Pull-through technique through antegrade radial artery puncture without sheath insertion in balloon-assisted radiocephalic arteriovenous fistulas maturation

A retrospective study was conducted on patients received balloon-assisted maturation in our department between 2019 and 2020. A total of 65 patients received balloon-assisted maturation in our hospital, with one patient died from heart disease two months after intervention, and two patients receiving kidney transplantation within six months after intervention. Finally, there were 62 patients included in this study. 15 patients received balloon-assisted maturation with PT technique without sheath insertion through the antegrade radial artery approach. And 47 patients received a regular venous approach.

Patients who satisfied the following criteria were included in the study: (1) At least 8 weeks after creation of radiocephalic AVFs; (2) The range of stenosis was > 50% of the normal peripheral vessel diameter determined by ultrasonography; 3) the blood flow was < 500 mL/min; (4) AVF cannot provide 200 ml/min pump blood flow or it was too hard to puncture. (5) no signs of central venous disease.

All patients underwent brachial plexus nerve block anesthesia before the start of the intervention. Once the anesthesia was deemed satisfactory, the Seldinger technique was used to insert a vascular sheath (5-6F, Terumo) via a retrograde vein puncture. A guidewire (RF*GA35153M, Terumo, Japan) and a Tempo Angiographic Catheter (451-514H0, Cordis Corporation, USA) were used to enter into the brachial artery through the anastomosis. Then angiography was performed to identify the precise site of stenosis, and an appropriately sized balloon (4-6 mm, Boston Scientific) was used for dilation. This was the standard procedure via a venous approach. If it was not possible to enter the proximal radial artery through the anastomosis, the ultrasound (VINNO 8, China) was used to guide antegrade radial puncture (the puncture needle was from the sheath introducer set, which allows a 0.035 inch guidewire to pass through its sleeve), which 3–5 cm proximal to the anastomosis. After successful puncture, the needle was removed, a guidewire (RF*GA35153M, Terumo, Japan) was inserted through the needle sleeve. After capturing the guidewire from the sheath by pull-through technique, the Catheter was sent to proximal radial artery. Then remove the guidewire and needle sleeve, local pressure was applied for 5 min. If no complications were found on ultrasound, the guidewire was re-inserted through the tempo angiographic catheter to the proximal radial artery and then it was sent to the brachial artery. Angiography was performed to identify the site of stenosis, followed by balloon dilation. This was the standard procedure for the PT group (Fig. 1).

All patients underwent evaluation of fistula maturation in our outpatient department 4–8 weeks after intervention. Subsequently, general and ultrasound examinations (VINNO 8, China) were conducted at least once every 3–6 months, and telephone follow-ups were performed every 6 months using a questionnaire (including blood pump flow, venous pressure, arterial pressures).

A total of 62 patients were included in this study. The demographic and clinical characteristic of patients were summarized in Table 1. The PT group consisted of 15 patients with an average age of 57.07 ± 14.96 years old. Among them, 6 were female. The preoperative blood flow was measured at 259.73 ± 78.06 ml/min, while the postoperative blood flow was measured at 680.40 ± 159.12 ml/min. 11 patients had hypertension, and 9 patients had diabetes. The most common site of stenosis was juxta-anastomotic segment. The control group consisted of 47 patients with an average age of 62.34 ± 13.06 years old. Among them, 22 were female. The preoperative blood flow was measured at 258.44 ± 76.31 ml/min, while the postoperative blood flow was measured at 672.19 ± 143.84 ml/min. 31 patients had hypertension, and 33 patients had diabetes. The most common site of stenosis was mixed site. Except for stenosis site, there were no significant differences between PT group and Control group in age, sex, blood flow before or after operation, patency duration, hemoglobin, albumin, serum calcium, serum phosphorus, serum parathyroid hormone levels and comorbidities of diabetes and hypertension. Much more patients in PT group tend to have stenosis in the juxta-anastomotic segment, while more Control group patients have stenosis in mixed site (P < 0.001).

There were 2 patients in the PT group and 5 patients in the control group still cannot be successfully used 8 weeks after intervention (P = 1.00). And 2 cases in PT group and 3 cases in control group had hematoma in the vein puncture site (P = 0.59). The average operation time of PT group was 48.9 ± 18.2 min, and that of the control group was 39.7 ± 20.4 min (P = 0.68, see the Table 2).

The median primary patency duration of PT group was 7 months (range from 3 to 13 months), while the control group was 6 months (range from 1 to 16 months). The post-intervention primary patency rate at 6 and 12 months in the PT group were 76.9% and 38.4%, and those in the control group were 70.7% and 41.5%. Figure 2 shows the Kaplan–Meier analysis for primary patency after intervention. There were no differences between the two groups at 6 and 12 months after intervention.

We also conducted a univariate and multivariate Cox regression analysis to analyse clinical variables associated with primary patency. The result showed that the primary patency was not affected by the factors, including age, sex, stenosis site and group (See the Table 3).