JVA

J Vasc Access 2016; 17 (Suppl 1): S60-S63

DOI: 10.5301/jva.5000517

ISSN 1129-7298 ORIGINAL ARTICLE

Access flow reduction for cardiac failure

Pierre Bourquelot

Angioaccess Surgery Department, Clinique Jouvenet, Paris - France

Abstract
High-flow in hemodialysis arteriovenous angioaccesses is frequent. It may result in high-output cardiac fail-
ure, which should be prevented by fistula flow reduction. The most frequently reported flow reduction pro-
cedure is banding but immediate and long-term results are questionable. Alternative techniques are related
here with personal results. Juxta-anastomosis “Proximal Radial Artery Ligation” (PRAL) is a very simple and
effective reduction technique for side-to-end radio-cephalic fistulas (82 patients; reduction rate [RR]: 54%
± 19%). For brachial artery-based fistulas flow reduction two variants of Revision Using Distal Inflow (RUDI)
procedures are used: 1) RUDI-1 using a polytetrafluoroethylene (PTFE) graft or a greater saphenous vein,
which we first described in 1989 as “Distal Report of the Arterial Inflow” (35 patients; RR: 53% ± 18%),
2) RUDI-2 procedure, “Transposition of the Radial Artery”, which we described in 2009 (47 patients; RR:
66% ± 14%).
Keywords: Arteriovenous fistula, Banding, Cardiac failure, Fistula ligation, Flow reduction, High-flow, RUDI,
Transposition of the radial artery

Introduction • Closure of the AVF when the creation of a more distal

Arteriovenous fistula (AVF) creation induces decreased
peripheral resistance and increased cardiac output, blood
volume, pulmonary flow and pressure.
Patients with large upper arm shunts are particularly at
risk of high-output cardiac failure (HOCF). With time, car-
diac hypertrophy and four chamber enlargement will take
place, and pulmonary hypertension will develop as well as
AVF-related coronary hypoperfusion resulting in ischemic
cardiomyopathy. Treatment includes fistula flow reduction
or fistula ligation.
For prevention of HOCF, access flow should be assessed
repeatedly and those with outputs >1.5 L/min should be
monitored closely for development of heart failure. Some
authors (1-2) consider surgical reduction of upper arm
shunts where flows average 1700 mL/min while others (3-4)
insist on the high predictive power for HOCF occurrence of
blood access flow (Qa) cut-off values >2.000 mL/min.
Apart from proceeding as distal as possible, there is no
reliable way to limit blood flow when creating an AVF.
The standard procedures to reduce (Qa) are:
Accepted: December 25, 2015
Published online: March 6, 2016
Corresponding author:
Pierre Bourquelot
Clinique Jouvenet
6 Square Jouvenet
F75014 Paris, France
pierre@bourquelot.fr
AVF is possible, which is rare, or after successful kidney
transplantation.
• Banding of the vein to reduce its caliber, but this proce-
dure rarely results in actual flow reduction.
We routinely used the following methods (5, 6) to reduce high
flow AVFs: juxta-anastomosis Proximal Radial Artery Ligation
(PRAL) for distal AVF (7), Distal Report of Arterial Inflow (RUDI-1)
(5) and more recently, Transposition of the Radial Artery (RUDI-2)
(8) for proximal AVF. These methods and their results are de-
scribed here.
AVF flow measurement
Although a flow rate of 300 to 500 mL/min is sufficient
to ensure proper hemodialysis, the actual AVF flow is usually
much higher.
Summarizing the current studies of Qa measurements
made with duplex scanning in upper arm fistula (cumulative
total 227 patients) gives a mean Qa that ranges from 1,126
to 1,722 mL/min. Based on these studies, at least 15% of
patients may have Qa greater than 2 to 2.5 L/min (9).
In a prospective evaluation of 45 autologous AVFs using
the ultrasound dilution technique (Transonic) the Qa of prox-
imal cephalic AVFs was approximately twice as high as the
Qa of distal cephalic AVFs, 1,285 ± 652 vs 647 ± 331 mL/min,
respectively (10).
High blood flow AVF
The magnitude of AVF blood flow is dependent on the
following:

