Radiocephalic and Brachiocephalic Fistulae

Hemodialysis is the most frequent and important treatment for end-stage kidney disease (ESKD) patients and requires a functional long-term hemodialysis access. Compared to arteriovenous grafts (AVG) or tunneled dialysis catheters, arteriovenous fistula (AVF) demonstrates more favorable mid- to longer-term outcomes with lower infection rates due to the native character, as well as better patency and usability rates. Several different locations for creation of an AVF are possible, and preoperative assessment is critical. Two options exist for use of the cephalic vein: a radiocephalic AVF and a brachiocephalic AVF. Forearm AVFs most commonly are constructed between the radial artery and the lateral forearm cephalic vein. The radiocephalic AVF (RC AVF) can be created at different locations of the forearm, starting distally at the wrist, and proceeding cranially towards the mid forearm. The most distal RC AVF creation location is the anatomical snuffbox. The snuffbox RC AVF is associated with satisfactory rates of maturation, usability, and secondary patency rates. If this AVF fails at the anastomosis or at the juxtaanastomotic region, a conventional forearm RC AVF creation is usually possible, and has a higher-than-expected success rate. The major disadvantage of an RC AVF is the lower maturation and failure rate due to the small vessels used and juxtaanastomotic stenoses (JAS). Several techniques to reduce the risk of JAS and AVF failure have been introduced within the last decade (pSLOT, RADAR, VasQ™ (Laminate Medical, Tel Aviv, Israel)) with promising results. The brachiocephalic AVF (BC AVF) is created at the distal upper arm/elbow crease by creating an anastomosis between the cubital brachial artery and upper arm or antecubital cephalic vein. Those AVFs are very common and favorable due to the mostly superficially located and bigger upper arm cephalic vein, leading to higher early maturation and cannulation rates. Due to the utilization of larger vessels, BC AVFs have higher risks of high-flow problems, hemodialysis access-induced distal ischemia (HAIDI), and aneurysmal degeneration of the vein. Proximalization of the anastomosis is practically impossible without an additional interposition (vein, if available, or graft), if it fails at the juxtaanastomotic region. Higher volume flows can lead to cardiac toxicity, and there may be a higher risk of cephalic arch stenosis. The higher maturation rates due to the larger vessels used with higher usability (cannulation) rates are an advantage of the BC AVF.