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Shahid Nazeer¹ , Ibtisam Nazir Khan¹ , Pankaj Kaul² , Junaid Gulzar Wani¹ , Bariq Athar Masoodi¹

¹Department of Dialysis Therapy Technology, University School of Allied Health Sciences, RayatBahra University, Mohali, Punjab, India

²University School of Allied Health Sciences, RayatBahra University, Mohali, Punjab, India

Corresponding Author Email: th3.shahid@gmail.com

DOI : https://doi.org/10.51470/AMSR.2025.04.02.78

Abstract

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Introduction

Chronic Kidney Disease (CKD) is a progressive disorder that causes irreversible damage to both kidneys. Its global prevalence is high, averaging 11% in the United States and Europe, excluding patients on dialysis or with functioning transplants. Diabetes mellitus is a leading cause of CKD.

The main goal of hemodialysis is to restore fluid and electrolyte balance similar to healthy kidney function [1]. Vascular access is crucial for the effectiveness and outcomes of hemodialysis. Among the various options, the native arteriovenous fistula (AVF) is preferred for its long-term patency, low rates of morbidity, mortality, and infection, along with a reduced need for additional interventions. Despite strong clinical recommendations like those from the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (NKF-KDOQI), which suggests a native AVF prevalence of at least 65%, many patients—particularly in developing regions—start dialysis with central venous catheters, with only a small percentage beginning with an AVF. Currently, there are three main types of chronic vascular access: native AVFs, arteriovenous grafts (AVG), and tunneled double-lumen central venous catheters (CVCs). AVFs, usually created as radiocephalic, brachiocephalic, or brachiobasilic fistulas, have the best success rates and durability [2]. The side-to-side and end-to-side anastomotic techniques are widely used, with the side-to-side approach seen as technically easier and showing positive patency results. AVGs are used when native vessels are not suitable, providing reliable access but with a slightly higher risk of complications like thrombosis and infection [3]. CVCs offer immediate access but carry the highest risk and are used mainly for urgent or short-term needs. Considering the various anatomical options and complications associated, this study aims to assess the best sites for AVF creation, success rates in different anatomical locations, and the range of complications experienced with arteriovenous fistulas in chronic hemodialysis [4].

Study Design

Randomized Controlled Trial

Sample Size

Using following values, the sample size was calculated using OPEN EPI software, the total sample size required is 150 patients. Considering 1:1 randomization, each group will have following sample size.

Group A: Patients of ESRD with Brachiobasalic Arteriovenous Fistula; n=75

Group B: Patients of ESRD with Brachiocephalic Arteriovenous Fistula; n = 75

Formula:

Desired Power= 95%

Ratio=1

a (Probability of a Type I error (false positive))=5%

(Common standard deviation)=0.81

d (Difference in means μ₂​−μ₁= 0.51

ẟ=0.62963

Minimum Sample size required is 134 (n1=67, n2=67) in each group.  

Consider dropout rate

Considering 10% drop out rate.

Group 1 = 75

Group 2 = 75

Considering 10% drop out rate.

Total Sample required is 150 (n1 = 75, n2 =75)

 

Study Population

Inclusion Criteria

1.All the patients with End Stage Renal Disease on Maintenance Hemodialysis (MHD).

2.All the patients with End Stage Renal Disease that required MHD as advised by treating Physicians or Nephrologists.

3.All the patients with End Stage Renal Disease that required Renal Transplant surgery, but was on Hemodialysis (HD).

4.Patients who previously had arteriovenous fistula surgery that failed for any reason, with vascular access created on the opposite upper arm.

Exclusion Criteria

1.Patients with previously operated AVF with complications.

2.Patients with failed arteriovenous fistula on both upper arms

 Result

Fisher’s exact test

Figure1:-Comparison of age (years) between brachiobasilic and brachiocephalic.

Distribution of age (years)was comparable between brachiobasilic and brachiocephalic. (<=20years:-1.33% vs 1.33% respectively, 2¹–³0years:-10.67 % vs 12%

respectively, 31-40 years:- 17.33% vs 25.33% respectively, 41-50years:-29.33% vs 29.33%

respectively, 51-60years:-21.33% vs 17.33 % respectively, 61-70years:- 12 % vs 10.67%

respectively, >70years:-8 % vs 4 % respectively)(p value=0.87).

