10
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1 Department of Renal Surgery, University Hospital Birmingham, UK.
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2 ReDVA Research Consortium
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3 Medical Research Institute, University of Dundee, UK
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Correspondence address:
18
Julien Al Shakarchi
19
Department of Renal Surgery
20
University Hospital Birmingham
21
Birmingham, UK
22
[email protected]
23
Tel: 07834 735276
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Keywords: Access, Ulnar, Basilic, Fistula, Haemodialysis.
26 27
1
ACCEPTED MANUSCRIPT ABSTRACT
29
Purpose
30
The fistula first initiative has promoted arteriovenous fistulas (AVF) as the vascular access of choice.
31
To preserve as many future access options as possible, multiple guidelines advocate that the most
32
distal AVF possible should be created in the first place. Generally snuff box and radio-cephalic are
33
accepted and well described sites for AVFs however the forearm ulnar-basilic AVF is seldom used or
34
recommended. The aim of this study is to assess and systematically review the evidence base for the
35
creation of the ulnar-basilic fistula and to critically appraise whether more attention should be given to
36
this site.
37
Methods
38
Electronic databases were searched for studies involving the creation of ulnar-basilic fistulas for
39
dialysis in accordance with PRISMA guidelines. The primary outcomes for this study were 1-year
40
primary and secondary patency rates. Secondary outcomes were rates of haemodialysis access
41
induced distal ischaemia (HAIDI) and infection.
42
Results
43
Following strict inclusion/exclusion criteria by 2 reviewers, eight studies were included in our review.
44
Weighted pooled data reveals 1-year primary patency rate for ulnar-basilic AVFs of 53.0% (95% CI:
45
40.1-65.8%) with a secondary patency rate of 72.0% (95% CI: 59.2-83.3). HAIDI and infection rates
46
were low.
47
Conclusion
48
Our review has shown that the ulnar-basilic AVF may be a viable alternative when a radio-cephalic
49
AVF is not possible and dialysis is not required urgently. It has adequate 1-year primary and
50
secondary patency rates and extremely low risk of haemodialysis access induced distal ischaemia
51
(HAIDI). Whilst it may be more challenging for both surgeons and dialysis nurses to make it a
52
successful vascular access it offers a further option of distal access which may be overlooked.
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INTRODUCTION
59 Haemodialysis (HD) is the main form of renal replacement therapy for the majority of patients with end
61
stage renal disease (ESRD). A critical factor in the survival of renal dialysis patients is the surgical
62
creation of definitive vascular access, that is an AV fistula or an AV graft. The fistula first initiative has
63
promoted arteriovenous fistulas (AVF) as the vascular access of choice as AVFs having better long-
64
term patency than arteriovenous grafts (AVG). To preserve as many future access options as
65
possible, it is recommended that the most distal AVF possible should be created in the first place. It
66
is also important to avoid haemodialysis access induced distal ischaemia (HAIDI), which is less likely
67
with AVFs distal to the elbow.
68
There are three distal options available for the creation of an AVF: snuffbox, radio-cephalic (RC) and
69
ulnar-basilic (UB). The snuffbox fistula is the most distal site and therefore gives a long segment of
70
vein for needling. It preserves proximal vessels for creation of a further AV fistula in the case of
71
failure, however the procedure is technically challenging and even in expert hands it is only feasible in
72
50% of patients. The radio-cephalic fistula is most commonly created AVF and has shown to have
73
good long term outcomes. Whilst some authors have advocated the creation of ulnar-basilic fistula it
74
has not gained popularity and remains a rarely performed AVF. UB AVFs are not mentioned in any
75
guidelines. Experience with UB AVFs is limited, so if an RC AVF is not possible the usual next step is
76
an upper arm fistula. There may be a perceived low patency rate and also a perception that the AVF
77
is awkward and associated with possible difficulty in needling.
78
The purpose of this study was to assess and systematically review the evidence base for the creation
79
of the ulnar-basilic fistula.
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METHOD
83 84
Search methodology for identification of relevant studies
85
Searches of Pubmed, Medline, Embase and the Cochrane Library were performed using the
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combination of the following search terms: haemodialysis, arteriovenous fistula and vascular access
87
with either ulnar-basilic or ulnar artery to identify articles published before 31 December 2014 in
3
ACCEPTED MANUSCRIPT 88
English, dealing primarily with the placement of ulnar-basilic AVF. In addition, the references cited in
89
selected articles were reviewed for any further relevant available studies. Articles that assessed
90
radial-basilic and ulnar-basilic transpositions were excluded.
91
We included published randomized trials and observational studies. We excluded abstracts, case
92
reports, review articles, editorials without original data, and non-English publications. Grey literature
93
was not searched or included. The systematic review was performed in accordance with PRISMA.
