Aneurysmal transformation of fistula veins: from classification to types of surgical treatment A.B. Zulkarnaev 1, B.V. Baykov 2,3, A.G. Yankov

Objective: to analyze the surgical correction of native arteriovenous fistula (AVF) aneurysms in patients on the program hemodialysis (HD). Materials and methods: a retrospective observational study included 158 patients who underwent various surgical interventions due the AVF aneurysms; 87 patients (55.1%) underwent pre-emptive surgeries; 71 patients (44.9%) underwent surgery after AVF thrombosis ("on-demand" surgery). Results: in the case of pre-emptive surgeries, secondary patency was 95.3% [95% CI 88; 98.2], 91.4% [95% CI 82.7; 95.8], 87.6% [95% CI 77.1; 93.5], after a year, two and three years, respectively, after 4.8 years (maximum follow-up) - 69% [95% CI 44.9; 84.2]. In the case of "on-demand" surgery, the secondary patency was 80.3% [95% CI 68.3; 88.1], 71.2% [95% CI 57.1; 81.4], 60.1% [95% CI 43; 73.6] at the same time points, respectively, and after 4.3 years (maximum follow-up) - 45.6% [95% CI 23.6; 65.2]. HR pre-emptive vs. "on-demand" surgeries 0.296 [95% CI 0.147; 0.592], p=0.0002. In patients who received "on-demand" surgery the risk of AVF function loss was higher (6.268 [95% CI 3.927; 9.49] versus 2.642 [95% CI 1.406; 4.519] 100 patient-years, incidence rate ratio (IRR)=2.372 [95% CI 1.2; 4.842], p=0.0127), the need for central venous catheter also was higher (2,821 [95% CI 2,292; 3.434] versus 1.728 [95% CI 1.38; 2.136] per 10 patient-years, IRR=1.633 [95% CI 1.222; 2.185], p=0.0009), and the number of operations was significantly less (2.963 [95% CI 2,421; 3.59] versus 4.207 [95% CI 3.654; 4.821] per 10 patient-years, IRR=0.704 [95% CI 0.555; 0.89], p=0.0031). The median volume blood flow (Qa) was 2.9 [interquartile range - IQR 1.9; 3.8] l/min, (minimum 1 l/min, maximum 4.5 l/min). Reconstruction in most cases lead to a significant change in Qa (p<0.0001). After reconstruction, the Qa median was 1.8 [IQR 1.6; 2.1] l/min (minimum 1.4 l/min, maximum 2.1 l/min). It is noteworthy that in patients with low Qa values, Qa increased slightly, and at high values, it decreased significantly. However, additional methods of blood flow reducing were not used. The median of the Qa difference was -1.2 [IQR -1.9; -0.2] l/min (minimum -2.7 l/min, maximum 1 l/min). Conclusions: the indication for surgical treatment is not an aneurism itself, but its complications, the risk of complications development or a combined pathology. Preventive surgical interventions can significantly extend the AVF patency and reduce the need for central venous catheters, however, this is achieved by significantly increasing the number of surgeries.

артериовенозная фистула, аневризма, аневризморафия, объемная скорость кровотока, стеноз, вторичная проходимость, сосудистый доступ, гемодиализ, arteriovenous fistula, aneurysm, aneurysmorhaphy, volume blood flow, stenosis, secondary patency, vascular access, hemodialysis

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