Effect of regional versus local anaesthesia on outcome after arteriovenous fistula creation: a randomised controlled trial

Emma Aitken; Andrew Jackson; Rachel Kearns; Mark Steven; John Kinsella; Marc Clancy; Alan Macfarlane

doi:10.1016/S0140-6736(16)30948-5

Effect of regional versus local anaesthesia on outcome after arteriovenous fistula creation: a randomised controlled trial

Lancet. 2016 Sep 10;388(10049):1067-1074. doi: 10.1016/S0140-6736(16)30948-5. Epub 2016 Aug 1.

Authors

Emma Aitken¹, Andrew Jackson², Rachel Kearns³, Mark Steven⁴, John Kinsella³, Marc Clancy², Alan Macfarlane³

Affiliations

¹ Department of Renal Surgery, Queen Elizabeth University Hospital, Glasgow, UK. Electronic address: emmaaitken@nhs.net.
² Department of Renal Surgery, Queen Elizabeth University Hospital, Glasgow, UK.
³ Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK; Department of Anaesthesia, Critical Care and Pain Medicine, University of Glasgow, Glasgow, UK.
⁴ Department of Anaesthesia, Golden Jubilee National Hospital, Clydebank, UK.

PMID: 27492881
DOI: 10.1016/S0140-6736(16)30948-5

Abstract

Background: Arteriovenous fistulae are the optimum form of vascular access in end-stage renal failure. However, they have a high early failure rate. Regional compared with local anaesthesia results in greater vasodilatation and increases short-term blood flow. This study investigated whether regional compared with local anaesthesia improved medium-term arteriovenous fistula patency.

Methods: This observer-blinded, randomised controlled trial was done at three university hospitals in Glasgow, UK. Adults undergoing primary radiocephalic or brachiocephalic arteriovenous fistula creation were randomly assigned (1:1; in blocks of eight) using a computer-generated allocation system to receive either local anaesthesia (0·5% L-bupivacaine and 1% lidocaine injected subcutaneously) or regional (brachial plexus block [BPB]) anaesthesia (0·5% L-bupivacaine and 1·5% lidocaine with epinephrine). Patients were excluded if they were coagulopathic, had no suitable vessels, or had a previous failed ipsilateral fistula. The primary endpoint was arteriovenous fistula patency at 3 months. We analysed the data on an intention-to-treat basis. This study was registered with ClinicalTrials.gov (NCT01706354) and is complete.

Findings: Between Feb 6, 2013, and Dec 4, 2015, 163 patients were assessed for eligibility and 126 patients were randomly assigned to local anaesthesia (n=63) or BPB (n=63). All patients completed follow-up on an intention-to-treat basis. Primary patency at 3 months was higher in the BPB group than the local anaesthesia group (53 [84%] of 63 patients vs 39 [62%] of 63; odds ratio [OR] 3·3 [95% CI 1·4-7·6], p=0·005) and was greater in radiocephalic fistulae (20 [77%] of 26 patients vs 12 [48%] of 25; OR 3·6 [1·4-3·6], p=0·03). There were no significant adverse events related to the procedure.

Interpretation: Compared with local anaesthesia, BPB significantly improved 3 month primary patency rates for arteriovenous fistulae.

Funding: Regional Anaesthesia UK, Darlinda's Charity for Renal Research.

Publication types

Comment

MeSH terms

Anesthesia, Local*
Arteriovenous Fistula
Arteriovenous Shunt, Surgical
Humans
Renal Dialysis*
Treatment Outcome
Vascular Patency / drug effects

Associated data

ClinicalTrials.gov/NCT01706354