ANGIOGRAPHIC FEATURES OF

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1 NOVEMBER, 5975 ANGIOGRAPHIC FEATURES OF CIMINO-BRESCIA FISTULAS* ABSTRACT: By JAN G#{246}THLIN, M.D., and ERIC LINDSTEDT, M.D. LUND, SWEDEN Forty-four patients with operatively created arteriovenous fistulas have been examined angiographically. Widening of the main arteries of the forearm was evident, the most pronounced widening occurring in the artery feeding the fistula. Stenosis of the arteries or veins seldom influenced the flow significantly. Blood from the fistula was often partly or totally directed into the hand. In nine patients filling of deep veins was evident, and in most of these cases big fistulas were present. A rough estimate of the blood supply to the hand indicated poor supply in eight patients of which only one had symptoms of ischemia. Brachial angiography is of value in estimation of the blood flow in fistulas, when cannulation of veins is difficult, when thrombosis is suspected, or when a new fistula is planned after decreased function of an old one. NGIOGRAPHY is a readily available examination for evaluation of operatively constructed arteriovenous shunts and fistulas. Several reports have appeared regarding Quinton-Scribner shunts, but the angiographic features of Cimino-Brescia fistulas have been described more extensively in only one report, coming from our hospital.3 As the number of angiographic examinations is now more than doubled, a more quantitative analysis is possible and is considered worth reporting. MATERIAL AND METHOD In our hospital arteriovenous fistulas have been constructed for hemodialysis or intravenous therapy in about 400 patients during an eight year period. We use the surgical technique described by Brescia et al. with some modifications.4 Forty-four of these patients, 29 males and i females with an age range of years (mean 53 years), have been examined by angiography 49 times. The interval between operation and angiography was one week to two years. Of the examined anastomoses 32 were side-to-side, eight end-to-side (artery to vein), one side-to-end (artery to vein), one directly end-to-end, and three end-toend with interposed vein grafts. The yessels involved are presented in Table I. The usual reason for the angiographic examination was difficulty in cannulation of the arterialized veins, but in some cases it was that local or general circulatory symptoms indicated large fistula flow. In the latter cases the angiography was cornbined with flow studies using a dye-dilution technique, the results of which will be reported elsewhere. The examination technique has varied somewhat. In most cases retrograde percutaneous catheterization of the brachial artery was performed just above or at the elbow level. After application of local anesthesia, a polyethylene catheter (PE i6o, ID/OD 1.14/1.57 mm) with a length of about 20 cm was introduced. Ten to twenty ml meglumine metrizoate (Isopague Cerebral, Nyegaard, Norway) were injected by hand or by a high pressure syringe. The usual series was ten films for five seconds using an Elema-Sch#{246}nander cut film changer. In some cases one series in anteroposterior projection was obtained with compression of the veins of the upper arm using a blood pressure cuff inflated to a pressure of 30 mm Hg and manual corn- $ From the Departments of Diagnostic Radiology and Urology, University of Lund, S Lund, Sweden. 582

2 VOL. 525, No. 3 Angiographic Features of Cimino-Brescia Fistulas 583 TABLE I Vessels Anastomosed No. of Patients Radial artery-cephalic vein 33 Radial artery-subcutaneous 4 (one with a graft) vein Radial artery-basilic vein (with graft) Ulnar artery -basilic vein 3 Ulnar artery -subcutaneous I (with graft) vein pression of the axillary artery. One series in lateral projection without compression was made. The measurements of vessel diameters and fistula widths have been made on films obtained without compression, the geometric magnification being about 1.1. RESULTS The mean diameter of the radial artery at its origin was 6.2 mm (range 3.0-I 1.0, S.D mm), decreasing to a mean of 5.2 mm (2.o-9.o, S.D. 1.69) 2 cm proximal to the fistula. In i8 roentgenograms there was flow into the radial artery distal to the fistula, the mean diameter being 3.8 mm (2.o-7.o, S.D. 1.21). The mean diameter of the ulnar artery at its origin was 4.3 mm ( , S.D. 1.76) and the mean of the interosseous artery 3.3 mm (i.5-8.o, S.D. 1.39). There were few normal brachial angiograms available in the files of this hospital and examination of the contralateral arm was not performed; thus no normal values can be presented. The mean diameter of the anastomosed TABLE Arteries Filled No. of Patients Radial+ulnar+interosseous i6 Radial+ interosseous 3 Radial+ulnar Radial 2 Ulnar+interosseous 9 Ulnar 9 Not possible to determine 9 II I FIG. I. Bridge graft of the saphenous vein interposed between the radial artery and the basilic vein. Despite the irregularities in the fistula and the stenosis of the artery close to it there is a good flow in the arterialized vein. vein (or the main channel when more than one vein was dilated) 2 cm proximal to the fistula was 7.! mm ( , S.D. 2.28), distal to the fistula 6.o mm (2.3-I I.0, S.D. 2.4!). The width of the fistula was difficult to measure in some cases, but in the 19 measured patients the mean was 2.5 mm (o.-io.o, S.D. 3.42). There was stenosis of the feeding artery (two ulnar arteries) proximal to the fistula (Fig. 3) in 5 patients and distal to the fistula in three (Fig. 5). Stenosis of the main vein proximal to the fistula (Fig. 8) was evident in seven patients, distal to the fistula in ten (Fig. 6). Occlusion of the feeding artery (Fig. 13)