Mean±S D of age (years) in brachiobasilic was 48.89±14.17 and brachiocephalic was

45.96±13.34 with no significant difference between them.(p value=0.194

^§Chisquare  test

Distribution of gender was comparable between brachiobasilic and brachiocephalic. (Female:-32% vs 37.33 %  respectively, Male:- 68 % vs 62.67% respectively) (p value=0.493). It is shown in table 2

^‡Fisher’s exact test,^§ Chisquare test

Proportion of patients with hypertension was significantly lower in brachiobasilic as compared to brachiocephalic (Hypertension:- 46.67% vs 66.67% respectively). (p value=0.013)

Distribution of co-morbidities was comparable between brachiobasilic and brachiocephalic. (Diabetes mellitus:- 52 % vs 44 % respectively (p value=0.327), Athero sclerosis:-8 % vs 4 % respectively (p value=0.494),CVA:-4 % vs 6.67 % respectively (p value=0.719), Peripheral arterial disease:- 58.67 % vs 56 % respectively (p value=0.741), Peripheral venous disorder:- 6.67 % vs 5.33 % respectively (p value=1), Any other disorder:- 36 % vs 46.67 % respectively (p value=0.185).It is shown in table 6

^‡Fisher’s exact test,^§ Chisquare test

Distribution of forearm inspection was comparable between brachiobasilic and brachiocephalic. (Abnormal condition of skin:-5.33 % vs 9.33 % respectively (p value=0.533), Visible veins:- 49.33 % vs 46.67 % respectively (p value=0.744), Previous scar marks:- 6.67 % vs 5.33 % respectively (p value=1).It is shown in table 7.

^‡Fisher’s exacttest,^§ Chisquare test

Proportion of patients with visible veins in upper arm was significantly lower in brachiobasilic as compared to brachiocephalic (Visible veins:- 46.67 % vs 66.67 % respectively). (p value=0.013)

Distribution of other upper arm inspection was comparable between brachiobasilic and brachiocephalic . Abnormal condition of skin:-5.33 % vs 9.33 % respectively (pvalue=0.533), Previous scar marks:- 6.67 % vs 5.33 % respectively (p value=1)).It is shown in table 8.

^‡Fisher’s exact test, ^§Chisquare test

Proportion of patients with low arterial volume was significantly higher in brachiobasilic as compared to brachiocephalic (Low volume:-53.33 % vs 33.33 % respectively). Proportion of patients with high arterial volume was significantly lower in brachiobasilic as compared to brachiocephalic (High volume:- 46.67 % vs 66.67% respectively). (p value=0.013) Distribution of condition of vessel wall was comparable between brachiobasilic and brachiocephalic. (Normal:- 92 % vs 96 % respectively, Atherosclerotic:-8 % vs 4 % respectively)(p value=0.494).Distribution of palpation of vein was comparable between brachiobasilic and brachiocephalic. (Non palpable:- 50.67 % vs 53.33 % respectively, Palpable:- 49.33 % vs 46.67 % respectively) (p value=0.744). It is shown in table 9.

Table 16:- Comparison of pre-operative colour Doppler of upper limb{Brachial artery} between brachiobasilic and brachiocephalic.

^†Mann Whitney test, ^§Chisquare test, ^‡Fisher’s exact test

Distribution of pre-operative colour doppler of upper limb {Brachial artery} was comparable between brachiobasilic and brachiocephalic.(Atherosclerotic changes:-22.67%vs 36 % respectively (p value=0.073),Wall calcification:- 8 % vs 4% respectively (p value=0.494), Tortuosity:- 5.33 % vs 9.33 % respectively (p value=0.533)).

No significant difference was seen in caliber (mm) (p value=0.962),V max (cm/sec) (p value= 0.056), depth from skin (mm) (p value=0.854) between brachiobasilic and brachiocephalic. Median (25th-75th  percentile) of caliber (mm), V max (cm/sec), depth from skin (mm) in brachiobasilic was 4.1(3.9-4.2), 84(83-85), 4.4(4.2-4.6) respectively and in brachiocephalic was 4.1(3.9-4.2), 84(82-85), 4.4(4.2-4.6) respectively with no significant difference between them.Significant difference was seen in Q max (mL/min) between brachiobasilic and brachiocephalic.(p value <.05) Median(25th-75th percentile) of Q max (mL/min) in brachiobasilic was 131.88(101.14-169.63) which was significantly higher as compared to brachiocephalic (103.86(72.17-140.52)(p value=0.021)).