94
Therefore all included studies were assessed for inclusion on the basis of their topic, type of study,
95
method, number of patients included and availability of their original results.
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96 Primary and secondary outcomes
98
All studies that met the above set criteria were reviewed and assessed for methodological quality. The
99
two reviewers (J.A. and N.I.) independently extracted data using a standardized table. This was done
100
in duplicate to increase accuracy. If there was any difference in the extracted data, we resolved it by
101
consensus. Data extracted included primary and secondary outcomes as well as year of publication,
102
number of patients included and duration of follow up. The primary outcomes for this study were
103
primary and secondary patency rates at 12 months. Secondary outcome endpoints were rates of
104
haemodialysis access induced distal ischaemia (HAIDI) and infection. Unfortunately some outcome
105
measures such as maturation time were not available in the literature.
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Statistical Analysis
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Data was extracted from studies which quoted specific figures for analysis only. Papers which showed
109
data in graph form were not included in the analysis so as to exclude interpretation bias. The inverse
110
of the Freeman-Tukey Double Arcsine transformation was applied to the primary and secondary
111
patency rates, which were then pooled using random-effects (DerSimonian and Laird) models. Pooled
112
patency rates at 12 months are quoted with confidence intervals.
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113 114
RESULTS
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One hundred and fifty three relevant articles and abstracts were identified from our search strategy.
116
After screening the contents of the abstract, sixteen full text articles were found to be relevant to UB
117
fistula formation and therefore underwent assessment for eligibility and quality inspection of
4
ACCEPTED MANUSCRIPT methodology. Following this, there were eight articles which included original data assessing the
119
creation of UB fistulas and therefore were eligible for the review. (Figure 1)
120
The eight studies that were included in this review (Table 1) included a total of 274 procedures in 269
121
patients. Indications for UB fistula formation were sparsely mentioned in the included studies however
122
those that did, all agreed that UB fistulas should be created as a second choice of forearm fistula if a
123
RC fistula is not an option due to the cephalic vein being destroyed. The pooled 1 year primary
124
patency rate for ulnar-basilic AVFs was 53.0% (95% CI: 40.1-65.8%) with a secondary patency rate of
125
72.0% (95% CI: 59.2-83.3). Maturation time was generally over 8 weeks in the majority of papers that
126
included that information. In papers that reported the occurrence of haemodialysis access induced
127
distal ischaemia, only a single patient (0.4%) out of 232 procedures developed the complication.
128
Infection rate was also low however only 3 studies with a total of 140 procedures reported it.
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DISCUSSION
132
2,15
133
The widely recognised guidelines (KDOQI/ERBP) do not mention UB AVFs.
134
Vascular Surgery guidelines
135
cephalic one however they advise that a transposition is always required to provide safe access for
136
haemodialysis. Therefore the ulnar-basilic AVF is seldom used for dialysis. This is reflected in the
137
current literature, which is as limited. Only 8 eligible papers were identified that fulfilled the inclusion
138
criteria for this review.
139
When these papers are analysed using weighted pooled results, the 1-year primary and secondary
140
patency rates of ulnar-basilic AVF of 52.6% (46.5-58.3%) and 69.2% (62.6-74.9) are comparable to
141
published data for radio-cephalic AVFs with 1-year primary patency rates of 63% (54-70%), with
142
secondary patencies of 66% (58-73%).
143
Despite this encouraging data the longer term outcomes have not been reported. It would be
144
postulated that as these are native AVFs they behave as RC AVF do once mature and have good
145
long term outcomes. The published data is from different international centres which is further
146
supportive of the creation of UB AVF as it applies to multiple populations.
do recommend UB AVF when it is not possible to create a radio-
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The Society of
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(Table 2)
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Whilst a RC AVF may be a more conventional approach where this is not possible the advantages of
149
an UB AVF are that it preserves the possibility of upper arm access sites in the future and is
150
associated with a low risk of hand ischemia. The extremely low incidence of hand ischemia (0.5%) in
151
these publications are encouraging and lower than in other proximal AVF which have been reported
152
at around 10%.
153
publication bias.
154
Despite the satisfactory outcomes, there are technical challenges. Firstly the ulnar artery and basilic
155
vein at the wrist tend to be small vessels and several authors have advocated the use of surgical
156
microscope for this type of AVF.
157
advocated when the ulnar artery is too small.
158
maturation time but it is difficult to ascertain accurately as only a few studies mentioned it.
159
Endovascular management has been advocated as a tool to help maturation.
160
experienced dialysis nurses are required for cannulation of UB AVFs. While initial cannulation
161
requires the elbow to be flexed, the elbow doesn’t need to be flexed during the dialysis session and
162
most patients tolerate it well.