3 584 Jan G#{246}thlin and Eric Lindstedt NOVEMBER, 1975 FIG. 2. Side-to-side fistula between the radial artery and a small volar vein. The shunt is functionally an end-to-end one. Twenty weeks after operation there are two dilated, tortuous veins. was encountered in two patients and occlusion of the main vein in three patients (Fig. 6). The number of dilated venous channels varied from one to more than five, and in most cases the anastomosed vein showed the most pronounced dilatation. In eleven patients there were dilated veins only in the arm, in 28 in both arm and hand (Fig. 4), and in two only in the hand. The arterial supply of the hand, roughly estimated, was good in 25 angio- grams, decreased in nine, bad in eight, and was not possible to evaluate in seven angiograms (Table ii). Only one of the eight patients classified as bad had clinical evidence of a poor blood supply. The circulation time in the artery feeding the fistula and the emptying time of the main draining vein are presented in Table I - FIG.. Radial artery and cephalic vein anastomosed side-to-side. Due to incompetent valves, blood is flowing both distally and proximally. This is the most common flow pattern encountered in our material.

4 VOL. 125, No. 3 Angiographic Features of Cimino-Brescia Fistulas TABLE III THE FLOW RATE IN ARTERIES AND VEINS Artery Time (sec.) No. of Patients Elbow-fistula <0.5 Vein <1.0 >1.0 >2.5 Fistula-elbow <0.5 <1.0 >1.0 iii. The low arterial flow rate in five patients was due to severe arterial stenosis with a functioning fistula or to a nonfunctioning fistula with impairment of the artery. The decreased flow in the main TABLE IV MORPHOLOGY AND POSSIBLE FUNCTION OF CIMINO-BRESCIA SHUNTS A. Anatomical side-to-side anastomosis I. Functionally end-to-side No contrast medium distally in the artery Contrast medium in both directions in the vein 2. Functionally end-to-end No contrast medium distally in artery or vein No contrast medium distal artery or proximal vein 3. Functionally side-to-end Contrast medium proximally and distally in artery No contrast medium distally in vein No contrast medium proximally in artery B. Anatomical end-to-end i. Direct anastomosis artery-vein 2. Graft artery-vein C. Anatomical end-to-side I. Functional end-to-side No contrast medium distally in artery 2. Functional end-to-end No contrast medium distally in vein No contrast medium proximally in vein D. Anatomical side-to-end I. Functional side-to-end Contrast medium distally in artery 2. Functional end-to-end No contrast medium proximally in artery I FIG. 4. Anastomosis side-to-side between the radial artery and the cephalic vein with blood flowing mainly distally in the veins. Abundant arterial and venous collaterals and filled deep veins (arrows). Stenosis of the cephalic vein proximal to the anastomosis and dilatation distal to it. draining vein in three patients was due to severe stenosis or thrombosis, except for one case where all blood from the fistula was directed into the hand. Schematically the shunts can be divided according to the morphology and function as presented in Table Iv. The most common type of anastomosis was side-to-side between the radial artery and the cephalic vein, usually appearing to be an end-toside anastomosis (Fig. 3). The second most commonly occurring was the same anastomosis with all four limbs filled but only