© 2016 Wichtig Publishing

Bourquelot
1. The initial diameter of the artery, while the role of the
initial caliber of the anteriovenous (AV) anastomosis re-
mains controversial, at least in the wrist. As known from
congenital AVF, the more proximal the AVF, the earlier
and more important is the cardiac overload. In fact, flow
of recently created accesses have been shown to be up
to twice as high in upper arm fistulas compared with low-
er arm fistulas (1,336 ± 689 vs. 645 ± 332 mL/min).
2. The ability of the artery to dilate with time. Among ther-
apeutic AVFs, the distal radial to cephalic AVF, which has
the longest life, may also be involved in high blood flow.
High flow appears infrequently in two kinds of angioaccesses:
• distal basilic-to-ulnar AVF, probably due to the small di-
ameter of the ulnar artery;
• prosthetic arteriovenous bridge-graft: probably because
of the early venous anastomosis stenosis.
Currently, there is no definition of when a fistula flow is too
high. According to the different authors the upper limit of
flow that is tolerable varies between 1,500 and 2,000 mL/
min. (1, 4, 11).
Standard flow reduction methods
When high flow is important and/or when a cardiac over-
load is observed, a flow reduction is necessary.
Closure of the high flow AVF should be done after successful
kidney transplantation or when it is possible to move to perito-
neal dialysis.
Replacement of a proximal AVF by a more distal perma-
nent access on either of both upper limbs is possible in a few
cases. Obviously in case of multiple fistulas, the ligation tech-
nique is also indicated.
The popular elbow side-to-side and the perforating vein
arteriovenous Gracz’s fistula deserves many criticisms: retro-
grade flow to the forearm may induce painful and ischemic
distal venous hypertension; perfusion of the profunda brachial
veins via the perforating vein will not give any chance of vein
cannulation; the same applies to the basilic vein, which is not
to be punctured without a serious risk of brachial artery dam-
age, unless previous surgical superficialization; arterial distal
ischemia, occurring very frequently in diabetics and cardiac
overload, are the major unrecognized risks of this technique.
Closure of the anastomosis straight above the artery is to be
done and a new side-to-end “only one downstream cephalic or
superficialized basilic vein anastomosis” is performed.
Banding was traditionally the method of choice to reduce
AVF flow. Objections to banding are multiple:
1) peroperative flowmeter is required but the previous sur-
gical dissection frequently induces an arterial spasm,
2) reduction of vascular caliber must be important and
precise to avoid the risk of either persistent high flow or
thrombosis.
Early successful results with banding have been published
by two different teams (12, 13), but recently the long-term
results of banding in brachial artery-based fistulas with flow
© 2016 Wichtig Publishing
S61
Fig. 1 - Juxta-anastomosis Proximal Radial Artery Ligation (PRAL).
>2 L/min in 50 adult male patients were disappointing (14).
Access flow was initially reduced by >50% but a recurrent
high flow (>2 L/min) developed in 52% of the patients during
the observation period (12 months). Young age and an access
flow >1 L/min immediately after banding were risk factors for
recurrent high flow.
These factors, in addition to the failure of previous banding
that we observed in referred high blood-flow AVF patients, led
us to abandon this technique.
Arterioarterial by-pass. We gave up early on the project
to change high flow AVF into arterioarterial by-pass. The the-
oretical advantage would have been a marked reduction of
basic blood flow, capable to increase highly after cannulation
for hemodialysis. The 10 artery-to-artery by-passes which we
had created in the upper arm were complicated with early
thrombosis, distal artery embolism and painful dialysis due to
high pressure intra-arterial reinjection.
Effective flow reduction methods
Juxta-anastomosis proximal radial artery ligation
Juxta-anastomosis Proximal Radial Artery Ligation (PRAL)
(Fig. 1) that we have described in 1989 (5), applies to fore-
arm side-to-end (radial-to-cephalic) high-flow AVFs. Results in
adults and children were reported in 2010 (7).
Anderson in 1977 was the first who observed that two-
thirds of the inflow in a side-to-end fistula at wrist is supplied
by the proximal artery, and that the remaining one-third
comes from retrograde flow through the distal artery. We
observed similarly that a distal AVF could remain patent and
sufficient for hemodialysis, after spontaneous proximal artery
thrombosis.
Before undertaking PRAL, it is necessary to check for out-
flow venous stenosis, which could lead to subsequent fistula
thrombosis. Retrograde flow from the distal radial artery and
the palmar arch is proved on the basis of a permanent, with
systolic reinforcement, Doppler audible signal.
The surgical procedure is very simple. A 3-weeks anticoag-
ulation therapy is recommended post-operatively to reduce
the risks of extensive thrombosis of the radial artery. Eighty-
two (mean age: 45 years, range: 5-82 years) whose high-flow
AVF was reduced by this method had 54 ± 19 (% ± SD) mean
reduction rate. Maximum reduction rate was observed on
highest flows.
High flow had persisted or reappeared postoperatively in
a few cases. Associated ligation of the distal artery reducing
AVF in-flow to small branches from ulnar and interosseous
S62
Fig. 2 - Revision Using Distal Inflow (RUDI-1).
arteries was necessary in five cases: mean preoperative
flow was 920 ± 372 (mL/min ± SD), mean postoperative
flow was 596 ± 271 (mL/min ± SD), mean reduction rate
was 34 ± 24%.
This method also applies in cases of proximal high-flow
AVF coexisting with high bifurcation of the brachial artery,
which is present in 14% of individuals. High bifurcation diag-
nosis is made on the existence of a permanent, with systolic
