TITLE: Contemporary Outcomes of a "Snuffbox First" Hemodialysis Access Approach in the United States
OBJECTIVE: Society guidelines for permanent hemodialysis (HD) access creation recommend prioritizing the most distal possible autogenous access in order to minimize complications and preserve more proximal options. The "snuffbox" arteriovenous fistula (AVF) is the most distal radial-cephalic AVF. Despite the theoretical benefits of the snuffbox approach, recent trends have been toward upper arm accesses. Our study sought to investigate the feasibility of a snuffbox-first strategy for hemodialysis access in all anatomically appropriate candidates.
METHODS: Between January 2016 and August 2019, all patients with end stage renal disease (ESRD) or pre-ESRD under consideration for HD access were evaluated for a snuffbox-first approach by a team of vascular surgeons and nephrologists at a single, urban academic medical center in the United States. Data were collected prospectively and supplemented by chart review. Survival analysis was performed to evaluate primary unassisted and secondary patency, as well as clinical and functional maturation. Patients were censored if they received a kidney transplant or died. Cox Proportional Hazards regression determined risk factors for prolonged clinical maturation and functional maturation.
RESULTS:A total of 55 snuffbox AVFs were created. The median age was 60 years (IQR 52-70); 52.7% were male. Median follow-up was 369 days (IQR 166-509). Median survival for primary unassisted patency was 90 days (95% CI 79-111). Secondary patency at one year was 92.3% (95% CI 85.3-99.9%). Clinical maturation at one year was 83.7% (n=55, 95% CI 66.8-91.9%) and functional maturation at one year was 85.6% (n=40, 95% CI 63.3-94.4%). Of patients who were pre-ESRD at time of AVF creation and initiated hemodialysis during the study period, 87.5% successfully received incident hemodialysis with their snuffbox AVF. Twenty-four patients were receiving hemodialysis via a catheter at the time of snuffbox creation, and among those patients, functional maturation at 1 year was 82.5% (95% CI 44.8-94.4%). Patients underwent a median of 2 (IQR 2, range 0-7) interventions in the first year; 46.9% were percutaneous angioplasties, 31.2% were side-branch ligations. Diabetes was associated with slower AVF clinical maturation (multivariate HR 0.35, 95% CI 0.15-0.82, P=.016). Larger artery diameter was associated with earlier AVF clinical maturation (multivariate HR 6.64, 95% CI 2.11-20.9).
CONCLUSIONS:A snuffbox-first approach to hemodialysis access is a viable option for distal access creation in a cohort of hemodialysis patients in the United States. Subsequent ancillary interventions to facilitate access maturation were required in the majority of patients.
SOURCE: Heindel P, Dieffenbach BV, Sharma G, et al. Contemporary Outcomes of a "Snuffbox First" Hemodialysis Access Approach in the United States: A "Snuffbox First" Hemodialysis Access Approach[J]. J Vasc Surg, 2021, DOI: 10.1016/j.jvs.2021.01.069.
目的：建立永久性血液透析（HD）通路的社会指南建议优先考虑最远端的自体通路，以最大程度地减少并发症，并保留更多的近端选择。 “鼻烟窝”动静脉瘘（AVF）是最远端的桡头型AVF。尽管鼻烟盒方法具有理论上的好处，但最近的趋势一直是上臂入路。我们的研究试图调查在所有解剖学上合适的候选人中采用鼻烟盒优先策略进行血液透析的可行性。
方法：在2016年1月至2019年8月之间，由一组美国的医疗中心的血管外科医生和肾脏病专家组成的一支城市外科医师团队，对所有考虑接受HD治疗的终末期肾病（ESRD）或ESRD之前的患者进行了鼻烟窝法的评估。前瞻性地收集数据，并通过图表加以补充。进行生存分析以评估原发性和非辅助性通畅性，以及临床和功能成熟度。如果患者接受了肾脏移植或死亡，则予以剔除。 Cox-回归确定了长时间临床成熟和功能成熟的危险因素。
结果：总共建立了55个鼻烟窝AVF。中位年龄为60岁（IQR 52-70）；男性占52.7％。中位随访时间为369天（IQR 166-509）。原发性无辅助通畅的中位生存期为90天（95％CI 79-111）。一年的二次通畅率为92.3％（95％CI 85.3-99.9％）。一年的临床成熟度为83.7％（n = 55，95％CI 66.8-91.9％），一年的功能成熟度为85.6％（n = 40，95％CI 63.3-94.4％）。在研究期间，在发生AVF时已处于ESRD之前并开始血液透析的患者中，有87.5％的鼻烟窝AVF成功地接受了紧急血液透析。在鼻烟窝建立时，有24名患者正在通过导管进行血液透析，在这些患者中，1年时的功能成熟率为82.5％（95％CI 44.8-94.4％）。在第一年，患者平均接受了2次干预（IQR 2，范围0-7）；经皮血管成形术占46.9％，侧支结扎占31.2％。糖尿病与AVF临床成熟较慢有关（多元HR 0.35，95％CI 0.15-0.82，P = .016）。较大的动脉直径与较早的AVF临床成熟有关（多变量HR 6.64，95％CI 2.11-20.9）。
结论：在美国的一组血液透析患者中，以“鼻烟窝优先”的方法建立血液透析通路是建立远端通路的可行选择。但大多数患者需要随后的辅助干预以促进通路成熟。
启发：鼻烟窝内瘘是建立远端内瘘的一种方式，但由于远端分支较多，血管偏细，内瘘成熟成了主要问题，通过合理的评估、结扎分支、球囊促成熟等方式，可以提高内瘘功能。