5 86 Jan G#{246}thlin and Eric Lindstedt NOVEMBER, 1975 DISCUSSION 1/ FIG. g. Radial artery and cephalic vein anastomosed side-to-side. No flow proximally in the cephalic vein. Retrograde flow in dilated veins in the hand. Note the collateral supply from the ulnar artery. small amounts of blood in the distal part of the artery (Fig. 4). It was not uncommon for the blood in side-to-side fistulas to empty mainly in the distal direction of the vein (Fig. 5; 6; and io). Such was the case in almost all the nine patients where deep veins of the hand and the arm were filled (Fig..; and io). The patients studied by angiography are selected, and the material is not representative of ordinary well-functioning fistulas. In spite of this, some general information is given about the angiographic pattern in patients with this type of fistula. Even if no normal material is available, it is obvious that the artery feeding the fistula is widened. The artery has also a fairly uniform diameter from its origin to the fistula, and the normal tapering-off is absent. Dilatation of the artery proximal to the fistula is a well known phenomenon, although the exact mechanism of its development is unknown. Aneurysmal degeneration of the artery, known from other types of arteriovenous fistulas, has been observed in one of our patients. The artery distal to the fistula was sometimes filled by collaterals from the ulnar FIG. 6. Side-to-side anastomosis radial artery to cephalic vein with poor function of the fistula. Blood flows only distally in the severely stenosed vein into the hand and through a superficial vein with severe stenosis at its origin. No impairment of the arterial blood flow.

6 VOL. 525, No. 3 Angiographic Features of Cimino-Brescia Fistulas 587 (Fig. 7) or interosseous (Fig. 8) artery. Non-filling of this part of the artery might indicate obstruction of the artery but is more probably a sign of retrograde flow toward the fistula as has been observed in patients studied by other techniques.5 In patients with small fistulas the artery distal to the fistula was filled in the normal direction. In several cases even the other main arteries of the arm seem to be dilated, and their form is changed. These signs of in- FIG. 7. Well functioning fistula between radial artery and cephalic vein (side-to-side). There is abundant collateral supply from the dilated ulnar artery. There is a pronounced dilatation of the radial artery. FIG. 8. Anastomosis side-to-side between the radial artery and the cephalic vein. No blood flow distally in the vein. There is an extensive collateral circulation from the grossly dilated interosseous artery. creased blood flow indicate that the blood supply to the hand is taken over by these arteries, which can be clearly demonstrated in some cases (Fig. 1; and 8), and also of steal by the fistula from collateral arteries.4 Dilatation of the arterialized veins, eventually even venous aneurysms, are also well known and are evidently caused by the turbulence of blood flow. Like other authors6 we have found the venous aneurysms just opposite the fistula (Fig. 4). In most cases only one single venous

7 588 Jan G#{246}thlin and Eric Lindstedt NOVEMBER, 1975 FIG. 9. Saphenous vein graft between radial artery and basilic vein. Well functioning anastomosis. Irregular narrowing of vein lumen (arrow). channel was widened, even if several superficial veins were filled. In other cases several veins were dilated and were also used for cannulation. Kaude and Lindstedt found no filling of deep veins in the arm. In the present material, filling of deep veins has been observed in several cases, mainly in the hand but also in the arm (Fig. ; and io). The veins accompanying the interosseous artery are most often filled. Filling of deep veins was found in some cases where the blood flow from the fistula was mainly into the peripheral branch of the fistula vein. Deep veins in the forearm were most apparent in two cases with huge edematous swelling of the whole arm. In these patients a several superficial veins in the middle third of the forearm were thrombosed. In these cases the superficial venous pressure was evidently so high that the valves of communicating veins to the deep system were made incompetent. Stenosis of the artery just proximal to the fistula may be due to improper surgical technique, to perivascular scarring, or to angulation of the artery due to elongation. Such arterial stenosis impaired blood flow significantly in only one case (Fig. 12). Stenosis of the central vein a few mm proximal to the fistula has been observed by several authors, and it occurs frequently in our material. It can be observed even at the fistula operation. It is probably caused by venous spasm at the site of temporary oc- FIG. 10. (A) Non functioning shunt due to venous thrombosis. No evident impairment of arterial flow. (B) Partial recanalization of the distal part of the veins some weeks later. Note the deep veins along the radial artery.

8 VOL. 125, No. 3 Angiographic Features of Cimino-Brescia Fistulas 589 clusion during operation. Negative pressure in this limb of the fistula may contribute. More careful surgical technique and cutting the adventitia of the vein in this area seem to diminish the tendency to development of this stenosis. Even venous stenosis seems not to have great influence on fistula flow. Poor function of a fistula was most often due to changes in the fistula itself. Repeated cannulation of the arterialized veins was tolerated well in most cases but could occasionally lead to poor function. Non-function of a fistula was due to thrombosis of the feeding artery (Fig. 13) or the emptying vein (Fig. 6). A new shunt could be created using the ulnar artery and the basilic or other vein. A graft using a FIG. II. (A) Side-to-side anastomosis between radial artery and cephalic vein. Three limbs at the anastomosis are filled. Moderate stenosis of the radial artery proximal to the shunt. (B) Thrombosis in the upper part of the cephalic vein, demonstrated by selective catheterization and injection. FIG. 12. Anastomosis side-to-side between radial artery and hypoplastic vein with some blood going distally in veins. piece of the great saphenous vein (Fig. 9) was sometimes installed. Venous compression and digital occlusion of the axillary artery were performed in an attempt to give more detailed information of the anatomy, especially at the region of the anastomosis. These factors were only occasionally of significant value. Brachial angiography is a simple method for study of the morphology of Cimino- Brescia fistulas and for obtaining a crude estimate of the fistula flow. More elaborate