reinforcement Doppler signal on both distal forearm arteries
(retrograde in one). The AVF, although situated at the elbow,
actually involves radial or ulnar artery which can be ligated
proximally without any risk of distal ischemia. In fact, the
surgical ligation could be a cumbersome procedure after a
2-stage basilic vein superficialization, and a percutaneously
inserted plug may be preferred (15).
Distal Report of the Arterial Inflow
Revision Using Distal Inflow (RUDI-1) (Fig. 2) involves re-
placing inflow from brachial artery of a proximal AVF by inflow
from one of its smaller caliber distal branches.
To our knowledge we were the first to describe this
technique in 1989 as “Distal report of the arterial inflow”
(5, 6). The original arteriovenous anastomosis was closed
at the elbow; an arteriovenous by-pass (thin-wall polytetra-
fluoroethylene [PTFE] in adults, greater saphenous vein in
children) was connected between the radial artery or the
ulnar artery at the forearm, as distal as possible using surgi-
cal microscope, and the out-flow tract (vein or prosthesis)
at the elbow. Distal anastomosis was easier to perform with
greater saphenous vein interposition as compared to PTFE.
Secondary stenosis of the vein anastomosis in the elbow
was observed in both grafts. A 60% ±18 mean postopera-
tive reduction rate was observed in 35 patients (mean age
44 years, range 2-67 years). Similar technique was reported
by a different author in two patients in 2004 (16).
A variant of this technique was published in 2005 as “RUDI”
(17) reporting a short distalization to the proximal radial or
ulnar artery approximately 2-3 cm distal to the brachial artery
bifurcation in four patients. Unfortunately the length of the dis-
talization may have been too short, and pre- and postoperative
flow rates were not reported.
Nineteen patients treated by RUDI were recently report-
ed (18). Mean preoperative access flow was reduced from
3,080 ± 200 to 1,170 ± 160 mL/min (p = 0.001). Mean access
flow at 12 months was 1,580 ± 260 mL/min. Better results
were observed with greater saphenous vein interposition as
compared with basilic vein interposition.
Flow reduction for cardiac failure
Fig. 3 - Transposition of the Radial Artery (RUDI-2).
In a few cases, RUDI may be impossible, due to diabetic
distal artery calcifications. Its drawback is eventual future
occurrence of a bridge-graft vein anastomosis stenosis.
Transposition of the radial artery
Transposition of the Radial Artery (RUDI-2) (Fig. 3) (8)
is also a surgical procedure to reduce excessive blood flow
through a proximal AVF: the brachial artery which supplies
the vein is replaced by the radial artery which has a much
smaller caliber. For that purpose, the radial artery is first dis-
sected from the forearm, divided at the wrist and then turned
upwards to reach the vein at the elbow.
No prosthesis, with its risk of vein anastomosis stenosis,
is used. This method is useful in young patients with normal
forearm arteries, especially in children in which bridge-graft
stenosis would appear early while life-long angioaccess is re-
quired. The new anastomosis is an end-to-side anastomosis
of the artery to the anterior aspect of the vein whose ex-
tremity has previously been closed. The surgical procedure
is greatly facilitated by the use of an operating microscope.
Forty-seven patients referred for flow reduction of their
elbow fistula (28 brachiobasilic and 19 brachiocephalic)
were treated with this technique. Mean patient age was
41 years (range: 2-76 years). The indications for flow reduc-
tion were cardiac failure (n = 13), concerns about future car-
diac dysfunction (n = 23), hand ischemia (n = 4), and chronic
venous hypertension resulting in aneurysmal degeneration
of the vein (n = 7). Forearm arteries were checked by ultra-
sound examination and/or angiography before intervention
to confirm the patency of the ulnar and radial arteries and
the palmar arch.
Flow rates were calculated according to body surface area
in order to create a standard measure for patients, particu-
larly taking into account the differences between the mor-
phology of men, women and children. Follow-up ranged from
2 months to 15 years.
Immediate success rate was 94%. Mean flow rate dropped
from 1,999 ± 808 to 726 ± 467 mL/min per 1.73 m² corre-
sponding to a mean flow rate reduction of 66%, with a low
standard deviation of 14% and a clinical success in 29/31
non-ischemic patients.
The only two immediate failures were due to major tech-
nical difficulties in the making of the new anastomosis be-
tween a small caliber radial artery and a thick wall elbow
vein. This resulted in acute thrombosis requiring redo of the
previous brachial artery anastomosis, with no subsequent
ischemic complication.
© 2016 Wichtig Publishing
Bourquelot
Including initial failures, primary patency rates after inter-
vention were 75% at 1 year, 53% at 3 years. During follow-
up nine patients were successfully treated by percutaneous
transluminal angioplasty, which included five anastomosis
angioplasties and 11 venous angioplasties. Secondary paten-
cy rates were 94% at 1 year, 87% at 3 years. No recurrence of
high-flow was observed at 48 months.
Finally, eight out of 13 patients with cardiac insufficiency
were clearly improved after fistula flow reduction.
Conclusion
When distal end-to-side AVF flow must be reduced, juxta-
anastomosis PRAL is the preferred method.
To reduce a proximal AVF high flow, Distal Report of the
Arterial Inflow (RUDI-1) or Transposition of the Radial Artery
(RUDI-2) is performed. The former is simple and effective,
but could be complicated with a bridge-graft vein anastomo-
sis stenosis. The latter is our first choice especially for young
patients.
Disclosures
Financial support: No grants or funding have been received for this
study.
Conflict of interest: The author has no conflict of interest related to
this study to disclose.
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