It is shown in table 16, figure 16.1 and 16.2.

^‡Fisher’s exact test, ^§Chisquare test

Distribution of side was comparable between brachiobasilic and brachiocephalic. (Left:- 37.33 % vs 44 % respectively, right:- 62.67 % vs 56 % respectively) (p value=0.406).

Distribution of loops used was comparable between brachiobasilic and brachiocephalic. (No:- 94.67 % vs 90.67 % respectively, Yes:- 5.33 % vs 9.33 % respectively) (p value=0.533).All the patients had side to side anastomosis and prolene suture material was used in all patients. It is shown in table 19.

^†Mann Whitney test, ^‡Fisher’s exact test, ^§Chisquaretest

Distribution of intra operative findings was comparable between brachiobasilic and brachiocephalic. (Peripheral location of the previous fistula:- 5.33% vs 9.33% respectively (p value=0.533), Atherosclerotic artery:- 22.67% vs 36% respectively (p value=0.073), Oedema over the extremity:- 8% vs 4% respectively (p value=0.494)).

None of the patient had mismatched diameters of artery and vein, vascular injury of the mobilized segment, presence of valve in the distal segment, more than one tributary of the vein.

No significant difference was seen in duration of prick over the extremity before surgery (days) (p value=0.819), length of anastomosis (mm)(p value=0.203), diameter of artery (mm) (pvalue=0.386),diameterofvein (mm) (p value=0.382) between brachiobasilic and brachiocephalic. Median (25th-75th percentile) of duration of prick over the extremity before surgery (days), length of anastomosis (mm), diameter of artery (mm),diameter of vein (mm) in brachiobasilic was 50 (45-56), 9 (8.5-9.6), 4.3 (4.1-4.6), 2.8(2.4-3.2) respectively and in brachiocephalic was 51(45-55), 8.9(8.5-9.5), 4.3(3.9-4.6), 2.9(2.6-3.4) respectively with no significant difference between them.

^†Mann Whitney test, ^‡Fisher’s exact test

Distribution of post operative radiological assessment was comparable between brachiobasilic and brachiocephalic.(Subcutaneous collections:-6.67 % vs 2.67 % respectively) (p value=0.442).

None of the patient had aneurysm.

No significant difference was seen in post-operative day (p value=1), caliber (mm)(p value=0.696), V max (cm/sec)(p value=0.222), Q max (mL/min)(p value=0.366) between brachiobasilic and brachiocephalic. Median(25th-75th percentile) of post-operative day, caliber (mm), V max (cm/sec), Q max (mL/min) in brachiobasilic was 3(3-3), 2.6(2.3-3.05), 134 (120-152), 643.23 (564.7-677.385) respectively and in brachiocephalic was 3(3-3),2.6(2.4-3.05), 132 (120-144.5), 653.33 (564.55-763.865) respectively with no significant difference between them.

^†Mann Whitney test, ^‡Fisher’s exact test

Figure 22.2:-Comparison of post-operative day between brachiobasilic and brachiocephalic.(non-parametric variable, Box-whisker plot)

Distribution of post operative clinical assessment was comparable between brachiobasilic and brachiocephalic. (Visible Veins at elbow and wrist: – 100% vs 96% respectively (p value=0.245), Palpation of distal arteries:- 97.33% vs 97.33% respectively (p value=1)).

No significant difference was seen in post-operative day (p value=0.319) between brachiobasilic and brachiocephalic. Median(25th-75th percentile) post-operative day in brachiobasilic was 40(37-43.5) and in brachiocephalic was 39(35.5-43) with no significant difference between them.It is shown in table 22

.

^†Mann Whitney test, ^‡Fisher’s exact test

None of the patients had aneurysm.