163
The limitations of the review include the small number of published studies and the low number of
164
patients included in those. In addition there is a high likelihood of publication bias with only single
165
centre or surgeon series published. In the absence of randomized controlled trials, the avoidance of
166
bias requires pooling of data to attempt to assess the results. Studies in this review have shown that
167
UB AVF is a viable option, however further work comparing the outcomes of UB AVF versus other
168
distal AVF would be beneficial as well as subgroup analysis of different populations.
169
In conclusion the UB AVF is a viable alternative when a RC AVF is not possible and therefore future
170
guidelines should include and encourage it. It has adequate 1-year primary and secondary patency
171
rates and extremely low risk of HAIDI. However it does require expertise and experience for both
172
surgeons and dialysis nurses to make it a successful vascular access.
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However this may represent the relatively small patient group included and
A transposition of the basilica vein to the radial artery has been Secondly there might also be an issue with prolonged
20
Finally skilled and
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ACKNOWLEDGEMENT
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ReDVA has been supported by the EU FP7 IAAP funding under grant agreement no. 324487.
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REFERENCES
179
181 182 183 184
1. Fistula First National Vascular Access Improvements Initiative. Available at: http://www.fistulafirst.org/. Accessed January 31 2015 2. Navuluri R, Regalado S. The KDOQI 2006 Vascular Access Update and Fistula First Program Synopsis. Semin Intervent Radiol. 2009 26(2):122–124
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3. Scheltinga MR, Van Hoek F, Bruijninckx CM. Time of onset in haemodialysis access-induced distal ischaemia (HAIDI) is related to the access type. Nephrol Dial Transplant. 2009
186
24(10):3198-204
188 189
4. Wolowczyk L, Williams AJ, Donovan KL, Gibbons CP. The snuffbox arteriovenous fistula for vascular access. Eur J Vasc Endovasc Surg. 2000 19(1):70-6.
M AN U
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SC
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5. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for
190
systematic reviews and meta-analyses: the prisma statement. PLoS Med. 2009
191
6:e1000097
193
6. JJ M. The Inverse of the Freeman-Tukey Double Arcsine Transformation. Am. Stat. 1978;32:138
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194
7. Kinnaert P, Vereerstraeten P, Toussaint C, Van Geertruyden J. Nine years' experience with
195
internal arteriovenous fistulas for haemodialysis: a study of some factors influencing the
196
results. Br J Surg. 1977 64(4):242-6
199 200 201
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8. Cetto C, Keller F. Relevance of the ulnaris fistula as a dialysis shunt. Nephrol Dial Transplant. 1995 10:877-78
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9. Salgado OJ, Chacón RE, Henríquez C. Ulnar-basilic fistula: indications, surgical aspects, puncture technique, and results. Artif Organs. 2004 28(7):634-8
10. Weyde W, Letachowicz W, Krajewska MK, Letachowicz K, Watorek E, Kusztal M, Porazko T,
202
Gołebiowski T, Madziarska K, Klinger M. Native forearm fistulas utilizing the basilic vein:
203
an underused type of vascular access. J Nephrol. 2008 21(3):363-7
204 205
11. Cavatorta F, Galli S, Zollo A, Crespi E, Carnabuci A. Ulno-basilic arteriovenous fistulae: indications and surgical technique. J Vasc Access. 2008 9(2):73-80
7
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12. Bourquelot P, Van-Laere O, Baaklini G, Turmel-Rodrigues L, Franco G, Gaudric J, Raynaud
207
A. Placement of wrist ulnar-basilic autogenous arteriovenous access for hemodialysis in
208
adults and children using microsurgery. J Vasc Surg. 2011 53(5):1298-302
210 211 212 213
13. Liu W, Lagaac R, Pettigrew GJ, Callaghan CJ. Outcomes after ulnar-basilic arteriovenous fistula formation Ann Vasc Surg. 2013 27(2):232-7 14. Shintaku S, Kawanishi H, Moriishi M, Bansyodani M, Tsuchiya S. Distal ulnar-basilic fistula as
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the first hemodialysis access. J Vasc Access. 2014 15(2):83-7
15. Tordoir J, Canaud B, Haafe P, Konner K, Basci A, Fouque D, Kooman J, Martin-Malo A,
Pedrini L, Pizzarelli F, Tattersall J, Vennegoor M, Wanner C, Ter Wee P, Vanholder R.
215
EBPG on Vascular Access. Nephrol Dial Transplant. 2007 22 S2:88-117
216
SC
214
16. Sidawy AN, Spergel LM, Besarab A, Allon M, Jennings WC, Padberg FT Jr, Murad MH, Montori VM, O'Hare AM, Calligaro KD, Macsata RA, Lumsden AB, Ascher E; Society for
218
Vascular Surgery. The Society for Vascular Surgery: clinical practice guidelines for the
219
surgical placement and maintenance of arteriovenous hemodialysis access. J Vasc Surg.
