3.2 AVF complications and ultrasound parameters
As shown in Table 3, of the 89 patients, 17 cases (19.1%) had complications (stenosis or thrombosis), 17 cases (19.1%) had stenosis (including 9 cases of anastomotic stenosis and 8 cases of venous stenosis), 2 cases (2.2%) had thrombosis (both in the vein, leading to thrombotic stenosis), and 2 cases (2.2%) had both stenosis and thrombosis (Fig. 2 and Fig. 3).
The mean brachial artery AVF D ranged from 3.70 to 10.30 mm, with an average of 6.25 ± 1.31 mm; the Vm ranged from 26.40 to 163.00 cm/s, with an average of 71.91 ± 24.10 cm/s; FV ranged from 140.00 to 1780 mL/min, with an average of 727.02 ± 326.90 mL/min; PSV ranged from 44.30 to 231.00 cm/s, with an average of 115.02 ± 35.97 cm/s; EDV ranged from 16.70 to 136.00 cm/s, with an average of 52.33 ± 19.17 cm/s; PI ranged from 0.31 to 2.15, with an average of 0.91 ± 0.31; and RI ranged from 0.27 to 0.79, with an average of 0.54 ± 0.10.
3.3 Relationship between AVF complications and ultrasound parameters
To determine the relationship between AVF complications and ultrasound parameters, their correlation was analyzed. According to the presence of complications, patients were divided into complication group (n = 17) and noncomplication group (n = 72). As shown in Table 4, the levels of D, Vm, FV, and EDV were significantly lower in the complication group than those in the noncomplication group (P < .05). PI and RI were significantly higher in the complication group than those in the noncomplication group (P < .05). There was no significant difference in PSV between complication and noncomplication groups (P > .05). It indicates that brachial artery D, Vm, FV, EDV, PI, and RI were significantly related to AVF complications.
3.4 Cut-off points of ultrasound parameters on AVF complications evaluation
To identify the cut-off points of ultrasound parameters, they were grouped by quartiles. In this study, K = 4, therefore P < .0083 was considered statistically significant to avoid type I error. The incidence of complications in each group is shown in Table 5.
Brachial artery D (range 3.70–10.30 mm) were grouped as: group A: ≤5.40, group B: 5.41 to 6.00, group C: 6.01 to 7.20, and group D: >7.20. It was found that the incidence of AVF complications significantly increased with the increase of brachial artery D (P < .05). There were significant differences between group A and group C, and between group A and group D (P < .0083). When the brachial artery D was ≤5.40 mm, there were high complication rates.
The brachial artery Vm (range 26.40–163.00 cm/s) was grouped as group A: ≤53.17 cm/s, group B: 53.18 to 67.70 cm/s, group C: 67.71 to 86.35 cm/s, and group D: >86.35 cm/s. There were no significant differences among the 4 groups (P > .05).
The brachial artery FV (range 140.00–1780.00 mL/min) was grouped as group A: ≤460.00 mL/min, group B: 460.01 to 710.00 mL/min, group C: 710.01 to 917.50 mL/min, and group D: >917.50 mL/min. The incidence of AVF complications was significantly decreased with the increase of brachial artery FV (P < .05). There was significant difference between group A and group B, group A and group C, and group A and group D (P < .0083). Therefore, when the brachial artery FV was ≤460 mL/min, the complication rate was high.
The brachial artery EDV (range 16.70–136.00 cm/s) was grouped as group A: ≤37.60 cm/s, group B: 37.61 to 49.30 cm/s, group C: 49.31 to 61.75 cm/s, and group D: >61.75 cm/s. There was no significant difference among the groups (P > .05).
The brachial artery PI (range 0.31–2.15) was grouped as group A: ≤0.71, group B: 0.72 to 0.87, group C: 0.88 to 1.04, and group D: >1.04. AVF complications increased with PI (P < .05). There were significant differences between group A and group D (P < .0083). Therefore, when brachial artery PI was >1.04, the complication incidence rate was high.
The brachial artery RI (range 0.27–0.79) was grouped as group A: ≤0.49, group B: 0.50 to 0.55, group C: 0.56 to 0.60, and group D: >0.60. AVF complications increased with RI (P < .05). There was significant difference between group A and group D (P < .0083). Therefore, when brachial artery RI was >0.60, the complication rate was high.
In conclusion, the cut-off points of brachial artery D, FV, PI, and RI are identified. It showed that when the brachial artery D was ≤5.40 mm, or FV was ≤460 mL/min, or PI was >1.04, or RI was >0.60, the complication rate was high.
Autonomic arteriovenous fistula is the first-line vascular pathway for dialysis patients, and ultrasound is the recommended AVF method.[7,8] The K/DOQI guideline recommends measuring the inflow of the infarcted blood vessels, rather than the anastomotic and outflow tract vessels, which may be because that the anastomotic blood flow is not laminar. Apart from this, the head vein wall is thin and superficial that is easily pressed by the probe, and dialysis puncture for a long time is easy to promote tumor-like expansion that is difficult for head vein measurement. The radial artery may underestimate the flow of AVF and ignore the ulnar artery flow into AVF at the distal end of anastomosis. In this study, brachial artery was selected to monitor AVF.
