Microsurgical approach for hemodialysis access: A pilot study of Brescia–Cimino fistulas constructed under microscopic guidance

The distal forearm is the preferred site for hemodialysis access. However, forearm vessels have small diameter, which may lead to complications of arteriovenous fistulas constructed at this site. Indeed, the mean patency rate of such fistulas has been reported at 65.2% (range, 56–79%) at 1 year postoperatively. In this study, we aimed to evaluate the patency rate of Brescia–Cimino arteriovenous fistulas constructed under microscopic guidance. We retrospectively evaluated the records of patients with chronic renal failure who received a Brescia–Cimino arteriovenous fistula between 2014 and 2015 for hemodialysis access. Preoperative venography and Doppler mapping were used to evaluate vein diameter at the wrist. Veins with a diameter of >2 mm were chosen. End-to-side microanastomosis was performed using Nylon #9-0 suture under microscopic guidance. Postoperatively, monthly follow-up (first with venography; with Doppler ultrasound thereafter) was conducted to detect vessel obstruction and evaluate blood flow. Six of the seven patients included in this study received hemodialysis without signs of obstruction or complications. On Kaplan–Meier survival analysis, the mean patency rate at 2 years postoperatively was 85.7%. One patient (female, 60 years) had vessel obstruction and underwent percutaneous transluminal angioplasty 3 times after receiving the arteriovenous fistula. The median follow-up duration was 41 months (range, 25–47 months). Our experience indicates that, for relatively healthy vessels with a diameter of >2 mm, Brescia–Cimino arteriovenous fistulas at the wrist can be safely constructed using microsurgical suturing under microscopic guidance, without complications such as ischemic hand syndrome or infection.