220
2008 48(5 Suppl):2S-25S
221
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17. Rooijens PP, Tordoir JH, Stijnen T, et al. Radiocephalic wrist arteriovenous fistula for hemodialysis: meta-analysis indicates a high primary failure rate. Eur J Vasc Endovasc
223
Surg 2004 28:58
226 227 228 229 230
Semin Vasc Surg. 2004 17(1):45-9.
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18. Schanzer H, Eisenberg D. Management of steal syndrome resulting from dialysis access.
19. Gefen JY, Fox D, Giangola G, Ewing DR, Meisels IS. The transposed forearm loop arteriovenous fistula: a valuable option for primary hemodialysis access in diabetic
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patients. Ann Vasc Surg. 2002 16(1):89-94
20. Natário A, Turmel-Rodrigues L, Fodil-Cherif M, Brillet G, Girault-Lataste A, Dumont G, Mouton A. Endovascular treatment of immature, dysfunctional and thrombosed forearm
231
autogenous ulnar-basilic and radial-basilic fistulas for haemodialysis. Nephrol Dial
232
Transplant. 2010 25(2):532-8
233
21. Al-Jaishi AA, Oliver MJ, Thomas SM, Lok CE, Zhang JC, Garg AX, Kosa SD, Quinn RR,
234
Moist LM. Patency rates of the arteriovenous fistula for hemodialysis: a systematic review
235
and meta-analysis. Am J Kidney Dis. 2014 63(3):464-78
8
ACCEPTED MANUSCRIPT Figure 1
237 Table 1
7
8
Cetto
29
29
18
18
9
60
10
13
Salgado
Weyde
Number of procedures
11
Mean Age
Diabetes n (%)
TE D
Kinnaert
Number of patients
Male n (%)
1 year Primary patency rate (%)
1 year Secondary patency rate (%)
HAIDI
Infection
(%)
(%)
Follow up (Month s)
na
na
14 (48)
60.9
na
na
na
na
na
na
na
47
na
na
na
na
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Reference
61
48.9
12 (20)
24 (40)
70.9
78.3
0
0
na
13
na
na
13 (48)
70.4
81.5
0
0
na
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Cavatorta
9
9
na
na
4 (44)
78
na
na
na
na
Bourquelot
63
63
54
8 (12.7)
36 (57)
42
60
0
na
20
48
52
69.5
10 (20.8)
37 (77)
43
54
1.9
3.8
41
29
29
72.9
16 (55.2)
18 (63)
25
85.5
0
na
na
12
13
Liu
14
Shintaku
9
ACCEPTED MANUSCRIPT Pooled rate % (95% CI)
53.0 (40.1-65.8)
72.0 (59.2-83.3)
239 240 241
243
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242 Figure and table legends
244 Figure 1
246
Flowsheet of results of search strategy with inclusion and exclusions following searches and
247
screening.
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245
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248 Table 1
250
Summary table for included studies assessing ulnar-basilic fistula. The pooled rate of primary
251
patency was 52.6% (46.5-58.3%) and secondary patency was 69.2% (62.6-74.9%). na = not
252
available
255 256 257 258 259 260
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261 262 263 264 265 10
ACCEPTED MANUSCRIPT 266
Supplementary material for reviewers:
267
The following search strategies were used to identify relevant publications. The information is not
268
intended for publication but to allow the reviewers to assess the search strategies
269 Embase (1974 – 2014)
271
Search
Query
272
#8
Search limit 7 to english language
273
#7
Search 1 and 6
274
#6
Search 2 or 3 or 4 or 5
275
#5
Search haemodialysis
276
#4
Search vascular access
277
#3
Search arteriovenous fistula
18386
278
#2
Search fistula
20820
279
#1
Search ulnar artery or ulnar basilic
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Items found
SC
150
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143
120684
76372 15261
1460
OVID MedLine (1946 – nov 2014)
282
Search
Query
283
#8
Search limit 7 to english language
21
284
#7
Search 1 and 6
21
285
#6
Search 2 or 3 or 4 or 5
43602
286
#5
Search haemodialysis
11743
287
#4
Search vascular access
6337
288
#3
Search arteriovenous fistula
12033
289
#2
Search fistula
14365
290
#1
Search ulnar artery or ulnar basilic
768
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Items found
291 292
PUBMED
293 294 295 296 297
Search ((((ulnar artery) OR ulnar basilic) OR ulnar-basilic)) AND ((((haemodialysis) OR fistula) OR arteriovenous fistula) OR vascular access) Filters: English
153 Articles
11
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ACCEPTED MANUSCRIPT
S0890-5096(16)30005-X
DOI:
10.1016/j.avsg.2015.09.027
Reference:
AVSG 2664
To appear in:
Annals of Vascular Surgery
Received Date: 14 May 2015 Revised Date:
12 September 2015
Accepted Date: 20 September 2015
Please cite this article as: Al Shakarchi J, Khawaja A, Cassidy D, Houston J, Inston N, Efficacy of the ulnar-basilic arteriovenous fistula for haemodialysis: A systematic review, Annals of Vascular Surgery (2016), doi: 10.1016/j.avsg.2015.09.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1 2 3
Efficacy of the ulnar-basilic arteriovenous fistula for haemodialysis: A systematic review J Al Shakarchi1,2
