Pierre Bourquelot, Paris
Gracz (Kidney Int 1977 1977) ) Gracz (Kidney Int Gracz (Kidney Int 1977 1977) ) Gracz (Kidney Int Elbow Perforating V. to Brachial / Pr. Radial A.AVF Major Risk was High Flow : due to the anastomosis of multiple veins to the large brachial artery (or the proximal radial artery prone to secondary dilatation) responsible for: Distal ischemia High-flow and cardiac issues Venous hypertension
Gracz AVF was rapidly abandoned by many surgeons who preferred one vein to brachial artery anastomosis Basilic Vein Brachial Vein Cephalic Vein
In 1977, Toledo-Pereyra promoted PRA as an alternative inflow site for AVF creation in 20 patients half of them were diagnosed with diabetes Outflow was upper arm cephalic vein Reported primary patency rate was 90 %
In 2003 , you Dr Jennings Reintroduced PRA AVF created in 71 patients. The overall assisted primary patency approached 100% at 1 year In 2006 you published an additional report of 105 PRAs. Again assisted primary patency was excellent at 97% In each of these reports, patency was defined as the percentage of fistulas that had flow at some post operative time, not necessarily the percent of PRAs being successfully accessed for hemodialysis treatments Was the inflow from brachial artery in 20 % of cases ? Outflow vein was described as basilic, cephalic, median antecubital, lateral antecubital or perforating deep vein
Actually, one of your current drawings is of course not very different from Gracz’s 40 years ago Cephalic Vein Perforating Vein Basilic Vein Comitans Radial Vein Radial Artery Gracz (Kidney Int) Jennings (J Vasc Surg 2017) 1977)
In 2015, Amendola …reported 284 male pts, 571 access procedures including 144 PRA (25%) : 87 P-PRA : no previous forearm AA 57 S-PRA : previous failed AVF/graft By one single senior surgeon
Amendola – Discussion, Results PRA has been established as an early viable surgical option for arteriovenous fistula creation. The overall assisted primary patency reported in the literature approaches 100% at 1 year. Amendola hypothesize that this excellent patency does not represent a functional result when seen in light of successful cannulation and fistula utilization. Actually, his overall cannulation rate was an abysmal 43% his overall cannulation rate was an abysmal 43% (S- PRA= 55%, P-PRA= 33%); however, he believes this analysis of his patient population is a real-world true functional outcome as it relates to successful use of this fistula type. The mean functional patency (successful cannulation to abandonment) was 645 ± 592 days
Pierre Bourquelot, Paris
Primary Angioacces (Personal data) 542 consecutive patients (1/05-12/08) 75 children (<16 years), 467 adults age: 52±25 years (range: 1 to 92) weight: 65±23 Kg, (range: 8 to 165) 25% were previously dialyzed on CVC
Systematic Angeiologist Duplex mapping Normal superficial veins Forearm cephalic v. stenosis
Surgical Microscope, Preventive Hemostasis
Primary Angioacces (n = 542 pts)
My job Your job 14
44 Children < 20 Kgs V.Karava P Bourquelot et al Pediatric Nephrology 2017 15
Wrist-RC AVF ≥ 22 years
Wrist-RC AVF ≥ 33 years 1982 HD (11 y.-old) 1985-90 : 1 st K Transplant 2002 - 2004 : 2 nd KT UA 1982 Dist. R-C AVF •Early bifurcation of BA •1987 Ligation (2L/min) •1990/1999: 2 Redos •2008 B. A. Aneurysm- PTFE by-pass (Thr) CV RA •2015: Qa = 600mL/min
≥ 22 yrs Flow reduction by Juxta-anastomotic Proximal Radial Artery Ligation after 5 years post- creation Current flow : 400 ml/min
> 33 yrs > 36 yrs
Drepanocytosis. Dia…..6 year-old boy, Ulno-Basilic AVF. 20 years later 20 years later
pierre@bourquelot.fr 22
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