Alternant Approach to Manage Patent AVF With Untreatable Venous Hypertension from Central Stenosis

Abstract

<h3>Introduction and Objective</h3> Arteriovenous fistula (AVF) associated venous hypertension from central venous obstruction is commonly seen to cause dysfunctional dialysis access and severe swelling. It is traditionally managed by a variety of surgical, interventional approaches, but when the central stenosis/occlusion cannot be corrected, focus shifts only to relieve the edema. The most common approach is sacrificing the vein with ligation and starting anew despite risks of non-maturity and/or using a non-autologous conduit. We report a novel approach by translocating a patient's native and "mature" vein to create a new AVF and treat both problems. This minimizes time-to-maturity, quickly establish long-term, autologous vascular access for hemodialysis and simultaneously treat the swollen extremity. <h3>Case Report</h3> 80-year-old female with a functional brachiocephalic AVF had severe and painful venous hypertension due to presumed central vein obstruction. The AVF was created in 2017 and unused until November 2019. It worked for 7 months until developing left upper extremity swelling and pain. She underwent five balloon angioplasty procedures at an outside facility without lasting resolution. In January 2021 her left upper extremity was tense, edematous and significant erythema. The left arm had evolving elephantiasis with Peux D'Orange skin changes, warmth, tenderness, with a distant, but palpable thrill. We attempted resolution via femoral venous access which revealed a >70% stenosis of her subclavian vein close to the innominate junction and near her first rib and clavicle interface. Balloon angioplasty with a 12 × 40mm Conquest balloon at 20 ATM had immediate reversal of her venous hypertension and symptomatic relief. At one month she reported recurrence of swelling and pain. We discussed first rib resection, AVF ligation and/or catheter-only dialysis or starting again. She refused a rib resection. We harvested and excised her large and mature left cephalic vein and translocated it to her right forearm to create a new radial artery to Brachial vein AVF (with a tunneled catheter for acute access). Due to size mismatch, we everted the left cephalic vein to do valvulotomy, and the anastomosis was done in a non-reversed fashion with two end-to-side anastomosis. This simultaneously corrected her venous hypertension and gave her an autologous AVF using her contralateral cephalic vein. At one month, her left upper extremity had complete resolution and the AVF was cleared for access. <h3>Discussion</h3> Venous hypertension and central venous obstruction with a functional AVF can compromise efficient dialysis and be very debilitating leading to AVF ligation and abandonment when it cannot be resolved. This approach offers an accessible technique for salvage of a relatively common AVF complication with high success for cannulation.