7
A Khawaja1,2
8
D Cassidy2,3
9
JG Houston2,3 N Inston1,2
11
M AN U
10
SC
5 6
RI PT
4
1 Department of Renal Surgery, University Hospital Birmingham, UK.
13
2 ReDVA Research Consortium
14
3 Medical Research Institute, University of Dundee, UK
15 16
TE D
12
Correspondence address:
18
Julien Al Shakarchi
19
Department of Renal Surgery
20
University Hospital Birmingham
21
Birmingham, UK
22
[email protected]
23
Tel: 07834 735276
AC C
EP
17
24 25
Keywords: Access, Ulnar, Basilic, Fistula, Haemodialysis.
26 27
1
ACCEPTED MANUSCRIPT ABSTRACT
29
Purpose
30
The fistula first initiative has promoted arteriovenous fistulas (AVF) as the vascular access of choice.
31
To preserve as many future access options as possible, multiple guidelines advocate that the most
32
distal AVF possible should be created in the first place. Generally snuff box and radio-cephalic are
33
accepted and well described sites for AVFs however the forearm ulnar-basilic AVF is seldom used or
34
recommended. The aim of this study is to assess and systematically review the evidence base for the
35
creation of the ulnar-basilic fistula and to critically appraise whether more attention should be given to
36
this site.
37
Methods
38
Electronic databases were searched for studies involving the creation of ulnar-basilic fistulas for
39
dialysis in accordance with PRISMA guidelines. The primary outcomes for this study were 1-year
40
primary and secondary patency rates. Secondary outcomes were rates of haemodialysis access
41
induced distal ischaemia (HAIDI) and infection.
42
Results
43
Following strict inclusion/exclusion criteria by 2 reviewers, eight studies were included in our review.
44
Weighted pooled data reveals 1-year primary patency rate for ulnar-basilic AVFs of 53.0% (95% CI:
45
40.1-65.8%) with a secondary patency rate of 72.0% (95% CI: 59.2-83.3). HAIDI and infection rates
46
were low.
47
Conclusion
48
Our review has shown that the ulnar-basilic AVF may be a viable alternative when a radio-cephalic
49
AVF is not possible and dialysis is not required urgently. It has adequate 1-year primary and
50
secondary patency rates and extremely low risk of haemodialysis access induced distal ischaemia
51
(HAIDI). Whilst it may be more challenging for both surgeons and dialysis nurses to make it a
52
successful vascular access it offers a further option of distal access which may be overlooked.
AC C
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SC
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28
53 54 55 56 57
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ACCEPTED MANUSCRIPT 58
INTRODUCTION
59 Haemodialysis (HD) is the main form of renal replacement therapy for the majority of patients with end
61
stage renal disease (ESRD). A critical factor in the survival of renal dialysis patients is the surgical
62
creation of definitive vascular access, that is an AV fistula or an AV graft. The fistula first initiative has
63
promoted arteriovenous fistulas (AVF) as the vascular access of choice as AVFs having better long-
64
term patency than arteriovenous grafts (AVG). To preserve as many future access options as
65
possible, it is recommended that the most distal AVF possible should be created in the first place. It
66
is also important to avoid haemodialysis access induced distal ischaemia (HAIDI), which is less likely
67
with AVFs distal to the elbow.
68
There are three distal options available for the creation of an AVF: snuffbox, radio-cephalic (RC) and
69
ulnar-basilic (UB). The snuffbox fistula is the most distal site and therefore gives a long segment of
70
vein for needling. It preserves proximal vessels for creation of a further AV fistula in the case of
71
failure, however the procedure is technically challenging and even in expert hands it is only feasible in
72
50% of patients. The radio-cephalic fistula is most commonly created AVF and has shown to have
73
good long term outcomes. Whilst some authors have advocated the creation of ulnar-basilic fistula it
74
has not gained popularity and remains a rarely performed AVF. UB AVFs are not mentioned in any
75
guidelines. Experience with UB AVFs is limited, so if an RC AVF is not possible the usual next step is
76
an upper arm fistula. There may be a perceived low patency rate and also a perception that the AVF
77
is awkward and associated with possible difficulty in needling.
