End-stage renal disease (ESRD) represents a growing global health burden, with haemodialysis serving as the primary renal replacement therapy for most patients [1]. Establishing reliable vascular access is critical for effective dialysis, and arteriovenous fistula (AVF) is widely considered the gold standard due to its superior long-term patency and lower infection rates compared to grafts and central venous catheters [2,3]. Despite these advantages, AVF creation is associated with a range of complications that may compromise its functionality and patient survival.

The two most commonly performed AVF types are radiocephalic (RC) and brachiocephalic (BC) fistulas. RC AVFs, typically created at the wrist, are preferred due to their distal location and preservation of proximal vessels; however, they may have higher rates of maturation failure [4]. In contrast, BC AVFs offer higher blood flow and faster maturation but are associated with increased risk of early complications such as bleeding and rupture [5].

Complications following AVF creation can be categorized into early and late events. Early complications include bleeding, infection, hematoma, and rupture, often occurring within the first 48 hours postoperatively [6]. Late complications include thrombosis, stenosis, aneurysm formation, and access failure, which significantly impact long-term usability [7]. Among these, thrombosis remains a leading cause of AVF failure, frequently resulting from underlying stenosis or poor vascular remodeling [8].

Infection is another critical concern, particularly in immunocompromised ESRD patients. The risk is influenced by patient comorbidities, hygiene, and access type [9]. Additionally, viral infections such as hepatitis C virus (HCV) have been implicated in vascular complications, including aneurysm formation due to chronic inflammation and endothelial dysfunction [10].

Given the increasing number of patients requiring haemodialysis, understanding the pattern of AVF-related complications is essential for optimizing outcomes. This study aims to evaluate the incidence and types of complications following AVF creation in ESRD patients, with particular emphasis on differences between RC and BC AVFs and the role of HCV infection.

This prospective observational study was conducted at a tertiary vascular care center in Hyderabad over a period of two years (January 2021 to December 2022). A total of 2000 patients diagnosed with ESRD and undergoing AVF creation for haemodialysis access were included.

Patients were evaluated preoperatively with clinical examination and Doppler ultrasonography to assess vessel suitability. Based on vascular anatomy and surgeon preference, patients underwent either radiocephalic (RC) or brachiocephalic (BC) AVF creation using standard surgical techniques under local anesthesia.

Patients were followed up for early (<48 hours) and late (>48 hours) complications. Early complications included bleeding, hematoma, infection, and rupture. Late complications included thrombosis, stenosis, aneurysm formation, and access failure. Infection was defined based on clinical signs such as erythema, discharge, and systemic symptoms. Thrombosis was confirmed by absence of thrill or bruit and Doppler findings.

Hepatitis C virus (HCV) status was recorded for all patients using serological testing. The association between HCV positivity and aneurysm formation was specifically analyzed.

Data were entered into Microsoft Excel and analyzed using SPSS version 26. Categorical variables were expressed as frequencies and percentages. Associations between AVF type and complications were assessed using the Chi-square test. A p-value of <0.05 was considered statistically significant.

Table 1

Among the 2000 patients, 1200 (60%) underwent radiocephalic AVF creation and 800 (40%) underwent brachiocephalic AVF. Early complications within 48 hours were significantly higher in BC AVFs, with rupture observed in 4.5%, bleeding in 8.0%, and infection in 6.5% of cases. In contrast, RC AVFs demonstrated lower early complication rates, with infection being the most common at 3.2%. The difference in early complication rates between RC and BC AVFs was statistically significant (p<0.001).

Table 1: Early Complications (<48 Hours) by AVF Type (n=2000)

Table 2

Late complications were observed in both AVF types, with thrombosis and stenosis being the most frequent. Thrombosis occurred in 10.5% of RC AVFs and 12.0% of BC AVFs, while stenosis was seen in 8.2% and 9.5%, respectively. Although BC AVFs showed slightly higher rates, the difference was not statistically significant (p>0.05). These findings highlight that both AVF types are susceptible to late complications affecting long-term patency.

