Surgical management of cephalic arch occlusive lesions: are there predictors for outcomes?

Cephalic arch lesions are common cause for dysfunction of brachiocephalic arteriovenous fistulas. For lesions resistant or not amenable to endovascular interventions, we used a term "cephalic arch occlusive lesions" (CAO) that included cephalic arch total occlusion, frequently recurrent stenosis (requiring angioplasty in <3-month intervals), high-grade elastic stenosis (residual stenosis >50% after angioplasty), or other lesions not amenable to endovascular interventions. Herein, we report 40 patients who underwent surgical revisions for total occlusions (17/40), frequently recurrent stenosis (17/40), high-grade elastic stenosis (5/40), and zigzag stenosis (1/40). The revisions included cephalic transposition and venovenostomy (CTV = 37/40), basilic transposition and venovenostomy (1/40), stenotic segment resection (1/40), and cephalic-jugular vein bypass graft (1/40). At 12-month post-CTV, the primary patency of the transposed cephalic vein, the fistula assisted primary and secondary patency rates were 25%, 82% and 97%, respectively. Notably, pre-CTV angioplasty of the proximal cephalic vein was the only significant predictor for the low primary patency rate (hazard ratio 4.5, p = 0.002). Accordingly, the primary patency rates were 12% and 58% in patients with and without pre-CTV angioplasty, respectively. In summary, surgical interventions are effective in salvaging fistulas complicated with CAO. Importantly, pre-CTV angioplasty of the proximal cephalic vein might adversely affect the outcome of CTV.