78
The purpose of this study was to assess and systematically review the evidence base for the creation
79
of the ulnar-basilic fistula.
81 82
1
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METHOD
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Search methodology for identification of relevant studies
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Searches of Pubmed, Medline, Embase and the Cochrane Library were performed using the
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combination of the following search terms: haemodialysis, arteriovenous fistula and vascular access
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with either ulnar-basilic or ulnar artery to identify articles published before 31 December 2014 in
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English, dealing primarily with the placement of ulnar-basilic AVF. In addition, the references cited in
89
selected articles were reviewed for any further relevant available studies. Articles that assessed
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radial-basilic and ulnar-basilic transpositions were excluded.
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We included published randomized trials and observational studies. We excluded abstracts, case
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reports, review articles, editorials without original data, and non-English publications. Grey literature
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was not searched or included. The systematic review was performed in accordance with PRISMA.
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Therefore all included studies were assessed for inclusion on the basis of their topic, type of study,
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method, number of patients included and availability of their original results.
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All studies that met the above set criteria were reviewed and assessed for methodological quality. The
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two reviewers (J.A. and N.I.) independently extracted data using a standardized table. This was done
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in duplicate to increase accuracy. If there was any difference in the extracted data, we resolved it by
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consensus. Data extracted included primary and secondary outcomes as well as year of publication,
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number of patients included and duration of follow up. The primary outcomes for this study were
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primary and secondary patency rates at 12 months. Secondary outcome endpoints were rates of
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haemodialysis access induced distal ischaemia (HAIDI) and infection. Unfortunately some outcome
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measures such as maturation time were not available in the literature.
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Statistical Analysis
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Data was extracted from studies which quoted specific figures for analysis only. Papers which showed
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data in graph form were not included in the analysis so as to exclude interpretation bias. The inverse
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of the Freeman-Tukey Double Arcsine transformation was applied to the primary and secondary
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patency rates, which were then pooled using random-effects (DerSimonian and Laird) models. Pooled
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patency rates at 12 months are quoted with confidence intervals.
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RESULTS
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One hundred and fifty three relevant articles and abstracts were identified from our search strategy.
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After screening the contents of the abstract, sixteen full text articles were found to be relevant to UB
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fistula formation and therefore underwent assessment for eligibility and quality inspection of
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creation of UB fistulas and therefore were eligible for the review. (Figure 1)
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The eight studies that were included in this review (Table 1) included a total of 274 procedures in 269
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patients. Indications for UB fistula formation were sparsely mentioned in the included studies however
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those that did, all agreed that UB fistulas should be created as a second choice of forearm fistula if a
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RC fistula is not an option due to the cephalic vein being destroyed. The pooled 1 year primary
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patency rate for ulnar-basilic AVFs was 53.0% (95% CI: 40.1-65.8%) with a secondary patency rate of
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72.0% (95% CI: 59.2-83.3). Maturation time was generally over 8 weeks in the majority of papers that
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included that information. In papers that reported the occurrence of haemodialysis access induced
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distal ischaemia, only a single patient (0.4%) out of 232 procedures developed the complication.
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Infection rate was also low however only 3 studies with a total of 140 procedures reported it.
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DISCUSSION
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2,15
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The widely recognised guidelines (KDOQI/ERBP) do not mention UB AVFs.
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Vascular Surgery guidelines
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cephalic one however they advise that a transposition is always required to provide safe access for
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haemodialysis. Therefore the ulnar-basilic AVF is seldom used for dialysis. This is reflected in the
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current literature, which is as limited. Only 8 eligible papers were identified that fulfilled the inclusion
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criteria for this review.
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When these papers are analysed using weighted pooled results, the 1-year primary and secondary
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patency rates of ulnar-basilic AVF of 52.6% (46.5-58.3%) and 69.2% (62.6-74.9) are comparable to
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published data for radio-cephalic AVFs with 1-year primary patency rates of 63% (54-70%), with
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secondary patencies of 66% (58-73%).
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Despite this encouraging data the longer term outcomes have not been reported. It would be
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postulated that as these are native AVFs they behave as RC AVF do once mature and have good
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long term outcomes. The published data is from different international centres which is further
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supportive of the creation of UB AVF as it applies to multiple populations.
do recommend UB AVF when it is not possible to create a radio-
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The Society of
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(Table 2)
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Whilst a RC AVF may be a more conventional approach where this is not possible the advantages of
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an UB AVF are that it preserves the possibility of upper arm access sites in the future and is
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associated with a low risk of hand ischemia. The extremely low incidence of hand ischemia (0.5%) in
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these publications are encouraging and lower than in other proximal AVF which have been reported
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at around 10%.
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publication bias.