We analyzed the relationship between the complications (stenosis and thrombosis) and the ultrasound parameters of AVF brachial artery. The result showed that D, Vm, FV, EDV, PI, and RI of brachial artery were significantly correlated with AVF complications, and cut-off points of each indicator were identified to provide the evidence for the early detection of AVF complications.
Apart from this, we found that the brachial artery D in the complication group was significantly lower than that in the noncomplication group. The incidence of AVF complications decreased as brachial artery D increased. When the brachial artery D was ≤5.40 mm, the complication incidence was high. This result indicates that the brachial artery D has significant individual differences; however, when it was ≤5.40 mm, AVF stenosis and thrombosis should be checked. The brachial artery Vm of the complication group was significantly lower than that of the noncomplication group. The incidence of complications decreased as the brachial artery Vm increased. However the quartile method found no boundary value, which may be due to small sample size. For AVF brachial artery Vm, follow-up with large sample size should be performed to determine the appropriate cut-offs. Additionally, we found that brachial artery FV in the complication group was significantly lower than that in the noncomplication group. The incidence of AVF complications decreased with FV increase. When the brachial artery FV was ≤460 mL/min, the complication incidence was high. Some reported that AVF and AVG flow should be between 300 and 400 mL/min to 3000 mL/min, most as 600 to 1500 mL/min. A Chinese study showed that brachial artery FV had large individual differences, including 46 cases of AVF brachial artery FV ranging from 203 to 2386 mL/min. The above differences could be resulted from differences of ethnicity.
It is suggested that the incidence of stenosis was great when the flow rate was <650 mL/min. It is also reported that the incidence of thrombosis was great when the flow rate was <500 mL/min or decrease >25%. The cut-off point was slightly lower in this study, probably due to the overall lower AVF flow of Chinese patients.[18,26] This study suggests that when the brachial artery FV is ≤460 mL/min, AVF stenosis and thrombosis should be checked. On the contrary, high brachial artery FV may increase heart load. It is recommended that cardiac ultrasound should also be used to determine whether interventions (such as anastomosis) should be used when brachial artery FV is high.
In this study, we also found that the brachial artery EDV in complication group was significantly lower than that in the noncomplication group. The incidence of complications increased as brachial artery EDV decreased. However, the cut-off points were unable to identify, possibly due to limited sample size. Future studies with larger sample size should be used to determine the cut-offs. Brachial artery PI was significantly higher in the complication group than in the noncomplication group. The incidence of AVF complication increased as brachial artery PI increased. When brachial artery PI value is >1.04, AVF stenosis and thrombosis should be checked. The brachial artery RI in the complication group was significantly higher than that in the noncomplication group. The incidence of AVF complication increased as brachial artery RI increased. When the brachial artery RI is >0.60, complication is more likely to happen. For brachial artery RI, Koseoglu et al showed that brachial artery RI (measured 3–4 cm above elbow) was a predictor of AVF failure. Moreno Sanchez et al reported that stenosis and thrombosis could lead to increased RI in artery inflow. Our study was consistent with these studies, demonstrating that with abnormal AVF, brachial artery RI significantly increases. Our study also recommend that, for AVF radial artery-head vein anastomosis, when brachial artery RI is >0.60, AVF stenosis and thrombosis should be checked.
This study is limited in the small sample size. Apart from this, the subjects were from the same dialysis center. Thus, the conclusion might be limited.
In conclusion, D, FV, PI, and RI of brachial artery were significantly related with AVF complications. This study showed that when the brachial artery D ≤5.40 mm, or brachial artery FV ≤460 mL/min, or brachial artery PI >1.04, or brachial artery RI >0.60, the incidence of complications (stenosis and thrombosis) may increase. Therefore, brachial artery diameter and hemodynamic parameters are helpful for the early detection of fistula stenosis and thrombosis. For brachial artery D ≤5.40 mm, brachial artery FV ≤460 mL/min, brachial artery PI >1.04, and brachial artery RI >0.60, stenosis and thrombosis should be checked for early detection of complications.
Data curation: Chong Ren, Yanpei Cao.
Funding acquisition: Yanpei Cao.
Investigation: Chong Ren, Wenwen Lu.
Methodology: Chong Ren.
Project administration: Jing Chen.
Resources: Yong Wang, Bihong Huang.
Software: Xiaoli Yang.
Validation: Jing Chen.
Writing – original draft: Chong Ren.
Writing – review & editing: Yanpei Cao.
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Keywords:Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
autologous arteriovenous fistula; brachial artery; color Doppler ultrasound; hemodialysis