Table 2: Late Complications (>48 Hours) (n=2000)

Table 3

Aneurysm formation was strongly associated with HCV positivity. Among HCV-positive patients, 50% developed AVF aneurysms compared to only 8% in HCV-negative individuals. This difference was statistically significant (p<0.001), indicating a strong correlation between chronic viral infection and vascular wall weakening. These findings emphasize the need for close monitoring of HCV-positive patients undergoing AVF creation.

Table 3: HCV Status and Aneurysm Formation (n=2000)

Table 4

Overall complication rates showed that infection was the most common complication in RC AVFs, whereas BC AVFs demonstrated higher rates of early severe complications such as rupture and bleeding. Thrombosis remained a major contributor to access failure in both groups. The overall complication burden was higher in BC AVFs (28%) compared to RC AVFs (22%), indicating that although BC AVFs mature faster, they carry a higher risk of complications.

Table 4: Overall Complication Distribution (n=2000)

The present study provides a comprehensive evaluation of complications following AVF creation in ESRD patients over a two-year period, highlighting significant differences between radiocephalic (RC) and brachiocephalic (BC) fistulas. The findings demonstrate that while AVF remains the preferred vascular access modality, complication rates remain substantial and vary depending on fistula type and patient factors.

Early complications were significantly higher in BC AVFs, particularly rupture, bleeding, and infection within the first 48 hours. This observation aligns with previous studies indicating that proximal fistulas, due to higher blood flow and vessel diameter, are more prone to hemodynamic stress leading to early complications [11]. In contrast, RC AVFs exhibited lower early complication rates, supporting their role as the first-line access option when anatomically feasible [12].

Infection was identified as the most common complication in RC AVFs. This finding is consistent with reports suggesting that distal AVFs, although safer in terms of hemodynamics, may be more susceptible to local infections due to repeated cannulation and superficial location [13]. However, overall infection rates remained lower than those associated with central venous catheters, reinforcing the superiority of AVFs [14].

Late complications, including thrombosis and stenosis, were observed in both AVF types without significant differences. Thrombosis remains a leading cause of AVF failure and is often secondary to underlying venous stenosis [15]. The rates observed in this study are comparable to those reported in the literature, where thrombosis incidence ranges from 10–15% [16]. Early detection through surveillance programs and timely intervention can significantly improve fistula survival.

A key finding of this study is the strong association between HCV positivity and aneurysm formation. Approximately 50% of HCV-positive patients developed aneurysms, which is markedly higher than in HCV-negative individuals. Chronic HCV infection has been linked to systemic inflammation, endothelial dysfunction, and vascular remodeling, predisposing patients to aneurysm formation [17]. Similar associations have been reported in previous studies, emphasizing the need for targeted monitoring in this subgroup [18].

The overall complication rate was higher in BC AVFs compared to RC AVFs, despite their advantages in terms of maturation and blood flow. This highlights the trade-off between rapid usability and complication risk. Clinical decision-making should therefore consider patient-specific factors such as age, comorbidities, and vascular anatomy [19].

The strengths of this study include a large sample size and comprehensive evaluation of both early and late complications. However, limitations include its single-center design and lack of long-term follow-up beyond two years. Future multicenter studies with extended follow-up are needed to validate these findings.

Complications following AVF creation remain a significant concern in ESRD patients undergoing haemodialysis. This study demonstrates that brachiocephalic AVFs are associated with higher early complication rates, including rupture, bleeding, and infection, particularly within the first 48 hours. In contrast, radiocephalic AVFs exhibit lower early complication rates but are more commonly associated with infection over time. Thrombosis and stenosis continue to be major causes of access failure in both AVF types.

A notable finding is the strong association between HCV infection and aneurysm formation, highlighting the importance of vigilant monitoring in this high-risk group. Overall, while AVFs remain the preferred vascular access, careful patient selection, early surveillance, and timely intervention are essential to minimize complications and improve long-term outcomes.

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