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Despite the satisfactory outcomes, there are technical challenges. Firstly the ulnar artery and basilic
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vein at the wrist tend to be small vessels and several authors have advocated the use of surgical
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microscope for this type of AVF.
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advocated when the ulnar artery is too small.
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maturation time but it is difficult to ascertain accurately as only a few studies mentioned it.
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Endovascular management has been advocated as a tool to help maturation.
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experienced dialysis nurses are required for cannulation of UB AVFs. While initial cannulation
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requires the elbow to be flexed, the elbow doesn’t need to be flexed during the dialysis session and
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most patients tolerate it well.
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The limitations of the review include the small number of published studies and the low number of
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patients included in those. In addition there is a high likelihood of publication bias with only single
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centre or surgeon series published. In the absence of randomized controlled trials, the avoidance of
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bias requires pooling of data to attempt to assess the results. Studies in this review have shown that
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UB AVF is a viable option, however further work comparing the outcomes of UB AVF versus other
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distal AVF would be beneficial as well as subgroup analysis of different populations.
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In conclusion the UB AVF is a viable alternative when a RC AVF is not possible and therefore future
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guidelines should include and encourage it. It has adequate 1-year primary and secondary patency
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rates and extremely low risk of HAIDI. However it does require expertise and experience for both
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surgeons and dialysis nurses to make it a successful vascular access.
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However this may represent the relatively small patient group included and
A transposition of the basilica vein to the radial artery has been Secondly there might also be an issue with prolonged
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Finally skilled and
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ACKNOWLEDGEMENT
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ReDVA has been supported by the EU FP7 IAAP funding under grant agreement no. 324487.
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REFERENCES
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181 182 183 184
1. Fistula First National Vascular Access Improvements Initiative. Available at: http://www.fistulafirst.org/. Accessed January 31 2015 2. Navuluri R, Regalado S. The KDOQI 2006 Vascular Access Update and Fistula First Program Synopsis. Semin Intervent Radiol. 2009 26(2):122–124
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3. Scheltinga MR, Van Hoek F, Bruijninckx CM. Time of onset in haemodialysis access-induced distal ischaemia (HAIDI) is related to the access type. Nephrol Dial Transplant. 2009
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24(10):3198-204
188 189
4. Wolowczyk L, Williams AJ, Donovan KL, Gibbons CP. The snuffbox arteriovenous fistula for vascular access. Eur J Vasc Endovasc Surg. 2000 19(1):70-6.
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5. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for
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systematic reviews and meta-analyses: the prisma statement. PLoS Med. 2009
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6:e1000097
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6. JJ M. The Inverse of the Freeman-Tukey Double Arcsine Transformation. Am. Stat. 1978;32:138
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7. Kinnaert P, Vereerstraeten P, Toussaint C, Van Geertruyden J. Nine years' experience with
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internal arteriovenous fistulas for haemodialysis: a study of some factors influencing the
196
results. Br J Surg. 1977 64(4):242-6
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8. Cetto C, Keller F. Relevance of the ulnaris fistula as a dialysis shunt. Nephrol Dial Transplant. 1995 10:877-78
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9. Salgado OJ, Chacón RE, Henríquez C. Ulnar-basilic fistula: indications, surgical aspects, puncture technique, and results. Artif Organs. 2004 28(7):634-8
10. Weyde W, Letachowicz W, Krajewska MK, Letachowicz K, Watorek E, Kusztal M, Porazko T,
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Gołebiowski T, Madziarska K, Klinger M. Native forearm fistulas utilizing the basilic vein:
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an underused type of vascular access. J Nephrol. 2008 21(3):363-7
204 205
11. Cavatorta F, Galli S, Zollo A, Crespi E, Carnabuci A. Ulno-basilic arteriovenous fistulae: indications and surgical technique. J Vasc Access. 2008 9(2):73-80
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12. Bourquelot P, Van-Laere O, Baaklini G, Turmel-Rodrigues L, Franco G, Gaudric J, Raynaud
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A. Placement of wrist ulnar-basilic autogenous arteriovenous access for hemodialysis in
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adults and children using microsurgery. J Vasc Surg. 2011 53(5):1298-302
210 211 212 213
13. Liu W, Lagaac R, Pettigrew GJ, Callaghan CJ. Outcomes after ulnar-basilic arteriovenous fistula formation Ann Vasc Surg. 2013 27(2):232-7 14. Shintaku S, Kawanishi H, Moriishi M, Bansyodani M, Tsuchiya S. Distal ulnar-basilic fistula as
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the first hemodialysis access. J Vasc Access. 2014 15(2):83-7
15. Tordoir J, Canaud B, Haafe P, Konner K, Basci A, Fouque D, Kooman J, Martin-Malo A,
Pedrini L, Pizzarelli F, Tattersall J, Vennegoor M, Wanner C, Ter Wee P, Vanholder R.
