Cimino or Brachiocephalic Fistula - Is One Better for Long Term Hemodialysis Access?

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Stephen L. Hill, M.D., Antonio T. Donato, MD.
Physicians Care of Virginia, Roanoke, VA, USA.

OBJECTIVES: The Cimino fistula has always been considered the gold standard for autogenous hemodialysis access - however the forearm cephalic vein in many renal failure patients is often sclerotic or thrombosed . The recent push for autogenous fistula for patients needing hemodialysis by the “Fistula First” initiative and the DOQI Guidelines have necessitated the increased use of the upper arm cephalic vein for access and this has been found to be a reliable, and perhaps better, alternative.
METHODS: We reviewed our results over a ten year period in a two-man private practice group to evaluate the advantages and disadvantages of both types of fistula. We tabulated the success rate, longevity, and complications associated with each type of fistula in an effort to determine if one should be chosen preferentially over the other in constructing an autogenous fistula.
RESULTS: There were a total of 286 patients treated for renal failure over the ten-year period. There were 38 Cimino fistulae constructed in 36 patients and 92 brachiocephalic fistulae constructed in 85 patients. The remaining patients either had temporary femoral dialysis catheters, tunneled dialysis catheters or prosthetic grafts placed for dialysis access. In the Cimino Fistula (CF) group, of the 38 procedures, there were 20 fistulae (53%) which were initially functional; while in the Brachiocephalic Group (BG) 71 (77%) were initially functional. Of those which were successful we grouped them into three categories - fistula which were functional at the patients death (CF 5/20; 25%; BG 32/71; 45%), functional at the end of the study (CF 8/20; 40%; BG 29/71 40%) and those patients whose fistula clotted (CF 6/20; 30 %; BG 10/71; 14%). The average length of patency combing all groups was 24.5 months for the Cimino Fistula group and 19.3 months for the Brachiocephalic Group. These averages underestimate the possible length of patency due to the fact that patients with functioning fistulae who died and those functioning at the conclusion of the study were included in the calculations. In the brachiocephalic group there were 27 (38%) procedures performed to revise, dilate or otherwise repair the fistula to attempt to keep it functional; in the Cimino group there were 10 (50%) procedures attempted to keep the fistula functional.
CONCLUSIONS: The Cimino fistula still appears to be the best autogenous access providing longer, more reliable, dialysis access, however, it is available less often, and has a lower success rate. The Brachiocephalic Fistula is an excellent alternative, if a Cimino fistula is not an option or has failed.

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