9 590 Jan G#{246}thlin and Eric Lindstedt NOVEMBER, 1975 FIG. 13. Side-to-side anastomosis between radial artery and cephalic vein with thrombosis of the radial artery proximal to the fistula. The distal part of radial artery is filled by retrograde flow from the ulnar artery. The fistula is functioning but the patient experienced pain at hemodialysis, indicating ischemia. flow studies can easily be performed in connection with the angiography using a dye-dilution technique.2 The angiographic examination is not painful as most of the contrast medium is diverted through the 4I fistula and thus the addition of local anesthetic agent to the contrast medium or anesthesia of the axillary plexus is not necessary. Preoperative brachial angiography is sometimes desirable to clarify the anatomy. Arterial size, atherosclerotic changes, thrombosis, and collaterals can be evaluated. By using papaverine and local anesthesia before the injection of contrast medium some information regarding the veins may be obtained. If a fistula has ceased to function, angiography reveals eventual possibilities for creating a new fistula. With poorly functioning fistulas, brachial angiography provides the information for deciding which step should be taken. Jan G#{246}thlin, M.D. Department of Diagnostic Radiology University of Lund S-22I85 Lund Sweden REFERENCES 1. BRESCIA, M. J., CIMINO, J. E., APPEL, K., and HURWICH, B. J. Chronic hemodialysis using venipuncture and surgically created arteriovenous fistula. New Englandj. Med., 1966, 275, Io8-Io Gothlin, J., et al. To be published. 3. KAUDE, J., and LINDSTEDT5 E. Angiographic studies in patients with Cimino-Brescia fistulae. Scand. 7. Urol. Nephrol., 1972, Suppl. 14, LINDSTEDT, E. Studies in therapeutic arteriovenous fistulae. Scand. 7. Urol. Nephrol., 1972, Suppl LINDSTEDT, E., and WESTLING, H. Effects of antebrachial Cimino-Brescia arteriovenous fistula on local circulation in hand. To be published. 6. R#{246}HL,L., FRANZ, H. E. M#{246}HRING, K., RITZ, E., SCHULER, H. W., UHSE, H. G., and ZIEGLER, M. Direct arteriovenous fistula for hemodialysis. Scand. 7. Urol. Nephrol., 1968,2, SCHENK, W. G., MARTIN, J. W., LESLIE, M. B., and PORTIN, B. A. Regional hemodynamics of chronic experimental arteriovenous fistulas. Surg., Gynec. & Obst., 1960, 110,

10 This article has been cited by: 1. J. Goldin, J.E. Dacie Technical report: Use of a 3 french catheter for transbrachial evaluation of surgically-created arteriovenous fistulae in dialysis patients. Clinical Radiology 49:4, [Crossref] 2. Jonathan S. Gani, Pamela R. Fowler, Adam W. Steinberg, John H. Wlodarczyk, Ranjit S. Nanra, Adrian D. Hibberd Use of the Fistula Assessment Monitor to Detect Stenoses in Access Fistulae. American Journal of Kidney Diseases 17:3, [Crossref] 3. Enrique M. Bursztyn. Angiography for Studying Hemodialysis Vascular Access [Crossref] 4. Shelley Nan Weiner Complications of Vascular Access Devices for Hemodialysis. Angiology 36:5, [Crossref] 5. C. Aldridge, R. N. Greenwood, W. R. Cattell, R. V. Barrett The assessment of a rteriovenous fistulae created for haemodialysis from pressure and thermal dilution measurements. Journal of Medical Engineering & Technology 8:3, [Crossref] 6. L. Forsberg, U. Tyl?n, T. Olin, E. Lindstedt Quantitative Flow Estimations of Arteriovenous Fistulas with Doppler and Dye-Dilution Techniques. Acta Radiologica. Diagnosis 21:4, [Crossref] 7. Paul Kinnaert, Julien Struyven, Jacques Mathieu, Pierre Vereerstraeten, Charles Toussaint, Jean Van Geertruyden Intermittent claudication of the hand after creation of an arteriovenous fistula in the forearm. The American Journal of Surgery 139:6, [Crossref]