Distribution of Subcutaneous collections was comparable between brachiobasilic and brachiocephalic. (Subcutaneous collections:- 6.67% vs 2.67% respectively) (p value=0.442). No significant difference was seen in post-operative day(pvalue=0.515),caliber(mm)(p value=0.417),Vmax (cm/sec) (p value=0.387), Qmax (mL/min) (p value=0.810) between brachio basilica and brachiocephalic. Median (25th-75^th percentile) of  post-operativeday, caliber (mm),Vmax (cm/sec),Qmax (mL/min) in brachiobasilic was 45 (43-47), 4.4 (4.2-4.85),  241 (229.5-276), 624.26 (565.2-728.87) respectively and in brachiocephalic was  45 (43-47), 4.6 (4.2-4.9), 234 (219-284), 623.98 (565.32-735.07) respectively with no significant difference between them. It is shown in table 23.

.

^§Chisquare test

Distribution of patency of fistula on 30 day follow up was comparable between brachiobasilic and brachiocephalic. (Patent:- 88% vs 88% respectively, Not patent:- 12% vs 12% respectively) (p value=1).It is shown in table 24

^‡Fisher’s exact test

Distribution of previous existing radial fistula was comparable between brachiobasilic and brachiocephalic. (No:- 93.33 % vs 94.67 % respectively, Yes:- 6.67 % vs 5.33 % respectively) (p value=1).It is shown in table 25.

Distribution of patency of fistula on 30 day follow up was comparable between brachiobasilic and brachiocephalic. (Patent:- 88% vs 88% respectively, Not patent:- 12% vs 12% respectively) (p value=1).

      Follow up 1

Distribution of post operative clinical assessment was comparable between brachiobasilic and brachiocephalic. (Visible Veins at elbow and wrist:- 100% vs 96% respectively (p value=0.245), Palpation of distal arteries:- 97.33% vs 97.33% respectively (p value=1).

No significant difference was seen in post-operative day day 3 V max (cm/sec) (p value=0.222),Qmax (mL/min) (p value=0.366) between brachiobasilic and brachiocephalic. Median (25th-75^th percentile) of Vmax(cm/sec), Qmax(mL/min) in brachiobasilic was 134 (120-152), 643.23 (564.7-677.385) respectively and in brachiocephalic was 132 (120-144.5), 653.33 (564.55-763.865) respectively with no significant difference between them.

       Follow up 2

Distribution of patency of fistula on 90 day follow up was comparable between brachiobasilic and brachiocephalic. (Patent:- 87% vs 83% respectively, Not patent:- 13 % vs 17 % respectively) (p value=0.65).

Distribution of post operative clinical assessment was comparable between brachiobasilic and brachiocephalic. (Visible Veins at elbow and wrist:- 100 % vs 96 % respectively (p value=0.245), Palpation of distal arteries:- 97.33 % vs 97.33 % respectively (p value=1)).

No significant difference was seen in V max (cm/sec)(p value=0.387), Q max (mL/min) (p value=0.810) between brachiobasilic and brachiocephalic. Median (25th-

75^th percentile) of V max (cm/sec), Qmax (mL/min) in brachiobasilic was 241(229.5- 276), 624.26 (565.2-728.87) respectively and in brachiocephalic was 234 (219-284), 623.98 (565.32-735.07) respectively with no significant difference between them.

None of the patients had aneurysm.

Distribution of Subcutaneous collections was comparable between brachiobasilic and brachiocephalic. (Subcutaneous collections:- 6.67% vs 2.67% respectively) (p value=0.442).

Distribution of patency of fistula on 6 months follow up was statistically better for brachiobasilic as compared to brachiocephalic. (Patent:-85 % vs 71 %  respectively, Not patent:- 15 % vs 29 % respectively) (p value=<0.05).

Distribution of post operative clinical assessment was comparable between brachiobasilic and brachiocephalic. (Visible Veins at elbow and wrist:- 100% vs 96% respectively (p value=0.245), Palpation of distal arteries:- 97.33% vs 97.33% respectively (p value=1)).

No significant difference was seen in post-operatively after 6 months V max (cm/sec) (p value=0.387), Qmax (mL/min) (p value=0.810) between brachiobasilic and brachiocephalic. Median (25th-75^th percentile) ofVmax (cm/sec), Qmax(mL/min) in brachiobasilic was 154 (229.5-276), 632.26 (565.2-728.87) respectively and in brachiocephalic was 234 (219-284), 623.98 (565.32-735.07) respectively with no

Significant difference ertween them. None of the patients had aneurysm.

