CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 252 AFRICA Fistula performance was monitored by nephrology nurses and nephrologists working in the dialysis units and were referred for revision in case of dysfunction or thrombosis. However, in our opinion, surgeon availability, failure to timeously refer dysfunctional BBAVF, late referral of thrombosed BBAVF and suboptimal access to elective/emergency theatre and interventional suites were some of the factors that contributed to the relatively low re-intervention rate. The importance of vigilant access monitoring has been emphasised in the literature, as up to 70% of BBAVF may need an intervention by 18 months to maintain patency.7 When considering the above patency rates, one has to be cognisant of the fact that, despite a relatively low median age of 45 years, many of the patients had been receiving haemodialysis for a long time, with the median cumulative haemodialysis days at the time of BBAVF creation calculated at 1 343 days (IQR 828–2 920). In addition, the median cumulative dialysis catheter days were calculated at 704 days (IQR 348–1 460). Both dialysis vintage and dialysis catheter days have been reported to increase primary failure rate and decrease AV access patency rates.12 The BBAVF procedure had not been frequently performed in our unit prior to the study period, with brachio-axillary AV grafts preferred in patients with no superficial AVF option. Consequently, 19 of the 41 patients (46.3%) had a previous attempt at brachio-axillary AV graft creation. A pre-existing (failed) ipsilateral brachio-axillary AV graft was present in 12 of 41 patients that ultimately underwent BBAVF creation. Importantly, none of the grafts had undergone revision surgery or interventional procedures at the graft–vein interface. Axillary vein occlusion or high-grade stenosis were excluded with pre-operative duplex ultrasound in all 12 patients prior to BBAVF creation. In this subgroup, six BBAVF were performed as a one-stage procedure, of which two failed to mature. Six were performed as a two-stage procedure, with all six reaching maturation. Overall, 24 BBAVF (58.5%) were performed as a one-stage procedure and 17 (41.5%) as a two-stage procedure. Maturation failure occurred in four of the 41 patients (9.8%), all of which were performed as one-stage procedures. Therefore, the maturation failure rate with the one-stage procedure in our series was 16.7%, as opposed to 0% with the two-stage procedure. However, 24 of the first 27 BBAVF in our series were performed as one-stage procedures and the impact of a learning curve may, in part, contribute to the disproportionately high rate of maturation failure observed with the one-stage procedure in our study. This study reports on a real-world experience with the use of BBAVF in a resource-constrained environment and provides longterm patency data. We acknowledge that the sample size was small therefore results should be interpreted with caution. Despite the retrospective and single-centre nature of the study, we believe that the study supports the safety and feasibility of BBAVF creation and use in accordance with international clinical practice guidelines. Conclusion This study indicates that BBAVF can successfully be performed in a resource-constrained environment by surgeons with limited prior experience with the technique. However, careful monitoring, well-established referral pathways for dysfunctional fistulae and access to surgical or endovascular revision seem to be key factors in ensuring long-term patency. References 1. Stanifer JW, Jing B, Tolan S, et al. The epidemiology of chronic kidney disease in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Glob Health 2014; 2(3): e174–e181. [Correction in Lancet Glob Health 2014; 2(5): 266]. 2. Purnell TS, Auguste P, Crews DC, et al. Comparison of life participation activities among adults treated by hemodialysis, peritoneal dialysis, and kidney transplantation: a systematic review. Am J Kidney Dis 2013; 62(5): 953–973. 3. Global Observatory on Donation and Transplantation. http://www. transplant-observatory.org/export-database/ 4. Lok CE, Huber TS, Lee T, et al. 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