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EBPG on Vascular Access. Nephrol Dial Transplant. 2007 22 S2:88-117
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16. Sidawy AN, Spergel LM, Besarab A, Allon M, Jennings WC, Padberg FT Jr, Murad MH, Montori VM, O'Hare AM, Calligaro KD, Macsata RA, Lumsden AB, Ascher E; Society for
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Vascular Surgery. The Society for Vascular Surgery: clinical practice guidelines for the
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surgical placement and maintenance of arteriovenous hemodialysis access. J Vasc Surg.
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17. Rooijens PP, Tordoir JH, Stijnen T, et al. Radiocephalic wrist arteriovenous fistula for hemodialysis: meta-analysis indicates a high primary failure rate. Eur J Vasc Endovasc
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Semin Vasc Surg. 2004 17(1):45-9.
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18. Schanzer H, Eisenberg D. Management of steal syndrome resulting from dialysis access.
19. Gefen JY, Fox D, Giangola G, Ewing DR, Meisels IS. The transposed forearm loop arteriovenous fistula: a valuable option for primary hemodialysis access in diabetic
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patients. Ann Vasc Surg. 2002 16(1):89-94
20. Natário A, Turmel-Rodrigues L, Fodil-Cherif M, Brillet G, Girault-Lataste A, Dumont G, Mouton A. Endovascular treatment of immature, dysfunctional and thrombosed forearm
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autogenous ulnar-basilic and radial-basilic fistulas for haemodialysis. Nephrol Dial
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Transplant. 2010 25(2):532-8
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21. Al-Jaishi AA, Oliver MJ, Thomas SM, Lok CE, Zhang JC, Garg AX, Kosa SD, Quinn RR,
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Moist LM. Patency rates of the arteriovenous fistula for hemodialysis: a systematic review
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and meta-analysis. Am J Kidney Dis. 2014 63(3):464-78
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ACCEPTED MANUSCRIPT Figure 1
237 Table 1
7
8
Cetto
29
29
18
18
9
60
10
13
Salgado
Weyde
Number of procedures
11
Mean Age
Diabetes n (%)
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Kinnaert
Number of patients
Male n (%)
1 year Primary patency rate (%)
1 year Secondary patency rate (%)
HAIDI
Infection
(%)
(%)
Follow up (Month s)
na
na
14 (48)
60.9
na
na
na
na
na
na
na
47
na
na
na
na
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48.9
12 (20)
24 (40)
70.9
78.3
0
0
na
13
na
na
13 (48)
70.4
81.5
0
0
na
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Cavatorta
9
9
na
na
4 (44)
78
na
na
na
na
Bourquelot
63
63
54
8 (12.7)
36 (57)
42
60
0
na
20
48
52
69.5
10 (20.8)
37 (77)
43
54
1.9
3.8
41
29
29
72.9
16 (55.2)
18 (63)
25
85.5
0
na
na
12
13
Liu
14
Shintaku
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53.0 (40.1-65.8)
72.0 (59.2-83.3)
239 240 241
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244 Figure 1
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Flowsheet of results of search strategy with inclusion and exclusions following searches and
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screening.
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Summary table for included studies assessing ulnar-basilic fistula. The pooled rate of primary
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patency was 52.6% (46.5-58.3%) and secondary patency was 69.2% (62.6-74.9%). na = not
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available
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Supplementary material for reviewers:
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The following search strategies were used to identify relevant publications. The information is not
268
intended for publication but to allow the reviewers to assess the search strategies
269 Embase (1974 – 2014)
271
Search
Query
272
#8
Search limit 7 to english language
273
#7
Search 1 and 6
274
#6
Search 2 or 3 or 4 or 5
275
#5
Search haemodialysis
276
#4
Search vascular access
277
#3
Search arteriovenous fistula
18386
278
#2
Search fistula
20820
279
#1
Search ulnar artery or ulnar basilic
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Items found
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120684
76372 15261
1460
OVID MedLine (1946 – nov 2014)
282
Search
Query
283
#8
Search limit 7 to english language
21
284
#7
Search 1 and 6
21
285
#6
Search 2 or 3 or 4 or 5
43602
286
#5
Search haemodialysis
11743
287
#4
Search vascular access
6337
288
#3
Search arteriovenous fistula
12033
289
#2
Search fistula
14365
290
#1
Search ulnar artery or ulnar basilic
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Items found
291 292
PUBMED
293 294 295 296 297
Search ((((ulnar artery) OR ulnar basilic) OR ulnar-basilic)) AND ((((haemodialysis) OR fistula) OR arteriovenous fistula) OR vascular access) Filters: English
153 Articles
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