High flow reduction of distal radio-cephalic fistula: Description of a novel banding technique over proximal radial artery (PRAB)

BACKGROUND: Distal radio-cephalic arteriovenous fistula (RCAVF) is the gold standard vascular access for haemodialysis (HD). A rare complication of RCAVF is high blood flow (defined as flow (Qa) >1.5 L/min). In order to reduce high flow in such RCAVF, we conceived a novel banding technique of the proximal radial artery (PRAB), as a variant of the Bourquelot's proximal radial artery ligation (PRAL). We describe our experience, which began in 2016. METHODS: We retrospectively examinated prospectively collected data from 20 consecutive patients treated from 2016 to 2023 in a single centre.All patients were referred because of high-flow RCAVF and evaluated systematically by colour Doppler ultrasound (CDU) examination preoperatively and 1, 6 and 12 months postoperatively (Qa0, Qa1, Qa6 and Qa12), with flow measurements and verification of ulnar artery and palmar arches patency.The procedure consisted in the ligation of the juxta-juxtaanastomotic proximal radial artery over a 2 mm external tutor (proximal radial artery banding), therefore - compared to classic PRAL - preserving continuity of the proximal radial artery. The aim of this variant was to prevent involution of the radial artery proximally to ligation.Patient characteristics (means): age 69 years, comorbidities (hypertension 85%, diabetes 0%), HD vintage 21 months, AVF vintage 31.5 months, Qa0 2650 mL/min.Primary and secondary patency following PRAB were calculated at 6 and 12 months (PP6, PP12, SP6, SP12). RESULTS: At T1, T6 and T12, AVF mean flow reduction rates were 52%, 52% and 51%, respectively, proximal radial artery patency was verified in all patients by CDU. Primary and secondary patency rates at 6 and 12 months were 100%, 83.3%, 100% and 100%, respectively. Three patients (16.6%) necessitated of iuxta-anastomotic vein revision because of low flow within 12 months after flow reduction, one patient died 5 months postoperatively unrelated to the procedure, one patient was lost to follow-up. No thrombosis or hand ischaemia occurred postoperatively. CONCLUSIONS: PRAB is as safe and effective as PRAL for surgical reduction of high-flow RCAVF with satisfying mid- and long-term patency results. The potential of preserving the patency of radial artery could represent an added value especially in younger patient. Further studies are needed to better define these results.