A RCT trial in hemodialysis patients: fistula

Written by Pierre Delanaye on Monday, 10 October 2016. Posted in OLA Blog

A RCT trial in hemodialysis patients: fistula

Lancet. 2016 Sep 10;388(10049):1067-74. doi: 10.1016/S0140-6736(16)30948-5. Epub 2016 Aug 1.

Effect of regional versus local anaesthesia on outcome after arteriovenous fistula creation: a randomised controlled trial.

Aitken E1Jackson A2Kearns R3Steven M4Kinsella J3Clancy M2Macfarlane A3.

Author information

Abstract

BACKGROUND:

Arteriovenous fistulae are the optimum form of vascular access in end-stage renal failure. However, they have a high early failure rate. Regional compared with local anaesthesia results in greater vasodilatation and increases short-term blood flow. This study investigated whether regional compared with local anaesthesia improved medium-term arteriovenous fistula patency.

METHODS:

This observer-blinded, randomised controlled trial was done at three university hospitals in Glasgow, UK. Adults undergoing primary radiocephalic or brachiocephalic arteriovenous fistula creation were randomly assigned (1:1; in blocks of eight) using a computer-generated allocation system to receive either local anaesthesia (0·5% L-bupivacaine and 1% lidocaine injected subcutaneously) or regional (brachial plexus block [BPB]) anaesthesia (0·5% L-bupivacaine and 1·5% lidocaine with epinephrine). Patients were excluded if they were coagulopathic, had no suitable vessels, or had a previous failed ipsilateral fistula. The primary endpoint was arteriovenous fistula patency at 3 months. We analysed the data on an intention-to-treat basis. This study was registered with ClinicalTrials.gov (NCT01706354) and is complete.

FINDINGS:

Between Feb 6, 2013, and Dec 4, 2015, 163 patients were assessed for eligibility and 126 patients were randomly assigned to local anaesthesia (n=63) or BPB (n=63). All patients completed follow-up on an intention-to-treat basis. Primary patency at 3 months was higher in the BPB group than the local anaesthesia group (53 [84%] of 63 patients vs 39 [62%] of 63; odds ratio [OR] 3·3 [95% CI 1·4-7·6], p=0·005) and was greater in radiocephalic fistulae (20 [77%] of 26 patients vs 12 [48%] of 25; OR 3·6 [1·4-3·6], p=0·03). There were no significant adverse events related to the procedure.

INTERPRETATION:

Compared with local anaesthesia, BPB significantly improved 3 month primary patency rates for arteriovenous fistulae.

Comments

Not so frequent to have a RCT on Fistula patency. Basically, the study design is simple. The rationale is also simple and makes sense. Eventually, the results are clear…and positive: regional aneasthesia (Brachial Plexus Block) does improve FAV maturation and patency after 3 months. The procedure is relatively easy but requires some expertise, formation and materials (echography). Moreover, one important point must be underlined: a good patency is also dependent of a good surgeon! Regional aneasthesia implies that surgeon did the fistula within one hour…

 

Pierre Delanaye

Dr Pierre Delanaye MD, PhD

OLA Director

Dr Pierre Delanaye is currently Nephrologist in the University hospital of Li├Ęge (CHU Sart...
Posted: 1 year 1 month ago by elnahas #21065
elnahas's Avatar
Excellent comments, good surgeons also mean dedicated renal surgeons rather than general or vascular surgeons with diverging priorities. Having said that, the ultimate difficulties with AVF formation nowadays is a reflection of the aging of the HD population and their comorbidities including poor vascular patencies.
Regarding BPB, they induce a sustained vasoplegia and vasodilatation that can last as long as 6hours thus favoring a satisfactory flow through the newly created AVF;
www.ncbi.nlm.nih.gov/pubmed/22266593
Also basilic and cephalic veins diameters increase after BPB:
www.ncbi.nlm.nih.gov/pubmed/22116664
these effects may contribute to BPB advantage over local, short acting, anesthesia?!
Posted: 1 year 1 month ago by delanaye #21066
delanaye's Avatar
Clearly the vasodilatory effect of BPB is the rationnal.

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