Wrist versus elbow arteriovenous fistula outcomes in diabetic patients and influencing factors

Abstract

Introduction: The multisystem impact of diabetes mellitus is well established, with the most severe consequence being end-stage kidney disease characterized by small-artery injury. However, evidence on how these vascular alterations affect the performance of the arteriovenous fistula (AVF), a life-sustaining access for hemodialysis, remains limited.

Methods: a descriptive cross-sectional study of 89 adults with chronic kidney disease and diabetes mellitus undergoing first-time AVF creation at Thong Nhat Hospital between 01/2022- 01/2025. Preoperative vascular mapping by ultrasound and a step-wise surgical strategy (wrist first, then elbow) were used. Outcomes included 6–8-week maturation, time to maturation, primary failure, and early dysfunction. Wrist versus elbow AVFs were compared using appropriate statistical tests.

Results: Comorbid hypertension was present in 92.1%. Compared with elbow AVFs, wrist AVFs had smaller arterial diameter (1.9 ± 0.2 vs 2.4 ± 0.3 mm; p=0.001), greater arterial wall thickness (0.84 ± 0.10 vs 0.72 ± 0.10 mm; p=0.001), and more calcification (42.3% vs 29.7%; p=0.04). The 6–8-week maturation rate was lower at the wrist (63.5% vs 83.8%; p=0.02). Perioperative metrics and early adverse events did not differ significantly (primary failure 19.2% vs 8.1%, p=0.12; early dysfunction 21.2% vs 10.8%, p=0.18).

Conclusions: In patients with diabetes mellitus, wrist AVFs exhibited lower and slower early maturation than elbow AVFs. Applying relative selection criteria with conditional exceptions may help individualize site selection, improve maturation rates, and optimize time to cannulation. Further studies that adjust for anastomotic technical variables and incorporate long-term follow-up are warranted to confirm effects on AVF performance.