Arteriovenous Fistula for Long Term Venous Access in Hemophiliac Boys

Irina Goncharova, MD, Walter J. McCarthy, III, M.D., Ana Bonilla, M.D., Tom Pooley, RVT, Audrey Taylor, R.N. and Valentino Leonard, M.D.
Vascular Surgery, Rush University Medical Center, Chicago, IL   

Objectives:
Hemophilia is a sex linked condition affecting about 1 per 5000 males in the United States. These children can be rendered normal by daily intravenous infusion (IV) of factor VIII thus preventing crippling and sometimes fatal hemorrhage. Maintaining this vital IV access is often hampered by gradual loss of superficial veins and/or repeating central line sepsis. The purpose is to review an experience with arteriovenous fistula (AVF) in selected patients with limited venous access as this has not been investigated in the United States.
Methods:
Consecutive patients operated on between October 2000 and September 2005 for venous access with the placement of an AVF were reviewed. Patency, ease of use, duplex scan derived brachial artery diameter and arm length were assessed.
Results:
Over 59 months eight AVFs were performed for seven patients, median age 4 years, range 1 -27 years. All were younger than 7 except the 27 year old. There were 4 brachial artery bascilic vein AVFs and 4 brachial artery cephalic vein AVFs, there were no post-operative hematomas requiring evacuation. One occluded at 13 months and one failed to mature and was successfully redone in the opposite arm. Of the mature fistulas, patency was 100% at one year and 4/5 (80%) at 3 years, and 3/4 (75%) at 4 years with mean follow up of 22 months.
Brachial artery diameter increased in the involved arm by a ratio of 1.81 (range 1.09-2.5) compared to the opposite arm. Arm length disparity was increased by 0.8cm (range 0-1.5cm) in the involved arm. All fistulas allowed good access at home by a care provider.
Conclusions:
For hemophiliacs with compromised venous access, AVFs provide good early patency. Brachial artery diameter and arm length require continued follow up .