Percutaneously created sutureless anastomosis.

Abstract

An 80-year-old male diabetic patient with end-stage renal disease was evaluated for decreasing access flow and difficult cannulation of his established percutaneous arteriovenous fistula (pAVF), created 6 months ago with the Ellipsys vascular access system (Avenu Medical, San Juan Capistrano, Calif).1Mallios A. Jennings W.C. Boura B. Costanzo A. Bourquelot P. Combes M. Early results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System.J Vasc Surg. 2018; 68: 1150-1156Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 2Mallios A. Fonkoua H. Allouache M. Boura B. Percutaneous arteriovenous dialysis fistula.J Vasc Surg. 2020; 71: 1395Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 3Mallios A. Bourquelot P. Franco G. Fonkoua H. Allouache M. Boura B. et al.Mid-term results of percutaneous arteriovenous fistula creation with the Ellipsys vascular access system, technical recommendations and an algorithm for maintenance.J Vasc Surg. 2020 Apr 7; ([Online ahead of print])Abstract Full Text Full Text PDF Scopus (26) Google Scholar The patient's ipsilateral hand was cool without distal pulses. Percutaneous transluminal angioplasty of the pAVF anastomosis had only modestly improved access flow because of significant diffuse arterial calcifications. Bilateral distal arterial occlusions were present and the pAVF remained dysfunctional. Further and more aggressive attempts with percutaneous transluminal angioplasty were thought likely to result in severe hand ischemia (steal syndrome); therefore, arterial inflow proximalization was established using a 4- to 7-mm graft (W. L. Gore & Associates, Flagstaff, Ariz) with a lateral axillary artery anastomosis and an end-to-end outflow anastomosis to the mature cephalic vein, ligating the distal pAVF inflow site. An excellent thrill was recovered immediately over the entire length of the cephalic vein in the arm. Distal circulation improved substantially. A/Cover, B, and Video 1 show a perioperative view of the percutaneously created Ellipsys anastomosis between the proximal radial artery and perforating vein of the elbow. To our knowledge, this is the first direct visualization of an Ellipsys pAVF anastomosis in a human. The anatomic configuration and natural course of the pAVF are apparent along with the absence of suture or fibrosis, yielding a shape similar to surgical proximal radial artery AVFs described by Jennings et al.4Jennings W. Mallios A. Mushtaq Proximal radial artery arteriovenous fistula for hemodialysis vascular access.J Vasc Surg. 2018; 67: 244-253Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar C (medial view), D (anterior view), and Video 2 show the ligated pAVF anastomosis. Need for ligation of a pAVF has been a concern of some critics because of the multiple venous branches. This report demonstrates that in the rare case in which ligation is necessary, an Ellipsys pAVF may be easily ligated without consequence or technical challenges. The patient's informed consent was obtained before submission of this manuscript. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkM2YxZjljYzQzMTczOTJhZDVmYzdiMjVmYjJmMDc3YSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjU5NjgwMTEyfQ.P2iwekbqoGENyxeFwVBltgYalZQe974yt_1Pylg0oqw2wFHO3H5CWSPevIxJUo12W3mIV07CWaNMIpXXz890jVkEezWvpGPFAxKusFybJG_J-dUhtw2jZOOPABJPZG57mLmCApG-jTPEMAHW9pySwjjAkCUSrKAtXkkDyhYRg9KC4hAUWNilnBi-_azL08GN--bXaVldB4WfATLWRNN0AD8X_3mTXzlx_QakMBjMTbIc_JlN1rqNjO2zj3X2xxIyscs4nu7HNDe4Yl8ALcJg4rbz3dXNZm9xYBzLti2FU-yetHtrydtcxMLAVp3Fyk5IF4QMtPBmJ6GImX4mAYjwgg Download .mp4 (0.98 MB) Help with .mp4 files Video 1Perioperative view of the percutaneously created Ellipsys anastomosis between the proximal radial artery and perforating vein of the elbow.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4Yjk0MWI1ZWQwOTI1YzFjNmE0ZTAyMTJkN2YyODFjNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjU5NjgwMTEyfQ.HCPbtwp0lEn6tVnP5ipUjgo9Onu8BqDai6EaTcoSnwhdy1nK0swZeXM-bhdYhkOHKJoygNoK2-KvvS0ogyTxmhdk4F4pH_uKLQ0aBVKS1U7mXOouNT7J4OYjQRKkWFFxHaJWdePogqOgipV0cU_g0q4Mvzdqrwz-NM5QJTjg-rCAciba72xGohrwgvkUD24fZ21KOdzuGHnQD3HJlUmu5pbDBMCl6oLq5Uq970eaiRxZt66Y9ky_xXvbywthSc5h81x5QAqsGyLpDWA7oyrVn61ol7zdANzYpKlKsL9YKEgXAoBS8SNAMubTKpBlYIGCQrUtMDl602MclcggLFcrRA Download .mp4 (0.63 MB) Help with .mp4 files Video 2Ligated percutaneous arteriovenous fistula anastomosis.