Distribution of Subcutaneous collections was comparable between brachiobasilic and brachiocephalic. (Subcutaneous collections:-0% vs 2.67% respectively) (p value=0.442).

Distribution of patency of fistula on 30 day follow up was comparable between brachiobasilic and brachiocephalic. (Patent:- 88 % vs 88 % respectively, Not patent:- 12% vs 12% respectively) (p value=1)

Distribution of patency of fistula on 90 day follow up was comparable between brachiobasilic and brachiocephalic. (Patent:- 87% vs 83% respectively, Not patent:- 13% vs 17% respectively) (p value=0.65).

The patency of brachiobasilic fistula was statistically significant as compared to brachiocephalic. (Patent:- 85% vs 71% respectively, Not patent:- 15% vs 29% respectively) (p value=<0.05) at 6 months follow up.

Analysis of postoperative non patency was comparable between brachiobasilic and brachiocephalic.

No significant difference was seen post-operatively after 10 days, time dependent and anatomic non patency was 0 % and 0 % respectively.

No significant difference was seen post-operatively after 30 days, time dependent non patency was 9 % and 9 % respectively and anatomic patency was 0% and 0 % respectively.

Some Difference was seen while analysing the non patency between brachiobasilic and brachiocephalic post-operatively after 90 days, time dependent non patency was 9% and 11% respectively and anatomic patency was 1% and 2% respectively.

Significant difference was seen while analysing the non patency between brachiobasilic and brachiocephalic post-operatively after 6 months, while the time dependent non patency was 9% and 18% respectively and anatomic patency was 2% and 4% respectively.

Analysis   of    Vascular   access  Maturation   was   comparable  between brachiobasilic and brachiocephalic.Immediate vascular access failure was seen in 0% of both brachiobasilic and brachiocephalic.No significant difference was seen in early dialysis suitability failure post- operatively it was 12% and 15% respectively.Significant difference was seen in late dialysis suitability failure post- operatively it was 15% and 29% respectively.In Fistula Used Successfully for Hemodialysis (FUSH) significant difference of 73% and 56 % respectively for brachiobasilic and brachiocephalic was observed.

Distribution of time of cannulation was comparable between brachiobasilic and brachiocephalic. (Mean: – 47.61 vs 52.64 respectively, Not patent:- 52.64 vs 2.98% respectively) (p value=0.0001). The difference was statistically significant.

Discussion

In this prospective study, intradialytic dysglycemia was observed in one‑third of hemodialysis sessions and was strongly associated with intradialytic hypotension after adjustment for ultrafiltration and insulin timing. This confirms that glucose fluctuations are not simply incidental but clinically relevant contributors to dialysis instability. Hypoglycemia and large glucose swings likely trigger osmotic shifts and autonomic responses that amplify hemodynamic compromise. Our results align with recent multicenter reports using continuous glucose monitoring in dialysis patients and extend them by linking session‑level dysglycemia to immediate clinical outcomes [4-5].

The clinical implications are clear: patients with frequent intradialytic hypotension or cramps may benefit from CGM to identify high‑risk patterns. Targeted strategies such as adjusting insulin timing, dialysate glucose, and ultrafiltration profiling could mitigate these risks. Emerging interventional studies suggest CGM‑guided care is feasible in dialysis units and may reduce adverse events. Further randomized trials are needed to test whether CGM‑based interventions improve patient outcomes [6-8].

Strengths include prospective CGM data, rigorous mixed‑effects modeling, and multiple sensitivity analyses. Limitations include the single‑center setting, modest sample size, and residual confounding. Nevertheless, these findings underscore the importance of recognizing glycemic variability during dialysis as a modifiable risk factor [9-11].

Ethical Clearance

The present study entitled “Comparison of Vascular Access of Brachiobasilic Arteriovenous Fistula to Brachiocephalic Arteriovenous Fistula for Hemodialysis in Patients with End Stage Renal Disease” was conducted in the Department of Dialysis Therapy Technology, University School of Allied Health Sciences, RayatBahra University, Mohali, Punjab, India.

Conflict of Interest: The authors declare no conflict of interest.

Funding Statement: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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